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Hip examination
HISTORY
It is important to bear in mind the following points when performing a hip examination:

Age of the patient

o Younger patients - traumatic injuries, osteonecrosis and developmental dysplasia of the
hip are more prevalent
o Older patients - hip fractures and osteoarthritis are more common
Mechanism of injury
Duration of problem
CLINICAL EXAMINATION

Follow the scheme below:

Inspection
Palpation
Measurment
Movement

Before starting

Introduce yourself
Explain what the examination entails
Ask permission to perform examination
Expose the patient appropriately - from waist down exposing both the lower limbs, but leaving the
underwear on
Preserve dignity by using a blanket appropriately
Tell the patient to let you know if anything you do is uncomfortable
Remember - always watch the patients face

Inspection

General observation
o Does the patient look well?
o Is there a walking stick? Frame?
o Is there a shoe raise?
o Hands (Rheuamtoid arthritis?)

Patient Standing

Remember to inspect from all sides (front, laterally and from behind):
o Skin
Scars (previous injuries or surgical scars)
Sinuses (secondary to TB or infected hip replacements)
Colour - discolouration?
o Deformity
Abduction / adduction contracture

Fixed flexion deformity

Limb shortening
Limb rotation
Scoliosis
Lumbar lordosis
Swelling (the hip joint is deep and thus swelling is not generally seen)
Muscle wasting - look at the gluteal folds
gluteals? quadraceps?
Pelvic obliquity (anterior superior iliac spines (ASIS) not horizantal)
Is there a leg length discrepancy?
Is there a fixed deformity?

o
o
o

Patient Walking

Observe the patient walking.

o Gait pattern. There are different types of gait:
Stiff hip (pelvis swing)
Antalgic (short stance phase)
Short leg
Trendelenburg (Lurching gait, watch the shoulders)
Drop foot gait
Broad based gait (ataxia)
o Stride length
o Use of a walking aid

Patient Lying down - supine with one pillow under the head

Observe the patient climb onto the examination couch

Deformity
o Rotational deformity is common in osteoarthritis (observe the position of the patella and
foot on either side)
o Fixed flexion deformity (look at the angle between the thigh and the bed). Perform
Thomas's test at this stage (see below)
o Abduction / Adduction deformity (adduction deformity - tilted pelvis and apparent
shortening of that leg)
Detailed check:
o Skin - scars

Palpation
Ask the patient.."Does it hurt anywhere?"

Skin temperature (use dorsal surface of your hand to compare temperatures over both hips)
Is there tenderness over the bony landmarks?
o Anterior and posterior superior iliac spines
o Ischial Spine
o Greater Trochanters (trochanteric bursitis)
o Iliac crests
o Ischial tuberosity (hamstring tear)
o Pubic Tubercle
Is there tenderness of the soft tissues?
o Muscles
o Femoral triangle

Joint line tenderness (beneath the mid inguinal point)

Measurement
Before measuring, if a fixed deformity of one leg has been observed, the unaffeted leg should be placed in
the same position as the one affected to make them identical.
The different types of measurements to be taken are:

Apparent length - the distance between the xiphi-sternum (a fixed point) and the medial mallelous.
True length - the distance between the ASIS and the medial malleolus
Circumference of the quadriceps at a fixed point (from the tibial tuberosity).

If a difference has been observed in true leg length measurements, it is important to determine whether the
shortening is above (femoral) or below (tibial) the knee:

Having asked the patient to bend their knees, keeping their ankles together, compare the position
of both knees.

Movement
These should be performed both actively and passively for both legs. When assessing hip movements, it is
important to fix the pelvis and prevent any movement taking place at this anatomical structure. This is done
either by dropping one leg over the edge of the couch and assessing movements of the other leg, or by
placing one forearm between the ASIS's.
Active movement

Flexion (0-130o)- "Can you bring your heel to your bottom?"

Extension (0-10o) - Having asked the patient to lie prone, ask them to raise each leg off the bed
with the knee straight.
Abduction (0-45o) - "Can you move your leg away from the bed?"
Adduction (0-30o) - "Can you move your leg across your other leg"

Passive movements
Repeat the above movements but additionally testing for hip rotation.

Rotation - With each leg in turn, flex both hip and knee to 90o , and having stabilised it with one
hand, move the heel first outwards (internal rotation - 0-45o) and inwards (external rotation - 0-45o)
with the other hand.

Special Tests
There are two special tests:
Trendelenburg test - test of abductor function (gluteus medius weakness)

Stand behind the patient and identify the iliac crests

Have another person in front of the patient for balance
Ask the patient to stand on the normal and then the affected leg by flexing the knee rather than
flexing the hip. This is for testing the abductors on the opposite side.

Watch for the patients' response in terms of balance (truncal position) and pelvic tilt
Negative test (normal)
o If pelvis stays level or rises slightly, with the trunk staying over the pelvis (i.e. staying over
the centre of gravity), AND can be maintained for 30 seconds.
Positive test (abnormal)
o The patient is unable to hold pelvis level and maintain this for 30 seconds.
o The patient leans over to the affected side, in order to keep their centre of gravity over
their foot

For further information about performing a Trendelenburg test, please Click Here.
Thomas' test - test for fixed flexion deformity

With the palm up, place your hand beneath the lumbar spine
Passively flex the unaffected hip until the hollow of the lumbar spine is eliminated
The affected leg rises up from the bed, if there is a fixed flexion deformity present.
Repeat for the other side

Finally

Check distal neurovascular supply.