Hip Examination

Original Editor - Laura Ritchie Top Contributors - Samuel Adedigba, Kim Jackson, Vidya Acharya, Rachael Lowe, Laura Ritchie, Admin, 127.0.0.1, Kai A. Sigel, Wanda van Niekerk, Tony Lowe and Naomi O'Reilly

Introduction

The Hip Joint

The Hip joint is one of the most important joints in the body because of the vital role it plays in locomotion. It is the second largest weight-bearing joint in the body, after the knee joint. It is a ball-and-socket synovial joint formed between the os coxa (hip bone) and the femur. The rounded head of the femur forms the ball, which fits into the acetabulum (socket in the pelvic bone) and ligaments connect the ball to the socket, thereby providing tremendous stability to the joint. Functionally, the hip joint enjoys a very high range of motion.

All of the various components of the hip mechanism assist in the mobility of the joint. Damage to any single component can negatively affect range of motion and ability to bear weight on the joint. In hip injury, as with other traumatic presentations, age distribution is bimodal with high-energy trauma in the younger population and potentially trivial mechanisms of injury in the older population, e.g. a simple fall.

Subjective Examination

Patient Intake

The first step during the examination is the patient interview, during which the clinician gets a description of the presenting symptoms from the patient. Research suggests patient history plays a vital role in the differential diagnosis of hip pain and, in some cases, can be superior to objective tests and measures. Taking the history is a vital component of the subjective examination as it helps the clinician develop a hypothesis about the mechanism of injury, type of the injured structures and extent of the injury or damage. Details like the location of the pain, nature of the pain, 24-hour pattern of the pain, activities that trigger the pain, pain aggravating and relieving factors etc., are gotten from the patient during the interview. According to new systematic review published in the Archives of Physical Medicine and Rehabilitation, thigh/groin pain and constant back/buttock pain are better indicators of hip OA  than stand-alone tests and reported hip crepitus is a strong indicator of intra-articular hip pathology.

The patient's past medical history, as well as their social/family history is also important as this helps the clinician rule out hereditary conditions. Any surgical histories that are specific to the hip region is also vital, for example, a patient who had a hip joint replacement surgery and is currently complaining of pain at the hip joint. The patient's drug history and current medications they are on should also be documented as well as any allergies they might have. The effects of the condition on the patient' functional status and Activities of Daily Living (ADLs) should be well assessed and documented.

In the elderly it is also worth considering whether a fall was the result of a simple trip, or secondary to another reason, e.g. seizure, cardiovascular trigger, stroke or loss of consciousness. Relevant assessment of the cardiovascular or neurological system may be required with additional tests, e.g. ECG, CT brain.

Special Considerations

Red Flags

• Sudden onset of pain.
• A history of trauma
• Any swelling
• Any deformity
• An inability to bear weight
• Any lumps or bumps felt in the groin
• Night pain
• Any noticeable groin pulsations
• Constipation or vomiting
• Haematuria
• Fever
• Lower limb neurological symptoms - weakness, numbness or tingling
• History of steroid use
• Testicular swelling
• Night sweats, unintentional weight loss, appetite loss
• History of malignancy
• High-risk sexual activity

Other Flags

It is also important to screen for other (yellow, orange, blue and black) flags as these may interfere with physiotherapy interventions.

Investigations

The first investigation of choice in a patient with hip pain following trauma is a hip x-ray. This will be an AP radiograph of the pelvis and a lateral radiograph of the painful hip. Fractures are not always identified on initial x-ray imaging. If there is a clinical concern for a hip fracture, but the x-ray is normal, further imaging is required. Both CT and MRI can be used to look for a radiographically occult fracture - MRI is more sensitive, but CT is usually easier to organise and in many institutions is the second-line investigation of choice.

In complex fractures, CT can be helpful to get additional preoperative information that can be used to plan surgery and aid discussion about consent and prognosis. It is also worthwhile considering that interpretation of a hip x-ray will be complicated in the elderly by the present of other conditions, e.g. secondary osteoarthritis.

Objective Examination

Observation

Upon conclusion of the patient interview, the clinician proceeds to the objective examination. A Pain VAS is administered to determine the patient's baseline pain level and then the examiner observes and documents the following:

• Bony deformity / Bony alignment

1. 1. Gait pattern: There are several types of abnormal gait patterns associated with hip pathologies which the clinician needs to look out for such as Antalgic gait, Trendelenburg gait, Arthrogenic gait and Lurching gait.
   2. Weight Bearing
   3. Balance and Posture
   4. In Standing: Lumbar spine, Level of iliac crests (To rule out pelvic/SIJ dysfunction)
   5. Lying Supine: Leg length (apparent and real leg lengths), External rotation of leg.

• Colour changes e.g. bruising, inflammation, infection, rash.
• Muscle wasting, muscle spasm and muscle bulk
• Swelling, scarring, skin changes (wounds)

Palpation

During palpation, the examiner checks:

• Vascular System – Distal pulses, capillary refill
• Sensation (Neurological Examination) – Peripheral nerve skin sensation and power
• Temperature – Infection / Inflammation
• Swelling – Effusion, Synovial thickening, Extra capsular
• Tenderness
  • Lumbar spine
  • Pelvis: Iliac crest, ASIS, Pubic rami, Symphysis pubis, PSIS, SIJ, Ischial tuberosity, Sacrum, Coccyx
  • Greater trochanter
  • Inguinal ligament
  • Femoral triangle (hip joint)
  • Knee

Neurologic Assessment

• Manual Muscle Testing: The strength of the muscle groups surrounding the hip joint, namely the hip extensors, flexors, abductors, adductors, internal and external rotators should be graded and documented.
• Straight Leg Raise
• Dermatome Testing
• Skin sensation test

Movement Testing

The available ranges of motion at the hip joint (Active and Passive) are measured using a goniometer and documented. These measurements serve as baseline readings and help determine if the intervention is yielding results.

Special Tests

• Thomas test
• Trendelenberg sign
• FABER test
• FADDIR test
• Ober's test
• Log roll test
• Stinchfield test
• Ely's test

Differential Diagnosis

Orthopaedic/rheumatological causes

• Osteoarthritis
• Septic arthritis
• Osteomyelitis
• Hip dislocation
• Gout
• Fractured neck of femur

Pathological causes

• Trochanteric bursitis
• Iliotibial band syndrome
• Meralgia paraesthetica
• Avascular necrosis
• Labral tears
• Referred from lumbar spine
• Referred from sacroiliac joint

Hernias, aneurysms and benign lumps

• Inguinal lymphadenopathy secondary to multiple causes
• Inguinal hernia
• Femoral hernia
• Femoral artery aneurysm
• Lipoma
• Sebaceous cyst

Malignant causes

• Osteosarcoma
• Metastatic disease such as prostate cancer or pelvic tumours

Miscellaneous

• Renal calculus (loin to groin pain)
• Iliopsoas abscess

Outcome Measures

• Harris Hip Score (HHS),
• Hip Disability and Osteoarthritis Outcome Score (HOOS),
• Oxford Hip Score (OHS),
• Lequesne Index of Severity for Osteoarthritis of the Hip (LISOH).
• American Academy of Orthopedic Surgeons (AAOS) Hip and Knee Questionnaire.
• Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC):