adult hip evaluation

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The Pattern and Technique in the Clinical Evaluation of the

Adult Hip: The Common Physical Examination Tests of

Hip Specialists

Hal D. Martin, D.O., Bryan T. Kelly, M.D., Michael Leunig, M.D., Marc J. Philippon, M.D.,John C. Clohisy, M.D., RobRoy L. Martin, Ph.D., P.T., C.S.C.S., Jon K. Sekiya, M.D.,

Ricardo Pietrobon, M.D., Ph.D., Nicholas G. Mohtadi, M.D., Thomas G. Sampson, M.D.,and Marc R. Safran, M.D.

Purpose: The purpose of this study was to systematically evaluate the technique and tests usedin the physical examination of the adult hip performed by multiple clinicians who regularly treatpatients with hip problems and identify common physical examination patterns. Methods: Thesubjects included 5 men and 6 women with a mean age (SD) of 29.8 9.4 years. Theyunderwent physical examination of the hip by 6 hip specialists with a strong interest inhip-related problems. All examiners were blind to patient radiographs and diagnoses. Patientexaminations were video recorded and reviewed. Results: It was determined that 18 tests weremost frequently performed (40%) by the examiners, 3 standing, 11 supine, 3 lateral, and 1prone. Of the most frequently performed tests, 10 were performed more than 50% of the time.The tests performed in the supine position were as follows: flexion range of motion (ROM)(percentage of use, 98%), flexion internal rotation ROM (98%), flexion external rotation ROM(86%), passive supine rotation test (76%), flexion/adduction/internal rotation test (70%), straightleg raise against resistance test (61%), and flexion/abduction/external rotation test (52%). Thetests performed in the standing position were the gait test (86%) and the single-leg stance phasetest (77%). The 1 test in the prone position was the femoral anteversion test (58%). Conclusions:There are variations in the testing that hip specialists perform to examine and evaluate theirpatients, but there is enough commonality to form the basis to recommend a battery of physicalexamination maneuvers that should be considered for use in evaluating the hip. ClinicalRelevance: Patients presenting with groin, abdominal, back, and/or hip pain need to have a basicexamination to ensure that the hip is not overlooked. A comprehensive physical examination ofthe hip will benefit the patient and the physician and serve as the foundation for futuremulticenter clinical studies.

From the Oklahoma Sports Science & Orthopaedics (H.D.M.), Oklahoma City, Oklahoma, U.S.A.; Hospital for Special Surgery (B.T.K.),New York, New York, U.S.A.; Schulthess Clinic (M.L.), Zrich, Switzerland; Steadman-Hawkins Research Foundation (M.J.P.), Vail,Colorado, U.S.A.; Washington University (J.C.C.), St Louis, Missouri, U.S.A.; Center for Rehab Services/University of Pittsburgh MedicalCenter and Duquesne University (R.L.M.), Pittsburgh, Pennsylvania, U.S.A.; MedSportDepartment of Orthopaedic Surgery, University of

Michigan (J.K.S.), Ann Arbor, Michigan, U.S.A.; Department of Surgery, Duke University Medical Center (R.P.), Durham, North Carolina,U.S.A.; University of Calgary (N.G.M.), Calgary, Alberta, Canada; Post Street Surgery Center and Total Joint Center at St Francis MemorialHospital (T.G.S.), San Francisco, California, U.S.A.; and Stanford University (M.R.S.), Stanford, California, U.S.A.

The authors report no conflict of interest.Received January 7, 2009; accepted July 9, 2009.Address correspondence and reprint requests to Hal D. Martin, D.O., Oklahoma Sports Science & Orthopaedics, 6205 N Santa Fe, Ste

200, Oklahoma City, OK 73118, U.S.A. E-mail: [email protected] 2010 by the Arthroscopy Association of North America0749-8063/10/2602-0915$36.00/0doi:10.1016/j.arthro.2009.07.015

161Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 26, No 2 (February), 2010: pp 161-172
mailto:[email protected]:[email protected]:[email protected]


