Introduction
- Introduce yourself to the patient
- Wash your hands
- Briefly explain to the patient what the examination involves
- Ask the patient to remove their bottom clothing, exposing the hip
- Offer the patient a chaperone, as necessary
Always start with inspection and proceed as below unless instructed otherwise; be prepared to be instructed to move on quickly to certain sections by the examiner.
Inspection
Whilst the patient is standing:
- Assess patient gait, such as
- Trendelenburg gait – caused by dysfunction of the hip abductors (gluteus medius and minimus), the patients contralateral hip drops when walking; the patient often offsets this by leaning their trunk toward the affected hip
- Antalgic – produced from weight bearing on painful leg, resulting in a shortened stance-phase and producing the characteristic ‘limping’ patient
- Examine for quadriceps muscle bulk
Ask the patient to lie supine on the bed:
- Assess for:
-
- Skin changes (uncommon in primary hip pathology as the joint is deep)
- Scars (indicative of previous surgery)
- Swelling (also uncommon, as the joint is deep)
- Measure leg length with a tape measure. This assesses whether there is an actual leg length discrepancy and whether there is any pelvic tilt present to compensate for this:
- True leg length = ASIS to medial malleolus
- Apparent leg length = pubic symphysis to medial malleolus
Palpation
- Assess for temperature
- Feel for trochanteric bursa tenderness
- Palpate over the greater trochanter
Movement
All movements are passive when examining the hip, ensuring to note any pain, the range of motion, and any crepitus.
- Abduction and adduction
- Place one hand across the patient’s pelvis to ensure that the pelvis remains still and that the movement is coming from the hip joint and not the pelvis
- Flexion and extension
- Internal and external rotation (assessed with the hip flexed)
Special Tests
- Thomas’ Test (assesses for fixed flexion deformity)
- Have patient lying in the supine position, and place one hand underneath the patients lumbar spine to ensure loss of the lumbar lordosis
- Fully flex the contralateral hip and observe the ipsilateral hip (i.e. the one that you are examining). Any flexion in this hip suggests a fixed flexion deformity. Repeat this test on both sides
- Trendelenburg test (assesses abductor muscle function)*
- Ask patient to place their hands on your outstretched hands (for stability) and ask them to stand on the leg that you are examining, lifting the contralateral leg off the ground (for 30 seconds).
- Feel for a drop in the pelvis on the contralateral side. If there is abductor pathology (gluteus medius and minimus) on the side you are examining then the contralateral side (the normal side) will sag down (“Sound Side Sags”)
Complete the Examination
Thank the patient and allow them to redress. Remember, if you have forgotten something important, you can go back and complete this.
State to the examiner that to complete your examination you would also like to examine the joint above and below (lumbar spine and knees), the contralateral hip, and reviewing any relevant imaging available.