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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
ï” Ball and socket joint of synovial joint.
ï” Connects the pelvic girdle to the lower limb
ï” Made up of femoral head and acetabulum
ï” Designed for stability and wide range of
movement
ï” Covered with a thin layer of hyaline cartilage
3. REVIEW OF HIP ANATOMY
ï” The articular surface of is horse-shoe
shaped and is deficient inferiorly-
acetabular notch
ï” 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
ï” This is a strong ligament which connects
the pelvis to the femur
ï” At the front of the joint
ï” It resembles a Y in shape
ï” Stabilises the hip by limiting
hyperextension
5. REVIEW OF HIP ANATOMY
ï” Pubofemoral ligament
ï” 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.
ï” Ischiofemoral ligament:
ï” This is a ligament which reinforces the posterior aspect of the capsule
ï” attaches the ischium to the two trochanters of the femur.
ï” Transverse acetabular Ligament:
ï” Bridges acetabular notch.
ï” Ligament of head of femur: flat and triangular in shape
ï” Lies within joint, ensheathed by synovium
6. REVIEW OF HIP ANATOMY
ï” Gluteals:
ï” Gluteus Maximus, Gluteus Minimus and Gluteus
Medius
ï” Attach to the Ilium and travel laterally to insert into
the greater trochanter of the femur
ï” Medius and Minimus abduct and medially rotate
the hip joint, as well as stabilising the pelvis
ï” Gluteus maximus extends and laterally rotates the
hip joint
7. REVIEW OF HIP ANATOMY
ï”Quadriceps
ï” The four Quadricep muscles are Vastus
lateralis, medialis, intermedius and Rectus
femoris
ï” All attach inferiorly to the tibial tuberosity
ï” Rectus femoris originates at the Anterior
Inferior Iliac Spine and acts to flex the hip
ï” 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
ï”Iliopsoas:
ï” The is the primary hip flexor muscle which
consists of 2 parts
ï” Attaches superiorly to the lower part of the
spine and the inside of the ilium
ï” Cross the hip joint and insert to the lesser
trochanter of the femur
9. REVIEW OF HIP ANATOMY
ï”Hamstrings:
ï” The hamstrings are three muscles which
form the back of the thigh
ï” Attach superiorly to the ischial tuberosity
ï” Cause hip extension
10. REVIEW OF HIP ANATOMY
Flexors:
âąIliopsoas,
âąSartorius
âąTensor fascia lata
âąRectus femoris
âąPectineus
âąAdductor longus
âąAdductor brevis
âąAdductor magnus
âąGracilis
Extensors:
âąHamstrings
âąAdductor magnus
âąGluteus maximus
Adductors:
âąAdductor longus
âąAdductor brevis
âąAdductor magnus
âąGracilis
âąPectineus
11. REVIEW OF HIP ANATOMY
Abductors:
âąGluteus medius
âąGluteus minimus
âąTensor fascia lata
External rotators:
âąObturator
externus,
âąObturator
internus
âąPiriformis
âąQuadratus
femoris
âąGluteus maximus
Internal Rotators:
âąGluteus medius
âąGluteus minimus
âąTensor fascia lata
12. REVIEW OF HIP ANATOMY
ï” Femoral (L2,3,4)
ï” Obturator (L2, 3, 4)
ï” Sciatic (L4,5, S1, 2,)
ï” 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
âą Arthritis
âą Hip flexor strain
âą Iliopsoas bursitis
âą Labral tear
Lateral hip pain
âą Greater trochanteric
bursitis
âą Gluteus medius tear
âą Iliotibial band syndrome
(athletes)
âą Meralgia paresthetica
(an entrapment
syndrome of the lateral
femoral cutaneous
nerve)
Posterior hip pain
âą Hip extensor and
external rotator
pathology
âą Degenerative disc
disease
âą Spinal stenosis
26. INSTABILITY
ï” History of instability
ï” Anterior or Posterior
ï” Subluxation or dislocation
ï” Aggravating factors
ï” Repetitive movements, sports
ï” Relieving factors/treatments tried
ï” Rest, immobility, medications, other treatments
ï” History of Prior Shoulder Problems or Surgeries
28. LOSS OF FUNCTION
Mode of onset
âą Sudden
âą Gradual
Duration
âą Congenital
âą Chronic
âą Acute
Involved region
and function(s)
Progression
Associated
features
29. SWELLING
Site Shape Size
First notice
Associated Symptoms
âąPain
âąPressure
âąNeurological
âąVascular
âąArticular
Progression
Any other swelling Reducibility
Any discharge
âąIf present
âąDuration
âąRegular or intermittent
âąCharacter of discharge
36. REGIONAL EXAMINATION
âą InspectionLOOK
âą PalpationFEEL
âą Strength TestingMOVE
âą Shortening or Lengthening
âą Range of Motion
âą Regional measurements
MEASURE
âą Depends upon specific region in considerationSPECIAL TESTS
37. EXAMINATION OF THE HIP
ïObserve the gait and posture.