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As advances in technology aid in our understand-ing of normal and pathologic hip conditions, theclinical examination of the adult and adolescent hipcontinues to evolve. Many generations of surgeons,therapists, and physicians have developed clinical

tests designed to detect a variety of hip disorders.1-4

Anumber of diagnostic tests of the hip are used forclinical evaluation; however, there is little researchsuggesting which tests are of the greatest value to theexaminer. There have been a few reports publishedthat have recommended the most effective tests thatcould help organize the structure of the physical ex-amination of the hip in a simple, reproducible man-ner.5,6 There is no recognized hip evaluation protocolwith a systematic structure as used in evaluating other

joints such as the shoulder.7 Patients presenting withgroin, abdominal, back, and/or hip pain need to have a

basic examination to ensure that the hip is not over-looked. A comprehensive physical examination willbenefit the patient and the physician and serve as thefoundation for future multicenter clinical studies be-cause a uniform patient evaluation process will facil-itate common diagnostic strategies.

Assessment of hip pain can be quite complex, andin many cases symptoms of back pain present alongwith hip pain, which may be associated with or inde-pendent of a hip problem.8 Low-back dysfunctioncould lead to knee pain, groin pain, and/or a limitedrange of motion (ROM) in the hip.9 Likewise, con-

tracture of hip flexion or leg length discrepancies havebeen implicated as causes of both hip and low-backpain.10-14 Furthermore, pelvic and genitourinary prob-lems and symptoms may also present as hip pain.Therefore a thorough understanding of the osseous,ligamentous, and musculotendinous contribution tothe underlying pathology is essential.15,16

To establish a standardized protocol, there must beagreement within the community of hip specialistsabout which tests are considered important in theassessment of the adult and adolescent hip. An orga-nized structured physical examination, together with

an understanding of the osseous, ligamentous, andmusculotendinous contribution to the underlying pa-thology, will guide the examiner to accurate treatmentrecommendations or further diagnostic studies. Al-though an experienced hip specialist is guided byfindings during the examination, the inexperiencedexaminer would greatly benefit from a systematic andreproducible physical examination. Therefore the pur-pose of this study was to systematically evaluate thetechnique and tests used in the physical examination

of the adult hip performed by 6 orthopaedic surgeonswho regularly treat patients with hip problems andidentify common physical examination patterns.

METHODS

Study Design

Institutional review board approval was obtainedfor this study. Eleven adult subjects with hip pain, fivemen and six women (mean age, 29.8 9.4 years),volunteered for this study. All subjects read andsigned a written informed consent form before thestart of the study. In a randomized order, subjectsunderwent physical examination of the hip by 6 or-thopaedic surgeons. All examiners have a strong in-terest in hip-related problems, have clinical expertise

and experience in treating patients with hip-relatedproblems, have been in practice for 4 to 9 years, andexamine 10 to 70 patients with hip pain per week intheir daily practice. A written summary of each sub-

jects history was provided to each examiner; how-ever, all examiners were blind to patient radiographsand diagnoses. Subjects were asked to only answerspecific questions asked by the examiner and not todiscuss any procedures or information offered by pre-vious examiners. Before the start of the study, therewas no discussion of clinical tests between examin-ers and examiners were blind to the examinationsperformed by other examiners. Examiners were in-

structed to perform their examination in the samemanner that they would in their own practice. Patientexaminations were video recorded and reviewed by asingle researcher for analyses. Outcome variables in-cluded the number of clinical tests, type of clinicaltest, and number of positive tests (reproduction ofpatients pain).

Tests of Interest

The descriptions of the following tests are based onthe technique used by the clinicians in this study. For

international clarification among clinicians, each testwas given a descriptive functional title.

Standing Assessment

Gait: Gait testing is performed in a hallway so thatat least 3 to 4 stride lengths can be viewed from bothin front of and behind the patient. The clinician ob-serves gait with awareness of abnormal gait patternssuch as the abductor-deficient gait (also known as theTrendelenburg gait), antalgic gait, pelvic wink, exces-

162 H. D. MARTIN ET AL.


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sive internal or external rotation, short leg limp, andabnormal foot progression.

