2 History and Physical Examination
Diagnosing Disorders of the Hip
I. Comprehensive history and physical examination are essential in evaluating the patient:
They allow one to establish a preliminary differential diagnosis.
They help determine course of the physical examination and special testing.
II. Presentation of hip pathologies can be broad and vague, requiring thorough investigation into the course of the disease process.
III. Pathologies arising from sites other than the hip such as knee or back may present as hip pain. 1
IV. Characterizing the patient complaint:
Symptoms of hip disease include pain, stiffness, deformity, mechanical (e.g., popping, snapping, locking, etc.), and limping.
V. Progression of degenerative hip disease:
Typically, external rotation is the first motion to be lost:
Patients will complain of difficulty putting their shoes on. 2
This is followed by loss of abduction/adduction.
Flexion is generally well preserved until more advanced stages.
I. Pain in the presence of locking, catching, or popping indicate better prognostic outcome:
It implies a mechanical problem that is typically correctable.
It is not a pathognomonic, injury-specific finding, as the hip can be completely normal.
II. Pain in the absence of other symptoms is a poorer prognostic indicator.
III. Characterize specific movements precipitating pain:
Patient typically lacks symptoms in straight plane activity.
Pain arises in direction change and twisting motions.
IV. Classic activities triggering symptoms:
Sitting, particularly with excess flexion.
Standing up from the seated position.
Ascending or descending stairs.
Putting on shoes and socks involves rotation.
I. Assessment of gross appearance:
Lesions, bruising, and visible trauma.
Symmetry and pelvic obliquity.
Visible signs of variable limb length.
II. Assessment of stance:
Signs of abnormality:
Slight flexion of the symptomatic hip with associated ipsilateral knee flexion.
III. Assessment of gait. The patient is asked to walk normally and in a toe-and-heel gait in the examination room.
Gait is steady, even, and with equal stride length with normal trunk and pelvis control.
Indication that legs are of equal length and motion is intact.
A possible consequence of hip pain.
The patient will alter position to avoid placing body weight over the affected hip.
Short leg limp: seen in limb length discrepancy. During walking, the body lands onto the short leg and takes off with the long leg.
It indicates abductor muscle weakness and inability to support pelvic weight.
Unaffected hip shifts downward when the affected leg is in midstance of the gait cycle ( Fig. 2.1 ).
I. Ensure the patient’s pelvis remains stationary by keeping a hand on the anterosuperior iliac spine.
In the supine position and with the knee flexed, bend the patient’s leg into the abdomen until resistance is met.
Normal range is 120 to 135 degrees.
In the prone or upright position, draw the leg backward until pelvic movement is detected or resistance is met.
Normal range is 20 to 30 degrees.
In the lateral decubitus position, place a hand on the iliac crest, and pull the leg away from midline until pelvic movement is detected or resistance is met.
Normal range is 40 to 50 degrees.
It is assessed with the patient in the supine or lateral decubitus position, with the test leg resting on the table. The upper leg is abducted to 25 degrees with resistance hand placed on the distal medial femur of the test leg while the patient actively adducts.
Normal range is 20 to 30 degrees.
VI. Internal rotation:
In the supine position, the knee and hip are both flexed at 90 degrees, and the leg is rotated outward while stabilizing the knee in position.
Normal is 30 degrees. It is positive in femoroacetabular impingement (FAI) syndrome.
VII. External rotation:
In the supine position, the knee and hip are both flexed at 90 degrees, and the leg is rotated inward while stabilizing the knee.
Normal is 50 degrees.