hip examination -final

8/12/2019 Hip Examination -Final

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Department Of Orthopaedics

KMC Mangalore

Examination of Hip Joint Movements, Measurements and Special tests

Moderators: Prof. B.J.Kamath Presenters: Dr.Vinay J ChackoDate: 2 Octo!er" 2 # Dr.Vi$ek P %ahar

Dr. Vi&ay 'eddy

Courage gives a leader the ability to stand straight and not sway no matter which way the wind blowsfor this a stable hip is of utmost importance!

Movements : -

Expected Range of Movement

lexion: -"# $egrees

Anterior motion in the saggital plane is defined as hip flexion whereas posteriormotion is defined as extension. The patients knee is flexed during testing flexionso as to prevent hamstring tightness from limiting the movement.

%bduction: -&' $egrees

To test, abduction in extension , the examiner stands at the side of the patientfacing the supine patient. One of the examiners hands grasps the ankles whilethe other hand is lightly placed over the ASIS. This allows the examiner to detectany complimentary motion of the pelvis during a duction. The examiner then,passively a ducts the patients lower extremity away from the midline until thepelvis is felt to !ust start moving. The angle etween the axis of the thigh and themid"line of the patient is measured. To test abduction in flexion , the hip is allowedto fall outward into a position of a duction# the examiner assists as necessary.one of the examiners hands is placed over the ASIS to detect the pelvis rotationsupplementing the a duction of the hip.

%dduction: -# $egrees

To test, adduction in extension , the examiner stands at the side of the patientfacing the supine patient. One of the examiners hands grasps the ankles whilethe other hand is lightly placed over the ASIS. This allows the examiner to detectany complimentary motion of the pelvis during a duction. The examiner then


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passively adducts the patients lower extremity towards the midline. On reachingthe mid"line, it is necessary to flex the hips slightly to allow the extremity eingtested to pass in front of the contra lateral lim . Again, the lim is adducted untilthe pelvis is felt to !ust start moving. The angle etween the axis of the thigh andthe mid"line of the patient is measured. To test adduction in flexion , the examinergrasps the patients knee and adducts the thigh ack across the midline whilegently pressing posteriorly on the ipsilateral ASIS to prevent the pelvis fromrotating.

MR: -&' $egrees

(R: -) $egrees

$ip rotation also may e measured in oth the flexed and extended positions.The rotational motions o served in these two positions. The rotational ROM inextension affects foot placement (in toeing or out toeing) during ambulation, andthus its physiologically more important. $ip rotation in extension may eassessed in either the supine or the prone position. To assess rotation in thesupine position, the patient is asked to lie comforta ly with the hips and kneesextended. %efore eginning examination, note the resting position of the lowerextremities. To assess the maximum possi le external rotation possi le, theexaminer grasps the patients feet, then uses them to fully externally rotate theextremity at the hip. The orientation of the medial order of the foot may e used

to estimate the amount of external rotation present. The examiner then internallyrotates the entire lim and estimates the amount of internal rotation present. Anincrease in internal rotation at the expense of external rotation may indicateincreased femoral anteversion. $ip rotation in extension may also e assessed

with the patient in prone position. In this case, the patients knees are flexed andthe axis of the ti ia is used as an indicator of the amount of rotation present. Onemust remem er that during internal rotation, the foot moves away from themidline whereas during external rotation the foot moves across the midline.

Extension: -* $egrees

&or testing extension of the hip, the patient is in prone position , and theexaminer must ensure that only hip movement is occurring. 'um ar extensionshould not e allowed to occur.

The amount of motion needed to perform activities of daily living is at least ()*+degreesof flexion, )*+degrees of a duction, and )*+degrees of external rotation.


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+,uaring the pelvis : he limbs should be ad.usted in such a way that both%+/+ come at the same level0 with the affected limb held in exaggeratednoted deformity 1adduction2abduction3 with both %+/+ e,uidistant fromumbilicus4

+,uaring the pelvis is difficult in :

" &ixed pelvic o li-uity

" Iatrogenic ASIS removed

" al development of hemipelvis

" /nreduced dislocation of SI0

" alunited vertical 1 of ilium

If any fixed deformity is found, the opposite movement $AS to e 2ero degree.3.g. patient can not have extension of any degree with a fixed flexion deformity.

homas est : or diagnosing fixed flexion deformity of the hip

homas /: 5atient supine0 /nsinuate your fingers under lumbar lordosis as6the patient to flex the unaffected hip over the abdomen till lordosisobliterated and as6 the patient to hold the 6nee in that position and loo6 for

fixed flexion deformity on the affected side4 his has diagnostic value4

homas //: %ssess further free flexion beyond the $4 his has 5rognostic/mportance4

&ree movement eyond the fixed deformity has to e assessed as further freemovement. Total movement thus e-uals fixed deformity 4 &urther activemovement 4 &urther passive movement.