Single-Leg Stance Phase Test: The single-legstance phase test is similar to the traditional Tren-delenburg test. The single-leg stance phase test is an

assessment of the neural loop of proprioception of theextremity and function of the abductors to hold thepelvis in a balanced position by simulating the single-leg stance phase with load on the hip. The patientstands with the feet shoulder width apart and then liftsthe unaffected leg forward to 45 of hip flexion and45 of knee flexion and holds this position for 6seconds. The single-leg stance phase test is performedon both sides for comparison. A positive test is apelvic shift or a decrease of more than 2 cm.17

Laxity: Observation of increased ROM in otherjoints such as the thumb to forearm and hyperextensionat the elbow and knee is performed to assess laxity.

Supine Assessment

ROM Testing: ROM testing is a critical test todetermine both osseous and ligamentous functions.Internal and external rotation ROM is performed pas-sively in a supine or seated position (Fig 1), with thehip flexed at 90. The seated position ensures that theischium is square to the table, thus providing sufficientstability at 90 of hip flexion and a reproducible plat-form for accurate rotational measurement. It is alsohelpful to determine the internal/external rotation withthe hip extended, performed in a prone position. The

extent of osseous versus ligamentous contribution can

be determined by differentiation in both the flexed andextended positions. The flexed position releases themedial and lateral arms of the iliofemoral ligament;however, the dominate control for internal rotation, bothin extension and in flexion, is the ischiofemoral liga-

ment.15 ROM is dictated by a firm endpoint or by patientpain. Preoperative ROM can be compared with intraop-erative ROM.

Dynamic External Rotatory Impingement Test: Thedynamic external rotatory impingement test (DEXRIT) issimilar to the traditional McCarthys test, in which a posi-tive test is associated with the detection of a pop duringthe maneuver.18,19 In the supine position the patient isinstructed to hold the contralateral leg in flexion be-yond 90, thus establishing a zero set point of thepelvis by eliminating lumbar lordosis. The examinedhip is then brought into 90 of flexion or beyond and

is passively taken through a wide arc of abduction andexternal rotation (Figs 2A-C). A positive test is notedwith re-creation of the patients pain. The DEXRITcan be performed in the operating theater for directvisualization of femoral neck and acetabularcongruence.

Dynamic Internal Rotatory Impingement Test:

The dynamic internal rotatory impingement test issimilar to the traditional McCarthys test, in which apositive test is associated with the detection of a popduring the maneuver.18,19 As with the DEXRIT, elim-ination of lumbar lordosis and a zero pelvic set point

is achieved by the patient holding the contralateral leg inflexion beyond 90 while in the supine position. Theexamined hip is then brought into 90 of flexion orbeyond and is passively taken through a wide arc ofadduction and internal rotation (Figs 2D-F). A positivetest is noted with re-creation of the patients pain. Thedynamic internal rotatory impingement test can also beperformed in the operating theater for direct visualizationof femoral neck and acetabular congruence.

Palpation: Palpation is always performed duringevery hip examination. The patient is asked to locateor point to the site of pain, and the examiner palpates

the area to assess the osseous and musculotendinouslocations. Additional areas of interest for palpationinclude the abdomen, supra-sacroiliac joint, sciaticnotch, anterior-superior iliac spine, greater trochanter,ischial tuberosity, gluteus maximus insertion, and piri-formis tendon.4

Flexion/Abduction/External Rotation: The flex-ion/abduction/external rotation (FABER) test is his-torically known as the Patrick test, designed to differ-entiate between lumbar sacroiliac and posterior hip

FIGURE 1. Internal rotation ROM testing in seated position. Withthe patient in the seated position, the examiner passively brings thehip into internal rotation until a firm endpoint is achieved or thepatients pain is reproduced.

163CLINICAL EVALUATION OF ADULT HIP


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pain by specifically locating the area of reproducedpain.4,20 The examiner brings the leg into 45 offlexion and externally rotates and abducts the leg sothat the ipsilateral ankle rests proximal to the knee ofthe contralateral leg.4 Passive abduction ROM of the

flexed leg is noted and compared side to side. Poste-rior pain is localized to indicate lumbar, sacroiliac

joint, or posterior hip pathology. Of distinction fromother tests of FABER is the pelvic set point andflexion angle. With the contralateral leg in extension,

FIGURE 2. (A) DEXRIT. Pa-tient positioning is supine withthe contralateral hip held in

flexion by the patient. The ex-aminer begins with the affectedhip in flexion, slight adduction,and neutral rotation. (B, C) Theexaminer passively brings the af-fected hip through a wide arc ofabduction and external rotation.(D) Dynamic internal rotatoryimpingement (DIRI) test. Patientpositioning is supine with thecontralateral hip held in flexionby the patient. (E, F) The exam-iner passively brings the affectedhip into flexion and through awide arc of adduction and inter-nal rotation.



