tramer-et-al-2023-comprehensive-physical-examination-of-the-hip

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Comprehensive Physical Examination
of the Hip
Joseph S. Tramer,*y MD , Kinsley Pierre,y BS, Anne Owen,y PA-C, and Marc R. Safran,y MD
Investigation performed at Stanford University, Redwood City, California, USA
Background: Hip pain is a common chief complaint among sports medicine patients, and there is a wide variety of pathology that
may cause pain around the hip joint.
Indications: Any patient presenting to a clinic with a complaint of hip and groin pain should undergo a comprehensive physical
examination to aid in diagnosis and treatment planning.
Technique Description: All patients presenting with hip pain, regardless of the complaint, undergo a screening examination to fur-
ther identify potential etiology of their pain. Based on the screening examination, as well as a comprehensive history and imaging
findings, more specific examination maneuvers may be conducted to further establish an accurate diagnosis and treatment plan.
Conclusion: Hip pain presents a diagnostic challenge for sports medicine providers, as there is a wide range of pathology that may
manifest as pain around the hip joint. It is vital for all sports providers, regardless of the area of interest, to have the ability to perform
a comprehensive physical examination of the hip to obtain an accurate diagnosis and to initiate appropriate treatment plans.
Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in
this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of
approval from the patient(s) with this submission for publication.
Keywords: hip; groin; physical examination; femoroacetabluar impingement; snapping hip; hip instability
VIDEO TRANSCRIPT
The following video is an overview of the physical examina-
tion of the hip, as well as other common pathology that
may cause pain around the hip joint.
Our disclosures are listed here.
We will begin with the senior author’s general screening
examination that is at minimum performed on all patients,
as well as additional examination maneuvers that may be
included based on the patient’s history and positive find-
ings on the screening examination. Please note that all
these tests should be performed bilaterally for all patients
to allow side-to-side comparison, but unilateral examina-
tion was performed for the sake of brevity in this video.
All patient visits must start with a thorough history, using
typical lines of questioning to determine the location and
duration of pain, specific activities that cause pain, and
any prior treatment or past surgical intervention.
The physical examination of the hip begins with observ-
ing both how the patient is seated in their chair and how the
patient is rising from sitting, looking for any avoidance
behavior such as slouching to keep the hip extended or lean-
ing heavily on the handles when standing. While standing,
the Trendelenburg test is performed by placing the hands
on the lateral iliac crests with the thumbs at the same level
and on the posterior superior iliac spine (PSIS). If the con-
tralateral thumb drops during a single leg raise, this is
a positive test and indicative of abductor weakness.
Next, we move to the examination table with the patient
seated at the edge of the table in 90� hip flexion. This posi-
tion isolates the iliopsoas muscle complex as the primary
hip flexor, and the strength of the iliopsoas is tested and
graded on a standard 5-point scale for muscle testing.
The patient then moves to the supine position, where
hip range of motion (ROM) in flexion is tested as well as
any pain with maximal flexion. Internal rotation and
external rotation at 90� of hip flexion are tested to screen
for ROM deficits or potential rotational abnormalities.
Next, the impingement test and labral stress (also
known as the scour maneuver) tests are performed to
test for pain potentially caused by symptomatic labral
*Address correspondence to Joseph S. Tramer, Department of
Orthopaedic Surgery, Stanford University, 450 Broadway, Redwood
City, CA 94063, USA (email: joe.tramer@gmail.com).
yDepartment of Orthopaedic Surgery, Stanford University, Redwood
City, California, USA.
Submitted January 17, 2023; accepted March 17, 2023.
One or more of the authors has declared the following potential con-
flict of interest or source of funding: M.R.S. is a consultant for Medacta,
Smith and Nephew, Subchondral Solutions, Marrow Access Technolo-
gies, and MiCare; received research support from Smith and Nephew;
and received royalties from Lippincott, Elsevier, DJO, Blossum Hill, Smith
and Nephew, and Top Shelf Inc. AOSSM checks author disclosures
against the Open Payments Database (OPD). AOSSM has not conducted
an independent investigation on the OPD and disclaims any liability or
responsibility relating thereto.
Video Journal of Sports Medicine (VJSM�), 3(3), 26350254231168161
DOI: 10.1177/26350254231168161
� 2023 The Author(s)
This open-access article is published and distributed under the Creative Commons Attribution - NonCommercial - No Derivatives License (https://
creativecommons.org/licenses/by-nc-nd/4.0/), which permits the noncommercial use, distribution, and reproduction of the article in any medium, provided the
original author and source are credited. You may not alter, transform, or build upon this article without the permission of the Author(s). For article reuse guidelines, please visit
SAGE’s website at http://www.sagepub.com/journals-permissions.
Physical Examination Techniques
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tears or other intra-articular pathology. The leg is then
placed in flexion-abduction-external rotation and the dis-
tance from the knee to the examination table is measured.
