Hip Examination for Physiotherapists | Comprehensive Guide

Hip Examination Overview 

During a hip examination, healthcare providers typically assess various aspect of the hip joint to diagnose potential issues. The hip assessment typically involves a combination of physical, medical history review and sometimes imaging studies like X-ray and MRI Scan. In this article, we will cover physical hip examination that includes various aspects of the hip joint. This guide is useful for hip clinical examination and post-op surgery as well. 

What is a Hip Joint?

The hip joint is a ball-and-socket joint in which the femoral head acts as the ball and the acetabulum as the socket. The hip joint is a synovial joint as its articular surfaces are surrounded by a fibrous capsule and a synovial membrane which reduces the articular friction. The stability of the joint is increased by a strong ligamentous system formed by the iliofemoral, ischiofemoral, and pubofemoral ligaments and by the acetabular labrum. 

Subjective Hip Assessment :

History of Present Condition (HCP):

• Consider the mechanism of injury, trauma, high velocity, sports, occupational?
  • Insidious or repetitive
• Work-related –repetitive work, level of activity with work, overhead work sedentary role?
• Any change in occupation, level of activity or general health?
• Any paraesthesia/anesthesia, motor loss, is this pre-existing or recent?
• How long have they had the problem for and is it getting worse, better or is it the same?
• Have they had similar problems in the past of previous injuries to the area?
• Have they had any previous treatment for the problem & if so did it help?
• Sleep- do they sleep well. If not is it because of this problem or other factors impairing sleep quality.
• How are they feeling about the problem & what are their expectations?

Aggravating factors

• Easing factors –e.g. rest, analgesia, heat etc.
• Is the problem getting better/ staying the same or worsening with time?
• 24 Hour/ diurnal pattern. Worse as the day goes on perhaps activity-dependent?
• Severity – pain score typically VAS (at worst, at best, currently)
• Irritability – how easily/quickly does the pain come on & if aggravated how long will it take to settle?
• Nature – the type of pain peripheral nociceptive, peripheral neurogenic, central neurogenic?
• Functional limitations- what can’t they do because of this problem?
• Investigations- what & when have they had? What are the results?

Past medical history: 

• General health Current medical problems – THINK THREAD
• (thyroid, heart, RA, epilepsy, asthma and diabetes) 
• History of surgery or major illness (cancer) 
• Drug History (DH): Current medication for any medical problems (analgesia, NSAIDs etc),pain-relieving drugs – how long for and how often do they take them? 
• Family History (FH): Family history of problems (RA, cancer etc) 
• Social History (SH): Current occupation, are they at work, on sick leave, light duties if at work? How long have they done their current job, particularly relevant if change in role perhaps from a more sedentary to a physical role? 
• Hand dominance. Hobbies again to gauge the level of activity that is normal for them, static, dynamic or sedentary. The volume of activity may be relevant are they doing the activity every day or once per week, what does it feel like after that activity? 
• Living circumstances, who they are living with and the level of ADLs may be relevant depending on the level of disability or loss of function. Lifestyle- do they smoke or drink excessively? 

Special questions/Red flags: 

• General health – poor appetite, weight loss, fatigue Trauma – RTC Night sweats 
• History of cancer:
• Fever- generally unwell 
• Signs of cord compression:
• Pins and needles 
• Bladder/bowel dysfunction 
• Cervical myelopathy – gait disturbance, signs in legs and feet 5D’s:   
• Dizziness.
• Dysarthria (difficulty speaking)
• Dysphagia (swallowing problems)
• Drop attacks 
• Diplopia (double vision). 
• 3 N’s: 
• -Nausea 
• -Nystagmus (involuntary eye movement)
• Facial numbness 

     Headaches – how long, pattern, worsening, investigations 

• Saddle anaesthesia

    From your subjective you should be able to come away and think about SIN:                     

• Severity – pain score (VAS)

1. Irritability – how easily/quickly does the pain come on? 
2. Nature – type of pain: atherogenic (joints),myogenic (muscles),neurogenic (nerves)

Objective Hip Assessment :

The hip examination is typically divided into the following steps:

• Position
• Inspection
• Palpation
• Motion
• Special maneuvers

(The middle three steps are remembered with the saying look, feel, move)

POSITION:

The patient should be supine and the examination table must be flat. The patient’s head resting on a pillow and hands should remain at the sides. The hips should be in the neutral position, neither flexed nor extended and the knee extended. 

Lighting- adjusted so that it is ideal. 

Draping- The patient’s hips should be exposed to assess quadriceps muscles and greater trochanter.

INSPECTION:

(Inspection done while in standing position):

When examining the hip joint ,  physiotherapists should evaluate the surrounding muscle, tendon and fascia that contribute to hip function. Assessing myofascial chain dysfunction is important to assess the muscle tightness, weakness or imbalance that contribute to hip pain.  At Physiotherapy Online, we have introduced online CPD courses for physiotherapists in which you can learn about myofascial chain dysfunction for the lower limb.  

LOOK:

• Front and back of pelvis and legs:
• Tropic or ischemic changes.
• Level of Anterior superior iliac spine (ASIS)
• Scars- previous surgery or old injuries.
• Swelling- Soft tissue or bony swellings.
• Deformities- leg length discrepancy, scoliosis, lordosis, kyphosis, pes cavus.
• Sinuses- neuropathic ulcers or any infection.
• Muscle wasting or hypertrophy.

FEEL:

Any swellings in the trochanteric or gluteal region. Or anteriorly in Scarpa’s triangle.

Pelvic tilt by palpating the level of Anterior superior iliac spine (ASIS).

MOVE:

Gait Observation:

• Smooth and progression of phases of the gait cycle.
• Any contracture
• ABNORMAL GAIT PATTERNS:
• Trendelenburg- Pelvic tilt/sway.
• Ataxia.
• Antalgic gait- reduced stance phase on the left or right side.
• Persistent femoral anteversion- In-toeing.
• (Inspection done while supine):
• The hip should be examined for the following:
• Masses.
• Scars.
• Signs of trauma.
• Bony alignment- rotation and leg length.
• Symmetry at the hip and knee.
• Muscle bulk.

Measures:

• True leg length- Greater trochanter of the femur or ASIS to medial malleolus of ipsilateral leg.
• Apparent leg length- Umbilicus or xiphisternum to the medial malleolus of ipsilateral leg. (2)
• PALPATION:
• Palpatio for  hip pain assessment , other than the joint itself. To assess the hip pain, one should palpate:
• Lumbar spine.
• Sacroiliac (SI) joints.
• Ischium.
• Iliac crest.
• Lateral aspect of the greater trochanter.
• Trochanteric bursa
• Pubic symphysis. 

MOTION: 

Hip range of motion examination is important for area of restriction. The different movement are evaluated such as :

• Flexion
• Extension
• Internal rotation
• External rotation

Conclusion

In summary , a comprehensive hip examination is important in physiotherapy to ascertain the status off hip join and surrounding structure . This examination involves systematic approach , that is integrated to subjective information such as patient history, and objective assessments including physical examination and specialized tests that we covered in our other article. Assessment of hip joint in physiotherapy practice helps in making informed diagnoses and relieving pain.