Physical Examination of the Pelvis and Hip




Key words

pelvis, hip

 




Introduction


The hip joint is one of the more stable joints of the body. The stability stems from the intimacy of the head of the femur within the acetabulum like a ball in a socket. This results in a paradox. Most traumatic injuries require substantial force. However, because of the limited tolerances associated with the constrained anatomy, slight incongruences can lead to early age wear as exemplified both by dysplasia and femoroacetabular impingement. In general, injuries to the hip joint result in difficulty with ambulation. However, pain in the hip region may be referred from other areas such as the sacroiliac joint (SIJ) or lumbar spine. Therefore, careful examination of the hip and the surrounding regions is essential.




Inspection, Palpation, and Range of Motion


The initial examination should occur with the individual standing. The examiner should document any soft tissue or bony contour abnormalities, edema, skin discoloration, or scars. In addition, the examiner should note the alignment of the lower extremities. Excessive external rotation at the ankle is potentially indicative of femoral retroversion, while excessive internal rotation (“toeing in”) is potentially indicative of femoral anteversion. Patients with intra-articular hip pathology may stand with the involved hip and ipsilateral knee in a slightly flexed position to unload the involved limb. The individual should then be examined for any asymmetry of shoulder height, spinal alignment, iliac crest height, and both femoral and tibial height. Any asymmetry may be indicative of an underlying scoliosis or leg length discrepancy. Compensatory lumbar lordosis may be present in cases of a tight iliopsoas. Similarly, the patient should be examined while supine to further assess for any obvious asymmetries.


A general assessment of the patient’s gait in both the sagittal and frontal planes is essential. Abnormal gait patterns, such as hip hiking, circumduction, or excessive trunk extension, may be evidence of muscle weakness, leg length discrepancy, or pain. With intra-articular pathology, the patient may have a shortened stance phase of gait on the affected side, avoidance of hip extension, and shifting of the torso over the involved hip, creating an abductor lurch. Any of these findings should prompt a more focused examination. In addition, the examiner will get a sense of the patient’s overall posture and balance while ambulating.


Palpation of the hip area is generally divided into anterior, medial, lateral, and posterior regions. The examiner should be familiar with the deep anatomy and correlating bony landmarks, and any areas of tenderness should be noted. Asking the patient to locate the area of maximal tenderness with one finger can help focus the palpatory examination. While structures should be palpated in a systematic manner, the examiner shoulder reserve the area identified by the patient using the “one-finger test” for last in order to build the patient’s trust by not stimulating pain at the beginning.


Often palpation is more useful for extra-articular problems, but deep palpation over the anterior hip capsule may cause pain in cases of intra-articular pathology. In addition, the anterior examination should include palpation of the anterior superior iliac spine and the insertion of the sartorius, anterior hip flexor region, and both the pubic rami and pubic symphysis. The femoral artery and lymph nodes are easily palpated in the femoral triangle, roughly half the distance between the anterior superior iliac spines (ASIS) and pubic symphysis distal to the inguinal ligament.


Laterally, the iliac crest, greater trochanter, insertion site of the gluteus minimus and gluteus medius, muscle belly of the gluteus medius, and origin of the tensor fascia lata should be palpated. Tenderness over the greater trochanter may be indicative of greater trochanter pain syndrome, a common source of lateral hip pain. Posterior palpation should include the posterior superior iliac spine, SIJ, ischial tuberosities and the origin of the hamstrings, and the piriformis and overlying gluteus maximus muscles.


Active and resisted range of motion (ROM) of the hip is generally assessed with the patient either in a sitting or supine position. The exception is hip abduction, which is most easily performed in the lateral position. Stabilization of the pelvis is important when assessing ROM of the hip. Resisted hip flexion with the knee flexed isolates the iliopsoas, while the rectus femoris, which crosses both the hip and knee joint, is recruited when the knee is extended. There can be a wide range of what is considered “normal,” so of greater importance is assessing for asymmetry from one side to the other.




Muscle Tightness or Pathology of the Lumbopelvic Region ( Table 8.1 )


Thomas Test ( )


In 1876, Hugh Owens Thomas described a novel method to help differentiate “morbus coxae,” or inflammatory disease of the hip, from “abscesses, sciatica, or hysterical simulation” of hip joint pain. He described the test as follows :



