Physical Examination of the Hip

Abstract

The hip and pelvis have a complex anatomy and are a common source of pain and injury in the athletic population. The clinical examination of the hip requires a systematic approach to differentially diagnose hip problems with overlapping pain referral patterns. Because of the complex anatomy of the hip, the physical examination is a comprehensive evaluation of the 4 main pain generators of the hip from deep to superficial: the osteochondral, capsulolabral, musculotendinous, and neurovascular elements of the hip. The hip examination begins with the standing examination and gait analysis followed by a seated, supine, lateral, and prone examination. A targeted physical examination used in conjunction with a layered understanding of the hip and pelvis can help guide diagnostic testing, distinguish hip-specific diagnoses from similar presenting pathologies, and inform treatment.

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DOI: 10.1177/1941738120953418.M1

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Hip injuries are common in sports medicine, and clinicians must maintain a broad differential due to the complex anatomy of the hip and overlapping pain referral patterns. Prior to the physical examination of the hip, a thorough patient history should be assessed, including the time of onset, the mechanism of injury, activities that exacerbate pain, and which, if any, treatment modalities have been attempted since the onset of pain.⁴ The hip physical examination follows a systematic approach to assess pathology in the different layers of the hip, including the osteochondral, capsulolabral, musculotendinous, and neurovascular layers.¹ However, some of these examination findings have limited sensitivity and specificity for intra-articular and extra-articular sources. Additionally, many of these examination maneuvers can elicit pain in patients with an inflamed hip joint.

Standing Examination and Gait

The gait examination is performed to evaluate the kinematic chain. At least 6 to 8 strides should be observed to evaluate foot progression angle, stance phase, stride length, and arm swing.⁴ A negative foot progression angle (in-toeing) can be a compensatory mechanism for increased femoral anteversion, while a more positive foot progression angle (out-toeing) can be seen with decreased anteversion or retroversion. An antalgic gait refers to a nonspecific limp resulting from a shortened stance phase due to pain on the affected side. Patients with hip pain may demonstrate a coxalgic gait, in which the upper trunk shifts toward the affected side during stance phase on the affected leg. Similar to using a cane in the ipsilateral upper extremity, this has the effect of reducing the joint reactive force by reducing the abductor moment arm through a more favorable load distribution. As long as the abductors are not weak and are functioning normally, the pelvis remains level. This is in contrast with a waddling Trendelenburg gait in which patients shift weight over the affected side to accommodate insufficient abductors that are unable to maintain a level pelvis while the affected side is in stance phase, causing the contralateral hemipelvis to dip.

With the patient standing, leg-length discrepancies are assessed by comparing shoulder and iliac crest height bilaterally. The Trendelenberg test is performed by asking the patient to stand on 1 leg. A drop in the pelvis by over 2 cm toward the nonweightbearing side is a positive test, indicating insufficient gluteal abductor musculature.⁴ While standing, the patient may be asked to bend forward at the trunk to assess spinal alignment and signs of scoliosis.

Supine Examination

Tenderness to palpation is assessed over bony prominences and tendon insertions. Localizing the source of the pain may help focus the physical examination. With the patient in the supine position, the examiner may palpate the anterior superior iliac spine, iliopsoas, rectus femoris, hip adductors origin, inguinal ligament, and pubic tubercle.

The patient should be encouraged to demonstrate distinct, provocative movements that reproduce any previously described clicking, snapping, or popping sensations. The circumduction clunk test for internal coxa saltans, or snapping of the iliopsoas over the femoral head or anterior capsule of the hip, is performed by asking the patient to actively flex the hip to 90° and circumduct the hip to an extended position. Reproduction of clunking is positive for iliopsoas snapping. Internal coxa saltans can also be elicited by maneuvering the hip into the extension, adduction, internal rotation (EADIR) position.⁸ Additionally, these patients may demonstrate a positive Thomas test with reciprocal hip flexion when the contralateral hip and knee are pulled in toward the chest, consistent with iliopsoas tightness or contracture.

