11/13/24, 7\:10 PM Guide | Trendelenburg's test & gait

Trendelenburg's test & gait

Table of contents

Introduction

The aim of the Trendelenburg's test is to assess the strength of the hip abductors, speci
minimus.
1

Background

The test is named after Friedrich Trendelenburg, who described the test in 1895.
Hip abductors assessed in Trendelenburg's test 2
The hip abductors which are assessed with Trendelenburg's test are shown in the table below.
Hip abductor Origin Insertion Action Nerve
Gluteus
medius
Gluteus
minimus
Gluteal surface of
the ilium
Gluteal surface of
the ilium
Greater trochanter of the
femur
All
Anterior
rotate the hip
Posterior
rotate the hip
Greater trochanter of the
Abduct, medially rotate and
femur
hip
Superior gluteal
nerve
Superior gluteal
nerve

Gait cycle in brief

The gait cycle is the sequence of events between the time one foot touches the ground and the time the same foot returns to
the same position. Events of the gait cycle include heel strike; foot
phases.
1
During the foot
air and the ipsilateral leg is on the
observe when assessing the strength of the hip abductors (because all the weight of the body is being borne on one leg).
If the hip abductors aren’t strong enough, or there's pain inhibition, the patient can't counterbalance the weight of the upper
body on the a
being lifted.
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Gait cycle

Indications for Trendelenburg's test

When a patient complains of a limp, or hip pain or as part of a normal physical examination assessing gait.

Performing Trendelenburg’s test

See our hip examination guide for more details.

Position patient

If the patient is comfortable to stand alone, stand behind the patient. Alternatively stand in front of the patient, with their
forearms positioned on yours to support them.

Single-leg stance

Ask the patient to lift each foot in turn o
When the patient lifts their right foot, the left hip abductors are being tested.
When the patient lifts their left foot, the right hip abductors are being tested.

Observe

this).
Position your hands on the patient's iliac crests (make sure to clearly explain each of the steps and gain consent prior to doing
Observe carefully if the hip on the unsupported side lifts or droops.
If the patient is using your arms for support, you will feel them pressing down on one of your arms if their hip abductors are
unable to support their weight.
Abductors should be su
elevation of the pelvis on the unsupported site (this is due to the abductor muscles contracting - see Figure 1).
3
Positive sign
A positive Trendelenburg's sign (pathological) involves sagging of the pelvis on the unsupported side due to the abductor
muscles failing to stabilise the hip towards the weight-bearing femur (see Figure 2).
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Positive & negative Trendelenburg sign

Trendelenburg's gait

Trendelenburg's gait involves excessive up-down motion of the pelvis whilst walking.
It occurs as a result of compensatory mechanisms due to the drooping pelvis.
3
Unilateral positive Trendelenburg's sign produces a lurching gait.
Bilaterally positive Trendelenburg's sign produces a waddling gait.

Pathophysiology

Imagine a chair...when you remove a leg what happens? The chair will normally fall towards the side that had the leg removed.
The human body is the same, the centre of gravity passes midway through the body and through the pubic symphysis.
When standing on one leg, the centre of gravity, much like the chair, shifts to the unsupported leg.
We don't fall because the hip abductors pull the pelvis towards the femur of the weight-bearing leg.

Lever mechanics of the hip joint

The operation of most skeletal muscles involves leverage - using a lever to move an object.
A lever is a rigid bar that moves on a
In the human body, the joints are fulcrums, and the bones act as levers.
Forces can be exerted across levers in the form of load and e
Muscle contraction provides the e
The load is the bone itself, along with the overlying tissues.
There are 3 types of levers and they di
other.
6
The hip, in this case, is a class 3 lever. This means that the e
fulcrum (hip joint) and the load (upper body weight), across a lever (the neck of the femur) - see Figure 3.
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Class 3 lever
In order to keep the structure absolutely level, the forces of e
must be balanced and cancel each other out (Figure 4).
How forces across distances on lever are balanced.
Applying this to the hip joint (Figure 5), as the distance between the hip joint and the hip abductors is half of the distance
between the hip joint and the centre of gravity (pubic symphysis), it so follows that the e
must be twice the force exerted by the upper body weight.
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Class 3 lever applied to the hip

