Examination of the Hip Joint

Introduction

• Introduce yourself and get the consent of the patient or the parent of the child for examination.
• Note down the name, age, sex, race and occupation of the patient.
• The patient should be adequately exposed while making sure that external genitalia are covered and the patient is comfortable and relaxed. Explaining why you need to expose and the steps of examination will help in relaxing the patient and in establishing a good rapport.
• When examining a female patient make sure that you have a female nurse or assistant.
• Examine the child with the parents by the side. Very young children may be examined in the parent’s lap.
• First examine the normal or less symptomatic side first to establish the normal range of movement for the particular patient and to make the patient understand what is going to be done on the painful side.
• Steps of all procedures should be explained to the patient to ensure patient comfort and cooperation.

Patients with hip joint disease may present with pain, alteration of gait, instability, functional limitation or limb length discrepancy as their presenting complaint. Hip symptoms may be due to intra-articular, extra-articular or referred causes. Intra-articular conditions usually will cause deformity, limitation of range of movement and worsening of symptoms on joint activity. Extra-articular conditions usually will not cause restriction of range of movement, pain will be present mainly in one particular movement or position of joint and tenderness will be localized to a specific area. Always rule out referred pain from spine, pelvis, and sacroiliac joint or vascular causes. Rarely hip disease may present as pain referred to the knee.

Examine the patient in standing, sitting, walking and lying down. When the patient is lying in the supine position, always examine the patient from the right side. Make sure that the patient lies on a hard surface to ensure that deformities are not concealed by a soft mattress.

HISTORY

Presenting complaints – Give the presenting complaints in the chronological order.

History of presenting complaints

Pain

• Duration – How long the pain is present?
• Onset – How it started?
• Progress – What has happened to the pain after it started? Has it increased, decreased or remain in the same intensity. Is it constant or intermittent?
• Site- Ask the patient to pinpoint the site of pain with a single finger. Note down whether in the groin, trochanteric area, buttocks etc. and don’t use vague terms like pain in the hip. Remember that a patient with hip disease may present with knee pain.
• Severity- How disabling is the pain? What is its effect on routine activities, self care, locomotion, occupation and recreational activities?
• Character – What is the nature of pain? Throbbing pain is due to inflammatory causes, burning pain is due to neuropathic causes.
• Radiation- Pain of hip may radiate to knee or thigh. Pain radiating to the testes is suggestive of ureteric calculi. Pain radiating below knee is due to sciatica.
• Aggravating and relieving factors- Mechanical pain due to osteoarthritis or impingement is aggravated by activity and relieved by rest. Pain due to inflammatory arthritis is aggravated by rest and partially relieved by activity.
• Diurnal variation- Pain of osteoarthritis is more towards the evening and less when patient gets up in the morning. Pain of inflammatory arthritis like ankylosing spondylitis is more in the morning and less in the evening. Nocturnal pain that interferes with sleep is an ominous sign of malignancy or infection.
• Associated symptoms

Deformity

• How long the deformity is present?
• How did it start?
• How is it progressing?
• Any associated symptoms?
• Is there any history of trauma or infection?

Limb length discrepancy

• How long it is present?
• Is it static or progressive?
• Associated symptoms?
• Any history of infection or trauma?

History to assess function

• Walking ability
  • Normal or altered
  • Restricted or unrestricted
  • Aided or unaided
  • If aided; which aid is used
• Ability to squat
• Ability to sit cross legged
• Ability to drive car
• Ability to tie shoes

Fever – Whether associated with chills and rigor, severity, continued or intermittent and the treatment taken.

Past history

• Hypertension
• Diabetes mellitus
• Inflammatory arthropathy
• Septic arthritis
• Tuberculosis
• Umbilical sepsis
• H/o prolonged IV infusion in childhood
• Blood Dyscriasis
• Frequent episodes of bleeding
• Frequent episodes of infection
• H/o Childhood limping
• Previous hospital admission
• Previous surgery
• Previous trauma

Personal history

• Prolonged drug intake
• Alcohol abuse
• Smoking
• Diet
• Menstrual history
• Occupational history
• Recreational activities

Treatment History

Family history

• Any family history of dwarfism
• Any family history of angular deformities
• Metabolic disorders
• Similar illness
• Tuberculosis

GENERAL EXAMINATION

Head to foot examination

Eyes- Blue sclera, irirtis ,uveitis, squint, microophtalmos, cornea, pigmentation of sclera.

