Mastering the Hip Examination: A Complete Tutorial for Medical Students

Hip examinations are an essential component of musculoskeletal assessments, particularly for patients presenting with hip pain, instability, or decreased mobility. A systematic and thorough examination can help diagnose a wide range of hip pathologies, from simple strains to complex joint disorders. This guide is designed to provide a step-by-step approach to performing a hip examination, ensuring that medical students and healthcare professionals can confidently assess and diagnose hip-related issues.

1. Introduction to Hip Anatomy

Before delving into the examination process, it’s crucial to have a solid understanding of the hip joint's anatomy. The hip is a ball-and-socket joint formed by the articulation between the femoral head (the ball) and the acetabulum of the pelvis (the socket). The hip joint is stabilized by a complex arrangement of muscles, ligaments, and tendons, allowing for a wide range of motion while bearing significant weight.

Key Structures:

• Bones: Femur, Pelvis (Ilium, Ischium, Pubis)
• Muscles: Gluteus maximus, medius, and minimus, Iliopsoas, Adductors, Quadriceps, Hamstrings
• Ligaments: Iliofemoral, Ischiofemoral, Pubofemoral, Ligamentum teres
• Bursae: Trochanteric, Iliopsoas, Ischial
• Nerves: Femoral nerve, Sciatic nerve, Obturator nerve

Understanding these structures is critical, as they are the focal points during both inspection and palpation.

2. Patient History

The hip examination begins long before any physical contact. A detailed patient history is crucial for understanding the context of the symptoms and narrowing down potential diagnoses.

Key Questions to Ask:

• Pain Location: Where exactly is the pain located? (Anterior, lateral, or posterior hip)
• Pain Onset: Was the onset of pain gradual or sudden? Is there a history of trauma?
• Pain Character: Is the pain sharp, dull, aching, or throbbing? Does it radiate to other areas?
• Aggravating/Relieving Factors: What activities exacerbate or alleviate the pain? (e.g., walking, running, sitting)
• Associated Symptoms: Any numbness, tingling, or weakness in the leg?
• Functional Limitations: Difficulty with specific movements like sitting, climbing stairs, or putting on shoes?

The history helps to hypothesize potential issues such as arthritis, bursitis, tendinitis, or even referred pain from the lumbar spine.

3. Inspection

After taking the patient history, proceed with the physical examination, starting with inspection. The patient should be undressed to their underwear to allow a clear view of the hip area.

Key Points During Inspection:

• Gait Analysis: Observe the patient walking. Look for limping, waddling gait, or Trendelenburg gait (hip drop).
• Posture: Check the patient’s standing posture for any pelvic tilt, lordosis, or scoliosis.
• Skin: Look for any discoloration, scars, or signs of inflammation such as redness or swelling.
• Muscle Bulk: Compare both sides for muscle wasting, particularly in the gluteal region.
• Alignment: Assess leg length and alignment. Discrepancies may indicate hip pathology.

Inspection often provides the first clues about the underlying problem, particularly if the issue is structural or related to muscle wasting.

4. Palpation

Palpation allows you to identify tenderness, deformities, and temperature changes that may indicate inflammation or injury.

Key Areas to Palpate:

• Anterior Structures:
  • Anterior Superior Iliac Spine (ASIS): Tenderness may indicate hip pointer injury or apophysitis.
  • Iliopsoas Muscle: Palpate deep in the groin area; tenderness suggests tendinitis or bursitis.
  • Inguinal Ligament: Pain here may indicate a hernia or referred pain from the hip joint.
• Lateral Structures:
  • Greater Trochanter: Tenderness can be a sign of trochanteric bursitis.
  • Iliotibial Band: Pain or tightness may suggest IT band syndrome.
• Posterior Structures:
  • Ischial Tuberosity: Pain may indicate hamstring tendinopathy or ischial bursitis.
  • Sacrum and Sacroiliac Joint: Check for tenderness that might suggest sacroiliac joint dysfunction or referred pain from the lower back.

Palpation should be gentle but thorough, ensuring that all relevant anatomical landmarks are assessed for abnormalities.

5. Range of Motion (ROM) Assessment

Assessing the hip joint’s range of motion helps determine if there is any restriction, pain, or instability in the joint. It’s important to compare both sides to identify asymmetries.

Active ROM:

Ask the patient to perform movements while you observe:

• Flexion: Bringing the knee towards the chest (Normal: 110-120°)
• Extension: Moving the leg backward (Normal: 10-15°)
• Abduction: Moving the leg away from the midline (Normal: 40-50°)
• Adduction: Moving the leg towards the midline (Normal: 20-30°)
• Internal Rotation: Rotating the leg inward (Normal: 30-40°)
• External Rotation: Rotating the leg outward (Normal: 40-60°)

Passive ROM:

You should perform the same movements on the patient’s leg while they relax:

• Flexion and Extension: Note any crepitus or pain during movement.
• Abduction and Adduction: Look for pain or resistance.
• Internal and External Rotation: Pay attention to the smoothness of motion and any discomfort.

Restricted ROM or pain during these movements can indicate conditions like osteoarthritis, labral tears, or muscle strain.

6. Strength Testing

Assessing muscle strength is crucial for identifying weaknesses that may contribute to hip dysfunction.

