II. Anatomy

  1. See Hip Anatomy
  2. Images
    1. orthoLegHipJointRtCapsuleGrayBB343.gifLewis (1918) Gray's Anatomy 20th ed (in public domain at Yahoo or BartleBy)

III. Precautions: Findings most suggestive of hip intra-articular cause

  1. Pain on external and internal hip rotation
  2. Pain on hip axial loading (force applied at foot or knee towards hip)

IV. Exam: Telemedicine

  1. See Telemedicine
  2. Patient stands facing camera with feet at Shoulder width apart
  3. Patient places both hands with palms against the iliac crests
    1. Examiner compares the level of hands for symmetry (e.g. Leg Length Discrepancy)
    2. Examiner compares the anterior/posterior placement of hands for symmetry (pelvic rotation)
  4. Observe for C Sign, Cupping the painful, anterolateral hip (intraarticular hip disorder)
    1. OrthoHipCSign.jpg
  5. Patient self-palpates regions for tenderness
    1. Anterior superior iliac spine
    2. Anterior inferior iliac spine
    3. Greater trochanter
  6. Evaluate Hip Range of Motion
  7. Perform hip specific testing as below
  8. Leg Neurologic Exam
    1. Patient stands unassisted
    2. Heel Walking (L4)
    3. Toe Walking (L5 and S1)
    4. Hip Extension (L5 and S1)
    5. Hip Abduction while patient lies on their unaffected side (L5 and gluteus medius)

V. Exam: External to hip

  1. Critical to evaluate for referred pain
    1. Low Back Exam (e.g. radicular pain)
    2. Lower extremity Neurologic Exam (sensory and motor function)
    3. Evaluate femoral and pedal pulses
    4. Exam of Abdomen and Pelvis
      1. Appendicitis or Diverticulitis may present with Hip Pain
  2. Other common causes of pain referred to the hip
    1. Knee Exam
    2. Greater trochanter tenderness to palpation
      1. Trochanteric Bursitis

VI. Exam: Hip and Groin

  1. Observe for groin Ecchymosis (avulsion, Muscle tear, abdominal wall Hematoma)
  2. Observe for bulge in the abdominal and inguinal region (Hernia)
    1. Also palpate the Superficial Inguinal Ring with valsalva or cough
  3. Examine in frog-leg position
    1. Palpate the lower Abdomen and pupic symphysis
    2. Palpate adductor insertions (pubic tubercle, medial inferior pubic ramus)
    3. Palpate abdominal Muscles
    4. Palpate anterior superior iliac spine (ASIS, sartorius and tensor fasciae latae insertion)
    5. Palpate anterior inferior iliac spine (AIIS, rectus femoris insertion)
    6. Palpate anterior hip
    7. Palpate greater trochanter

VII. Exam: Observation

  1. Resting position of the hip
  2. Hip deformity or swelling
  3. Overlying skin changes
  4. Hip Asymmetry
    1. Leg Length Discrepancy
    2. SI Joint Dysfunction

VIII. Exam: Hip Range of Motion

  1. See Hip Range of Motion for normal findings
  2. Perform active range of motion and passive range of motion
  3. Pain on even slight range of motion should suggest intrinsic hip pathology
    1. Septic Arthritis of the hip should be on the differential
    2. See causes of inability to bear weight below

IX. Exam: Observation of Mobility and Gait

  1. See Abnormal Gait
  2. Observe sitting, standing and Transferring
  3. Observe while standing
    1. Look for C Sign (Cupping the painful, anterolateral hip)
      1. OrthoHipCSign.jpg
    2. Modified Trandelenburg Test (Single leg stance phase)
      1. GaitLeftLegUpTrand.jpg
  4. Observe for limp or altered gait
    1. See Gait
    2. Trandelenburg Gait (hip adductor weakness)
    3. Waddling Gait
    4. Antalgic Gait
    5. Pelvic Rotational Wink
  5. Observe for inability to bear weight
    1. Hip Stress Fracture
    2. Hip Septic Arthritis
    3. Avascular Necrosis of the Hip
    4. Femoral lesion (e.g. malignancy)
  6. Observe for inability to climb onto exam table
    1. Decreased Hip Joint flexibility
    2. Iliopsoas Muscle or quadriceps Muscle Weakness
  7. Observe Leg Neurologic Exam
    1. Patient stands unassisted
    2. Heel Walking (L4)
    3. Toe Walking (L5 and S1)
    4. Hip Extension (L5 and S1)
    5. Hip Abduction while standing if able to balance on one leg (L5 and gluteus medius)

X. Exam: Specific Tests - General

XI. Exam: Specific Tests in Posterior Hip Pain (e.g. Gluteal Tendinopathy)

  1. Modified Trandelenburg Test
    1. Standing on one leg and observe for pelvic drop on the side of the lifted leg
    2. Positive in Gluteal Tendinopathy or hip pathology (e.g. Hip Labral Tear, LGP, SCFE, Transient Synovitis)
  2. Resisted External Derotation Test
    1. Lateral Hip Pain with hip extension and external rotation against resistance
    2. Positive in Gluteal Tendinopathy
  3. Seated Piriformis Stretch Test
    1. Pain on ischial palpation and passive hip internal rotation
    2. Positive in Deep Gluteal Syndrome including Piriformis Syndrome
  4. Long-Stride Walking Test
    1. Long step onto unaffected foot provokes Posterior Hip Pain and Sciatica in the affected hip
    2. Positive in Ischiofemoral Impingement Syndrome

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