Pinna- Low set, blackish discoloration.

Cheeks- Malar rash.

Mouth – Normal dental hygiene, arch of palate.

Hair Line- Normal or low

Neck – Webbing , thyroid swelling.

Nipples- Normal level or not.

Shape of chest wall- Pectus carinatum/ excavatum.

Abdomen- Protuberant , undescended testis , hernias.

Nails- Pitting.

Palms and soles- Hyperkeratosis.

Thickening of lower end radius, malleoli and costochondral junctions.

Ligamentous laxity (Wynne-Davis Criteria- 3 out of 5 needed for diagnosing generalized laxity)

• Apposition of thumb to flexor aspect of forearm
• Passive extension of fingers so that they lie parallel to the forearm.
• Hyperextension of elbow at least 10 degrees
• Hyperextension of knee at least 10 degrees
• Excessive passive dorsiflexion of ankle (45 degree) with eversion of foot.

Neurocutaneous markers-

LOCAL EXAMINATION

The steps of local examination are inspection, palpation, movements, measurements, gait analysis, special tests and examination of spine and other joints and other system.

Inspection

Inspection should be done with the patient standing, walking, sitting and lying down. Look from the front, sides and back. Look for any asymmetry when compared to the normal side.

Look for the following.

• Attitude
• Deformity
• Bony contours
• Soft tissue contours
• Swelling
• Wasting
• Limb length discrepancy
• Skin over the joint

Attitude and Deformity

Attitude is the position of joint which is most comfortable to the patient. Position of comfort for the hip joint is flexion, abduction & external rotation; as it allows maximum distension of the capsule. If the joint is moved it can be brought to neutral position. In deformity; there is a fixed contracture of the joint which will prevent the joint from being placed in the neutral position. A flexed attitude of the hip joint can be corrected but a fixed flexion deformity cannot be corrected.

Normally when a person lies supine on a firm surface the lumbar spine lies flat on the table and there will not be any gap between the lumbar spine and the couch; if there is a gap then lumbar lordosis is exaggerated. In the case of flexion deformity of the hip (FFD) it is usually masked by forward tilting of the pelvis, which in turn is masked by increased lumbar lordosis. Hence exaggerated lumbar lordosis is a sign of fixed flexion deformity of the hip. Unmasking of the fixed flexion deformity of hip can be done by the Thomas well leg raising test.

A coronal plane deformity such as abduction or adduction is masked by compensatory coronal tilting of the pelvis, which can be identified by looking at the level of both anterior superior iliac spines (ASIS). In case of an adduction deformity; the ASIS of the deformed side will be at a higher level, the affected limb will appear to be shortened and there will lumbar scoliosis with convexity to the opposite side. In case of abduction deformity; the ASIS of the deformed side will be at a lower level, the affected limb will appear to be lengthened and there will lumbar scoliosis with convexity to the same side.

Anteriorly from proximal to distal;

• Level of ASIS
• Normal hollowing of iliac fossa
• Inguinal orifices
• Widened perineum
• Femoral artery pulsations
• Abnormal fullness in the Scarpa’s triangle
• Contour and level of the greater trochanter
• Contour and bulk of the thigh muscles looking for abnormal contour and wasting
• Scars, discolorations, swellings and sinuses

Laterally:

• Exaggerated lumbar lordosis
• Position and bulk of the trochanter- Look for any superior migration and more posterior position when compared to opposite side. Superior migration may be due to dislocation/subluxation, joint space destruction, fracture of neck /trochanter and coxa vara. Excessive lateral prominence is seen in subluxation/dislocation. Reduced prominence seen with protrusio acetabuli.
• Scars sinuses or any abnormal prominences

Posteriorly:

• Scoliosis
• Level of posterior superior iliac spine and iliac crests
• Symmetry of the gluteal folds
• Wasting of gluteal muscles
• Scars, sinus or abnormal masses

Palpation

Palpate for any local rise in temperature, tenderness, bony thickening or swelling, soft tissue mass or defect.

