What are the expected findings on a detailed physical assessment of a patient with end-stage right hip osteoarthritis?

Physical Assessment of End-Stage Right Hip Osteoarthritis in a 53-Year-Old Female

In a 53-year-old woman with end-stage right hip osteoarthritis, expect to find antalgic gait with possible assistive device use, restricted internal rotation (most predictive finding), pain with passive hip adduction/abduction, decreased hip flexion and extension, hip abductor weakness, and intact skin without erythema over the affected joint. 1, 2, 3

Gait and Mobility Assessment

• Antalgic gait pattern is the hallmark finding, where the patient minimizes weight-bearing time on the affected right leg to reduce pain 1
• The patient will likely use an assistive device (cane or walker) for ambulation 1
• Observe for compensatory trunk lean toward the affected side during stance phase, which correlates with hip abductor weakness 4
• Expect 3.5 degrees less peak hip flexion and 8.8 degrees less hip extension during walking compared to the unaffected side 4
• Greater pelvis and trunk rotation in the frontal plane occurs as compensation for hip muscle weakness 4

Range of Motion Testing (Most Critical Component)

Internal rotation restriction is the single most predictive physical finding for radiographic hip OA, with sensitivity of 66% and specificity of 79% 2, 3

• Test internal rotation first: With the patient supine and hip/knee flexed to 90 degrees, rotate the lower leg outward (hip internally rotates). Restriction in internal rotation has the highest discriminatory ability for OA 3
• Hip adduction testing: Decreased passive hip adduction shows sensitivity of 80% and specificity of 81% (LR 4.2) for radiographic OA 2. Normal passive hip adduction effectively rules out severe OA (negative LR 0.25) 2
• Hip flexion: Expect reduced flexion, though this is the least predictive plane of movement for OA 3
• Extension: Measure with patient prone; expect significant restriction compared to contralateral side 4
• Restriction in all three planes (internal rotation, adduction, flexion) has 93% specificity for radiographic OA, though sensitivity is only 33% for moderate disease 3

Pain Provocation Tests

• Groin pain with passive abduction or adduction: Sensitivity 33%, specificity 94%, LR 5.7 - highly specific for hip OA 2
• Squat causing posterior hip pain: Sensitivity 24%, specificity 96%, LR 6.1 - the most specific single finding when present 2
• Pain reproduction with internal rotation: This maneuver reproduces the patient's chief complaint in end-stage disease 1
• The patient should deny pain with small-arc range of motion testing, which helps differentiate intra-articular pathology from periarticular sources 1

Strength Testing

Hip abductor weakness is a cardinal finding in end-stage hip OA, with sensitivity of 44% and specificity of 90% (LR 4.5) 2

• Test hip abduction strength with the patient side-lying using a hand-held dynamometer or manual muscle testing 4, 5
• Weaker hip abductor muscles directly correlate with greater compensatory pelvis rotation (r = -0.291) and trunk rotation (r = -0.332) during gait 4
• Knee extensor strength should also be assessed, as it significantly influences performance-based functional measures 5
• Hip and knee strength explain additional variance in functional performance beyond pain alone 5

Inspection and Palpation

• Skin over the right hip should be intact without erythema - this is specifically documented to rule out inflammatory or infectious processes 1
• The patient should deny pain with palpation of the greater trochanter, which helps exclude trochanteric bursitis 1
• Assess for leg length discrepancy, which may develop with severe joint space narrowing 1
• Observe standing posture for pelvic obliquity and compensatory spinal alignment changes 1

Functional Assessment Components

Beyond isolated physical findings, assess real-world functional limitations as recommended by EULAR guidelines 1:

• Activities of daily living: Quantify difficulty with stairs, walking distances, putting on shoes/socks, getting in/out of car 1
• Pain characteristics: Rate pain intensity (0-10 scale), noting that pain significantly predicts self-reported disability but strength better predicts performance-based measures 5
• Fatigue and sleep quality: These biopsychosocial factors influence overall disability 1
• Weight/BMI: Document as this affects surgical risk and outcomes 1

Proprioception and Postural Stability

• Assess single-leg stance time on the affected leg, which will be reduced compared to the unaffected side 1
• Test proprioception by having the patient reproduce passive hip positioning with eyes closed 1
• Observe for Trendelenburg sign (pelvis drops on contralateral side during single-leg stance), indicating hip abductor weakness 1

Critical Pitfalls to Avoid

• Do not rely on pain alone to assess functional status - hip and knee strength explain significant additional variance in performance-based measures beyond pain 5
• Do not skip internal rotation testing - this is the most predictive single finding and missing it reduces diagnostic accuracy 2, 3
• Do not assume all hip pain originates from the hip joint - comprehensive examination must include lumbar spine and sacroiliac joint assessment, as these commonly refer pain to the hip region 6
• Do not overlook contralateral hip examination - bilateral comparison is essential for detecting subtle restrictions 2
• Do not forget to assess comorbidities (diabetes, cardiovascular disease) that influence treatment decisions and surgical candidacy 1

Quantifiable Outcome Measures

Document baseline functional status using validated tools 1:

• Six-Minute Walk Test distance (influenced by both pain and strength) 5
• Timed Up & Go test (influenced by pain, hip strength, and knee strength) 5
• Stair Climbing Test performance (influenced by pain and strength) 5
• Hip Outcome Survey score (primarily influenced by pain rather than strength) 5