Table 8.1

Tests for Periarticular Hip Pathology
























































































































































Test Description Reliability/Validity Tests Comments
Thomas Test The patient lies supine while the examiner checks for excessive lordosis. The examiner flexes one of the patient’s hips, bringing the knee to the chest to flatten out the lumbar spine, and the patient holds the flexed hip against the chest. If there is no flexion contracture, the hip being tested (the straight leg) remains on the examining table. If a contracture is present, the patient’s leg rises off the table. The angle of contracture can be measured. Bartlett et al. 1985
Interrater reliability: 0.89–0.93, mean difference 1.1–5.1 degrees
Intrarater reliability: 0.70–0.90, mean difference 1.9–9.2 degrees
Reliability of 2 experienced therapists examining 15 children with spastic diplegic CP, 15 with meningomyelocele and 15 healthy children
Kilgour et al. 2003
Intrarater reliability: 0.17–0.66 CP and 0.09–0.91 control
Reliability of 1 pediatric therapist examining 25 children with spastic diplegic CP, 25 healthy controls
McWhirk and Glanzman 2006
Interrater reliability: 0.58, mean absolute difference 3.96
Reliability of 2 therapists with varying experience examining 46 legs of 25 children with spastic CP
Mutlu et al. 2007
Interrater reliability: 0.95
Intrarater reliability: 0.99
Reliability of 3 therapists examining 38 children with spastic diplegic CP on 2 different occasions
Glanzman et al. 2008
Intrarater reliability: 0.98
Reliability of 2 therapists with varying experience examining 50 legs of 25 patients with spastic CP
Lee et al. 2011
Interrater reliability: 0.5 CP and 0.2 control
Reliability of 3 examiners of 37 children with CP and 36 healthy controls
Herrero et al. 2011
Intrarater reliability: 0.83–0.95
Interrater reliability: 0.375–0.475
Reliability of 5 therapists examining 7 children (14 limbs) with spastic CP during 2 different sessions
Prone hip extension (Staheli test) The patient lies prone with the pelvis on the table and the hips at the edge of the table. The examiner supports the uninvolved leg and extends the involved leg until the pelvis rises off the table. The angle of extension can be measured. Bartlett et al. 1985
Interrater reliability: 0.82–0.93, mean difference 1.1–5.8 degrees
Intrarater reliability: 0.80–0.92, mean difference 2.1–9.6 degrees
Reliability of 2 experienced therapists examining 15 children with spastic diplegic CP, 15 with meningomyelocele and 15 healthy children
Kilgour et al. 2003
Intrarater reliability: intrasessional 0.78–0.91 CP and 0.8–0.92 control; intersessional 0.55–0.8 CP and 0.04–0.2 control
Reliability of 1 pediatric therapist examining 25 children with spastic diplegic CP, 25 healthy controls. Two measurements were taken at the initial visit (intrasessional) and again at 7 days (intersessional) by a pediatric PT
Glanzman et al. 2008
Intrarater reliability: 0.98
Reliability of 2 therapists with varying experience examining 50 legs of 25 patients with spastic CP
Lee et al. 2011
Interrater reliability: 0.2 CP and 0.1 control
Reliability of 3 examiners of 37 children with CP and 36 healthy controls
Modified Thomas test The patient is positioned at the end of the examination table with the uninvolved leg flexed to flatten the lordotic curve, and the involved leg is allowed to extend with gravity. The degree of hip extension is measured. Ashton et al. 1978
Interrater reliability: 0.33–0.52 moderate CP and 0.4–0.516 severe CP
Reliability of 16 therapists examined 2 children with moderate and 2 children with severe CP
Harvey 1998
Intrarater reliability: 0.91
Reliability of 3 measurements of the modified Thomas test as a measure of iliopsoas flexibiilty of 117 elite athletes (tennis, basketball, rowing, running)
Clapis et al. 2008
Interrater reliability: 0.89–0.92
Intrarater reliability: 0.86–0.92
Reliability of 2 therapists using inclinometer and goniometric measurements of hip extension in 42 healthy subjects
Cejudo et al. 2015
Intersession reliability: 0.87–0.91
Reliabilty of 2 therapists across 3 sessions examining 90 asymptomatic athletes
Wakefield et al. 2015
Interrater reliability: GON 0.3–0.65; TRIG 0.91–0.94
Intrarater reliability, GON 0.51–0.54; TRIG 0.9–0.95
Reliability of 2 examiners using goniometric (GON) and trigonometric (TRIG) measurements in 22 healthy college students
Pelvifemoral angle The patient is side-lying with the hip to be measured upward. The examiner passively extends the hip with the knee in 30 degrees of flexion.
Mundale method: Stationary arm perpendicular to the ASIS-iliac spine line. Moveable arm along the axis of the femur forming an angle stationary arm.
Milch angle: Stationary arm along the ASIS-ischial tuberosity line. Moveable arm along the axis of the femur, forming the pelvifemoral angle.
Bartlett et al. 1985
Mundale:
Interrater reliability: 0.63–0.91, mean difference 5.8–7.8 degrees
Intrarater reliability: 0.79–0.84, mean difference 7.1–10.9 degrees
Milch:
Interrater reliability: 0.78–0.92, mean difference 3.6–4.3 degrees
Intrarater reliability: 0.73–0.77, mean difference 6.7–7.8 degrees
Reliability of 2 experienced therapists examining 15 children with spastic diplegic CP, 15 with meningomyelocele and 15 healthy children
Ely test The patient lies prone while the examiner passively flexes the patient’s knee. Upon flexion of the knee, the patient’s hip on the same side spontaneously flexes, indicating that the rectus femoris muscle is tight on that side and that the test is positive. The two sides should be tested and compared. Peeler and Anderson 2008
Intrarater reliability: 0.69
Interrater reliability: 0.66
Reliability of 3 therapists examining 54 healthy subjects in 2 distinct sessions
Rectus femoris contracture test (modified Thomas test) The patient lies prone while the examiner passively flexes the patient’s knee. Upon flexion of the knee, the patient’s hip on the same side spontaneously flexes, indicating that the rectus femoris muscle is tight on that side and that the test is positive. The two sides should be tested and compared.
The patient lies supine with the knees bent over the end or edge of the examining table. The patient flexes one knee onto the chest. The angle of the test knee should remain at 90 degrees. A contracture may be present if the test knee extends slightly.
