Clinical Examination of the Hip

Hal David Martin, DO

The hip history involves the standard medical history review components in addition to
screening for hip related complaints with emphasis on function and activity. Primary
systems of diagnosis have direct correlation of historical relevance, requiring a systematic
approach to the history. The patient’s function status can be defined by symptoms reported
during rotation with load. Rotation sports commonly have been associated with injuries to
the intra-articular structures, including the acetabular labrum and ligamentum teres. The
twenty-point examination is a tool to help organize the structure of the physical examina-
tion. It will aid in the diagnosis or screening of the osseous, ligamentous, and musculo-
tendonous pathological conditions. The physical exam is performed in three positions: the
standing, sitting, lateral and supine examinations. A thorough evaluation takes time and
thorough understanding of the anatomy.
Oper Tech Orthop 15:177-181 © 2005 Elsevier Inc. All rights reserved.

KEYWORDS history, symptoms, hip physical exam

K ey components in the history and physical examination

are of paramount importance in assisting with a diagno-
sis in patients presenting with hip pain. Most authors agree
on the basics of traditional quality, region, severity, and tim-
ing of pain.1 The hip history is composed of the first 3 steps in
standard form of age, chief complaint, and presence or ab-
sence of trauma.2 In addition, hip pain history is assessed
through documentation of length of symptoms, previous
treatments, past injuries, limitations, associated complaints,
and sports and activity level. Patient expectations and the
goals of treatment also should be addressed.
The physical examination of the hip is evolving as our
technology for understanding normal and pathological hip
conditions progresses. To make an accurate diagnosis and
treatment recommendations, examinations should be per-
formed in a systematic, reproducible order. The benefit to
understanding the osseous, ligamentous, and musculotendo-
nous contributions, which may coexist in pathological pre-
sentation, cannot be underestimated. Conditions related to
genitourinary, gastrointestinal, neurologic, and vascular eti-
ology compound the importance of a thorough, all-encom-
passing examination.
Oklahoma Sport Science and Orthopedics, Oklahoma City, OK.
Address reprint requests to Hal David Martin, DO, 6205 N. Santa Fe, Suite
200, Oklahoma City OK 73118. E-mail: halm@okss.com
Patient History
A thorough evaluation of the patient history is necessary. The
modalities used by the patient or other physicians to treat the
hip, including nonsteroidal anti-inflammatory drugs, physi-
cal therapy, injections, or use of assistive devices, such as
cane or crutches, should be documented. Any previous sur-
gical intervention should also be considered useful informa-
tion on hip pathology. It is important to determine whether
the patient has reinjured himself or herself after the previous
surgery or if his or her symptoms did not improve or worsen
after surgery.
In addressing the history of the present illness, symptoms,
such as pain, severity of symptoms, and timing of the injury,
are standard questions. The date of onset is first recorded
with the presence or absence of trauma. The location of pain
or discomfort with description of pain type is useful with
exacerbating or decreasing factors. In addition to pain, the
presence of popping or locking and anatomical locations of
the symptoms is useful in determining intra-articular or ex-
tra-articular emphasis in examination. The positions in
which the symptoms occur and which positions aid in dimin-
ishing the discomfort or locking are noted. The presence of
mechanical symptoms has a positive predictive value in de-
termining the possible outcome in hip arthroscopy related
treatment of internal derangement, such as a torn acetabular
labrum.3 Back pain also can be a common differential diag-
nosis and may exist in combination with hip pathology. The
exact location, with degree of discomfort, is expressed as a
dominant or mild component to the primary complaint. The

1048-6666/05/$-see front matter © 2005 Elsevier Inc. All rights reserved. 177
doi:10.1053/j.oto.2005.07.008
178 H.D. Martin

presence of nocturnal awakening with discomfort, numb-

ness, and weakness are expressed with the exact region in-
volved.
The patients functional status can be useful in determining
the presence of symptoms with rotation under load. The
ability to perform sports, level of activity from running, jog-
ging, walking, stairs, sitting, work capacity, activity of daily
living, and any household activity restriction is documented.
The nature of sports in which the patient is involved is useful
again to determine the type of injury.4 Rotation sports, such
as golf, tennis, ballet, and martial arts, have been associated
commonly with injuries to the intra-articular structures in-
cluding the acetabular labrum and ligamentum teres. Dam-
age to the iliofemoral ligament with similar sports has been
reported.5
Treatment may vary based on the patient’s expectations
and postoperative goals. Unrealistic goals should be ad-
dressed before any diagnostic testing and treatment recom-
mendations. Understanding of the expected outcome for
each option should be explained thoroughly and completely.
Good communication is important to obtaining any history.
Time, understanding, empathy and compassion are of para-
mount importance in working through differences in expec-
tation and can save much undue hardship later.

