Hip Exam and Interventions

What questions should you ask during your history?

Any N/T or symptoms beyond the knee?

Any changes in running/training/exercise routine?

Do symptoms change with lumbar movements?

Any stiffness? If so, when and how long does it last?

Any catching/clicking/snapping?

What is the lower extremity functional scale (LEFS)?

Self-reported measure

Rank difficulty of ADL

Sports subscale available as well

Lower score indicates greater disability

MDC/MCID = 9

What is the flow of the hip exam?

History/subjective/constitutional s/s

Cardio screen

UQ neuro screen

Clinical movement assessment

Screening (lumbar/knee overpressure)

Static postural assessment

AROM/PROM

Strength (MMT)

Palpation

Special tests

What should you do during the lumbar screening?

Seated extension/rotation

Slump test

Repeated motions

Straight leg raise

If your pt has dysfunctional MS flexion on SFMA, what should you check?

Active/passive SLR

Double knees to chest

Prone rock test

If your pt has dysfunctional MS extension on SFMA, what should you check?

Active/passive SLR lumbar locked thorax rotation/extension

Prone on elbow lumbar rotation/extension

FABER

Modified Thomas test

If your pt has dysfunctional MS rotation on SFMA, what should you check?

Seated and prone ER/IR

What are the extra-articular conditions of the hip?

Muscle strain/tear

Stress fracture

Athletic pubalgia

IT band syndrome

Trochanteric bursitis

Piriformis syndrome

Snapping hip

What are the trauma conditions of the hip?

Hip/femur fracture

What are the intra-articular conditions of the hip?

Femoral-acetabular impingement (FAI)

Acetabular labrum tear

Degenerative arthritis (OA)

What are the congenital/pediatric conditions of the hip?

Legg-Calve-Perthes disease

Slipped capital femoral epiphysis

Avascular necrosis of femoral head

What is the common presentation of hip/femur fx?

Over age 60

Hip pain

Can't bear weight

**Trauma

What is important to remember about hip/femur fractures?

Mortality is high (30 day mortality rate 1-12%)

Permanent loss of function (up to 50%)

What are the special tests for hip/femur fx?

Fulcrum test

Patellar-pubic percussion

What are the different types of femur fx?

Subcapital neck

Transcervical neck

Intertrochanteric

Subtrochanteric

Fx of greater trochanter

Fx of lesser trochanter

What is the fulcrum test for hip fx?

Pt is seated. PT places arm under painful leg and hand on opposite leg. PT applies a downward force at distal femur on painful side

Positive test = reproduction of pain

What is the patellar-pubic percussion test?

Place stethoscope over pubic bone, tap on patella

**Listening for difference from side to side

What is the presentation of a hamstring strain/tear?

Typically ages 15-45

Due to sudden overload of hamstrings (usually eccentric)

Pain typically in post thigh or buttock

How to clinically diagnose a hamstring strain/tear?

Pain with resisted testing (hip ext, knee flex) and passive SLR; tenderness over hamstring muscle belly

What are the additional special tests for hamstring injury?

Puranen-Orava test

Bent knee stretch test

Modified bent knee stretch test

What is the "take off the shoe test"?

Pretty self explanatory

Ask the pt to take their shoe off the painful side

Positive test = pt reports pain with mvmt

What is a 1st degree hamstring injury?

Pathophys- tearing of only a few muscle or tendon fibers

S/S - Minor swelling and discomfort with no or minimal loss of strength

What is a 2nd degree hamstring injury?

Pathophys - more severe partial tear without complete disruption of of the musculotendinous unit

S/S - clear loss of strength with more discomfort

What is a 3rd degree hamstring injury?

Pathophys -a complete rupture of musculotendinous unit

S/S - total lack of muscle function and commonly associated with massive hematomas

How to diagnose other muscle strains in the hip?

Same concept as hamstring (exam and grading can be applied to other muscles - adductor, quads, etc)

Generally pain with resistance and stretching of involved muscle

What is the adductor squeeze test for muscle strain?

