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Examination of the Hip

Look

  • Introduction
  • Look for
    • Walking aids & equipment
    • Shoes
      • Wear pattern
      • orthotics
  • Exposure
    • start by undressing the patient to his or her underwear including removal of the socks

Standing

Front (Coronal plane)

  • General comment
    • does patient looks well?
    • looks their age, jaundiced or obvious skin condition
      • venous vascular changes
  • Alignment
    • does patient stand straight
      • shoulders level?
    • alignment of lower limb
      • intoeing / out-toeing
        • what level is causing the ER?
    • knees
      • squinting patellae
  • Scars, Sinuses, Swelling
  • Wasting
    • quadriceps

Side (Sagital plane)

  • Spine
    • flexion attitude
    • lumbar hyperlordosis
      • suggests Fixed Flexion Deformity of hip
  • Hip
    • scar of previous hip procedure
      • common mistake is to not lift underwear & hence miss a scar!
  • Knee
    • flexed posture of hip or knee
    • Ask Patient to push knee back to see if FFD of knee

Back (Posteriorly)

  • Spine
    • Sagittal deformity
    • Scoliosis or straight
      • Compensated or not
      • if scoliosis
        • bend forward to see if fixed or structural
        • if they cannot do this then sit them before lying to see if that obliterates scoliosis
  • Alignment of lower limbs
  • Scars
  • Gluteal folds
  • Hamstrings atrophy
  • Popliteal creases
    • Level / not level
  • Calf atrophy
  • Hindfoot abnormality

Pelvis

  • Feel for iliac crests & PSIS
  • Level / tilted
    • If Pelvis tilted / LLD
      • Comment on
        • Pelvis level in Comfortable stance
          • Pelvis is level / not level
    • Attain Symmetrical stance
      • Knees extended
      • Feet flat on ground
    • Now Comment on
      • Pelvis is level with symmetrical stance
      • Pelvis is not level with symmetrical stance
      • Pelvis is level with asymmetrical stance
      • Pelvis is not level with asymmetrical stance
    • Ask for blocks if pelvis not level to assess Functional leg length discrepancy
      • place blocks under short side until pelvis level
      • comment on number of cm necessary to make pelvis level
      • (also ask patient when they feel their pelvis is level)
      • beware of fixed hip abduction or adduction contracture;
        • if pushed by examiner: State that you would like to place patient supine on the bed to assess for contracture
      • see if scoliosis is obliterated by blocks levelling pelvis i.e. postural or fixed
    • Tips / tricks
      • Girl with surgical scar: beware previously osteotomy
        • Cannot use ASIS for leg lengths
  • Perform Trendelenburg test
    • from behind (sound side sags + lean)
    • if unable then perform from in front with palms supporting both theirs
    • Do not continue a delayed Trendelenburg test if the patient is in severe pain
    • Causes
      • Pain
      • Pivot
      • Power
      • Problem with abductors
        • NM disease
        • Surgery
      • Problem with fulcrum
        • Dysplastic hip
        • Very stiff hip from Osteoarthritis

Lumbar spine

  • forward flexion → comment “there is normal unrolling of lumbar spine”

Gait

  • 2 laps
    • observe : towards & away from you
    • observe: from the side
  • Descriptions of Gait
    • Limp
      • any abnormal gait
    • Short
      • shoulder drops on ipsilateral side
      • head drops in vertical plane
    • Stiff
      • Reduced stride length
    • Antalgic
      • Reduced stance phase on affected limb
    • Trendelenburg gait (lurch)
      • 1895 Friedrich Trendelenburg
      • in trendelenburg, shoulder dips to side of pain
      • sometimes called ‘lurching gait’
      • This has a sideways lurch of the trunk to bring the body weight over the affected limb
        • weak abductors or trochanteric insufficiency
          • When standing on the involved leg the pelvis sags on the opposite side. To balance the center of gravity the upper body lurches to the affected side (adductor lurch)
        • painful hip but normal adductors (e.g. Osteoarthritis)
          • Here the lurch brings the bodies center of gravity over the hip, which reduces the joint reaction force (and pain) from X3 body weight to near x1 body weight
    • Waddling
      • Bilateral trendelenburg gait
    • Swing Through
      • This is seen in ankylosed hips, with motion primarily occurring at the lumbar spine
    • Knee
      • Thrust
      • Stiff
    • Foot
      • 3 rockers
    • Spastic
    • High stepping
    • Foot drop gait
    • Complex
  • Walking aid
    • ? in correct hand
    • correct length
      • A stick held upside down should come to the level of the wrist
  • Foot progression
    • plantigrade
    • is ankle or foot inverted, everted or in equines
      • if so, mention you would like to examine this areas later
      • also examine hips for associated contracture
        • eg. adduction causing the patient to walk on the outside of the foot
        • cerebral palsy, peroneal muscular atrophy