Physical Examination Figure 1 Patient performing Trendelenburg’s test as part of the

The 20-point examination is a tool to help organize the struc-
ture of the physical examination in a simple, reproducible
manner, to aid in the diagnosis or screening of the osseous,
ligamentous and musculotendonous pathological condi-
tions. The physical examination is performed in 3 positions:
the standing, sitting, and lateral and supine examinations.
Each position has 5 components for assessment.
The Standing Examination
The 5 points in this position to be evaluated include gait,
spinal alignment, Trendelenburg’s test, laxity test, and leg
length. The gait should be observed so that full stride length
can be observed from the frontal and sagittal planes.6 Com-
mon key points should include the stride length, stance
phase, foot rotation (internal/external progression angle),
pelvic rotation in the x and y axes,4,7 Trendelenburg gait,
antalgic gait patterns, leg length issues, and pelvic wink. The
pelvic wink demonstrates excessive rotation in axial plane
greater than the normal 40° toward the affected hip to obtain
terminal hip extension. This gait pattern is associated with
internal hip pathology and secondary hip flexion contrac-
ture.
Shoulder heights should then be observed with the iliac
crest to further address leg length issues. Measure the ante-
rior superior iliac spine to medial malleolus and record any
discrepancy. Forward bending will allow the inspection of
the spine from behind for scoliosis, and lateral inspection of
the lumbar spine for any excessive lordosis or paravertebral
muscle spasm. A tight ilipsoas will produce an increase in the
lumbar lordosis, similar to the finding in neuromuscular dis-
standing examination. (Color version of figure is available online.)
ease. Trendelenburg’s test should be performed on both legs,
first nonaffected and then the pathologic, to help establish a
baseline neuroproprioceptive function (Fig. 1). The acetabu-
lar labrum is dense with neuroreceptors.1 The Trendelburg’s
test is helpful in testing not only the strength of the abductor
mechanism, but also the entire affective/effective loop. Laxity
examination should include inspection of the middle finger,
knee and elbow. Hyperrecurvatum at the knee or the elbow
greater than 5° is important in the determination of the in-
terrelationship of the osseous, ligamentous and musculoten-
donous function.
The Sitting Examination
The sitting examination is composed primarily of the basics
of extremity assessment. Neurologic evaluation comprises
the motor assessment of the obturator, superior gluteal, sci-
atic and femoral nerve function graded on a standard 0 to 4/4
scale. Sensory of the L2 through S1 should be compared left
to right. The straight leg raise should be performed to aid in
the differential of radicular etiologies.8 The deep tendon re-
flexes are recorded in traditional fashion at the Achilles and
patellar region and graded 0 to 4/4. The pulses of the dorsalis
pedis and posterior tibialis are recorded as present or absent.
The skin and lymphatics are inspected, compared, and any
scarring of extremity noted.
Many differential diagnoses exist in the presentation of hip
pain.9 One of the most common is lumbar spine pathology,
which may exist concomitantly or independently of hip pa-
Clinical examination of the hip
Figure 2 Evaluation of internal rotation in the sitting position. (Color
version of figure is available online.)
thology.1 The internal and external rotation measurements of
the hip are recorded in the sitting position to have a stable
and fixed angle of 90° at the hip joint.10 Differences exist in
internal and external rotation in extension and flexion. Vari-
ation exists in the recommendation for the degree of hip
flexion for the recording of rotational parameters. The most
reliable way to record these ranges of motion in our hands is
in the sitting position (Fig. 2). Loss of internal rotation is one
of the first signs of internal hip pathology and can be related
to diagnoses, such as arthritis, effusion, internal derange-
ments, and musculotendonous contracture. Osseous con-
straint pathology, such as femoroacetabular impingement,11
or rotational constraint from increased or decreased femoral
acetabular anteversion, can result in significant differences
between sides. Increase in femoral or acetablular anteversion
usually demonstrates an increase in the internal rotation. The
normal range of motion is 20 to 35° for internal rotation and
30 to 45° for external rotation. The internal rotation is im-
portant to normal hip function requiring a minimum of 10°
at terminal hip extension.
The Supine Examination
The key in addressing the multifactorial presentation of com-
plex hip pathology is the supine examination. This battery of
tests helps to begin further distinction of internal versus ex-
tra-articular sources of dysfunction. The 5 initial examina-
tions of the hip in the supine position include the hip ranges
of motion beginning with flexion (normal 120°), hip abduc-
tion (normal 45°), and adduction (normal 20°; Fig. 3). The
Thomas test is used to demonstrate the presence of a hip
flexion contracture.
Patrick/FABER is the classic examination for the distinc-
179
tion of hip pain with rotation in the abducted position, op-
posing the anterior superior rim of the femoral neck adjacent
to the twelve-o’clock position of the acetabulum. Pain may be
referred to the spine or the sacroiliac joint directing further
evaluation to these areas. The abdominal examination should
include the basics of inspection, palpation for mass or fascial
hernia, which can be assessed by isometric contraction of the
rectus abdominus and obliques. The ilioinguinal region
should be inspected; Tinel’s at the femoral nerve12 and pal-
pation of the femoral pulse are assessed. Palpation for ab-
dominal or iliofemoral mass should be performed on all pa-
tients. Palpation of the adductor tubercle as the patient
adducts the extended leg may help identify adductor tendon-
itis. Finally, Stinchfield and Fulcrum tests will aid in the
diagnosis of internal derangements primarily of the anterior
portion of the acetabulum.12
Lateral Hip Examination
The lateral hip examination is performed with the patient in
the lateral position lying on the unaffected hip with shoulders
at 90° to the table. The tests of the lateral position are useful
in the determination of lateral based hip pain and in further
confirmation of intraarticular pathology. First, palpation of
the sacroiliac joint, gluteus maximus origin, piriformis, sci-
atic nerve, iliotibial band, greater trochanteric bursae, tensor
fascia lata, and ischial tuberosity are performed to locate the
exact area of discomfort.13 The Ober’s test, flexion adduction
internal rotation test, and the abduction extension external
rotation complete the five tests in the lateral position (Figs.
4-6). The Ober’s test is performed in both the extended hip
with the knee flexed in traditional fashion, as well as with the
shoulders rotated back toward the table starting with the
knee straight to assess the gluteus maximus contribution to
the iliotibial band. Knee flexion may decrease the pain at the
maximus origin in cases with specific gluteus maximus con-
Figure 3 Details of the examination in the supine position. (Color
version of figure is available online.)
180 H.D. Martin

