Abstract
Purpose
To establish the clinical utility of the hip drop test (HDT) for diagnosing hip abductor tendon tears as well as for predicting future surgery and to identify patient risk factors associated with tears and surgery.
Methods
A single institution’s electronic medical records, comprising patients treated by a single sports medicine fellowship-trained orthopaedic surgeon, were reviewed to identify patients aged 18 years or older with suspected hip abductor tendon tears with documented HDT results who underwent hip magnetic resonance imaging (MRI). Hip MRI served as the diagnostic gold standard. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated, and logistic regression analysis of various associated factors was performed.
Results
Our initial review yielded 366 patients. After we excluded patients without positive or negative HDT results, as well as those without MRI results, 261 patients underwent analysis. Of these patients, 245 had negative HDT results whereas 16 had positive results. Of the patients with positive HDT results, 8 underwent surgery. Sensitivity for a future MRI-confirmed diagnosis of hip abductor tendon tear was 30.4% (95% confidence interval [CI], 19.1%-44.8%), and specificity was 99.1% (95% CI, 96.7%-99.7%). The PPV of the HDT for a future MRI-confirmed diagnosis was 87.5% (95% CI, 64.0%-96.5%), and the NPV was 86.9% (95% CI, 82.1%-90.6%). For the prediction of future hip abductor tendon surgery, a positive HDT result yielded a sensitivity of 80.0% (95% CI, 49.0%-94.3%), specificity of 96.8% (95% CI, 93.8%-98.4%), PPV of 50.0% (95% CI, 28.0%-72.0%), and NPV of 99.2% (95% CI, 97.1%-99.8%).
Conclusions
The HDT is a reliable clinical examination maneuver for diagnosing hip abductor tendon tears in patients with lateral hip pain when performed by an experienced medical provider. The HDT shows a high NPV for both a hip abductor tendon tear diagnosis on MRI and the prediction of future surgery and may be used to guide initial clinical decision making. Patients with lateral hip pain and negative HDT results may forego immediate advanced imaging and, instead, consider nonoperative management. Additionally, demographic variables such as female sex, older age, and higher body mass index raise the risk of a hip abductor tendon tear and thus increase suspicion for an abductor tendon tear requiring advanced imaging and, possibly, future surgery.
Level of Evidence
Level III, development of diagnostic criteria based on nonconsecutive patients.
Lateral hip pain is common, with a variety of etiologies. Hip pain is increasingly common as patients age, with 14.3% of individuals older than 60 years reporting consistent pain.1,2 The most common cause of lateral hip pain in outpatient primary care clinics is greater trochanteric pain syndrome (GTPS), which reportedly affects 10% to 25% of individuals.1, 2, 3 GTPS can include gluteus medius tendinopathy or tear, femoral greater trochanteric bursitis, and iliotibial (IT) band syndrome.3, 4, 5 However, it can be clinically challenging to differentiate nonoperatively managed causes of GTPS, such as greater trochanteric bursitis and IT band syndrome, from surgically treated causes of GTPS, such as hip abductor tendon tears.2,6, 7, 8, 9
The gluteus medius, gluteus minimus, and tensor fascia latae are the primary abductors of the hip and provide stability to the hip and pelvis.10, 11, 12 The gluteus medius and minimus originate on the posterolateral ileum and share a common insertion at the greater trochanter, with occasional variation leading to insertion onto the hip joint capsule.10,13, 14, 15 The tensor fascia latae originates on the anterior superior iliac spine and the anterior aspect of the iliac crest and terminates distally as the IT band.16 The abductors are innervated by various branches of the superior gluteal nerve.13 Many factors, including anatomy, may contribute to the pathophysiology of hip abductor tendon tears. Although hip abductor tendon tears develop after acute trauma in some patients, most cases result from chronic degenerative changes and inflammatory processes that may present as GTPS.17,18 Patients with hip abductor tendon tears often complain of hip pain and instability that can be aggravated by activities such as walking and navigating stairs or compression of the affected side. Severe cases can lead to hip dislocation.5,17, 18, 19 In some cases, hip abductor tendon tears respond poorly to nonoperative management, and accurate assessment is necessary for appropriate surgical planning.17
