11/13/24, 7\:05 PM Guide | Hip examination

Hip examination

Table of contents
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Introduction

Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Con
Brie
Ask if the patient has had a hip replacement (if so internal rotation, adduction and
due to the risk of joint dislocation).
should be avoided
Gain consent to proceed with the examination.
Adequately expose the patient’s legs (typically this involves the patient wearing only their underwear) and provide a blanket to
cover the patient when not being examined.
Position the patient standing for initial inspection of the lower limbs.
Ask the patient if they have any pain before proceeding with the clinical examination.

Look

General inspection

Clinical signs
Perform a brief general inspection of the patient, looking for clinical signs suggestive of underlying pathology\:
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Body habitus\: obesity is a signi
Scars\: may provide clues regarding previous lower limb surgery.
Wasting of muscles\: suggestive of disuse atrophy secondary to joint pathology or a lower motor neuron injury.
Objects or equipment
clinical status\:
Look for objects or equipment on or around the patient that may provide useful insights into their medical history and current
Walking aids\: the ability to walk can be impacted by a wide range of knee, hip and ankle pathology.
Prescriptions\: prescribing charts or personal prescriptions can provide useful information about the patient’s recent
medications (e.g. analgesia).

Closer inspection of the hips

Ask the patient to stand and turn in 90° increments as you inspect the lower limbs from each angle for evidence of pathology.
Anterior inspection
Inspect the anterior aspect of the hip joints and lower limbs, noting any abnormalities\:
Scars\: note the location of scars as they may provide clues as to the patient's previous surgical history or indicate previous
joint trauma.
Bruising\: suggestive of recent trauma or surgery.
Swelling\: note any evidence of asymmetry in the size of the hip joints that may suggest unilateral swelling (e.g. e
in
Quadriceps wasting\: note any asymmetry in the bulk of the quadriceps muscles which may be due to disuse atrophy or a
lower motor neuron lesion.
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).
Pelvic tilt\: lateral pelvic tilt can be caused by scoliosis, leg length discrepancy or hip abductor weakness.
Lateral inspection
Inspect the lateral aspect of the hip joints and lower limbs, noting any abnormalities\:
Flexion abnormalities\:
previous trauma, in
Posterior inspection
Inspect the posterior aspect of the hip joints and lower limbs, noting any abnormalities\:
Scars\: again look for scars indicative of previous trauma or surgery.
Muscle wasting\: inspect for any asymmetry in the muscle bulk of the posterior compartment of the thigh and the gluteal
region suggestive of disuse atrophy or a lower motor neuron lesion.
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Inspect from the front

Gait

Ask the patient to walk to the end of the examination room and then turn and walk back whilst you observe their gait paying
attention to\:
Gait cycle\: note any abnormalities of the gait cycle (e.g. abnormalities in toe-o
Range of movement\: often reduced in the context of chronic joint pathology (e.g. osteoarthritis, in
Limping\: may suggest joint pain (i.e. antalgic gait) or weakness.
Leg length\: note any discrepancy which may be the cause or the result of joint pathology.
Turning\: patients with joint disease may turn slowly due to restrictions in joint range of movement or instability.
Trendelenburg's gait\: an abnormal gait caused by unilateral weakness of the hip abductor muscles secondary to a superior
gluteal nerve lesion or L5 radiculopathy.
Waddling gait\: an abnormal gait caused by bilateral weakness of the hip abductor muscles, typically associated with
myopathies (e.g. muscular dystrophy).
Assess the patient's footwear\: unequal sole wearing is suggestive of an abnormal gait.
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Observe the patient's gait
Gait cycle
The gait cycle has six phases\:
1. Heel-strike\: initial contact of the heel with the
2. Foot
3. Mid-stance\: the weight is aligned and balanced on this leg.
4. Heel-o
5. Toe-o
6. Swing\: the foot swings forward and comes back into contact with the
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Stages of the gait cycle (1-5) [1]
Trendelenburg's gait and waddling gait
During the leg lift and swing phase of the gait cycle, all of the body's weight is placed on the limb that is still in contact
with the ground. In this phase, the hip abductor muscles (gluteus medius and minimus) on the opposite side to the
raised leg contract to prevent the pelvis from dropping on the side of the raised leg.
If a patient has unilateral hip abductor weakness, the pelvis will drop toward the contralateral side when the leg on that
side leaves the ground (i.e. if there is left hip abductor weakness, the pelvis will drop towards the right whenever the right
foot is lifted o
This sagging of the pelvis secondary to hip abductor weakness is known as Trendelenburg’s sign. Unilateral hip abductor
weakness is typically caused by a superior gluteal nerve lesion or L5 radiculopathy.
Trendelenburg’s gait refers to the gait in an individual with unilateral hip abductor weakness, which is typically
described as ‘lurching’ in nature. As the pelvis sags towards the una
side in an e
If an individual has bilateral hip abductor weakness, they typically present with a waddling gait, caused by the overuse
of circumduction to compensate for gluteal weakness. Bilateral hip abductor weakness is typically associated with
myopathies (e.g. muscular dystrophy).

