Introduction

The hip is a complex joint that is surrounded by deep muscle and ligamentous tissues. Problems of the hip are often not recognized as the source of symptoms in a timely fashion. The time delay until treatment leaves patients in search of answers, which confounds and confuses the clinical picture after other treatments have been rendered. The modern understanding of other joints (e.g., knee, shoulder) developed rapidly as arthroscopic and clinical evaluations became structured, and the physical examinations became more inclusive as this understanding grew. At this time, the hip is being replaced, resurfaced, reconstructed, and reshaped as never before to provide improved patient function and to meet the expectations of both the patient and the surgeon.

The physical examination of the adult and adolescent hip continues to evolve as a product of biomechanical and surgical advancements, and it is a comprehensive assessment of three distinct tissue types that interrelate in a static and dynamic fashion. A thorough physical assessment is critical to the development of treatment options, interoperative considerations, and future diagnostic strategies. Hip motion occurs in 6 degrees of freedom in a symphony of musculotendinous, ligamentous, and osseous balance. To appreciate this achievement of function, it is important to understand the balance and interrelationship that each system has with the others. The hip will optimally be recognized early during the presentation of the complaint, but this is dependent on a consistent way of interpreting these interrelationships. The goal of this chapter is to do three things: 1) to identify key tests to be routinely performed during the physical examination of the hip; 2) to describe how these critical tests are performed, and to begin a discussion of the biomechanical importance of these assessments.

Ideally, orthopedic surgeons are familiar with an organized basic hip examination that can be performed quickly and efficiently to screen the hip, back, abdominal, neurovascular, and neurologic systems and to find the comorbidities that coexist with complex hip pathology. It is important that the physical examination of the hip is inclusive enough to rule out other joints as the primary cause of a complaint. Each examination or physical evaluation has a specific way of being performed, although interobserver consistency and practice are some of the most important aspects of the evaluation.

The order of the examination is one that is easy on the patient and on the flow of the physician and an assistant, if available. A physical examination is dictated by the pertinent history and especially by the age of the patient; any history of trauma or other related symptoms of the back; or neurologic, abdomen, or lower-extremity complaints. Some hint of the presence of an intra-articular cause versus an extra-articular one is assimilated by the presenting location. A review of the patient’s history is obtained, which includes the history of the present condition, the date of the onset, the presence or absence of trauma, the mechanism of injury, the pain, the location, and factors that increase or decrease any associated pain. The presence or absence of popping is also beneficial to assess. Potential sources of disruption of the vascular supply of the femoral head are assessed, including metabolic disorders such as abnormalities that involve lipids, the thyroid, homocysteine, and clotting mechanisms. The patient’s social history can also affect the blood supply to the femoral head; therefore, the presence of or exposure to tobacco, alcohol, steroids, and altitude issues are routinely recognized.

Past tests or evaluative studies are recorded, which may include magnetic resonance imaging or arthrography, x-rays, laboratory results, or previous consults. Current limitations that involve the activities of rotation (e.g., getting into or out of a bathtub or car, activities of daily living, jogging, walking, stairs) will help to detect and direct possible further intra- or extra-articular assessment. The presence of associated complaints (e.g., abdominal or back pain, numbness, weakness, cough or sneeze exacerbation) helps to rule out thoracolumbar issues, which are occasionally confused with the hip as a partial or dominant cause of complaint. Finally, the goals of treatment are discussed and reviewed with the patient.

A Modified Harris Hip Score is a general guide to establishing gross levels of function. Other hip scores have been outlined with quantifications in more specific patient populations, such as the Non-Arthritic Hip Score, the Hip Disability and Osteoarthritis Outcome Score, the Musculoskeletal Function Assessment, the Short Form 36, and the Western Ontario and McMaster University Osteoarthritis Index. An ongoing consensus score is under way by the Multicenter Arthroscopy of the Hip Outcomes Research Network (MAHORN) Group to add an internationally accepted score; this is in its final stages of testing. This test will help to compare outcomes and provide a consensus for comparison among examiners as well as among different centers. The use of a verbal analog score is also subjectively useful.

The technique of physical examination

Hip complaints may present in a complex fashion that requires a thorough assessment to separate the comorbidities that frequently exist. The technique of physical examination is dependent on the examiner’s experience and efficiency. Adequate time with the patient is scheduled to allow for a comprehensive assessment. Most hip examiners have a structured examination that is generally used in all cases and that helps to differentiate the specific pathologies upon presentation. The physical examination will be fine tuned and directed through the review of the history of present illness.

