MSK LQ Unit 2 Special Tests

What are the main intra-articular hip pathologies tested in Unit 2?

Purpose: Identify pathology inside the hip joint capsule.

Examples:

• FemoroAcetabular Impingement Syndrome (FAIS)

• Microinstability

• Hip Osteoarthritis (OA)
  

Clinical clue: Anterior hip/groin pain usually points toward hip joint involvement.

What are the main extra-articular hip pathologies tested in Unit 2?

Purpose: Identify pathology outside the hip joint capsule

Examples:

• Iliopsoas complex

• Adductor injury

• Hamstring injury

• Greater Trochanteric Pain Syndrome (GTPS)

• Piriformis syndrome

• Ischiofemoral impingement
  

Clinical clue: Pain location helps differentiate lateral, posterior, and medial/groin sources

What is the diagnostic triad suggesting intra-articular/local hip joint pain?

Purpose: Helps distinguish true hip joint pain from referred lumbar/SIJ/visceral pain

Positive triad: Limp + groin pain + limited hip IR

Interpretation: Strongly suggests intra-articular/local hip joint involvement

What is the hip OA clinical prediction rule cluster?

Purpose: Rule in hip OA clinically

Positive cluster: 4/5 findings positive = high likelihood of hip OA

Findings:

• Limited active hip flexion with lateral hip pain

• Pain with active hip extension

• Passive IR ≤ 25°

• Painful/limited squat

• Hip Scour with adduction causes lateral hip or groin pain

What is Craig's Test?

Purpose: Assess femoral anteversion vs retroversion

How to Perform:

1. Pt prone, knee flexed to 90°

2. Palpate posterior greater trochanter while passively IR/ER hip

3. Rotate until greater trochanter is most lateral/parallel to table, then measure the hip IR angle
   

Positive/Interpretation:

• Normal ≈ 8–15° IR

• Increased angle = femoral anteversion/toe-in/greater IR

• Decreased angle = femoral retroversion/toe-out/greater ER

What is femoral anteversion?

Answer: Forward torsion of the femoral neck relative to the femoral shaft

Clinical presentation: Pt may toe-in to keep the femoral head seated in the acetabulum

ROM clue: Greater hip IR available

What is femoral retroversion?

Answer: Backward torsion of the femoral neck relative to the femoral shaft

Clinical presentation: Pt may toe-out to keep the femoral head seated in the acetabulum

ROM clue: Greater hip ER available

What is FABER / Patrick's Test?

Purpose: Assess hip joint, FAI/intra-articular pathology, gluteal/trochanteric involvement, or SIJ depending on pain location

How to Perform:

1. Pt supine

2. Place test leg into Flexion, ABduction, External Rotation figure-4

3. If no pain, stabilize opposite ASIS and apply downward pressure to test knee

Positive Test: Reproduction of pain

Interpretation:

• Groin/anterior hip pain = FAI/intra-articular hip joint involvement

• Lateral hip pain = gluteal tendon or trochanteric bursa

• Posterior pain = SIJ involvement

What is the Hip Scour / Quadrant Test?

Purpose: Assess intra-articular hip pathology

How to Perform:

1. Pt supine with hip flexed to about 90° and knee flexed

2. Apply axial compression through femur

3. Sweep hip through flexion/adduction toward extension/abduction
   

Positive Test: Joint pain, apprehension, catching, or audible/palpable crepitus.

Interpretation:

• Labral tear, hip OA, loose bodies, or other intra-articular pathology

• Anterior hip/groin pain = hip joint involvement

• Crepitus = intra-articular structure disruption

What is FADIR / FAIR Test?

Purpose: Assess FAI and anterior labral/intra-articular pathology

How to Perform:

1. Pt supine

2. Passively move hip into 90° flexion + adduction + IR

3. If negative, move into full flexion + adduction + IR
   

Positive Test: Anterior hip or groin pain.

Interpretation:

• Hip joint involvement due to FAI or acetabular/anterior labral injury

• Highly sensitive for FAI and anterior labral tears

What is the Posterior Impingement Test?