Pt in hook lying. PT places fist between pt's legs. Ask pt to squeeze fist

Positive test = pain and/or weakness

What are additional adductor injury tests?

Hip flexed to 30 degrees, pt resists abduction motion

- can do single or bilateral

Positive test = pain is reproduced

What is the presentation of femoral neck stress fx?

Persistent groin pain that worsens with activity

Usually in endurance athletes/training errors (female athlete triad)

**Pain with ROM, tenderness to greater trochanter

What is the female athlete triad?

Low energy availability (disordered eating), Irregular period (amenorrhea), Low bone density (osteoporosis)

What is the additional test for hip fx?

Heel strike test (no metrics)

What is the presentation of adductor tendinopathy?

Usually point tender and pain localized to pubic tubercle

Commonly associated with twisting the foot planted, repetitive kicking, sudden changes in directions, lateral movements

May have associated pelvic floor weakness (Ask about incontinence)

*sometimes called a sports hernia

What is the description of adductor tendinopathy?

"disruption and/or separation of the more medial common aponeurosis from the pubis, usually with some degree of adductor tendon pathology"

Commonly seen in soccer and hockey players

What is the clinical diagnosis of adductor tendinopathy?

Deep groin/lower abdominal pain

Pain exacerbated with exertion (sprinting, cutting, sit-ups but improves with rest)

TTP pubic ramus

What is the special test for adductor tendinopathy?

Single adductor test

What are the 2 types of snapping hip syndrome?

External = iliotibial band syndrome

Internal = iliopsoas bursitis

What is iliotibial band syndrome?

Gradual onset of lateral hip, thigh or knee pain

May have snapping over greater trochanter

What is the Ober test for IT band syndrome?

Examined leg up, abduct and extend hip until it is in line with the trunk; allow gravity to adduct hip as much as possible

Positive test = if unable to adduct to horizontal position and/or pain

What is tronchanteric bursitis?

May have history of trauma or overuse

Difficulty lying on affected side

What is the clinical diagnosis of trochanteric bursistis?

TTP greater trochanter; pain with active and resisted hip abd or ER

What is the special test for trochanteric bursitis?

Trendenlenburg sign

What is the presentation of ilipsoas bursitis?

Deep snapping sensation (even with walking)

Common in sports with forceful, repetitive hip flex/ext

May reproduce symptoms with active or passive hip flex/ext; painful resisted hip flexion; usually limited hip extension

What is the presentation of piriformis syndrome?

Gradual onset of buttock or posterior thigh pain, mimics radiculopathy (pain will stay above the knee)

May have pain with transitional mvmts (bending, stooping)

What is the FAIR test for piriformis syndrome?

Pt is sidelying on uninvolved side

Involved side is flexed to 90 degrees and maximally adducted before adding passive IR

Positive test = symptoms reproduced

What is the presentation of FAI?

2 types

Can be associated with labral tears

Commonly seen in active individuals

May be due to limited capsular mobility

Where is a pt's pain with FAI?

Groin

C - sign: pt indicates pain over anterolateral hip (deep pain)

What is the FADDIR special test for FAI?

Passive combined flexion, adduction, IR in supine

Positive test = reproduction of groin pain and/or clicking

*can also add axial compression

What are the additional special test for FAI?

Flexion IR test

Internal rotation-flexion-axial compression test

What is the special test for FAI/Labral tear/Intra-articular pathology?

Patrick (FABER) test

Positive test = reproduction of pain, clicking, catching is noted; also quality and quantity of motion

**not great metrics

What is the presentation of an acetabular labrum tear?

Wide age range

Women > men

Groin pain (up to 55%)

No known MOI (74%)

Who is at risk for acetabular labrum tears?

Runners, pro athletes, or rotational sports; gym attendance of 3x/week

How do you diagnose a labrum tear?

FADIR, FADIR + axial compression, Flexion/IR, etc. all have great sensitivity

No tests to confidently rule in

Arthrogram MRI is best option to capture

What is the special test for labrum tear?

