Examination Of The Hip

Question 1

What type of joint is the hip ?

Answer 1

A ball socket joint : femoral neck as the ball and acetabulum of the pelvis as the socket.

Question 2

What are the main ligaments of the hip joint ?

Answer 2

In the joint capsule which maintain stability for the hip, there’s the ligament teres. It contains one artery bringing blood to the femoral head.

The labrum is attached around the edge of the acetabulum to create a deeper cut for the socket.

Question 3

What is the main tendon of the hip joint ?

Answer 3

The iliotibial band alongside the femur. It goes from the hip to the knee and provide attachement for many muscle.
But if it is too tight it could cause knee and hip problem.

Question 4

What are the main muscles of the hip ?

Answer 4

The gluteus (minimus/medius/maximus) : thight extension, abduction. Maintain the pelvic level.

Adductor muscle : adduct the thighs

Iliopsoas muscle : flexion

Quadriceps muscles : flexion

Sartorius muscle : form the hip across the knee connecting to the medial side of the tibia

External rotators muscles : stabilise hip joint

Hamstring muscles : extension

Question 5

What are the main nerves of the hip/upper leg ?

Answer 5

Femoral nerve : front
Sciatic nerve : back
Obturator nerve : inside the hip

Question 6

What are the main arteries of the hip ?

Answer 6

Femoral artery : front of the pelvis towards inner edge of the knee.

Profunda femoris : branch of the femoral artery. Branching into 2 circumflex artery supplying the femoral head.

Question 7

What is a bursa ?

Answer 7

A thin sac of tissue containing fluid to lubricate the area and reduce friction.

Question 8

What are the main bursas of the hip ? What pathologies are associated ?

Answer 8

Greater trochanter bursa => irritation and inflammation = trochanteric bursitis

Iliopsoas bursa => Iliopsoas bursitis

Schilling tuberosity bursa (what we sit on) => ischial bursitis

Question 9

What do you pay attention to during inspection of the hip?

Answer 9

Contour :
- quadriceps femoris
- tensor fascia latae
- iliotibial tract muscle
- erector spinae muscle
- gluteus maximus
- hamstring muscle
- triceps surea muscle

Skin :
- greater trochanter region : swelling, color change, operation scars

Posture :
- position of the pelvis in relation to ASIS => horizontal line
- visible deviation of hip, knee, ankle

Movement side :
- gait : stride lengh

Symmetry :
- reference point : iliac crest, PSIS
- gait : loading on each side

Question 10

How do you check for excessive lumbar lordosis ?

Answer 10

It can cause of flexion of the back due to a fracture of the hip.
Push your hand between the table and back of the patient. It is normally not possible.

Question 11

Step of active movement examination of the hip : flexion and extension

Answer 11

Flexion : patient supine, bring knee towards the nose in a straight line
- smoothness and course of movement

Extension : patient prone, raise leg straight with foot in neutral position
- pelvis stabilised
- foot in neutral position

Question 12

Step of active movement examination of the hip: abduction and adduction :

Answer 12

Abduction : extend leg to the side as far as possible with the toes pointing the ceiling
- stabilise the pelvis

Adduction : extend leg as far as possible medially with toes pointing the ceiling

Question 13

What are indications to perform a passive movement examination of the hip?

Answer 13

If : pain, loss of strength or change in hip mobility

Question 14

Step of passive movement examination of the hip : flexion and extension

Answer 14

Flexion : patient supine, hold leg below the knee joint. Raise the bent knee by flexing the hip in one movement until stopped by the tissue of the abdomen.

Extension : patient prone, extension of the leg. Grasp the middle thigh and stabilise the pelvis. Lift the leg.

Question 15

Step of passive movement examination of the hip: abduction and adduction

Answer 15

Abduction : hold ankle with one hand the other on the ipsilateral iliac crest to prevent sliding. Move leg outward then bring back with toes toward the ceiling.

Adduction : stand at the foot of the table, hold ankle with one hand and lift the other leg upward straight. Move extended leg across the median line then bring it back.

Question 16

Step of passive movement of hip : rotation

Answer 16

External rotation : flex knee and hip at 90°. Stabilise the leg with hand on the knee and the calcaneus. Move the leg inward.

