The importance of history taking cannot be overemphasized as the potential causes of hip pain are numerous (Table 19-9). The history should determine the onset of the symptoms, the mechanism of injury, if any, and the patient's chief complaint. A medical screening questionnaire for the pelvis, hip, and thigh is provided in Table 19-10. It is important for the clinician to determine:
Table 19-9 Potential Causes of Hip Pain ||Download (.pdf)
Table 19-9 Potential Causes of Hip Pain
Type of Pain/Structure Involved
Slipped capital femoral epiphysis
Local nerve entrapment
Stress fractures of the femur
Lumbar disk pathology
Lumbar spine-degenerative joint disease
Sacroiliac joint pathology
Genitourinary tract pathology
Abdominal wall pathology
Systemic lupus erythematosus
Soft tissue contusion
Fractures of the femoral head
Dislocation of the femoral head
Table 19-10 Medical Screening Questionnaire for the Pelvis, Hip, and Thigh Region ||Download (.pdf)
Table 19-10 Medical Screening Questionnaire for the Pelvis, Hip, and Thigh Region
Have you recently had a trauma, such as a fall?
Have you ever had a medical practitioner tell you that you have osteoporosis?
Have you ever had a medical practitioner tell you that you have a problem with the blood circulation in your hips?
Are you currently taking steroids or have you been on prolonged steroid therapy?
Do you have a history of cancer or has a member of your immediate family (i.e., parents or siblings) ever been diagnosed with cancer?
Have you recently lost weight even though you have not been attempting to eat less or exercise more?
Have you had a recent change in your bowel functioning such as black stools or blood in your rectum?
Have you had diarrhea or constipation that has lasted for more than a few days?
Do you have groin, hip, or thigh aching pain that increases with physical activity, such as walking or running?
The patient's age may help in the diagnosis. OA of the hip is diagnosed most often in patients over 60 years of age, although it can occur earlier.
The location of the pain can provide the clinician with some useful information (Table 19-12). Complaints of hip or groin pain, morning stiffness, stiffness after sitting, and hip pain with weight-bearing are suggestive of joint involvement, such as OA. It is important to identify patients with symptomatic OA correctly and to exclude conditions that may be mistaken for or coexist with OA.113,114 Periarticular pain that is not reproduced by passive motion and direct joint palpation suggests an alternate etiology such as bursitis, tendinitis, or periostitis. Groin pain can result from local and referred sources. One of the more common causes of groin pain in the older patient is OA of the hip. However, OA of the hip may also cause pain behind the greater trochanter, anterior thigh, and knee because of the various nerves that cross the hip.115
Lateral and posterior hip (buttock) and thigh pain may be referred from the lumbar spine.
The distribution of painful joints is helpful to distinguish OA from other types of arthritis because MCP, wrist, elbow, ankle, and shoulder arthritis are unlikely locations for OA except after trauma.
The time of day that appears to change the pain for better or worse can provide some clues. Hip joint pathology is usually associated with stiffness of the hip in the morning on arising. Such pathologies include
- OA of the hip joint;
- rheumatoid arthritis of the hip joint; prolonged morning stiffness (greater than 1 hour) should raise suspicion for this type of inflammatory arthritis;
- avascular necrosis of the femoral head.
The first two motions that are diminished in hip OA are usually hip internal rotation and hip flexion, although as previously discussed, this can vary significantly.116 A significant decrease or loss of motor function will always necessitate imaging studies to rule out an avulsion fracture, and/or nerve injury (see Chap. 7).
Patients who present with acute macrotrauma (e.g., falls and motor vehicle accidents) and who report having difficulty moving the hip or bearing weight require radiographs to rule out a fracture and/or dislocation. Falls on the outside of the hip are a common cause of trochanteric bursitis or contusion of the iliac crest (hip pointer). Such an injury may also involve the abdominal and/or gluteal muscles at their attachment sites. When the abdominal muscles are involved, patients may complain of pain with deep inspiration or have difficulty with trunk rotation.117 Macrotraumatic forces applied along the femur such as those that occur with dashboard injuries and falls on the knee can result in damage to the articular cartilage, an acetabular labrum tear, a pelvic fracture, or a hip subluxation. An immediate loss of movement following direct trauma to this area usually indicates the presence of a hip or pelvic fracture, or a dislocation. Posterior contusions to the gluteus maximus and sciatic nerve can occur from a direct blow to the buttock.117 In such cases, the patient may complain of pain in the buttocks and of pain, numbness, and/or tingling radiating down the course of the sciatic nerve. Both the athlete and nutritionally compromised individual are at risk of pelvic rami or femoral neck stress fractures. Anterior blows to the thigh can produce quadriceps contusions. These contusions can also result in myositis ossificans. The femoral nerve is fairly well protected and not usually injured. Acute muscle strains in the hip and thigh region, especially of the hamstrings, are usually seen in the athletic individual, most often occurring following a short sprint, jump kick, fall, or collision.117 Quadriceps strains, usually involving the rectus femoris, occur in sprinters and kickers. The most frequently strained adductors are the longus and magnus, while hamstring injuries usually involve the biceps femoris.118–120
Ironically, in general, a history of a significant traumatic event is a good prognostic indicator of a potentially correctable problem,121 whereas arthritis is an indicator of poor long-term outcomes.122
If the patient is unable to recall a specific mechanism, the clinician should suspect a systemic (see “Systems Review” section and Chap. 5) or biomechanical cause. The hip is a region that is prone to overuse injuries. Walking or running can aggravate trochanteric bursitis, ITB friction syndrome, hamstring and adductor strains, or a femoral neck stress fracture. Pain with bursitis is frequently referred along the course of the muscle it underlies and nearby neurologic structures.117 Obturator internus bursitis can refer pain to the back and buttock or along the course of the sciatic nerve. Subtrochanteric bursitis commonly refers pain to the LB, lateral thigh, knee, and hip.117 Iliopectineal bursitis can refer pain along the course of the femoral nerve and anterior thigh. Ischiogluteal bursitis can refer pain along the posterior femoral cutaneous or sciatic nerve.117
Reports of twinges of pain with weight-bearing activities may indicate the presence of a loose body within the joint. Noises in and around the joint can result from many causes so are not particularly diagnostic. One of the more common causes for clicking is a “snapping” hip, especially if the snapping consistently occurs at approximately 45 degrees of hip flexion. This type of snapping hip is thought to be because of the iliopsoas tendon riding over the greater trochanter or anterior acetabulum. The other types of snapping hip are described in the “Interventions” section. If pain is associated with the clicking, it requires further investigation.
Mechanical symptoms such as locking, catching, popping, or ones that are sharp stabbing in nature are better prognostic indicators of a correctable problem.123
Aggravating or Relieving Factors
Information must be gathered with regard to the activities or positions that appear to aggravate or lessen the symptoms. For example, prolonged sitting on a hard surface may aggravate the ischial bursa, whereas buttock pain with prolonged sitting on a soft surface is more likely to be the result of a lumbar disk lesion. Rising from a seated position can be especially painful and the patient may experience an accompanying catching or sharp stabbing sensation. Entering and exiting an automobile is often difficult, because the hip is in a flexed position along with twisting maneuvers. As the hip is a weight-bearing joint and weight-bearing tends to aggravate articular pathologies, it is very important to gather information concerning the role of weight-bearing in painful activities, particularly whether the patient has pain at rest as well as during weight-bearing, or whether specific weight-bearing activities (e.g., stair climbing and walking) are the cause of increased pain.