Causes of Trendelenburg's sign

Any problems that a
changed or a
(neuromuscular abnormalities).
8
Trendelenburg’s sign in the hip

Skeletal abnormalities

Examples of skeletal abnormalities which can result in Trendelenburg's sign\:
7,8,9
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Developmental dysplasia of the hip (DDH) - a spectrum of disorders that cause spontaneous dislocation of the hip
Coxa vara - the angle between the femoral neck and femoral shaft is less than 120°
Slipped capital femoral epiphysis (SCFE) - the femoral metaphysis slides in relation to the epiphysis
Legg-Calve-Perthes disease - a childhood hip disorder marked by femoral head necrosis
Chronic subluxation/dislocation of the hip - resulting in hip instability
Greater trochanter fracture (acute or non-united) - insertion of the gluteus medius and minimus are compromised

Neuromuscular abnormalities

Examples of neuromuscular abnormalities which can result in Trendelenburg's sign\:
7,8,9
Superior gluteal nerve injury - often iatrogenic following total hip replacement/hemiarthroplasty or due to trauma
L5 radiculopathy - the superior gluteal nerve is formed from L4, L5 and S1 spinal roots; often accompanied by foot drop
Gluteus medius and minimus weakness or damage (e.g. tears or tendonitis)
Poliomyelitis - causing paralysis of the hip abductors
Muscular dystrophy and other neuromuscular disorders
Pain inhibition leading to gluteal weakness (e.g. osteoarthritis of the hip)

Limitations

A positive Trendelenburg's sign may be concealed in early stages of osteonecrosis and pelvic drop can occur in healthy
individuals with normal hip abductor mechanism but inadequate function.
8
False positives can occur with lack of understanding/compliance, signi
impinge on the iliac crest).
False negatives may occur when patients compensate by shifting their torso (and centre of gravity) over the weight-bearing
hip, so be vigilant for upper body movements.
9

Further investigations

The goal is to identify the underlying cause of the abnormal gait. A thorough history and clinical examination are essential
before further investigations are considered.
Imaging\:
X-ray of the local joints (e.g. knee, hip, lumbar spine)
Consider ultrasound, CT or MRI
Laboratory investigations\:
Baseline blood tests may be performed to screen for evidence of system diseases (e.g. in
Special investigations\:
Muscle biopsy
Nerve conduction studies

Di

It is useful to be able to di
3,4
Antalgic gait\: occurs due to pain upon weight-bearing, causing the patient to only brie
Short-leg gait\: caused by a discrepancy in length between the two legs; a consistent dip of the pelvis on the shorter side is
observed

Key points

Trendelenburg’s test assesses the strength of the hip abductors.
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It is performed as part of a routine gait examination or when a patient complains of a limp or hip pain.
A positive Trendelenburg's sign (pathological) involves sagging of the pelvis on the unsupported side due to the abductor
muscles failing to stabilise the hip towards the weight-bearing femur.
If a positive sign is present, Trendelenburg’s gait may also be observed.
Causes of a positive Trendelenburg’s sign include skeletal and neuromuscular abnormalities a
abductors respectively.
Trendelenburg’s gait should be di
length).

Reviewer

Miss Margaret Brooks
Orthopaedic Registrar
University Hospitals of Birmingham NHS Foundation Trust

References

1. T h e O r t h o p a e d i c P h y s i c a l E x a m i n a t i o n n d
2 e d , Elsevier, 2005
r d
2. T r a i l G u i d e t o t h e B o d y 3 e d , Books of Discovery, 2005
t h
3. Hamblen and Simpson. A d a m s’ s O u t l i n e o f O r t h o p a e d i c s 1 4 e d , Churchill Livingstone Elsevier, 2010
4. Solomon, Warwick and Nayagam. A p l e y a n d S o l o m o n’ s C o n c i s e S y s t e m o f O r t h o p a e d i c s a n d T r a u m a , 4 t h
ed, Taylor & Francis
Group, 2014
Source\: geekymedics.com
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