Supplementary Notes to the Hip Examination:

Draping & Inspection:

• Positioning and Draping: The patient should be examined standing, walking, and supine. When supine, a drape can be placed between the patients legs (as in the video) so both hips can be uncovered.

• Inspection: The hip is a deep joint, so one cannot view the joint specifically. Instead, the examiner can observe the patient’s gait and posture when standing, as well as the following;

  • Measurement of Leg lengths: True leg length- the distance between the anterior superior iliac spine (ASIS) of the os coxae and medial malleolus of the tibia. Apparent leg length- the distance from a common reference point (usually the umbilicus) to the medial malleolus.

  • Detection of a flexion contracture:  A condition of fixed high resistance to passive stretch of a muscle, resulting from fibrosis of the tissues supporting the muscles or the joints or from disorders of the muscle fibres. By eliminating the lumbar lordosis, by flexing the contralateral hip, the presence of a flexion contracture can be identified.

Palpation:

• Palpation of landmarks: Common landmarks that can be palpated include the anterior superior iliac spine (ASIS), pubic symphysis, greater trochanter, trochanteric bursa, posterior superior iliac spine (PSIS), ischial tuberosities.
   

Range of Motion:

• Testing Flexion: easily tested by active movement by the patient.

• Testing Internal and External rotation: Remember that when we speak of rotation, we are talking about the head of the femur inside the acetabulum of the pelvis. Testing this passively, avoids confusion and giving complicated instructions to the patient.

• Testing Abduction and Adduction: Problems in the hip joint can be compensated for by movement of the pelvis. Movements of the pelvis must be monitored by the examiner (as shown in the video) when examining abduction and adduction of the hip.

• Testing Extension: To examine extension, have the patient roll onto their side.  The neutral position of the hip joint range of motion can be found by landmarking from the ASIS and the PSIS (see video).

Table. 1 Normal ranges for movements of the hip joint (may vary between sources).

Observation of standing and walking:

• Types of gait:

  • Antalgic: in order to avoid pain during weight bearing, the time in the stance phase of the injured limb is minimized.

  • The Trendelenburg (lurch) gait- is marked by the dropping of the pelvis on the unaffected side of the body at the moment of heel-strike on the affected side.  The pelvic drop during the walking cycle lasts until heel-strike on the unaffected side and has with it a sideways movement of the entire trunk and the affected lower limb. The gait is also known as an uncompensated gluteal gait and is caused by weakness of the hip abductors.

Special Maneuvers:

• Trendelenburg test for hip abductor function:  To detect weakness in the abductors of the hip, the patient is asked to stand on one foot.  If the abductors of the hip joint cannot fully compensate for the shift in the patient’s weight, then excess pressure may be placed on the examiner’s hands.  Gait inspection may also show a Trendelenburg’s lurch.