Examination of the Hip

Prof. Mamoun Kremli

Lina Serhan

Orthopedic Examination System

The systematic approach to orthopedic examination includes:

• Look - Visual inspection
• Feel - Palpation
• Move - Range of motion assessment
• Special tests - Specific diagnostic maneuvers

Look

General Assessment

• General patient observation: Patient’s overall condition and comfort level
• Local hip-thigh-lower limb assessment:
  • Position and alignment
  • Major deformities and swelling
  • External devices: casts, splints, traction, dressings

Anatomical Local Assessment

• Skin: Swelling, scars, color, hair distribution, dryness
• Subcutaneous tissue: Lymph nodes, veins, nerves, tendons
• Muscles: Bulk, wasting, fasciculations (twitches)
• Bones: Landmarks, swelling, angulation, deformity
• Joints: Position, swelling, redness

Important: Always examine the posterior aspect - all patients have a posterior aspect!

General Patient Position Examples

Normal Positioning

• Patient lying comfortably in bed, not in pain

Abnormal Positioning Examples

Left hip pathology:

• Patient lying uncomfortably in bed, in pain
• Left hip abducted and externally rotated

Bilateral hip pathology:

• Patient lying uncomfortably in bed
• Right hip adducted and internally rotated
• Left hip abducted and externally rotated

Severe bilateral involvement:

• Patient sitting uncomfortably in wheelchair
• Both hips adducted (scissoring)
• Left hip extended

Local Hip-Thigh-Lower Limb Assessment

Position Assessment

• Abduction/Adduction
• Flexion/Extension
• External/Internal Rotation

Postural Changes

• Lumbar lordosis: Increased curvature may compensate for hip pathology

Major Deformities and Swelling

• Lateralized contour
• Asymmetrical skin folds
• Wide perineum
• Masses

External Devices

Immobilization:

• Casts
• Splints

Traction:

• Skin traction
• Skeletal traction

Orthotics and Dressings:

• Orthotics:
  • AFO (Ankle-Foot Orthosis)
  • KAFO (Knee-Ankle-Foot Orthosis)
  • HKAFO (Hip-Knee-Ankle-Foot Orthosis)
• Dressings: Various types and applications

Anatomical Local Examination (Detailed)

• Skin: Swelling, scars, color, hair, dryness
• Subcutaneous: Lymph nodes, veins, nerves, tendons
• Muscles: Quadriceps/Gluteii - bulk, wasting, fasciculations
• Bones: Landmarks, swelling, angulation, deformity
• Joints: Position (hip joint too deep to visualize swelling)

Feel

Palpation Assessment

• Tenderness:

  • Generalized: Diffuse tenderness
  • Localized: Specific points of tenderness

• Temperature: Compare distal/proximal and right/left sides

• Anatomical structures:

  • Skin: Dryness, hypo/hyperesthesia, scars
  • Subcutaneous: Lymph nodes, nerves, vessels, tendons, nodules
  • Muscles: Tone, bulk, fasciculations, gaps, tenderness
  • Bone: Landmarks (ASIS, Greater Trochanter, Ischial Tuberosity), tenderness, masses, crepitus
  • Joint: Swelling, effusion, crepitation, synovial thickening, joint line tenderness (hip joint too deep to elicit)

Move

Movement Assessment Principles

• Active vs. Passive: Start with active movement to screen for pain
• Passive assessment: Used when needed to evaluate:
  • Painless vs. painful range of motion
  • Muscle power assessment

Critical Technical Considerations

• Differentiate true hip joint motion from pelvic motion
• Stabilize the pelvis in neutral position

Important note: Patients with fixed hip flexion may appear to have full range when supine by tilting the pelvis forward, which creates increased lumbar lordosis.

Range of Motion Assessment

Flexion

• Initial position: Determined by Thomas Test
• Procedure:
  1. Check for lumbar lordosis
  2. Flex opposite hip fully
  3. Lumbar lordosis disappears
  4. Check hip position
  5. Flex hip to assess range

Range of motion: Flexion from 30° to 90°

• From 30° fixed flexion
• To 90° flexion

Extension

• Normal range: 30°
• Positions for assessment:
  • Lateral position

• Prone position

Important: In presence of fixed flexion deformity, extension is already in “minus” range and doesn’t require assessment.