Anteriorly:

• Local rise of temperature
• Anterior joint line tenderness- Anterior joint line is 2-3 cm below and lateral to mid-inguinal point. Mid-inguinal point is the centre of a line connecting ASIS and the symphysis pubis.
• Confirm level of ASIS.
• Feel the resistance over the Scarpa’s triangle. It will be reduced if the hip is dislocated and it will be more in case of cold abscess.
• Femoral pulsations- The volume of pulse when compared to opposite side will be reduced if the head is dislocated (Vascular sign of Narath).

Laterally:

• Greater trochanter
• Level in both supero-inferior as well as antero-posterior directions.
• Surface – Smooth or irregular or is it thickened.
• Tenderness both local and on thrust

Posteriorly:

• Any mass- Globular bony mass that moves with the femur is suggestive of dislocated femoral head in presence of an unstable hip.
• Posterior joint line tenderness- Located at the junction of the lateral one third and the medial two third of a line connecting the posterior superior iliac spine (PSIS) and greater trochanter.

Movements

Look for active and passive movements in all three axes. Look for flexion & extension, abduction & adduction and the external & internal rotation. Look for any fixed rotation deformities in both hip flexion as well as extension.

A deformity almost always occurs in all three planes, but it will be predominantly in one or two planes. It may occur in the sagittal plane (Flexion-Extension), coronal plane (Abduction-Adduction) or in the axial plane (Internal rotation-External rotation). In the case of flexion deformity of the hip (FFD) it is usually masked by forward tilting of the pelvis, which in turn is masked by increased lumbar lordosis. Hence exaggerated lumbar lordosis is a sign of fixed flexion deformity of the hip. Normally when a person lies supine on a firm surface the lumbar spine lies flat on the table and there will not be any gap between the lumbar spine and the couch; if there is a gap then lumbar lordosis is exaggerated. Unmasking of the fixed flexion deformity of hip can be done by the Thomas well leg raising test.

A coronal plane deformity such as abduction or adduction is masked by compensatory coronal tilting of the pelvis, which can be identified by looking at the level of both anterior superior iliac spines (ASIS). In case of an adduction deformity; the ASIS of the deformed side will be at a higher level, the affected limb will appear to be shortened and there will lumbar scoliosis with convexity to the opposite side. In case of abduction deformity; the ASIS of the deformed side will be at a lower level, the affected limb will appear to be lengthened and there will lumbar scoliosis with convexity to the same side.

In order to assess the deformity, the coronal plane deformity is made manifest by correcting the coronal compensatory tilting of the pelvis. This is called squaring of the pelvis.

Squaring of the pelvis is done by making both the ASIS at the same level. This is done by further adducting the affected hip in presence of an adduction deformity till both ASIS are at the same level. If there is some degree of free adduction present then the hip has to move through that free range before the pelvis starts tilting. Hence before measuring the degree of adduction deformity, gently abduct the limb till the free range of movement is over and pelvis just starts to tilt again. Now measure the degree of adduction deformity by using a goniometer. The goniometer is place with the hinge over the centre of hip and one arm is parallel to the midline of trunk and the other arm is parallel to the lower limb. Abduction deformity is measured by further abducting the affected hip using the same principles.

Normal ROM in Hip in adults

Flexion 120⁰

Extension 10⁰

Abduction 40⁰

Internal rotation in flexion 35⁰

Internal rotation in Extension 30⁰

External rotation in flexion 45⁰

External rotation in Extension 40⁰

Range of movement depends largely on the age, gender and race. Children and women have greater range of movement. Elderly will have lesser range of motion. Asian populations have greater range of movement.

Movements should be tested both actively and passively.

The important points to be noted are the following.

