Given the close proximity of structures, pelvic disorders should also be considered as a source of anterior hip or “groin” pain. Primary pathologic conditions to consider include athletic pubalgia (sports hernia), adductor-related groin pain, inguinal hernia, osteitis pubis, pelvic floor dysfunction, and fractures of the femoral neck and pubic ramus. These disorders produce similar regional symptoms that are often mechanical and are exacerbated by sports or physical activity. Chapters 5, 8, and 11 provide comprehensive discussions of these disorders.
Lateral Hip Pain
Pain in the lateral hip is often more superficial, with the patient describing symptoms over the greater trochanter and surrounding lateral hip region.3 The patient’s symptoms may be mechanical or diffuse, depending on the pathologic process (see Table 2-1). The intraarticular disorders described in the foregoing section can also be a source of lateral hip pain and should be considered in the differential diagnosis. More commonly, extraarticular disorders such as external snapping hip syndrome, greater trochanteric bursitis, and gluteal tendon tears should be considered.10 These disorders may elicit more focal mechanical symptoms that may be easily identified. Diffuse lateral hip and thigh symptoms may also originate from the lumbar spine or the sacroiliac joint or from entrapment of the lateral cutaneous nerve of the thigh (e.g., meralgia paresthetica).1,2 Lumbar spine disorders should also be considered if symptoms travel distal to the knee.2 Other injuries such as femoral head or neck fractures or hip pointer may result from a traumatic event.10
Posterior Hip Pain
Pain in the posterior hip is the least common region of complaint and is often caused by extraarticular disorders.6 Pathologic conditions to consider include proximal hamstring tears, sacroiliac joint dysfunction, lumbar spine disorders, piriformis syndrome, and ischiogluteal bursitis (see Table 2-1). Lumbosacral disorders should be considered first because of all the nerves that course through the region.6 Intraarticular disorders such as labral tears, FAI, and osteoarthritis can refer mechanical pain into the posterior hip region and should be considered in the differential diagnosis.3 If trauma to the posterior pelvic and hip occurred (e.g., a fall), then a possible proximal femur or pelvic fracture should be considered.
During the patient interview, the clinician should determine whether any medical “red flags” or contraindications to treatment are present. This determination can be accomplished through the standard medical screening questionnaire, systems review, and specific questioning of the patient. Table 2-2 provides a summary of nonmusculoskeletal causes of hip, pelvic, and groin pain.2,11 Symptoms such as fever, malaise, night sweats, weight loss, past or current diagnosis of cancer, immunocompromise, and history of trauma may indicate a medical red flag that necessitates further investigation and possible referral.4 Ultimately, the clinician should determine whether the patient’s condition is appropriate for physical therapy or requires further investigation and possible referral.
Nonmusculoskeletal Causes of Hip and Groin Pain
|Genital or Reproductive||Gastrointestinal||Vascular||Other|
|Epididymitis||Crohn disease||Abdominal aortic aneurysm||Lymphadenopathy|
|Hydrocele/varicocele||Diverticular disease||Aortoiliac occlusive disease||Appendicitis|
|Prostatitis||Inflammatory bowel disease||Intraabdominal abscess|
|Testicular neoplasm or torsion||Rheumatic disease|
Hernia (e.g., inguinal, femoral, umbilical)
|Pelvic inflammatory disease|
|Urinary tract infection|
A systematic approach to the hip and pelvic examination begins with a comprehensive history. Taking a regional approach to questioning (e.g., anterior, lateral, or posterior) and determining whether the disorder is intraarticular or extraarticular will help the clinician to formulate a plausible hypothesis about what occurred and which anatomic structures are involved. This approach helps guide the objective portion of the examination.
The use of a systematic format for the clinical examination allows the clinician to perform the needed test and measures while the patient moves through the desired positions.12 The patient’s level of irritability should also be considered. Patients in acute pain may not be able to perform some of the clinical tests and may require the clinician to modify the examination. Continued testing in the presence of pain may produce a false-positive result, thus decreasing the diagnostic value of the clinical tests. The examination may also change depending on the patient’s functional ability and suspected pathologic process. The examination format described in this chapter follows a specific sequence of standing, sitting, supine, side lying, and prone. The patient is dressed appropriately, with shoes off, if possible. The clinician is also observing the patient’s demeanor, movements, and communication during all positions of testing. The suggested test and measures are described for each position.
