Physical Examination Tests for Hip Dysfunction and Injury
Physical Examination Tests for Hip Dysfunction and Injury
Trendelenburg's Sign.Patient Position: Standing in front of the examiner, with both feet on ground.
Clinician Position: Observing the patient from the front.
Movement: The patient is instructed to lift one leg up by flexing their hip and knee, standing on only one leg (figure 1A).
(Enlarge Image)
Figure 1.
(A) Trendelenburg's sign. (B) Angle of measurement for Trendelenburg's sign.
Assessment: The clinician assesses the weight-bearing leg by evaluating the degree of drop of the contralateral pelvis once the leg is lifted. A pelvic on femoral angle with ≤83° angle criteria with specified time duration of 30 s was used as a positive sign. Figure 1B shows the pelvic on femoral angle (angle between the two lines).
Diagnostic Accuracy: Sensitivity (SN) 55%, specificity (SP) 70%, positive likelihood ratio (+LR) 1.83 and negative likelihood ratio (−LR) 0.82.
Special note: Monitor for patient compensating by leaning their trunk to avoid having pelvis drop. Leaning compensation constitutes a positive test as well.
Background: Generally considered a physical performance test of hip strength, this test has also been utilised for assessment of gluteal tendinopathy with a positive test being reproduction of spontaneous pain within 30 s on involved leg compared with the contralateral leg during single leg stance.
The use of a supporting stick was suggested in the hand only on the side of the weight-bearing hip. Alternatively, both shoulders could be supported by the examiner so as to maintain balance without a stick.
Commentary on Hip Osteoarthritis Tests. The Trendelenburg's sign alters post-test probability of a diagnosis to a very small degree. The clinician should carefully incorporate functional assessment (gait, stairs, etc) as part of the examination continuum even though they have not been specifically investigated for this cohort. In addition, consideration of additional components such as (1) more than one plane of motion restriction, (2) age >50 and (3) stiffness ≤60 min, are a necessity for clinical assessment of hip osteoarthritis.
Resisted External Derotation Test. Patient Position: Supine, hip flexed 90°, and in external rotation.
Clinician Position: Clinician, standing just to the side of leg being tested, slightly decreases external rotation just enough to relieve pain (if any was present).
Movement: Patient then actively returns the leg to neutral position (placing leg along the axis of the bed) against resistance (figure 2).
(Enlarge Image)
Figure 2.
Resisted external derotation test.
If test result is negative, the test is repeated with patient lying prone, hip extended and knee flexed to 90°.
Assessment: A positive test is spontaneous reproduction of patient's concordant pain.
Diagnostic Accuracy: SN 88%, SP 97.3%, +LR 32.6 and −LR 0.12.
Special Note: Monitor for patient compensation of grabbing onto table for stabilisation during test.
Background: The combination of passive stretch, followed by active contraction is likely to provide the tensile load across the involved structure(s).
Commentary on Gluteal Tendinopathy Tests. Only the resisted external derotation test demonstrated the ability to modify the post-test probability of a gluteal tendinopathy diagnosis. The sole study examining this test only had a sample size of 17 participants, with an average age of 68.1±10.8 years, thus limiting the external generalisability. The Trendelenburg's sign (as described above in the Hip osteoarthritis section) demonstrated a pooled SN of 61%, SP 92%, +LR 6.83 and −LR of 0.25; across three studies with 78 patients.
Impingement (Flexion-adduction-internal Rotation) (FADDIR) Test. Patient Position: Supine, bilateral legs extended.
Clinician Position: Standing at the side of the leg to be tested.
Movement: Clinician passively moves the patient's leg to 90° of hip and knee flexion. The leg is then passively adducted and internally rotated with overpressure to both motions at end-range (figure 3).
(Enlarge Image)
Figure 3.
Flexion-adduction-internal rotation test.
Assessment: A positive test is reproduction of concordant pain, locking, clicking and catching.
Pooled Diagnostic Accuracy: (MRA criterion reference) SN 94%, SP 8%, +LR 1.02, −LR 0.48; across four studies with 128 patients.
(Arthroscopy criterion reference) SN 99%, SP 7%, +LR 1.06, −LR 0.15; across two studies with 157 patients.
Special Note: Monitor for patient compensation of rolling trunk toward non-involved leg to avoid pain. Discordant lateral hip pain is a negative test.
Background: The combination motions of flexion, adduction and internal rotation cause an abutment between the femoral head and anterior acetabulum.
Flexion-internal Rotation Test. Patient position: Supine, bilateral legs extended.
Clinician Position: Standing at the side of the leg to be tested.