Figure 5 The flexion adduction internal rotation test is useful in the

diagnosis of impingement. (Color version of figure is available on-
line.)

combination with flexion and extension will help in distinc-

tion of internal and external popping. The Scour’s can also be
performed in the supine position. It attempts to elicit pain or
clicking with passive flexion through an arc of external rota-
tion to internal rotation. The abduction extension external
rotation test is comparable to the apprehension test in the
shoulder. The knee is straight with the hip abducted at 30°, in
neutral rotation, and brought from 10° flexion to terminal
extension externally rotating the straight leg while pushing
forward on the greater trochanter to reproduce any com-
plaint of pain or discomfort. A positive test is relief of the pain
once the anteriorly directed force is released. A positive test
can be associated with microinstability or combined anterior
anteversion, acetabular anteversion summation. Hyperlaxity,
or strain of the iliofemoral ligament, either chronic or acute,
Figure 4 (A and B) The Ober’s test. (Color version of figure is avail-
able online.)

tracture. The gluteus medius tone can be graded with the

iliotibial band and released with the knee in flexion, which
aids in the diagnosis of medius tears. Patients with large tears
will not be able to raise the leg even against gravity. The
flexion adduction internal rotation test is used to aid in the
diagnosis of femoroacetabular impingement in the anterior
location. Reproduction of the pain is suggestive for femoral
acetabular impingement.
The examiner stands behind the patient with the arm be-
neath the patient’s lower leg grasping the knee, while the
opposite hand of the examiner is monitoring the hip in front Figure 6 Hip range of motion measured in the lateral position.
with the index finger and thumb behind. Passive rotation in (Color version of figure is available online.)
Clinical examination of the hip
will produce a positive examination. The emphasis in lateral
examination should be directed toward the primary area of
complaint and additional examinations performed as neces-
sary.
The prone examination or additional tests are included as
necessary. The Ely test is performed to check for rectus fem-
oris contracture. The Craig’s test is intermittently helpful in
determination of femoral anteversion. The modified Thomas
test is also useful in determination of isolated iliopsoas con-
tracture or in combination of rectus femoris contracture. The
prone position is helpful in palpation of the exact location of
the sacroiliac (SI)-related pain. The SI region should be pal-
pated in 3 areas: the infra SI region adjacent to the origin of
the gluteus maximus, the spinous process of L5-L4, and the
supra SI region. The knee and ankle should be considered as
additional examinations or as a part of the routine physical
assessment.
Discussion
The differential of hip pain can be vast and confounding to
even experienced hip surgeons and diagnosticians. Patient
history and the physical examination will assist in screening
the patient with a painful hip and in directing further evalu-
ative studies. The history should be recorded in a reproduc-
ible and systematic method using useful questions to direct
the physical examination. Next to age, the presence of trauma
is next most important in directing the course of the physical
examination to be performed, and in which order. As with
any examination, practice is essential to gain an appreciation
of nuances of normal and pathologic. When used consis-
tently and with practice, the twenty point hip examination
181
will help formulate an osseous, ligamentous and musculoten-
donous differential diagnosis. Many times, the patient with
hip pain is presenting with multifactorial symptoms. A thor-
ough evaluation takes time and thorough understanding of
the anatomy, of osseous, ligamentous, and musculotendon-
ous structures in and about the hip.
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