The Hip Physical Examination for Telemedicine Encounters

Introduction

In recent years, there has been an increasing focus on telehealth that has expanded exponentially during the COVID-19 pandemic. Prior to the pandemic, multiple medical specialties began using telemedicine as a substitute for in-person visits given the ease of use, decreased time, and cost benefits [16,19]. Telemedicine was not widely adopted among orthopedic surgeons, however, often due to concerns about the utility of a virtual physical exam [11]. With the institution of social distancing requirement and restrictions on in-office visits, telehealth provides a safe method for evaluation of the orthopedic patient.

Hip and groin pain in the young adult and adolescent population has historically been considered difficult to evaluate and accurately diagnose. Patients previously saw an average of 3.3 providers before arriving at a correct diagnosis [4,18]. Recent advances in the field of hip preservation have led to significant improvements in our understanding of hip pathology. In-person hip examinations have become more systematic and reproducible [5]. Many hip exam techniques can be performed virtually with modifications. A recent study by Owusu-Akyaw et al found the diagnostic accuracy of hip self-administered exams to be statistically significantly higher than the traditional clinical exam [15].

The purpose of this article is to provide clinicians with a comprehensive hip physical examination for the telehealth visit. We include verbal instructions to be provided to the patient prior to or read verbatim during the visit and a corresponding checklist for documentation.

Preparation for the Telehealth Visit

Baseline information for the patient should be completed prior to starting the telehealth visit. Specifically, the patient should indicate their chief complaint, history of present illness, past medical and surgical history, allergies, home medications, social history, and a review of systems. Patients should also indicate any family history of hip pathology or rheumatologic disorders. Additionally, a comprehensive birth history is important when examining young patients with hip dysplasia.

The patient should also review instructions on how to log on to the visit and properly set up their camera to optimize visualization of the hip (Fig. 1).

Fig. 1.

Schematic of virtual hip examination.

Hip Examination

Prior to the start of the hip exam, the patient should review the guidelines provided by the practitioner (Supplemental Table 1). Hip pain is frequently nonspecific and a thorough evaluation of the lumbar spine, core, and neurovascular structures is essential for differentiating the source of pain [6,10]. Additionally, hip injuries can often occur concurrently with pathology in these other areas, and recognition is important for guiding treatment [8].

A systematic approach to the hip exam should be employed, including a basic exam and pathology-specific special testing. The exam can be divided into standing, sitting, supine, lateral, and prone components for ease of exam flow [12]. The basic hip exam includes inspection with gait analysis, palpation, range of motion testing, motor and sensory testing, and peripheral vascular exam [5]. An overall assessment of joint hyperlaxity with the Beighton score is also important for evaluating patients with hip pain, particularly when hip dysplasia or a hypermobility syndrome is suspected [2,3]. Pathology-specific special testing is performed at the discretion of the examiner based upon a complete history and core exam findings.

Primary Hip Exam

The primary hip exam begins with the standing exam during which the patient is instructed to stand facing the camera at a distance so the entire lower extremity can be visualized. The standing exam focuses on inspection of the hip region, overall mechanical alignment of the spine and lower extremities, and gait analysis. The patient should be asked to turn toward the front, side, and away from the camera to inspect the skin and musculature around the hip for any abnormalities. The camera view should allow for a minimum of 3 to 4 stride lengths to comprehensively evaluate gait. The camera angle should also be adjusted to visualize knee and foot progression during gait for an assessment of femoral version. In addition to inspection, palpation can be performed while the patient is standing. The patient can be asked to localize symptoms with 1 finger and the area can be self-palpated for the region of maximal tenderness. Patients with groin pain will frequently exhibit the C-sign [5].

The seated portion of the exam is useful for hip range of motion (ROM) evaluation and comprehensive neurovascular testing. The patient should be instructed to sit with the hips at 90 degrees of flexion and active internal and external rotation is performed and held for 5 seconds. Symmetry and pain with ROM are assessed and a virtual goniometer may be utilized for specific measurements [20]. Seated examination allows for motor, sensory, and vascular examination with a stabilized pelvis.

The supine exam focuses on complete hip ROM testing and provocative tests. Hip flexion is best assessed in the supine position and a hip flexion contracture can be observed with the Thomas test [13]. An active straight leg raise can also be performed in the supine position, which can reproduce hip pain by generating a force across the articular surface that is several times the body weight [5].

The peritrochanteric region is most completely evaluated in the lateral portion of the exam with the patients lying on the unaffected side. Patients can be asked to palpate the greater trochanter for suspected trochanteric bursitis or gluteus medius and minimus tendon tears. Active abduction against gravity or with a remote examiner can help identify abductor strength deficiency. Intra-articular pathology can also cause secondary pain in the peritrochanteric region due to overload of the abductor mechanism [8,21]. Iliotibial band (ITB) tightness can be evaluated with the Ober test and external snapping of the ITB can be reproduced by having the patient bring the hip from extension to flexion with slight abduction [1,17].

Fig. 2.

Modifications to common exam maneuvers for a virtual hip exam. (a) Traditional squat for subspine impingement. (b) Knock knee squat for FADIR test. (c) Seated FADIR exam. (d) Supine test for subspine impingement. (e) FABER test. (f) Apprehension test. (g) Resisted adduction with towel roll for athletic pubalgia. (h) Ischiofemoral impingement test. (i) PART test. FADIR flexion adduction internal rotation, PART prone apprehension relocation test.