As with other extremity examinations, loose-fitting clothing around the waist that allows for access and patient comfort is helpful. An assistant to record the examination is useful for the accuracy and documentation of the examination. A standardized written form is helpful for thoroughness, especially when first starting a comprehensive hip evaluation or when the presentation is complex.

A vast number of tests exist for the examination of the hip, and it is not necessary to include them all in a single evaluation. Therefore, components of the examination can be classified as basic, which should always be included, and specific, which should be used as needed to define a specific diagnosis or combination of diagnoses. The most common examinations as determined by the MAHORN Group are shown in Table 6-1. This is a consensus among hip specialists to identify basic and specific components of the physical examination.

Table 6–1 Most Frequent Tests Performed by Mahorn Group Specialists

The standing examination of the hip

As the patient stands, a general point of pain is noted with one finger, and this can usually help to direct the examination. Pain in the groin region leads to the suspicion of an intra-articular problem, and lateral-based pain is primarily associated with both intra- and extra-articular aspects. Posterosuperior pain requires a thorough evaluation for differentiating hip and back pain; back issues are many times noted concomitantly with musculotendinous hip pathology. The shoulder height and iliac crest heights are noted to evaluate leg-length discrepancies. The general body habitus is assessed, and issues of ligamentous laxity are determined by the middle-finger test or hyperextension of the elbows or knees. Structural versus nonstructural scoliosis is differentiated by forward bending, and the degree of spinal motion is recorded.

Gait abnormalities often help to detect hip pathology as a result of the hip’s role in supporting the body weight. Joint stability, preservation of the labrum and articular cartilage, and proper functioning of the hip joint involve three biomechanical and anatomic geometries of the femur and the acetabulum: femoral head–neck offset, acetabular anteversion, and acetabular coverage of the femoral head. These relationships are important for the transfer of dynamic and static load to the ligamentous and osseous structures. Hip congruency (i.e., the rotation of the femoral head within the acetabular–labral complex) and articular stabilization (i.e., limiting translations of the femoral head within the acetabular–labral complex) are also regulated by the ligaments and muscles that cross the hip joint. The ligamentous capsule must maintain the stability of the hip, whereas the musculature of the lower limbs produces the forces that are required during ambulation.

The patient is taken into the hallway so that a full gait of six to eight stride lengths can be observed (video). Key points of gait evaluation include foot rotation (i.e., the internal/external progression angle), pelvic rotation in the X and Y axes, stance phase, and stride length. The gait viewed from the foot-progression angle will detect the possibility of osseous or static rotatory malalignment that exists with increased or decreased femoral anteversion as compared with a capsular or musculotendinous issue. The knee and thigh are observed simultaneously to assess for any rotatory parameters. The knee may want to be held in either the internal or external rotation to allow for proper patellofemoral joint alignment, but this may produce a secondary abnormal hip rotation. This abnormal motion is usually present in cases of severe increased femoral anteversion that precipitates a battle between the hip and knee for a comfortable position, which will affect the gait.

Pelvic rotation is assessed by noting iliac crest rotation and terminal hip extension. On average, a normal gait requires 8 degrees of hip rotation and 7 degrees of pelvic rotation, for a total rotation of 15 degrees. The pelvic wink is demonstrated by an excessive rotation in the axial plane toward the affected hip, thus producing extension and rotation through the lumbar spine to obtain terminal hip extension. This winking gait is associated with laxity or hip-flexion contractures, especially when seen in combination with increased lumbar lordosis or a forward-stooping posture. Excessive femoral anteversion or retroversion can affect a wink on terminal hip extension, because the patient will try to create greater anterior coverage with a rotated pelvis. Injury to the anterior capsule can also contribute to a winking gait.

The normal gait can be broken down into two phases: the stance phase (60%) and the swing phase (40%). During the stance phase, the body weight must be supported by a single leg with the gluteus maximus, vasti, gluteus medius, and gluteus minimus providing the majority of the support forces. The maximum ground reactive force occurs during heel strike at 30 degrees of hip flexion. A shortened stance phase can be indicative of neuromuscular abnormalities, trauma, or leg-length discrepancies. The Abductor Deficient gait is an unbalanced stance phase that is attributed to abductor weakness and that is often referred to as an abductor lurch. The Abductor Deficient gait may present in two ways: with a shift of the pelvis away from the body (i.e., a “dropping out” of the hip on the affected side) or with a shift of the weight over the adducted leg (i.e., a shift of the upper body “over the top” of the affected hip). The antalgic gait is characterized by a shortened stance phase on the painful side, thus limiting the duration of weight bearing (i.e., a self-protecting limp caused by pain). A short leg gait is noted by the drop of the shoulder in the direction of the short leg.