1. Is the range of movements normal?
The range of movement in all three axes should be measured using a goniometer. The hinge of the goniometer should be at the centre of rotation of hip. The proximal arm of the goniometer should be in the long axis of the body and the distal arm should be in the long axis of the lower limb.
2. If restricted; which movement is restricted?

Global limitation of all movements is seen with arthritis and differential limitation of abduction and external rotation is seen with coxa vara.
3. If restricted; what is the severity?

Compare with the opposite side. If the opposite side is also abnormal then compare with the normal range for the age, gender and race
4. Is the movements painless, painful?
5. If painful; during which movement and during which part of the arc of movement?
In patients with synovitis, the range of movements is normal but the terminal part of the arc is painful. In case of arthritis all movements are restricted to some degree and painful. Pain on one particular movement alone with normal range of movement is suggestive of extra-articular cause of pain.
6. Is the limitation of movement due to mechanical causes or due to pain and spasm?
7. Is the axis of movement normal?
Normally when the hip is flexed the lower limb flexes towards the opposite shoulder. Axis deviation during flexion can be seen in patients with slipped capital femoral epiphysis.
8. Was there any exaggeration of the normal movements?
In presence of childhood septic arthritis (Tom Smith arthritis), dysplastic hip or post polio residual paralysis the range of movements is exaggerated in all directions. In SCFE there will be exaggerated extension, adduction and external rotation and limitation of flexion, abduction and internal rotation.

Measurement

One should measure the length and circumference of the limb. Longitudinal measurement includes measurement of the length of the entire lower extremity and measurement of segments. The segements to measure are the leg segment, infratrochanteric segment and the supratrochanteric segment. Longitudinal measurement of lower extremity involves measurement of apparent length and true length.

Apparent length:

Keep both lower limbs parallel to each other in line with the trunk and measure from the xiphisternum to the medial malleolus tip.

True length:

Square the pelvis in the method described earlier. Further adduct if there is an adduction deformity and vice versa. True length of the affected limb is measured from the inferior edge of ASIS to the tip of medial malleolus. Place the normal limb in exactly the same position as the affected limb and then measure from ASIS to medial malleolus.

Segmental measurements

If there is limb length discrepancy then one should identify the anatomic region of discrepancy.

Supratrochanteric region is assessed by drawing the Bryant’s triangle, Nelaton’s line and Shoemakers’ line. Infratrochanteric region is measured from the tip of greater trochanter to lateral knee joint line. Leg segment is measured from medial malleolus tip to medial knee joint line.

Bryant’s triangle is drawn by placing the patient in the supine position. Mark the tip of greater trochanter and the inferior edge of ASIS with a skin pencil. Draw a line from the inferior edge of ASIS vertically to the couch. Draw another line from the tip of trochanter to the first line and measure. Normally the greater trochanter lies about 2-3 cm below the first line. Compare with the opposite side. In case of severe shortening the greater trochanter may lie above the first line; in such cases shortening will be the measured length of the line with 3 cm or normal side measurement added to it.

Nelaton’s line is drawn by placing the patient in the lateral position with affected side up. Flex the hip and knee to 90⁰. Draw a line connecting the inferior edge of ASIS to the most prominent portion of ischial tuberosity. In the normal hip the tip of greater trochanter will be just touching the line. In patients with supratrochanteric shortening it will be above the line.

Shoemaker’s line is drawn on both sides from the tip of trochanter to the inferior edge of ASIS and extended further on to the abdomen. Normally the lines will cross in the midline. In case of supratrochanteric shortening the lines will cross on the opposite side.

Girth measurement is done at the bulkiest part of thigh and calf to look for wasting of muscles. Wasting of muscles is usually found in long standing disease.

Special tests

Special tests are done as required depending on the clinical diagnosis. They can be divided into the following.

1. Tests for deformity assessment
2. Tests for stability
3. Tests to assess limb length discrepancy
4. Tests for impingement
5. Tests for muscle contracture

Tests for deformity assessment

Thomas well leg raising test

Patient position- Supine

Procedure – Stand on the right side of the patient with one hand under the lumbar spine of the patient. With the other hand hold the unaffected side. Flex the unaffected knee fully, then flex the unaffected hip till the excessive lumbar lordosis disappears. Measure the angle between the thigh of the affected side and the couch to assess the angle of fixed flexion deformity of the hip.

