Physical Examination
The following processes should take place in order to reach an informed diagnosis. Firstly, carefully assess ease of movement around the examination room, particular attention should be paid to the patient’s gait. Many hip problems manifest clearly through ambulation. Secondly the passive range of motion of the hip should be undertaken in flexion, extension, abduction, adduction, internal and external rotation. Thirdly muscle testing of the major groups should be performed. Fourthly, appropriately performed special tests can be used to aid a diagnosis. These are explained below and performed in the following video clips.
Patrick (Faber’s) Test (Flexion, Abduction, External Rotation)
The patient lies supine; the affected leg is flexed, abducted, and externally rotated. Lower the leg toward the table. A positive test elicits anterior or posterior pain and indicates hip or sacroiliac joint involvement.
Thomas Test
The patient should be placed supine on the examination table. The unaffected hip is flexed as far as possible (usually when the anterior portion of the thigh approximates with the abdomen, almost touching the chest wall). The affected thigh is then flexed in a similar manner. The patient is asked to grasp the unaffected leg and then lower the affected leg down until it is flat on the table. If the affected hip does not extend fully, the patient may have a fixed flexion contracture of the hip. If he or she rocks forward, lifting his or her thoracic spine from the table or arches his or her back to reform the lumbar lordosis when lowering the leg, then this also indicates compensatory mechanisms for a contracted hip. The extent of the flexion contracture can be approximated if you observe the patent from the side and estimate the angle between his or her leg and the table at the point of greatest extension.
Trendelenburg Test
This is a test for pathology of a hip joint and is performed kneeling in front of the patient with a hand on each of the patients hips. The patient can then rest their hands on the examiners shoulders for balance. If the patient bears weight on the normal side then in order to raise the contralateral leg off the floor that side of the pelvis is tilted upwards. This is largely a function of the ipsilateral abductors of the hip. On the abnormal side they are unable to tilt the pelvis upwards and as the contralateral leg comes off the floor (by hip and knee flexion) the pelvis becomes unsupported and may drop (it certainly does not rise). A positive Trendeleburg is relatively non-specific and may indicate pain (e.g. due to OA), weak abductors, short femoral neck, medial migration of the femoral head and neuropathy. A ‘Trendelenburg gait’ due to abductor weakness is characterised by a sideways lurch to bring the body weight over the affected limb.
Ober’sTest.
This test assesses the tensor fasciae latae (iliotibial band) for contracture. The patient is in the side lying position with the lower leg flexed at the hip and knee for stability. The examiner then passively abducts and extends the patient’s upper leg with the knee straight or flexed to ninety degrees. The examiner slowly lowers the upper limb. If a contracture is present, the leg remains abducted and does not fall to the table. When performing this test it is important to extend the hip slightly so that the iliotibial band passes over the greater trochanter of the femur.