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Trendelenburg Sign

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Original Editor - Tyler Shultz, Lesley Dumitresco as part of the Vrije Universiteit Brussel's Evidence-based Practice project.


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Purpose

Positive and negative Trendelenburg sign

The purpose of the Trendelenburg Test is to identify the weakness of the hip abductors.[1]A positive Trendelenburg sign usually indicates weakness in the hip abductor muscles: gluteus medius and gluteus minimus.[1] These findings can be associated with various hip abnormalities such as congenital hip dislocation, rheumatic arthritis, osteoarthritis.[1][2]

The Trendelenburg sign is a quick physical examination that can assist the therapist in assessing for any hip dysfunction.[1]This is often referred to as the Trendelenburg test but should not be confused with the Brodie–Trendelenburg test which is used to determine the competency of the valves in the superficial and deep veins of patients with varicose veins. [3]

Besides the identification of weakness in the hip abductors of the standing leg, the Trendelenburg sign can be used to assess other mechanical, neurological or spinal disorders, such as the Congenital dislocation of the hip or hip subluxation.[1][2][4][5]

Gluteus medius and minimus are the primary abductors of the hip. When fully weight bearing they act to abduct the femur away from the mid-line of the body and provide stability of the hip and pelvis.[6]

Technique

This test is performed in standing:

  • Position the patient standing on one leg for 30 seconds. The patient may hold onto a support if needed for balance.
  • Observe whether the pelvis remains level during the single-leg stance.
  • A positive Trendelenburg Test is indicated by a drop of the pelvis on the contralateral (unsupported) side. This may also be identified during gait, where the trunk compensates by side-flexing towards the involved side during the stance phase.[1] [7]

Several dysfunctions can produce a positive Trendelenburg Test:[7]

A Trendelenburg gait can also be observed caused by abductor insufficiency and is characterized by:

  • Pelvic drop in the swing phase
  • Trunk side flexion towards the stance limb
  • Hip adduction during the stance phase.

Evidence

While the Trendelenburg test has demonstrated good reliability in certain contexts, its validity and clinical utility may be limited in some populations. Further research is needed to fully establish its psychometric properties across different patient groups and conditions. When interpreting the Trendelenburg test results, it's important to consider:

  • False-positive tests may occur due to pain, poor balance, or lack of patient cooperation.
  • False-negative tests can happen if the subject uses muscles above the pelvis to elevate the non-weight-bearing side or shifts the torso over the weight-bearing side.
  • The test's reliability and validity may vary depending on the specific population being assessed.[10]

Reliability

The Trendelenburg test has demonstrated good reliability in various studies:

  • Very strong intra-rater reliability was reported when assessed using goniometry in people with multiple sclerosis, with a minimal detectable change (MDC) of 2.1°.[11]
  • Test-retest reliability coefficients (kappa) were greater than 0.75 for the Trendelenburg score in patients with chronic nonspecific low back pain.[10]
  • The test showed good reliability in diagnosing hip abductor muscle dysfunction in various orthopaedic conditions.[11]

Validity

The validity of the Trendelenburg test has been questioned in some studies:

  • In a study examining subjects with and without hip joint osteoarthritis, the sensitivity of the Trendelenburg test for identifying subjects with hip joint OA was 0.55, and specificity was 0.70, yielding a positive likelihood ratio of 1.83.[8]
  • The same study concluded that the Trendelenburg test is not useful in identifying subjects in the early stages of hip joint OA.[8]
  • A recent study found no significant relationship between normalised peak isometric and isokinetic hip abductor torque and frontal plane pelvic motion during the Trendelenburg test in a healthy young adult population.[12]

Clinical bottom line

The Trendelenburg sign alone cannot diagnose hip conditions such as osteoarthritis or hip instability[8]. It has been shown to be more effective when part of a battery of tests such as hand dynamometry and observation to help assess hip abductor strength[13]. It is a quick, easy test that can help identify functional weakness in a standing position.

See Also

Trendelenburg Gait

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 Hardcastle PH, Nade SY. The significance of the Trendelenburg test. The Journal of bone and joint surgery. British volume. 1985 Nov;67(5):741-6.
  2. ↑ 2.0 2.1 2.2 2.3 Macnicol MF, Makris D. Distal transfer of the greater trochanter. The Journal of bone and joint surgery. British volume. 1991 Sep;73(5):838-41.
  3. ↑ Krishnan S, Nicholls SC. Chronic venous insufficiency: clinical assessment and patient selection. InSeminars in Interventional Radiology 2005 Sep (Vol. 22, No. 03, pp. 169-177). Copyright© 2005 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA..
  4. ↑ Rang M. Anthology of orthopaedics. Edinburgh. E&S Livingstone, 1966; 139-43. [1]
  5. ↑ 5.0 5.1 Windhager RE, Pongracz NI, Schonecker WO, Kotz RA. Chiari osteotomy for congenital dislocation and subluxation of the hip. Results after 20 to 34 years follow-up. The Journal of bone and joint surgery. British volume. 1991 Nov;73(6):890-5.
  6. ↑ Palastanga N, Soames R. Anatomy and Human Movement: Structure and Function. 6th ed. London, United Kingdom: Churchill Livingstone; 2012.
  7. ↑ 7.0 7.1 Dutton M. Orthopaedic: Examination, evaluation, and intervention. 2nd ed. New York: The McGraw-Hill Companies, Inc; 2008.
  8. ↑ 8.0 8.1 8.2 8.3 Youdas JW, Madson TJ, Hollman JH. Usefulness of the Trendelenburg test for identification of patients with hip joint osteoarthritis. Physiotherapy theory and practice. 2010 Jan 1;26(3):184-94.
  9. ↑ Odak S, Ivory J. Management of abductor mechanism deficiency following total hip replacement. The bone & joint journal. 2013 Mar;95(3):343-7.
  10. ↑ 10.0 10.1 10.2 Roussel NA, Nijs J, Truijen S, Smeuninx L, Stassijns G. Low back pain: clinimetric properties of the Trendelenburg test, active straight leg raise test, and breathing pattern during active straight leg raising. Journal of manipulative and physiological therapeutics. 2007 May 1;30(4):270-8.
  11. ↑ 11.0 11.1 Kline PW, Christiansen CL, Judd DL, Mañago MM. Clinical utility of the Trendelenburg Test in people with multiple sclerosis. Physiotherapy theory and practice. 2023 May 4;39(5):1016-23.
  12. ↑ McCarney L, Andrews A, Henry P, Fazalbhoy A, Selva Raj I, Lythgo N, Kendall JC. Determining Trendelenburg test validity and reliability using 3-dimensional motion analysis and muscle dynamometry. Chiropractic & Manual Therapies. 2020 Dec;28:1-0.
  13. ↑ Grimaldi A. Assessing lateral stability of the hip and pelvis. Manual therapy. 2011 Feb 1;16(1):26-32.
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