Interpretation- Normally the limb will lie flat on the examination table. But if there is a fixed flexion deformity the affected side will be off the couch. The angle between the long axis of thigh and the examination table gives the angle of flexion deformity.

Staheli prone extension test

Patient position- Prone with hip and knees dangling beyond the end of the examination table

Procedure- Place one hand over the sacrum to stabilise the patient and to detect pelvic motion. Gently extend the tested lower limb till the pelvis starts to move. Measure the angle between the long axis of thigh and long axis of the examination couch.

Interpretation- The angle between the thigh and the table is the fixed flexion deformity.

Craig’s test

Patient position – Prone

Procedure- One hand of the examiner is placed flat on the greater trochanter. Knee flexed to 90⁰. Hold the leg and gently rotate the hip in both directions till the greater trochanter is maximally prominent.

Interpretation- The amount of internal rotation needed to make the greater trochanter maximally prominent is the degree of anteversion.

Tests for stability

Trendelenberg test

Described by Freidreich Trendelenberg in 1894.

Patient position – Standing.

Examiner position- Standing behind the patient.

Procedure- Ask the patient to do a one legged stance on the affected limb for one minute. Note the level of gluteal fold and PSIS.

Interpretation- Normally the pelvis on the opposite side will move up to shift the centre of gravity due to contraction of gluteus medius of weight bearing side. Up to 5⁰drop is considered normal. If more than 2cm or 5­⁰ then it is abnormal and suggests abductor insufficiency. Insufficiency may be due to abnormal fulcrum, lever or power of the abductor mechanism.

Fallacies- False positive in adduction deformity of hip, quadratus lumborum paralysis and painful lesions of sacroiliac joint. False negative in abduction deformity.

Don’t do if hip has fixed adduction or abduction deformity.

Telescopy test (Piston or Dupuytren’s test)

Patient position – Supine

Procedure- Flex the knee and hip to 90⁰ and 10⁰ adduction. Stabilise the pelvis with one hand. Hold the knee and thigh with the other hand. Push and in a to and fro motion.

Interpretation- Relative movement of the hip is suggestive of instability.

Ortolani test

Described by Prof Marino Ortolani in 1936.

Patient position – Infant should be relaxed and in supine position.

Procedure- Flex the hip to 90⁰ and fully flex the knees. Hold both the proximal thigh with the thumb over the medial aspect of thigh and other fingers over the greater trochanter region. Apply pressure over the greater trochanter and gentle longitudinal traction. Move the hip into abduction gently.

Interpretation- If the hip is dislocated; resistance to abduction will be felt at 30-40⁰ of abduction, then a clink will be felt as the femoral head reduces into the acetabulum slipping over the acetabular rim. Once the hip is reduced further abduction will be possible up to normal.

Barlow test

Has two parts. First step is similar to Ortolani test, but each hip is separately tested.

Patient position – Infant should be relaxed and in supine position.

Procedure- Flex the hip to 90⁰ and fully flex the knees. Hold both the proximal thigh with the thumb over the medial aspect of thigh and other fingers over the greater trochanter region. Apply pressure over the greater trochanter and gentle longitudinal traction. Move the hip into abduction gently.

Interpretation- If the hip is dislocated; resistance to abduction will be felt at 30-40⁰ of abduction, then a clink will be felt as the femoral head reduces into the acetabulum slipping over the acetabular rim. Once the hip is reduced further abduction will be possible up to normal.

Second Part is as follows

Apply backward and outward pressure over the medial aspect of proximal femur with the thumb.

Interpretation- If the hip is unstable the head will be felt to dislocate with a clunk. Once the pressure is removed, the head relocates.

Gouvain’s test

Patient position- Supine or lateral position

Procedure- Hold the femur with one hand, stabilise the pelvis. Adduct and internally rotate the hip. Look for spasmodic contraction of muscles

Interpretation- Seen in Tuberculous hip with fibrous ankylosis

Tests to assess limb length discrepancy

Galeazzi’s test

Patient position – Supine

Procedure- Flex the hip and knee to 90⁰. Note the relative level of knees.