In addition to body habitus and gait evaluation, the Single Leg Stance Phase test is performed during the standing evaluation of the hip. The Single Leg Stance Phase test is performed on both legs, with the nonaffected leg examined first to establish a baseline reference for the patient’s function. As the patient lifts and holds one foot off the ground for 6 to 8 seconds, the contralateral hip abductor musculature and neural loop of proprioception are being tested. The pelvis will tilt toward the unsupported side if the musculature is weak or if the neural loop of proprioception is disrupted. Normal dynamic midstance translocation is 2 cm during a normal gait pattern; therefore, the rationale is that a shift of more than 2 cm constitutes a positive Single Leg Stance Phase test. Table 6-2 provides an outline of the standing examination.

Table 6–2 Standing Examination Associations

The seated examination of the hip

The seated hip examination consists of a thorough neurologic and vascular examination (video). The need to check the fundamentals would appear obvious even in healthy individuals. Criteria exist for both the care of the patient and coding. The posterior tibial pulse is checked first, any swelling of the extremity is noted, and an inspection of the skin is performed at this time. A straight-leg raise test is then performed by having the patient extend the knee into full extension. This test is helpful for detecting radicular neurologic symptoms, such as the stretching of an entrapped nerve root.

The loss of internal rotation is one of the first signs of the possibility of an intra-articular disorder; therefore, an important assessment is the internal and external rotation in the seated position. The seated position ensures that the ischium is square to the table, thus providing sufficient stability at 90 degrees of hip flexion and a reproducible platform for accurate rotational measurement. Passive internal and external rotation testing is performed gently and compared between the two sides. Seated rotation range of motion is also compared and contrasted with the extended position of the hip. Table 6-3 provides normal internal and external rotation ranges of motion in these positions.

Table 6–3 Seated Examination Associations

Musculotendinous, ligamentous, and osseous control of internal and external rotation is complex (Figure 6-1); therefore, any differences in seated positions as compared with extended positions may raise the question of ligamentous abnormality as compared with osseous abnormality. Sufficient internal rotation is important for proper hip function; there should be at least 10 degrees of internal rotation during the midstance phase of the normal gait. The loss of internal rotation at the hip can be related to diagnoses such as arthritis, effusion, internal derangements, slipped capital femoral epiphysis, and muscular contracture. Pathology related to femoroacetabular impingement or to rotational constraint from increased or decreased femoroacetabular anteversion can result in significant differences between the sides. An increased internal rotation in combination with a decreased external rotation may indicate excessive femoral anteversion, although the hip capsular function will require further assessment; this is correlated with the radiographic findings. Table 6-3 provides an outline of the seated examination.

Figure 6–1 Summary of the internal rotation of cadaveric hip ligaments through ranges of motion from 30 degrees of flexion to 10 degrees of extension along a neutral swing path. After transection of the ischiofemoral ligament (Ischio), internal rotation doubled. The lateral arm of the iliofemoral ligament (Lat ilio) was also noted to contribute to the stability of the hip in internal rotation. Med ilio, medial arm iliofemoral ligament; Pubo, pubofemoral ligament.

Reprinted from Arthroscopy, 24, The function of the hip capsular ligaments: a quantitative report. Martin HD, Savage A, Braly BA, Palmer IJ, Beall DP, Kelly B. 188-95, 2008, with permission from Elsevier.

The supine examination of the hip

A battery of tests with the patient in the supine position helps to further distinguish internal from extra-articular sources of hip symptoms. The supine examination begins with the assessment of passive hip flexion. Both knees are brought up to the chest, and the degree of flexion is recorded. It is important to note the pelvic position; the hip may stop early in flexion, with the end range of motion being predominately pelvic rotation. From this position, the Hip Flexion Contracture test is performed by having the patient extend and relax one leg down toward the table. Any lack of terminal hip extension, which is noted by the inability for the thigh to reach the table, demonstrates a hip-flexion contracture. This exercise is performed on both sides to compare the differences. An important aspect of the Hip Flexion Contracture test is to obtain the zero set point for the lumbar spine. Patients with hyperlaxity or connective tissue disorders could have a false-negative result. In these patients, the zero set point can be established with an abdominal contraction. The Hip Flexion Contracture test could also be falsely negative if there is lumbar spine hyperlordosis as a result of a previous spinal fusion (video).