Harvey 1998
Intrarater reliability: 0.94
Reliability of 3 measurements of quadriceps flexibility of 117 elite athletes
Peeler and Anderson 2008
Intrarater reliability: 0.67
Interrater reliability: 0.5
3 therapists assessing 57 healthy subjects during 2 different sessions
Atamaz et al. 2011
Intrarater reliability: 0.84–0.91
Interrater reliability: 0.75–0.87
Reliability of 2 examiners assessing 66 healthy subjects in a test-retest design
Peeler and Leiter 2013
Intrarater reliability: 0.98
Interrater reliability: 0.97
Ten therapists scoring the degree of rectus femoris flexibility from digital photographs of 28 healthy college students being examined with the modified Thomas test
Ober test Original Ober test: The patient lies on the side, with the thigh next to the table flexed to obliterate any lumbar lordosis. The upper leg is flexed at a right angle at the knee. The examiner grasps the ankle lightly with one hand and steadies the patient’s hip with the other. The upper leg is abducted widely and extended so that the thigh is in line with the body. If there is an abduction contracture, the leg will remain more or less passively abducted.
Modified Ober test: Peformed as above, but knee is fully extended before allowing gravity to bring the leg into adduction.
Melchione and Sullivan 1993
Intrarater reliability: 0.94
Interrater reliability: 0.73
Two therapists examining 10 subjects with anterior knee pain using the modified Ober test with a test-retest design
Gajdosik et al. 2003
Intrarater reliability: 0.83–0.87
Intrarater reliability: 0.82–0.92
Reliability of one therapist taking 3 measurements using the Ober and modified Ober tests examining 49 healthy subjects
Reese and Bandy 2003
Intrarater reliability: 0.90
Intrarater reliability: 0.91
Reliability of the Ober and modified Ober tests in a study of 61 subjects examined by 1 therapist using an inclinometer during 2 distinct sessions
Piriformis test SLR or Lasègue’s sign:
The patient is supine; examiner passively lifts extended leg.
Martin 2011
Straight-leg raise
Validity of 3 different tests for piriformis syndrome in retrospective study. Examination performed on 35 patients with unexplained posterior hip pain evaluated by single examiner and diagnosis confirmed with endoscopic evaluation
Pace test/active piriformis test:
The patient is seated. The examiner places his or her hands on the lateral aspect of the knee and asks the patient to push the hands apart. Pain with resisted abduction–external rotatation is a positive test.
Active piriformis test
Passive pirifomris stretch:
The patient is side-lying with the nontest leg against the table, and the patient flexes the test hip to 60 degrees with the knee flexed. The examiner applies a downward pressure to the knee, which the patient resists. Pain is elicited in the muscle if the piriformis is tight. The traditional variation described by Pace was with the patient seated. This test can also be performed with the patient in a seated position as described by Martin.
Seated piriformis stretch
Sensitivity: 52%
Specificity: 90%
+LR: 5.22
−LR: 0.53
OR: 9.82
Popliteal angle The popliteal angle is measured with the patient supine and the hip flexed 90 degrees. The examiner attempts to extend the knee until firm resistance is met while the hip is maintained at 90 degrees (passive knee extension [PKE] method). This can also be performed with the patient actively extending the knee (AKE method). The popliteal angle is the angle from the tibia to the femur. Gajdosik and Lusin 1983
Intrarater reliability: 0.99
Reliability of single examiner using AKE method in 15 healthy subjects during 2 sessions
Sullivan et al. 1992
Intrarater reliability: 0.99
Interrater reliability: 0.93
Reliability of 2 examiners using the AKE method before and after stretching while examining 12 subjects
Davis et al. 2008
Intrarater reliability: 0.94
Reliability and correlation of PKE, sacral angle, SLR, and sit and reach in test-retest design assessing 81 college-age subjects
Atamaz et al. 2011
Intrarater reliability: 0.68–0.73
Interrater reliability: 0.61–0.79
Reliability of 2 examiners using PKE method to assess 66 healthy subjects in a test-retest design
Hamid et al. 2013
Intrarater reliability: 0.75–0.97
Interrater reliability: 0.81–0.87
Reliability of a sports physician and therapists examining 16 healthy subjects using the AKE method in a test-retest design
Reurink et al. 2013
AKE method
Interrater reliability: 0.89 injured; 0.76 uninjured knee
PKE method
Interrater reliability: 0.77 injured; 0.69 uninjured knee
Reliability of 2 examiners using the AKE and PKE methods and an inclinometer in assessing 50 athletes with an acute hamstring injury confirmed by MRI
Trendelenburg test The patient is observed standing on one limb. The test result is felt to be positive if the pelvis on the opposite side drops. A positive Trendelenburg test result is suggestive of a weak gluteus muscle or an unstable hip on the affected side. Bird 2001
Sensitivity: 72.7%
Specificity: 76.9%
Intrarater reliability: 0.676 (95% CI; 0.270–1.08)
Twenty-four women with GTPS examined in both standing and ambulation, compared to MRI finding of gluteus medius tear
Altman 2001
Sensitivity: 37%
Specificity: 81%
Two hundred twenty-seven consecutive patients with clinical plus radiographic diagnosis of hip OA, compared with control group without hip OA. Intraobserver κ: 0.676 (95% CI; 0.270–1.08); 24 women underwent MRI for gluteus medius tear
Burnett et al. 2006
Sensitivity: 38%
Retrospective review of clinical findings in 66 consecutive patients with arthroscopically confirmed labral tear
Woodley 2008
Sensitivity: 23%
Specificity: 94%
+LR: 3.64
−LR: 0.82
Cross-sectional study of 40 patients with with GTPS, clinical findings compared with MRI
Lequesne 2008
Sensitivity: 100%
Specificity: 97%
Prospecitve study of 17 patients with GTPS, compared with MRI using sustained or fatigue
Trendelenburg test
Clohisy et al. 2009
Sensitivity: 33%
Prospective evaluation of 51 patients with symptomatic FAI
Youdas et al. 2010
Sensitivity: 55%
Specificity: 70%
+LR: 1.83
Intrarater reliability: 0.63–0.69
20 patients with hip OA, and 20 healthy adults examined by 2 therapists using a goniometer over the ASIS and the axis of the femur