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the hip is at a normal dynamic pelvic inclination andthe hip flexion angle is 45 or less.

Straight Leg Raise Against Resistance: Histori-cally, the straight leg raise against resistance test isalso known as the Stinchfield test.4 The patient per-forms an active straight leg raise to 45; the examin-ers hand is then placed proximal to the knee whileapplying downward force. The straight leg raise

against resistance test is an assessment of hip flexor/psoas strength and is a sign of an interarticular prob-lem as the psoas places pressure on the labrum inactive resistance. A positive test is noted with re-creation of the patients pain or weakness.

Strength Testing: Muscular strength about the hipjoint including the hip abductors, adductors, flexors,and extensors is tested during the hip examination.The examiner applies a force to the leg, and the patientis instructed to resist the force. Each muscle group isgraded in the traditional fashion on a 5-point scale.These tests can be performed in a supine, seated, or

lateral position. To test the gluteus medius, the ili-otibial band must be released by flexing the knee.Passive Supine Rotation Test: Historically, the

passive supine rotation test has been known as the logroll.20 In a supine position, with the patients legsextended and relaxed on the table, each leg is sepa-rately internally and externally rotated by the exam-iner, and differences are noted in terms of guarding orlaxity. A restriction or pain may indicate interarticularor extra-articular pathology.

Posterior Rim Impingement: To assess posteriorrim impingement, the patient is positioned at the edge ofthe examination table so that the legs hang freely at thehip, and the patient draws up both legs toward the chest,thus eliminating lumbar lordosis. The affected leg is then

extended off the table, allowing for full extension of thehip, and is abducted and externally rotated (Fig 3). Theposterior rim impingement test takes the hip into exten-sion, allowing assessment of the congruence of the pos-terior acetabular wall and femoral neck. A variation ofthis test is the lateral FABER test, or lateral rim impinge-ment test, performed in the lateral position. The exam-iner cradles the patients lower leg with one arm andmonitors the hip joint with the opposing hand. Theexaminer passively brings the affected hip through awide arc from flexion to extension in continuous abduc-tion. Reproduction of the patients pain indicates a pos-itive test. The supine position with the contralateral legflexed eliminates lumbar lordosis, whereas the lateralposition is used to test the normal dynamic pelvic incli-nation. Pelvic inclination may affect testing, and bothpositions are helpful in evaluation.

Flexion/Adduction/Internal Rotation: The flex-ion/adduction/internal rotation (FADDIR) test is tradi-tionally performed in the supine position with passivemovement of the thigh into full flexion, adduction, andinternal rotation21; however, the FADDIR test can alsobe performed in the lateral position. With the patient inthe supine position, the hip is passively brought into 90of flexion, adduction, and internal rotation (Fig 4). Re-

FIGURE 3. Posterior rim impingement test. The patient is posi-

tioned at the edge of the examination table and holds the contralat-eral leg in flexion. The examiner passively brings the affected hipinto extension, abduction, and external rotation.

FIGURE 4. FADDIR test. With the patient in the supine position, theexaminer passively brings the hip into 90 of flexion, adduction, andinternal rotation. This test can also be performed in the lateral position.



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production of the patients pain indicates a positive test,and the degree of flexion and internal rotation is noted.