Purpose: Assess posterior FAI or posterior labral involvement.

How to Perform:

1. Pt supine

2. Start in FADIR position: 90° hip flexion + IR + adduction

3. Passively sweep the leg through an arc into ER + extension + abduction
   

Positive Test: Reproduction of posterior hip or gluteal pain.

Interpretation: Posterior FAI or posterior labral involvement.

What is the Log Roll Test?

Purpose: Assess intra-articular pathology and anterior capsuloligamentous laxity/microinstability

How to Perform:

1. Pt supine with both legs extended

2. Passively roll/IR the test leg, then release and observe ER range and symptoms
   

Positive Test: Clicking, pain, or excessive ER/lateral rotation

Interpretation:

• Click = labral tear

• Increased ER range = anterior capsuloligamentous laxity

• Anterior hip/groin pain = hip microinstability

What is the HEER Test?

Purpose: Assess anterior hip microinstability or anterior labral pathology.

How to Perform:

1. Pt supine with buttocks at edge of table and test leg extended

2. Pt holds non-test leg in flexion

3. Move test hip into passive hyperextension + external rotation to stress anterior joint structures
   

Positive Test: Reproduction of anterior groin pain.

Interpretation: Anterior microinstability or anterior labral pathology.

What is the Adductor Squeeze Test?

Purpose: Assess adductor strain or pubic symphysis pathology.

How to Perform:

1. Pt supine with hips flexed about 45° and knees bent

2. Place ball or fist between knees

3. Instruct pt to squeeze knees together, building from submax to max
   

Positive Test: Pain in medial groin region.

Interpretation: Adductor strain or pubic symphysis pathology.

What is the External / Gluteal De-Rotation Test?

Purpose: Assess GTPS/gluteal tendinopathy and help differentiate from hip OA.

How to Perform:

1. Pt supine with hip/knee in 90-90

2. Passively ER hip to offload gluteal tendons

3. Pt resists further ER by performing isometric IR

4. Let pt move fully through IR AROM and compare IR PROM vs AROM

5. If supine test is negative, repeat prone with hip extended, knee flexed 90°, full ER → resisted IR → AROM/PROM IR
   

Positive Test: Reduction of lateral hip pain during offloading and/or reproduction of pain during resisted IR from ER position

Interpretation:

• Offloading reduces lateral hip pain = GTPS

• PROM IR > 1.5× AROM IR with groin pain during passive IR suggests hip OA; no groin pain is more likely GTPS

What is the Trendelenburg Sign?

Purpose: Assess gluteus medius/minimus strength and pelvic stability.

How to Perform:

1. Pt stands unassisted on one leg for 6–30 sec

2. Observe pelvis on non-stance side

3. Progress with single-leg squat or corkscrew test to assess dynamic control
   

Positive Test: Contralateral pelvic drop > 2 cm.

Interpretation:

• Gluteus medius weakness on the stance leg

• Lateral hip pain reproduction may indicate GTPS

• Normal = pelvis rises slightly on lifted side

What is the SLS Pain Provocation Test?

Purpose: Assess pelvic stability, muscular control, joint integrity, and lateral hip pain provocation

How to Perform:

1. Pt stands on one leg with light support/fingertip support

2. Hold trunk upright for 30 sec or until pain develops over greater trochanter
   

Positive Test: Pain over greater trochanter, early hip adduction, or pelvic drop.

Interpretation:

• Lateral hip pain/early adduction suggests limited abductor strength/endurance and tendon compression

• Pain may also indicate articular cartilage injury or degenerative joint changes

What is the Side-Lying Ischiofemoral Impingement Test?

Purpose: Assess ischiofemoral impingement

How to Perform:

1. Pt side-lying with test leg on top; clinician stands behind pt

2. Support test leg and passively bring hip into extension + adduction + ER
   

Positive Test: Deep posterior hip pain with firm/hard end-feel.

Interpretation: Ischiofemoral impingement

What is the Long-Stride Ischiofemoral Impingement Test?

