HIP

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HIP

Précis of the Hip Assessment ^*

Observation

Examination

Active movements (supine)

Hip lateral rotation

Hip medial rotation

Passive movements (supine) as in active movements (if necessary)

Resisted isometric movements (supine)

Hip medial rotation

Hip lateral rotation

Special tests (supine)

Patrick’s test

Flexion-adduction test

Trendelenburg’s sign

Anterior labral tear test

Posterior labral tear test

Leg length tests

Weber-Barstow maneuver

Sign of the buttock

Rectus femoris contracture test

90-90 straight leg raise test

Abduction-adduction contracture tests

Noble compression test

Reflexes and cutaneous distribution (supine)

Peripheral nerves

Joint play movements (supine)

Lateral distraction

Palpation (supine)

Active movement (prone)

Passive movement (prone)

Resisted isometric movements (prone)

Hip medial rotation (if not previously done)

Hip lateral rotation (if not previously done)

Knee flexion (if not previously done)

Knee extension (if not previously done)

Special tests (prone and side lying)

Prone lying test

Reflexes and cutaneous distribution (prone)

Palpation (prone)

Diagnostic imaging

^*The examination is shown in an order that limits the amount of movement the patient must do but ensures that all necessary structures are tested. After the rest of the examination has been completed, the examiner may ask the patient to perform the appropriate functional test. Also, after any assessment, the patient should be warned that symptoms may be exacerbated by the assessment.

SELECTED MOVEMENTS

ACTIVE MOVEMENTS

Figure 10-1 Active movements of the hip. A, Flexion. B, Extension. C, Abduction. D, Adduction. E, Rotation in the supine position. F, Rotation in the prone position. (A, E, and F redrawn from Beetham WP, Polley HF, Slocumb CH, Weaver WF: Physical examination of the joints, pp 134, 137, 138, Philadelphia, 1965, Saunders.)

GENERAL INFORMATION

The active movements of the hip are performed with the most painful ones being done last. Some movements are done with the patient supine and some with the patient prone. If the history indicates that repetitive movements, sustained postures, or combined movements have caused symptoms, the examiner should make sure these movements are tested as well. For example, sustained extension of the hip may provoke gluteal pain in the presence of claudication in the common or internal iliac artery.¹

During the active movements, the examiner should always watch for the possibility of muscle or force couple imbalances that lead to abnormal muscle recruitment patterns. For example, during extension, the normal pattern is contraction of the gluteus maximus followed by the erector spinae on the opposite side and the hamstrings (depending on the load being extended). If the erector spinae contract first, the pelvis will rotate anteriorly, and hyperextension of the lumbar spine will occur.

During the active movements, the examiner should watch the pelvis and the anterior superior iliac spines (supine) and posterior superior iliac spines (prone). During hip movement, if the pelvic force couples are normal, the pelvis and anterior superior iliac spines (ASISs) and posterior superior iliac spines (PSISs) will not move. If they do, it may be an indication of muscle imbalance.

PATIENT POSITION

The patient is supine or prone, depending on the movement to be tested.

EXAMINER POSITION

The examiner is positioned at the patient’s side to observe the movements and to palpate the ASISs (in supine) or the PSISs (in prone).

Flexion (in Supine)

The patient is asked to flex the hip up toward the chest as far as possible.

INDICATIONS OF A POSITIVE TEST

Hip flexion normally ranges from 110º to 120º with the knee flexed. If the ASIS on the test side begins to move, the movement is stopped, because pelvic rotation is occurring rather than hip flexion. The patient’s knee is flexed during the test to prevent limitation of movement caused by hamstring tightness. If the range of movement is less than the above normal ROM or is less than the unaffected leg, the test result is positive.

CLINICAL NOTES/CAUTIONS

• During the movement, if the abdominals are weak, the pelvis will rotate anteriorly. If the hip flexors are weak, the pelvis will rotate posteriorly.

• If sharp groin pain is elicited on flexion and medial rotation (combined movement), the pain may be the result of anterior impingement of the femoral neck against the acetabular rim.2–6

Abduction (in Supine)

Before asking the patient to do the abduction or adduction movement, the examiner should make sure the pelvis is “balanced” or level, with the ASISs level and the legs perpendicular to a line joining the two ASISs. This ensures the angles measured for adduction and abduction are measured from the same starting point for each leg. The patient then is asked to abduct one leg at a time.

INDICATIONS OF A POSITIVE TEST

Hip abduction normally ranges from 30º to 50º. Abduction is stopped when the pelvis begins to move. If the range of movement is less than normal or is less than the unaffected leg, the test result is considered positive. Pelvic motion is detected by palpation of the ASIS and by telling the patient to stop the movement as soon as the ASIS on either side starts to move. Normally, the ASIS on the movement side elevates; the opposite ASIS may drop or elevate. When the patient abducts the leg, the opposite ASIS tends to move first; with an adduction contracture, this occurs earlier in the range of movement. If lateral rotation and slight flexion occur early in the abduction movement, the tensor fascia lata may be stronger and the gluteus medius and gluteus minimus weak. If lateral rotation occurs later in the ROM, the iliopsoas or piriformis may be overactive. If the pelvis tilts up at the beginning of movement, the quadratus lumborum is overactive. All these movements demonstrate imbalance patterns.

