Comprehensive Physical Examination of the Hip

Abstract

Background:

Hip pain is a common chief complaint among sports medicine patients, and there is a wide variety of pathology that may cause pain around the hip joint.

Indications:

Any patient presenting to a clinic with a complaint of hip and groin pain should undergo a comprehensive physical examination to aid in diagnosis and treatment planning.

Technique Description:

All patients presenting with hip pain, regardless of the complaint, undergo a screening examination to further identify potential etiology of their pain. Based on the screening examination, as well as a comprehensive history and imaging findings, more specific examination maneuvers may be conducted to further establish an accurate diagnosis and treatment plan.

Conclusion:

Hip pain presents a diagnostic challenge for sports medicine providers, as there is a wide range of pathology that may manifest as pain around the hip joint. It is vital for all sports providers, regardless of the area of interest, to have the ability to perform a comprehensive physical examination of the hip to obtain an accurate diagnosis and to initiate appropriate treatment plans.

Patient Consent Disclosure Statement:

The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Graphical Abstract

This is a visual representation of the abstract.

Video Transcript

The following video is an overview of the physical examination of the hip, as well as other common pathology that may cause pain around the hip joint.

Our disclosures are listed here.

We will begin with the senior author’s general screening examination that is at minimum performed on all patients, as well as additional examination maneuvers that may be included based on the patient’s history and positive findings on the screening examination. Please note that all these tests should be performed bilaterally for all patients to allow side-to-side comparison, but unilateral examination was performed for the sake of brevity in this video. All patient visits must start with a thorough history, using typical lines of questioning to determine the location and duration of pain, specific activities that cause pain, and any prior treatment or past surgical intervention.

The physical examination of the hip begins with observing both how the patient is seated in their chair and how the patient is rising from sitting, looking for any avoidance behavior such as slouching to keep the hip extended or leaning heavily on the handles when standing. While standing, the Trendelenburg test is performed by placing the hands on the lateral iliac crests with the thumbs at the same level and on the posterior superior iliac spine (PSIS). If the contralateral thumb drops during a single leg raise, this is a positive test and indicative of abductor weakness.

Next, we move to the examination table with the patient seated at the edge of the table in 90° hip flexion. This position isolates the iliopsoas muscle complex as the primary hip flexor, and the strength of the iliopsoas is tested and graded on a standard 5-point scale for muscle testing.

The patient then moves to the supine position, where hip range of motion (ROM) in flexion is tested as well as any pain with maximal flexion. Internal rotation and external rotation at 90° of hip flexion are tested to screen for ROM deficits or potential rotational abnormalities.

Next, the impingement test and labral stress (also known as the scour maneuver) tests are performed to test for pain potentially caused by symptomatic labral tears or other intra-articular pathology. The leg is then placed in flexion-abduction-external rotation and the distance from the knee to the examination table is measured. The iliopsoas tendon may be readily palpated by first instructing the patient to perform an isometric hold with the leg in slight flexion and external rotation to activate the sartorius muscle. Just medial to the sartorius is the iliopsoas tendon, which may be palpated and will contract when the patient is instructed to perform a straight leg raise. Discomfort with palpation at rest and/or when straight leg raise is indicative of iliopsoas pathology.

The patient is then asked to move to the end of the table and let the legs fully extend. In this position, the Thomas test may be performed to assess the inability to full extend the limb, indicative of iliopsoas contracture. In addition, the hyperextension-external rotation (HEER) test is the first routine instability examination performed, which will be discussed further in the instability section.

The patient then moves to the lateral decubitus position. Here, we begin by palpating the greater trochanter to assess trochanter and bursal tenderness, as well as palpating the muscle belly and insertion of the gluteus medius. With the hip and knee flexed and adducted, the piriformis is palpated for tenderness midway between the trochanter and ischial tuberosity.

The Ober test is performed to evaluate iliotibial band tightness, as well as the next instability test, the abduction-hyperextension-external rotation (AB-HEER) test.

Finally, the patient is directed into the prone position where the prone instability test is performed.

In addition, the patient is examined for hamstring dominance, or gluteal inhibition, by placing the fingers over the gluteus and hamstring muscles and determining which muscle group activates first when the patient is asked to extend the leg with a flexed knee. Based on the results of the screening examination, further tests detailed to follow may be conducted to aid in accurate diagnosis.

Range of motion may also be examined in the seated position, as well as hip internal and external rotation strength to evaluate potential muscle deficits. Again, the lateral position allows for palpation of the structures around the greater trochanter and posterior gluteal region. When patients have tenderness over the piriformis, the piriformis motor test may be performed by having the patient externally rotate against resistance with the hip flexed and adducted to assess increase in pain in the gluteus and piriformis area. The Ober test and AB-HEER test are again demonstrated.

We conclude with the ischiofemoral impingement test, with the patient’s hip externally rotated in hip extension and adduction to assess abutment of the lesser trochanter and the ischium, which may be added when the patient complains primarily of posterior gluteal pain.

The prone examination provides for another opportunity to check the ROM of both hips to check for stiffness or potential rotational abnormalities. In addition, hamstring dominance is evaluated. Studies have shown that the firing of the hamstring muscle group before the gluteus muscles increases the load on the iliopsoas, often resulting in iliopsoas tendinopathy, and possibly places the patient at risk of hamstring injury.^1,4 When prone, we can also palpate the ischial tuberosity and hamstring for tenderness and ischial bursitis.

When patients complain of hip snapping or popping, there are 4 examination maneuvers that are useful for eliciting snapping hip, each performed with the examiners hand palpating the anterior hip for a snap, although the snapping is often audible. First, the patient is asked to actively flex the hip fully and then externally rotate maximally and return to full extension and neutral rotation. Second, the patient alternates from maximal hip flexion, abduction, and external rotation to full extension, adduction, and internal rotation. ² Third, straight hip flexion and extension and finally while in full extension, the patient alternates from external rotation and abduction to internal rotation and adduction.

Patients complaining of medial thigh pain should have a focused examination of the adductor muscles and core muscle injury. Performing resisted adduction in both extension and flexion can identify weakness and pain in adductor tendinopathy.

Core muscle injury can be assessed by the Hesselbach test by palpating the lower abdominal muscles at their insertion on the pubis and having the patient perform a sit-up to evaluate for pain consistent with a sports hernia. In addition, a resisted sit-up can be performed and considered positive for potential sports hernia, with reproduction of groin pain during this maneuver.

Prior investigation by the senior author has demonstrated the 3 instability tests, AB-HEER, prone instability, and HEER, to have a high specificity for hip microinstability as shown in the table, with multiple positive tests further increasing specificity. ³ During these tests, it is important to ask where the patient feels pain, with anterior-based pain indicative of instability and considered a positive test. Additional instability examination maneuvers include the posterior instability test to examine posterior instability, as well as an axial distraction test.

Finally, patients complaining of more posteriorly based pain must be screened for potential sacroiliac joint dysfunction. The Gaenslen test and the Patrick test shown here are performed and a positive test considered when the patient complains of posterior-based pain during the examination.

Overall, there are many potential causes of pain around the hip joint, and it is vital to have an efficient screening physical examination as well as knowledge of advanced maneuvers to accurately diagnose and treat this patient population.

Thank you for your attention.