During the course of the supine examination, any pop in this plane can sometimes be related to a snapping iliopsoas tendon. A fan test (video) in which the patient circumducts and rotates the hip in a rotatory fashion can help to delineate the presence of the snapping iliopsoas tendon over the femoral head or the innominate. A hula-hoop maneuver in which the patient stands and twists can help to distinguish the pop internally from the external pop of coxa sultans externus as a result of the subluxing iliotibial band over the greater trochanter.

Tests—including those of flexion, adduction, and internal rotation—are useful for the detection of impingement or intra-articular pathology. The degree of flexion required in this position of adduction and internal rotation depends on the degree of impingement and the type and location of the impingement. The degree of hip flexion with the amount of pressure of the internal rotation is taken on a case-by-case basis, depending upon the function required of the patient as well as the patient’s complaint. The traditional McCarthy test elicits a pop when the examined hip is circumducted in this flexed, adducted, internally or externally rotated position while the contralateral leg is held in flexion, as with the Hip Flexion Contracture test. The Dynamic Internal Rotatory Impingement test (DIRI) and Dynamic External Rotatory Impingement test (DEXRIT) (video) are performed as a traditional McCarthy test; however, a positive test is noted by recreation of the patient’s pain. It is important that the zero set point of the pelvis is obtained by having the patient hold the nonaffected leg in flexion beyond 90 degrees. The DEXRIT (Figure 6-2) is performed passively by rotating the examined hip in a wide arc from the flexed position to an abducted, extended position while simultaneously externally rotating the femur. The DIRI test is performed by rotating the hip conversely in a wide arc from a slightly abducted, flexed position into a flexed, adducted, and internally rotated position. The reproduction of these dynamic supine tests is interoperatively helpful for assessment and treatment.

Figure 6–2 A, Dynamic External Rotatory Impingement Test (DEXRIT). Patient positioning is supine with the contralateral hip held in flexion by the patient. The examiner begins with the affected hip in flexion, slight adduction, and neutral rotation. B, C, The examiner passively brings the affected hip through a wide arc of abduction and external rotation. D, Dynamic internal rotatory impingement (DIRI) test. Patient positioning is supine with the contralateral hip held in flexion by the patient. E, F, The examiner passively brings the affected hip into flexion and through a wide arc of adduction and internal rotation.

Reprinted from Arthroscopy, 26, The pattern and technique in the clinical evaluation of the adult hip: the common physical examination tests of hip specialists. Martin HD, Kelly BT, Leunig M, et al. 161-172, 2010, with permission from Elsevier.

The flexion/abduction/external rotation test or the FABER test (video) is helpful in for determining hip complaints as compared with non-hip complaints. A positive recreation of pain can be associated with musculotendinous or osseous posterior lateral acetabular incongruence.

Palpation of the abdomen is performed, and any abdominal tenderness is appreciated. Abdominal tenderness is differentiated from fascial hernia and adductor tendonitis. Resisted torso flexion with palpation of the abdomen will differentiate the fascial hernia from other complaints. Palpation of the adductor tubercle with active testing will detect adductor tendonitis.

Other useful tests may include the Tinel’s test of the femoral nerve. The Tinel’s test is found to be positive with hip-flexion contractures of more than 25 degrees. A heel strike test (video) is performed by striking the heel abruptly, which is indicative of some type of trauma or stress fracture. The Passive Supine Rotation test (video) involves passive internal and external rotation of the femur, with the leg lying in an extended or slightly flexed position. The Passive Supine Rotation test is performed bilaterally, and any side-to-side differences with regard to this maneuver can alert the examiner to the presence of laxity or effusion. Table 6-4 provides an outline of several supine examinations and their possible associations.

Table 6–4 Supine Examination Associations

The importance of multiple examinations is recognized for the detection of intra-articular pathology. Even in the presence of normal internal and external rotation, there is a need for the further delineation of the relationships that exist between the musculotendinous, osseous, and ligamentous structure. Tests for impingement can have good specificity and reasonable predictive value for osseous abnormalities; however, no single test is sensitive enough to be used exclusively for the detection of subtle pathology. Furthermore, the ligamentous contribution to the range of motion varies with flexion and rotation.

