Examination of the Hip

Special Tests

Leg Length Discrepancy

  • Assess
    • True vs apparent
    • Source of discrepancy
    • Magnitude of discrepancy

Real or True length

  • ASIS to medial Malleolus
  • measures from lateral to axis of hip movement
    • exaggerated length if adducted
    • underestimated on abducted side
  • To obtain accurate True Length measure 2 limbs must be placed in comparable positions relative to pelvis
  • Metal end of tape placed immediately distal to ASIS & pushed up against it
  • Tip of index placed immediately distal to MM & pushed up against it
  • Thumb nail brought down against tip of index with tape in between
  • Point of measure indicated by thumb nail

Apparent or False Discrepancy

  • from fixed pelvic tilt
  • only necessary when there is incorrectable pelvic tilt
  • Xiphisternum to medial mall
  • legs must be placed parallel to one another & in line with trunk
  • Square pelvis & hips neutral
    • if unable to then comment that unable & note position
  • beware FFD
    • put the legs in equivalent positions for both leg length measurements
  • comment if obvious apparent leg length discrepency (and measure?)
    • tip of medial malleolus
  • if equal then say real & apparent leg lengths equal without measuring
  • if not equal
    • xiphisternum to mm’s for apparent
    • ASIS to mm’s with hips/knees in same position for real ( may just say real = apparent if happy that pelvis square & hips neutral)
  • Note
    • amount of apparent shortening is the sum of the true shortening plus the shortening due to fixed deformity. It is the apparent shortening that matters to the patient
    • measures from lateral to axis of hip movement
    • Abduction contracture
      • comment on contracture
      • unable to place legs perpendicular to pelvis because of abduction contracture
      • must place other leg in same position
      • abduct unaffected hip same degree
      • look below medial malleolus
      • measure leg length
    • Adduction contracture
      • comment on contracture
      • unable to place legs perpendicular to pelvis because of adduction contracture
      • must place other leg in same position
      • note difficulty
      • cannot be done simultaneously
      • ideally lift other leg up out of way sequentially but need assistance
      • more practical to cross legs sequentially
      • look below medial malleolus
      • measure leg lengths sequentially
      • cross one leg & measure
      • cross other leg & measure
    • Flexion contracture of knee / FFD hip with flexion attitude of knee
      • comment on contracture
      • unable to place legs straight because of fixed flexion of knee / hip
      • must place other leg in same position
      • flex unaffected knee over bolster to same degree
      • look below medial malleolus
      • measure leg length
    • Valgus knee
      • comment on contracture
      • unable to place legs straight because of valgus knee
      • unable to place other leg in same position
      • note difficulty
      • must measure component parts of leg
      • approximates true leg length
      • look below medial malleolus
      • measure leg lengths
      • from ASIS to tibial tuberosity
      • from tibial tuberosity to medial malleolus
    • Equinus foot
      • look below medial malleolus
      • difference in effective heel height because of equinus contracture
      • measure leg lengths

Assess if Discrepancy is above or below the knee

Galleazi Test

  • with knees at 90 & hips & ankle at 45° (hips at 90 in children)
  • flex knees to 90° with hips & ankles at 45°
  • put malleoli at same level
    • if unable, due to hindfoot asymmetry
    • makes test inaccurate
  • note:
    • level of knees
    • parallelism of femora & tibia
  • comment
    • knees at different levels
    • tibias parallel so discrepancy not above knee (i.e. in tibia)
    • femora parallel so discrepancy not below knee le. (in femur)

Assess Shortening Above Greater Trochanter

Bryant’s triangle

  • identify ASIS with thumb & tip of greater trochanter with forefinger
  • comment
    • difference in distance between ASIS & GT suggests discrepancy proximal to GT
    • assess perpendicular distance between points with fingers of other hand
  • comment
    • when Bryant’s triangle constructed, perpendicular distance between points is different by (x) fingerwidths
    • if reduced, construct Roser-Nelaton’s line

Nélaton’s line

    • Patient lying on sound side
    • ASIS to ischial tuberosity by the shortest route
    • normally crosses the top of the greater trochanter
    • Compare one side with the other

Schoemaker’s line

    • supine
    • line from greater trochanter thru ASIS
    • projection from each side should cross proximal to umbilicus
    • if shortening above gr trochanter then lines will cross below umbilicus

Klisic’s line

    • GT to ASIS
    • Should point to umbilicus
    • If DDH
      • Points to opposite ASIS

Power

  • abductors gluteal nerves
  • adductors obturator nerve
  • flexors femorla nerve

Neurovascular

Impingement test

  • was carried out by passively moving the hip joint in flexion (to 90°), internal rotation, & adduction. The test was regarded as being positive on reproduction of groin pain

FABER (Flexion, ABduction, External Rotation) test

  • the hip joint was passively flexed, abducted, & externally rotated with the knee flexed (figure-of-four-position). The ankle was brought to rest just above the contralateral knee & slight pressure was applied to the medial side of the knee, approximating it to the examination table. The test was regarded as being positive on reproduction of groin pai