Lateral Assessment

Passive Adduction Tests: Passive adduction testsare historically similar to Obers test performed withthe hip in extension.4 The patient is positioned on theunaffected hip with the shoulders at 90 to the table.The examiner stands behind the patient, cradles thepatients lower leg, and assesses full passive adduc-tion of the hip using the following 3 tests (Fig 5): (1)The tensor fascia lata contracture test is performedwith the hip and knee in extension, thus placing ten-sion on the tensor fascia lata when the hip is adducted.(2) The gluteus medius contracture test is performedwith 0 of hip extension and 45 to 90 of kneeflexion, thus releasing the iliotibial band and placingtension on the gluteus medius with hip adduction. (3)The gluteus maximus contracture test is performedwith the shoulders rotated back toward the table withhip flexion and knee extension, thus placing tensionon the gluteus maximus with hip adduction. Any re-strictions of these motions are recorded. A healthypatient should be able to perform passive adduction

past the midline of the body.

Prone Assessment

Femoral Anteversion Test: The femoral antever-sion test is historically similar to Craigs test.4 Withthe patient in the prone position, the knee is flexed to90 and the examiner manually rotates the leg whilepalpating the greater trochanter. The examiner rotatesthe limb so that the lateral prominence of the greatertrochanter is felt to be maximal, thereby placing the

femoral head into the center portion of the acetabu-lum.4 Femoral anteversion/retroversion is assessed bynoting the angle between the axis of the tibia and animaginary vertical line.4 Normally, femoral antever-sion is between 8 and 15.4 If there is a significantdifference in internal rotation in the extended andseated flexed position, the examiner should differen-tiate between osseous and ligamentous causes.

Data Analysis

The physical examination tests performed by eachexaminer were recorded separately for each patient.All data are reported as mean SD. Pearson cor-relation coefficients were calculated to determinesignificant relations. The level of significance wasset at P .05.

RESULTS

All examiners began each examination by review-ing the patients written history and by asking ques-

tions regarding mechanism, time of onset of pain,location of pain, and severity of pain. The mean lengthof time spent with the patient by the examiners was6.6 minutes (range, 4.6 to 9.1 minutes). The meannumber of clinical tests performed by each examinerwas 15.6 2.5 (examiner 1), 12.5 2.6 (examiner 2),13 2.5 (examiner 3), 33.8 1.5 (examiner 4), 18.82.9 (examiner 5), and 12.4 2.5 (examiner 6). Eachexaminers routine physical examination of the hip isshown in Table 1.

FIGURE 5. Passive adduction testing. (A) The tensor fascia lata contracture test is performed with knee extension. The examiner passivelybrings the hip into extension and then adduction. (B) The gluteus medius contracture test is performed with the hip in a neutral position andthe knee in flexion, thus eliminating contribution of the iliotibial band. The examiner passively adducts the hip toward the examination table.(C) The gluteus maximus contracture test is performed with the ipsilateral shoulder rotated toward the examination table. The examined legis held in knee extension as the examiner passively brings the hip into flexion and adduction.



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It was determined that 18 tests were most frequentlyperformed (40%) by the examiners, 3 standing, 11supine, 3 lateral, and 1 prone (Fig 6). Of the tests mostfrequently performed, 10 were performed more than50% of the time. The tests performed in the supineposition were as follows: flexion ROM (percentageof use, 98%), flexion internal rotation ROM (98%),flexion external rotation ROM (86%), passive su-

pine rotation test (76%), FADDIR test (70%),straight leg raise against resistance test (61%), andFABER test (52%). The tests performed in thestanding position were the gait test (86%) and thesingle-leg stance phase test (77%). The 1 test per-formed in the prone position was the femoral ante-version test (58%).

Table 2 presents the agreement between examiners

TABLE 1. Routine Physical Examinations Performed by 6 Hip Specialists

Examiner 1

Position

Standing Gait, SLSP, single-leg squat, laxity

Supine ROM (flexion, IR, abduction), FADDIR, DIRI, FABER, SLRAR, PSR, PRI,

abdominal crunch with palpationLateral ABDEER

Prone Femoral anteversion

Examiner 2

Position

Standing Gait

Supine ROM (flexion, IR, ER), palpation, FABER, SLRAR, PSR

Lateral Palpation, tensor fascia lata contracture, gluteus medius contracture,

FADDIR

Examiner 3

Position

Standing Gait, SLSP, laxity

Supine ROM (active flexion, passive flexion, abduction, IR, ER), FADDIR,

DEXRIT, PSR, PRI

Lateral Palpation, bicycle test

Examiner 4Position

Standing Iliac height, shoulder height, gait, SLSP, spine, SI joint palpation, laxity