The passive range of motion of both hips should be examined (Table 1). It is important to first measure the unaffected hip in order to identify a standard with which to compare the affected hip.

Table 1.

Normative values for hip range of motion according to standards published by the American Academy of Orthopaedic Surgeons^a

Motion	Value, deg, Mean ± SDb
Flexion	128.4 ± 6.7
Extension	17.0 ± 3.9
Abduction	33.0 ± 4.8
Adduction	13.8 ± 6.3
Internal rotation	42.1 ± 9.6
External rotation	43.9 ± 8.4

^aSupine position is used for flexion, abduction, adduction, internal rotation, and external rotation. Prone position is used for extension.

^bAs variation from the neutral, midline position.

In the supine position, flexion is measured by bringing the knee as close to the chest as possible with the flexed knee approximately 90°. Next, with the hip flexed 90°, internal rotation is measured by maintaining the femur in a vertical position while rotating the limb around the vertical axis of the femur away from the midline. External rotation is measured by rotating in the opposite direction. Abduction and adduction are both measured with the hips and knees in a neutral extended position. The leg is abducted by moving the limb away from the body and adducted by bringing the limb toward the midline, above the contralateral leg. Subtle asymmetry in passive range of motion may suggest mechanical impingement. Additionally, reproduction of lateral pain when the leg is fully abducted in neutral rotation is a positive lateral rim impingement test, indicating possible impingement of the superolateral part of the femoral neck against the posterior superior acetabular rim.

Multiple examination maneuvers have been proposed to differentiate the various mechanisms of impingement resulting from intra- and extra-articular pathologies (Figure 1; Table 2).

Figure 1.

(a) Subspine impingement test with affected hip placed in the hyperflexed position while in neutral rotation. (b) Flexion, adduction, internal rotation test in the supine position. (c) Flexion, abduction, external rotation test with lower extremity placed in a figure-of-4 position. (d) Ishiofemoral impingement test in the lateral position with affected hip placed in extension, adduction, and external rotation. (e) Log roll test with extended leg manually shifted into internal and external rotation. (f) Posterior impingement test with the patient’s legs hanging freely off the edge of the table and the affected hip placed in extension, abduction, and external rotation.

Table 2.

Physical examination maneuvers for differentiating sources of impingement

Patient Position	Test	Maneuver	Impingement Etiology
			Location	Source of Impingement
Supine	Subspine impingement test	Affected hip is hyperflexed in neutral rotation while unaffected hip lies flat on the table	Anterior subspine region	Bony prominence below anterior inferior iliac spine and femoral neck
Supine or lateral	Flexion, adduction, internal rotation	Affected hip is flexed to 90°, internally rotated, and adducted	Anterior and anterolateral	Anterior acetabular rim and femoral head-neck junction
Supine	Flexion, abduction, external rotation	Affected extremity placed in figure-of-4 position with hip flexed 45°, abduction, and external rotation, ankle resting on contralateral knee	Posterolateral Deep posterolateral Anterior	Greater trochanter and iliotibial band Quadratus femoris (between greater trochanter and ischium) Iliopsoas tendon and femoral head
Supine	Superolateral impingement test	Affected hip is flexed to 90°, slightly externally rotated, and abducted	Superior and superolateral	Acetabular rim and femoral neck/head-neck junction
Supine	DIRI (dynamic internal rotation impingement test)	Affected hip is placed in flexion or hyperflexion and moved through a full arc of adduction with the hip internally rotated. Maneuver may be assisted by having the patient flex the contralateral hip to his/her chest to reduce lumbar lordosis2,3	Anterior (11 o’clock to 3 o’clock)	Acetabular rim and femoral neck/head-neck junction
Supine	DEXRIT (dynamic external rotation impingement test)	Affected hip is flexed to 90°, externally rotated and moved through a full arc of abduction2,3	Superolateral and posterior (1 o’clock to 10 o’clock)	Acetabular rim and femoral neck/head-neck junction
Supine	Scour test	Variation of DIRI/DEXRIT tests performed while applying a downward force at the knee to increase pressure in the hip joint while maneuvering into different quadrants2,3	Varies (generally 10 o’clock to 3 o’clock depending on technique)	Acetabular rim and femoral neck/head-neck junction
Supine	Posterior rim impingement test	While patient lies at the end of the examination table allowing the legs to hang freely, the affected hip is placed into extension, abduction, and external rotation	Posterior	Acetabular rim and femoral neck/head-neck junction
Lateral	Greater trochanteric–pelvic impingement test	Affected hip is passively abducted in extended position. Positive “gear stick sign” refers to relative increase in abduction range with hip in flexed position	Lateral	Greater trochanter and ilium
Lateral	Ischiofemoral impingement test	Affected hip brought into extension, adduction, and external rotation	Deep posterior	Quadratus femoris (between lesser tuberosity and ischium)