The differentiation of nonoperative causes of GTPS from hip abductor tendon tears is critical because high-grade partial and complete hip abductor tendon tears often require operative intervention whereas other causes of GTPS symptoms are often managed nonoperatively.2,17 The prevalence of abductor tendon rupture is less than 10% in patients aged younger than 60 years but increases to more than 50% in patients aged 70 years or older.3,16,20,21 Given the aging population of the United States, the study of hip abductor tendon tears has become increasingly important.22
Although imaging may be necessary to assist with diagnosis, its use in all patients with lateral hip pain is time-intensive, poses a financial burden for patients, and may delay patient care.23 Increasing utilization of medical imaging is a significant contributor to rising health care costs, and Medicare spent approximately $9.9 billion on medical imaging in 2022.8,24, 25, 26 Timely assessment of hip abductor tendon tears is critical to achieving good clinical outcomes, and the difficulties involved with imaging all lateral hip pain patients may be exacerbated in resource-limited settings.7,25,27 Moreover, high-grade partial-thickness tears may or may not require surgical intervention depending on clinical examination findings. Consequently, reliable clinical examination maneuvers for lateral hip pain patients are crucial in differentiating true hip abductor tendon tears, which benefit from surgical intervention, from GTPS and low-grade abductor tendon tears, which are typically managed nonoperatively. A number of physical examination maneuvers, such as the Ober test, flexion–abduction–external rotation (FABER) text, flexion–adduction–external rotation (FADER) test, Trendelenburg sign, and single-leg stance test, may be used to assess patients with hip pain.28, 29, 30, 31, 32 The Ober test can assess the tension of the IT band; the flexion–abduction–external rotation (FABER) test is a provocation test for intra-articular hip pathology; the flexion–adduction–external rotation (FADER) test is a provocation test for gluteal pathology; the Trendelenburg sign assesses the strength of the hip abductors via lag motion during ambulation; and the single-leg stance test stresses a patient’s balance and posture. These maneuvers may also serve as appropriate indications for further imaging workups in difficult cases.
The hip drop test (HDT) is a clinical examination maneuver for hip abductor tendon injury (Fig 1). The HDT was developed as a modification of the hip lag sign, first described by Kaltenborn et al.,13 which can help differentiate among the causes of lateral hip pain. The hip lag sign was described as a reliable, easy, and fast examination maneuver to assess the hip abductors, with high interobserver consistency of 98.1%. The HDT examination maneuver and the hip lag sign are performed with the patient lying in a lateral position on the asymptomatic side with the symptomatic hip oriented upward. The symptomatic extremity is then passively flexed to 90° at the knee, and the hip is extended 10° and abducted 20°. The hip is then maximally internally rotated. After this passive hip and knee position is achieved, the patient is instructed to actively retain this position as the examiner releases passive assistance. A patient’s inability to retain this position as well as a depression of the foot by 10 cm or more constitutes a positive sign.13 The primary difference between the HDT and the hip lag sign is the degree of knee flexion because the knee is flexed 90° in the HDT compared with 45° in the hip lag sign. This increase in knee flexion increases the lever arm applied to the hip and may increase the diagnostic value of this test. Although the HDT has been used clinically, the sensitivity, specificity, and diagnostic utility of the HDT require further evaluation.
Fig 1.
Clinical demonstration of hip drop test (HDT). (A) Initial position for HDT. The examiner placed the patient in a side-lying position with the symptomatic lower extremity positioned upward. Once this was accomplished, the examiner passively flexed the knee to 90°, extended the hip by 10°, abducted the hip about 20°, and maximally internally rotated the extremity. (B) Positive HDT result. From the position maintained by the examiner in A, the examiner instructed the patient to maintain the position and released the extremity. As shown, the patient was not able to maintain the position, and the extremity dropped sharply (≥10 cm), indicating a positive test result and possible hip abductor tendon tear(s). (C) Negative HDT result. From the position maintained by the examiner in A, the examiner instructed the patient to maintain the position and released the extremity. As shown, the patient was able to maintain the position with minimal lowering of the extremity (<10 cm), indicating a negative test result.