Purpose: Extra-articular Hip Pathology

• IschioFemoral Impingement (IFI)

• Proximal Hamstring Tendinopathy (PHT)

How to Perform:

1. Pt standing

2. Have pt take a long step forward with non-test leg so test leg trails behind in extension

3. Check pain on extended test leg

4. Repeat with test leg and firm heel strike forward to mimic terminal stance → initial contact transition
   

Positive Test:

• Deep buttock or posterior hip pain (broad deep ache near or lateral to the ischium) when the trailing leg extends → IschioFemoral Impingement (IFI)

  • Mechanism: Compression of the quadratus femoris between the ischial tuberosity and lesser trochanter during hip extension/adduction

• Localized pain directly at the ischial tuberosity or proximal hamstring origin during forward heel strike → Proximal Hamstring Tendinopathy (PHT)

  • Mechanism: Rapid eccentric hamstring loading during terminal swing → initial contact as the hamstrings decelerate the limb

• Pain relieved when stride is shortened → IFI or PHT, but IFI more likely

  • Mechanism: Shortening the stride reduces hip extension and decreases quadratus femoris compression

• Pain worsens with faster walking or running → PHT more likely

  • Mechanism: Increased walking/running speed increases eccentric demand on the hamstrings

Interpretation:

• Hip hyperextension narrows ischiofemoral space, stressing quadratus femoris and proximal hamstring tendon

• Symptoms can mimic proximal hamstring tendinopathy or sciatic nerve irritation

What is the Active Piriformis Test?

Purpose: Assess piriformis/deep external rotator involvement causing sciatic-type symptoms.

How to Perform:

1. Pt side-lying with test leg on top

2. Flex top leg so foot rests on table

3. Palpate piriformis just lateral to ischium

4. Apply resistance at knee as pt actively abducts and ER hip
   

Positive Test: Reproduction of neurological symptoms.

Interpretation: Piriformis or obturator internus/gemelli complex involvement.

What is the Seated Piriformis Test?

Purpose: Assess piriformis/deep external rotator irritation or entrapment

How to Perform:

1. Pt seated upright at edge of table with hands on table

2. Clinician passively extends knee and IRs hip while palpating piriformis just lateral to ischium/near sciatic notch

Positive Test: Reproduction of pain at piriformis region or sciatic-line symptoms

Interpretation: Piriformis or deep external rotator irritation/entrapment

What is True Leg Length Test?

Purpose: Assess true structural leg length discrepancy

How to Perform:

• Pt supine

• Have pt bridge and return to neutral to clear pelvic asymmetry - the legs should be 15–20 cm (4–8 inches) apart and parallel to each other

• Measure ASIS to medial malleolus with tape measure
  

Positive Test: Side-to-side difference > 1–1.5 cm

Interpretation: True structural discrepancy in femoral or tibial bone length

What is Functional Leg Length Measurement?

Purpose: Assess apparent/functional leg length discrepancy from soft tissue or positional factors

How to Perform:

1. Pt supine

2. Have pt bridge and return to neutral

3. Measure umbilicus to medial malleolus bilaterally

Positive Test: Umbilicus-to-malleolus measurements differ while true structural lengths are equal

Interpretation: Functional discrepancy from soft tissue restriction, pelvic position, or alignment factors

What is the Weber-Barstow Maneuver?

Purpose: Screen for leg-length asymmetry

How to Perform:

1. Pt supine with hips & knees flexed

2. Pt bridges and returns to neutral

3. Examiner stands at end of table, places thumbs on distal medial malleoli

4. Examiner passively extends both legs and ompares the levels of the medial malleoli by observing the thumb positions

Positive Test: Unequal malleolar levels

Interpretation: Leg length discrepancy

What is the (Patellar) Pubic Percussion Test?

