Hip Evaluation Notes

History

  • Prior Medical Conditions

    • Congenital or childhood diseases: Legg-Calve-Perthes disease, Slipped Capital Femoral Epiphysis (SCFE)

    • Menstrual history: Irregular or absent menses increase the risk of stress fractures (female athlete triad)

  • Location of Symptoms

    • Deep pain: May indicate issues with the coxofemoral joint, lumbar spine, or sacroiliac joint

    • Anterior pain: Often associated with hip flexors

    • Pain in the pubic area: Typically related to adductors

    • Posterior pain: May suggest greater trochanteric bursitis

  • Onset

    • Most hip injuries are chronic or due to overuse

History cont.

  • Aggravating Activities

    • Increased pain with bowel movements or coughing may indicate a hernia

  • Mechanism of Injury

    • Direct blow: Can cause a hip pointer injury

    • Sudden pain during eccentric contraction: Usually indicates a muscle strain

    • Pain that builds over time: Can lead to tendinopathies or stress fractures

Observation

  • Have patients demonstrate the positions that cause pain

  • Angle of Torsion

    • Anteverted femur: Leads to internal femur rotation, "pigeon toed" appearance

    • Retroverted femur: Leads to external femur rotation, "toe-out" gait

Palpation

  • Key bony landmarks for palpation include:

    • Anterior Superior Iliac Spine (ASIS) levels

    • Posterior Superior Iliac Spine (PSIS) levels

    • Iliac crest

    • Iliac fossa

    • Base of the sacrum

    • Sacroiliac joint

    • Ischial tuberosity

    • Pubic symphysis

Range of Motion / Manual Muscle Tests

  • Range of Motion (ROM)

    • Active, Passive, Resisted

    • Flexion, Extension, Abduction, Adduction, Internal Rotation, External Rotation

  • Manual Muscle Tests (MMT)

    • Semimembranosus

    • Semitendinosus

    • Biceps Femoris

    • Quadriceps

    • Glute Medius

    • Glute Maximus

    • Glute Minimus

    • Sartorius

    • Iliopsoas

Special Tests

  • Trendelenburg Test: Evaluates Glute Medius weakness

  • Thomas Test: Assesses hip flexor tightness

  • Ely’s Test: Assesses hip flexor tightness

  • Hip scouring test: Assesses for labral tears or articular cartilage defects

  • FABERs Test: (Flexion, ABduction, External Rotation) Used for multiple pathologies

  • FADIR Test: (Flexion, ADduction, Internal Rotation) Used for impingement, labral tears

  • Fulcrum Test: Used to identify stress fractures

FABER’s Test

  • (Flexion, abduction, external rotation)

    1. Sarcoiliac Joint Pain on external hip rotation

      • Sacroiliac Joint Dysfunction

      • Sacroiliitis

    2. Groin Pain on external hip rotation

      • Iliopsoas Strain or Iliopsoas Bursitis

      • Intraarticular Hip Disorder

        • Hip Impingement (femoral acetabular impingement)

        • Hip Labral Tear[8]

        • Hip loose bodies

        • Hip chondral lesion

        • Hip Osteoarthritis[10]

    3. Posterior Hip Pain on external hip rotation

      • Posterior Hip Impingement

Iliac Crest Contusion (Hip Pointer)

  • MOI: Direct blow to the Ilium

  • Rapid onset of swelling/redness, bruising overtime

  • Crepitus on palpation; associated muscles (obliques) may have spasms

  • Pain during hip flexion and trunk rotation/flexion

  • Rule out neurovascular damage

  • All muscles that attach to the ilium may be affected

  • Treatment: conservatively with padding, ice, NSAIDs

Hamstring Strains

  • Biceps Femoris most commonly involved

  • Occur during explosive activities

  • Strength deficits bilaterally and compared to the quads put patients at risk

  • Patients will report “popping” or “snapping” sensation

  • Palpation may reveal a divot in the muscle

  • Pain with resisted knee flexion and hip extension, as well as passive hip flexion (stretch)

