What are the key components of a hip special exam?

Hip Special Examination: Systematic Approach

The hip special examination should include 18-21 core maneuvers organized by patient position (standing, supine, lateral, prone), with the FADIR test being the single most evidence-supported screening maneuver for hip-related pain, though it has limited diagnostic accuracy and should never be used in isolation. 1, 2, 3, 4

Standing Position Tests (Perform First)

• Gait assessment (86% usage by specialists): Observe for antalgic gait, Trendelenburg gait, or other abnormalities that indicate hip pathology 4
• Single-leg stance phase test (77% usage): Evaluates hip abductor strength and stability; positive Trendelenburg sign suggests gluteus medius weakness 4

Supine Position Tests (Core Battery)

Range of Motion Assessment

• Hip flexion ROM (98% usage): Normal is 110-120 degrees; reduced flexion suggests intra-articular pathology or osteoarthritis 4
• Flexion with internal rotation ROM (98% usage): Limited internal rotation is highly sensitive for intra-articular hip disease 4
• Flexion with external rotation ROM (86% usage): Assesses posterior capsule and external rotator function 4

Provocative Maneuvers

• FADIR test (Flexion-Adduction-Internal Rotation) (70% usage): Despite low-quality supporting evidence, this is the recommended screening test for all hip-related pain, including FAI syndrome and labral pathology, though it has very limited ability to confirm diagnosis 1, 4
• FABER test (Flexion-Abduction-External Rotation) (52% usage): Evaluates anterior hip structures and can provoke pain from labral tears or FAI 4
• Passive supine rotation test (76% usage): Patient supine with hip/knee at 90 degrees; internal and external rotation assessed for pain or restriction 4
• Straight leg raise against resistance (61% usage): Tests hip flexor strength and can reproduce pain from iliopsoas pathology 4

Lateral Position Tests

• Lateral hip examination (performed by specialists in 3 common tests): Evaluates greater trochanteric pain syndrome, IT band tightness, and lateral hip structures 4

Prone Position Tests

• Femoral anteversion test (58% usage): Assesses rotational alignment of the femur; excessive anteversion may contribute to hip pain 4

Critical Limitations and Pitfalls

Evidence Quality Issues

• Most special tests have poor diagnostic accuracy: The Thomas test, prone instability test, and ligamentum teres tear test have very limited ability to confirm FAI syndrome, with only limited to substantial ability for acetabular dysplasia/instability in low-quality studies 1
• ROM and muscle performance tests lack validated diagnostic accuracy for specific hip conditions and should not be used to definitively diagnose the source of hip-related pain 1
• No special test can rule in or rule out hip disease definitively: Post-test probability shifts are insufficient for diagnosis based on physical examination alone 1

Integration with Imaging

• Physical examination must be combined with imaging findings: The British Journal of Sports Medicine consensus strongly recommends that clinical signs should never be used in isolation but must be integrated with patient symptoms and imaging results when making treatment decisions 1
• Plain radiographs (AP pelvis and hip views) are mandatory first imaging: Both views rated 9/9 by the American College of Radiology and should precede any advanced imaging 1, 2, 5
• MR arthrography (rating 9/9) is indicated when radiographs are negative/equivocal and labral tear or FAI is suspected 1, 2, 5
• MRI without contrast (rating 9/9) is indicated when extra-articular soft tissue pathology is suspected 1, 2, 5

Diagnostic Injection as Definitive Test

• Image-guided anesthetic ± corticosteroid injection (rating 8/9) can definitively determine if pain originates from the hip joint versus surrounding structures or referred sources when physical examination and imaging are equivocal 1, 2, 5

Pain Localization Patterns

• Anterior hip/groin pain: Most commonly associated with intra-articular pathology (osteoarthritis, labral tears, FAI syndrome) 6
• Posterior hip/buttock pain: Associated with piriformis syndrome, sacroiliac joint dysfunction, lumbar radiculopathy, or ischiofemoral impingement 6
• Lateral hip pain: Typically indicates greater trochanteric pain syndrome 6

Common Pitfalls to Avoid

• Never rely on a single positive special test to make a diagnosis, as sensitivity and specificity are insufficient across all hip special tests 1
• Do not skip plain radiographs: All advanced imaging is rated 1/9 as the first test; proceeding directly to MRI without radiographs is inappropriate 1, 2
• Failing to obtain both pelvis and hip views may miss important pathology 2
• Occult femoral neck fractures can present with normal initial radiographs; if pain worsens or persists beyond 2-3 days, MRI is required urgently as this may indicate an occult fracture requiring surgical intervention 2