5OT$A6I Angle to measure fixed a duction deformity 7 0oin oth ASIS in

unsquared pelvis, draw a perpendicular from each side ASIS over midline, theangle etween these two lines gives fixed a duction deformity.

&ixed A%8/9TIO: is complimentary to S$O6T3:I:;. A88/9TIO: iscomplimentary to '3:;T$3:I:;. 6oughly as a rule of thum 7 for each (cm ofTRUE shortening there should e (* degrees of fixed a duction deformity.


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9ompensation for a deformity is for either or all of the following 7 9oncealing thedeformity, Attaining e-uili rium, Apparently make up for lim length discrepancyand to sta ili2e the unsta le hip. 3.g In &&8 hip extension is lost which is verydisa ling to cover up for that the patient develops exaggerated lum ar lordosis.

o be chec6ed both 5assive 7 %ctive4 %ctive R8M gives an additional idea aboutany axis deviation of the hip .oint4

PROM :

Capsular 5attern

( (imitation in flexion0 abduction and /R

) ax loss Internal 6otation, moderate loss of flexion, and moderateloss of a duction with minimal loss of extension < 0ames 9yriax

( 8rder may vary 9 only .oint to exhibit this

Minimal loss of extension greater functional limitation than the same loss offlexion

Measurements :

%pparent leg length : Measure from tip of xiphoid process to inferior borderof medial malleolus ;/ =%R/?@ =%R/?@


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Measuring limb length : After S !AR"#$ the pel%is from AS"S to Medialmalleolar tip 4

(8CD ME talus or calcaneus?canalso produce this appearance.


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rue +hortening In true shortening the affected lim is physically shorter than

the other and this may e caused y pathology proximal or distal to the

trochanters. True shortening from causes distal to the trochanters most

fre-uently results from previous fractures of the femur or ti ia or growth

distur ance >e.g. from polio or epiphyseal trauma?. @roximal to the trochanters

causes include femoral neck fractures, OA and hip dislocation.

rue shortening indicates actual shortening and apparent indicates

compensation4 /f true shortening e,uals apparent 9 there is ?8

compensation4 /f R=E shortening more than apparent 9 part of it is

compensated by fixed abduction deformity4 /f R=E shortening is less than

apparent it indicates fixed adduction deformity and no compensation4

otal limb length emoral component ibial Component

emoral Component +upratrochanteric length /nfratrochanteric length

+upratrochanteric measurements :

ryantFs riangle : Identify greater trochanter and ASIS. 0oin ASIS and greater

trochanter. 8rop a vertical from ASIS and !oin tip of greater trochanter with this

vertical lin at =* degrees. This line forms the ase of the %ryants triangle. This is

a measure of supratrochanteric length and is to e compared with the normal

side. $ypotenuse of the %ryants triangle forms a part of the :elatons line.

&A''A9 7 8iscrepant results in ilateral affection of the hip !oint.

$raw on both sides

elevation of trochanter

C anteropsterior movementof trochanter G ?8 0

5ost dislocation


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Morris itrochanteric est 7 'ines drawn connecting Symphysis pu is andgreater trochanter and thy should measure e-ual normally. In supratrochantericshortening this is decreased.

ChieneFs est : Two lines drawn, one !oining oth ASIS B other line !oining oth

greater trochanters. :ormally these lines are parallel. They intersect on theaffected side.

+hoema6erFs (ine : 'ines drawn %C' from ;T to ASIS should dissect at theum ilicus in the midline. In case of shortening this decussation is displacedtowards the unaffected side.

?elatonFs (ine : The patient lies on his sound side. 'ine drawn from ischialtu erosity to ASIS, the tip of the greater trochanter !ust touches this line normally.In supratrochanteric shortening tip will e a ove this line.

