MUSCULOSKELETAL EXAMINATON HIP AND PELVIS (P2: HIP Objective Exam)

If the hip is affected, the weight is lowered carefully on the ___________ side and the knee _______ slightly to absorb the shock.

If the hip is affected, the weight is lowered carefully on the affected side and the knee bends slightly to absorb the shock.

The length of the step on the affected side is (shorter/longer?)

The length of the step on the affected side is shorter

True or False:

If the hip is stiff, the entire trunk and affected leg swing forward together.

True

In standing, the patient commonly has the hip slightly _______ if there is pain in the hip

In standing, the patient commonly has the hip slightly flexed if there is pain in the hip

What muscles are tight when there is pathology of the hip?

• adductors

• iliopsoas

• piriformis

• tensor fasciae latae

• rectus femoris

• hamstrings

What muscles are weak when there is pathology of the hip?

• gluteus maximus, medius, and minimus

• Weak abductors lead to what gait?

• In this gait deviation there is a lateral pelvic shift of how many centimeters?

• The lateral pelvic shift is toward which side (WB/NWB)?

• This gait may be accompanied by trunk ____________

• Trendelenburg gait / Abductor lurch / May West gait

• 2 cm (0.8 inches)

• Toward weight bearing side

• This gait may be accompanied by trunk inclination

Internal hip pathology or a flexion contracture may lead to a ____________

pelvic wink or butt wink

It may be due to muscle tightness (i.e., iliopsoas) or structural change (e.g., anteversion angle of acetabulum or femoral neck, diameter of femoral neck, or depth of acetabulum)

Pelvic Wink / Butt wink :

• excessive (anterior/posterior?) pelvic rotation in the axial plane

  • toward the affected hip as the patient flexes the hip and knee in an attempt to obtain terminal hip extension in the opposite leg

• How many degrees of pelvic rotation

Pelvic Wink / Butt wink :

• excessive posterior pelvic rotation in the axial plane

  • toward the affected hip as the patient flexes the hip and knee in an attempt to obtain terminal hip extension in the opposite leg

• more than 40°

Compensation of the trunk for hip conditions:

• (B) Hip flexion contracture = Excessive Trunk ________

• Weak hip extensors = Trunk moves (backward/forward?)

Compensation of the trunk for hip conditions:

• (B) Hip flexion contracture = Excessive Trunk extension

• Weak hip extensors = Trunk moves backward

If the lateral rotators are significantly stronger than the medial rotators, as is normally the case what is the result?

Excessive toe-out

If the patient uses a cane, it should be held in the (opposite/same?) side as the affected hip

Proper use of the cane can decrease the load on the hip by how many percent

If the patient uses a cane, it should be held in the opposite side as the affected hip

40%

Posterior rotation of the innominate bone causes what type of leg rotation?

Lateral Rotation

True or False:

Tightness of the iliopsoas can cause deviation of the spine to the opposite side.

False:

Tightness of the iliopsoas can cause deviation of the spine to the same side

True or False:

Symmetrical skinfolds may indicate anatomical variations such as pelvic obliquity, leg-length discrepancy, developmental dysplasia of the hip, or muscle atrophy.

False:

Asymmetrical skinfolds may indicate anatomical variations such as pelvic obliquity, leg-length discrepancy, developmental dysplasia of the hip, or muscle atrophy.

Traumatic posterior hip dislocation:

• Limb is shortened/lengthened?

• Limb is adducted/abducted?

• Limb is medially/laterally rotated?

• What femoral bone structure is prominent?

Traumatic posterior hip dislocation:

• Limb is shortened

• Limb is adducted

• Limb is medially

• Greater Trochanter

True or False:

If the piriformis (or other lateral rotators) is in spasm, then the affected leg will be laterally rotated when the patient is standing.

False:

If the piriformis (or other lateral rotators) is in spasm, then the affected leg will be laterally rotated when the patient is relaxed and lying in supine.

Anterior hip dislocation:

• Limb is adducted/abducted?

• Limb is medially/laterally rotated?

• Increased pressure in what triangle?

Anterior hip dislocation:

• Limb is abducted

• Limb is laterally rotated

• Femoral Triangle

With what type of fractures is the limb is shortened and laterally rotated?