ïObserve the patient in standing and lying on couch
ïObserve the patient from front, side and back.
ïLook 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
âąActive sinus
âąHealed sinus
âąScars of old surgery
Trendelenburgâs Test
40. INSPECTION: LYING
Position of anterior superior iliac spine (ASIS)
Lumbar Lordosis
Position of Hip
âąFABER (Flexion ABduction External Rotation) : Synovitis/Septic Arthritis
âąFlexion 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)
ï” Evaluate active ROM
ï” If movement limited by pain, weakness, or tightness, assist
passively
ï” Evaluate bilaterally for comparison
49. SPECIAL TESTS
âąAllis Test
âąOrtolaniâs Click Test
Paediatric Hip
âąAnvil Test
âąTelescoping
Occult Fracture
âąThomas Test
âąElyâs Test
Flexion Deformity
âąTrendelenburgâs TestHip Instability
âąFABER Test
âąNarath Sign
Other Tests
50. ALLIS TEST
ï” Procedure: Infant supine, flex the knees, Feet should approximate
one another on the table.
ï” Positive Test: A difference in the height of the knees is a positive
test.
ï” Short knee on the affected side â posterior displacement of the femoral head
or a short tibia.
ï” Long knee on the affected side â anterior displacement of the femoral head
or increase in tibia length.
53. ORTALANIâS CLICK TEST
ï” Procedure:
ï” Infant supine.
ï” Grasp both thighs with thumbs on the lesser trochanters.
ï” Flex and abduct the thighs b/l.
ï” Positive Test: Palpable or audible click is a positive sign.
ï” The click signifies displacement of the femoral head in or out
of the acetabular cavity.
55. ANVIL TEST
ï” Procedure:
ï” Patient supine.
ï” Tap the inferior calcaneum with your fist.
ï” Positive Test: Local pain in the hip joint may indicate a femoral
head fracture or joint pathology.
ï” Pain in the thigh or leg secondary to trauma may indicate a femoral, tibial, or
fibula fracture.
ï” Pain local to the calcaneum may indicate a calcaneal fracture.
57. THOMAS TEST
ï” Procedure:
ï” Supine patient.
ï” Approximate each knee to the chest one at a time.
ï” Palpate quadriceps on the un-flexed leg.
ï” Positive Test:
ï” No tightness â suspect restriction at the hip joint structure or joint capsule.
ï” If tightness is palpated on the side of the involuntary flexed knee â hip flexure
contraction is suspected.
59. ELYâS TEST
ï” Procedure:
ï” Patient prone.
ï” Grasp ankle and passively flex the knee to the buttock.
ï” 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)
ï” Procedure:
ï” Patient supine.
ï” Flex leg and place foot flat on table.
ï” Grasp femur and press it into the acetabular cavity.
ï” Cross leg to opposite knee.
ï” Stabilize ASIS opposite and press down on knee of side tested.
ï” Positive Test:
ï” Pain in the hip â inflammatory process in the hip joint
ï” Pain secondary to trauma â may indicate fracture
ï” Pain may indicate avascular necrosis of femoral head
63. TRENDELENBURG TEST
ï” Procedure:
ï” Patient standing.
ï” Grasp waist.
ï” Thumbs on PSIS b/l.
ï” Instruct patient to flex one leg at a time.
ï” Positive Test:
ï” If the patient cannot stand on one leg because of pain
ï” If the opposite pelvis falls or fails to rise
ï” This tests the integrity of the hip joint opposite the side of hip flexion
65. VASCULAR SIGN OF NARATH
ï” Procedure:
ï” Patient supine.
ï” Palpate femoral artery in femoral triangle.
ï” Positive Test:
ï” If the femoral pulses are not palpable : Hip dislocation
ï” If the femoral pulses are feeble : Fracture neck of femur
Avascular Necrosis of Hip