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The Hip Exam for the Generalist

Alan Zhang MDAssistant ProfessorSports Medicine and Hip ArthroscopyUCSF Department of Orthopaedic Surgery

The Layers of the Hip

To treat hip pathology-

1st task is to understand the source of hip pain

Bryan Kelly et al Arthroscopy 2012

• Layer 1- Osteochondral

• Layer 2- Inert

• Layer 3- Contracile

• Layer 4- Neuromechanical

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Layer 1- Osteochondral

Structures

• Femur

• Acetabulum

• Articular cartilage

Pathology

• Cam impingement

• Pincer impingement

• Subspine impingement

• Articular cartilage delamination

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Layer 2- Inert

Structures

• Capsule

• Labrum

• Ligamentum teres

Pathology

• Labral tear

• Capsular instability

• Adhesive capsulitis

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Layer 3- Contractile

Structures

• Muscles crossing hip

• Pelvic floor

• Lumbosacral muscles

Pathology

• Gluteus medius tear

• Hip flexor strain

• Proximal hamstring strain

• Adductor tendinopathy

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Layer 4- Neuromechanical

Structures

• Neuro-vascular structures in hip region

• Regional mechanoreceptors

Pathology

• Pain syndromes

• Neuromuscular dysfunction

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Location, Location, Location

Anterior/groin

• FAI

• Arthritis

• Flexor strain

Lateral/thigh

• Trochanteric pathology

• Snapping hip

Buttock/posterior

• Low back/sciatic nerve

• Referred pain

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Physical Exam

Asses ambulation

• Antalgic gait

‒ Arthritis/acute injury

• Trendelenberg gait/Single leg stance

‒ Trochanteric pathology

‒ Gluteus tear

• FAI gait

‒ Loss of peak hip extension

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TrendelenbergGait

FAI gait

FAI gait

• Loss of peak hip extension

Zhang et al AJSM 2016

• Increased hip joint loading in FAI patients

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Supine Exam

ROM

Strength testing

Provocative exams

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Range of Motion

Flexion (0-130)

IR @ 90 degrees of flexion (0-30)

ER @ 90 (0-60)

Abduction (0-60)

Extension (0-20)

Arthritis- decreased globally

FAI- decreased IR and flexion

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Strength/Muscle Exam

Rectus—hip flexion against resistance

Abductors—push out legs

Adductors—pull in legs

Provocative Exams

Log roll

FADIR

FABER

Labral stress test/ Scour test

Sports hernia exam

Straight leg raise

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Log Roll

Assess for intra-articular hip pathology

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Flexion ADduction Internal Rotation

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FADIR for FAI

FABER Test

SI pathology

Sometimes anterior labral pathology

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Flexion ABduction External Rotation

Labral Testing/Scour Test

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Sports Hernia (Athletic Pubalgia)

Strain or tear of soft tissue in lower abdomen or groin area

• Inguinal disruption

• Adductor injury

• Abdominal wall injury

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Sports Hernia Exam

Palpation

• Pubic symphysis/Pubic tubercle

• Insertion of rectus (confluence of structures)

• Adductor origin (AL, AB, pectineus)

• Superficial inguinal ring

‒ Rule out true hernia

‒ Size of ring (dilation indicates weakened area)

‒ Check tenderness of posterior wall

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Sports Hernia Exam

Special maneuvers

• Resisted sit up (legs straight, 10-30 deg trunk flexion)

• Adductor Squeeze test (0 deg and 90 deg of hip flexion) – pain/strength

• Valsalva

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Straight Leg Raise

Hamstring tightness

Radiating pain (lumbar radiculopathy)

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Lateral Exam

OBER test

• IT band tightness

Palpate Greater Trochanter

• Trochanteric bursitis

Gluteus Medius strength testing

Ober Test

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Gluteus Medius Strength Test

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Prone exam

Hamstring exam

• Palpate for defects

• Evaluate for weakness

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Thank You

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