The standing examination may begin with a postural assessment to determine how the person holds himself or herself in a static posture. The clinician should take an organized approach to posture assessment with a focus on the lumbopelvis and lower extremities, with observation in all planes. It has been well documented in the literature that patients with hip disorders often demonstrate postural deviations. For example, patients with hip labral tears and anterior hip pain have been found to assume a swayback posture (Fig. 2-2) that affects their gait kinematics.13,14 Anterior pelvic tilting has been associated with patients with cam-type FAI and acetabular dysplasia.15 Patients with unilateral hip osteoarthritis may present with decreased lumbar lordosis and thoracic kyphosis with the body tilting forward.16,17 The patient may also attempt to assume the position of least discomfort. For example, patients with synovitis or inflammation may position the hip in a flexed, abducted, and externally rotated position.5 The clinician should attempt to identify any posture deviations (e.g., a swayback posture) that may be contributing to the patient’s primary complaints.
The gait assessment should be conducted to determine how the hip pain and posture (e.g., swayback) affects the patient’s function.13 Sagittal and frontal plane motion should be observed to obtain a complete picture of the patient’s gait pattern. Common gait parameters to assess include stance and swing phase, stride length, stride width, and pelvic motion.7 The patient may develop a compensatory gait pattern as a result of hip pain, stiffness, decreased range of motion (ROM), and fear-based avoidance.18–20 These impairments can lead to a slower gait pattern (cadence), decreased stride length, decreased stance, increased contralateral loading of the opposite hip (e.g., leaning toward the uninvolved hip), and decreased or abnormal pelvic motion.20–25
To obtain a better understanding of how the patient can perform activities of daily living, the patient should undergo functional testing. Suggested activities to test include sit to stand and stair ambulation to provide insight into the patient’s current functional abilities. Patients with mild to moderate hip osteoarthritis often unload the involved hip during sit to stand transition movements.26 For example, the patient may lean toward the uninvolved hip to unload or reduce the forces through the involved hip as he or she is rising from the seated position. In addition, patients with FAI may present with altered sagittal plane hip ROM during stair climbing and decreased hip flexion ROM during squatting activity.25,27 The patient’s level of pain and functional abilities should direct functional testing.
Athletes or active persons with higher functional levels can undergo performance testing. Often, such testing is used as a repeated measure to help determine whether the patient is ready to return to sport or physical activity. For example, the 30-second single leg stance test has a high sensitivity (100%) and specificity (97.3%) for detecting gluteus medius and minimus tendinopathy.28 Performance testing may yield valuable information but can lead to increased pain and poor patient performance from the high demands of testing. The clinician must decide when is the best time to introduce such testing in the examination process. Appendix B provides a summary and normative values for common performance tests of the hip and lower extremity.29
Joint hypermobility testing can be conducted while the patient is in standing. Joint hypermobility has been recognized as a characteristic of various connective tissue disorders (Ehlers-Danlos and Marfan syndromes) and musculoskeletal disorders such hip FAI.30 The Beighton score is a common test used to investigate the presence of hypermobility (Fig. 2-3).30 The test measures hypermobility (1 is yes, 0 is no) at the lumbosacral spine, both thumbs, fifth metacarpophalangeal joints (little fingers), elbows, and knees. The Beighton score is calculated as follows: (1) one point if the patient can bend forward from a standing position and place the palms on the ground with legs straight, (2) one point for each thumb that touches the forearm when bent backward, (3) one point for each little finger that bends backward beyond 90 degrees, (4) one point for each elbow that bends backward, and (5) one point for each knee that bends backward. A score of 4 or higher out of 9 is considered to be positive for joint hypermobility.31 The reproducibility of the test to diagnose both general joint hypermobility and benign joint hypermobility syndrome was found to be high (kappa, 0.74 to 0.84).32,33 Benign joint hypermobility syndrome is another condition involving a cluster of subjective and objective findings including joint arthralgia, back pain, spondylosis, spondylolysis or spondylolisthesis, joint dislocation or subluxation, soft tissue rheumatism, marfanoid habitus, abnormal skin, eye signs, varicose veins, or hernia or uterine or rectal prolapse.31 The Beighton score is a valid and reliable34 measure in children,35 women,31 dancers,36 and various ethnic groups.31
A general lumbar spine screen can be conducted at this phase if a potential concomitant pathologic process is suspected. Testing may include ROM and selected special tests to rule out any suspected disorder. Please see the later section on lumbosacral issues.