Movement: Clinician passively performs the combined movements of flexion to 90° and internal rotation (figure 4).
(Enlarge Image)
Figure 4.
Flexion-internal rotation test.
Assessment: A positive test is reproduction of concordant pain, locking, clicking or catching.
Pooled Diagnostic Accuracy: SN 96%, SP 17%, +LR 1.12, −LR 0.27; across three studies with 42 patients.
Special Note: Monitor for patient compensation of rolling trunk toward non-involved leg to avoid pain.
Background: This test produces a likely similar abutment described for the FADDIR test without the end-range adduction. In addition, moving from neutral adduction to end-range internal rotation could impinge an anterior labral tear.
Thomas Test. Patient Position: Sitting at the end of the table, feet on floor.
Clinician Position: Standing at end of table, directly facing patient.
Movement: Clinician passively lays the patient onto their back, bringing bilateral knees up to patient's chest. Patient holds non-tested leg toward their chest with bilateral arms as the clinician passively lowers the tested leg into extension. The clinician stabilises the ipsilateral side of the pelvis with their other arm (figure 5).
(Enlarge Image)
Figure 5.
Thomas test.
Assessment: A positive test is reproduction of painful click or concordant groin pain.
Diagnostic Accuracy: SN 89%, SP 92%, +LR 11.1 and −LR 0.12.
Special Note: Monitor for tightness/compensation of the lumbar spine arching, tested leg abducting and externally rotating.
Background: Although this test does not reproduce the mechanical abutment between the femoral head and acetabulum similar to the FADDIR or flexion internal rotation test, it does recreate hip extension, which has been shown to recreate the greatest forces on the hip joint.
Commentary on Impingement/Labral Tear/Intra-articular Pathology Tests. In general, these tests demonstrate better screening than diagnostic ability. The one study with the least risk of bias demonstrated that the Thomas test has value as both a screen and diagnostic test. Caution should be used though as this was only one study.
Patellar-pubic Percussion Test. Patient Position: Supine, bilateral legs extended.
Clinician Position: Standing at the side of the leg to be tested.
Movement: Clinician places a stethoscope over the pubic tubercle of the patient. Clinician taps the patella of patient's leg being assessed and qualitatively reports the sound. A tuning fork has also been used in place of tapping (figure 6).
(Enlarge Image)
Figure 6.
Patellar-pubic percussion test.
Assessment: A positive test is diminished percussion noted compared with contralateral side.
Pooled Diagnostic Accuracy: SN 95%, SP 86%, +LR 6.11, −LR 0.07; across three studies with 782 patients.
Special Note: Clinician must ensure that stethoscope is placed firmly over pubic tubercle and lateral to the pubic symphysis joint (on the side ipsilateral to side being tested).
Background: The sound produced with either tapping or the tuning fork is dampened with the fracture/stress fracture.
Fulcrum Test. Patient position: Sitting on side of table with bilateral distal portion of legs off the edge of the table. Patient is instructed to lean back on bilateral hands.
Clinician Position: Standing or kneeling to the side of the leg to be tested.
Movement: Clinician places one forearm under patient's thigh to be tested. Clinician arm is used as a fulcrum under the thigh and is moved from the distal to the proximal thigh as gentle pressure is applied to the dorsum of the knee with the opposite arm (figure 7).
(Enlarge Image)
Figure 7.
Fulcrum test.
Assessment: A positive test is reproduction of patient's concordant discomfort/sharp pain, usually accompanied by apprehension.
Diagnostic Accuracy: SN 93%, SP 75%, +LR 3.7, −LR 0.09; SN 88%, SP 13%, +LR 1.0, −LR 0.92.
Special note: The length of the femur assessed is limited due to the ability to place the arm under the assessed femur.
Background: Fulcrum and pressure applied in the direction opposite creates stress force to the area of suspected stress fracture.
Commentary on Fracture/Stress Fracture Tests. The patellar-pubic percussion test has strong diagnostic value as both a screen and diagnostic test. The use of stethoscope and tuning fork has previously been demonstrated as a valid measure for this diagnosis. Caution is suggested with the use of the stress fracture test (despite demonstrated ability to function as a screening test) due to high risk bias and small subject sizes in studies investigating this test.
Single Adductor Test. Patient position: Patient is supine with bilateral legs extended.
Clinician Position: Standing at patient's foot to be assessed.
Movement: Clinician passively flexes leg to be assessed to 30° with slight abduction and internal rotation. Patient resists the clinicians attempt to abduct the leg to be tested, effectively contracting their adductor muscles on that side (figure 8).
(Enlarge Image)
Figure 8.