ASIS, Anterior superior iliac spines; CI, confidence interval; CP, cerebral palsy; FAI, femoroacetabular impingement; GTPS, greater trochanteric pain syndrome ; LR, likelihood ratio; MRI, magnetic resonance imaging; OA, osteoarthritis; OR, odds ratio; PT, physical therapist; SLR, straight-leg raise.



Having undressed the patient and laid him on his back upon a table or other hard plane surface, the surgeon takes the sound limb and flexes it, so that the sound knee joint is in contact with the chest. Thus he makes certain that the spine and back of the pelvis are lying flat on the table; an assistant maintains the sound limb in this fixed position; the patient is then urged to extend, as far as he is able, the diseased limb, and this he will be able to do in a degree varying with the previous duration of the infection. … By noticing the amount of flexion, the surgeon will, with practice, soon be able to guess the previous duration of the disease.


Since Thomas’s original description, this test has become a common method of assessing fixed flexion deformities of the hip. Several modified versions of this test have been described in an attempt to isolate the hip joint and account for the impact of lumbar lordosis and/or pelvic tilt on motion at the hip. In 1936, Cave and Roberts described a variant of the original Thomas test that is similar to the current description. In this method, the patient is positioned supine with the involved leg flat against the table and the uninvolved leg maximally flexed bringing the knee to the chest to flatten out any lumbar lordosis. If a contracture is present, the involved leg will rise off the table, and the angle of contracture can be measured ( Fig. 8.1 ).




Figure 8.1


A, Normal Thomas test result. B, Iliopsoas tightness demonstrated by Thomas test.




The lack of a “gold standard” for measuring hip flexion makes validating the Thomas test challenging, but a number of subjects have assessed the reliability of the Thomas test. In children with spastic cerebral palsy (CP), most studies have shown an excellent intrarater reliability with an intraclass coefficient (ICC) value of more than 0.80, although not all studies have shown such a high intrarater reliability. The interrater reliability has been fair in most, but not all, studies.


Modified Thomas Test


In 1978, Ashton and colleagues described a variation of the Thomas test in which the patient is positioned at the end of the examination table, the uninvolved leg is flexed to flatten the lordotic curve, and the involved leg is extended ( Fig. 8.2 ). In this study, therapists examined 4 children with spastic CP and found this method to lack interrater and intrarater reliability.




Figure 8.2


Normal Modified Thomas test.


Harvey used this “modified Thomas test” to assess the flexibility of the iliopsoas, as well as the quadriceps and tensor fascia lata (TFL)/iliotibial (IT) band, in 117 elite athletes. Harvey performed the modified Thomas test in the following manner:



[T]he subject sat on the end of the plinth, rolled back onto the plinth, and held both knees to the chest. This ensured that the lumbar spine was flat on the plinth and the pelvis was in posterior rotation. The subject held the contralateral hip in maximal flexion with the arms, while the tested limb was lowered towards the floor.


The mean angle of hip extension, reflecting the flexibility of the iliopsoas, was −11.9 degrees, and the intrarater reliability was excellent (ICC = 0.91). Eland and associates advocated stabilizing the pelvis and eliminating any regional motion by applying “enough pressure to maintain the position of the [anterior superior iliac spine] during extension.” This counterbalances the weight and leverage of the lower extremity and prevents anterior rotation of the innominate bone during the test.


A number of studies have examined the reliability of the modified Thomas test in healthy subjects. Clapis and colleagues examined 42 asymptomatic subjects and found a high interrater and intrarater reliability using both an inclinometer and goniometer (r = 0.86 to 0.93; ICC = 0.86 to 0.92; r = 0.089 to 0.92; ICC = 0.91 to 0.93). Cejudo and coworkers also found the modified Thomas test to be highly reliable when examining 60 futsal and 30 handball players (intersession reliability of 0.87 to 0.91). Wakefield and coworkers examined 22 asymptomatic college students using a protocol similar to Clapis and associates and compared measurements using a tape measure and trigonometric principles. In Wakefield’s study, the reliability of the goniometric measurements was low (intrarater ICC = 0.51 to 0.54; interrater ICC = 0.30 to 0.65; confidence interval [CI], 95%), but the reliability of the trigonometric technique was excellent (intrarater ICC = 0.90 to 0.95; interrater ICC = 0.91 to 0.94; CI, 95%).


Prone Hip Extension (Staheli Test)


In 1945, West advocated measuring hip extension with the patient in a prone position on the examination table to “stabilize the torso.” In the original description, the axis of the goniometer was centered over the greater trochanter, with the reference arm placed along the midaxillary line and the movable arm along the lateral midline of the femur. Moore reported a similar method with the patient either in a prone or side-lying position.


Staheli presented the “prone hip extension test,” with the patient in a prone position with both hips comfortably flexed over the end of the examining table. The examiner stabilizes the noninvolved leg, places one hand on the pelvis, and gradually extends the involved thigh with the other hand ( Fig. 8.3 ). The precise point at which the pelvis begins to rise marks the end of the hip motion and the beginning of spine motion. At this point, the examiner measures the degree of hip extension. The reliability of the prone hip extension test has been fair in most studies. In Kilgour and coworkers’ study, the prone hip extension test was performed during the initial visit (intrasessional) and again in 7 days (intersessional). The intrasessional reliability was higher (spastic CP ICC = 0.78 to 0.91; control ICC = 0.80 to 0.92) than that of the intersessional reliability (spastic CP ICC = 0.55 to 0.80; control ICC = 0.04 to 0.20). Lee and associates found the prone hip extension test to have an interrater reliability ICC value of 0.198 (CI, 95%; 0.012 to 0.437) in the spastic CP group and 0.107 (CI, 95%; 0.033 to 0.294) in the control.




Figure 8.3


Prone hip extension.