The seated portion of the examination may include a seated posture assessment, ROM, neurologic screen, integument and vascular screen, and muscle performance evaluation. A seated posture assessment can be conducted that may provide some insight into how the hip symptoms affect sitting posture. Passive or active ROM measurements can be taken for the hip, knee, and ankle in this position. However, aggravating hip motions should be tested with caution. For example, seated internal rotation may aggravate the condition in a patient who is diagnosed with FAI, or hip flexion may aggravate a patient with low back pain and limited hip mobility.27,37 Chapter 1 provides a description of hip ROM norms.
The neurologic screen should include testing of lower extremity motor, deep tendon reflex, and dermatome sensation.38 Often, neurologic testing is done to screen for diskogenic or radicular disease. Motor testing from L3 to S1 has good specificity (100%) but weaker sensitivity (0% to 28%).39 The Achilles deep tendon reflex (sensitivity, 87%; specificity, 89%) has stronger diagnostic accuracy than does the extensor digitorum brevis (sensitivity, 14%; specificity, 91%). Dermatome sensation testing of light touch or of sharp or dull has stronger specificity (100%) than sensitivity (50%).40 Table 2-3 summarizes the components of the neurologic screen.
Lower Extremity Neurologic Screen
|T12||None||Medial thigh and inguinal area||None|
|L1||None||Back, anterior thigh, as well as medial upper thigh||None|
|L2||Psoas and hip adductors||Back to anterolateral to proximal medial thigh||None|
|L3||Psoas and quadriceps||Back, upper buttock, to anterior and medial thigh to patella||Patellar reflex|
|L4||Tibialis anterior and extensor hallucis||Medial buttock, lateral thigh to medial lower leg and medial aspect of foot||Patellar reflex|
|L5||Extensor hallucis, peroneals, gluteus medius, and ankle dorsiflexors||Buttock, posterior and lateral thigh to anterolateral aspect of leg to the dorsum of foot||None|
|S1||Ankle plantar flexors and hamstrings||Buttock, thigh, and posterior leg and lateral foot||Achilles reflex|
Manual muscle testing (MMT), graded using a 0 to 5 scale, can also be done with the patient seated for the hip, knee, and ankle. Figure 2-4 provides an example of MMT for seated hip flexion and internal and external rotation.38 Hip muscle deficits have been demonstrated in patients with FAI, hip osteoarthritis, and chronic hip pain.41–43 MMT has proven to be a good clinical tool, but it may be enhanced by using a hand-held dynamometer to obtain a more quantitative and reproducible measurement.44–46
A general lower extremity integument inspection and vascular screen can also be conducted. Palpation of the femoral, popliteal, posterior tibialis, and dorsalis pedis pulses can determine whether the pulses are present or absent.47
The supine examination can begin with standard goniometric hip ROM measurements for flexion (120 degrees with knee bent), abduction (40 degrees), adduction (25 degrees), internal rotation (35 degrees), and external rotation (45 degrees).48,49 A digital inclinometer can also be used for enhanced accuracy.48,50 For hip internal and external rotation, the hip and knee are flexed to approximately 90 degrees. Care should be taken to avoid the impingement positions of flexion and adduction, which may cause pain during testing. Muscle length testing can be performed at this time to assess for any length deficits, bilaterally. Common muscle length tests include the 90-90 hamstring test, the straight leg raise test, and the modified Thomas test.
90-90 Hamstring Test
• Procedure: The examiner passively moves the ipsilateral hip to 90 degrees of flexion and maintains the position.51,52 The knee is then passively extended to maximum range. The contralateral lower extremity is kept in full knee extension (Fig. 2-5).51,52
• Note: The clinician needs make sure the patient maintains a stable pelvis because an anterior or posterior pelvis can significantly affect the test results.54 The contralateral extremity can also be fixed to the table by using a nylon strap to prevent movement.52 A second examiner can also be used to take measurements.