Intertrochanteric Fractures

Conditions that cause structural changes at the hip:

• Hip Angulation Deformity

• Congenital Hypoplasia

• Femoral growth plate problems

• developmental disorders

Normal ROM values for the HIP (NORKIN)

• Hip flexion = 0-120

• Hip extension = 0-20

• Hip abduction = 0-40

• Hip adduction = 0-20

• Hip medial rotation = 0-45

• Hip lateral rotation = 0-45

• Lumbar Flexion = 0-80

• Lumbar Extension = 0-25

• Lumbar Lateral Flexion = 0-35

True or False:

normal pattern of contraction = gluteus maximus followed by the erector spinae on the same side and the hamstrings

False:

normal pattern of contraction = gluteus maximus followed by the erector spinae on the opposite side and the hamstrings

If sharp anterior groin pain that may refer to the gluteal or trochanteric region is elicited on full flexion, adduction and medial rotation, the pain may be the result of

Anterolateral impingement of the femoral neck on the anterior acetabular rim (FAI)

If medial rotation is limited relative to other movements, it is predictive of mild to moderate ___________

If medial rotation is limited relative to other movements, it is predictive of mild to moderate osteoarthritis

Cam-type impingement:

• also called an _____________ injury as the bony deformity at the femoral head-neck junction enters the joint when the hip flexes

• commonly due to impingement of a large aspherical head in a tight ___________

• common in young adult (males/females?)

• Age range:

• Increased stress at the ___________

• precursor to ____________

Cam-type impingement:

• also called an inclusion type injury as the bony deformity at the femoral head-neck junction enters the joint when the hip flexes

• commonly due to impingement of a large aspherical head in a tight acetabulum

• young adult males

• 20 to 30 years of age

• Increased stress at the symphysis pubis

• precursor to athletic pubalgia

Femoral head abnormality = cam type

Pincer type (rim) impingement

• Also called a _____________ -type

• Abnormal (femoral head/acetabulum)

• Commonly seen in older (females/males)?

• Age range

• overcoverage/undercoverage of the femoral head?

• prominent ____________?

Pincer type (rim) impingement

• Also called a impaction -type

• Abnormal acetabulum

• Commonly seen in older females

• 40+ y/o

• overcoverage of the femoral head

• prominent acetabular rim

In the presence of acetabular retroversion or decreased femoral anteversion,

• hip flexion in the neutral line is limited to as little as how many degrees?

• full range is accomplished if the hip is allowed to rotate _________ and __________

• __________ rotation may exceed 60°, with _________ rotation limited

In the presence of acetabular retroversion or decreased femoral anteversion,

• hip flexion in the neutral line is limited to as little as 90°

• full range is accomplished if the hip is allowed to rotate laterally and abduct

• Lateral rotation may exceed 60°, with medial rotation limited

True or False:

Pincer and cam types of FAI may occur in isolation or more rarely together

False:

Pincer and cam types of FAI may occur in isolation or more commonly together

If Pincer and cam types of FAI are not combined, which type of FAI is more common?

Cam-type FAI

Signs and symptoms of FAI:

True or False:

In the presence of FAI, the ASIS moves early due to limited hip flexion as the lumbar spine flexes to allow more movement

True

For patients with FAI, If medial rotation is measured at ______ of flexion, medial rotation in the FAI patient will be limited

For patients with FAI, If medial rotation is measured at 90° of flexion, medial rotation in the FAI patient will be limited

Excessive end-range repetitions into medial rotation causes what type of FAI?

Excessive end-range repetitions into lateral rotation causes what type of FAI?

Cam-type

Pincer-type

True or False:

Iliopsoas impingement may also occur with extension and has been linked to acetabular labral tears.

False

Iliopsoas impingement may also occur with flexion and has been linked to acetabular labral tears.

This impingement is between the AIIS and the femoral neck can occur with knee flexion and hip extension and can lead to avulsion of the AIIS

Subspine Impingement

Subspine impingement results from an overactive ___________ in an ____________ patient

Subspine impingement results from an overactive rectus femoris in an adolescent patient

Iliopsoas impingement average age and gender preference =

Subspine (AIIS) impingements average age and gender preference =

Ischiofemoral impingement average age and gender preference =

Iliopsoas impingement average age and gender preference = 25-35 y/o , females more than males

Subspine (AIIS) impingements average age and gender preference = 14-30 y/o males more than females

Ischiofemoral impingement average age and gender preference = 51-53 y/o females more than males

Most common types of extra-articular impingements:

• ischiofemoral impingement (IFI)

• deep gluteal syndrome (DGS)