Seated Sensory, DTR, circulation, skin inspection, IR, ER

Supine Flexion ROM, DIRI, DEXRIT, leg lengths, palpation, hip flexor contracture,

FABER, SLRAR, PSR

Lateral Palpation, tensor fascia lata contracture, gluteus medius contracture, gluteus

maximus contracture, FADDIR, ABDEER, LRI, abductor strength

(gluteus maximus/medius)

Prone Rectus contracture, femoral anteversion, SI joint palpation

Examiner 5

Position

Standing Gait, SLSP, spine, SI joint palpation

Seated IR, ER

Supine ROM (flexion, IR, ER), FADDIR, DIRI, DEXRIT, hip flexor contracture,

SLRAR, strengthLateral Tensor fascia lata contracture, ABDEER, LRI, abductor strength (gluteus

maximus/medius)

Prone Femoral anteversion

Examiner 6

Position

Standing Gait, SLSP, double-leg squat, hop

Supine ROM (flexion, IR, ER), leg lengths, SLRAR, strength

Prone Femoral anteversion, extension strength

Abbreviations: SLSP, single-leg stance phase test; IR, internal rotation; DIRI, dynamic internal rotatoryimpingement test; SLRAR, straight leg raise against resistance test; PSR, passive supine rotation test; PRI,posterior rim impingement test; SI, sacroiliac; ABDEER, abduction/extension/external rotation test; ER,external rotation; DTR, deep tendon reflex of patella and Achilles tendons; LRI, lateral rim impingementtest.



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for obtaining positive tests. The number of positive

findings per test performed are separated by patient for

the 10 most frequently used tests (where reproduction

of the patients pain or firm endpoint in ROM indi-

cated a positive test). Included in the table is the

posterior rim impingement test, which was included

because of high agreement between examiners but

was performed less than 30% of the time.

There was a significant (P .01) positive moderate

relation (r 0.46, n 66) of positive tests to tests

performed with all patients included (Fig 7). Relations

varied greatly when calculated based on individualpatients. These data are shown in Table 3.

DISCUSSION

The examiners observed in this study followed avery consistent pattern within their own physical ex-amination of the hip. Examiners exhibited little vari-ation from their average chosen tests by using 2 to 3additional tests. All examiners structured their physi-cal examination in the same manner, beginning with

FIGURE 6. The 18 hip examination tests mostfrequently performed by the 6 hip specialists:(A) standing tests, (B) supine tests, and (C) lat-

eral and prone tests. Passive adduction tests include1 or more of the following: tensor fascia lata con-tracture test, gluteus maximus contracture test, andgluteus medius contracture test. (IR, internal rota-tion; ER, external rotation; SLRAR, straight legraise against resistance test; PS Rotation, passivesupine rotation test.)



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standing evaluations followed by seated, supine, lat-

eral, and prone positions. Between examiners, how-ever, the chosen tests differed. Presented here are themost common tests performed by the 6 hip specialists.The main finding in this study was the observation ofthe 10 most commonly performed tests (50%); 7 in thesupine position (flexion ROM, internal rotation ROM,external rotation ROM, passive supine rotation test,FADDIR test, straight leg raise against resistance test,and FABER test), 2 in the standing position (gait testand single-leg stance phase test), and 1 in the proneposition (femoral anteversion test). Eight additionaltests were also performed 40% to 50% of the time.

The consistent use of these tests stresses the impor-tance of physical examination techniques and tests tobe routinely used. Incorporation of these 18 tests intoa structured protocol of standing, seated, supine, lat-eral, and prone examinations should be considered.