Report of clicking in hip (best option)

What special tests can be used to elicit a click?

Fitzgerald test (SN= .98): D1/D2 PNF pattern

McCarthy test: passively go from flexion to extension

What is the presentation of Degenerative arthritis?

Age >60

Reports pain and stiffness in hip that may radiate to the groin

Reports morning stiffness that lasts <1 hour, generally gets better with mvmt

Limited IR in early stages; all ranges limited as OA progresses

What is the Scour test for OA?

Pt in supine, passively flexes the symptomatic hip to 90 degrees and then move the knee toward the opposite shoulder and applies an axial load to the femur

What happens if a pt reports pain in ER, flexion, abduction during Scour test?

Doesn't fulfill criteria but still need to document the test reproduced pain and where the pt felt it

According to the 2017 clinical practice guidelines, what is the hip OA diagnostic criteria?

Pt is over 50 AND:

- moderate anterior or lateral hip pain during WB activities

- morning stiffness less than an hour in duration after waking

- hip IR ROM less than 24 degrees OR IR and hip flexion 15 degrees less than non-painful side

- AND/OR increased hip pain associated with passive hip iR

What is the CPR for OA (2008)?

- Squatting aggravates symptoms

- Lateral pain with hip flexion

- Scour test with adduction causing lateral hip pain or groin pain

- Pain with active hip extension

- Passive IR of 25 degrees or less

**4+ variables = SP .98, LR+ 24.3

**5 variables = SP .98, LR+ 7.3

What are some functional tests for hip OA?

30 second chair stand test

4-square step test

Step test

Timed single leg stance

Berg Balance Scale

Timed up and go

6 minute walk test

Stair measure

How do we differentiate between OA and FAI/labral tear?

Symptoms we expect for FAI or labral tear: clicking, C sign, young, active individuals

- flexion and IR reproduce pain, joint restrictions in 1 plane, ROM limitation in 1 plane

Symptoms for OA: morning stiffness, groin/lateral pain, older

- joint restrictions in multiple planes, ROM loss in multiple planes, pain w WB activities

How to differentiate between OA and trochanteric bursitis?

Bursitis: don't expect joint restrictions, positive Ober test, can't lay on that side

What is the diagnosis of Legg-Calve-Perthes?

Decreased blood flow to the femoral head which leads to avascular necrosis

Roughly 4x more common in males, ages 2-13

Familial link (20-25%)

What is the presentation of Legg-Calve-Perthes?

Insidious onset (1-3 months) of limp; may be accompanied by groin

May have pain during or immediately after activity, but pain-free at rest

May have quad atrophy

Will have limited hip ABduction and IR

Interventions include Petrie casting (4-6 weeks) - prefer this method

What is the diagnosis of Slipped Capital Femoral Epiphysis (SCFE)?

Displacement of the upper femoral epiphysis

Age 8-17 years

Slightly more common in males (60%)

Obesity is a risk factor (95%)

What is the presentation of SCFE?

Most are insidious, but can have trauma

Reports dull, vague, intermittent pain in hip, thigh, knee

Limited and painful IR, leg is typically in ER

Difficulty WB (limp)

Risk for avascular necrosis

How do we differentiate between Legg-Calve-Perthes and SCFE?

LCP:

- pain with activity, better with rest

- younger, usually boys

- No pain with IR

SCFE:

- typically high BMI, boys (a bit older)

- Painful IR, stay in FABER position

What is the diagnosis of avascular necrosis (AVN)?

Anterolateral region of femoral head most commonly affected, may be due to trauma

What is the presentation of AVN?

Dull ache or throbbing usually in groin, may radiate to lateral hip or buttock

Age range varies

May have history of previous fracture, prolonged steroid use, alcoholism, or SCFE

Pain w/ROM, but especially extension (<15 degrees)

Antalgic gait/difficulty WB

What is the summary of hip exam?

- Several hip diagnoses exist but they look very similar

- The tests to differentiate between diagnoses aren't great, so we rely heavily on subjective and demographic info