Hip External Rotation Test | Heer Test

The hip external rotation test is one of the most important clinical tests that physiotherapy utilizes in order to determine the health of structures around the hip and diagnose injuries and pathologies that may be associated with the hip joint particularly involving the labral tissue as well as the musculature around the hip. This test is more useful like in early diagnosis of hip hyperextension, FAI, labral tears, hip instability.

Purpose of the Hip External Rotation Test

The External Rotation Test is mainly used to determine situations that cause dysfunction and instability of the hip joint. The most common conditions evaluated with this test include:

• Femoroacetabular Impingement (FAI): Hydrocele is a condition in which the femoral head contacts the acetabulum in an abnormal manner, a situation that will cause pain and limitation with any type of movement in the hip joint. This test assists in pointing out symptoms related to this condition:
• Labral Tears: Epithelial acetabular labrum is a circular flaps of fibrocartilages that broaden the hip joint socket and strengthen it. Labral tears are often initiated by acute trauma or may appear secondary to degenerative changes that result in discomfort and instability. In particular, when applying pressure during External Rotation Test some symptoms associated with labral tear can be observed.
• Hip Osteoarthritis: This is an inflammatory degenerative kind of disease that can lead to joint pains and stiffness and restricted joint movements. The External Rotation Test can give an indication as to the degree of joint involvement and aid standardization between OA and other hip conditions.

Anatomy Involved in the Hip External Rotation Test

Knowledge of the components of the hip joint is fundamental in the analysis of the results of the External Rotation Test. Key anatomical structures involved include:

• Hip Joint: This is a ball and socket joint comprising the femoral head in the acetabulum of the pelvis. Articular factory is stabilized by the joint capsule together with the ligaments as well as the overlying musculature.

• Acetabular Labrum: The labrum is a fibrocartilaginous lip that lies around the acetabulum giving extra depth and mechanical support to the hip joint. It has a significant function in load sharing and load localization.
• Hip Muscles: Some of the muscles involved are gluteal muscles, specifically; Gluteus maximus and gluteus medius muscles, iliopsoas muscle, and the big group of muscles known as the external rotators of the hip which include the; piriformes, obturator internus and quadratus femoris muscles. Hip pain and hip instability may also develop from a malfunction or an injury in these muscle groups.

Indications for the External Rotation Test

The External Rotation Test is indicated in the following clinical scenarios:

• Femoroacetabular impingement (FAI)

Symptomatic patients may complain of external hip pain during flexion and internal rotation activities, and may likely be diagnosed with FAI. In order to provoke symptoms of this condition, it is possible to employ External Rotation Test.

• History of Hip Trauma

Many people have suffered hip trauma in cases like falls or accidents and might have a labral tear or another injury. The most important part of the External Rotation Test is that it is used to identify complications that may be experienced by a patient.

• Hip pain: 

Hip is that dull throb or ache that lingers in your joint day in and day out making it extremely difficult to move around with ease and freedom.This test may be useful for patients with chronic hip pain especially during activities such as running, squats or climbing stairs alone.

• Pre - Operative Evaluation

In patient preparation for surgical procedures such as hip arthroscopy for labral repair or FAI correction the External Rotation Test is useful in setting functional capability parameters prior to surgery.

How to Perform the Hip External Rotation Test: A Step-by-Step Guide

Execution of the External Rotation Test must reach correct conclusions, and this depends on the proper procedures followed. Here’s a detailed step-by-step guide:

Step 1: Patient Positioning

The patient should be lying flat on the examination table face upwards with only the hip to be exercised relaxed. The opposite leg can be placed in a convenient position, for instance, can be placed on the table or hanging from it.

Step 2: Therapist Positioning

According to the rules of infection control, the therapist should stand at the patient’s feet when performing the examination. This positioning enables preparation for a reduction in the access to the hip joint while at the same time observing the reaction of the patient.

Step 3: Hand Placement

The therapist should be able to hold the ankle of the affected leg with one hand and cup the opposite hip with the other hand. This stabilization is important so as to eliminate movement that is corrective during the test.

Step 4: Perform the Test

The stability at the hip joint must be stabilized as the therapist slowly moves the hip in an outward direction, usually referred to as the hip being loaded in a lateral direction. To avoid discomfort, the patient should external rotate slowly and with moderate force.

Step 5: Observation and Assessment

While performing the test, you should observe the patient’s reaction carefully. Fortunately there were no adverse reactions and I saw Sherrie sitting there, so I took the opportunity to observe for any feelings of pain, or discomfort or fear-somehow she looked unfamiliar. In limited movements of the hip joint and if there are any cracking or sticking sensations while moving the hip joint, they should be captured.

Outcome Measures of the External Rotation Test

The results of the External Rotation Test can be categorized as positive or negative based on the presence of symptoms:

Positive Test

A positive test result is obtained when the pain recurs at the hip joint particularly at the end of the range of external rotation. Other symptoms may be a snap or locking during the motion, which may point to labral tear or FAI.

Negative Test

A negative test result is anyway when the external rotation can be conducted gently and no painful sensation or other feelings can be felt. This indicates absence of any destruction of joint structures and normal function of the hip joint.

Differential Diagnosis with the Hip External Rotation Test

The External Rotation Test can assist in differentiating between several conditions affecting the hip:

Labral Tears

Traumatic labral tears can also present sensitively and clinically in a similar fashion as FAI with hip pain and clicking. Nonetheless, flexible application of the score may prove challenging, as the External Rotation Test may provoke specific symptoms associated with the labrum.

Osteoarthritis

Co-coordinative test reveals that patients with hip osteoarthritis may also feel pain during the phase of external rotation of the hip joint. Although, crepitus or stiffness may serve to distinguish this entity from that of FAI or labral tears.

Hip Flexor Strain

Telescoping and hip flexor strains can produce symptoms which are very typical for FAI or labral tears. These conditions can thus be differentiated through detailed analysis of hip flexor strength, muscle tenderness on palpation.

Related Tests for the Heer Test

Several related tests can complement the External Rotation Test in assessing hip conditions:

• FADIR (Flexion, Adduction, and Internal Rotation) Test: This test determines hip reaction to a blend of flexion, adduction, and internal rotation to enable early diagnosis of FAI and labral tears.
• FABER (Flexion, Abduction, and External Rotation) Test: The hip joint scores are used in the FABER test to determine pathologic changes of hip joint in conjunction with sacroiliac joint dysfunction in case hip pain origination is in question.
• Thomas Test: This test serves to check the tightness of hip flex or to determine lack of hip extension and may alter the overall test of hip.

Recent Research on External Rotation Test and Hip Conditions

A few research articles underscore the value of the External Rotation Test for identifying hip joint disorders, and for planning physiological approaches to treatment. The present study suggests that FAI and labral tears can be identified with greater accuracy and offer improved patient results when the procedure is followed by appropriate treatment.

Importance for Physiotherapists

Therefore, the knowledge of the External Rotation Test is important for physiotherapists when assessing and designing the management strategies of clients with hip joint pathology. Thus, physiotherapists can optimize functional restoration and optimize patients’ satisfaction as a result of correct identification of the underlying disorders and development of the corresponding rehabilitation programs.

Conclusion

Thus, recognition of the External Rotation Test constitutes a valuable tool for a physiotherapist when evaluating the aforementioned clients as well as designing a plan of their further treatment. Therefore, physiotherapists have the opportunity to maximize the restoration of function and increase patient satisfaction due to the correct identification of the pathological processes and the construction of the relevant rehabilitation procedures.