Thurston proposed a similar prone method but differed in the initial positioning of the patient. In Thurston’s method, instead of positioning the legs over the end of the examination table, the affected leg is positioned off the side of the table. Similar to Staheli’s description, the examiner steadies the pelvis, extends the affected leg until the pelvis begins to move, and then measures the angle of fixed flexion deformity. Thurston compared this new method with the Thomas test, and the degree of flexion contracture and variability in measurements was consistently larger using the Thomas tests compared with Thurston’s method, 5 to 20 degrees and 0.5 to 4.5 degrees, respectively.


Measurements of the Pelvifemoral Angle


In 1942, Milch argued that lumbar and pelvic rotation compromised the validity of the Thomas test and “merely determines the amount of hip extension possible at any given degree of pelvic flexion. Since [pelvic rotation] cannot be fixed as a standard of reference, the whole procedure loses its validity.” As an alternative, Milch proposed using the pelvifemoral angle to measure hip extension. In this test, the patient is placed in a side-lying position, and the examiner passively extends the involved upper hip. Milch’s pelvifemoral angle is formed by the Nelaton line, a line between the ASIS and ischial tuberosity, and the axis of the extended femur ( Fig. 8.4A ).




Figure 8.4


Measurements of the pelvifemoral angle. A, Milch angle. B, Mundale angle.

(Reproduced with permission from Bartlett MD, Wolf LS, Shurtleff DB, et al. Hip flexion contractures: a comparison of measurement methods. Arch Phys Med Rehabil. 1985;66:620-625.)




Mundale and others described another method for measuring the pelvifemoral angle. In the original article, the authors argued that this method better took into account the position of the innominate bone. To establish the position of the innominate bone, the ASIS and posterior superior iliac spines are used as fixed landmarks. A perpendicular line is drawn from the line connecting the iliac spines, through the greater trochanter. The Mundale pelvifemoral angle is measured between the perpendicular line and a line along the axis of the extended femur ( Fig. 8.4B ).


The reliability of the aforementioned methods to assess hip flexor flexibility (Thomas test, Staheli’s prone hip extension test, and both Mundale’s and Milch’s pelvifemoral angle measurements) were evaluated by Bartlett and associates. In this study, two therapists examined 45 children aged 4 to 19 years (15 with CP and spastic diplegia, 15 with meningomyelocele, and 15 healthy children). In the cohort of patients with meningomyelocele, the Thomas test had the smallest mean intrarater difference (6.4 degrees, r = 0.90), and the Mundale had the largest (10.9 degrees, r = 0.79). For the cohort of CP patients, the prone hip extension test had the largest variability of intrarater difference (9.6 degrees, r = 80) and the Mundale method the lowest (7.1 degrees, r = 0.84). When all four tests were compared in the CP group, there was no significant difference in the reliability of the techniques. In the healthy group, the prone hip extension and Thomas test had the smallest intrarater difference (2.1 degrees and 1.9 degrees, respectively) compared with the Mundale and Milch methods (7.1 degrees and 7.8 degrees, respectively), which required identifying multiple bony landmarks. The authors concluded that no single measurement technique was superior in all cases.


Ely Tests and Rectus Femoris Contracture Test ( , )


Although the original description of the Ely test could not be found, several sources have described the Ely test as a method to assess flexibility of the rectus femoris muscle. In the Ely test, the patient lies prone. The examiner passively flexes the patient’s knee, and if the ipsilateral hip spontaneously flexes, the test result is considered positive, indicating that the rectus femoris muscle is tight ( Fig. 8.5 ). Both sides should be tested and compared.




Figure 8.5


Normal Ely test result.


The reliability of Ely’s test was examined by Peeler and Anderson. In this study, 54 healthy subjects were examined by three therapists during two distinct sessions, and the Ely test demonstrated only moderate levels of intrarater and interrater reliability (ICC = 0.69 and 0.66, respectively). In Atamaz and associates’ study, two examiners examined 66 healthy subjects in a test-retest design, and the interrater and intrarater reliability ranged from an ICC = 0.75 to 0.87 and 0.84 to 0.91, respectively.


A different test used to identify tightness of the rectus femoris muscle is the rectus femoris contracture test. This test is also referred to as the modified Thomas test in the literature because the positioning is the same as that used to measure iliopsoas flexibility (see Fig. 8.2 ). Magee describes the test in the following manner :



The patient lies supine with the knees bent over the end or edge of the examining table. The patient flexes one knee onto the chest and holds it. The angle of the test knee should remain at 90 degrees when the opposite knee is flexed to the chest. If it does not (i.e., the test knee extends slightly), a contracture is probably present. The examiner may attempt to passively flex the knee to see whether it will remain at 90 degrees of its own volition. The examiner should always palpate for muscle tightness when doing any contracture test. If there is no palpable tightness, the probable cause of restriction is tight joint structures (e.g., the capsule). The two sides should be tested and compared.


Ferber and colleagues presented normative values for rectus femoris flexibility using the rectus femoris contracture test. The average inclinometer angle was −10.6 degrees ±9.6 degrees (−9.5 to 11.7 degrees, 95% CI). When declared a negative test result by the examiner, the average angle was −15.5 degrees ±5.8 degrees, and when declared a positive test result, the average angle was −0.3 degrees ±7.0 degrees.


In Harvey’s study, the flexibility of three muscles (iliopsoas, TFL/IT band, and quadriceps) were assessed. A total of 117 elite athletes were examined while in the modified Thomas test position, and the intrarater reliability of two measurements of passive quadriceps length was excellent (ICC = 0.94). Peeler and Anderson evaluated the reliability of the rectus femoris contracture test in a test-retest design. Fifty-seven healthy subjects were examined by three therapists during two sessions 7 to 10 days apart. The interrater and intrarater reliability was modest (ICC = 0.5 and 0.67, respectively). In 2013, Peeler and Leiter presented another study assessing the flexibility of the rectus femoris in 28 active university students. The subjects were photographed while being evaluated by a therapist, and 10 examiners then used the digital photographs to score the degree of rectus femoris flexibility. The interrater and intrarater reliability of the measurements from the digital photographs was excellent (0.97 and 0.98, respectively).


