Inspection
- Inspect patient in standing and while walking, anteriorly, posteriorly and laterally
- Gait
- Stance (60% of gait cycle): heelstrike, foot flat, midstance, push-off
- Swing (40% of gait cycle)
- Width of base (mid-heel to mid-heel) should be 2-4 in
- Waddling or circumduction: hip dislocation, arthritis, labrum tear, femoral acetabular impingement, adbductor weakness all cause pelvis to drop on contralateral side
- Posture and stance
- Compare height of iliac crests and gluteal folds
- Loss of lordosis: paravertebral spasm, hamstring tightness
- Excess of lordosis: flexion deformity of hip, hip flexor tightness
- Muscle atrophy, spasm or increased tone
- Gluteal fold symmetry
- Illiac crest symmetry
- Approximate comparative leg length
- Inspect lumbosacral spine and knees for causes of cervical spine issues
- Assess for weak hip abductors using the Trendelenberg test
Palpation
While patient standing, note areas of pain, swelling, spasm, muscular atrophy, ligamentous laxity, deformity or crepitus in the following structures:
- Anterior surface (patient supine)
- Iliac crests
- Anterior superior iliac spine (ASIS)
- Pubic symphysis
- If hip painful, palpate iliopsoas bursa below inguinal ligament
- Inguinal structures: NAVEL (Nerve, artery, vein, empty space, lymph nodes)
- Posterior surface (patient prone)
- Greater Trochanters
- Posterior Superior Iliac Spine (PSIS)
- Sacroiliac Joint
- Patient semiprone (Lateral surface)
- Greater trochanter
- Trochanteric bursa
- Ischiogluteal bursa
- Assess for leg length discrepancy (while patient supine) with the true leg length test
Range of Motion
- Patient supine
- Flexion (normal = 90-120°), “Bend knee to chest”. Monitor for normal flattening of lumbar lordosis and look for a flexion deformity of hip if contralateral leg flexes or if lordosis increases
- Abduction (normal = up to 45°) “Move leg out to side”
- Stabilize contralateral hip. This is a commonly difficult in OA
- Adduction (normal = up to 30°) “Move leg across other leg”
- External rotation (normal = 45°) “Flex knee and rotate outward”
- Note: lower leg and foot turn inward with knee bent. Difficult with OA
- Internal rotation (normal = 40°) “Flex knee and rotate inward”
- Note: lower leg and foot turn outward with knee bent. Difficult with OA, most sensitive test
- Combined Movements - FADIR (Flexion-ADduction-Internal Rotation)
- Passively flex and internally rotate the hip by bringing the lower leg externally, and bring knee up to opposite shoulder
- Helps to detect early OA, femoral acetabular impingement, or labral tears
- Patient prone
- Extension (normal = up to 30°) “Turn onto stomach, move leg backwards away from table without displacing contralateral leg”
Special Hip Tests
- Sciatic nerve
- Patient semiprone with hips flexed, palpate midway between ischial tuberosity and greater trochanter, positive if pain elicited
- Specific sciatic tests
References
- Baxter S, ed., McScheffrey G, ed. Toronto Notes: Comprehensive Medical Reference & Review for MCCQE 1 & USMLE 2. 26th ed. Toronto: Toronto Notes for Medical Students Inc; 2010.
- Bickley L. Bate’s Guide to Physical Examination and History Taking. 11th ed. New York: Lippincott Williams & Wilkins; 2013.
- Hurley K. OSCE and Clinical Skills Handbook. Halifax: Elsevier Canada; 2005.
- Pawa J, Lesniak, D., & Lott, A. Approach to the OSCE: The Edmonton Manual of Common Clinical Scenarios. Edmonton Manual; 2011.