The iliopsoas tendon may be readily palpated by first
instructing the patient to perform an isometric hold with
the leg in slight flexion and external rotation to activate
the sartorius muscle. Just medial to the sartorius is the
iliopsoas tendon, which may be palpated and will contract
when the patient is instructed to perform a straight leg
raise. Discomfort with palpation at rest and/or when
straight leg raise is indicative of iliopsoas pathology.
The patient is then asked to move to the end of the table
and let the legs fully extend. In this position, the Thomas
test may be performed to assess the inability to full extend
the limb, indicative of iliopsoas contracture. In addition,
the hyperextension-external rotation (HEER) test is the
first routine instability examination performed, which
will be discussed further in the instability section.
The patient then moves to the lateral decubitus posi-
tion. Here, we begin by palpating the greater trochanter
to assess trochanter and bursal tenderness, as well as pal-
pating the muscle belly and insertion of the gluteus med-
ius. With the hip and knee flexed and adducted, the
piriformis is palpated for tenderness midway between the
trochanter and ischial tuberosity.
The Ober test is performed to evaluate iliotibial band
tightness, as well as the next instability test, the abduc-
tion-hyperextension-external rotation (AB-HEER) test.
Finally, the patient is directed into the prone position
where the prone instability test is performed.
In addition, the patient is examined for hamstring dom-
inance, or gluteal inhibition, by placing the fingers over the
gluteus and hamstring muscles and determining which
muscle group activates first when the patient is asked to
extend the leg with a flexed knee. Based on the results of
the screening examination, further tests detailed to follow
may be conducted to aid in accurate diagnosis.
Range of motion may also be examined in the seated
position, as well as hip internal and external rotation
strength to evaluate potential muscle deficits. Again, the
lateral position allows for palpation of the structures
around the greater trochanterand posterior gluteal region.
When patients have tenderness over the piriformis, the
piriformis motor test may be performed by having the
patient externally rotate against resistance with the hip
flexed and adducted to assess increase in pain in the glu-
teus and piriformis area. The Ober test and AB-HEER
test are again demonstrated.
We conclude with the ischiofemoral impingement test,
with the patient’s hip externally rotated in hip extension
and adduction to assess abutment of the lesser trochanter
and the ischium, which may be added when the patient
complains primarily of posterior gluteal pain.
The prone examination provides for another opportu-
nity to check the ROM of both hips to check for stiffness
or potential rotational abnormalities. In addition, ham-
string dominance is evaluated. Studies have shown that
the firing of the hamstring muscle group before the gluteus
muscles increases the load on the iliopsoas, often resulting
in iliopsoas tendinopathy, and possibly places the patient
at risk of hamstring injury.1,4 When prone, we can also pal-
pate the ischial tuberosity and hamstring for tenderness
and ischial bursitis.
When patients complain of hip snapping or popping,
there are 4 examination maneuvers that are useful for elic-
iting snapping hip, each performed with the examiners
hand palpating the anterior hip for a snap, although the
snapping is often audible. First, the patient is asked to
actively flex the hip fully and then externally rotate maxi-
mally and return to full extension and neutral rotation.
Second, the patient alternates from maximal hip flexion,
abduction, and external rotation to full extension, adduc-
tion, and internal rotation.2 Third, straight hip flexion
and extension and finally while in full extension, the
patient alternates from external rotation and abduction
to internal rotation and adduction.
Patients complaining of medial thigh pain should have
a focused examination of the adductor muscles and core
muscle injury. Performing resisted adduction in both
extension and flexion can identify weakness and pain in
adductor tendinopathy.
Core muscle injury can be assessed by the Hesselbach
test by palpating the lower abdominal muscles at their
insertion on the pubis and having the patient perform
a sit-up to evaluate for pain consistent with a sports her-
nia. In addition, a resisted sit-up can be performed and
considered positive for potential sports hernia, with repro-
duction of groin pain during this maneuver.
Prior investigation by the senior author has demon-
strated the 3 instability tests, AB-HEER, prone instability,
and HEER, to have a high specificity for hip microinstabil-
ity as shown in the table, with multiple positive tests fur-
ther increasing specificity.3 During these tests, it is
important to ask where the patient feels pain, with
anterior-based pain indicative of instability and considered
a positive test. Additional instability examination maneu-
vers include the posterior instability test to examine poste-
rior instability, as well as an axial distraction test.
Finally, patients complaining of more posteriorly based
pain must be screened for potential sacroiliac joint dys-
function. The Gaenslen test and the Patrick test shown
here are performed and a positive test considered when
the patient complains of posterior-based pain during the
examination.
Overall, there are many potential causes of pain around
the hip joint, and it is vital to have an efficient screening
physical examination as well as knowledge of advanced
maneuvers to accurately diagnose and treat this patient
population.
Thank you for your attention.
ORCID iD
Joseph S. Tramer https://orcid.org/0000-0002-0422-
2554
2 Tramer et al Video Journal of Sports Medicine
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Video Journal of Sports Medicine Hip Physical Exam 3