Ober Test ( )


In 1936, Frank R. Ober, an American orthopedic surgeon, described the role of the IT band and TFL as a source of sciatica after observing that certain patients experienced relief of their pain after surgical release of the fascia. Ober surmised “that the relief of symptoms in these cases might be due to releasing the fascial pull exerted through the fascia lata and its attachments to the gluteus maximus muscle.” Ober described a method of identifying tightness of the TFL and IT band, as follows :



The patient lies on his side, with the thigh next to the table and flexed enough to obliterate any lumbar lordosis. The upper leg is flexed at a right angle at the knee. The examiner grasps the ankle lightly with one hand and steadies the patient’s hip with the other. The upper leg is abducted widely and extended so that the thigh is in line with the body. If there is any abduction contracture, the leg will remain more or less passively abducted, depending upon the shortening of the iliotibial band. This band can be easily felt with the examining fingers between the crest of the ilium and the anterior aspect of the trochanter. ( Fig. 8.6 , )



Figure 8.6


Ober test.


In the original article, Ober described flexing the involved knee 90 degrees, abducting and extending the hip, and then allowing the force of gravity to bring the leg into adduction. Ferber and associates presented normative values for IT band flexibility using the Ober test. The average inclinometer angle was −24.6 degrees ±7.3 degrees (−23.8 to 25.4 degrees, 95% CI), and when the examiner declared the test result as negative, the average angle was −27.1 degrees ±5.5°, and when the test result was positive, the average angle was −16.3 degrees ±6.9 degrees.


Kendall described a similar test but with the knee fully extended to 0 degrees as opposed to flexed as originally described. This variation has come to be known as the modified Ober test. In a study by Melchione and Sullivan, two therapists examined 10 subjects with anterior knee pain using the modified Ober test in a test-retest study design and reported an intrarater and interrater reliability ICC of 0.94 and 0.73, respectively.


Reese and Bandy and Gajdosik and coworkers examined the reliability of both the Ober test and the modified Ober test and did not find a significant difference between the reliability of the two tests. In a study by Reese and Bandy, 61 subjects were examined by one therapist using an inclinometer in a test-retest design, and the ICC values for intrarater reliability were 0.90 for the Ober test and 0.91 for the modified Ober test. In a study by Gajdosik and associates, three measurements were taken while examining 49 subjects without lower extremity symptoms during a single session. The ICC values for intrarater reliability ranged from 0.83 to 0.87 for the Ober test and 0.82 to 0.92 for the modified Ober test.


Piriformis Tests ( )


In 1928, Yeoman published the first reference to the piriformis muscle as a source of sciatic pain. Usually the sciatic nerve emerges from the pelvis through the greater sciatic foramen and passes beneath the piriformis muscle. In a subset of patients, the piriformis muscle or sciatic nerve splits, altering the “normal” relationship. The various relationships between the piriformis muscle and sciatic nerve were first described in 1896 in the English literature by Parsons and Keith and include (1) the sciatic nerve passing above or below the piriformis muscle, (2) the sciatic nerve splitting and passing around the muscle, or (3) the piriformis muscle splitting to surround the nerve.


Provocative tests for piriformis syndrome elicit symptoms by compressing the sciatic nerve beneath the piriformis muscle, and over the years, a number of tests have been described to assess for piriformis syndrome. While the piriformis muscle is an external rotator, in flexion, the piriformis tendon becomes an abductor. Therefore, tests for intra-articular hip pathology that place the hip in flexion–adduction–internal rotation may also stretch the piriformis and provoke symptoms in cases of piriformis syndrome.


The historic lack of a “gold standard” to compare the diagnostic accuracy of these clinical tests has led to a lack of literature on the sensitivity and specificity of piriformis provocative tests. Martin and associates conducted the only currently available study that has studied the validity of provocative maneuvers for piriformis syndrome. In this retrospective study, the accuracy of the straight-leg raise (SLR), active piriformis test, and seated piriformis stretch were assessed in 33 patients and compared with endoscopic findings of sciatic nerve entrapment. The specific results for each test are described subsequently. Combing the active piriformis test and seated piriformis stretch test resulted in a sensitivity of 0.91, specificity of 0.80, positive likelihood ratio (+LR) of 4.57, −LR of 0.11, and diagnostic odds ratio of 42.00.


Active Piriformis Test (Pace Test)


Albert H. Freiberg is often credited with publishing the first description of piriformis syndrome provocative maneuvers. Freiberg found that sciatic pain could be attributed to piriformis syndrome if (1) the SLR test result was positive, (2) if there was marked tenderness at the sciatic notch, or (3) if internal rotation of an extended hip reproduced symptoms. The Freiberg test was initially described in 1934 as follows :



Clinical evidence of [piriformis] spasm has been found in the presence of limitation of motion in inward rotation of the thigh, if looked for with the patient’s hip joints fully extended but not hyperextended.


A variation of the Freiberg test has been described that places the hip into flexion, adduction, and internal rotation, putting tension on the deep rotators and compressing the sciatic nerve.


The Pace test is a variation of the Freiberg test and involves flexion, adduction, and internal rotation of the hip. This test was first described by Pace and Nagle in 1976 as follows :



A more consistent finding in piriformis syndrome is that of pain and weakness on resisted abduction-external rotation of the thigh … With the patient seated, the examiner places his hands on the lateral aspects of the knees and asks the patient to push the hands apart.


