Focused Physical Examination for a Man with Right Hip Pain in the ED
The focused physical examination for a man presenting with one week of right hip pain to the ED should include assessment of the hip position, range of motion, provocative tests, neurovascular status, and examination of adjacent structures that could refer pain to the hip region.
Initial Observation and Positioning Assessment
- Observe the patient's gait if ambulatory
- Note the position of the affected limb (shortened, externally rotated limb suggests fracture) 1
- Look for visible deformity, swelling, or ecchymosis
Hip Range of Motion Assessment
- Perform passive and active range of motion testing:
- Flexion
- Internal rotation (particularly important for detecting intra-articular pathology) 1
- External rotation
- Abduction
- Adduction
- Extension (if patient can tolerate prone positioning)
- Document which movements reproduce the patient's pain
Provocative Maneuvers
- FADIR test (Flexion, Adduction, Internal Rotation) - most sensitive test for intra-articular pathology 1, 2
- FABER test (Flexion, Abduction, External Rotation) - evaluates for sacroiliac joint dysfunction and hip pathology 3
- Scour test - for labral tears (flex hip to 90°, apply axial load while moving hip in circular motion) 2
- Straight leg raise against resistance - evaluates hip flexor function 3
- Trendelenburg test (if patient can stand) - assesses gluteus medius function 1
Neurovascular Assessment
- Palpate distal pulses (dorsalis pedis, posterior tibial) 1
- Assess sensation to light touch in lower extremity dermatomes 1
- Test motor strength in major muscle groups of the lower extremity
- Check for signs of vascular compromise
Palpation
- Palpate for areas of tenderness:
- Greater trochanter
- Ischial tuberosity
- Anterior hip/groin
- Pubic symphysis
- Sacroiliac joint
- Palpate the hip from pubic bone to coronal sulcus to assess for occult deformities 1
Adjacent Structure Examination
- Lumbar spine examination (flexion, extension, rotation)
- Knee examination to rule out referred pain
- Abdominal examination to exclude intra-abdominal causes of hip pain
- Digital rectal examination is not required for evaluation of hip pain 1
Special Considerations
- For suspected fracture, avoid excessive manipulation of the hip
- Document any leg length discrepancy
- Note any muscle atrophy suggesting chronic pathology
- Assess for signs of infection (fever, erythema, warmth)
Pitfalls to Avoid
- Failing to consider occult hip fracture in elderly patients with normal radiographs (consider MRI if high suspicion) 1
- Missing referred pain from lumbar spine or intra-abdominal pathology
- Neglecting to assess neurovascular status, which could indicate emergency conditions
- Relying solely on imaging without correlating with clinical findings 1
This focused physical examination approach will help identify the most likely cause of hip pain and guide appropriate diagnostic imaging and management decisions for a man presenting with right hip pain to the ED at 2 am.