The purposes of this study were to establish the clinical utility of the HDT for diagnosing hip abductor tendon tears as well as for predicting future surgery and to identify patient risk factors associated with tears and surgery. We hypothesized that the HDT would have adequate sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for clinical diagnosis of magnetic resonance imaging (MRI)–confirmed hip abductor tendon tears and, similarly, that positive and negative HDT results would have good correlations with future surgical interventions and nonsurgical interventions, respectively.
Methods
We retrospectively queried the electronic medical record database of a single institution for patients treated by a single sports medicine fellowship-trained orthopaedic surgeon (T.M.) from 2020 to 2024. The inclusion criteria were patients with lateral hip pain and clinically suspected hip abductor tears examined with the HDT who underwent subsequent hip MRI. Patients were excluded if they had incomplete documentation of the HDT or had an MRI scan that was performed at an outside institution. Included patients were followed up for at least 6 months after our initial data pull to assess whether any underwent hip abductor tendon surgery.
We compared the clinical examination results of the HDT with the official MRI report written by our institution’s fellowship-trained musculoskeletal radiologists. Study groups were established by the presence (positive) or absence (negative) of the HDT (Table 1). The presence of a positive HDT and MRI-confirmed full- or partial-thickness abductor tendon tear was further evaluated through electronic medical record query for the presence or absence of future surgical intervention. Initial and final Single Assessment Numerical Evaluation (SANE) scores and patient characteristics such as age, height, weight, body mass index (BMI), sex, and laterality were also analyzed.
Table 1.
Associations Between HDT and Demographic Variables
| Variable | All Patients | Negative HDT Results | Positive HDT Results | P Value |
|---|---|---|---|---|
| Age at admission, yr | N = 261 | n = 245 | n = 16 | |
| Mean (SD) | 40.2 (14.7) | 38.6 (13.4) | 64.5 (12.0) | <.001∗ |
| Median (IQR) | 39.0 (29.0, 48.0) | 38.0 (28.0, 47.0) | 67.0 (57.0, 71.5) | — |
| Range | 14.0-84.0 | 14.0-82.0 | 40.0-84.0 | — |
| Height, cm | N = 261 | n = 245 | n = 16 | |
| Mean (SD) | 170.5 (10.1) | 170.5 (10.1) | 169.8 (10.0) | .83 |
| Median (IQR) | 170.2 (162.6, 177.8) | 170.2 (162.6, 177.8) | 170.2 (163.8, 171.4) | — |
| Range | 152.4-201.9 | 152.4-201.9 | 152.4-188.0 | — |
| Weight, kg | N = 261 | n = 245 | n = 16 | |
| Mean (SD) | 76.1 (17.5) | 76.1 (17.7) | 75.6 (14.6) | .97 |
| Median (IQR) | 75.1 (62.1, 86.2) | 75.3 (62.1, 86.3) | 71.7 (66.2, 82.3) | — |