Purpose: Hidden hip fracture

• Femoral, periacetabular, iliopubic, or ischiopubic ramus fracture / bony integrity disruption
  

How to Perform:

1. Pt supine with legs extended

2. Pt holds stethoscope bell over pubic symphysis

3. Examiner taps/percusses each patella, starting with uninvolved side

4. Compare the sound quality (pitch and loudness) between sides
   

Positive Test: Dull or diminished sound and/or pain on affected side
Negative Test = Equal, clear sounds bilaterally

What is the Fulcrum Test?

Purpose: Femoral shaft stress fracture

How to Perform:

1. Pt seated edge of table with legs hanging

2. Examiner places their forearm under mid-thigh as fulcrum with hand on contralateral thigh

3. With the opposite hand, apply gentle but firm downward pressure superior to anterior knee (distal femur)

Positive Test:

• Sharp, localized anterior thigh/groin pain

• Apprehension/pain when the fulcrum arm passes under the fracture site

Prone Knee Bend Test

Nachlas Test

Femoral Nerve Tension Test

Purpose:

• Upper lumbar nerve root involvement (L2–L3)

• Quadriceps muscle flexibility/tightness

• Femoral nerve tension

How to Perform:

1. Pt prone

2. Stabilize pelvis on test side

3. Passively flex knee as much as possible, moving heel toward buttock

4. If knee flexion >90° is limited, extend hip while maintaining knee flexion

5. Monitor reproduction of pain in hip joint or SIJ

Positive Test: pain

• Pain in the lumbar region, buttock, or posterior thigh = L2–L3 nerve root irritation

• Pain in the anterior thigh = tight quadriceps OR femoral nerve stretching (paresthesia)

Sign of the Buttock

Purpose: Non-musclar lesion in the buttock or hip region, not just hamstring/sciatic restriction

How to Perform:

1. Pt supine

2. Examiner performs passive SLR

3. If hip flexion is limited, flex pt’s knee and try to flex hip further
   

Positive Test: Hip flexion does not increase even when knee is flexed

Interpretation: Non-muscular lesion/restriction in buttock or hip joint region (rather than sciatic nerve or hamstring muscle) such as ischial bursitis, neoplasm (tumor), abscess in the buttock, fracture, and hip joint pathology

What is the Flexion-Adduction Test?

Purpose: Screen for early hip dysplasia

How to Perform:

1. Pt supine

2. Passively flex test hip to 90° in neutral rotation, then move leg across body midline toward opposite hip

Positive Test: Inability to adduct the flexed hip past anatomical midline

Interpretation: Early/underlying hip dysplasia screen.

What is Ortolani's Sign?

Purpose: Screen newborns for developmental hip dysplasia/dislocated hip that can be reduced.

How to Perform:

1. Pt supine/newborn

2. Flex hips

3. Thumbs on inner knees/thighs; fingers along outer thighs/buttocks

4. Apply gentle traction, abduct thighs, and apply pressure against greater trochanters

Positive Test: Palpable/audible click or clunk as femoral head reduces into acetabulum; increased abduction obtained.

Interpretation: Displaced femoral head reduced back into acetabular socket. Valid only during first few weeks of life.

What is Barlow's Test?

Purpose: Screen infant hip instability/dislocatable hip in DDH

How to Perform:

1. Infant supine, hips flexed to 90°, knees flexed

2. Test each hip individually while stabilizing opposite femur/pelvis

3. Place middle finger over greater trochanter and thumb near inner knee/thigh

4. Abduct hip with forward pressure behind greater trochanter, then apply backward/outward pressure on inner thigh
   

Positive Test: Femoral head slips out over posterior lip and reduces again when pressure removed; click/clunk/jerk may be felt

Interpretation: Hip is unstable/dislocatable

What is Galeazzi Sign?