It should be noted that the flexion, abduction, external rotation (FABER) test can elicit symptoms resulting from pathology involving the hip joint, sacroiliac joint, or iliopsoas tendon. Anterior/groin pain suggests iliopsoas tightness or femoral head impingement by the iliopsoas tendon. The trochanteric pain sign refers to posterolateral pain from irritation between the greater trochanter and the iliotibial band, though lateral pain may also occur with various other trochanteric or gluteal pathologies. Additionally, the FABER maneuver can elicit posterior pain due to sacroliac pathology by stressing this joint. During the FABER examination, the distance from the knee to the surface of the examination table can be compared between sides to determine if there is significant stiffness in the hip or iliopsoas muscle compared with the unaffected side.^3,5

For patients in whom there is a concern for instability or capsular insufficiency, additional examination maneuvers can be performed to assess for excessive motion and to elicit apprehension (Table 3).⁷

Table 3.

Physical examination maneuvers for identifying hip instability or capsular insufficiency

Positioning	Test	Maneuver	Positive Findings	Differential Diagnosis
Supine	Log roll test	Extended leg is manually shifted into internal and external rotation	Groin pain	Intra-articular hip pathology, including femoral neck stress fracture
Supine	Dial test	Examiner passively rotates the patient’s foot to maximal internal rotation and lets go, allowing the foot to spontaneously return to an externally rotated position	Foot reaches a resting position in greater external rotation that the contralateral side, or foot forms an angle of <20° with the examination table	Anterior capsular instability
Supine	Axial distraction test	Examiner places his/her knee against the patient’s ischium, flexes the hip to 30°, and applies an axially distracting force7	Apprehension, pain, and instability
Supine	Posterior apprehension test	Hip and knee are flexed to 90° and examiner internally rotates and abducts the hip, applying a downward and posteriorly directed force	Posterior pain or apprehension	Posterior capsular instability
Supine	HEER (hyperextension external rotation test)	While patient lies at the end of the examination table allowing the legs to hang freely, the examiner applies a downward force on the knee and externally rotates the hip7	Anterior pain or apprehension	Anterior capsular instability
Lateral	Abduction-extension–external rotation test	Affected leg is abducted to 30°, extended, and then externally rotated	Anterior pain or apprehension	Anterior capsular instability
Prone	Prone external rotation test	Knee of affected limb is flexed to 90° and the hip is externally rotated by bringing the leg across the midline, then a downward force is applied behind the greater trochanter	Anterior pain or apprehension	Anterior capsular instability

With the patient supine, the examiner may also assess for core muscle injury, athletic pubalgia, or “sports hernia.” The affected leg is placed in a semiflexed, externally rotated position, and the adductor tendon origin on the pubis is palpated while the patient attempts to adduct against resistance. Next, the patient should be instructed to perform a sit-up against manual resistance. Pain with either of these examinations may be a positive indicator of a core muscle injury.