Single adductor test.
Assessment: A positive test involves reproduction of patient's concordant pain.
Diagnostic Accuracy: SN 30%, SP 91%, +LR 3.3 and −LR 0.66.
Special Note: Force is applied at the ankle with the knee straight.
Background: As with the other sports related chronic groin tests, adduction contraction elicits stress across the common origin of the adductor muscles on the pubic symphysis region.
Squeeze Test. Patient position: Supine with bilateral hips flexed 45° and knees flexed 90° so that bilateral feet are flat on table.
Clinician Position: Standing at patient's bilateral knees, placing fist between knees.
Movement: Patient is asked to contract maximally both adductor muscles simultaneously to 'squeeze the fist' effectively (figure 9).
(Enlarge Image)
Figure 9.
Squeeze test.
Assessment: Reproduction of patient's concordant pain is considered a positive test.
Diagnostic Accuracy: SN 43%, SP 91%, +LR 4.8 and −LR 0.63.
Special Note: Monitor for patient compensation of lower trunk rotation.
Background: As with the other sports-related chronic groin tests, adduction contraction elicits stress across the common origin of the adductor muscles on the pubic symphysis region.
Bilateral Adductor Test. Patient Position: Patient is supine with bilateral legs extended.
Clinician Position: Standing at patient's bilateral feet, directly facing patient.
Movement: Patient is asked to contract maximally both adductor muscles simultaneously, thereby attempting to bring bilateral legs together (figure 10).
(Enlarge Image)
Figure 10.
Bilateral adductor test.
Assessment: Reproduction of patient's concordant pain is considered a positive test.
Diagnostic Accuracy: SN 54%, SP 93%, +LR 7.7 and −LR 0.49.
Special Note: Monitor for compensations of patient grabbing onto table and/or bending knees.
Background: As with the other sports related chronic groin tests, adduction contraction elicits stress across the common origin of the adductor muscles on the pubic symphysis region.
Commentary on Sports Related Chronic Groin Pain Tests. The bilateral adductor test was the most diagnostic of these tests, with the potential to alter post-test probability to a moderate degree. The other two tests, single adductor test and the squeeze test, also have greater capability as a diagnostic versus screening test. Both of these tests can alter posttest probability to a small degree.
Physical Examination Tests of the Hip
Hip osteoarthritis
Trendelenburg's Sign.Patient Position: Standing in front of the examiner, with both feet on ground.
Clinician Position: Observing the patient from the front.
Movement: The patient is instructed to lift one leg up by flexing their hip and knee, standing on only one leg (figure 1A).
(Enlarge Image)
Figure 1.
(A) Trendelenburg's sign. (B) Angle of measurement for Trendelenburg's sign.
Assessment: The clinician assesses the weight-bearing leg by evaluating the degree of drop of the contralateral pelvis once the leg is lifted. A pelvic on femoral angle with ≤83° angle criteria with specified time duration of 30 s was used as a positive sign. Figure 1B shows the pelvic on femoral angle (angle between the two lines).
Diagnostic Accuracy: Sensitivity (SN) 55%, specificity (SP) 70%, positive likelihood ratio (+LR) 1.83 and negative likelihood ratio (−LR) 0.82.
Special note: Monitor for patient compensating by leaning their trunk to avoid having pelvis drop. Leaning compensation constitutes a positive test as well.
Background: Generally considered a physical performance test of hip strength, this test has also been utilised for assessment of gluteal tendinopathy with a positive test being reproduction of spontaneous pain within 30 s on involved leg compared with the contralateral leg during single leg stance.
The use of a supporting stick was suggested in the hand only on the side of the weight-bearing hip. Alternatively, both shoulders could be supported by the examiner so as to maintain balance without a stick.
Commentary on Hip Osteoarthritis Tests. The Trendelenburg's sign alters post-test probability of a diagnosis to a very small degree. The clinician should carefully incorporate functional assessment (gait, stairs, etc) as part of the examination continuum even though they have not been specifically investigated for this cohort. In addition, consideration of additional components such as (1) more than one plane of motion restriction, (2) age >50 and (3) stiffness ≤60 min, are a necessity for clinical assessment of hip osteoarthritis.
Gluteal Tendinopathy
Resisted External Derotation Test. Patient Position: Supine, hip flexed 90°, and in external rotation.
Clinician Position: Clinician, standing just to the side of leg being tested, slightly decreases external rotation just enough to relieve pain (if any was present).
Movement: Patient then actively returns the leg to neutral position (placing leg along the axis of the bed) against resistance (figure 2).
(Enlarge Image)
Figure 2.
