Exam Summary

1. Introduction

  • Introduce yourself and the exam
  • Ask if the patient has any pain
  • Ask the patient to expose their hip
  • Ask the patient to stand up
  • Hand hygiene

2. General Inspection

Examine the back and hip from front ,back and side. Look for:
  • Scars
  • Scoliosis, Excess Lordosis
  • Hamstring and Gluteal bulk
  • Body habitus - obesity can lead to hip deterioration
  • Walking aids

3. Gait

  • Fluidity of movement
  • The way the foot strikes the floor
  • Symmetry
  • Some gaits to look out for
    • Limp - Asymmetric gait rhythm
    • Antalgic gait - A gait where the patient limits weight bearing on the affected side due to pain
    • Trenedelendburg gait - Hip depression on affected side
    • Foot drop - poor dorsiflexion of the foot

4. Trendelenburg Sign

The Trendelenburg test assesses gluteal muscle (medius and minumus) weakness.
  • With the patient standing.
  • Place hands on the dimples of Venus
  • Ask the patient to raise one leg slightly (and use you for support) for 30 seconds.
  • The iliac crest on the contralateral side should rise, failure to do so or easy fatigue indicates gluteal weakness (gluteus medius and gluteus minimus are the abducters of the hip).

5. Palpation

Ask the patient to lie down:
  • Feel just behind the midpoint of the Inguinal Ligament. Here the head of the femur is not in the acetabulum.
  • Feel the Anterior Superior Iliac Spine and Iliac Crest
  • Feel the Greater trochanters.
  • Push down on the pelvis and assess tenderness which may be due to Osteoarthritis.

6. Movements

  • Hip Flexion - place one hand behind the lumbar spine to detect spine flexion. Flex the hip with the knee bend.
  • Hip abduction - place one hand on the opposite iliac crest to the tested leg as to isolate the joint. Abduct with the knee extended. Normal range 45⁰.
  • Hip adduction - place one hand on the opposite iliac crest to the tested leg as to isolate the joint. Abduct with the knee extended. Normal range 25⁰.
  • Hip Internal and External Rotation (hip extended) - Roll the leg on the bed in both directions. Normal range 45⁰.
  • Hip Internal and External Rotation (hip flexed) - Flex the hip and knee and then swivel in both directions the leg at the knee joint. Normal range 45⁰.
  • Hip Extension - Move the patient into the prone and ask them to extend their leg backwards. The normal range is 20⁰. Make sure that the patient is not rotating their pelvis. This can be done by holding the patient's hips and applying a force downwards into the bed.

7. Thomas Test

This tests for a fixed flexion deformity.
  • Passively Flex both hips for the patient
  • Hold one leg at full hip flexion
  • Ask the patient to extend their other leg so that it is flat on the bed. Inability to do so is a deformity.
  • Repeat with the other leg flexed.

8. Straight Leg Raise
  • Perform a straight leg test and dorsiflex the ankle. Ask if the movement causes pain - stop if it does. A sciatic nerve problem will cause pain in the 10-60º range.

9. Leg length

  • Apparent length - measure from the umbilicus to the medial malleolus on both sides.
  • True length - measure from the iliac crest to the ipsilateral medial malleolus on both sides.

10. Other Examinations


10. Conclude

Thank the patient and offer assistance

See Also

Talley and O'Connor - Clinical Examination 7th edition pp317-19