The lateral examination of the hip

The lateral examination places the hip in an excellent position for further musculotendinous, ligamentous, and osseous evaluations. The lateral examination begins with the patient on the contralateral side for palpating the areas of the supra-SI and SI joints, the muscles of abduction, and, in particular, the origin of the gluteus maximus as it inserts along the lateral border of the sacrum and the most posterior aspect of the ilium. The next point of palpation is the ischium for detecting hamstring avulsions or tendonitis. Finally, the piriformis is palpated for any sign of tenderness, along with the abductor musculature, which includes the gluteus maximus, the gluteus medius, the gluteus minimus, and the tensor fascia lata. An active piriformis test (Figure 6-3; video) is performed by having the patient push the heel down into the table, thus abducting and externally rotating the leg against resistance, while the examiner monitors the piriformis. The Active Piriformis test is similar to Pace’s sign performed in the seated position useful for evaluating deep gluteal syndrome.

Figure 6–3 The active piriformis test.

Tests of Passive Adduction (Figure 6-4) are performed with the leg in three positions: extension (the tensor fascia lata contracture test), neutral (the gluteus medius contracture test), and flexion (the gluteus maximus contracture test). A traditional Ober test is performed with the hip in extension or neutral and then in adduction toward the table. Evaluation of gluteus medius tension is achieved by the release of the iliotibial band with knee flexion, and the hip should be able to be adducted down toward the table. Any restrictions of these motions are recorded. When performing the gluteus maximus contracture test, the shoulder is rotated toward the side of the table, with the hip flexed and knee extended. If adduction cannot occur in this position, the gluteus maximus portion is contracted. The hip should be able to freely come into a full adducted position, and any restriction of the gluteus maximus is recognized. The gluteus maximus is balanced with the tensor fascia lata anteriorly. If the hip does not come beyond the midline in the longitudinal axis of the torso, it is graded as 3+ restriction above the torso, 2+ at the midline, and 1+ restriction below. A clear delineation of the exact area of restriction will help to direct physical therapy and treatment options.

Figure 6–4 Passive adduction testing. A, The tensor fascia lata contracture test is performed with knee extension. The examiner passively brings the hip into extension and then adduction. B, The gluteus medius contracture test is performed with the hip in a neutral position and the knee in flexion, thus eliminating contribution of the iliotibial band. The examiner passively adducts the hip toward the examination table. C, The gluteus maximus contracture test is performed with the ipsilateral shoulder rotated toward the examination table. The examined leg is held in knee extension as the examiner passively brings the hip into flexion and adduction.

Reprinted from Arthroscopy, 26, The pattern and technique in the clinical evaluation of the adult hip: the common physical examination tests of hip specialists. Martin HD, Kelly BT, Leunig M, et al. 161-172, 2010, with permission from Elsevier.

Strength is assessed with any type of lateral-based hip complaint. The gluteus medius strength test is performed with the knee in flexion. Each muscle group is graded in the traditional fashion on a 5-point scale.

Next is the passive assessment of flexion, adduction, and internal rotation, which is performed in a dynamic manner. The critical factor is the way in which the leg is held (Figure 6-5). The examiner holds the monitoring hand in and around the superior aspect of the hip, with the lower leg cradled on the forearm with the knee upon the hand. The hip is then brought into flexion and adduction and internally rotated. Any reproduction of the patient’s complaint and the degree of impingement are noted. FADDIR can also be performed in the supine position.

Figure 6–5 A, The lateral flexion, adduction, and internal rotation test (FADDIR). B, The FADDIR test can also be performed in the supine position. Figure 6-5B

reprinted from Arthroscopy, 26, The pattern and technique in the clinical evaluation of the adult hip: the common physical examination tests of hip specialists. Martin HD, Kelly BT, Leunig M, et al. 161-172, 2010, with permission from Elsevier.

The lateral rim impingement test (video) is performed with the hip passively abducted and externally rotated. Any type of recreation of a posterior or lateral rim complaint or impingement can be precipitated in this position. Other tests may include the extension, abduction, and external rotation test (as with the apprehension test performed on the shoulder) for the detection of any type of anterior capsular laxity or injury. Forward pressure is applied to the posterior aspect of the hip, and the recreation of the patient’s complaint pain is a positive test. Current research suggests that this position specifically releases the teres ligament. Table 6-5 provides an outline of several lateral examinations and their possible associations.

