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PS SESSION : EXAMINATION OF HIP
1. History & Physical
Exam of the Hip
DR UTKARSH SHAHI
ASSISTANT PROFESSOR
DEPARTMENT OF ORTHOPEDICS
2. REVIEW OF HIP ANATOMY
Ball and socket joint of synovial joint.
Connects the pelvic girdle to the lower limb
Made up of femoral head and acetabulum
Designed for stability and wide range of
movement
Covered with a thin layer of hyaline cartilage
3. REVIEW OF HIP ANATOMY
The articular surface of is horse-shoe
shaped and is deficient inferiorly-
acetabular notch
Has a labrum
- It a circular layer of cartilage which
surrounds the outer part of the acetabulum
making the socket deeper and so helping
provide more stability
- Acetabular labral tears are a common injury
from major or repeated minor trauma
4. REVIEW OF HIP ANATOMY
This is a strong ligament which connects
the pelvis to the femur
At the front of the joint
It resembles a Y in shape
Stabilises the hip by limiting
hyperextension
5. REVIEW OF HIP ANATOMY
Pubofemoral ligament
The pubofemoral ligament attaches the part of the pelvis known as the pubis
(most forward part, either side of the pubic symphysis) to the femur.
Ischiofemoral ligament:
This is a ligament which reinforces the posterior aspect of the capsule
attaches the ischium to the two trochanters of the femur.
Transverse acetabular Ligament:
Bridges acetabular notch.
Ligament of head of femur: flat and triangular in shape
Lies within joint, ensheathed by synovium
6. REVIEW OF HIP ANATOMY
Gluteals:
Gluteus Maximus, Gluteus Minimus and Gluteus
Medius
Attach to the Ilium and travel laterally to insert into
the greater trochanter of the femur
Medius and Minimus abduct and medially rotate
the hip joint, as well as stabilising the pelvis
Gluteus maximus extends and laterally rotates the
hip joint
7. REVIEW OF HIP ANATOMY
Quadriceps
The four Quadricep muscles are Vastus
lateralis, medialis, intermedius and Rectus
femoris
All attach inferiorly to the tibial tuberosity
Rectus femoris originates at the Anterior
Inferior Iliac Spine and acts to flex the hip
The 3 other Quad muscles do not cross the
hip joint, and attach around the greater
trochanter and just below it.
8. REVIEW OF HIP ANATOMY
Iliopsoas:
The is the primary hip flexor muscle which
consists of 2 parts
Attaches superiorly to the lower part of the
spine and the inside of the ilium
Cross the hip joint and insert to the lesser
trochanter of the femur
9. REVIEW OF HIP ANATOMY
Hamstrings:
The hamstrings are three muscles which
form the back of the thigh
Attach superiorly to the ischial tuberosity
Cause hip extension
10. REVIEW OF HIP ANATOMY
Flexors:
•Iliopsoas,
•Sartorius
•Tensor fascia lata
•Rectus femoris
•Pectineus
•Adductor longus
•Adductor brevis
•Adductor magnus
•Gracilis
Extensors:
•Hamstrings
•Adductor magnus
•Gluteus maximus
Adductors:
•Adductor longus
•Adductor brevis
•Adductor magnus
•Gracilis
•Pectineus
11. REVIEW OF HIP ANATOMY
Abductors:
•Gluteus medius
•Gluteus minimus
•Tensor fascia lata
External rotators:
•Obturator
externus,
•Obturator
internus
•Piriformis
•Quadratus
femoris
•Gluteus maximus
Internal Rotators:
•Gluteus medius
•Gluteus minimus
•Tensor fascia lata
12. REVIEW OF HIP ANATOMY
Femoral (L2,3,4)
Obturator (L2, 3, 4)
Sciatic (L4,5, S1, 2,)
WHY ARE THESE IMPORTANT???
- Referred pain to the knee can hide
hip pathology and vis versa
14. HIP CONDITIONS
Injury and mechanical derangement.
Congenital and developmental abnormalities.
Infection and inflammation.
Arthritis and rheumatic disorders.
Metabolic and endocrine disorders.
Tumours and lesions that mimic them.
Neurological disorders and muscle weakness.
15. HISTORY TAKING
PATIENT DETAILS CHIEF COMPLAINTS
HISTORY OF PRESENT ILLNESS PAST HISTORY
FAMILY HISTORY PERSONAL HISTORY
TREATMENT HISTORY NEGATIVE HISTORY
17. PAIN
Site Time and mode of onset
Severity or Intensity Character or Nature
Progression Referred pain
Aggravating factors Relieving factors
Any diurnal variation Any seasonal variation
18. HIP PAIN KEY POINTS
Anterior hip pain
• Arthritis
• Hip flexor strain
• Iliopsoas bursitis
• Labral tear
Lateral hip pain
• Greater trochanteric
bursitis
• Gluteus medius tear
• Iliotibial band syndrome
(athletes)
• Meralgia paresthetica
(an entrapment
syndrome of the lateral
femoral cutaneous
nerve)
Posterior hip pain
• Hip extensor and
external rotator
pathology
• Degenerative disc
disease
• Spinal stenosis
26. INSTABILITY
History of instability
Anterior or Posterior
Subluxation or dislocation
Aggravating factors
Repetitive movements, sports
Relieving factors/treatments tried
Rest, immobility, medications, other treatments
History of Prior Shoulder Problems or Surgeries
28. LOSS OF FUNCTION
Mode of onset
• Sudden
• Gradual
Duration
• Congenital
• Chronic
• Acute
Involved region
and function(s)
Progression
Associated
features
29. SWELLING
Site Shape Size
First notice
Associated Symptoms
•Pain
•Pressure
•Neurological
•Vascular
•Articular
Progression
Any other swelling Reducibility
Any discharge
•If present
•Duration
•Regular or intermittent
•Character of discharge
36. REGIONAL EXAMINATION
• InspectionLOOK
• PalpationFEEL
• Strength TestingMOVE
• Shortening or Lengthening
• Range of Motion
• Regional measurements
MEASURE
• Depends upon specific region in considerationSPECIAL TESTS
37. EXAMINATION OF THE HIP
Observe the gait and posture.