• greater trochanteric-pelvic impingement

• psoas impingement

This impingement occurs during extension in the narrow space between the ischial tuberosity and the lesser trochanter

may involve what muscle?

ischiofemoral impingement (IFI)

quadratus femoris

Pinching of contractile or neurological tissue can also occur between the lateral aspect of the ischium and the lesser trochanter of the proximal femur by 3 combined movements:

extension, adduction, and lateral rotation

These patients have chronic groin or lower buttock pain with no history of injury

Syndrome caused by limitation hip extension which can lead, over time, to increased load on L3-L4 and L4-L5 lumbar facets, leading to back pain

hip-spine syndrome

True or False

most end-range movements are painful and there may be a snapping sensation, crepitation, or locking. The mean femoral anteversion is lesser in patients with this problem.

False:

most end-range movements are painful and there may be a snapping sensation, crepitation, or locking. The mean femoral anteversion is greater in patients with this problem.

If the sciatic nerve is trapped along its course through the hip area, the patient will demonstrate an inability to sit for more than how many minutes?

more than 30 mins

Activities that hold the hip in _____ degrees of hip flexion can produce sciatic symptoms when the hamstrings are activated.

This is present in what syndrome?

Activities that hold the hip in 30 degrees of hip flexion can produce sciatic symptoms when the hamstrings are activated.

hamstring syndrome

True or False:

Patients with DGS are comfortable sitting, while long-stride walking can exacerbate the pain.

False:

Patients with IFI are comfortable sitting, while long-stride walking can exacerbate the pain.

Short stride or hip abduction alleviates the pain.

True or False:

Patients with IFI may also present with low back pain

True

With IFI there is _____ gluteal pain and distal pain _____ to the ischium

With IFI there is deep gluteal pain and distal pain lateral to the ischium

The condition is caused by narrowing between the ischium and the lesser trochanter, increased neck-shaft angle, or coxa breva

True or False:

If the foot is medially rotated and if the hip adducts during gait, the pelvic tilt associated with the rotary motion may contribute to greater trochanteric impingement against the ischium.

False:

If the foot is medially rotated and if the hip adducts during gait, the pelvic tilt associated with the rotary motion may contribute to lesser trochanteric impingement against the ischium.

Rare impingement in which a high greater trochanter (decreased neck-shaft angle—coxa vara) abuts against the ilium during hip abduction in extension.

greater trochanteric-pelvic impingement

greater trochanteric-pelvic impingement:

• typically caused by what condition?

• morphological change of what femoral structures?

• leading to contact between the ilium and greater trochanter when the hip is extended in __________.

• Patients may have a (shortened/lengthened?) involved leg and a positive _________ gait

• The _______ sign will be positive

greater trochanteric-pelvic impingement:

• Legg-Calvé-Perthes

• morphological change of what femoral head and neck

• leading to contact between the ilium and greater trochanter when the hip is extended in abduction

• Patients may have a shortened involved leg and a positive Trendelenburg Gait

• The “gear-stick shift sign” will be positive

coxa valga and femoral anteversion, which are associated with hip dysplasia, will also demonstrate limitation in what hip movements?

extension, adduction, and lateral rotation.

True or False:

For the hamstring syndrome (or ischial tunnel syndrome), the pain is lateral to the ischium and pain occurs at heel strike

True

in DGS, tenderness is usually felt over the piriformis muscle and retrotrochanteric area, and sitting for more than _______ minutes is painful.

20-30 mins

True or False

In addition to piriformis syndrome, the DGS may include involvement of fibrous bands, obturator internus/gemellus syndrome, and quadratus lumborum muscle

False:

In addition to piriformis syndrome, the DGS may include involvement of fibrous bands, obturator internus/gemellus syndrome, and quadratus femoris muscle

True or false:

When the patient abducts the leg, the same side ASIS tends to move first with an adduction contracture; this occurs earlier in the ROM.

False:

When the patient abducts the leg, the opposite ASIS tends to move first with an adduction contracture; this occurs earlier in the ROM.

If, during abduction, lateral rotation and slight flexion occur early in the movement what muscle is stronger than the gluteus medius/minimus?

Tensor Fascia Lata

True or False:

If lateral rotation occurs earlier in the ROM, the iliopsoas or piriformis may be overactive

False:

If lateral rotation occurs later in the ROM, the iliopsoas or piriformis may be overactive

If the pelvis tilts up at the beginning of movement, what muscle is overactive.