Prone evaluation is important for evaluating posterior hip structures, femoral version, and provocative testing for hip instability. Focused proximal hamstring strength testing is best performed in the prone position with a remote examiner, when available. Passive internal and external hip rotation can be measured with the knees flexed to 90 degrees and allowing the leg and foot to fall to the floor. Excessive internal or external motion can be indicative of femoral version abnormalities.

Special Testing

Pathology-specific special testing can be subdivided into intraarticular impingement, extra-articular impingement, instability, and athletic pubalgia.

Intra-articular impingement

The classic flexion adduction internal rotation (FADIR) test is most commonly used for intraarticular impingement [18]. This test can best be performed with the patient supine in a virtual setting if a remote examiner is available to dynamically manipulate the leg. Modifications to the classic FADIR test can be made to facilitate remote examination of the impingement with high diagnostic accuracy [15]. Owusu-Akyaw and colleagues described the Knock Knee Squat, which can be performed during the standing exam the patient by instructing the patient to squat and bringing the knees toward each other [15]. Similarly, during the seated exam, the patient can be instructed to sit with their knees shoulder-width apart and gradually bring knees closer together. A positive test eliciting pain with dynamic internal rotation is indicative of impingement or labral tear.

The flexion abduction external rotation test can also be performed remotely by having the patient make a “figure four” configuration with the ankle of the affected extremity placed on the nonaffected thigh. Similarly, the patient can be instructed to perform a bent knee fallout by flexing both knees with the feet flat on the floor and letting the knees fall to the outside [15]. Anterior groin pain with these maneuvers may indicate anterior capsular irritation or superolateral impingement.

Extra-articular impingement

Subspine impingement can be reproduced in the standing exam with anterior hip pain when performing a traditional squat with the knees in the same plane as the feet. When supine, subspine impingement can be provoked with pain at end range hip and knee flexion.

Ischiofemoral impingement can be tested in the standing exam with the Long Stride Walking (LSW) test as described by Gomez-Hoyos et al [7]. The test is performed by instructing the patient to take very long strides when walking toward or away from the camera. Deep posterior hip pain with terminal extension indicates a positive test. The ischiofemoral impingement (IFI) test can also be performed during the lateral portion of the exam. Patients with IFI will have deep posterior hip pain with hip extension and adduction that is relieved when the leg is abducted with hip extension. Gomez-Hoyos et al recently demonstrated a sensitivity of 0.94 and specificity of 0.85 for the LSW test and a sensitivity of 0.82 and sensitivity of 0.85 for the IFI test [7].

Instability

Anterior hip instability can be assessed in both the supine and prone portions of the examination. When supine, the patient can be instructed to allow the leg to fall off the couch toward the floor. This is best performed with a remote examiner supporting the leg. Anterior hip pain or feeling of apprehension may indicate hip instability. Similarly, anterior hip pain may be elicited in the prone position with the affected knee bent 90 degrees and allowing the leg to rotate and drop down toward the unaffected leg.

Athletic pubalgia

Evaluation of athletic pubalgia can begin by having the patient palpate the pubic symphysis, adductor origin, and inguinal ring for areas of tenderness. In the supine position, resisted adduction can be performed by instructing the patient to squeeze a rolled-up towel between their legs with their knees bent at 90 degrees. A positive test is pain in the groin area [14]. Pain with resisted abdominal curl up may also indicate athletic pubalgia [9].

Postoperative hip exam

The postoperative virtual hip exam is an abbreviated core hip exam with care taken to identify any concerning findings that may necessitate an in-person evaluation. Similar to other joints, the initial postoperative visit should focus on the incision and evaluate for any erythema, drainage, or excessive swelling. Subsequent virtual visits at 6-weeks, 3-months, and 6-months should focus on evaluation of hip ROM and progression of gait. Gradual improvement in muscle strength around the hip should be observed.

Discussion

A systematic approach to the virtual hip exam improves the overall efficiency and accuracy of the telehealth visit for nonarthritic hip pain. We recommend starting with the “primary hip exam,” followed by specialty testing based upon clinical suspicion from the patient’s history and primary hip exam findings. A thorough spine exam is also important for evaluating concomitant or primary lumbar spine pathology.

There are numerous limitations associated with telehealth visits for hip pathology. The telehealth visit is not intended to completely replace in-person evaluation. Rather, the telehealth visit provides an effective and safe method of triaging patients for advanced imaging and the need for in-person consultation. In addition, the sensitivity and specificity for all hip exam maneuvers has not yet been established. Future research should focus on establishing known validity and inter- and intrarater reliability of the hip exam to further standardize the virtual comprehensive hip exam.

In conclusion, the comprehensive virtual hip exam is a valuable tool for evaluating patients with non-arthritic hip pain during the COVID-19 pandemic and beyond. Telemedicine provides the ability to safely expand access to care for these patients in a cost-effective manner. Although in-person examination remains gold standard, a systematic hip examination can easily be performed with minor modifications in a virtual setting. Future research will focus on standardizing these hip exam techniques.