Motion
Flexion
Extension
Abduction
Adduction
Internal rotation
External rotation
Range in degrees
110–120
0–15
30–50
30
30–40
40–60
The majority of the range-of-motion testing can easily be performed with the patient supine. One can assess internal and external rotation by having the patient lying with his or her legs slightly separated and passively rolling the entire lower extremity as if performing a log roll. An alternate method involves flexing the patient at the knee and rotating the leg around the vertical axis of the femur (Figs. 2.1 and 2.2). This method may make measurements easier, but it is important to remember that pivoting the ankle in one direction causes the hip to rotate in the opposite plane. For example, moving the ankle laterally, while using this method, causes internal rotation at the hip. Abduction (Fig. 2.3) and adduction (Fig. 2.4) are performed by anchoring the patient’s pelvis with one hand while moving one leg at a time through the transverse plane with the other. When the hip begins to rotate (despite the added support provided by the examiner) the full range of motion in that plane has been reached. Hip flexion should be tested in the supine position by having the patient draw both knees to his or her chest, as flexion at the knee eliminates hamstring tightness as a potential limiting factor for this exam. Extension , on the other hand, is best performed with the patient in the prone position by raising the selected thigh from the exam table (Fig. 2.5).
Fig. 2.1
Internal rotation
Fig. 2.2
External rotation
Fig. 2.3
Abduction
Fig. 2.4
Adduction
Fig. 2.5
Extension
2.5.2 Palpation
Palpation constitutes another significant portion of the exam. The musculature, tendinous origins and insertions, bony prominences (e.g., the greater trochanter), bony articulations (including the SI joint (Fig. 2.6) and pubic symphysis), bursae, and apophyses all must be palpated to the extent possible. The examiner must be attentive to any snapping or popping throughout the range of motion. While this usually indicates benign tendinous friction over a bony prominence, it can at times indicate an intra-articular lesion or free-floating loose body [13]. This information may be obtained by palpating the portion of the joint being assessed with the free hand while performing the range-of-motion testing as detailed above.
Fig. 2.6
SI (sacroiliac) joint palpation
2.5.3 Neurologic Testing
The hip and pelvis channel numerous nerves from the back to the groin and lower extremity. Accordingly, a thorough neurologic exam is essential even when neurological involvement is not suspected. Strength testing of the lower extremity must include each of the major muscle complexes that mobilize the hip and knee. As described previously, these muscle complexes can be divided into four cardinal muscle groups: the flexors (e.g., iliopsoas and rectus femoris), the extensors (e.g., gluteus maximus and hamstrings), the abductors (e.g., gluteus medius and gluteus minimus), and the adductors (e.g., adductor longus, adductor brevis, adductor magnus, pectineus, and gracilis.) Strength should then be graded on a scale from 1 to 5 (Table 2.2).
Table 2.2
Strength testing values
Strength test value | Meaning of the value |
|---|---|
1/5 | No signs of muscle firing |
2/5 | Visible twitching or fibrillations of the contracted muscle group without any movement |
3/5 | Active movement when gravity is eliminated |
4/5 | Active muscle activity against resistance with decreased strength |
5/5 | Indicating normal strength |
After palpating the muscle bellies and tendinous junctions of the individual muscles, the examiner may proceed to test the strength of each muscle grouping. In order to test the flexor group , the examiner places his or her hand over the seated patient’s thigh and asks the patient to push upward against his or her hand while offering resistance. Similarly, to test the hip extensors, the patient is placed in a prone position and instructed to raise his or her thigh from the exam table as resistance is applied from behind the knee. Abduction and adduction may be assessed from the supine position with knees extended. The patient is instructed to separate the legs as the examiner offers resistance from the lateral malleoli and then to squeeze the legs together as resistance is applied to the medial malleoli. These latter tests may also be performed with the patient in the lateral decubitus position with the hips neutral. In this scenario, the patient is instructed to abduct the upper thigh to 30° and strength testing proceeds as above for the elevated leg (Fig. 2.7) . The authors suggest that this technique may offer a greater degree of sensitivity to subtle deficits of strength (SOR-C).
Fig. 2.7
Abduction strength testing
2.5.4 Special Tests
One may employ a number of special tests to narrow the differential diagnosis after history, range-of-motion testing, neurologic testing, and palpation have been completed. Despite variability in sensitivity and specificity (Tables 2.3, 2.4, 2.5, 2.6, 2.7, and 2.8), as well as significant crossover, such tests can be helpful when employed within the context of the previously obtained information.