Adduction (in Supine)

Hip adduction is measured from the same starting position as abduction. The patient is asked to adduct one leg over the other while the examiner makes sure the pelvis does not move. Adduction also may be measured by asking the patient to abduct one leg and leave it abducted, as the examiner makes sure the test leg is 90º to a line formed by the ASISs. The other leg then is tested for the amount of adduction present. The advantage of this method is that the test leg does not have to be flexed to clear the other leg before the adduction movement is done.

INDICATIONS OF A POSITIVE TEST

Hip adduction normally is 30º. When the patient adducts the leg, the ASIS on the same side moves first. The movement occurs earlier in the ROM if an abduction contracture is present.

Rotation (in Supine)

In the supine position, the patient simply rotates the straight leg on a balanced pelvis. Turning the foot or leg outward tests lateral rotation; turning the foot or leg inward tests medial rotation. The examiner can then measure hip rotation by having the patient hold the foot in plantigrade and measuring the angle of the foot to a vertical line from the middle of the heel. In another supine test, the patient is asked to flex both the hip and knee to 90º, as the patient would do when tested in sitting.⁷ When this method is used, it must be recognized that having the patient rotate the leg outward tests medial rotation, whereas having the patient rotate the leg inward tests lateral rotation.

INDICATIONS OF A POSITIVE TEST

Medial rotation normally ranges from 30º to 40º and lateral rotation from 40º to 60º. If the ASIS begins to move, the movement is stopped, because pelvic rotation is occurring rather than hip rotation. If the range of movement is less than normal or less than in the unaffected leg, the test result is considered positive.

Extension (in Prone)

The patient is asked to extend the hip.

INDICATIONS OF A POSTIVE TEST

Extension of the hip normally ranges from 0º to 15º. If the range of movement is less than this or less than in the unaffected leg, the test result is positive. The examiner must be careful to differentiate between hip extension and spinal extension. Patients often have a tendency to extend the lumbar spine at the same time they extend the hip, giving the appearance of increased hip extension. Elevation of the pelvis or movement of the PSIS superiorly indicates that the patient has passed the end of hip extension.

Rotation (in Prone)

With the patient prone, the pelvis is balanced by aligning the legs at right angles to a line joining the PSISs. The patient then flexes the knee to 90º. Medial rotation is tested when the leg is rotated outward, and lateral rotation is tested when the leg is rotated inward. Usually, this method (prone) is used to measure hip rotation, because it is easier to measure the angle during the test.

INDICATIONS OF A POSITIVE TEST

Medial rotation normally ranges from 30º to 40º, and lateral rotation from 40º to 60º. If the range of movement is less than these amounts or less than the unaffected leg, the test result is considered positive.

SPECIAL TESTS FOR HIP PATHOLOGY 8–13

Relevant Special Tests

Patrick’s test (flexion, abduction, and external rotation [FABER] or figure-four test)

Flexion-adduction test

Trendelenburg’s sign

Anterior labral tear test (flexion, adduction, and internal rotation [FADDIR] test)

Posterior labral tear test

Definition

Historically, the diagnosis of hip injury and pathological conditions has been limited to diagnoses such as bursitis, arthritis, or genetic dysplasias. Recently, new imaging and surgical techniques have widened the range of pathological conditions routinely diagnosed in the hip region. Injuries to the labrum and the cartilage around the hip have become potential sources of symptoms and dysfunction. The larger scope of pathological conditions in and around the hip joint has made the diagnosis of such conditions much more challenging for the clinician.

Suspected Injury

Adductor tendinopathy

Anterior hip instability

Anterior-superior impingement syndrome

Posterior-inferior impingement

Avascular necrosis

Hip flexor/adductor strain

Iliopsoas tendinitis or spasm

Labral tears (hip)

Legg-Calvé-Perthes syndrome

Slipped capital femoral epiphysis

Snapping hip syndrome

Epidemiology and Demographics

The epidemiology and demographics of patients with a pathological condition of the hip vary greatly, depending on the tissues injured or the pathology involved.

• Osteoarthritis affects 10% to 25% of the population over age 55.

• Osteonecrosis can occur in people of any age, but it is most common in people in their 30s, 40s, and 50s.

• In children, the most common cause of hip pain is acute transient synovitis. The incidence of slipped capital femoral epiphysis is about 6.1 per 10,000 in boys and 3 per 10,000 in girls. The incidence of Leg!g-Calvé-Perthes disease is about 1.5 to 5 per 10,000.

• In newborns, the prevalence of developmental dysplasia of the hip (DDH) has been reported in screened populations at rates of 2.5 to 20 per 1000 births; however, it reaches 40 to 90 per 1000 births in some communities.

Relevant History

Previous musculoskeletal injuries can contribute to biomechanical changes and stresses placed on the hip region. Ankle, knee, abdominal, groin, thoracic, and lumbar spine injuries all can lead to movement compensations, which change the normal mechanics of the hip. Over time, these changes result in abnormal wear on hip joint structures, leading to deterioration and degeneration.