SI Joint

  • Lateral pelvic compression for SIJ
  • FABER (Patrick) test
    • Flexion, abduction & external rotation (patient supine, leg in figure 4). One hand presses on the knee, the other stabilizes the contralateral ASIS. Pain should be in the SIJ to be positive. Pain medially = iliopsoas tendinitis
  • Gaenslin’s test
    • patient is supine, with the buttock of the involved side projecting off the bed. The hips are maximally flexed, then the same leg is allowed to drop over the side of the table into full extension (with the other leg still in full flexion). Pain in the SIJ is positive

On side

  • Ober’s test (JBJS 1936;18:105-10) for iliotibial tract
    • test for abduction contracture
      • abduction hip & flex knee to relax the ITB
      • Then allow hips to come together
      • If they do = no abduction contr
  • Abductor power
    • active abduction
    • palpate contraction
    • grade power
  • hip extension?
  • Femoral stretch test

Prone

  • avoid with significant pain or FFD
  • Gluteal bulk
    • look at bullock contours
  • Rotation in extension
    • fix pelvis
    • place hand across SI joints
    • flex knee to 90°
    • Rotate the hip till the GT is maximally prominent, the angle of the tibia = version
    • Tibial torsion
      • Normally up to 20° of external torsion is present. To measure, the patient lies prone, knees flexed 90°. This aligns the knee flexion axis perpendicular to the bed. The angle that the medial boarder of the foot makes with the thigh is the tibial torsion
  • Buttock wasting may be noted
  • Rotational profile
  • Elys

  • spine
    • A spinal cause for the patient’s pain must be considered, & if present, its proportional cause of the symptoms
    • A mobile, pain-free spine is required if hip arthrodesis is proposed
    • Conversely, back pain may be an indication for taking down an otherwise symptomless hip fusion & conversion to a total hip replacement
    • Ling
      • has described a helpful sign to differentiate spinal from hip pain
      • supine patient is asked to elevate the lower limb with the knee extended until pain prevents further movement. The examiner then places his/her hand under the distal leg & asks the patient to press down on the hand
      • If the pain eases, the hip is probably the source
  • Knee
  • Abdomen (for AAA)
  • PR (for prostate)
  • Other large joints
    • Fusions or fixed deformities in either lower limb must be considered in planning joint replacement surgery if recurrent deformity is to be avoided

Note on Pelvic Obliquity

  • Fixed
    • i.e. at spine / lumbosacral junction
    • may compensate by holding lower limb of lower side flexed or raise heel of higher side
    • will not correct with blocks (patient may just ↑ compensation mechanism)
    • will not correct with sitting or forward flexion
  • If due to paraspinal spasm from thoracic spine pain: will not correct with sitting or blocks but scoliosis should correct with forward flexion?
  • Intrapelvic (e.g. one hemipelvis smaller)
  • will apparently correct with blocks under lower side (brings iliac crests to same level) but not with sitting (ischial tuberosities at same level)
  • Compensatory infrapelvic
    • will correct with blocks & sitting
  • Fixed infrapelvic (hip abduction or adduction contracture)
  • may hold lower limb of lower side flexed or raise heel of higher side
  • will not correct with blocks (patient may just ↑ compensation mechanism)
  • will correct with sitting or forward flexion
  • Patrick’s test is occasionally useful for detection of early arthritis in the hip joint. To test the right hip, both hips & knees are flexed. Place the right foot on the left knee & gently press down the right knee. Pain during the manoeuvre is regarded as one of the first signs of osteoarthritis of the hip joint

Iliospoas

  • Test in sitting position
  • Place hand on thigh & ask patient to left the thigh against resistance

Tests for contractures

  • Ober’s test for iliotibial tract
    • Pain may occur over the GT or lateral femoral condyle. The patient is lateral, the knee is flexed 90° & then hip adducted 40° & extended to its limit. The pelvis is stabilized with the other hand, then the leg is adducted from this position. Inability to adduct beyond the midline indicates a tight iliotibial band
  • Ely’s test for tight rectus femoris
    • patient is prone, knee is maximally flexed. If the rectus is tight then this will cause the hip to passively flex (seen as the buttock rising)
  • Tripod sign for tight hamstrings
    • patient sits, knees flexed to 90°. The examiner then passively extends the knee fully. If the hamstring is tight then there will be passive extension of the hip which causes the patient to lean backwards, such that the patient needs to support themselves with their hand behind their back. (Differential Diagnosis sciatica)
  • Phelps test for tight gracilis
    • patient is prone, knees fully extended, passively abduct the hips as much as possible. Repeat with the knee flexed. If abduction is ↑ then the gracilis is tight
  • Piriformis syndrome
    • piriformis test is for sciatic type pain due to compression of the nerve as it passes through the muscle (15% people). The patient is lateral, the pelvis is stabilized, the hip flexed 45°, knee flexed 90°. The hip is the internally rotated. Pain in the muscle is due to tightness, sciatic type pain is indicative of piriformis syndrome
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