  • Treatment: gradual stretching and strengthening, focusing on eccentric control of hip flexion

Quadriceps Contusion

  • Direct blow to the muscle belly

  • Results in death of muscle fibers

  • Limits knee extension strength

  • Limits knee flexion due to pain and spasm

  • Bruising and swelling are present

  • Limit activity if pain and weakness are present

  • Ice with knee flexed

  • DO NOT massage the area

  • Work on knee flexion range of motion

Femoral Neck Stress Fractures

  • Chronic pain in the femoral triangle, occurring during activity, with no pain at rest

  • Throbbing, burning pain may be present

  • Often associated with a sudden increase in intensity and distance of training

  • Possible tenderness to palpation (TTP) over the anterior hip

  • Limitations in extreme ranges of motion where the femoral neck is under torque

  • Rule out low back injury causing referred pain

  • Perform Fulcrum test

Labral Tears

  • Can be acute or degenerative

  • Pain in the anterior or medial hip

  • Patient may describe catching or locking sensations

  • MOI: Hip dislocation or subluxation; can also be insidious due to multiple subtle subluxations, hip impingement, repeated weight-bearing external rotation, abduction, or extension

  • Clicking or popping may be noted during ROM

  • Pain when moved from flexion, ER, ABduction to Extension, IR, ADduction

  • Perform hip scour test

  • Pain with internal rotation, flexion, and compression

Athletic Pubalgia

  • Tear of muscles in the pelvic floor or abdomen

  • Usually chronic, but one episode may result in severe localized pain

  • Pain is located in the pubic bone, symphysis, lower abs, and/or genitals

  • Pain is worse with coughing/sneezing

  • Hip abduction, adduction, flexion, and extension place a shear force across the pubic symphysis, creating stress on the inguinal muscles

  • Tenderness to palpation (TTP) over the adductor tendon, pubic tubercle, mid-inguinal region

  • Pain during active hip adduction

  • Weak adductors, sartorius, trunk flexion

  • Valsalva maneuver may elicit pain

  • Sudden movements of the hip joint will cause pain/weakness

Piriformis Syndrome

  • Pain deep in the posterior aspect of the hip, radiating down the posterior aspect of the leg

  • Pain decreases with supine position and knee flexion

  • MOI: Blow to the buttock, excessive internal rotation causing spasm of the piriformis

  • Pain during ER (contraction puts pressure on the sciatic nerve)

  • MMT pain during ER and hip abduction

  • Passive IR causes pain

Snapping Hip Syndrome

  • Pain, discomfort, and snapping over the greater trochanter (external type) or the anterior hip (internal type)

  • Internal type: Iliopsoas tendon contacting the femoral head or other structures

  • External type: IT band snapping over the greater trochanter

  • Hip flexion and extension produces snapping

  • Ask patient to demonstrate the motion that causes snapping; palpate during motion

  • Pain when hip is moved from flexed, ABducted, and ER to extension, ADDucted, and IR

  • Internal type is often associated with labral tears

  • Treatment: conservatively with NSAIDs, rest, stretch/soft tissue mobilization, strengthening

Hip Impingement Syndrome

  • Femoroacetabular impingement (FAI)

  • Abnormal contact between the head of the femur and the acetabulum

    • CAM impingement: Head of the femur is not perfectly round

    • PINCER impingement: The acetabulum has a longer anterior surface

  • Signs and Symptoms:

    • Stiffness, inability to fully flex the hip, pain in the groin, lower back, and hip