Relevant Signs and Symptoms

In the elderly, arthritis is a common source of hip pain. Patients with hip osteoarthritis experience two distinct types of pain: a dull, aching pain, which becomes more constant over time, and short episodes of a more intense, often unpredictable, emotionally draining pain. Both of these pains can occur at the same time. Hip pain tends to be on the medial and anterior aspect of the hip. Posterior and lateral pain often is referred from the lumbar spine or sacroiliac joints. In children, pathological conditions of the hip can be pain free or can manifest as pain in the knee, especially on the medial side. A child with a pathological condition of the hip commonly presents with a limp and Trendelenburg weakness.

Mechanism of Injury

The mechanism of injury plays a large role in the differential diagnosis of patients with acute hip and thigh pathological conditions and a lesser role for chronic pain. Acute traumatic injuries often can be traced back to the movement or motion that occurred at the time of injury. Muscle strains around the hip and thigh region often occur during eccentric deceleration movements. Trauma to the hip may produce a fracture, subluxation, dislocation, compartment syndrome, muscle strain, contusion, or labral tear.

A gradual onset of symptoms often indicates tendinopathy, bursitis, hernia, osteitis pubis, femoral acetabular impingement, or a stress fracture. An insidious onset often indicates degenerative joint disease or referred pain. Acute symptoms generally are the result of trauma to the tissue; chronic or insidious hip pain may be associated with a previous injury to the hip or lower extremity. Compensation begins to occur, and eventually the body breaks down around the hip region.

PATRICK’S TEST (FLEXION, ABDUCTION, AND EXTERNAL ROTATION [FABER] OR FIGURE-FOUR TEST)14–16

Figure 10-2 Patrick’s test (FABER or figure-four test) for detecting limitation of motion in the hip. (Redrawn from Beetham WP, Polley HF, Slocumb CH, Weaver WF: Physical examination of the joints, p 139, Philadelphia, 1965, Saunders.)

To assess for pathological conditions of the hip joint, iliopsoas spasm, or sacroiliac joint dysfunction.

SUSPECTED INJURY

• Hip joint pathological conditions

• Iliopsoas spasm

• Sacroiliac joint dysfunction

PATIENT POSITION

The patient is supine. The test leg is flexed, and the contralateral leg is straight.

EXAMINER POSITION

The examiner stands adjacent to the patient’s test hip.

One of the examiner’s hands is placed on the knee of the test limb. The examiner’s other hand is placed on the contralateral ASIS and will be used to stabilize the contralateral pelvis. The examiner places the patient’s test leg so that the foot of the test leg is on top of the knee of the opposite leg. The examiner then slowly lowers the knee of the test leg toward the examining table.

INDICATIONS OF A POSITIVE TEST

A negative test result is indicated if the knee of the test leg falls to the table or at least is parallel to the opposite leg. A positive test result is indicated if the knee of the test leg remains above the opposite straight leg. If the result is positive, the test indicates that the hip joint may be affected, that iliopsoas spasm may be present, or that the sacroiliac joint may be affected (if the patient has posterior pain).

CLINICAL NOTE/CAUTION

• FABER is the position of the hip when the patient begins the test. This test sometimes is referred to as Jansen’s test.

RELIABILITY/SPECIFICITY/SENSITIVITY ^15,¹⁶

Reliability: Test-retest ICC: 0.93

Intrarater: 0.87

FLEXION-ADDUCTION TEST ^17,¹⁸

Figure 10-3 The normal hip permits the ipsilateral knee to move convincingly across the midline of the body without rolling the pelvis. The knee should enter zone 1 by overlapping the opposite hip and, in a youthful or supple patient, reaches a position lateral to the thigh. Progressive pathological changes in the hip limit adduction to zones 2 and 3, with the production of pain by this maneuver. (Redrawn from Woods D, Macnicol M: The flexion-adduction test: an early sign of hip disease, J Pediatr Orthop 10:181, 2001.)

To assess for pathological conditions of the hip in older children and young adults.

SUSPECTED INJURY

• Slipped capital femoral epiphysis

• Anterior hip impingement of the adductor longus, pectineus, iliopsoas, sartorius, or tensor fascia lata

• Anterior labral pathological conditions

PATIENT POSITION

The patient is supine, and the contralateral lower extremity should be straight.

EXAMINER POSITION

The examiner stands adjacent to the pelvis on the side of the test hip.

One of the examiner’s hands grasps the patient’s knee. The examiner flexes the patient’s hip to at least 90° with the knee flexed. The examiner then adducts the flexed leg.

INDICATIONS OF A POSITIVE TEST

Normally, the knee passes over the opposite hip without pelvic movement. In hips with a pathological condition, adduction is limited and accompanied by pain or discomfort, and the pelvis rotates laterally toward the straight leg.

CLINICAL NOTE/CAUTION

• Maitland ¹⁸ called this test the quadrant, or scouring, test if the hip was fully flexed. He believed that the test stressed or compressed the femoral neck against the acetabulum, or pinched the adductor longus, pectineus, iliopsoas, sartorius, or tensor fascia lata.

RELIABILITY/SPECIFICITY/SENSITIVITY

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