Internal rotation : same but move the leg outward.

Question 17

Step of isometric muscle test of hip :

Answer 17

Flexors : bend knee 90°, foot on table. Grasp top of the knee with both hands. Ask patient to pull knee toward nose.

Abductors : at the foot of the table, grasp the lateral side of ankles. Ask patient to push leg outward.

Adductors : grasp medial side of the ankle. Ask patient to push inward.

Extensor : prone position, grasp middle of thigh, popliteal fossa and stabilise the pelvis. Ask patient to raise leg.

Question 18

What can you palpate in the hip with the patient standing ?

Answer 18

Iliac crest : stand behind the patient to palpate both at the same time with the index and middle finger.
- tilted pelvis ?

ASIS : palpate from the front using index and thumb.

PSIS : palpate laterally of the dimples of the back

Sacroiliac joint : both thumbs on PSIS move them medially toward SI joint follow them distally.

Question 19

What can you palpate with the patient supine in hip ?

Answer 19

Greater trochanter : when the patient is lying on their side, in a passive internal rotation with hip slightly flexed.

Ischial tuberosity : in prone or sitting position with hip flexed to 90°

Adductor ligament : hip in slight flexion and abduction. Palpate attachement of the ligament to the pubic bone.

Question 20

What kind of specific test can you do for the hip examination ? What are their result ?

Answer 20

The abductor test :
- Duchenne’s sign : weakness of hip abductors of the supported side, to compensate for the Trendelenburg. Or in case of osteoarthritis to prevent the muscle from contracting which cause pain.
- Trendelenburg’s sign : weakness of the gluteus medius muscle preventing stabilisation of supporting side.

Test for suspected hip and pelvic fracture.

Question 21

Step of the abductor test :

Answer 21

Stand on one leg for 30 s. Knee and hip flexed 90°. The gluteus medius muscle of the supporting leg will need to tightens to stabilise the pelvis.

Does the trunk leans over the supporting leg => Duchenne’s sign
Does the pelvis sag towards the unsupported side => Trendelenburg’s sign

Question 22

What kind of gait are indication to perform the abductor test ?

Answer 22

Duchenne’s gait / coxalgic gait : leaning on the trunk on one side, center of gravity over the femoral head

Trendelenburg’s gait : pelvis tilt toward one leg with leaning of the trunk

Question 23

What are the kind of test for a suspected fracture of hip or knee ?

Answer 23

Femoral neck fracture. Generally following a trauma, one leg is shortened and will lie in external rotation.

Pain on axial pressure : while pushing the heel of the leg cranially. Indication of greater trochanter or femoral neck fracture.

Tenderness in the groin : while exerting pressure on it with your palm. Indication of osteoarthritis of hip or femoral neck fracture.

Bitochanteric tenderness : both hands over the greater trochanters, exert pressure medially towards the symphysis. Indication of femoral neck or pelvic fracture and symphysiolysis.

Question 24

What can appear during active flexion of the hip ? What do you do then ?

Answer 24

If the contralateral leg cannot be kept extended with the hip and knee showing a tendency to flex
=> flexion contracture of the hip of the contralateral side

You can perform the Thomas test to confirm the result.

Question 25

Symptoms of osteoarthritis of the hip ?

Answer 25

• Age > 60 years
• Pain on palpation over the inguinal ligament
• Reduced external rotation
• Reduced internal rotation
• Reduced adduction
• A ‘bony’ end-feel
• Loss of muscle strength in abduction of the hip

Question 26

Step and result of Thomas test ?

Answer 26

Bring patient knee toward the chest.

Positive test : upper contralateral leg comes off the table
=> reduced flexibility of the rectus femoris or of the iliopsoas

Question 27

What are the hip flexor ?

Answer 27

Iliopsoas, rectus femoris, sartorius

Question 28

What are the hip abductors ?

Answer 28

Gluteus medius and tensor fasciae latae.

Question 29

What are the hip adductors ?

Answer 29

Adductor longus, brevis and Magnus.

Question 30

What are the hip extensors ?

Answer 30

Gluteus maximus, hamstrings.