Quadratus Lumborum

True or False:

When the patient adducts the leg, the ASIS on the same side moves first. This movement occurs earlier in the ROM if there is an abduction contracture

True

True or False:

Asymmetric lateral rotation may indicate acetabular anteversion, femoral retrotorsion, or femoral head-neck abnormalities

False:

Asymmetric lateral rotation may indicate acetabular retroversion, femoral retrotorsion, or femoral head-neck abnormalities

Loss of medial rotation is one of the first signs of ________ hip pathology

Loss of medial rotation is one of the first signs of internal hip pathology

If, in supine lying, the patient demonstrates enough lateral rotation that the lateral border of the foot touches the table, there is probably a lax ________capsule or hip _________

If, in supine lying, the patient demonstrates enough lateral rotation that the lateral border of the foot touches the table, there is probably a lax anterior capsule or hip retroversion

opposite for limited lateral rotation

MMT TESTING:

HIIISSLOOOPPP

ROM:

NOOOORKINNN

Test adductors with hip flexed to 30^o to 45^o = optimal test position

This test is called wat?

Thigh Adductor Squeeze Test

Test bilateral adductors with knees extended

Most diagnostic of the adductor tests

Bilateral Adductor Test

Strength of the hamstrings 

• Pt in crook-lying, resting on elbows 

• Pt then lifts buttocks off table maintaing body weight on elbows and heels 

• Alternately lift good leg and affected leg 

• (+) pain at ischial origin or hamstrings pr pelvic “collapse” or rotation = weak hamstrings

Supine Plank Test

Special Tests for Hip Pathology

• Patrick’s Test

• Craig’s Test

• Hip Scour (Grind) Test (Flexion- Adduction Test

• Lateral FABER Test (yellow)

• Log Roll Test

• Anterior Labral Tear Test

Honestly the name the test shit was NOT working so the following slides would just be a review of the tests

Patrick’s Test

AKA figure 4 or Jansen’s test 

• Pt in supine then test leg placed in figure 4 position 

• PT lowers leg (on top of knee) 

• (+) pain and test leg remaining on top of opposite knee 

• If pressure produces lateral pain then it may indicate superolateral and lateral FAI 

• Groin pain may indicate iliopsoas pathology or psoas impingement 

• Posterolateral may indicate ischiotrochanteric impingement

Craig’s Test

AKA Ryder method

• Pt in prone with knee flexed to 90 degs

• PT palpates posterior aspect of greater trochanter then IR and ER  hip until greater trochanter is parallel to bed or in most lateral position 

• Measure the angle of lower leg with vertical line

• For femoral anteversion

  • 30 degs at birth; 8-15 degs for adults

  • Inc anteversion leads to squinting patella and in toeing

  • 2x more common in girls 

Hip Scour (Grind) Test (Flexion- Adduction Test)

AKA quadrant or scouring test

• Pt in supine, then PT flexes and adducts hip until it reaches opposite shoulder and the resistance is felt

• PT maintains slight resistance on the hip while passively abducting the hip (maintain knee flexion) 

• Look for “bumps”, pain, apprehension

• (+) sign not mentioned so just look for abnormalities 

causes impingement of the femoral neck against the acetabular rim and pinches the adductor longus, pectineus, iliopsoas, sartorius, and/or tensor

fascia lata, depending on the position of the hip

Lateral FABER Test (yellow)

• Pt in sidelying 

• PT holds upper leg while palpating the hip then abducts the leg while flexing/extending it

• (+) if pain; indicates intra articular hip involvement

Log Roll Test (passive supine rotation)

• Pt in supine with extended leg 

• PT then IR and ER leg to end rage 

• Normally PT just IR leg then let leg passively fall to ER 

• Pain or restricted ROM = intra articular hip pathology 

• Click may indicate labral tear 

• Inc ER = lax iliofemoral lig

• Stresses only intra articular tissue NO EXTRA ARTICULAR TISSUES

Anterior Labral Tear Test

AKA fitzgerald, anterior apprehension test 

Used to test for anterosuperior impingement syndrome, anterior labral tears,and iliopsoas tendinitis 

• Pt in supine 

• PT puts hip into full flexion, ER and abduction then PT extends, IR and adducts hip

(+) if pain, reproduction of sx, or apprehension

Tests for Muscle Dysfunction:

• 90–90 straight leg raise test

• Trendelenburg test

• Ely’s test

• Ober’s test

• Thomas test

• Noble compression test

• Adductor Squeeze test

• Hip Lag sign

• Phelp’s test (red)

• Piriformis test

• Sign of the buttock

• Tripod sign (hamstring contracture test)

90–90 straight leg raise test

• Pt in supine, hips and knee flexed to 90 deg 

• Stabilize behind the knees, extend knees as much as possible on each knee 

• (+) if cant do more than 20 deg

Magee:

• Pt in supine flexes both hips to 90 degs with knees flexed 

• Pt is asked to extend each knee

• (+) replication of sx 

Trendelenburg test

• Pt has to balance on one leg then PT observes 

• +) if pelvis on non stance leg drops 

• Weakness of Gmeds or instability

Ely’s test

• Pt in prone 

• PT flexex pt’s knee maximall; compare 

• (+) if hip flexion occurs in knee flexion  

 Magee:

• Pt lies in prone, while PT flexes knee 

• (+) if ipsilateral hip flexes 

Ober’s test

• Pt in sidelying, lower leg and hip flexed for stability 

• PT passively abducts upper leg and bring it to slight extension 

• Stabilize pelvis then slowly lower upper leg to table 

• (+) upper leg stays in the air and does not fall down on table 

Magee:

• Pt in side lying with lower leg and hip flexed 

• PT abducts and extends upper leg while knees are extended

• (+) if during hip extension, upper leg stays abducted

Thomas test

• Pt in supine; check for excessive lordosis 

  • Ask pt to bring knee to chest and hold it 

• (+) extended leg is lifted off the Muscle table with yan ty

• ``J-sign or stroke - if extended leg abducts = tight ITB 

Magee:

• Pt lines supine  while PT checks for excessive lordosis 

• PT flexes one hip towards chest while pt holds that position with hands 

• (+) if the other hip lifts off the table 

Noble compression test

For checking if pt has ITB friction syndrome near knee (chronic inflammation of ITB near insertion / femoral condyles)

• Pt in supine with knee flexed to 90 degs with hip flexion 

• PT extends the knee while applying pressure on lateral femoral condyle 

• (+) if at 30 degs knee flexion of pt feels pain on lateral femoral condyle 

• Same pain pt feels when running

Adductor Squeeze test

AKA fist squeeze test 

• Pt in supine with hips flexes to 45 degs, knees at 90 degs 

• PT puts his fist in between the knees (dynamometer or sphygmomanometer if you want numbers) 

• Pt has to squeeze the fist 

• (+) if reproduces sx; indicates adductor pathology 

• May also be used for determining symmetry of symphysis pubis

Hip Lag sign

Tests hip abductors

• Pt in sidelying, then PT abducts and IR the extended leg to 45 degs 

• Pt holds that position for 10 secs

• (+) if pt cannot hold position, leg drops 4 inches(10cm) or IR decreases

• (+) sign indicates Gmeds tear 

Phelp’s test

• Pt in prone with knees extended 

• PT abducts both legs as far as possible 

• At maximum abduction PT flexes knee to 90 degs and try to abduct the hip further 

• (+) gracilis contracture  if abduction increases

Sign of the buttock

• Pt in supine then PT does an SLR test

• If present limitation, flex knee

• (+) If hip flexion does not increase = lesion is in buttock or hip not the hamstrings or sciatic nerve

• (+) sign may indicate ischial bursitis, neoplasm, abscess in ass, fx, hip pathology

Tripod sign (hamstring contracture test)

• Pt sitting with both knees flexes to 90 degs over edge of bed 

• PT extends the knee 

• (+) if pt extends spine (extending spine relieves tension in hamstrings)

Straight Leg Raising Test or Lasegue's Test

Hello Again

Pain referral:

Sites of Entrapment, Key Signs and/or Symptoms with Nerves in the Anterior and Posterior Hip Region:

Tests For Balance Assessment

• Timed- Single Leg Stance

  • Ask the patient to balance first on one leg (good leg) and then the other

    • first with the eyes open and then with the eyes closed

• Stork Standing Test (proprioception) 

  • SI jt, knee, ankle, foot 

• Y-Balance Test

• Star Excursion Balance Test

  • Postero-medial/lateral = measures FAI and susceptibility to injury

Dislocation from hip trauma with FADIR?

Posterior hip dislocation

Dislocation from hip trauma with EABER

Anterior hip dislocation