| Range | 44.0-140.6 | 44.0-140.6 | 58.1-106.6 | — |
| BMI | N = 261 | n = 245 | n = 16 | |
| Mean (SD) | 26.1 (5.5) | 26.1 (5.6) | 26.1 (3.7) | .60 |
| Median (IQR) | 25.1 (22.1, 28.6) | 25.1 (22.1, 28.6) | 25.4 (23.1, 28.5) | — |
| Range | 17.1-51.4 | 17.1-51.4 | 21.3-34.1 | — |
| Sex code | N = 261 | n = 245 | n = 16 | |
| M | 82 (31.5) | 77 (31.6) | 5 (31.2) | .98 |
| Laterality | N = 261 | n = 245 | n = 16 | |
| Bilateral | 13 (5) | 13 (5.3) | 0 (0) | .68 |
| L | 108 (41.4) | 100 (40.8) | 8 (50) | — |
| R | 140 (53.6) | 132 (53.9) | 8 (50) | — |
| Symptom length, wk | N = 261 | n = 245 | n = 16 | |
| Mean (SD) | 122.5 (175.2) | 127.9 (179.9) | 48.1 (35.8) | .15 |
| Median (IQR) | 52.0 (20.0, 156.0) | 52.0 (20.0, 156.0) | 52.0 (24.0, 52.0) | — |
| Range | 1.0-1,440.0 | 1.0-1,440.0 | 8.0-156.0 | — |
| Initial SANE score | N = 261 | n = 245 | n = 16 | |
| Mean (SD) | 52.1 (21.6) | 52.9 (21.8) | 40.3 (14.2) | .015∗ |
| Median (IQR) | 50.0 (35.0, 70.0) | 50.0 (35.0, 70.0) | 40.0 (30.0, 50.0) | — |
| Range | 0.0-100.0 | 0.0-100.0 | 10.0-70.0 | — |
| Final SANE score | N = 261 | n = 245 | n = 16 | |
| Mean (SD) | 66.2 (20.9) | 66.7 (20.4) | 59.5 (27.6) | .41 |
| Median (IQR) | 70.0 (50.0, 80.0) | 70.0 (50.0, 80.0) | 50.0 (42.5, 82.5) | — |
| Range | 9.0-100.0 | 9.0-100.0 | 20.0-100.0 | — |
| Abductor surgery | N = 261 | n = 245 | n = 16 | |
| Y | 10 (3.8) | 2 (0.8) | 8 (50.0) | <.001 |
| N | 251 (96.2) | 243 (99.2) | 8 (50.0) | — |
| MRI abductor tear | N = 261 | n = 245 | n = 16 | |
| Y | 46 (17.6) | 32 (13.1) | 14 (87.5) | <.001∗ |
| N | 215 (82.4) | 213 (86.9) | 2 (12.5) | — |
| Partial- or full-thickness tear | n = 46 | n = 32 | n = 14 | |
| Partial | 35 (76.1) | 28 (87.5) | 7 (50) | .010∗ |
| Full | 11 (23.9) | 4 (12.5) | 7 (50) | — |
NOTE. Data are presented as number (percentage) unless otherwise indicated.
BMI, body mass index; HDT, hip drop test; IQR, interquartile range; L, left; M, male; MRI, magnetic resonance imaging N, no; R, right; SANE, Single Assessment Numerical Evaluation; SD, standard deviation; Y, yes.
Statistically significant (P ≤ .05).
Statistical Analysis
Kruskal-Wallis, Fisher, and χ2 tests were performed to assess the relationships between the positive and negative groups (α = .05). Sensitivity and specificity were calculated and used to further establish the PPV and NPV of the HDT in association with MRI-confirmed tears and future surgical intervention. These are reported with 95% confidence intervals (CIs). Logistic regression was used to calculate odds ratios (ORs) of predictive factors such as a positive HDT result, age at the time of admission, male sex, BMI, and length of symptoms for MRI-confirmed abductor tears and future surgical intervention. All statistical evaluations were performed by the Study Design and Biostatistics Center at our institution.