Pain and weakness with resisted abduction and external rotation of the hip is a positive test result. In one study, the active piriformis test has a sensitivity of 0.78, specificity of 0.80, +LR 3.90, −LR 0.27, and odds ratio of 14.4 for sciatic nerve entrapment.


A variant of the Pace test has been described with the patient in a side-lying position. In this test, the patient lies on the nonaffected side, and the involved knee is flexed with the foot on the table behind the nonaffected knee. The patient is instructed to push the involved heel down into the table, thus actively abducting and externally rotating the involved leg while the examiner provides resistance.


Passive Piriformis Stretch Test


A passive piriformis stretch test has also been described and can be performed with the patient in a side-lying or seated position. Magee described the side-lying test ( Fig. 8.7 ) as follows :




Figure 8.7


Piriformis test.



[The patient is placed] in the side-lying position with the non-test leg against the table. The patient flexes the test hip to 60 degrees with the knee flexed, while the examiner applies a downward pressure to the knee. Pain is elicited in the muscle if the piriformis muscle is tight. Radiation of pain down the leg will occur if the substance of the piriformis muscle compromises the sciatic nerve.


In the seated version, also known as the seated piriformis stretch test, the patient is sitting with the hip in 90 degrees of flexion. While palpating the sciatic notch, the examiner extends the knee and passively adducts and internally rotates the hip, stretching the piriformis muscle. In a positive test result, the patient reports reproduction of the posterior gluteal and leg pain. Martin and colleagues used the seated version in studying the validity of passive stretch for identifying patients with sciatic nerve entrapment. In this study, the seated piriformis stretch test had a sensitivity of 0.52, specificity of 0.90, +LR 5.22, −LR 0.53, and odds ratio of 9.82.


Straight-Leg Raise (Lasègue’s Sign)


Freiberg hypothesized that pain during an SLR ( Fig. 8.8 ), or Lasègue’s sign, was due to the close relationship between the neurovascular bundle and piriformis muscle. While many authors attributed the positive SLR to stretching of the sciatic nerve, cadaveric studies have shown the sciatic nerve experiences a proximal excursion of 28 mm when the hip is flexed. Abnormal contraction of the piriformis muscle or adhesions between the piriformis and nerve may limit the ability of the sciatic nerve to glide or stretch and provoke sciatic pain. Martin and coworkers reported that the SLR had a sensitivity of 0.15, specificity of 0.95, +LR 3.20, −LR 0.90, and odds ratio of 3.59 for an endoscopic finding of sciatic nerve entrapment. While not always positive in cases of piriformis syndrome, Martin and colleagues still recommended using this test clinically to alert the examiner to the presence of radicular pain.




Figure 8.8


Straight-leg raise.


Popliteal Angle or Knee Extension Angle ( )


The popliteal angle has been used in the pediatric literature as an indirect measurement of hamstring flexibility. In 1966, Koenigsberger was the first to use the terminology “popliteal angle” when measuring knee extension in premature infants. Since muscle tone increases longitudinally as the neurologic system develops, the popliteal angle can be used to help estimate cerebral maturation and thus gestational age when unknown. In addition to gestational age, hamstring hypertonicity in an infant can alert the clinician to potential neuromuscular pathology, such as CP. In one study of 1843 infants, a popliteal angle of less than 100 degrees had a sensitivity of 51% and a specificity of 92% in identifying children who will go on to be diagnosed with CP.


A variety of methods have been proposed to measure the popliteal angle, but many descriptions are vague and fail to describe the exact position of the hip or contralateral limb. In 1979, Bleck described a method of measuring the popliteal angle which is commonly used today ( Fig. 8.9 ). According to Bleck :




Figure 8.9


Popliteal angle measurement.



… the popliteal angle is measured with the patient supine and the hip flexed 90 degrees. The examiner attempts to extend the knee until firm resistance is met while the hip is maintained at 90 degrees. The popliteal angle is the acute angle between the lower leg and an imaginary line extending up from the flexed femur.


The angle measured by Bleck has also been named the knee extension angle and differed from earlier descriptions of the popliteal angle, which measured the angle at the popliteal fossa. The popliteal and knee extension angles are complementary, and their sum is 180 degrees. Variations of Bleck’s method involve placing the hip in full flexion instead of 90 degrees. Authors also differ in whether the noninvolved hip should be in full extension or flexed until lumbar lordosis is relieved. In addition to differences in positioning, articles differ in whether the knee extension should be active (AKE) or passive (PKE).


A number of other clinical tests with comparable intrarater reliability have been used to measure hamstring muscle flexibility (sacral angle [SA], SLR, sit and reach test [SR]), but these methods have potentially confounding variables. These variables include inconsistencies in pelvic positioning, limitations due to neural stretch, and tightness of the hip joint capsule or contralateral hip flexors and have made some suggest the popliteal angle as the gold standard measurement for assessing hamstring length.


In Davis and coworkers study, four investigators took three measurements of hamstring length in 81 college-age subjects using the PKE and three other hamstring examination techniques (SA, SLR, SR) in a test-retest design with 1 week between the two tests. There was excellent intrarater reliability for the PKE (ICC = 0.94) and the other three tests, but among the 4 tests, there was poor to fair correlation (Pearson’s correlation coefficient, r = 0.45 to 0.65). Atamaz and coworkers presented 66 healthy subjects evaluated by two examiners using the PKE test in a test-retest design. There was good to very good interrater and intrarater reliability with and ICC ranging from 0.68 to 0.73 and 0.61 to 0.79, respectively.