Interpretation- If the knee of the affected side is at a lower level there is limb length discrepancy.

Allis test

Patient position – Supine

Procedure- Flex the knee to 90⁰, flex the hip and place the foot flat on the couch. Note the relative level of knees.

Interpretation- If the knee of the affected side is at a lower level there is limb length discrepancy. If it is lower towards the hip side; the femoral side is shortened. If it is lower towards the leg side; the tibial segment is shortened.

Tests to assess impingement

FABERE (Flexion-Abduction-External rotation-Extension) test

Patient position – Supine

Procedure- Put the affected limb on the opposite limb in the Flexion-Abduction-External rotation (FABER) position or Figure 4 position. Apply hand over the medial aspect of knee and force the hip into full abduction and extension.

Interpretation- If the hip cannot be fully abducted and extended to the level of opposite limb or if there is catching type of pain then test is positive.

Scour test

Patient position- Supine

Procedure- Done by moving the hip in an arc involving flexion-adduction and extension-abduction. During this movement apply axial load and rotate into external and internal rotation.

Interpretation- Pain and limitation of movement suggest intra-articular pathology.

Stinchfield test (Resisted SLR test)

Patient position- Supine

Procedure- Ask the patient to actively flex the hip to 30 degrees while keeping the knee in extension and to hold the position. Apply resistance just proximal to the knee.

Interpretation- Pain felt in the groin is suggestive of intra articular pathology.

Posterior impingement test (Hyperextension-Abduction-External rotation (HEABER test))

Patient position – Prone

Procedure- Passively place the affected hip in the Hyperextension-Abduction-External rotation (HEABER) position.

Interpretation- If there is catching type of pain then test is positive.

FADDIR (Flexion-Adduction-Internal rotation) test or Anterior impingement test

Patient position – Supine

Procedure- Put the affected limb in the Flexion-Adduction-Internal rotation (FADDIR) position. Apply hand over the anterolateral aspect of knee and force the hip into full adduction and internal rotation.

Interpretation- If there is catching type of pain then test is positive.

McCarthy test

Patient position- Supine on the couch.

Procedure- Flex both hips fully. Extend the affected hip.

Interpretation- If patient complains of catching pain the test is positive.

Tests to assess muscle contracture

Piriformis test (FAIR (Flexion-Adduction-Internal Rotation test)

Patient position – Lateral position with the affected side up.

Procedure- Flex the hip to 60⁰ and flex the knee. Stabilise the pelvis with one hand. Hold the leg with other hand. Move the hip into adduction and internal rotation with gentle force.

Interpretation- If there is pain in the buttocks or sciatica then test is positive.

Obers test

Patient position – Lateral position with the affected side up. Opposite hip and knee flexed to 90⁰.

Procedure- Flex the hip and the knee to 90⁰. Stabilise the pelvis with one hand. Hold the leg with other hand. Move the hip into full abduction and external rotation. Extend the knee and hip and let the limb drop down due to gravity.

Interpretation- Normally the limb should drop down and rest on the couch. If the limb is held high in abduction, there is contracture of the iliotibial band.

Ely’s test

Patient position – Prone

Procedure- Flex the knee fully. Observe for flexion of hip.

Interpretation- If the hip flexes, there is rectus femoris contracture.

Examination of Gait:

Front : Look at trunk , pelvis and swinging of hand (contralateral to the hand)

Back : Look at shoulder and pelvis:

Side : Excessive Lordosis, ankle plantar flexion and knee flexion, hip and knee extension.

Examination of the opposite hip, knee and spine

Examination of the sacroiliac joint

Examination of the distal neurovascular deficit

Per rectal examination

SUMMARY

DIAGNOSIS

Anatomical : Synovitis/Arthritis/Coxa vara/Unstable hip/ Ankylosis of hip

Pathological : Traumatic/Inflammatory/Neoplastic/Infective/Degenerative