Results
Our initial review yielded 366 patients. We excluded 5 patients without “positive” or “negative” HDT results. In addition, we excluded 100 patients without MRI results. Ultimately, 261 patients were included in our analysis. Of these patients, 245 had negative HDT results whereas 16 had positive results. Of the patients with positive HDT results, 8 underwent hip abductor tendon surgery. Of the patients with negative HDT results, 2 underwent surgery. The overall rate of surgical intervention for hip abductor tendon tears was 3.8% (10 of 261), with surgical intervention rates of 0.8% (2 of 245) for patients with negative HDT results and 50.0% (8 of 16) for patients with positive HDT results. A positive HDT result was significantly correlated (P ≤ .05) with increased age (P < .001), lower initial SANE score (P = .015), need for future surgical intervention (P < .001), presence of an abductor tear on MRI (P < .001), and presence of a partial tear (P < .010). No statistically significant relationship was found between positive HDT results and height (P = .83), weight (P = .97), BMI (P = .60), sex (P = .98), laterality (P = .68), length of symptoms (P = .15), or final SANE score (P = .41).
HDT and MRI
The sensitivity of the HDT for any hip abductor tendon tear (Table 2) was calculated to be 30.4% (95% CI, 19.1%-44.8%). The specificity was calculated to be 99.1% (95% CI, 96.7%-99.7%). The PPV and NPV were calculated to be 87.5% (95% CI, 64.0-96.5%) and 86.9% (95% CI, 82.1%-90.6%), respectively. Regarding true, MRI-confirmed hip abductor tears, logistic regression predicted the following factors to be significant (Table 3): positive HDT result (OR, 9.73; 95% CI, 1.91-77.53; P = .012); increased age (OR, 1.15 years; 95% CI, 1.10-1.22 years; P < .001); male sex (OR, 0.18; 95% CI, 0.04-0.61; P = .011); and increased BMI (OR, 1.13; 95% CI, 1.04-1.24; P = .005).
Table 2.
Diagnostic Utility of Positive HDT Results
| Metric | Value, % | Lower CI Bound, % | Upper CI Bound, % |
|---|---|---|---|
| Positive HDT result compared with MRI-confirmed hip abductor tendon tear | |||
| Sensitivity | 30.4 | 19.1 | 44.8 |
| Specificity | 99.1 | 96.7 | 99.7 |
| Positive predictive value | 87.5 | 64.0 | 96.5 |
| Negative predictive value | 86.9 | 82.1 | 90.6 |
| Positive HDT result compared with surgical intervention | |||
| Sensitivity | 80.0 | 49.0 | 94.3 |
| Specificity | 96.8 | 93.8 | 98.4 |
| Positive predictive value | 50.0 | 28.0 | 72.0 |
| Negative predictive value | 99.2 | 97.1 | 99.8 |
CI, confidence interval; HDT, hip drop test; MRI, magnetic resonance imaging.
Table 3.
Logistic Regression Comparing Predictive Factors With Presence of MRI-Confirmed Hip Abductor Tendon Tear
| Predictor | OR (95% CI) | P Value |
|---|---|---|
| Intercept | 0.00 (0.00-0.00) | <.001 |
| Positive HDT result | 9.73 (1.91-77.53) | .012∗ |
| Age at admission, yr | 1.15 (1.10-1.22) | <.001∗ |
| Male sex | 0.18 (0.04-0.61) | .011∗ |
| BMI | 1.13 (1.04-1.24) | .005∗ |
| Length of symptoms, wk | 1.00 (1.00-1.00) | .478 |
BMI, body mass index: CI, confidence interval; HDT, hip drop test; MRI, magnetic resonance imaging; OR, odds ratio.
Statistically significant (P ≤ .05).
HDT and Surgical Intervention
The sensitivity and specificity (Table 2) of the HDT regarding later surgical intervention were calculated to be 80.0% (95% CI, 49.0%-94.3%) and 96.8% (95% CI, 93.8%-98.4%), respectively. The PPV and NPV were calculated to be 50.0% (95% CI, 28.0%-72.0%) and 99.2% (95% CI, 97.1%-99.8%), respectively. Regarding surgical intervention, logistic regression predicted the following factor to be significant (Table 4): positive HDT result (OR, 55.40; 95% CI, 5.70-1,672.68; P = .003).
Table 4.
