Hip examination

Question 1

What is the first part of any introduction to an examination?

Answer 1

Wash hands
Intro self
Pt details

Question 2

Explain the hip exam to a patient

Answer 2

I’ve been asked to examine your hip joints today, it’s going to involve me having a general inspection, feeling and moving your joints and then perform a few special tests?

Question 3

What else would you include in your intro?

Answer 3

Expose ok?
Chaperone?
Pain or discomfort?

Question 4

What are you looking for when inspecting the front?

Answer 4

Pelvic tilt.
Joint deformities (fixed flexion).
Wasting of the quadriceps muscles.

Question 5

What are you looking for when inspecting the side?

What might a change suggest?

Answer 5

Exaggerated lumbar lordosis

Fixed flexion deformity of the hip.

Question 6

What are you looking for when inspecting from the back?

Answer 6

Wasting of the gluteal muscles.
Scoliosis of the spine

Question 7

What can scoliosis of the spine be primary or secondary to?

Answer 7

Pelvic tilt

Question 8

What do you assess when observing gait?

Answer 8

Assess gait from various angles.
Assess patient’s footwear as unequal sole wearing = abnormal gait.
Assess speed/smoothness/turning

Question 9

What are the following associated with?
a) Waddling gait
b) Antalgic gait

Answer 9

a) Hip pain or proximal muscle weakness.

b) Reflects pain on weight-baring -> avoid pain while
walking meaning the stance phase of gait is abnormally
shortened relative to the swing phase

Question 10

How should you position the patient?

How do measure symmetry in a hip exam?

Answer 10

Ask the patient to lay down on the examination couch

Apparent leg length

True leg length

Question 11

How do you measure apparent leg length?

What can it be influenced by?

Answer 11

Tape-measure from the xiphisternum to the medial malleolus of each length…

Pelvic tilt.

Question 12

How do you measure true leg length?

Answer 12

Tape-measure from the anterior superior iliac spine (ASIS) to the medial malleolus.
If there is true leg length discrepancy, assess whether this originates in the tibia or femur

Question 13

How do you assess if length discrepancy originates in the tibia or femur?

Answer 13

Position patient with knees bent to a right angle + heels flat on bed.
Inspect from side.
Place hand across both tibial tuberosities, in femoral shortening hand will dip down towards the shortened side.
Place hand across both suprapatellar regions, in tibial shortening hand will dip down towards the shortened side.

Question 14

What do you ask the patient before palpating in a hip exam?

Answer 14

Any pain or tenderness in their hips

Question 15

What do you assess and palpate in a hip exam? (FEEL)

Answer 15

Assess temperature using dorsum of hand in the upper thigh + greater trochanter.
Palpate the greater trochanter for trochanteric bursitis.

Question 16

What types of movement do you assess in a hip exam?

Answer 16

Active and passive

Question 17

What active movement do you test?

What instructions do you give to the patient?

What are the normal ROM for these movements?

Answer 17

Abduction
“Keep your leg straight and move them both outwards”
Normal ROM is 45°

Adduction;
“Keep your leg straight and
Normal ROM is 30°

Flexion;
“Bring your knee towards your chest”
Normal ROM is 120°

Question 18

What passive movement do you test?

What instructions do you give to the patient?

What are the normal ROM for these movements?

Answer 18

Extension

Flexion
Assess the degree of flexion in each hip individually whilst stabilising the ASIS.

Abduction
Stabilise the contralateral iliac crest + use other hand to abduct hip until you feel pelvis begin to tilt.
Normal ROM is 45°

Adduction
Stabilise the contralateral iliac crest + use other hand to adduct hip across the midline as far as possible.
Normal ROM is 30°

Internal rotation;
Flex the hip + knee joint at 90°
Rotate the foot laterally.
Normal ROM is 40°

External rotation;
Flex the hip + knee joint at 90°
Rotate the foot medially.
Normal ROM is 45°

Question 19

How do you perform Thomas’ test?

Answer 19

Place your hand under the patient’s lumbar spine.
Passively flex the unaffected leg (hips/knees) as far as possible.
Hand should detect that lumbar lordosis is now flattened.
With the unaffected leg flexed, the contralateral leg should be flat on the bed.
Repeat to assess contralateral hip joint.

Question 20

What is a positive Thomas’ test?

Answer 20

Positive test if affected thigh raises off the bed indicated a loss of extension in the hip and so a fixed flexion deformity in the affected hip as the pelvis is forced to tilt a normal hip would extend allowing the leg to remain on the couch.

Question 21

How do you perform Trendelenburg’s sign?

Answer 21

Place hands on the iliac crests on either side of the pelvis.
Ask patient to stand on one leg for 30 seconds.

Observe your hands to see which moves up or down.

Normally the iliac crest on the side with the foot off the ground should rise

Question 22

What is a positive Trendelenburg’s sign?

Answer 22

Positive test if pelvis falls on the side with the foot off the
ground suggesting weak hip abductors on the contralateral side of the pelvis.

Question 23

Upon completing the exam what do you do first?

Answer 23

Thank patient
Wash hands

Question 24

To complete my exam…

Answer 24

I’d like to examine the patients lumbar spine and ipsilateral knee joint and perform a full neurological and vascular examination of the patient’s lower limb