Questions about work environment, athletic participation, and other daily and recreational activities help the clinician identify risk factors for cumulative trauma that might not be apparent to the patient.117 Activities and positions that aggravate and alleviate symptoms should be identified (Table 19-11).
Table 19-11 Subjective Reports and Possible Diagnoses ||Download (.pdf)
Table 19-11 Subjective Reports and Possible Diagnoses
Pain that is usually worse with sitting on hard surfaces, cycling, and prolonged standing
Pain with squatting, lying on the involved side, climbing stairs, and walking
A clicking or popping sound that occurs during running and dancing activities
Snapping hip syndrome
Pain with prolonged sitting, trunk flexion, and coughing/sneezing
Lumbar disk herniation
Pain with activities that involve lumbar extension
Spinal stenosis, spondylolisthesis, or facet syndrome
Pain at night unrelated to movement
Pain with walking, which is relieved with cessation of the activity
Pain that appears to be affected by the weather
Arthritic condition or fibromyalgia syndrome
Progressive loss of or change in motor, bowel, bladder, or sexual function
Myelopathy, conus medullaris syndrome, or cauda equinus syndrome
The hip and pelvic areas are also common sites for pain referral (Table 19-12). The differential diagnosis of hip pain is described in Chapter 5. To help determine the symptom distribution, a pain diagram should be completed by the patient (see Chap. 4). Following its completion, the patient should be encouraged to describe the type of symptoms experienced for each of the areas highlighted on the diagram, as well as the motions or positions that increase or decrease the symptoms. Since the lumbar spine can refer symptoms to the hip region, the clinician should always rule out involvement of the lumbar spine before a hip problem is suspected. The most common source of referred pain from the LB includes both neurogenic (nerve root compression) and spondylogenic (facet or sacroiliac joint) causes. Brown and colleagues124 identified a limp, groin pain, and limited hip internal rotation as signs that significantly predicted a hip problem rather than a lumbar problem.
Table 19-12 Differential Diagnosis for Pain in the Hip or Buttock Area ||Download (.pdf)
Table 19-12 Differential Diagnosis for Pain in the Hip or Buttock Area
Stress fractures of the pelvis and femur
Groin and inner thigh region
Crystal-induced synovitis (gout)
An inguinal/femoral hernia
Inflamed lymph nodes
Hip adductor strain
Lower abdominal muscle strain
Referred pain from viscera or spinal nerve
Iliopsoas strain or avulsion fracture of the lesser
Arthritis of the hip
Femoral neck fracture
Osteonecrosis of the femoral head
Pubic symphysis dysfunction:
- Osteitis pubis
- Osteomyelitis pubis
- Pyogenic arthritis
- Pubic fracture
- Pubic osteolysis
- Postpartum symphyseal pain
Sacroiliac joint lesion
Inflammatory synovitis (e.g., rheumatoid arthritis, ankylosing spondylitis, and systemic lupus erythematosus)
Lateral buttock area
Anterior and lateral thigh
Anterior–superior iliac spine
Sprain of pubic symphysis
Abdominal muscle strain
Tendinitis of abductors or external rotators
Apophysitis of greater trochanter
Referred pain from mid or lower lumbar spine
Thrombosis of gluteal arteries
Strain of quadriceps
Entrapment of femoral nerve
Thrombosis of femoral artery or great saphenous vein
Stress fracture of femur
Referred pain from hip or mid-lumbar spine
Strain of adductor muscles
Entrapment of obturator nerve
Referred pain from hip or knee
Apophysitis or sartorius or rectus femoris
Strain of gluteal, oblique abdominals, tensor fascia, latae, and quadratus lumborum
Entrapment of iliohypogastric nerve
Referred pain from upper lumbar spine
Finally, the clinician should determine the impact that the patients' condition has on their activities of daily living (ADL).
The hip can be one of the more challenging joints to examine. Unlike the knee or ankle, the joint is not readily palpable, and one must rely on a number of provocative tests and maneuvers to identify intra-articular or bony abnormalities.117 Even many of the soft tissue structures are difficult to manually identify but can usually be isolated with proper clinical skills.
The most important aspect of inspection is stance (standing and sitting) and gait. The patient is observed from the front, back, and sides for general alignment of the hip, pelvis, spine, and lower extremities (see Chap. 6). While standing, a slightly flexed position of the involved hip and the ipsilateral knee is a common finding associated with hip pathology. In the seated position, slouching or listing to the uninvolved side avoids extremes of flexion. An antalgic gait may or may not be present depending on the severity of the symptoms.
The clinician observes the hip region, noting any scars, anatomical abnormalities, muscle atrophy, bruising, swelling, etc.
- A localized soft tissue mass or swelling may indicate a bursitis, an acute muscle contusion or tear with a hematoma, an avulsion fracture, myositis ossificans, a tumor, infection, or deep vein thrombosis.117
- Asymmetric muscle atrophy is usually an indication of a radiculopathy or peripheral neuropathy, but can also be seen with a tendon rupture.
- An ecchymosis may be seen with contusions, muscle tear, fracture, and patients with a bleeding diathesis.117
- Vesicular skin lesions that have a dermatomal distribution may be found in cases of herpes zoster. Café au lait spots greater than 3 cm and greater than six in number are characteristic of neurofibromatosis.
- Skin rashes may be because of secondary psoariatic arthritis, drug reactions, or one of the collagen vascular diseases.
- Obvious joint or bony deformity should raise suspicion of a fracture or dislocation.
Both pain and musculotendinous dysfunction can produce movement and postural dysfunctions at the hip joint.125 According to Kendall,126 the ideal alignment of the pelvis is indicated when the ASIS is on the same vertical plane as the symphysis pubis. The degree of pelvic tilt, which is measured as the angle between the horizontal plane and a line connecting the ASIS with the PSIS, varies from 5 to 12 degrees in normal individuals.127 Both a low ASIS in women and a structurally flat back in men can cause structural variations in pelvic alignment, which can be misinterpreted as acquired postural impairments.125 According to Sahrmann, all of the following are necessary to indicate the presence of a postural impairment of the hip125:
- An increase or decrease in the depth of the normal lumbar curve.
- A marked deviation from the horizontal line between the ASIS and PSIS.
- An increase or decrease in the hip joint angle in the anterior–posterior plane, with neutral knee joint alignment.
The following should be examined125:
- The glutei should be symmetrical and well rounded, not hanging loosely. The pelvic crossed syndrome (see Chap. 6) demonstrates weakness and inhibition of the glutei muscles.128 This syndrome can be easily identified by having the patient perform a partial bridge with single leg support. This maneuver results in cramping of the hamstrings within a few seconds if the pelvic crossed syndrome is present. Atrophy of one buttock cheek compared with the other side may also indicate a superior or inferior gluteal nerve palsy. A balling-up of the gluteal muscle typically indicates a grade III tear of the gluteal muscles. Buttock swelling occurs with the “sign of the buttock.”108
- Swelling over the greater trochanter could indicate trochanteric bursitis.
- Adaptive shortening of the short hip adductors is indicated by a distinct bulk in the muscles of the upper third of the thigh.128
- The bulk of the TFL should not be distinct. A visible groove passing down the lateral aspect of the thigh may indicate that the TFL is overused, and both it and the ITB are adaptively shortened.128
The architecture and position of the hip joint and lower extremity is observed.
- In acute arthritis and gross osteoarthrosis, the hip joint is usually held in flexion and external rotation. This may be compensated for by an anterior tilt of the pelvis, together with an increased lordosis of the lumbar spine.