Observe the patient in standing and lying on couch
Observe the patient from front, side and back.
Look for any evidence of shortening.
38. GAIT PATTERN CAUSE
ANTALGIC GAIT Time taken on affected leg is reduced >
Body weight is shifted quickly to normal leg
Hip synovitis
Incomplete fracture
Painful hip conditions
STIFF HIP GAIT Lifts the pelvis and swing it forward with leg
in one piece
Hip joint tuberculosis
Rheumatoid Hip
Ankylosing Spondylosis
SHORT LIMB GAIT Becomes apparent only if the affected
limb is shorter than 2 inches.
The body on affected side moves up and
down every time the weight is born on the
affected leg
Congenital Short Femur
Shortening secondary to
fracture
TRENDELENBURG
GAIT
The body swings to affected side every
time the weight is born on normal side
Dislocated Hip
Congenital Dysplasia of Hip
Congenital Coxa Vara
GLUTEUS MAXIMUS
LURCH
The body swings backward, every time the
weight is born on affected side
Poliomyelitis
39. INSPECTION: STANDING
Any obvious deformity
Any compensatory mechanism
Gross shortening
Muscle wasting
Any swelling
Any scar
•Active sinus
•Healed sinus
•Scars of old surgery
Trendelenburg’s Test
40. INSPECTION: LYING
Position of anterior superior iliac spine (ASIS)
Lumbar Lordosis
Position of Hip
•FABER (Flexion ABduction External Rotation) : Synovitis/Septic Arthritis
•Flexion Adduction Internal Rotation : Posterior Hip Dislocation
Muscle wasting
Any swelling
Any Scar
42. Palpation of Hip Joint
1. Greater Trochanter
2. Posterior Superior Iliac Spine
3. Anterior Superior Iliac Spine
4. Lateral Femoral Condyle
43. RANGE OF MOTION (ROM)
Evaluate active ROM
If movement limited by pain, weakness, or tightness, assist
passively
Evaluate bilaterally for comparison
49. SPECIAL TESTS
•Allis Test
•Ortolani’s Click Test
Paediatric Hip
•Anvil Test
•Telescoping
Occult Fracture
•Thomas Test
•Ely’s Test
Flexion Deformity
•Trendelenburg’s TestHip Instability
•FABER Test
•Narath Sign
Other Tests
50. ALLIS TEST
Procedure: Infant supine, flex the knees, Feet should approximate
one another on the table.
Positive Test: A difference in the height of the knees is a positive
test.
Short knee on the affected side – posterior displacement of the femoral head
or a short tibia.
Long knee on the affected side – anterior displacement of the femoral head
or increase in tibia length.
53. ORTALANI’S CLICK TEST
Procedure:
Infant supine.
Grasp both thighs with thumbs on the lesser trochanters.
Flex and abduct the thighs b/l.
Positive Test: Palpable or audible click is a positive sign.
The click signifies displacement of the femoral head in or out
of the acetabular cavity.
55. ANVIL TEST
Procedure:
Patient supine.
Tap the inferior calcaneum with your fist.
Positive Test: Local pain in the hip joint may indicate a femoral
head fracture or joint pathology.
Pain in the thigh or leg secondary to trauma may indicate a femoral, tibial, or
fibula fracture.
Pain local to the calcaneum may indicate a calcaneal fracture.
57. THOMAS TEST
Procedure:
Supine patient.
Approximate each knee to the chest one at a time.
Palpate quadriceps on the un-flexed leg.
Positive Test:
No tightness – suspect restriction at the hip joint structure or joint capsule.
If tightness is palpated on the side of the involuntary flexed knee – hip flexure
contraction is suspected.
59. ELY’S TEST
Procedure:
Patient prone.
Grasp ankle and passively flex the knee to the buttock.
Positive Test: If the patient has a tight rectus femoris or
hip flexion contracture, the hip on the same side will flex,
raising the buttock off the table.
61. PATRICK TEST (FABER)
Procedure:
Patient supine.
Flex leg and place foot flat on table.
Grasp femur and press it into the acetabular cavity.
Cross leg to opposite knee.
Stabilize ASIS opposite and press down on knee of side tested.
Positive Test:
Pain in the hip – inflammatory process in the hip joint
Pain secondary to trauma – may indicate fracture
Pain may indicate avascular necrosis of femoral head
63. TRENDELENBURG TEST
Procedure:
Patient standing.
Grasp waist.
Thumbs on PSIS b/l.
Instruct patient to flex one leg at a time.
Positive Test:
If the patient cannot stand on one leg because of pain
If the opposite pelvis falls or fails to rise
This tests the integrity of the hip joint opposite the side of hip flexion
65. VASCULAR SIGN OF NARATH
Procedure:
Patient supine.
Palpate femoral artery in femoral triangle.
Positive Test:
If the femoral pulses are not palpable : Hip dislocation
If the femoral pulses are feeble : Fracture neck of femur
Avascular Necrosis of Hip