Logistic Regression Comparing Predictive Factors With Future Surgical Intervention
| Predictor | OR (95% CI) | P Value |
|---|---|---|
| Intercept | 0.01 (0.00-44.47) | .275 |
| Positive HDT result | 55.40 (5.70-1,672.68) | .003∗ |
| Age at admission, yr | 1.09 (1.00-1.21) | .057 |
| Male sex | 1.20 (0.11-12.37) | .877 |
| BMI | 0.84 (0.57-1.13) | .309 |
| Length of symptoms, wk | 1.00 (0.98-1.01) | .820 |
BMI, body mass index: CI, confidence interval; HDT, hip drop test; OR, odds ratio.
Statistically significant (P ≤ .05).
Discussion
Our results show that the HDT had a relatively low sensitivity, moderate-high specificity and PPV, and remarkably high NPV for diagnosing hip abductor tendon tears, as confirmed by the diagnostic gold standard of hip MRI. For predicting future surgical intervention, the HDT maintained a high specificity and NPV, had a moderate-high sensitivity, and had a low-moderate PPV. These results support our hypothesis that the HDT would have an adequate level of sensitivity, specificity, PPV, and NPV in identifying MRI-confirmed tears of the hip abductors, with more limited ability to predict future surgical intervention.
There were also significant correlations between a positive HDT result and increased age, lower initial SANE score, need for future surgical intervention, presence of an abductor tear, and presence of a full-thickness tear. There were no significant differences between the group with positive HDT results and the group with negative HDT results based on height, weight, BMI, sex, laterality, length of symptoms, final SANE score, or use of MRI. These results indicate that the HDT is a reliable clinical examination maneuver for the diagnosis of true hip abductor tendon tears in a variety of patients and can be used to stratify patients for advanced imaging evaluation. Few patients with negative HDT results will have evidence of gluteal tendon tears on MRI. Moreover, the HDT may be used to identify patients who are unlikely to proceed to surgical intervention given the high NPV.
With respect to MRI-confirmed gluteal tendon tears, the HDT has a sensitivity of 30.4% and specificity of 99.1%, indicating few false-positive results. The high PPV (87.5%) means that 13.5% of patients who have positive HDT results will not have MRI evidence of hip abductor tendon tears; thus, the HDT can suggest a diagnosis of hip abductor tendon tear but an MRI scan is likely necessary for confirmation. Nevertheless, the HDT’s high NPV of 86.9% indicates that 13.1% of patients with negative HDT results will have abductor tears. Consequently, a negative HDT result, in isolation, may reliably rule out most hip abductor tears in the current study population. The evaluation of GTPS was previously reliant on expensive MRI.6, 7, 8,23,24
One factor that contributes to rising health care costs is increased use of advanced medical imaging, which comprises a significant portion of Medicare expenditures.25,27 Furthermore, advanced medical imaging is not always available, particularly in resource-limited settings.8,25,27 Given our findings of notable specificity, PPV, and NPV of the HDT, medical providers may reliably use the HDT to minimize use of advanced imaging, even in resource-limited settings, thereby reducing overall health care costs and saving patients’ time, as well as minimizing inconvenience.
Our study findings for the HDT support the results of the hip lag sign described by Kaltenborn et al.13 Our study expands on the previous work in a larger cohort, allowing evaluation of the sensitivity, specificity, PPV, and NPV of the HDT, as well as analyzing statistical relationships with a variety of factors (Tables 3 and 4). Furthermore, the greater power of this study has allowed for more precise results. Prior data estimated an OR of 239 (95% CI, 20.031-2,827.819) when comparing a positive hip lag sign with a future gluteal tendon tear diagnosis.13 Our study estimated the HDT OR for the prediction of a gluteal tear to be 9.73 (95% CI, 1.91-77.53). The current results support the HDT as a tool for medical providers to evaluate hip abductor tendon tears.