Table 2.3
Physical exam tests for muscle/tendon pathology
Test/lead author (year published) | Pathology | SN/SPa |
|---|---|---|
1. Trendelenburg’s Sign | ||
Bird (2001) [14] | Gluteal tear/tendinopathy | 73/77 |
Woodley (2008) [15] | Gluteal tear/tendinopathy | 23/94 |
Lequesne (2008) [16] | Gluteal tear/tendinopathy | 97/96 |
2. Ely’s Test | ||
Marks (2003) [17] | Flexion contracture (rectus femoris spastisity)—pedatric CP patients only | 56–59/64–85 |
Table 2.4
Physical exam tests for intra-articular pathology
Test/lead author | Pathology | SN/SPa |
|---|---|---|
1. FABER (Jansen or Patrick’s test) | ||
Martin (2008) [18] | Labral tear, FAI, arthritis, dysplasia | 60/18 |
Troelsen (2009) [19] | Labral tear | 42/75 |
Maslowski (2010) [20] | Labral tear, FAI, arthritis, avascular necrosis | 81/25 |
2. Impingement (FADIR) | ||
Reiman (2015) [21] | Labral tear, FAI, arthritis, chondral defects | 94/8 |
Reiman (2015) [21] | Labral tear, FAI, arthritis, chondral defects | 99/7 |
3. Stinchfield (resisted straight leg raise) | ||
Maslowski (2010) [20] | Labral tear, FAI, arthritis, avascular necrosis | 59/32 |
4. Scour (quadrant) test | ||
Maslowski (2010) [20] | Labral tear, FAI, arthritis, avascular necrosis | 50/29 |
5. Thomas test | ||
McCarthy (1995) [22] | Labral tear, arthritis, loose bodies | 89/92 |
Table 2.5
Physical exam tests for osteoarthritis of the hip
Test/lead author | Pathology | SN/SPa |
|---|---|---|
1. Trendelenburg’s sign | ||
Youdas (2010) [23] | Osteoarthrisis | 55/70 |
2. FABER (Jansen or Patrick’s test) | ||
Sutlive (2008) [24] | Osteoarthritis | 57/71 |
Table 2.6
Physical exam tests for femoral shaft fracture
Test/lead author | Pathology | SN/SPa |
|---|---|---|
1. Fulcrum test | ||
Johnson (1994) [25] | Femoral shaft fracture | 93/75 |
Kang (2005) [26] | Femoral shaft fracture | 88/13 |
2. Patellar pubic percussion test | ||
Bache (1984) [27] | Femoral neck fracture | 91/82 |
Adams (1997) [28] | Femoral Fx at the neck or proximal/ trochanteric Fx | 94/95 |
Tiru (2002) [29] | Femoral neck fracture | 96/86 |
Table 2.7
Physical exam tests for neurologic disease
Test/lead author | Pathology | SN/SPa |
|---|---|---|
1. Straight leg raise | ||
Vroomen (1999) [30] | Ipsilateral lumbar herniated disk disease | 85/52 |
Vroomen (1999) [30] | Contralateral lumbar herniated disk disease | 30/84 |
2. Piriformis (FAIR) test | ||
Fishman (1982) [31] | Sciatic nerve impingement | 88/83 |
3. Lateral pelvic compression test | ||
Nouraei (2007) [32] | Meralgia parasthetica | 95/93.3 |
Table 2.8
Physical exam tests for pelvic disorders
Test/lead author | Pathology | SN/SPa |
|---|---|---|
1. Suppine to sit (long sitting test) | ||
Bemis (1987) [33] | Pelvic dysfunction, pelvic malrotation | 17/38 |
2. Standing flexion test | ||
Levangie (1999) [34] | SI joint dysfunction | 17/79 |
3. Gillet test | ||
Dreyfuss (1996) [35] | SI joint dysfunction | 43/68 |
Levangie (1999) [34] | SI joint dysfunction | 8/93 |
4. Gaenslen sign | ||
Russel (1981) [36] | SI joint dysfunction | 21/72 |
Dreyfus (1996) [35] | SI joint dysfunction | 68/35 |
van der Wurff (2000) [37] | SI joint dysfunction | 71/26 |
5. Compression test | ||
Russel (1981) [36] | SI joint dysfunction | 7/90 |
Ozgocmen (2008) [38] | Rt sided sacroiliitis | 22/83 |
Ozgocmen (2008) [38] | Lt sided sacroiliitis | 27/93 |
Trendelenburg’s sign is a test used to determine whether the patient has adequate hip abductor strength, particularly of the gluteus medius. To perform this test the patient is instructed to stand on both feet and slowly raise one foot off of the ground without additional support. If the patient has adequate abductor strength, then the iliac crest of the raised leg should remain parallel with or elevated slightly in relation to the contralateral side (Fig. 2.8). In addition, the patient should maintain an upright posture without significant tilt of the upper trunk, which would indicate a compensatory mechanism to help the patient maintain his or her balance (Fig. 2.9). A positive Trendelenburg sign is defined as either a compensatory tilt of the torso (vide supra) or a drop of the contralateral iliac crest (Fig. 2.10), indicating that the ipsilateral hip abductors are unable to contract with adequate force to maintain a level pelvis. Instability of the pelvis from other etiologies may also create a positive Trendelenburg’s sign resulting from increased tensile forces on the bony structures of the hip. Therefore, diagnoses causing pelvic instability, such as Legg–Calve–Perthes disease or acetabular fractures of any etiology, may be considered as alternate causes of a positive test [39].