Common Strength Tests:

• Hip Flexion: Have the patient lift their knee against resistance.
• Hip Extension: Ask the patient to push their leg back against your resistance.
• Hip Abduction: The patient should move their leg outward against your resistance.
• Hip Adduction: Test by having the patient move their leg inward against resistance.
• Internal and External Rotation: Apply resistance to assess the strength of the muscles involved in these movements.

Grading strength on a scale from 0 to 5, with 5 being normal strength, allows you to quantify any deficits.

7. Special Tests

Special tests are designed to assess specific conditions or injuries within the hip joint.

Common Hip Special Tests:

• Trendelenburg Test: Have the patient stand on one leg. A positive test (hip drop on the opposite side) indicates gluteus medius weakness.
• FABER (Patrick’s) Test: Flexion, Abduction, and External Rotation of the hip. Pain in the groin suggests hip joint pathology, while pain in the sacroiliac region suggests SI joint dysfunction.
• FADIR Test: Flexion, Adduction, and Internal Rotation. A positive test indicates femoroacetabular impingement (FAI).
• Thomas Test: With the patient supine, have them pull one knee to their chest while the other leg remains extended. If the extended leg lifts off the table, this suggests hip flexor tightness.
• Ober’s Test: Assesses for iliotibial band tightness. The patient lies on their side, and you lower the leg. If it remains abducted, the IT band is tight.
• Scour Test: This involves flexing and internally rotating the hip while applying axial pressure. Pain or clicking suggests labral pathology.

These tests can provide valuable information about specific conditions that may not be obvious during routine ROM and strength testing.

8. Neurological Examination

A neurological examination is essential when hip pain is associated with neurological symptoms such as numbness, tingling, or weakness.

Key Points to Assess:

• dermatomes: Test sensation in the areas supplied by L2-S1 nerve roots, which innervate the hip and surrounding areas.
• Myotomes: Assess motor function in the same nerve roots through hip flexion (L2-L3), knee extension (L3-L4), and plantarflexion (S1).
• Reflexes: Test the patellar and Achilles reflexes to assess the integrity of the L4 and S1 nerve roots, respectively.

A neurological examination helps rule out referred pain from the lumbar spine, nerve impingements, or other neuropathies that might present with hip pain.

9. Differential Diagnosis

Based on the findings from the history and physical examination, formulate a differential diagnosis. Common conditions that should be considered include:

• Osteoarthritis: Characterized by decreased ROM, pain with weight-bearing, and morning stiffness.
• Trochanteric Bursitis: Pain and tenderness over the greater trochanter, often exacerbated by lying on the affected side.
• Femoroacetabular Impingement (FAI): Pain with hip flexion and internal rotation, often seen in younger athletes.
• Hip Labral Tear: Groin pain with clicking or locking sensations during hip movement.
• Hip Fracture: Common in elderly patients, presenting with severe pain, inability to bear weight, and leg shortening.
• Avascular Necrosis: Gradual onset of hip pain, often in young adults, associated with corticosteroid use or alcohol abuse.
• Referred Pain: Consider lumbar spine pathology if the pain radiates down the leg or is associated with neurological symptoms.

Each diagnosis should be confirmed with appropriate imaging or further testing as required.

10. Imaging and Further Investigations

If the clinical examination suggests a specific diagnosis, further imaging or laboratory tests may be necessary to confirm it.

Common Investigations:

• X-rays: Useful for detecting fractures, osteoarthritis, or structural abnormalities like FAI.
• MRI: Best for soft tissue injuries, labral tears, and avascular necrosis.
• Ultrasound: Can be used to assess bursitis, tendinopathy, or effusions.
• CT Scan: Provides detailed images of the bone, helpful in complex fractures or when MRI is contraindicated.
• Blood Tests: May be indicated if an infection or inflammatory condition is suspected.

These investigations should be chosen based on the clinical findings and differential diagnosis.

11. Management and Treatment

Management of hip conditions depends on the specific diagnosis but generally includes a combination of:

Conservative Management:

• Rest: Essential for most acute injuries to reduce inflammation.
• Physical Therapy: Focuses on strengthening the hip muscles, improving flexibility, and correcting any biomechanical issues.
• Medications: NSAIDs for pain and inflammation, corticosteroid injections for more severe cases.
• Assistive Devices: Crutches or canes to offload weight from the affected hip.

Surgical Management:

• Arthroscopy: Indicated for labral tears, FAI, or loose bodies within the joint.
• Hip Replacement: Considered in cases of severe osteoarthritis or avascular necrosis when conservative treatment fails.
• Fracture Repair: Surgical fixation is often required for hip fractures, especially in the elderly.

The choice of treatment should be individualized based on the patient’s condition, age, activity level, and overall health.

12. Conclusion

A comprehensive hip examination is a vital skill for medical students and healthcare professionals, enabling accurate diagnosis and management of hip-related conditions. By following a structured approach, including patient history, inspection, palpation, ROM assessment, strength testing, special tests, and neurological examination, you can systematically evaluate the hip joint and identify the underlying pathology. This guide provides a foundation for mastering the hip examination, ensuring that you can confidently assess and manage patients with hip pain or dysfunction.