In 1982, Gajdosik and Lusin investigated the intrarater reliability of the AKE test in 15 healthy subjects during two testing sessions and found excellent reliability with a Pearson correlation coefficient of r = 0.99. Sullivan and coworkers used the AKE method when assessing the results of two different hamstring stretching techniques. Two examiners examined 12 subjects before and after the stretching session, and the ICC values for interrater and intrarater reliability were 0.93 and 0.99, respectively. Hamid and colleagues examined the reliability of the AKE method. In this study, a sports physician and therapists evaluated 16 healthy subjects; each angle was measured twice, and all subjects were measured at two different sessions. The interrater and intrarater reliability ICC values ranged from 0.81 to 0.87 and 0.75 to 0.97. Reurink and associates evaluated the reliability of the AKE and PKE tests in examining 50 consecutive athletes with an acute hamstring injury confirmed by magnetic resonance imaging (MRI). Two testers (out of a pool of eight clinicians) used an inclinometer to examine each subject during a single session, and the intertester reliability ICCs for the AKE test were 0.89 and 0.76 for the injured and uninjured leg, respectively. For the PKE test, the intertester reliability ICCs were 0.77 and 0.69, respectively.


Trendelenburg Sign or Test


Friedrich Trendelenburg originally described the Trendelenburg test in 1895 to explain the waddling gait pattern of children with developmental dysplasia of the hip and progressive muscular atrophy :



The pelvis hangs down on the swinging side, and the upper part of the body leans far over to the standing side to restore balance. From what has been said, the cause of the pelvis hanging down can only be that the abductors of the standing leg cannot keep the pelvis horizontal.


While initially described as an assessment of abductor function during gait, the Trendelenburg test now is often performed by instructing the patient to stand on the affected leg, while the examiner assesses pelvic movement. Contraction of the hip abductors during single-leg stance should prevent a downward tilting of the contralateral pelvis, but in a positive Trendelenburg test, the pelvis drops suggesting gluteus medius or minimus weakness ( Fig. 8.10 ).




Figure 8.10


Trendelenburg sign.

(Adapted with permission from Goldstein B, Chavez F. Applied anatomy of the lower extremities. Phys Med Rehabil State Art Rev. 1996;10:601-630.)


There is some evidence that the nonstance leg should be flexed to 30 degrees while maintaining single-leg posture. In one study, when hip flexion was to 90 degrees, the authors found a higher rate of false-negative test results compared with 30 degrees of flexion. The authors hypothesized that at 90 degrees, there is increased pelvic rotation that elevates the iliac crest or results in contraction of the latissimus dorsi, psoas major, or quadratus lumborum to stabilize the pelvis.


While various methods for performing the Trendelenburg test have been described in textbooks, only a few studies have looked at the validity of the Trendelenburg test. The Trendelenburg test has been studied as a clinical test to identify patients with intra-articular hip pathology, but it lacks sensitivity. In two studies of patients with early hip osteoarthritis (OA), the Trendelenburg test had a sensitivity of 0.37 to 0.55, specificity of 0.70 to 0.81, and +LR of 1.83. As a tool to identify patients with femoroacetabular impingement or labral pathology, the Trendelenburg test also lacked sensitivity (0.33 to 0.38 in two uncontrolled studies.)


The reliability and validity of the Trendelenburg test is better for greater trochanteric pain syndrome (GTPS). The gluteus medius is the primary pelvic stabilizer and is commonly implicated as a source of pain or weakness in GTPS. In 2001, Bird and colleagues examined 24 women with clinical evidence of GTPS using the Trendelenburg test with the patient standing and while walking. For this study, the pelvic tilt was only regarded as abnormal if the tilt was seen in both standing and with ambulation, and clinical findings were compared with MRI findings (partial or complete gluteus medius tear). The Trendelenburg test had a sensitivity of 0.73, specificity of 0.77, and intraobserver kappa score (κ) of 0.676 (95% CI; 0.270 to 1.08). Woodley and associates assessed the validity of the Trendelenburg test in a prospective cross-sectional study of 40 patients with lateral hip pain. Unlike Bird and others’ study, this study only looked at the results of a standing Trendelenburg test. Clinical findings were compared with MRI findings, and the Trendelenburg test had a sensitivity of 0.23, specificity of 0.94, +LR of 3.64, and −LR of 0.82 (95% CI) in predicting gluteal tendon pathology.


In 2008, Lequesne and associates tested the validity of the sustained single-leg stance test, or “fatigue” Trendelenburg test in which the patient holds the single-leg stance for 30 seconds. The sustained single-leg stance test was first described by Hardcastle and Nade in 1985. Although performed the same way, the Trendelenburg test result is positive if the pelvis drops, and the “fatigue” Trendelenburg test result is positive if it reproduces lateral hip pain. Lequesne and colleagues found a sensitivity and specificity of 1.0 and 0.97, respectively.


Resisted Internal Rotation of the Thigh (Resisted External Derotation)


In GTPS, reproduction of pain can also be provoked at the extremes of rotation by stretching the gluteus medius and minimus tendons or with resisted hip abduction. External rotation has long been recognized to elicit pain in cases of GTPS. In 1961, Gordon presented a series of 61 cases of clinical trochanteric bursitis and tendinopathy. Gordon found that external rotation and abduction, as achieved with the FABER maneuver, elicited pain in 35 of the patients. In 2001, Bird and coworkers reported that resisted internal rotation (active external rotation) had a sensitivity and specificity of 0.55 and 0.69 for GTPS, respectively. In this study, the leg was in neutral rotation, not in a position of extreme rotation.


In 2008, Lequesne and coworkers described a similar maneuver that placed the hip in extreme external rotation ( Fig. 8.11 ) to maximize the stretching of the gluteus medius and minimus tendons:


Jul 23, 2019 | Posted by in MUSCULOSKELETAL MEDICINE | Comments Off on Physical Examination of the Pelvis and Hip
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