This study had other notable findings. There was a lower risk of abductor tears in male patients (OR, 0.18), indicating approximately 1 gluteal tendon tear in male patients for every 5 gluteal tendon tears in female patients. Similarly, increased age (OR, 1.15 years) and higher BMI (OR, 1.13) are 1.15 and 1.13 times as likely to have a true tear per unit increase, respectively. These results mirror previous literature regarding GTPS and hip abductor tendon tears.2,6,33 Consequently, medical providers should have higher diagnostic suspicion for tendon tears and a lower threshold for ordering advanced imaging in female patients, elderly patients, and patients with elevated BMI—particularly those with positive HDT results.
With respect to surgical intervention, the HDT had moderate-high sensitivity (80.0%) and high specificity (96.8%) whereas the PPV and NPV were 50.0% and 99.2%, respectively. Initial management of most patients with GTPS is nonoperative,3,34,35 so most GTPS patients seen in the clinic will not undergo surgical intervention. According to our data, patients with positive HDT results were associated with a higher surgical intervention rate for hip abductor tendons (50.0%) than patients with negative HDT results (0.8%), and a positive HDT result had an OR of 55.40 for future surgical intervention. For comparison, Walsh et al.36 found that 89 of 161 patients (55.3%) referred to the primary surgeon for unremitting lateral hip pain underwent gluteal tendon repair or reconstruction. Altogether, most patients seen for GTPS likely will not undergo surgical intervention. In this context, the high NPV of the HDT is useful to surgeons for patient counseling. Although a positive HDT result may not provide a highly robust positive surgical correlation, a negative HDT result is strongly indicative of a remarkably low likelihood of proceeding to surgery given that only 0.8% of patients with negative HDT results underwent surgical intervention.
The primary finding of this study is the evidence linking a positive HDT result with future surgery. Prior work, such as the study by Kaltenborn et al.,13 established the clinical utility of this clinical examination maneuver for use in practice. The HDT has been shown to be easy and reliable so other examiners will likely perform the technique with similar efficacy.13 This study has corroborated the previous findings with greater statistical power. Furthermore, we assessed the HDT’s relationship with other factors, such as age, sex, and future likelihood of surgical intervention. We believe this study will further establish the utility of the HDT and support its routine use in assessing the hip abductors.
Limitations
Our study involved prospective data collection with retrospective analysis, and the retrospective nature of the design limited us from controlling all potential sampling biases. This study involved results from a single hip preservation surgeon at a large urban referral center, which may limit the generalizability of these findings to more diverse cohorts. In addition, we did not assess the inter-rater or intrarater reliability of the HDT, which limits the generalizability of these diagnostic findings to other examiners. However, the hip lag sign is highly similar to the HDT and has excellent interobserver consistency (98.1%).13 Furthermore, the low incidence of positive HDT results limited the subgroup sample sizes because there were 16 patients with positive HDT results out of 261 total patients (6.1% incidence). This relatively low incidence would decrease the PPV and increase the NPV of the HDT in this study. If the incidence of positive HDT results differs in other populations, then the incidence-dependent statistics of the PPV and NPV would vary from this study. Regardless, the HDT’s sensitivity and specificity were robust results, and these do not vary with incidence, so clinicians can still rely on the HDT to help guide management of suspected gluteal tendon tears.
Conclusions
The HDT is a reliable clinical examination maneuver for diagnosing hip abductor tendon tears in patients with lateral hip pain when performed by an experienced medical provider. The HDT shows a high NPV for both a hip abductor tendon tear diagnosis on MRI and the prediction of future surgery and may be used to guide initial clinical decision making. Patients with lateral hip pain and negative HDT results may forego immediate advanced imaging and, instead, consider nonoperative management. Additionally, demographic variables such as female sex, older age, and higher BMI raise the risk of a hip abductor tendon tear and thus increase suspicion for an abductor tendon tear requiring advanced imaging and, possibly, future surgery.
Disclosures
The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: T.M. reports a consulting or advisory relationship with Arthrex; receives funding grants from Arthrex; and receives speaking and lecture fees from Arthrex. All other authors (D.Q., N.B., H.R., Z.W., D.E., A.P.P.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
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