An improperly performed test could constitute afalse-positive or false-negative finding. This fact callsfor standardization of how tests are performed. True

agreement or reliability between examiners could not

be calculated because not all tests were specificallyused by all examiners for all patients; however, therewas good agreement between examiners (whether thetest was positive or negative) for the most frequentlyperformed tests. Interestingly, there was 1 test (poste-rior rim impingement test) that showed good agree-ment but was not frequently used (performed in30% of patients). Fair levels of agreement have beenreported for the FABER test ( 0.63), FADDIR test( 0.58), and passive supine rotation test ( 0.61).22

Although the tests described are used by the 6 hip

specialists studied, the specificity, sensitivity, and va-lidity require further documentation and study. Futurestudies need to include a comprehensive physical ex-amination with detailed findings associated with thepresentation of hip disorders.23 A recent report spe-cific to the clinical presentation of patients with ante-rior hip impingement reported the physical examina-tion findings of ROM (flexion, extension, abduction,

FIGURE 7. Relation of number of positive testsand number of tests for all patients.

TABLE 2. Agreement for Positive Tests Between Examiners

Test

Patient

A B C D E F G H I J K

Flexion ROM 6/6 6/6 6/6 6/6 5/5 6/6 5/5 6/6 6/6 6/6 6/6

Internal rotation ROM 6/6 6/6 6/6 6/6 6/6 5/5 6/6 6/6 6/6 6/6 6/6

External rotation ROM 5/5 5/5 6/6 5/5 6/6 5/5 5/5 4/4 6/6 6/6 4/4

Passive supine rotation test 1/5 1/4 0/4 1/4 1/6 0/5 0/6 0/5 1/4 0/4 0/4

Gait 0/4 1/5 0/5 1/5 2/5 1/6 0/5 0/5 0/6 0/5 0/6

Single-leg stance phase test 0/5 2/5 0/5 2/4 1/3 0/5 0/5 3/4 0/5 0/5 1/5

Straight leg raise against resistance test 0/4 3/3 1/4 1/3 2/4 0/5 0/5 1/4 0/2 1/5 0/1

FABER test 2/4 2/2 1/2 0/3 2/5 2/3 1/2 0/4 3/3 0/4 1/2

FADDIR test 2/3 3/4 4/4 4/4 3/4 1/5 2/4 1/5 0/4 0/5 1/4

Posterior rim impingement test 1/2 1/1 1/2 1/2 2/3 1/2 0/2 1/2 1/1 2/2 2/2

NOTE. Data are presented as positive tests/number of tests performed.



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adduction, internal rotation in neutral position, inter-nal rotation at 90 of flexion, external rotation inneutral position, and external rotation at 90 of flex-ion) and provocative tests (FADDIR, FABER, straightleg raise against resistance, passive supine rotation,

and posterior rim impingement).23

Our findings arelimited to the specific population of patients studied. Itis assumed that all examiners performed the tests thatthey believe are the most effective in evaluatinghealthy individuals with hip pain. However, for acomprehensive evaluation of the hip, it is necessary torule out lumbar spine, abdominal, and neurovascularconditions in each patient.

Not every test can or should be administered forevery given patient. Our data show that performinga high number of tests yields a high number ofpositive tests (examiner 4 performed a mean of 34tests with a mean of 7 positive tests [20%]). How-ever, performing a high number of tests does notyield the highest percentage of positive tests (ex-aminer 2 performed a mean of 13 tests with a meanof 4 positive tests [36%]). The relation between thenumber of tests performed and the number of pos-itive tests across all patients was positive and mod-erate in strength (r 0.44) yet varied greatly de-pending on the patient.

There are basic tests that need to be performedwhen examining the painful hip (skin inspection, neu-rovascular assessment, palpation, ROM assessment,and strength assessment), as with other joints. An

experienced examiner will be guided by the findingsof the presenting patient; however, the inexperiencedexaminer must not be too quick to omit tests from anexamination. Therefore the most comprehensive and

TABLE 3. Relation of Number of Positive Tests andNumber of Tests for Each Patient

Patient r Value P Value

A 0.60 .20

B 0.90* .02

C 0.86* .03D 0.94 .01

E 0.74* .09

F 0.08 .88

G 0.66 .15

H 0.77 .07

I 0.55 .26

J 0.39 .45

K 0.33 .52

*P .05.P .01.