- Excessive external rotation of the leg, accompanied with toeing-out, occurs in extreme femoral neck retroversion, or a slipped femoral epiphysis.
- Increased hip flexion in standing can result from weakness or excessive lengthening of the external oblique or rectus abdominis muscles. Increased hip flexion may also be because of a hip flexion contracture.
- Increased hip extension in relaxed standing is indicative of a swayback posture. This is characterized by a posterior pelvic tilt and hyperextension of the knees, and results in a stretch on the anterior joint capsule of the hip and stress on the iliopsoas muscle and tendon.
- Lateral asymmetry in relaxed standing is characterized by a high iliac crest on one side. The difference in height between the two crests must be greater than one-half inch to have clinical significance. Lateral asymmetry may indicate a positive Trendelenburg sign (see “Special Tests” section), which indicates hip-abductor weakness.
Observation of the lower components of the kinetic chain includes
- the degree of genu varum/valgus (see Chap. 20);
- the degree of tibial torsion (see Chap. 20);
- the amount of calcaneal inversion/eversion (see Chap. 21).
The pelvic crossed syndrome is exhibited by adaptively shortened hip flexors and hamstrings, and inhibited glutei muscles and lumbar erector spinae.
Analysis of both the stance and swing phases of gait is essential (see Chap. 6). Determinants of the stance-phase of gait involve interaction between the pelvis and hip and distal limb joints (knee and ankle)129,130 The clinician should note whether70
- the patient is using an assistive device. If they are, is it fitted at the correct height and do they use it correctly?
- there is a lack of hip motion, particularly extension. A lack of hip extension can have an impact on gait (see Chap. 6).
- there is a lateral horizontal shift of the pelvis and trunk over the stance leg during the swing phase. This may indicate a positive Trendelenburg sign (see “Special Tests”section). Activation of the abductor mechanism on weight-bearing is necessary to stabilize the hip and pelvis and prevent excessive lateral tilting of the pelvis to the contralateral side during the swing phase.
- the ankle alignment is neutral. Increased ankle pronation increases the degree of hip internal rotation which can place greater stress on hip rotators. This can be especially traumatic to those hip rotators that cross bony prominences, increasing the risk of bursitis; conversely, supination causes greater external rotation.
Strong activation of the hip extensors (with the abductors) is necessary at initial contact into early stance, from 30 degrees initial flexion to approximately 10 degrees of extension at terminal stance.129 If the hip flexors are short or stiff in relation to the abdominal muscles, there may be an exaggeration in the anterior pelvic tilt and increased lumbar extension during this phase.125
Pain on weight-bearing is a common complaint in some patients with hip joint pathology, including rheumatoid arthritis and OA.70 Depending on the capability of the patient, the following weight-bearing tests may produce pain:
- High step. The patient places one foot on a chair and then leans onto it (Fig. 19-18). This maneuver flexes the raised hip and extends the other. The test is repeated on the other side. This test gives the clinician an indication as to the range of flexion and extension at the hip.
- Unilateral standing. The patient stands on one leg (Fig. 19-19). An inability to maintain the pelvis in a horizontal position during unilateral standing is called a positive Trendelenburg (see “Special Tests” section).
Trendelenburg sign indicating weakness of the left hip abductors.
The palpatory exam is done to identify both anatomic abnormalities and potential sources of symptoms other than from the hip joint itself. Given the location of the hip joint, palpation is usually unrevealing as far as any specific areas of discomfort related to an intra-articular source of hip symptoms. A palpable mass following acute trauma that is not well defined usually indicates a muscle tear, a muscle spasm, or hematoma.117 A mass that developed 2–3 weeks after the initial injury and is warm and erythematous may be the first indication of myositis ossificans. A bursitis usually presents with some localized swelling, warmth, and erythema, and no history of acute trauma. Trigger points are usually identified as discrete nodules or bands within muscle tissue. There is no associated swelling and no warmth or erythema. Postural or bony malalignment can increase the risk of both acute traumatic and overuse injuries. The anatomic relationships of the joints of the lower extremity should be compared, looking for valgus and varus deformities, pes cavus or planus, spine mobility, hip anteversion, pelvic asymmetry, and leg length discrepancies (see Chap. 29).117
Hoppenfeld131 advocates an approach to palpation that is organized by region. Under this system, the palpation of bony structures occurs separately from the palpation of the soft tissues. While this may be helpful to the clinician, time constraints often dictate that the two are examined concurrently.
The following are useful landmarks to use when locating the hip joint center of rotation18:
- The midpoint between the ASIS and pubic symphysis, lies over the femoral pulse.
- The superior tip of the greater trochanter is in line with the center of rotation.
Anterior Aspect of Hip and Groin
Anterior–Superior Iliac Spine. The anterior iliac spine serves as the origin for the sartorius muscle and the TFL. Both can be located by flexing and abducting the patient's hip, which produces a groove that resembles an inverted V close to the ASIS. The lateral side of the inverted V is formed by the TFL, while the medial side is formed by the tendon of the sartorius.
Anterior–Inferior Iliac Spine. The anterior–inferior iliac spine can be palpated in the space formed by the sartorius and the TFL, during passive flexion of the hip in the space known as the lateral femoral triangle. The lateral cutaneous nerve of the thigh passes through this triangle. Compression of this nerve produces a condition called meralgia paresthetica (see Chap. 5). The AIIS serves as the origin for the rectus femoris tendon.
Pubic Tubercle. The pubic tubercle is located by finding the groin crease and then traveling in an inferomedial direction, or by following the tendon of the adductor longus proximally. In males, the spermatic cord runs directly over the tubercle and can be tender to palpation in normal individuals. Inguinal hernias are usually found superior and medial to the tubercle, while femoral hernias are located lateral to the tubercle.
Adductor Magnus. The adductor magnus is palpable in a small triangle in the distal thigh, posterior to the gracilis muscle and anterior to the semimembranosus.
Rectus Femoris. The rectus femoris has its origin at the AIIS, which is located just distal to the ASIS, between the TFL and sartorius.
Iliopsoas Bursa. At the iliopectineal eminence, the iliopsoas muscle makes an angle of about 30 degrees in a posterolateral direction. To palpate this bursa, the patient is positioned in supine, with the hip being positioned in approximately 40 degrees of flexion and external rotation, and resting on a pillow. At the proximal end of the femur, the clinician palpates the adductor tubercle and then moves to the ASIS. From there, the clinician proceeds to the inguinal ligament, under the fold of the external oblique, and into the femoral triangle. The psoas bursa is located under the floor of the triangle, close to the pubic ramus.
Femoral Triangle. The femoral artery lies superficial and medial to the iliopsoas muscle and is easily located by palpation of the pulse. The femoral nerve is the most lateral structure in the femoral triangle. To examine the femoral triangle, the patient is positioned in supine and, if it is possible for the patient to do this, the heel of the leg is placed upon the opposite knee. This places the patient in a position of flexion–abduction and external rotation.
Inguinal Ligament. The inguinal ligament is located in the fold of the groin, running from the ASIS to the pubic tubercle. It can be located by using transverse palpation.
Adductor Longus. Together with the gracilis, the adductor longus forms the medial border of the femoral triangle. The gracilis is located medial and posterior to the adductor longus. The adductor longus is best viewed during resisted adduction, when it forms a cord-like structure just distal to the pubic tubercle, before crossing under the sartorius. It is often tender in dancers, cheerleaders, and others who perform strenuous activities requiring abduction at the hip.
Lateral Aspect of the Hip
The patient is positioned in side lying.