+5EC/%( E+ +

rendelenburg +ign: The test is performed with the patients ack to theexaminer. The model stands on the normal leg and flexes the knee of the otherleg to a right angle. The pelvis should remain level or tilt slightly upwards on theunsupported side. The model then stands on the affected leg and flexes the kneeof the other leg. If the pelvis tilts downwards on the unsupported side, then thisconfirms a positive Trendelen erg sign. @atient made to stand at least D*seconds to rule out any muscle weakness disorder.

$elayed positive rendelenburg sign: Several people have an initial negativetest, ut after standing for a short time, with the non"stance side of the pelvisraised, the pelvis gradually falls and they are not a le to maintain their initialposture. This has een called a delayed positive Trendelen urgs sign. The timeat which the pelvis egins to drop should e calculated. In such people, the gaitcan e normal ut when they are asked to walk -uickly, it ecomes apparen


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t that they egin to fatigue easily, and alimp with all the characteristics of a trendelen urgs gait ecome o vious.

5re Re,uisites of rendelenberg est: " &633 A%8/9TIO:C A88/9TIO: O& )* 83;.

" A%'3 TO STA:8 O: A&&39T38 'I % &O6 E D* S39.

" A;3 E F 3A6S.

/sed to assess the a ility of the hip a ductors to sta ilise the pelvis on thefemur. A positive test demonstrates that the hip abductors are not functioning.

Causes 7

8istur ance in pivotal mechanism < dislocation or su luxation of hip,shortening of femoral neck

Geakness of the hip a ductors e.g. myopathy, neuropathy

&allacies 7

Intact Huadratus 'um orum can produce &alse positive Test

SI 0oint involvement due to pain may produce pseudo positivetrendelenberg test

edial shift of axis of the lim elow the knee e.g. ow knee etc can producea pseudo positive test


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9auses of false negatives include 7 use of supra pelvic muscles, use ofpsoas and rectus femoris, wide lateral translocation of trunk to allow alanceover the hip as a fulcrum.

(eg (ength ests 1;eber arstow Maneuver3 @ross emur (ength2@rossibia (ength :

@atient supine with hips flexed F deg and knees =* deg. 3xaminer palpatesmedial malleolus with the thum s. @atient lifts the pelvis of the couch andreturns. 3xaminer passively extends the legs, a difference in the level indicatesasymmetry.

REC =+ EM8R/+ C8? R%C =RE E+ + :

ME


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pro a ly present. Always palpate for muscle tightness. The two sides should etested and compared.

ME


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elescoping est : @atient supine , flex the hip to =* degrees, the pelvis is fixed with one hand touching the greater trochanter. with the palm of one hand adductand push and pull the knee and with the other hand feel for the movement ofgreater trochanter up and down. It indicates old non union fracture neck of femur,paralytic hip or unreduced posterior dislocation of hip.

CraigFs est 1RyderFs Method3 : @rone with 5nee flexed L =*, @alpate greatertrochanter, @assively Internally B 3xternally rotate until trochanter is parallel isparallel to the ta le. Angle etween the vertical and long axis of the leg givesdegree of anteversion.

5rone Dnee lexion est for ibial +hortening : Gith patient lying prone, flexthe knee y =* degrees check the levels of oth heels to determine ti ialshortenening of any etiology.


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%/R 1 lexion %dduction /nternal Rotation %/R3 est : @iriformis syndromeis suggested y posterior hip pain caused y resisted external rotation of the hip

with the knee and hip flexed at =*+degrees >@ace test? and y uttock or sciaticpain exacer ated y hip flexion, adduction, and internal rotation >&AI6 test?.Anterior pain caused y resisted hip flexion and resisted straight leg raisesuggests hip flexor strain or tendinitis.

8ber est : The O er test is employed to test for a tight ilioti ial and >IT%?, as isoften seen in patients who have trochanteric ursitis. The patient is positioned on

his or her side with the ottom leg flexed at oth the hip and knee. The top leg isthen extended and a ducted. IT% contracture is present if the top leg does notpassively fall to the ta le. This maneuver often exacer ates pain over the greatertrochanter.

?obel Compression est

>uadrant est 2 +cour

Modified 8ber test : &-' I 8ber test 1more abduction compared to 8berFsest 9 marginally improves sensitivity of the 8berFs est3


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?oble Compression est 7&or iliotibial band friction syndrome " @atient liessupine with knee in =* degrees flexion and hip flexed, pressure over lateralfemoral condyle B with pressure maintained ask pt to extend the knee .Approximately t D* degrees of flexion severe pain is felt over lateral condyle.

