Department Of Orthopaedics

KMC Mangalore
Examination of Hip Joint Movements, Measurements and Special tests
Moderators: Prof. B.J.Kamath Presenters: Dr.Vinay J Chacko
Date: 2 Octo!er" 2# Dr.Vi$ek P %ahar
Dr. Vi&ay 'eddy
Courage gives a leader the ability to stand straight and not sway no matter which
way the wind blowsfor this a stable hip is of utmost importance!
Movements : -
Expected Range of Movement
lexion: !-"#! $egrees
Anterior motion in the saggital plane is defined as hip flexion whereas posterior
motion is defined as extension. The patients knee is flexed during testing flexion
so as to prevent hamstring tightness from limiting the movement.
%bduction: !-&' $egrees
To test, abduction in extension, the examiner stands at the side of the patient
facing the supine patient. One of the examiners hands grasps the ankles while
the other hand is lightly placed over the ASIS. This allows the examiner to detect
any complimentary motion of the pelvis during aduction. The examiner then,
passively aducts the patients lower extremity away from the midline until the
pelvis is felt to !ust start moving. The angle etween the axis of the thigh and the
mid"line of the patient is measured. To test abduction in flexion, the hip is allowed
to fall outward into a position of aduction# the examiner assists as necessary.
one of the examiners hands is placed over the ASIS to detect the pelvis rotation
supplementing the aduction of the hip.
%dduction: !-#! $egrees
To test, adduction in extension, the examiner stands at the side of the patient
facing the supine patient. One of the examiners hands grasps the ankles while
the other hand is lightly placed over the ASIS. This allows the examiner to detect
any complimentary motion of the pelvis during aduction. The examiner then
passively adducts the patients lower extremity towards the midline. On reaching
the mid"line, it is necessary to flex the hips slightly to allow the extremity eing
tested to pass in front of the contra lateral lim. Again, the lim is adducted until
the pelvis is felt to !ust start moving. The angle etween the axis of the thigh and
the mid"line of the patient is measured. To test adduction in flexion, the examiner
grasps the patients knee and adducts the thigh ack across the midline while
gently pressing posteriorly on the ipsilateral ASIS to prevent the pelvis from
rotating.
MR: !-&' $egrees
(R: !-)! $egrees
$ip rotation also may e measured in oth the flexed and extended positions.
The rotational motions oserved in these two positions. The rotational ROM in
extension affects foot placement (in toeing or out toeing) during ambulation, and
thus its physiologically more important. $ip rotation in extension may e
assessed in either the supine or the prone position. To assess rotation in the
supine position, the patient is asked to lie comfortaly with the hips and knees
extended. %efore eginning examination, note the resting position of the lower
extremities. To assess the maximum possile external rotation possile, the
examiner grasps the patients feet, then uses them to fully externally rotate the
extremity at the hip. The orientation of the medial order of the foot may e used
to estimate the amount of external rotation present. The examiner then internally
rotates the entire lim and estimates the amount of internal rotation present. An
increase in internal rotation at the expense of external rotation may indicate
increased femoral anteversion. $ip rotation in extension may also e assessed
with the patient in prone position. In this case, the patients knees are flexed and
the axis of the tiia is used as an indicator of the amount of rotation present. One
must rememer that during internal rotation, the foot moves away from the
midline whereas during external rotation the foot moves across the midline.
Extension: !-*! $egrees
&or testing extension of the hip, the patient is in prone position , and the
examiner must ensure that only hip movement is occurring. 'umar extension
should not e allowed to occur.
The amount of motion needed to perform activities of daily living is at least ()*+degrees,
of flexion, )*+degrees, of aduction, and )*+degrees, of external rotation.
+,uaring the pelvis : -he limbs should be ad.usted in such a way that both
%+/+ come at the same level0 with the affected limb held in exaggerated
noted deformity 1adduction2abduction3 with both %+/+ e,uidistant from
umbilicus4
+,uaring the pelvis is difficult in :
" &ixed pelvic oli-uity
" Iatrogenic ASIS removed
" .al development of hemipelvis
" /nreduced dislocation of SI0
" .alunited vertical 1 of ilium
If any fixed deformity is found, the opposite movement $AS to e 2ero degree.