Several supine tests can be performed to assess for piriformis syndrome. In the Freiberg test, the affected leg is passively maximally internally rotated while the patient lies with the hips and knees extended. Resisted external rotation in this position may also re-create symptoms. The Pace sign refers to reproduction of symptoms with resisted abduction with the hip and knee flexed, feet resting on the examination table, in the position used to test abduction strength. Finally, the piriformis test or piriformis stretch test is performed by asking the patient to pull the knee of the affected side toward the contralateral chest. Variations of this test can be performed with the patient in the lateral position or seated.

Strength assessment in the supine position consists of abduction, adduction, and hip flexion. Abduction and adduction are examined while the patient is supine with the knees in 90° of flexion and both feet flat on the examination table. Resisted hip abduction and resisted adduction are assessed by applying lateral pressure over the medial or lateral aspect of the distal femur. The patient’s legs are then placed flat on the table and resisted hip flexion is assessed by applying downward pressure over the distal femur while instructing the patient to perform a straight leg raise. In certain situations, hip flexion strength may also be assessed with the patient seated on the edge of the examination table, with the hips and knees flexed to 90°, which reduces the contribution of rectus femoris and better isolates the iliopsoas.

Lateral Examination

For the lateral examination, the patient is asked to lie on the unaffected limb, and the bony prominences of the lateral pelvis are first assessed. The examiner may palpate the iliac crest, facets of the greater trochanter, ischium, and proximal hamstring. When palpating the greater trochanter, the examiner may specifically assess the tendon insertion of the gluteus minimus at the anteromedial facet, the tendon insertion of the gluteus medius at the superoposterior and lateral facets, and the trochanteric bursa at the posterior facet.

Overall hip abductor strength is evaluated in the lateral examination by having the patient actively abduct their leg against manual resistance. The gluteus medius strength test is similarly performed with the patient’s knee flexed, which releases the gluteus maximus pull on the iliotibial band.⁴ Snapping or clicking of the iliotibial band over the greater trochanter, or external coxa saltans, is elicited by having the patient perform a bicycle maneuver with the affected leg. Ischiofemoral impingement is tested by extending the externally rotated and adducted hip while placing counterpressure over the hip and assessing for pain. The Ober test for iliotibial band tightness is performed by placing the hip into abduction and extension while the knee is flexed at 90° and is positive when the hip fails to adduct after release of knee support.

Prone Examination

The prone examination is useful to palpate bony prominences in the posterior aspect of the hip and pelvis, especially the lumbar spine, coccyx, posterior superior iliac spine, sacroiliac joint, and posterior iliac crest. Additionally, the examiner may palpate the greater trochanter, the ischium, and proximal hamstring. Proximal hamstring pain may be reproduced by palpating over the ischium with the knee bent and instructing the patient to flex the knee against resistance. Some range of motion measurements may be performed during the prone examination such as hip extension, internal rotation, and external rotation with the knee flexed to 90°. However, normative values for hip rotation measured in the prone position will differ from hip rotation measured in the supine position. In patients with hip impingement, hip internal rotation may be more restricted when measured in flexion rather than prone. Additionally, hip external rotation measured in the prone position has limited intrarater reliability.⁶

The gluteus maximus can be examined by having the patient extend the hip and lift the whole leg off the table. The Ely test for tightness/contracture of the rectus femoris is performed by passively flexing the knee with the other hand in the posterior superior iliac spine region to note any rise of the pelvis. Restriction in further knee flexion or the hemipelvis lifting off the table is a positive test.

Summary

Appropriate assessment of the hip requires observation of gait, station, and examination in the supine, lateral, and often prone positions. The basic examination will generally include gait and station, palpation of commonly painful areas, and assessments of strength, range of motion, and basic impingement testing. The examination should be tailored with additional tests and maneuvers when there is clinical concern for conditions such as laxity, instability or microinstability, hamstring pathology, core muscle injury, or piriformis syndrome.