Iliac Crest. The iliac crest is easy to locate. The cluneal nerves are superficial structures and can be located just superior to the crest.
Greater Trochanter. The superior border of the greater trochanter represents the transverse axis of hip, and when the leg is abducted, an obvious depression appears above the greater trochanter. The gluteus medius inserts into the upper portion of the trochanter and can be palpated on the lateral aspect.132
Palpation of the greater trochanter is also used to assess the angle of anteversion and retroversion using the Craig test (see “Special Tests” section).
Lesser Trochanter. The lesser trochanter, covered as it is with the iliopsoas and adductor magnus, is very difficult to palpate directly, but it can be located on the posterior aspect if the hip is placed in extension and internal rotation, and the palpation is performed deeply lateral to the ischial tuberosity.
Piriformis Attachment. The origin of the piriformis can be found on the medial aspect of the superior point of the greater trochanter. Moving inferiorly from this point and the quadratus femoris located on the quadrate tubercle, the following tendon insertions can be palpated: superior gemellus, obturator internus, and inferior gemellus.
Psoas. The insertion for the psoas is located on the inferior aspect of the greater trochanter and can be found by placing the patient's hip in maximum internal rotation. Once the superior aspect of the greater trochanter is located, the clinician moves in a posterior/medial/inferior direction to locate the inferior aspect of the greater trochanter.
Subtrochanteric Bursa. The subtrochanteric bursa cannot be palpated directly. However, it can be tested by positioning the patient's leg in hyperadduction. At this point, the patient is asked to abduct the hip isometrically against the clinician's resistance. The contraction of the hip abductors compresses the bursa and may cause pain if the bursa is inflamed.
Posterior Aspect of the Hip
The patient is positioned in side lying or prone.
Quadratus Lumborum. Palpation of the quadratus lumborum is best accomplished with the patient in side lying, with the arm abducted overhead to open the space between the iliac crest and the 12th rib.
Ischial Tuberosity. A number of structures have their attachments on the ischial tuberosity. These include the ischial bursa, the semimembranosus tendon, the sacrotuberous ligament, the biceps femoris and semitendinosus tendons, and the tendons of the quadratus femoris, adductor magnus, and inferior gemellus. The ischial tuberosity is best palpated in the side lying position with the hip flexed to 90 degrees (see Chap. 29). This position moves the gluteus maximus upward, permitting direct palpation at the tuberosity. The ischial bursa is located on the inferior and medial aspect of the ischial tuberosity. A diagnosis of ischial bursitis is usually based on a history of pain with sitting on a hard surface and finding tenderness with palpation of the ischial tuberosity.
Sciatic Nerve. One of the most important structures to palpate in this area is the sciatic nerve. It can be located for palpation at a point halfway between the greater trochanter and ischial tuberosity. Tenderness of this nerve can be produced by a piriformis muscle spasm or by direct trauma.
Active, Passive, and Resistive Tests
The clinical procedures for performing ROM measurements vary, and disagreement exists about the accuracy of visual estimates compared to goniometer measurements. A study by Holm and colleagues133 comprising 25 patients (6 M, 19 F; mean age 68.5 years, range 46–76 years) with osteoarthrosis of the hip, verified both clinically and radiologically, examined the reliability of goniometric measurements and visual estimates of hip ROM. Hip ROM measurements (abduction, adduction, extension, flexion, and internal /external rotation) were recorded by four different teams on the same day and were repeated 1 week later. Teams 1, 2, and 3 consisted of physiotherapists using standardized goniometric measurements. Team 4 involved an experienced orthopaedic surgeon making the assessments from visual estimates only. With the exception of abduction (p = 0.03), there were no significant differences between the measurements recorded on the first and second occasions for the same teams. The coefficient of variance was 5.5% for flexion (lowest) and 26.1% for extension (highest). Reproducibility was best for flexion. There was also high reliability when all the arcs of motion were summed up (abduction + adduction + extension + flexion + internal/external rotation). With the exception of internal rotation, there were highly significant differences between the teams when two people performed the measurements compared to the values measured by a single individual. Concordance, expressed as the standardized agreement index, between visual estimates made by one individual (the orthopaedic surgeon) and goniometric measurements made by two experienced physiotherapists, was 0.77–0.83, which indicates good agreement.
Bierma-Zeinstra and colleagues134 performed a study to compare the reliability of measurements of hip motions obtained with two instruments, an electronic inclinometer and a two-arm goniometer, and to investigate whether the two instruments, and different body positions, produce the same measurement data. Maximal active and passive hip movements were measured simultaneously with both instruments, in nine subjects during 10 consecutive measurements at short intervals. The results from the study demonstrated the following134:
- The intraobserver variability was lower with the inclinometer in measurements of passive hip rotations.
- The two instruments showed equal intraobserver variability for hip movements in general.
- The inclinometer showed lower interobserver variability in the measurements of active internal rotation.
- More rotational movement was measured with the two-arm goniometer and more extension and flexion with the inclinometer. Also, more rotational movement was found in the prone position compared to the sitting and supine positions.
The study concluded that the inclinometer is more reliable in measurements of hip rotation; for hip movements, in general, the two-arm goniometer is just as accurate when used by only one observer; and the two instruments, and some positions, are not interchangeable during consecutive measurements.134
During the examination of the ROM, the clinician should note which portions of the ROM are pain free and which portion causes the patient to feel pain. An assessment of the lumbopelvic rhythm can alert the clinician to the primary area of a particular limitation. During normal forward bending, the patient should be able to touch their toes without bending the knees and with a flattening of the lordosis (Fig. 19-20). However, if the hamstrings are adaptively shortened, toe touching, cannot be accomplished even with a flattening of the lordosis. If the tightness is located in the LB, as the patient bends forward, no flattening of the lordosis occurs, and the patient is unable to touch the toes even with good hamstring flexibility.
The capsular pattern of the hip appears variable and is an unreliable method for determining the presence of OA when used alone,110 Twinges of pain with active motions may indicate the presence of a loose body within the joint. At the end of available AROM, passive overpressure is applied to determine the end-feel. The normal ranges and end-feels for the various hip motions are outlined in Table 19-5. Abnormal end-feels common in the hip include a firm capsular end-feel before expected end range; empty end-feel from severe pain, as in the sign of the buttock; and bony block in cases of advanced OA.18 Horizontal abduction and adduction of the femur occur when the hip is in 90 degrees of flexion. Since these actions require the simultaneous, coordinated actions of several muscles, they can be used to assess the overall strength of the hip muscles.
Resisted testing of the muscles that cross the hip joint (Table 19-4) is performed to provide the clinician with information about the integrity of the neuromuscular unit, and to highlight the presence of muscle strains (see “Systems Review” section).131
If the history indicates that repetitive motions or sustained positions cause the symptoms, the clinician should have the patient reproduce these motions or positions.135
In the child, pain and loss of range at the hip joint should always alert the clinician to the possibility of transient synovitis, Legg–Calvé–Perthes disease, or a slipped femoral capital epiphysis (see Chap. 30).
In addition to reports of pain and overall ROM, the clinician also notes information about weakness, joint end-feel, palpation of the moving joint, and muscle tightness.
Flexion. The six muscles primarily responsible for hip flexion are the iliacus, psoas major, pectineus, rectus femoris, sartorius, and TFL (Table 19-4). The primary hip flexor is the iliopsoas muscle.
Hip flexion motion can be tested in sitting or supine, first with the knee flexed (Fig. 19-21) and then with the knee extended. With the hip flexed, the ROM should be approximately 110–120 degrees. More hip flexion should be available with the knee flexed.