Table 6–5 Lateral Examination Associations

The prone examination of the hip

The prone examination is composed predominately of the palpation of four distinct areas: the supra-SI, the SI, the gluteus maximus origin, and the spine (facet); these different areas are used to identify the exact area of the complaint. Should the pain be identified in the supra-SI joint region in or around the facet, a lumbar hyperextension test (video) can help to identify the exact location of suspected pain. If this test is positive, the patient can then be placed into a supine position with the knees flexed. If this helps to alleviate the pain, the back should be further evaluated.

The Femoral Anteversion test will give the examiner a generalized idea of femoral anteversion and retroversion. With the patient in the prone position, the knee is flexed to 90 degrees, and the examiner manually rotates the leg while palpating the greater trochanter. The examiner positions the greater trochanter so that it protrudes most laterally, thereby placing the femoral head into the center portion of the acetabulum. Femoral anteversion and retroversion are assessed by noting the angle between the axis of the tibia and an imaginary vertical line (video). Normally, femoral anteversion is between 8 and 15 degrees. If there is a significant difference of internal rotation in the extended and the seated flexed positions, an osseous cause versus a ligamentous one should be differentiated.

The Rectus Contracture test is performed with the patient in the prone position, and the lower extremity is flexed toward the gluteus maximus. Any raise of the pelvis or restriction of hip-flexion motion is indicative of rectus femoris contracture. Table 6-6 provides an outline of the prone examination.

Table 6–6 Prone Examination Associations

Specific tests

Further specific tests are useful for the assessment of complex hip pathology. Shown in the video are several tests performed by hip specialists. Dr. Marc Philippon (Figure 6-6) demonstrates the posterior rim impingement test in which the recreation of pain is a positive test. Dr. Jon Sekiya performs the passive supine rotation bilaterally for detecting capsular laxity of the left leg. Also shown is the scour test, which the examiner performs similarly to DIRI test but that involves the placement of pressure on the knee during the assessment for detecting interarticular congruence. Dr. Michael Leunig has the patient perform a bicycle test while monitoring the iliotibial band for the detection of coxa sultans externus. The fulcrum test (performed by the author) is performed with the examiner’s knee placed under the patient’s knee, thus acting as the fulcrum. The patient then performs a straight-leg test against resistance. The importance of bilateral assessment is demonstrated by Dr. Bryan Kelly when performing the straight-leg test against resistance. RobRoy Martin, PhD, demonstrates the foveal distraction test. Interarticular pressure is alleviated by gently pulling the leg away from the body. Both the relief of pain and the recreation of pain will help to delineate an extra-articular pathology from an intra-articular pathology. Also shown is the FABER test, which is described in the section entitled “The Supine Examination of the Hip.” The Seated Piriformis Stretch test is performed in the seated position with the hip at 90° of flexion. The examiner extends the knee and passively moves the flexed hip into adduction with internal rotation while palpating 1cm lateral to the ischium (middle finger) and proximally at the sciatic notch (index finger). A positive test is the recreation of the posterior pain and may indicate deep gluteal syndrome.

Figure 6–6 Posterior rim impingement test. The patient is positioned at the edge of the examination table and holds the contralateral leg in flexion. The examiner passively brings the affected hip into extension, abduction, and external rotation.

Reprinted from Arthroscopy, 26, The pattern and technique in the clinical evaluation of the adult hip: the common physical examination tests of hip specialists. Martin HD, Kelly BT, Leunig M, et al. 161-172, 2010, with permission from Elsevier.

Summary

A general overview of the hip examination form is provided in Figure 6-7. Further diagnostic tests (e.g., x-ray, magnetic resonance imaging and arthrography, injection tests) will also aid in the diagnosis of hip pathology. The use of a formalized, reproducible examination will help identify the hip as the source of pain and comorbidities in a timely fashion.

Figure 6–7 Physical Examination of the Hip Intake Form (from the upcoming Elsevier publication: Ch. 1 Clinical Examination and Imaging of the Hip. In C. Guanche & JWT Byrd (Eds.). Advanced Hip Arthroscopy. Arthroscopy Association of North America. Elsevier).

The physical examination of the hip involves an assessment of the balance of osseous, ligamentous, and musculotendinous tissues and their interrelationships; these relationships are important for the development of diagnostic and treatment strategies. This chapter has opened a framework for discussion of clinically and biomechanically relevant physical examinations, and it has identified and described a battery of tests that is common in the physical examination of the adult and adolescent hip at this time.

Acknowledgements

The procedures and reasoning set forth in this chapter would not be possible without the dedication of many physicians whose works set the foundation for the physical examination of the hip. I owe them all a tremendous debt of gratitude for allowing me to build upon their works and to take the research of the hip another step forward.