What is the proper technique for performing a comprehensive hip physical examination?

Hip Physical Examination Technique

A comprehensive hip physical examination should be performed systematically in five positions—standing, seated, supine, lateral, and prone—incorporating 18-21 core maneuvers that assess gait, range of motion, strength, provocative tests, and special maneuvers to identify intra-articular versus extra-articular pathology. 1, 2, 3

Systematic Examination Sequence

Standing Position

• Gait assessment (performed by 86% of hip specialists): Observe for antalgic gait, Trendelenburg gait pattern, stride length asymmetry, and compensatory movements 3
• Single-leg stance test (performed by 77% of specialists): Patient stands on affected leg for 30 seconds; pelvic drop on contralateral side indicates abductor weakness 3, 4
• Trendelenburg test: While standing on affected leg, observe for contralateral pelvic drop indicating gluteus medius/minimus weakness—though note this test has poor post-standardization reliability and should be interpreted cautiously 5, 4

Seated Position

• Palpation: Assess for tenderness over greater trochanter, ischial tuberosity, and anterior hip structures 1, 2
• Neurovascular assessment: Check distal pulses, sensation in lower extremity dermatomes, and motor function 2

Supine Position (Most Tests Performed Here)

• Hip flexion ROM (performed by 98% of specialists): Normal is 110-120 degrees; document any limitation 3, 4
• Flexion with internal rotation ROM (98%): Flex hip to 90 degrees, then internally rotate—this is the most commonly performed test 3
• Flexion with external rotation ROM (86%): Flex hip to 90 degrees, then externally rotate 3
• Passive supine rotation test (76%): With hip extended, internally and externally rotate the entire leg—pain suggests intra-articular pathology 3
• FADIR test (Flexion/Adduction/Internal Rotation) (70%): Flex hip to 90 degrees, adduct across midline, and internally rotate—positive test (groin pain) suggests femoroacetabular impingement or labral pathology 3, 4
• Straight leg raise against resistance (61%): Tests hip flexor strength and can provoke pain from iliopsoas pathology 3
• FABER test (Flexion/Abduction/External Rotation) (52%): Place ankle on contralateral knee in figure-4 position and apply downward pressure—pain suggests intra-articular hip pathology or sacroiliac joint dysfunction 3
• Log roll test: Gently roll extended leg internally and externally—highly reliable test for hip pain with post-standardization reliability >0.80 4
• Thomas test: Assess for hip flexion contracture by having patient pull opposite knee to chest while affected leg remains extended—highly reliable post-standardization 4
• True and apparent leg length measurement: Measure from anterior superior iliac spine to medial malleolus (true) and from umbilicus to medial malleolus (apparent)—discrepancy ≥1.5 cm has excellent reliability 4
• Strength testing: Assess hip flexion, extension, abduction, adduction strength—all have reliability coefficients >0.80 4

Lateral Position

• Abduction ROM and strength: Patient lies on unaffected side; assess active and resisted abduction 3
• Ober test: Assess for iliotibial band tightness 2
• Trochanteric bursa palpation: Direct palpation over greater trochanter for tenderness 2

Prone Position

• Femoral anteversion test (58%): Assess internal rotation of hip with knee flexed to 90 degrees—excessive internal rotation suggests increased femoral anteversion 3
• Hip extension ROM: Normal is 10-15 degrees; document limitations 4
• Rectus femoris tightness: Flex knee and observe for hip flexion (positive Ely test) 2

Critical Examination Principles

Standardization Improves Reliability

• Standardized examination techniques significantly improve inter-examiner reliability for most hip tests, with 71% (25 of 35) physical signs achieving adequate post-standardization reliability 4
• The most reliable signs include leg length discrepancy ≥1.5 cm, strength testing, log roll test, internal rotation ROM, flexion ROM, and Thomas test—all with reliability coefficients >0.80 4

Layered Diagnostic Approach

• Systematically evaluate the four main pain generators from deep to superficial: osteochondral structures, capsulolabral complex, musculotendinous units, and neurovascular elements 2
• This layered approach helps differentiate intra-articular pathology (labral tears, femoroacetabular impingement, osteoarthritis) from extra-articular sources (trochanteric bursitis, iliopsoas tendinitis, referred pain) 2

Common Pitfalls to Avoid

• Do not rely solely on Trendelenburg sign: This test remains highly unreliable even after standardization and should not be used as the sole indicator of abductor weakness 4
• Always compare to contralateral side: Bilateral examination allows identification of subtle asymmetries that may be missed when examining only the affected hip 6
• Perform passive rotation with hip extended: The passive supine rotation test (log roll) is more reliable than isolated ROM measurements and better identifies intra-articular pathology 3, 4
• Document specific ROM measurements: Vague descriptions like "limited ROM" are inadequate—record specific degrees of motion for flexion, internal rotation, external rotation, abduction, and adduction 4
• Consider referred pain sources: Hip pain may originate from lumbar spine, sacroiliac joint, or intra-abdominal pathology—a comprehensive examination must evaluate these potential sources 6, 2