Purpose: Screen infants for unilateral developmental dysplasia of the hip

How to Perform: Infant supine, flex both hips and knees to 90° with feet flat on table. Compare knee heights

Positive Test: One knee sits noticeably lower or higher than the other

Interpretation: Unilateral DDH or femoral length/hip position asymmetry

Ober / Modified Ober Test

Purpose: TFL/IT band tightness or contracture - MLT

How to Perform:

1. Pt side-lying with lower leg flexed at hip & knee; examiner behind pt stabilizes pelvis

2. Passively abduct and extend upper test leg, then let it slowly drop toward table

3. Variations:

   1. Original: knee flexed increases femoral nerve tension and reduces ITB stretch

   2. Modified: knee extended increases ITB tension
      

Positive Test: Leg remains suspended or fails to adduct past horizontal toward table

Interpretation:

• Neurological symptoms (pain, paresthesia) may suggest femoral nerve irritation

Thomas / Modified Thomas Test

Purpose: Hip flexor contracture & rectus femoris length - MLT

Thomas Test:

• Pt supine on table

• Examiner observes lumbar spine for excessive lordosis

• Pt or examiner brings non-test knee to chest to flatten lumbar spine and stabilize pelvis

• Test leg remains extended on table

Modified Thomas Test:

• Pt starts seated at edge of table

• Pt lies back while holding non-test knee to chest to stabilize pelvis and flatten lumbar spine

• Test leg lowers off edge of table into hip extension
  

Positive Test:

• Test/opposite thigh rises off table or cannot remain flat

• Increased lumbar lordosis when pressing leg down also supports positive

Hip Rotator Tightness Test

Purpose: Lateral (IR) vs medial (ER) hip rotator muscle tightness - MLT

How to Perform:

1. Pt supine with hip and knee flexed to 90°

Testing Lateral Rotator (IR) Tightness:

1. Ask pt to medially rotate (IR) hip by moving foot outward

2. Normal hip IR ROM: approximately 30–40°

Testing Medial Rotator (ER) Tightness:

• Ask pt to laterally rotate (ER) hip by moving foot inward

• Normal hip ER ROM: approximately 40–60°
  

Positive Test: Limited hip IR or ER with muscle stretch end-feel (rather than a firm capsular one)

• Limited IR <30–40° = tight lateral rotators (piriformis, obturator internus, gemelli)

• Limited ER <40–60° = tight medial rotators (tensor fasciae latae, gluteus minimus)

Hip Adductor Contracture Test

Purpose:

• Adductor muscle tightness or contracture (adductor longus, brevis, magnus, and pectineus) - MLT

How to Perform:

1. Pt supine with ASISs level and balanced pelvis

2. Examiner passively abducts the test leg while monitoring pelvic motion

3. Normal hip abducts about 30–50° before ASIS moves

Positive Test:

• ASIS shifts before 30–50° of abduction

• Affected leg forms <90° angle with line joining ASISs

• Pelvis tilts upward on the test side or downward on the nontest side during abduction, preventing proper "pelvic” balancing

• Muscle stretch end-feel confirms muscular restriction rather than capsular/joint restriction

Interpretation: Adductor contracture may cause functional/apparent limb shortening and contribute to pelvic obliquity or gait asymmetry

Hip Abductor Contracture Test

Purpose:

• Hip abductor muscle tightness or contracture, primarily gluteus medius and gluteus minimus - MLT

How to Perform:

1. Pt supine with ASISs level and balanced pelvis

2. Examiner passively adducts the test leg while monitoring pelvic motion

3. Normal hip adducts about 30° before ASIS moves

Positive Test:

• ASIS shifts before 30° of adduction and muscle stretch end feel

• Affected leg forms >90° angle with line joining ASISs

• When attempting to rebalance the pelvis, the ASIS shifts downward on the affected side or upward on the opposite side, making pelvic alignment difficult

Interpretation: Abductor contracture may cause functional/apparent limb lengthening and contribute to pelvic asymmetry or altered gait mechanics

90-90 Hamstring Test

Purpose: Hamstring muscle length - MLT

How to Perform:

1. Pt supine with both hips and knees flexed to 90°

2. Pt may hold behind knees to stabilize hips

3. Pt actively extends one knee as far as possible while keeping hip at 90°

Positive Test: Inability to extend knee within 20° of full extension

Interpretation:

• The angle formed between the femur and tibia is called the popliteal angle

• Normal = knee extends to within 20° of full extension

Rectus Femoris Contracture Test

Purpose: Rectus femoris contracture or tightness - MLT

How to Perform:

1. Pt supine with knees bent over edge of table

2. Pt flexes non-test knee to chest and holds while test leg hangs over the table

3. Examiner observes whether test knee stays at 90°

4. Examiner may passively flex knee to 90° and see if it remains there

5. Palpate for muscle tightness and compare sides

Positive Test:

• Test knee does not remain at 90° and extends slightly when non-test hip/knee is flexed to chest

• Muscle stretch end-feel and palpable tightness support rectus femoris restriction

Interpretation: No palpable tightness or a firm/capsular end-feel suggests joint/capsular restriction instead of muscular restriction

What is Ely's Test?

Purpose: Assess rectus femoris adaptive shortening

How to Perform: Pt prone. Passively flex knee by moving heel toward ipsilateral buttock

Positive Test: Pelvis lifts into anterior tilt or hip flexion before full knee range

Interpretation: Rectus femoris tightness/shortening

What is the Straight Leg Raise Test for muscle length/neural tension?

Purpose: Assess hamstring length and sciatic nerve neural tension

How to Perform: Pt supine. Keep test leg straight and passively lift LE into hip flexion

Positive Test: Tension/pain between 30–70° suggests sciatic nerve neural tension; tightness only without neuro symptoms suggests hamstring tightness

Interpretation: Differentiate neural tension vs hamstring muscle tightness

What is the Step-Down Test?

Purpose: Assess ability to control multiple joints and provoke symptoms during a single-leg dynamic task.

Setup: 20-cm/8-inch to 25-cm step.

How to Perform:

1. Pt stands on test leg on step

2. Slowly bends stance knee to lower opposite heel until it lightly touches floor

3. Do not fully load non-stance leg

4. Perform 3 reps bilaterally

Positive/Abnormal: Arm abduction, forward/lateral trunk lean, pelvic drop/backward rotation, hip adduction/IR, knee valgus/unsteadiness, decreased depth, or loss of balance.

Interpretation: Hip instability or weakness of lateral rotators/hip abductors on stance leg. Anterior hip/groin pain may indicate hip joint irritability.

What is the Single Leg Squat Test?

Purpose: Assess dynamic control of quadriceps, hamstrings, gluteals, gastroc, balance, and symptom provocation.

Setup: Use 1.5-inch athletic tape to make a T shape: 6-inch horizontal line crossing a 10-inch vertical line.

How to Perform:

1. Pt stands barefoot with test leg centered on vertical line

2. Opposite knee flexed to 90°

3. Squat until horizontal tape just disappears beyond toes, then return to start

4. Practice allowed
   

Positive/Abnormal: Excessive trunk/pelvis/hip/knee deviations, limited squat depth, valgus collapse, loss of balance, trunk lean, or anterior hip/groin pain

Interpretation: Poor movement control and possible hip joint irritability.

What are the Star Excursion Balance Test and Y Balance Test?

Purpose: Assess dynamic balance, functional symmetry, postural stability, and LE injury risk

Setup: SEBT uses 8 lines at 45° like a star. YBT uses 3 directions: anterior, posteromedial, posterolateral with sliding targets

How to Perform:

1. Pt stands on one leg and reaches as far as possible with non-stance leg, lightly touches, and returns to center without losing balance

2. Usually 3 trials/leg; average reach distance

Invalid Trial: Weight shift, heavy touchdown, or stance foot movement

Interpretation:

• Compare sides and normalize to leg length

• Involved LE should often reach ≥90% of uninvolved for return-to-sport guidance

• FAI may show deficits in posteromedial/posterolateral directions

What are the key Y Balance / SEBT directions commonly tested?

Answer: Anterior, posteromedial, and posterolateral

Why: These 3 directions strongly overlap with the 8-direction SEBT and make testing faster while maintaining accuracy

Clinical Use: Assesses dynamic balance, glute med strength demand, coordination, and functional symmetry