Resisted external derotation test.
If test result is negative, the test is repeated with patient lying prone, hip extended and knee flexed to 90°.
Assessment: A positive test is spontaneous reproduction of patient's concordant pain.
Diagnostic Accuracy: SN 88%, SP 97.3%, +LR 32.6 and −LR 0.12.
Special Note: Monitor for patient compensation of grabbing onto table for stabilisation during test.
Background: The combination of passive stretch, followed by active contraction is likely to provide the tensile load across the involved structure(s).
Commentary on Gluteal Tendinopathy Tests. Only the resisted external derotation test demonstrated the ability to modify the post-test probability of a gluteal tendinopathy diagnosis. The sole study examining this test only had a sample size of 17 participants, with an average age of 68.1±10.8 years, thus limiting the external generalisability. The Trendelenburg's sign (as described above in the Hip osteoarthritis section) demonstrated a pooled SN of 61%, SP 92%, +LR 6.83 and −LR of 0.25; across three studies with 78 patients.
Impingement/Labral Tear/Intra-articular Pathology
Impingement (Flexion-adduction-internal Rotation) (FADDIR) Test. Patient Position: Supine, bilateral legs extended.
Clinician Position: Standing at the side of the leg to be tested.
Movement: Clinician passively moves the patient's leg to 90° of hip and knee flexion. The leg is then passively adducted and internally rotated with overpressure to both motions at end-range (figure 3).
(Enlarge Image)
Figure 3.
Flexion-adduction-internal rotation test.
Assessment: A positive test is reproduction of concordant pain, locking, clicking and catching.
Pooled Diagnostic Accuracy: (MRA criterion reference) SN 94%, SP 8%, +LR 1.02, −LR 0.48; across four studies with 128 patients.
(Arthroscopy criterion reference) SN 99%, SP 7%, +LR 1.06, −LR 0.15; across two studies with 157 patients.
Special Note: Monitor for patient compensation of rolling trunk toward non-involved leg to avoid pain. Discordant lateral hip pain is a negative test.
Background: The combination motions of flexion, adduction and internal rotation cause an abutment between the femoral head and anterior acetabulum.
Flexion-internal Rotation Test. Patient position: Supine, bilateral legs extended.
Clinician Position: Standing at the side of the leg to be tested.
Movement: Clinician passively performs the combined movements of flexion to 90° and internal rotation (figure 4).
(Enlarge Image)
Figure 4.
Flexion-internal rotation test.
Assessment: A positive test is reproduction of concordant pain, locking, clicking or catching.
Pooled Diagnostic Accuracy: SN 96%, SP 17%, +LR 1.12, −LR 0.27; across three studies with 42 patients.
Special Note: Monitor for patient compensation of rolling trunk toward non-involved leg to avoid pain.
Background: This test produces a likely similar abutment described for the FADDIR test without the end-range adduction. In addition, moving from neutral adduction to end-range internal rotation could impinge an anterior labral tear.
Thomas Test. Patient Position: Sitting at the end of the table, feet on floor.
Clinician Position: Standing at end of table, directly facing patient.
Movement: Clinician passively lays the patient onto their back, bringing bilateral knees up to patient's chest. Patient holds non-tested leg toward their chest with bilateral arms as the clinician passively lowers the tested leg into extension. The clinician stabilises the ipsilateral side of the pelvis with their other arm (figure 5).
(Enlarge Image)
Figure 5.
Thomas test.
Assessment: A positive test is reproduction of painful click or concordant groin pain.
Diagnostic Accuracy: SN 89%, SP 92%, +LR 11.1 and −LR 0.12.
Special Note: Monitor for tightness/compensation of the lumbar spine arching, tested leg abducting and externally rotating.
Background: Although this test does not reproduce the mechanical abutment between the femoral head and acetabulum similar to the FADDIR or flexion internal rotation test, it does recreate hip extension, which has been shown to recreate the greatest forces on the hip joint.
Commentary on Impingement/Labral Tear/Intra-articular Pathology Tests. In general, these tests demonstrate better screening than diagnostic ability. The one study with the least risk of bias demonstrated that the Thomas test has value as both a screen and diagnostic test. Caution should be used though as this was only one study.
Femoral Fracture/Stress Fracture
Patellar-pubic Percussion Test. Patient Position: Supine, bilateral legs extended.
Clinician Position: Standing at the side of the leg to be tested.
Movement: Clinician places a stethoscope over the pubic tubercle of the patient. Clinician taps the patella of patient's leg being assessed and qualitatively reports the sound. A tuning fork has also been used in place of tapping (figure 6).
