What are the steps for a thorough hip physical exam?

Comprehensive Hip Physical Examination

A thorough hip physical examination should include assessment of gait, range of motion, provocative tests, strength testing, and evaluation of surrounding structures in a systematic manner to accurately diagnose the source of hip-related pain.

Initial Assessment

• Observation of gait pattern (86% of specialists perform this) 1

  • Look for antalgic gait, Trendelenburg gait, or other abnormal patterns
  • Assess single-leg stance phase (77% of specialists perform this) 1

• Standing examination

  • Observe posture, pelvic tilt, and leg length discrepancy
  • Assess for spinal alignment and pelvic obliquity
  • Check for greater trochanteric prominence or asymmetry

Supine Examination

• Range of motion assessment (most commonly performed tests) 1

  • Hip flexion (98% of specialists perform this)
  • Internal rotation in flexion (98% of specialists)
  • External rotation in flexion (86% of specialists)
  • Abduction and adduction
  • Extension (may require prone or lateral position)

• Provocative tests for intra-articular pathology

  • FADIR test (Flexion/Adduction/Internal Rotation) for FAI syndrome (70% of specialists) 1
  • FABER test (Flexion/Abduction/External Rotation) for posterior hip pain (52% of specialists) 1
  • Scour test for labral tears 2
  • Passive supine rotation test (76% of specialists) 1

• Strength testing

  • Straight leg raise against resistance (61% of specialists) 1
  • Hip abductor strength (gluteus medius)
  • Hip adductor strength
  • Hip flexor strength

Lateral Position Tests

• Assessment of greater trochanteric area
  • Palpation for tenderness suggesting greater trochanteric pain syndrome
  • Ober's test for iliotibial band tightness

Prone Position Tests

• Femoral anteversion test (58% of specialists) 1

  • Assessment of femoral neck anteversion

• Posterior structures assessment

  • Palpation of sciatic notch, piriformis, and posterior hip structures
  • Assessment of hip extension

Special Tests for Specific Conditions

• Tests for hip microinstability 2

  • Anterior apprehension test
  • Abduction-extension-external rotation test
  • Prone external rotation test
  • Note: When all three tests are positive, there is a 95% likelihood of microinstability

• Tests for extra-articular pathology

  • Palpation of greater trochanter for bursitis
  • Assessment of iliopsoas for snapping or impingement
  • Piriformis testing for piriformis syndrome

Neurovascular Assessment

• Neurovascular examination
  • Distal pulses
  • Sensory testing of lower extremity dermatomes
  • Motor testing of key muscle groups
  • Reflexes

Differential Diagnosis Considerations

• Regional examination
  • Lumbar spine assessment (for referred pain)
  • Sacroiliac joint examination
  • Knee examination
  • Abdominal examination when indicated

Clinical Pearls

• Patients often localize hip pain to one of three regions: anterior hip/groin (intra-articular pathology), posterior hip/buttock (piriformis syndrome, SI joint dysfunction), or lateral hip (greater trochanteric pain syndrome) 3

• Diagnostic imaging should never be used in isolation but combined with symptoms and clinical signs 4

• For suspected fractures, radiography should include anteroposterior view of the pelvis and frog-leg lateral view of the symptomatic hip 3

• If clinical suspicion remains high despite normal radiographs, MRI should be considered, particularly for occult fractures or labral tears 4, 3

• A combination of physical exam maneuvers is necessary for accurate diagnosis as individual tests vary in sensitivity and specificity 2

Remember that the physical examination findings should be correlated with the patient's history and appropriate imaging studies for a comprehensive evaluation of hip-related pain.