Inspection with the patient on the bed

Ask the patient to lay down on the clinical examination couch for the next part of the assessment.
Brie
Scars
Swelling
Bruising
Quadriceps wasting
Hip joint asymmetry
Fixed
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Feel

Temperature

With the patient still positioned supine on the clinical examination couch simultaneously assess and compare hip joint
temperature using the back of your hands.
Increased temperature of a joint, particularly if also associated with swelling and tenderness may indicate septic or
in

Hip joint palpation

Palpate the greater trochanter of each leg for evidence of tenderness, which may suggest trochanteric bursitis.

Leg length assessment

Leg length should be formally assessed to di
caused by other abnormalities (e.g. a leg appears shorter secondary to lateral pelvic tilt).
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.
Palpate the tissues surrounding the hip joint

Move

The hip joint of each leg should be assessed and compared.
If the patient is known to have an issue with a particular leg, you should assess the 'normal' leg

Active movement

Active movement refers to a movement performed independently by the patient. Ask the patient to carry out a sequence of
active movements to assess joint function. As the patient performs each movement, note any restrictions in the range of the
joint's movement and also look for signs of discomfort.
It's important to clearly explain and demonstrate each movement you expect the patient to perform to aid understanding.
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Active hip
Place your hand under the lumbar spine to detect masking of restricted hip joint movement by the pelvis and lumbar spine.
Normal range of movement\: 120°
Instructions\: Ask the patient to
" B r i n g y o u r k n e e a s c l o s e t o y o u r c h e s t a s y o u c a n .
"
Active hip extension
Normal range of movement\: the leg should be able to lie
Instructions\: Ask the patient to extend their leg, so that it is
" S t r a i g h t e n y o u r l e g o u t s o t h a t i t i s
"

Passive movement

Passive movement refers to a movement of the patient, controlled by the examiner. This involves the patient relaxing and
allowing you to move the joint freely to assess the full range of joint movement. It's important to feel for crepitus as you move
the joint (which can be associated with osteoarthritis) and observe any discomfort or restriction in the joint's range of
movement.
Passive hip
Normal range of movement\: 120°
Instructions\: Whilst supporting the patient's leg,
discomfort.
Passive hip internal rotation
Normal range of movement\: 40°
Instructions\: Flex the patient's hip and knee joint to 90°
and then rotate their foot laterally.
Passive hip external rotation
Normal range of movement\: 45°
Instructions\: Flex the patient's hip and knee joint to 90°
and then rotate their foot medially.
Passive hip ABduction
Normal range of movement\: 45°
Instructions\:
1. With the patient's legs straight and
place your other hand over the contralateral iliac crest to stabilise the pelvis.
2. Move the patient's ankle laterally to abduct the hip until the pelvis begins to tilt.
Passive hip ADduction
Normal range of movement\: 30°
Instructions\:
1. With the patient's legs straight and
place your other hand over the contralateral iliac crest to stabilise the pelvis.
2. Move the patient's ankle medially to adduct the hip until the pelvis begins to tilt.
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Active hip
Passive hip extension
Normal range of movement\: 10-20°
Instructions\:
1. Ask the patient to lie in a prone position.
2. Use one hand to hold the ankle of the leg being assessed and place the other hand on the ipsilateral pelvis.
3. Lift the leg to extend the hip joint and assess the range of hip joint extension.
Assess hip extension
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Special tests

Thomas's test

Thomas's test is used to assess for a
1. With the patient positioned
to prevent the patient from masking a
2. Passively
3. Repeat the assessment on the contralateral hip.
Interpretation
The test is positive (abnormal) if the a
suggest a
This test should not be performed on patients who have had a hip replacement as it can cause dislocation.
Place hand under lumbar spine

Trendelenburg's test

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
3. Ask the patient to stand on one leg and observe your
4. Repeat the assessment with the patient standing on the other leg.
Interpretation
leg.
If the patient's hip abductors are functioning normally the pelvis should remain stable or rise slightly on the side of the raised
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