TABLE 4. Comprehensive Physical Examination of Hip

Physical examination

Height (cm)

Weight (kg)

Temperature (F)

Respiration

Pulse (bpm)

Blood pressure (mm/Hg)

Gait/posture

Gait

Normal

Antalgic

Abductor deficient (Trendelenburg)

Pelvic wink

Arm swing

Short stride length

Short stance phase

Foot progression angle

External

Neutral

HyperpronationSingle-leg stance phase test (Trendelenburg test)

Right

Left

Shoulder height (equal/not equal) (cm)

Iliac crest height (equal/not equal) (cm)

Active forward bend ()

Spine

Straight

Scoliosis (structural/nonstructural)

Laxity

Thumb

Elbows

Knees

5

LordosisNormal

Increased

Paravertebral muscle spasmsSeated examination

Neurologic findings

Motor

Sensory

DTR

Achilles

Patella

Circulation

Dorsalis Pedis

Posterior Tibialis

Skin inspection

LymphaticLymphedema

No lymphedema

Pitting edema (1/2)Straight leg raise

R

L

ROM

Internal rotation

R

L



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efficient physical examination must be determined.

Presented in Table 4 is a comprehensive list of phys-

ical examination tests by position, including the tests

described in this article. These tests are the common

TABLE 4. Continued

External rotation

RL

Supine examination

Leg lengths (cm)

R

L

Equal/not equal

ROM

Right leg

Flexion (80/100/110/120/130/140)

Abduction (10/20/30/45/50)

Adduction (0/10/20/30)Left leg

Flexion (80/100/110/120/130/140)

Abduction (10/20/30/45/50)

Adduction (0/10/20/30)

Hip flexion contracture test

R (/)

L (

/

)FADDIR

R (/)

L (/)

DIRI

R (/)

L (/)

DEXRIT

R (/)

L (/)

Posterior rim impingement test

R (/)

L (/)

Apprehension sign

R (/)

L (/)Palpation

R (/)

L (/)

Tinels Testfemoral nerve

R (/)

L (/)

FABER

R (/)

L (/)

Straight leg raise against resistance

R (/)

L (/)

Passive supine rotation test

R (/)

L (/)Strength

R (/)

L (/)

Heel strike

R (/)

L (/)Lateral examination

Palpation

SI joint (tender/nontender)

Ischium (tender/nontender)

TABLE 4. Continued

Greater trochanter (tender/nontender)

ASIS (tender/nontender)

Piriformis (tender/nontender)

Tinels Testsciatic nerve

G. Max insertion into ITB (tender/nontender)Sciatic nerve (tender/nontender)

Gluteus medius (tender/nontender)

Abductor strength

Straight leg

Gluteus maximus

Gluteus medius

Tensor fascia lata contracture test

Grade (1-3)

Gluteus medius contracture test

Grade (1-3)

Gluteus maximus contracture test

Grade (1-3)

Lateral rim impingement test

R (/)

L (

/

)FADDIR test

R (/)

L (/)

Prone examination

Rectus contracture test (Elys test)

R (/)

L (/)

Femoral anteversion test ( anteversion)

Palpation

Spinous processes (/)

SI joints

R (/)

L (/)

Bursae ischium

Specific testsPhilippon internal rotation test

McCarthys sign

Scours test

Foveal distraction test

Bicycle test

Fulcrum test

Freibergs test

Pace sign

ABDEER test

Dynamic Trendelenburg test

Supine abduction external rotation test

NOTE. The tests most frequently used by the 6 hip specialists areindicated in bold.

Abbreviations: DTR, deep tendon reflex of patella and Achillestendons; ABDEER, abduction/extension/external rotation test; SI,sacroiliac joint; ASIS, anterior superior iliac spine; G. Max, gluteusmaximus; ITB, iliotibial band.



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denominator among the examiners in this study, andour recommendations can be a useful guide to ensurethat the hip is not overlooked. These suggestions areneither definitive nor final; however, these data pro-vide a foundation for the development of a standard-

ized protocol.

CONCLUSIONS

There are variations in the testing that hip special-ists perform to examine and evaluate their patients,but there is enough commonality to form the basis torecommend a battery of physical examination maneu-vers that should be considered for use in evaluatingthe hip.

Acknowledgment: The authors thank Ian J. Palmer,Ph.D., for his assistance in preparing the manuscript, and

Dr. Freddie Fu for his guidance and direction.

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