Straight Leg Raise Test (Passive)
• Procedure: The examiner passively flexes the ipsilateral hip. The knee is fully extended throughout the test. The ankle is held in slight plantar flexion to avoid any neural tension.51,55 At the end of the available ROM, the hip joint angle is measured. The contralateral lower extremity is kept in full knee extension (Fig. 2-6).51,52,55
• Interpretation: Straight leg raise of less than 80 degrees indicates hamstring tightness.51
• Reliability: Interrater reliability with inclinometer (ICC: >0.97).51
• Note: The straight leg raise test is also used to assess lumbar disk disease in patients who report “sciatic” symptoms. The pelvis and contralateral extremity can be fixed on the table by using a nylon strap to prevent movement.51 A second examiner can also be used to take measurements.
Modified Thomas Test
• Procedure: The patient maximally flexes the nontest hip, brings the knee to the chest, and holds the position.56 The lumbar spine and pelvis are flat on table. The examiner can conduct three measurements of the test leg: (1) hip angle for iliopsoas length, (2) knee angle for rectus femoris length, (3) hip abduction angle for TFL/iliotibial band (ITB) flexibility.56,57 The procedure can be repeated on the opposite side (Fig. 2-7).
• Interpretation: Normal muscle length is considered when the hip and posterior thigh are flat on the table, the hip is in line with the pelvis (not abducted), and the knee remains at a minimum of 90 degrees.57,58 Decreased muscle length is considered when the hip is not flat on the table, or the hip is abducted, or the knee angle is less than 90 degrees (see Fig. 2-7). The hip and knee angles can be calculated and used as repeated measures or graded as a pass or fail.
• Modification: The examiner can actively stabilize the pelvis or passively stabilize it by using a strap. The hip and knee can also be passively moved into different positions to help isolate a muscle and assess its length (e.g., if the hip is not in full extension [flat on the table], passively extend the knee to relax the rectus femoris and further assess iliopsoas length). These test modifications are common in clinical practice but have not been fully studied.
• Reliability: Rectus femoris length goniometric measurements: intrarater (ICC, 0.67) and interrater (ICC, 0.50) reliability. Pass/fail criteria: intrarater (kappa = 0.040) and interrater (kappa = 0.50).58 Active pelvic stabilization: intrarater (ICC, 0.99). Passive pelvic stabilization: intrarater (ICC, 0.98).59
• Note: A modified version of the Thomas test has also been used to assess the presence of intraarticular hip disorders. See Table 2-5 for a description of this test.
A secondary lower extremity integument inspection and palpation of suspected soft tissue structures can also be conducted. For palpation, a 0 to 4 scale is recommended to measure the patient’s pressure pain threshold and reactivity level, which will help determine the patient’s tolerance to further testing and treatment (Table 2-4).60–75 Palpation should focus on the anatomic structures most proximal to the patient’s region of complaint (e.g., the iliopsoas) because these structures are often involved in both intraarticular and extraarticular disorders.5 Palpation should be part of a comprehensive examination; however; the research on anterior hip palpation is sparse and inconclusive. This should be considered when interpreting the findings of the clinical examination. Special testing can also be conducted in the supine position to rule in and rule out specific pelvic and hip disorders. Table 2-5 provides a description of special tests for various intraarticular and extraarticular hip disorders. The description and interpretation of these tests are based on the investigations that described and reported the clinometric values of these tests. Other versions of the tests may exist or have been reported, but because their diagnostic value has not been studied, they are not included in this chapter.
Palpation Pressure Pain Threshold Scale
|0||No pain||No signs of pain or discomfort with pressure|
|I||Mild pain||Tenderness reported without flinching to pressure|
|II||Moderate pain||Wincing or flinching to pressure|
|III||Severe pain||Signs of severe pain such as verbal gestures and withdrawing of body part to pressure|
|IV||Noxious-intolerable pain||Unbearable pain; patient does not allow palpation to the specific area of pain|