What is the approach to a comprehensive physical exam of the hip?

Physical Examination of the Hip

A comprehensive hip physical examination should systematically assess muscle strength using objective dynamometry, functional performance through squat depth and single-leg balance tasks, and include position-specific testing (standing, supine, lateral, prone) to evaluate both intra-articular and extra-articular pain generators. 1

Core Components of Hip Physical Examination

Muscle Strength Assessment

Objective strength testing using handheld dynamometry is essential for evaluating hip adduction, abduction, flexion, internal rotation, and external rotation, as patients with hip-related pain consistently demonstrate deficits in these movements compared to asymptomatic individuals. 1

• Use either isometric or eccentric testing with a handheld dynamometer for clinical purposes 1
• External fixation is recommended for isometric testing when testers of different strength are involved to minimize systematic error 1
• Be aware that inter-rater reliability data is limited, so interpret results considering potential tester differences and instrument measurement error 1
• Extension strength deficits show conflicting evidence and may not be a reliable indicator 1

Functional Performance Testing

Include squat depth assessment, single-leg balance tasks, and the Star Excursion Balance Test (SEBT) as these consistently identify impairments in patients with hip-related pain. 1

• Reduced squat depth is a consistent finding in hip-related pain populations 1
• Single-leg standing test and SEBT have acceptable intratester reliability 1
• Single-leg squat and step-down tests lack established intertester reproducibility, so use caution when comparing results between examiners 1
• The minimal clinically important change for these measures is currently unknown 1

Position-Specific Examination Sequence

Conduct examination in standing, supine, lateral, and prone positions to comprehensively evaluate all hip structures from deep (osteochondral) to superficial (neurovascular). 2, 3, 4

Standing Position Tests (performed >75% of the time by hip specialists):

• Gait analysis (86% usage rate) 2
• Single-leg stance phase test (77% usage rate) 2
• Observe for Trendelenburg sign, antalgic gait patterns, and compensatory movements 3

Supine Position Tests (most commonly performed):

• Hip flexion range of motion (98% usage rate) 2
• Flexion with internal rotation ROM (98% usage rate) 2
• Flexion with external rotation ROM (86% usage rate) 2
• Passive supine rotation test (76% usage rate) 2
• FADIR test (flexion/adduction/internal rotation) (70% usage rate) to assess for intra-articular pathology 2
• FABER test (flexion/abduction/external rotation) (52% usage rate) 2
• Straight leg raise against resistance (61% usage rate) 2

Prone Position Tests:

• Femoral anteversion test (58% usage rate) to assess rotational alignment 2

Lateral Position Tests:

• Assess abductor strength and trochanteric tenderness 3

Range of Motion Assessment

The clinical utility of range of motion testing for diagnosing hip-related pain conditions is currently unclear, with conflicting evidence on optimal measurement methods. 1

• Methods with the highest clinimetric properties should be chosen when ROM measurement is performed 1
• ROM testing alone lacks diagnostic accuracy for specific hip conditions 1
• Active versus passive movements, pain-free range only, and optimal stabilization methods remain areas of uncertainty 1

Integration with Clinical Context

Physical examination findings must be combined with patient symptoms and imaging—never rely on examination alone for diagnosis. 1

• Clinical tests currently lack diagnostic accuracy for determining the specific cause of hip-related pain 1
• Screen for referred pain from spine and pelvis, as hip pathology can present with pain in the thigh, knee, or buttock 5
• Consider the patient's activity level and sport-specific demands when selecting functional tests 1

Common Pitfalls to Avoid

• Do not diagnose based on imaging or physical examination alone—both must be integrated with patient symptoms 1
• Recognize that normal physical examination does not exclude hip pathology, particularly in infants with developmental dysplasia risk factors 1, 5
• Avoid comparing symptomatic to asymptomatic limbs in research contexts, as the clinical interpretation of side-to-side differences is unclear 1
• Account for tester variability when using strength measurements, especially between different examiners 1
• Acknowledge measurement limitations when tracking change over time, as minimal detectable change values are not established for most functional tests 1

Physical Activity Quantification

Measure physical activity using objective methods (accelerometers/wearable devices) combined with self-reported measures to capture baseline activity, symptom fluctuations, and response to intervention. 1

• Commercial devices like Fitbit demonstrate adequate accuracy and validity for clinical use 1
• Self-reported measures capture different dimensions than objective measures, including patient response to activity 1
• Quantify patient expectations regarding return to sport level, performance, and occupational demands 1