Hip flexion with knee flexed.
Resisted tests are then performed.
- To test the strength of the iliopsoas, the patient is seated with the thigh raised off the bed and resistance is applied by the clinician.
- The action of the sartorius muscle, which flexes, abducts, and externally rotates the hip, is tested by asking the patient to bring the plantar aspect of the foot toward the opposite knee. The clinician applies resistance at the medial malleolus and at the lateral aspect of the thigh to resist flexion, abduction, and external rotation.
A painless weakness of hip flexion is rarely a good sign. Although it may indicate a disk protrusion at the L1 or L2 level, these protrusions are not common. A more likely scenario is compression of the nerves by a neurofibroma or a metastatic invasion. Pain with the active motion or resisted tests should prompt the clinician to examine the contractile tissues individually. Passive stretching can also produce pain in a contractile structure.
Active Range of Motion: Prone Hip Extension
The primary hip extensor is the gluteus maximus (Table 19-4). The hamstrings also serve as hip extensors. Hip extension also involves assistance from the adductor magnus, gluteus medius and minimus, and indirect assistance from the abdominals and the erector spinae.136
The patient is positioned in prone or over the end of a table. As the clinician monitors motion at the pelvis to ensure the lumbar spine does not extend, the patient is asked to lift the thigh toward the ceiling (Fig. 19-22). With a normal recruitment pattern, the order of firing should be gluteus maximus, opposite erector spinae, and then the ipsilateral erector spinae and hamstrings.128 Poor recruitment patterns are demonstrated as follows:
An initial activation of the hamstrings and erector spinae with a delayed contraction of the gluteus maximus. The biceps femoris has a tendency to become shortened and overactive, resulting in delayed activation of the gluteus maximus.137
The erector spinae initiate the movement with a delayed activity of the gluteus maximus. This would lead to little, if any, extension of the hip joint, as the leg lift would be achieved by an anterior pelvic tilt and a hyperextension of the lumbar spine. This is a very poor movement pattern.
The normal ROM for hip extension is approximately 10–15 degrees. Reduced hip extension with the knee flexed can be the result of a number of reasons, including
- adaptive shortening of the iliopsoas, characterized by an increased lumbar lordosis, an externally rotated lower extremity, and a noticeable groove in the ITB in standing138;
- a hip flexion contracture.
As before, the pelvis is monitored, and the patient is asked to raise the thigh off the table. The strength of the gluteus maximus is tested with the knee flexed (Fig. 19-23). The role of the hamstrings at the hip can be tested with the knee extended. By observing the patient's shoulder during this test, the recruitment pattern can be analyzed. The opposite shoulder should be seen to rise off the bed. With the abnormal pattern, the same shoulder rises off the bed. Patients who use this abnormal recruitment pattern will often have well-developed thoracic musculature on the posterior aspect and, as a result, develop problems at the thoracolumbar junction.128
Hip extension with knee flexed.
Resistance is then applied by the clinician. A strong and painful finding with resisted hip extension may indicate a grade I muscle strain of the gluteus maximus or hamstrings. It may also indicate a gluteal bursitis or a lumbosacral strain. The strength of the medial and lateral hamstrings is also tested using resisted knee flexion, with the patient positioned in prone (see Chap. 20).
Although hip extensor strength in the elderly has been identified as the primary predictor of walking ability, physical performance and balance, assessment of hip extensor strength in this population is commonly overlooked, as the presence of pain, contractures, and reduced mobility often limits the ability of the elderly patient with hip or spine impairment to adopt the prone position.71 In these situations, the clinician should modify the testing position to accommodate the patient (e.g., have the patient lean over a table).
Hip adduction (Fig. 19-24) and abduction (Fig. 19-25) ROM can be tested in supine or sidelying making sure that both ASIS are level, and the legs are perpendicular to a line joining the ASIS.
Hip adduction ROM using anti-gravity position.
Abduction. The clinician monitors the ipsilateral ASIS, and the patient is asked to abduct the leg. The abduction motion is stopped when the ASIS is felt to move. The prime movers for this movement are the gluteus medius/minimus and the TFL. The quadratus lumborum functions as the stabilizer of the pelvis. The strength of the gluteus medius and minimus can be tested against gravity in the sidelying position. The patient is asked to perform hip abduction of the uppermost leg without any flexion or external rotation occurring (Fig. 19-25). The clinician applies resistance to the distal thigh.
Progressive Resistive Exercise: Hip Abduction in Side Lying Using Thera-Band
The correct sequence of firing for hip abduction in side lying should be gluteus medius, followed by the quadratus lumborum and TFL after approximately 15 degrees of hip abduction. Altered patterning demonstrates the following:
External rotation of the leg during the upward movement, indicating an initiation and dominance of the movement by the TFL, accompanied by a weakness of the gluteus medius/minimus. The TFL has a tendency to become shortened and overactive.137
Full external rotation of the leg occurs during the leg lift, indicating a substitution of hip flexion and iliopsoas activity for the true abduction movement. If the piriformis is shortened and overactive, the external rotation of the leg is reinforced.137
A lateral pelvic tilt at the initiation of movement, indicating that the quadratus lumborum, which has a tendency to become shortened and overactive, is both stabilizing the pelvis and initiating the movement.137 This is indicative of a very poor movement pattern.
Adduction. Hip adduction is tested with the patient supine and with the uninvolved leg adducted over the other leg or held in flexion (Fig. 19-24). As before, the ASIS is monitored for motion, indicating the end of range for adduction. The primary hip adductor is the adductor longus. Adaptive shortening of the hip adductors can theoretically result in inhibition of the gluteus medius, a decrease in frontal stability, ITB tendinitis, and anterior knee pain. Pain can be referred from the hip adductors into the anterolateral hip, groin, medial thigh, the anterior knee, and medial tibia. Pain in these regions with passive abduction, or adduction, may indicate a strain of one of the adductors. The cause of the pain can be differentiated between the two-joint gracilis and the other hip adductors (longus, brevis, and pectineus) in the following manner. The patient is positioned in supine, with the tested leg over the edge of the table, monitored by the clinician. The clinician places the involved hip into the fully abducted position and the knee is flexed (Fig. 19-26). If no pain is reproduced with this maneuver, the patient is asked to extend the knee (Fig. 19-27), thereby bringing in the gracilis and implicating it if the pain is now reproduced. This can be confirmed with resisted hip adduction and knee flexion. If the other adductors are implicated, this can be confirmed with resisted adduction (longus and brevis) or resisted hip adduction and hip flexion (pectineus).
Differentiating hip-adductor muscles—knee flexed.
Differentiating hip-adductor muscles—knee extended.
The strength of the hip-adductor muscle group can also be tested in side lying, by flexing the uninvolved leg over the tested leg or by supporting the upper leg and then applying resistance. This position also stretches the hip abductors and can be a source of pain in the case of an ITB syndrome.
A strong and painful finding with resisted adduction is usually the result of an adductor longus lesion, whereas a painless weakness with resisted abduction is often found in a palsy of the fifth lumbar root because of a disk herniation of the same level.
Internal and External Rotation
Although a number of muscles contribute to external rotation of the femur (see Table 19-4), six muscles function solely as external rotators.32 These are the piriformis, gemellus superior, gemellus inferior, obturator internus, obturator externus, and quadratus femoris. Normal ROM for hip external rotation is approximately 40–60 degrees. Excessive external rotation of the hip may indicate hip retroversion.
