Hip examination

Question 1

How to complete hip examination?

Answer 1

Examine spine and knees
Neurovascular examination of LL
Review any available imaging

Question 2

Hip examination special tests?

Answer 2

Trendelenburg’s test

Thomas’s test

Question 3

How to perform Trendelenburg’s test and why?

Answer 3

Trendelenburg’s test is used to screen for hip abductor weakness (gluteus medius and minimus).

1. With the patient upright, stand in front of them and ask them to place their hands on your forearms or shoulders for stability.
2. Position your fingers on each side of the patient’s pelvis at the iliac crest.
3. Ask the patient to stand on one leg and observe your fingers for evidence of lateral pelvic tilt.
4. Repeat the assessment with the patient standing on the other leg.

Question 4

Positive Trendelenburg’s test?

Answer 4

If the patient’s hip abductors are functioning normally the pelvis should remain stable or rise slightly on the side of the raised leg.

If the pelvis drops on the side of the raised leg it suggests contralateral hip abductor weakness (this is known as Trendelenburg’s sign).

Question 5

How to perform Thomas’s test and why?

Answer 5

Thomas’s test is used to assess for a fixed flexion deformity (i.e. an inability for the patient to fully extend their leg).

1. With the patient positioned flat on the bed, place a hand below their lumbar spine with your palm facing upwards (this helps to prevent the patient from masking a fixed flexion deformity by increasing lumbar lordosis).
2. Passively flex the hip of the unaffected leg as far as you are able to and observe the contralateral limb.
3. Repeat the assessment on the contralateral hip.

Question 6

Results of Thomas’s test?

Answer 6

The test is positive (abnormal) if the affected thigh raises off the bed, indicating a loss of hip joint extension. This would suggest a fixed flexion deformity in the affected hip.

This test should not be performed on patients who have had a hip replacement as it can cause dislocation.

Question 7

LOOK aspect of hip examination?

Answer 7

Observe gait cycle - assess symmetery or turning, note signs of discomfort
FRONT: scars, pelvic tilt, quadriceps wasting
SIDE: lumbar lordosis, knee flexion, foot arches
BACK: scoliosis, iliac crest alignment, gluteal muscle bulk

Question 8

FEEL aspect of hip examination

Answer 8

Palpate greater trochanter - tenderness ?trochanteric bursitis
Measure - umbilicus to medial maleous
Compare joint temperature

Question 9

Normal range of motion of hip flexion

Answer 9

120

Question 10

MOVE aspect of hip

Answer 10

1. Active flexion
2. Passive flexion
3. Passive internal rotation (hold foot, move leg out)
4. Passive external rotation
5. Passive hip abduction
6. Passive hip adduction
   TURN PRONE
7. Passive hip flexion

Question 11

Normal range of hip internal rotation

Answer 11

40 degrees

Question 12

Normal range of hip external rotation

Answer 12

45 degrees

Question 13

Normal ROM for hip adduction

Answer 13

30 degrees

Question 14

Normal ROM abduction

Answer 14

45 degrees

Question 15

Hip extension ROM

Answer 15

10 to 20 degrees

Question 16

What does a positive Thomas’ test suggest?

Answer 16

Loss of extension in hip

Fixed flexion deformity

Question 17

What should you ask for, in addition to pain and consent, before moving the patient’s hip?

Answer 17

Ask if the patient has had a hip replacement (if so internal rotation, adduction and flexion greater than 90° should be avoided due to the risk of joint dislocation).

Question 18

Causes of leg length discrepancy?

Answer 18

Leg length discrepancy: may be congenital or acquired (e.g. fracture, degenerative joint disease, surgical removal of bone, trauma to the epiphyseal endplate prior to skeletal maturity).

Question 19

Causes of pelvic tilt?

Answer 19

Pelvic tilt: lateral pelvic tilt can be caused by scoliosis, leg length discrepancy or hip abductor weakness.

Question 20

How can assesing a patients shoes in an MSK examination be helpful?

Answer 20

Assess the patient’s footwear: unequal sole wearing is suggestive of an abnormal gait.

Question 21

Hip examination: leg length assement?

Answer 21

Apparent leg length
To assess apparent leg length, measure and compare the distance between the umbilicus and the tip of the medial malleolus of each limb.

True leg length
To assess true leg length, measure from the anterior superior iliac spine to the tip of the medial malleolus of each limb.

Question 22

Apparent vs true leg discrepancy?

Answer 22

Leg length should be formally assessed to differentiate between a true leg length discrepancy and an apparent discrepancy caused by other abnormalities (e.g. a leg appears shorter secondary to lateral pelvic tilt).