Trochanteric Bursitis

  • Acute or chronic

  • Pain over the greater trochanter; pain increases with stairs

  • Pain with pressure on the involved side

  • MOI: Direct blow; irritation from the IT band passing over the bursa

  • Tenderness to palpation (TTP) over the greater trochanter, crepitus

  • Flexion, Extension, ER, IR cause pain

  • Weak hip extension, adduction

  • Ober’s test may be positive

  • Treatment: soft tissue lengthening, NSAIDs, strengthening of weak musculature

Therapeutic Exercises

  • Common Muscular imbalances and problems with hip/knee pathologies:

    • Weak Glute Medius
      *Leads to overuse knee injuries (IT band syndrome, patellofemoral syndrome, patellar tendonitis), back pain, overactive adductors, shin splints

    • Tight/weak hamstrings
      *Leads to hamstring strains, low back pain, hip pain

    • Tight/overactive hip flexors
      *Anterior pelvic tilt, low back pain, sacroiliac dysfunction

    • Poor gluteals control
      *Leads to hamstring strains, low back pain

    • Tight hip rotators
      *Leads to shoulder tightness, sciatica

How to fix weak glute medius

  • Diagnosed by Trendelenburg's sign or MMT

  • Performs abduction, internal rotation, slight extension

  • Common exercises to strengthen glute med:

    • Clam shells

    • Glute med series

    • Lateral/monster band walks

    • Side shuffles

    • Single leg balance

    • Standing hip abduction

    • Side planks

    • Jumping to single leg landing

How to fix tight/weak hamstrings

  • Ways to diagnose tight hamstrings

    • Compare bilaterally with straight leg raise test and 90/90 test

  • Ways to diagnose weak hamstrings

    • MMT

  • Hamstrings perform hip extension/knee flexion. Stretch with knee extension/hip flexion

  • Ways to fix hamstring tightness

    • Nerve flossing

    • PNF stretching

    • Myofascial release

    • ART

    • 3-way hamstring stretch

  • Common exercises to strengthen hamstrings/rehabilitate hamstring strains

    • Romanian deadlifts

    • Glute/Ham raises

    • Bridges

    • Side shuffle with/without band

    • Single leg balance exercises

    • Squat on uneven surface

    • Hamstring curls

    • Planks (regular/side planks)

    • Plants with hip extension/abduction

How to fix tight/overactive hip flexors

  • Diagnose with Thomas test/Ely’s test

  • MMT Glutes (generally will be a little weak)

  • Exercises to fix tight/overactive hip flexors:

    • Myofascial release with tennis ball

    • ART for hip flexors

    • Hip flexors pnf stretch

    • Psoas release

    • Glute activation exercises

    • Self stretch hip flexors

    • Core strengthening

How to fix poor glute control

  • How to diagnose: evaluate muscular contraction for all three glutes, generally the hamstrings will contract before the glute max if it has poor control

  • Exercises to fix poor glute control

    • Quadruped glute activation

    • 3-way quad stretch with glute activation

    • Bridges

    • planks/side planks

    • Squats with bands

How to fix tight hip rotators

  • How to diagnose: could potentially have numbness and tingling down leg, limited hip external rotation

  • Exercises to treat tight hip rotators

    • Foam roll

    • Myofascial release

    • Piriformis stretch

    • Hip release

Other Common therapeutic exercises

  • Lunge variations

    • Single leg, lunges on bosu ball, plyometric lunges, side lunges, 3-way lunges

  • Squat variations

    • Wall squats, air squats, squats on bosu ball, single leg squats, squats with bands, sumo squats, squat jumps

  • Step up variations

    • Explosive step ups, lateral step ups

  • Plyometrics

    • Box jumps, lateral box jumps, dot drills, broad jumps, skater jumps, single leg hops, Depth jumps

  • Open chain exercises

    • Leg lifts, side lying abduction, leg extensions, short arc quads, hip extensions

  • Core exercises

    • Plank variations, ab roll ups, quadruped variations, superman's, Russian twists, leg lifts, leg throw downs

  • Balance exercises

    • Single leg balance (eyes opened and closed), marching exercises, single leg stance with functional activities, single leg RDLs, jumps to single leg landing