(Enlarge Image)
Figure 6.
Patellar-pubic percussion test.
Assessment: A positive test is diminished percussion noted compared with contralateral side.
Pooled Diagnostic Accuracy: SN 95%, SP 86%, +LR 6.11, −LR 0.07; across three studies with 782 patients.
Special Note: Clinician must ensure that stethoscope is placed firmly over pubic tubercle and lateral to the pubic symphysis joint (on the side ipsilateral to side being tested).
Background: The sound produced with either tapping or the tuning fork is dampened with the fracture/stress fracture.
Fulcrum Test. Patient position: Sitting on side of table with bilateral distal portion of legs off the edge of the table. Patient is instructed to lean back on bilateral hands.
Clinician Position: Standing or kneeling to the side of the leg to be tested.
Movement: Clinician places one forearm under patient's thigh to be tested. Clinician arm is used as a fulcrum under the thigh and is moved from the distal to the proximal thigh as gentle pressure is applied to the dorsum of the knee with the opposite arm (figure 7).
(Enlarge Image)
Figure 7.
Fulcrum test.
Assessment: A positive test is reproduction of patient's concordant discomfort/sharp pain, usually accompanied by apprehension.
Diagnostic Accuracy: SN 93%, SP 75%, +LR 3.7, −LR 0.09; SN 88%, SP 13%, +LR 1.0, −LR 0.92.
Special note: The length of the femur assessed is limited due to the ability to place the arm under the assessed femur.
Background: Fulcrum and pressure applied in the direction opposite creates stress force to the area of suspected stress fracture.
Commentary on Fracture/Stress Fracture Tests. The patellar-pubic percussion test has strong diagnostic value as both a screen and diagnostic test. The use of stethoscope and tuning fork has previously been demonstrated as a valid measure for this diagnosis. Caution is suggested with the use of the stress fracture test (despite demonstrated ability to function as a screening test) due to high risk bias and small subject sizes in studies investigating this test.
Sports Related Chronic Groin Pain
Single Adductor Test. Patient position: Patient is supine with bilateral legs extended.
Clinician Position: Standing at patient's foot to be assessed.
Movement: Clinician passively flexes leg to be assessed to 30° with slight abduction and internal rotation. Patient resists the clinicians attempt to abduct the leg to be tested, effectively contracting their adductor muscles on that side (figure 8).
(Enlarge Image)
Figure 8.
Single adductor test.
Assessment: A positive test involves reproduction of patient's concordant pain.
Diagnostic Accuracy: SN 30%, SP 91%, +LR 3.3 and −LR 0.66.
Special Note: Force is applied at the ankle with the knee straight.
Background: As with the other sports related chronic groin tests, adduction contraction elicits stress across the common origin of the adductor muscles on the pubic symphysis region.
Squeeze Test. Patient position: Supine with bilateral hips flexed 45° and knees flexed 90° so that bilateral feet are flat on table.
Clinician Position: Standing at patient's bilateral knees, placing fist between knees.
Movement: Patient is asked to contract maximally both adductor muscles simultaneously to 'squeeze the fist' effectively (figure 9).
(Enlarge Image)
Figure 9.
Squeeze test.
Assessment: Reproduction of patient's concordant pain is considered a positive test.
Diagnostic Accuracy: SN 43%, SP 91%, +LR 4.8 and −LR 0.63.
Special Note: Monitor for patient compensation of lower trunk rotation.
Background: As with the other sports-related chronic groin tests, adduction contraction elicits stress across the common origin of the adductor muscles on the pubic symphysis region.
Bilateral Adductor Test. Patient Position: Patient is supine with bilateral legs extended.
Clinician Position: Standing at patient's bilateral feet, directly facing patient.
Movement: Patient is asked to contract maximally both adductor muscles simultaneously, thereby attempting to bring bilateral legs together (figure 10).
(Enlarge Image)
Figure 10.
Bilateral adductor test.
Assessment: Reproduction of patient's concordant pain is considered a positive test.
Diagnostic Accuracy: SN 54%, SP 93%, +LR 7.7 and −LR 0.49.
Special Note: Monitor for compensations of patient grabbing onto table and/or bending knees.
Background: As with the other sports related chronic groin tests, adduction contraction elicits stress across the common origin of the adductor muscles on the pubic symphysis region.
Commentary on Sports Related Chronic Groin Pain Tests. The bilateral adductor test was the most diagnostic of these tests, with the potential to alter post-test probability to a moderate degree. The other two tests, single adductor test and the squeeze test, also have greater capability as a diagnostic versus screening test. Both of these tests can alter posttest probability to a small degree.
