Hip Exam

Hip Exam

General

  • Wash your hands upon entering the room
  • Introduce yourself and the exam to the patient in a way that the patient will understand
  • Patient should be supine on a flat bed
  • Drape the patient so their legs are exposed to the ASIS. Ensure that the groin remains draped.

Vital Signs

Vital signs should be measured on every patient. They include:

  • Blood pressure
  • Heart rate
  • Respiratory rate
  • Temperature
  • Oxygen saturation may also be included

Inspection

Inspect the legs for the following characteristics. Ensure that you compare both sides for symmetry.

Start with the patient supine

  • Patient's general appearance
    • Are they in obvious discomfort?
    • Check to see if one leg is externally rotated. This may indicate a hip fracture
  • Masses, scars, lesions
    • Examine for evidence of trauma or previous surgery
  • Swelling
    • The hip is a deep structure, so it may be hard to detect swelling
  • Ecchymoses
    • Examine for ecchymoses, indicating trauma
  • Atrophy/hypertrophy
    • Examine the muscle bulk bilaterally

Ask the patient to stand (you may wish to do this after completing the rest of the exam so you don't need to ask the patient to lie down again)

  • Gait inspection
    • Ask the patient to walk to the other side of the room and back
    • Examples of gait abnormalities:
      • Antalgic gait - Less time is spent load bearing on one leg due to pain
      • Trendelenburg gait - Due to abductor weakness. Upon heel strike of the weak side, the contralateral hip drops. The "Runway Model Walk"
  • Trendelenburg Test
    • Stand behind the patiet and place your hands on the patient's iliac crests
    • Ask the patient to lift one leg into a "marching" position, with the knee elevated
      • Normal - the iliac crests remain level
      • Abnormal - a drop in the non weight-bearing hip. This suggests weakness in the hip abductors of the weight bearing hip.
    • Repeat the above for the other leg

 Figure 1: Trendelenburg Test

Figure 1: Trendelenburg Test

Palpation

 Palpation of the hip consists of the following components:

  • Thomas Test (Detection of a Flexion Contracture)
    • With the patient supine, place your hand behind the patient's back
    • Flex the ipsilateral hip with the contralateral hip relaxed
    • As you flex, observe the contralateral hip for elevation. You should also feel the spine flatten against your hand under the patient's back
    • Elevation of the contralateral hip suggests a flexion contracture
    • Repeat for the other leg
  • Leg Length Measurement
    • True Leg Length - Measure from the anterior superior iliac spine (ASIS) to the medial malleolus
    • Apparent Leg Length - Measure from the umbilicus to the medial malleolus
  • Palpation of Landmarks
    • Anterior Superior Iliac Spine - Palpate with the patient supine
    • Greater Trochanter, Trochanteric Bursa - With the patient in the lateral decubitus position, palpate posteriorly along the iliac crest from the ASIS, then inferiorly to the greater trochanter and trochanteric bursa
      • Palpate for tenderness, bony abnormalities
    • Posterior Superior Iliac Spine - Palpate with the patient in the prone position

Range of Motion

Range of motion in the hip consists of active and passive components:

  • Active Range of Motion
    • Flexion - Ask the patient to bring their knee to their chest
      • Normal - 120o
  • Passive Range of Motion
    • Flexion - If there is limitation in active flexion, repeat the movement by flexing the patient's hip passively. To streamline the exam, you can perform internal/external rotation while each leg is flexed (see below)
      • Normal - 120o
    • Internal Rotation - With the patient's knee flexed to 90o, Rotate the leg so the patient's foot points outwards
      • Normal - 45o
    • External Rotation - With the patient's knee flexed to 90o, Rotate the leg so the patient's food points inwards
      • Normal - 45o
    • Abduction - With your hand on the patient's contralateral ASIS, carefully abduct the ipsilateral hip. Stop when you feel the contralateral ASIS begin to rotate
      • Normal - 45o
    • Adduction - With your hand on the patient's ipsilateral ASIS, carefully adduct the hip. Stop when you feel the ASIS begin to rotate
      • Normal - 30o
      • The leg being tested should be able to cross over the other leg. You will have to slightly lift the tested leg to do this.
    • Extension - With the patient in the lateral decubitus position, ensure the leg is in the neutral position (which is a line drawn perpendicular to an imaginary line drawn between the ASIS and PSIS). Then stabilize the pelvis, and attempt to extend the hip. When the pelvis begins to rotate, this is the end of the range of motion.
      • Normal - 30o