The major internal rotator of the femur is the gluteus minimus, assisted by the gluteus medius, TFL, semitendinosus, and semimembranosus. The internal rotators of the femur are estimated to be only approximately one-third the strength of the external rotators.96 Normal ROM for hip internal rotation is approximately 30–40 degrees. Excessive internal rotation of the hip may indicate hip anteversion.
If an asymmetry exists between the two positions such that more ROM is available in the prone position compared with supine, a muscle restriction is likely present.139 When the asymmetry of internal rotation ROM is much greater than the external rotation range in both the hip flexed and hip extended positions, structural anteversion may be present.139 If retroversion is present, the range of external rotation is greater than the range of internal rotation in both the flexed and extended positions of the hip.139
To assess the ROM of the hip rotators, the patient is positioned in supine, with the leg in 90 degrees of hip flexion and 90 degrees of knee flexion. Hip IR (Fig. 19-28) and ER (Fig. 19-29) is then assessed. Alternatively, the patient can be positioned in prone, with the knee flexed to 90 degrees and the hip in neutral. Once the ROM measurements have been established, the strength of the internal rotators and external rotators is then assessed.
Manual Muscle Testing: Hip Internal Rotators
Manual Muscle Testing: Hip External Rotators
In addition to gait analysis, the function of the hip can be assessed through observation during functional activities such as sit to stand, or through use of a self-report measure, which allow a patient to rate his or her capacity to perform ADL. Table 19-14 outlines a functional assessment tool for the hip.
Table 19-14 Functional Tests of the Hip ||Download (.pdf)
Table 19-14 Functional Tests of the Hip
Hip flexion: lift foot onto an 8-inch/20-cm step and return
5–6 repetitions: functional
3–4 repetitions: functionally fair
1–2 repetitions: functionally poor
Zero repetitions: nonfunctional
Hip extension: sit in a chair and return to standing
5–6 repetitions: functional
3–4 repetitions: functionally fair
1–2 repetitions: functionally poor
Zero repetitions: nonfunctional
Hip abductors: lift leg to the articular surfaces balance on one leg while keeping pelvis level
Hold 1–1.5 min: functional
Hold 30–59 s: functionally fair
Hold 1–29 s: functionally poor
Cannot hold: nonfunctional
Hip adductors: walk sideways 6 m
6–8 m one way: functional
3–6 m one way: functionally fair
1–3 m one way: functionally poor
0 m: nonfunctional
Hip internal rotation: test leg off floor (holding onto object for balance if necessary), internally rotate non–weight-bearing hip
10–12 repetitions: functional
5–9 repetitions: functionally fair
1–4 repetitions: functionally poor
Zero repetitions: nonfunctional
Standing, facing closed door
Hip external rotation: test leg off floor (holding onto object for balance if necessary), externally rotate non–weight-bearing hip
10–12 repetitions: functional
5–9 repetitions: functionally fair
1–4 repetitions: functionally poor
Zero repetitions: nonfunctional
The Harris Hip Rating Scale (Table 19-15) is the most commonly used functional outcome assessment for the hip and can be used to assess patient status following the onset of traumatic arthritis, and a variety of hip disorders.
Table 19-15 Harris Hip Rating Scale ||Download (.pdf)
Table 19-15 Harris Hip Rating Scale
Harris Hip Function Scale
Examination of Movement Patterns
Some of the movement patterns were assessed in the “Active, Passive, and Resistive Tests” section. One further test is described here.
This test assesses the patient's ability to sit up from a supine position and the relationship between the abdominal and iliopsoas muscles. The patient is positioned in supine with the hips and knees flexed, both feet flat on the bed.
The patient is then asked to perform a sit-up while actively plantar flexing their ankles, thus removing the effect of the iliopsoas.136 The patient progressively flexes the spine, starting at the cervical region, until the lumbar region is flexed. As soon as the iliopsoas becomes involved in the motion, the patient's feet will lift from the bed. Normally, the patient should be able to curl up so that the thoracic and lumbar spines are clear of the bed before the feet lift. A patient in excellent condition can complete a full sit-up without the feet lifting from the bed.
Passive Accessory Movements
Because of the extreme congruency of the joint partners at the hip joint, this is a difficult area to assess with any degree of accuracy, especially as the glides that occur are very slight. Unless otherwise indicated, the patient is positioned supine with the hip in its resting position. The clinician can wrap a belt around the patient's pelvis and the treatment table to help stabilize the pelvis.
A joint distraction can be used to assess for pain and any hypomobility at the hip joint. The patient's thigh is grasped by the clinician as proximal as possible, and a distraction force is applied along the line of the femoral neck (see Fig. 19-30).
The clinician grasps the patient's ankle and applies a longitudinal force along the length of the leg (Fig. 19-31).
The clinician stands on the medial side of the patient's thigh. A belt can be placed around the clinician's shoulder and under the patient's thigh, to help hold the weight of the lower extremity. The clinician places one hand on the distal thigh of the patient and the other hand on the anterior surface of the patient's proximal thigh (Fig. 19-32). Keeping the elbows extended and flexing the knees, the clinician applies a force through the patient's hip in a posterior direction (Fig. 19-32).
Posterior glide of the hip.
The patient is positioned prone, with the trunk resting on the table, their thigh over the edge, and the opposite foot supported (Fig. 19-33). The clinician stands on the lateral side of the patient's thigh. A belt can be placed around the clinician's shoulder and under the patients thigh to help hold the weight of the lower extremity. Using one hand, the clinician grasps the patient's lower leg. The other hand of the clinician is placed posteriorly on the proximal thigh of the patient, just below the buttock (Fig. 19-33). Keeping the elbows extended and flexing the knees, the clinician applies a force through the proximal hand in an anterior direction.
Anterior glide of the hip.
The patient is positioned with the hip and knee each flexed to 90 degrees and the lower leg placed against the clinician's shoulder. The clinician grasps the anterior aspect of the proximal femur as far proximally as possible with one hand. An inferior glide is imparted using the hands, while simultaneously rocking the patient's thigh into flexion (Fig. 19-34).
Inferior glide of the hip.
For sensation testing, the clinician should be aware of the dermatomal pattern as well as the areas supplied by the peripheral nerves (inferior femoral cutaneous nerve, lateral cutaneous nerve of the thigh, and posterior femoral cutaneous nerve).
Paresthesia or anesthesia is not commonly found in the buttock, hip, or groin region because of the degree of dermatome overlap. However, paresthesia in the “saddle” region should be considered indicative of a sign of cauda equina compression.
Special tests are merely confirmatory tests and should not be used alone to form a diagnosis. The results from these tests are used in conjunction with the other clinical findings to help guide the clinician. To assure accuracy with these tests, both sides should be tested for comparison.
The quadrant or scour test is a dynamic test of the inner and outer quadrants of the hip joint surface.140
The patient is positioned in supine, close to the edge of the bed, with their hip flexed and foot resting on the bed. The clinician places one hand over the top of the patient's knee. The patient's hip is placed in 90 degrees of flexion, with the knee being allowed to flex comfortably. From this point, the clinician adducts the hip to the point at which the patient's pelvis begins to lift off the bed, to assess the inner quadrant (Fig. 19-35). At the end range of flexion and adduction, a compression force is applied through the knee along the longitudinal axis of the femur. From this point, the clinician moves the hip into a position of flexion and abduction to examine the outer quadrant. Throughout the entire movement, the femur is held midway between internal and external rotation, and the movement at the hip joint should follow the smooth arc of a circle. An abnormal finding is resistance, apprehension, or pain felt anywhere during the arc. The pain can result from compression of, or stress to, a number of structures including140
- the articular surfaces of the hip joint;
- the labrum;
- the hip joint capsule;
- the insertion of the TFL and the sartorius;
- the iliopsoas muscle;
- the IPB and neurovascular bundle;
- the insertion of the pectineus;
- the insertion of the adductor longus;
- the femoral neck.