Abduction/Adduction

• Normal ranges:

  • Abduction: 45°
  • Adduction: 15°

• Pelvic stabilization techniques:

  • Perform motion on both hips simultaneously
  • Anchor knee of opposite side over examination table edge
  • Palpate ASIS to assess pelvic motion

Both hips simultaneously:

• Stabilizes pelvis and compares both sides
• Can be performed in flexion or extension

Flexion

Extension

Alternative stabilization: On both hips simultaneously Stabilize pelvis and compare both sides

Edge of table technique: Stabilizing the other hip at the edge of couch

ASIS palpation technique: Holding ASIS to assess beginning of pelvic motion

Internal/External Rotation

• Must stabilize pelvis to prevent pelvic motion
• Best technique: Perform on both hips simultaneously

Assessment positions:

1. Supine with hips extended:

   • Observe patella orientation

2. Supine with hips flexed:

   • Use leg as pointer

3. Prone with hips extended:

Special Tests

Thomas Test

Positive Thomas test in neonates and young children is normal

Purpose: Detect fixed flexion deformity of the hip

Procedure:

• Assess lumbar lordosis before testing
• Precaution: When knee has fixed flexion deformity, keep knee outside edge of couch

Precaution ⇒ when knee has fixed flexion deformity Solution ⇒ keep knee outside edge of couch

Trendelenburg Test

Purpose: Assess hip abductor strength and stability

Principle: Testing the hip the patient is standing on

• Normal: Pelvis tilts down on weight-bearing hip (performed by hip abductors)
• Positive: Pelvis on non-weight-bearing hip tilts down AND trunk tilts to weight-bearing side

Causes of Positive Trendelenburg

• Weak hip abductors:
  • Paralyzed/wasted muscles
• Mechanically inefficient hip abductors:
  • Reduced distance between origin and insertion (e.g., coxa vara)
• Unstable pivot of motion:
  • Hip subluxation/dislocation
• Inhibited hip abductors:
  • Painful to move (trauma, infection, irritation, tumor)
• Reduced range of motion:
  • Hip incongruency, stiffness, osteoarthritis

Note: Almost any hip disease can cause a positive Trendelenburg test

Leg Length Assessment

Galleazzi Test

Purpose: Detect leg length discrepancy

Technique: Both heels must be at the same level

Leg Length Measurements

Apparent Length:

• Measurement: Midpoint to medial malleolus
• Affected by: Pelvic tilt

Both lower limbs - Should be Parallel

True Length:

• Measurement: ASIS to medial malleolus
• Not affected by Pelvic tilt

Position of both lower limbs - Should be identical

Additional measurement examples:

Neonatal Examination for Developmental Dysplasia of the Hip (DDH)

Ortolani Test

Purpose: Reduces a dislocated hip

• Expected finding: Feel a “clunk” (not a “click”)

Barlow Test

Purpose: Dislocates a reduced hip

• Expected finding: Feel a “clunk” (not a “click”)

Combined Ortolani/Barlow technique:

Gait Assessment

Normal Gait Cycle

• Stance phase: 60% of gait cycle
  • Heel strike
  • Foot flat - mid-stance
  • Push off

• Swing phase: 40% of gait cycle
  • Acceleration
  • Mid-swing
  • Deceleration

Abnormal Gait Patterns

Gait Type	Explanation
Normal	Normal stance and swing phases
Antalgic	Painful to weight-bear - short stance phase
Lurch	Shortening - painless limping - normal stance period
Circumduction	Stiff hip - motion of pelvis compensates
High Step	Foot drop - more hip & knee flexion needed to free toes from ground
Tip-toe	Heel off the ground -l4/l5

Summary

Systematic approach to clinical examination in orthopedics:

• Look, Feel, Move, Special tests
• Sub-system helps ensure no steps are forgotten

Key considerations for hip examination:

• Important exposure considerations
• In “Move” assessment, must stabilize pelvis
• Special tests: Thomas, Trendelenburg, instability tests, length measurements
• Gait assessment is essential