ErichsonFs +ign 7 Ghen iliac ones are sharply pressed towards each other painfelt in the SI !oint region and not in the hip !oint.


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arlowFs est : od. Of Ortolanis Test. Supine, hips =* *, knees extended ,iddle finger on ;.T., thum medial at '.T. A duct $ip, with distal pressure on

;.T. @OSITIJ3 if MslipNC8islocation occurs. /se thum , apply post.Csup. &orce toreduce Jalid in infants P months. %ilateral alternate test.

5ositive +ign of the uttoc6 : Supine# perform S'6 test, If limitations on S'6examiner flexes patients 5nee to see if further $ip flexion can e o tained. If $ip

flexion does not increase, the lesion is in uttocks or $ip, not sciatic nerve or$amstring muscle

+cour est of uadrant est of


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5ositive est

@ain or reproduction of symptoms at the hip

5ositive est /mplications

8efect in the articular cartilage of the femur or aceta ulum

@auvainFs +ign : Sir $enry ;auvain in (=(*" In active T% of the hip !ointrotatory movements at the hip !oint produce contraction of muscles around thehip !oint and a domen. $olding the lower end of femur, the thigh is rotated at the

!oint inwards and outwards. After movement is checked any further sharp rotation

is met with ipsilateral !oint and a dominal muscle contraction. 6eason 7Transmission of movement from hip to the trunk.


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lexion 9 %dduction est 7 Goods and acnicol )**( < in a normal patientthe knee should adduct to Qone (, with pathologic changes only to Qones ) or D>limitation ) * to pain, apprehension, or limited end range? >4? for nonspecific hipdisease

+taheli est : 5rone hip extension test : for flexion posture of hip (hips flexedover end of couch, support pelvis posteriorly & passively extend hip). For childrenwith cerebral palsy.

ulcrum est : @atient sits on exam ta le with knee extended @lace one handunder sitting patientRs femur Other hand placed over knee apply firm pressureupward on femur B downward on knee. @OSITIJ3 if pain is elicited . Site of painis usually near site of stress fracture.

%nterior (abral ear est : 5ositive if pain or clic6 present on externalrotation of the hip4

5osterior (abral ear est : 5ositive if pain or clic6 present on internalrotation of the hip4

+(R est 1(asKgueFs test3 : %ctive +(R indicates anatomical integrity fromfoot to hip4


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(aguerreLs +ign : This test is done with the patient supine while the thigh andknee are flexed to right angles. Then the thigh is a ducted and rotated outward.This forces the head of the femur against the anterior portion of the hip !ointcapsule. The sign is present when this action produces pain, tending to rule out alum osacral lesion, ut indicating a hip !oint lesion, iliopsoas muscle spasm or asacroiliac lesion.

Fabere Sign or Patricks est *+est for ,- &oint pain

/le0ion" 1!d ction" 30ternal 'otation. Patient is s pine and +he knee is fle0ed" the hip ise0ternally rotated 4ith a!d ction Positi$e finding ( if the knee does not drop !elo4 the

le$el of the opposite h ip.

5helpFs est >Assessment for contracture of gracilis with associatedpathology of hip !oint? 7

@rocedure 7 @rone posture with knees extended and thighs maximallya ducted >pain B resistance? " Actively flex knees ilaterally to right angle" :ote changes in hip a duction

6ationale

(. @ositive test if knee flexion increases hip a duction

). @ositive test if knee extension decreases hip a duction

D. Test indicates contracture of gracilis muscle


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(udloffFs +ign >Assessment for traumatic separation of the lessertrochanter?

@rocedure 7

Seated posture " /na le to raise affected lim from ta le along with 3cchymosisand edema in Scarpas triangle.

RE ERE?CE+ :-

(? 9linical Orthopaedic 3xamination < 6onald c6ae < F th edition

)? A anual on clinical surgery < S.8as < P th edition

D? $oppenfield 9linical 3xamination

? Orthopaedic @hysical Assessment " 8avid 0. aggie < th edition

F? 9linical Orthopaedic Tests < @rem @. ;ogia

P? The @elvifemoral Angle , $enry ilch < 0%0S Am (= )#) 7( "(FD

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hip examination -final

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