The resistance may be caused by capsular tightness, an adhesion, a myofascial restriction, or a loss of joint congruity. Given all of the possible diagnoses, extreme care must be taken when interpreting the results from this test. Of the various studies that have looked at the Scour test, most have had poor study designs. Given the wide range of possible diagnoses with a positive finding, and the variety of patients this test is used with, bias is likely to result.
The FABER (flexion, abduction, external rotation) test (Fig. 19-36) is a screening test for hip, lumbar, or sacroiliac joint dysfunction, or an iliopsoas spasm (see Chap. 29).
A number of tests can be used to examine the sacroiliac joint (see Chap. 29).
In addition to the provocative tests, the passive motions of the hip can be examined with the innominate stabilized. The hip motions and their respective innominate motions in parenthesis are outlined in Table 19-6.
The Craig test is used to assess femoral anteversion/retroversion. The patient is positioned in prone with the knee flexed to 90 degrees. The clinician rotates the hip through the full ranges of hip internal and external rotation, while palpating the greater trochanter and determining the point in the range at which the greater trochanter is the most prominent laterally. If at this point the angle is greater than 8–15 degrees in the direction of internal rotation, when measured from the vertical and long axis of the tibia, the femur is considered to be in anteversion.80,87,139,141
One study141 showed this test to be accurate to within 4 degrees of intraoperative measurements, for the assessment of femoral anteversion/retroversion, and was more accurate than radiographic measurement techniques.
This test is used as a screening test for early hip dysplasia.142 The patient is positioned in supine, and the hip is passively flexed to 90 degrees and in neutral rotation while maintaining the contact of the patient's pelvis to the bed. From this position, the clinician monitors the pelvis and the hip is passively adducted (Fig. 19-37). The resultant end-feel, restriction, discomfort, or pain is noted and compared with the normal side. A positive test for an early sign of hip dysplasia is the inability to adduct the flexed hip past midline toward the opposite hip. Although Woods and Macnicol142 found the sensitivity to be 100% with this test, the test was performed on adolescents and demonstrated many design flaws.
This test is used to detect hamstring weakness or injury. The patient is positioned in supine, resting on his or her arms and heels. The patient is asked to elevate the pelvis while maintaining their body weight on the arms and heels (Fig. 19-38). The patient is then asked to alternately lift one leg at a time. The test is positive for weakness if pelvic collapse or rotation occurs, or for injury if pain occurs at the ischial origin or in the hamstring musculature.
The Trendelenburg sign indicates weakness of the gluteus medius muscle during unilateral weight-bearing. This position produces a strong contraction of the gluteus medius, which is powerfully assisted by the gluteus minimus and TFL, in order to keep the pelvis horizontal. For example, when the body weight is supported by the left foot (Fig. 19-19), the left hip abductors contract both isometrically and eccentrically to prevent the right side of the pelvis from being pulled downward by gravity.
The clinician crouches or kneels behind the patient so that the eyes are level with the patient's pelvis, and ensures that the patient does not lean to one side during the testing. The patient is asked to stand on one limb for approximately 30 seconds, and the clinician notes whether the pelvis remains level. If the hip remains level, the test is considered negative. A positive Trendelenburg sign is indicated if during unilateral weight-bearing the pelvis drops toward the the side of the unsupported limb (Fig. 19-19). A number of dysfunctions can produce the Trendelenburg sign. These include superior gluteal nerve palsy, lumbar disk herniation, weakness or tear of the gluteus medius, and advanced degeneration of the hip. Thus, if used in isolation, this test has little diagnostic value.
The patient is asked to place one foot on a 20-cm (8-inch) stool or step and to stand up straight. The patient then lowers the non–weight-bearing leg to the floor (Fig. 19-39). On lowering the leg, there should be no arm abduction, anterior or pelvic motion, trunk flexion, or any hip adduction or internal rotation occuring at the weight-bearing hip. These compensations are indications of weak external rotators or an unstable hip.
Piriformis Compression of the Sciatic Nerve.117
Piriformis compression of the sciatic nerve can be reproduced by maximally stretching the piriformis muscle. The patient lies supine with both legs flat on the exam table. The clinician raises one leg, and positions it in maximum flexion of the hip and knee. The hip is then internally rotated and fully adducted (Fig. 19-40). Pain radiating down the leg constitutes a positive test for piriformis syndrome.
Stinchfield's test is designed to help determine the source of a patient's back, buttock, groin, and/or leg pain. The patient is positioned in supine and asked to lift their leg, without bending the knee, to about 30 degrees. If this maneuver does not reproduce any pain, the clinician applies pressure downward on the patient's raised leg, in an attempt to extend the flexed hip, while the patient resists the force (Fig. 19-41). Pain produced either with or without resistance is assessed for location. If the pain is felt in the groin or anterior thigh, it is considered to arise from the hip; if from the buttock or lumbar spine, the sacroiliac joint or lumbar spine is the likely source. Stinchfield's test should not be confused with the straight-leg raise test used to detect neuromeningeal problems (see Chap. 11). Stinchfield's test is not dependent on the range obtained but rather on the location of symptoms. The only manner in which the two diagnoses could be confused is if a lumbar lesion was producing a restriction of the SLR at or below 30 degrees, but other signs and symptoms would help differentiate between the two. Unfortunately, Stinchfield's test has not been subjected to criteria validity research, so no sensitivity or specificity numbers are available.
Auscultatory Patellar-Pubic Percussion Test.143–145
The ausculatory patellar-pubic percussion test is used when there is a suspicion of occult hip fracture. The patient is positioned in supine, and the clinician places the head of a stethoscope over the pubic symphysis. With the lower extremities extended and positioned symmetrically, the clinician taps (percusses) each patella with a finger or reflex hammer and compares the generated sound (Fig. 19-42). The percussion note should have symmetrical quality and intensity of sound. Any bony disruption along the conduction path (femur) will result in a diminished or muffled sound intensity of a duller quality. Reliability and validity of the technique has been demonstrated.143 Tiru and colleagues146 noted a positive predictive value of 0.98, sensitivity of 0.96, and specificity of 0.76. Although the study design was not without fault, the test does appear to have diagnostic value as a screening tool and as a diagnostic tool. Thus, a positive patellar-pubic percussion test should prompt a referral for diagnostic imaging.143
Auscultatory Patellar-Pubic Percussion test.
Restrictions in motion limit functional capacity, decrease muscle strength (by adversely affecting the muscle length–tension relationship), and can have an adverse effect on muscle and joint biomechanics.
Thomas Test and Modified Thomas Test. The original Thomas test was designed to test the flexibility of the iliopsoas complex but has since been modified and expanded to assess a number of other soft tissue structures. Neither the original test nor the suggested variations have ever been substantiated for reliability, sensitivity, or specificity.
The original test involves positioning the patient in supine, with one knee being held to the chest at the point where the lumbar spine is felt to flex (Fig. 19-43). The clinician assesses whether the thigh of the extended leg maintains full contact with the surface of the bed. If the thigh is raised off the surface of the table, the test is positive. A positive test indicates a decrease in flexibility in the rectus femoris or iliopsoas muscles or both. One of the limitations of this test is that it merely determines the amount of hip extension possible at any given degree of pelvic flexion.147 Another problem is that there are better methods of measuring the flexibility of the iliopsoas complex. For example, positioning the patient in prone, stabilizing the pelvis, and then extending the thigh. The precise point at which the pelvis begins to rise marks the end of the hip motion and the beginning of pelvic and spine motion.
Thomas test demonstrating adaptive shortening.
A modified version of this test is commonly used to help eliminate the effect of the lumbar curve. For the modified version, the patient is positioned in sitting at the end of the bed. From this position, the patient is asked to lie back, while bringing both knees against the chest. Once in this position, the patient is asked to perform a posterior pelvic tilt. While the contralateral hip is held in maximum hip flexion by the patient's hands, the tested limb is lowered over the end of the bed toward the floor (Fig. 19-44). If normal, the thigh should be parallel with the bed, in neutral rotation, and neither abducted nor adducted, with the lower leg being perpendicular to the thigh and in neutral rotation. There should be 100–110 degrees of knee flexion present with the thigh in line with the table.
If the thigh is raised compared to the table, a decrease in the flexibility of the iliopsoas muscle complex should be suspected. If the rectus femoris is adaptively shortened, the amount of knee extension should increase with the application of overpressure into hip extension.136 If the decrease in flexibility lies with the iliopsoas, attempts to correct the hip position should result in an increase in the external rotation of the thigh.136
The application of overpressure into knee flexion can also be used. If the increase in knee flexion produces an increase in hip flexion (the thigh rises higher off the bed), the rectus femoris is implicated, whereas if the overpressure produces no change in the degree of hip flexion, the iliopsoas is implicated.
This test can also be used to assess the flexibility of the TFL, if the hip of the tested leg is maximally adducted while monitoring the ipsilateral ASIS for motion. There should be 20 degrees of hip adduction available.
Two things must be remembered when interpreting the results of this test:
- The criteria are arbitrary and have been shown to vary between genders and limb dominance and to depend on the types and the levels of activity undertaken by the individual.148
- The apparent tightness might simply be normal tissue tension, producing a deviation of the leg because of an increased flexibility of the antagonists.
As always, the cause of the asymmetry must be found (or at least looked for) and addressed.
Ely's Test. This is a test designed to assess the flexibility of the rectus femoris. The patient is positioned in prone and the knee is passively flexed by the clinician (Fig. 19-45). If the rectus is tight, the hip flexes on the same side and the pelvis is observed to anteriorly rotate early in the range of knee flexion. The other side is tested for comparison. No diagnostic accuracy studies have been performed to determine the sensitivity and specificity of this test.
Ober Test. The Ober test is used extensively to evaluate the flexibility of the ITB and TFL (see Thomas test).149 The patient is placed in the side lying position, and with the hip extended and abducted and the knee flexed to 90 degrees, the proximal part of the tested leg is released and allowed to drop passively (Fig. 19-46). The test is considered positive when the leg fails to lower. However, there have been some doubts expressed as to the reliability of the Ober test as a measure for ITB tightness and to date, no diagnostic accuracy studies have been performed to determine the sensitivity and specificity of this test.150
Modified Ober Test. The modified Ober test is performed in the same fashion as the Ober test except that the knee of the tested leg is extended (Fig. 19-47).151 A study by Reese and Bandy151 was performed to determine the intrarater reliability of the Ober test and the modified Ober test for the assessment of IT band flexibility using an inclinometer to measure the hip adduction angle and to determine if a difference existed between the measurements of IT band flexibility between the Ober and the modified Ober test. Sixty-one subjects, with a mean age of 24.2 (SD = 4.3) years, were measured during two measurement sessions over 2 consecutive days.151 During each measurement session, subjects were positioned on their left side and, with an inclinometer at the lateral epicondyle of the femur, hip adduction was measured during the Ober test (knee at 90 degrees of flexion) and the modified Ober test (knee extended).151 If the limb was horizontal, it was considered to be at 0 degrees, if below horizontal (adducted), it was recorded as a positive number, and if above horizontal (abducted), it was recorded as a negative number. The ICC values calculated for the intrarater reliability of the repeated measurement were 0.90 for the Ober test and 0.91 for the modified Ober test.151 Results of the dependent t test indicated a significantly greater ROM of the hip in adduction using the modified Ober test as compared to the Ober test.151 The study concluded that the use of an inclinometer to measure hip adduction using both the Ober test and the modified Ober test appears to be a reliable method for the measurement of IT band flexibility, and the technique is quite easy to use.151 However, given that the modified Ober test allows significantly greater hip adduction ROM than the Ober test, the two examination procedures should not be used interchangeably as a measurement of IT band flexibility.151
Straight-Leg Raise Test for Hamstring Length. The patient is positioned in supine with the legs staright and together resting on the table. The clinician stands on the side of the leg to be tested and grasps the patient's ankle with one hand, while visually monitoring, or palpating the patient's opposite ASIS. With the patient's knee extended, the clinician lifts the patient's leg, flexing it at the hip until motion is detected at the opposite ASIS (Fig. 19-48). The angle of hip flexion from the table is measured. The clinician returns the leg to the table and repeats the maneuver from the other side of the table with the other leg. The hamstrings are considered shortened if a straight leg cannot be raised to an angle of 80 degrees from the horizontal, while maintaining the other leg straight.128 Any limitation of flexion is interpreted as being caused by adaptively shortened hamstring muscles.
Straight-Leg Raise test for Hamstring Length.
This straight-leg raise test may also be used as a screen for adverse neural tension, particularly of the sciatic nerve (see Chap. 11), and to differentiate between a hamstring lesion and a sciatic nerve lesion by adding ankle dorsiflexion (Fig. 19-49)—adding dorsiflexion places tension through the sciatic nerve but does not alter hamstring length.
Straight-Leg Raise test with ankle dorsiflexion.
90–90 Straight-Leg Raise. Hamstring length can also be assessed with the patient positioned in supine and the tested leg flexed at the hip and knee to 90 degrees. From this position, the patient is asked to extend the knee of the involved side without extending the hip (Fig. 19-50). A measurement of knee motion is taken at the first resistance barrier.
90–90 Straight-Leg Raise.
Piriformis. The FAIR (flexion, adduction, and internal rotation) test is designed to detect compression of the sciatic nerve by the piriformis. The patient is positioned in side lying or supine with the involved extremity by the clinician. Holding the patient's knee, the clinician brings the involved extremity into a position of hip flexion, adduction, and internal rotation (Fig. 19-51). If pain is elicited at a point corresponding to the intersection of the sciatic nerve and the piriformis during this test, the result is considered positive.152,153 The FAIR test has been demonstrated to have a sensitivity of 0.88, a specificity of 0.83, a + LR of 5.2, and a –LR of 0.14.152,154
The tests used to detect the presence of a leg length discrepancy are described in Chapter 29.
The fulcrum test155 is used to test for the presence of a stress fracture of the femoral shaft. The patient is positioned in sitting, with their knees bent over the edge of the bed and feet dangling. The clinician positions his or her arm under the thigh to be tested and moves it proximal to distal, as gentle pressure is applied on the thigh with the clinician's hand (Fig. 19-52). A positive test is when the patient reports sharp pain or expresses apprehension when the fulcrum arm is placed under the fracture site. The fulcrum test has not been subjected to criteria validity research, so no sensitivity or specificity numbers are available.
The standard radiographic views of the hip include anteroposterior views and axial or frog leg views (see Chap. 7).