3.g. patient can not have extension of any degree with a fixed flexion deformity.
-homas -est : or diagnosing fixed flexion deformity of the hip
-homas /: 5atient supine0 /nsinuate your fingers under lumbar lordosis as6
the patient to flex the unaffected hip over the abdomen till lordosis
obliterated and as6 the patient to hold the 6nee in that position and loo6 for
fixed flexion deformity on the affected side4 -his has diagnostic value4
-homas //: %ssess further free flexion beyond the $4 -his has 5rognostic
/mportance4
&ree movement eyond the fixed deformity has to e assessed as further free
movement. Total movement thus e-uals fixed deformity 4 &urther active
movement 4 &urther passive movement.
5OT$A6I Angle to measure fixed aduction deformity 7 0oin oth ASIS in
unsquared pelvis, draw a perpendicular from each side ASIS over midline, the
angle etween these two lines gives fixed aduction deformity.
&ixed A%8/9TIO: is complimentary to S$O6T3:I:;. A88/9TIO: is
complimentary to '3:;T$3:I:;. 6oughly as a rule of thum 7 for each (cm of
TRUE shortening there should e (* degrees of fixed aduction deformity.
9ompensation for a deformity is for either or all of the following 7 9oncealing the
deformity, Attaining e-uilirium, Apparently make up for lim length discrepancy
and to staili2e the unstale hip. 3.g In &&8 hip extension is lost which is very
disaling to cover up for that the patient develops exaggerated lumar lordosis.
-o be chec6ed both 5assive 7 %ctive4 %ctive R8M gives an additional idea about
any axis deviation of the hip .oint4
PROM :
Capsular 5attern
( (imitation in flexion0 abduction and /R
) .ax loss Internal 6otation, moderate loss of flexion, and moderate
loss of aduction with minimal loss of extension < 0ames 9yriax
( 8rder may vary 9 only .oint to exhibit this
Minimal loss of extension : greater functional limitation than the same loss of
flexion
Measurements :
%pparent leg length : Measure from tip of xiphoid process to inferior border
of medial malleolus ;/-<8=- +>=%R/?@ -<E 5E(A/+4
%pparent +hortening /n apparent shortening the limb is not altered in
length0 but appears shortened4 -his may be as a result of an adduction
contracture of the hip .oint0 which has to be compensated for by tilting of
the pelvis0 or +/B pathology causing pelvic rotation
-rue leg length : Measure from %4+4/4+ to inferior border of medial
malleolus %-ER +>=%R/?@ -<E 5E(A/+
Measuring limb length : After S!AR"#$ the pel%is from AS"S to Medial
malleolar tip4
C(8CD ME-<8$- lock or locks of varying thicknesses may e placed under
the shorter lim of the shorter lim of the standing patient until the pelvic oli-uity
is eliminated and the imaginary line etween the iliac crests is parallel to the
floor. .easuring the thickness of the material necessary to level the pelvis yields
a fairly accurate estimate of leg length discrepancy.
emoral versus -ibial discrepancy : if a true leg length discrepancy is present,
further examination may determine whether the discrepancy is in the femur or
tiia. To detect a femoral discrepancy, the patient lies supine on the examination
tale with the hips and knees flexed to =* degrees. If one femur is longer than
the other, the patients knees rest at different heights from the examinational
tale. To detect a tiial length discrepancy, the patient is placed prone with the
knees flexed to =* degrees. If the tiias differ in length, the soles rest at different
heights. Although uncommon, shortening in the hindfoot >talus or calcaneus?can
also produce this appearance.
-rue +hortening In true shortening the affected lim is physically shorter than
the other and this may e caused y pathology proximal or distal to the
trochanters. True shortening from causes distal to the trochanters most
fre-uently results from previous fractures of the femur or tiia or growth
disturance >e.g. from polio or epiphyseal trauma?. @roximal to the trochanters
causes include femoral neck fractures, OA and hip dislocation.
-rue shortening indicates actual shortening and apparent indicates
compensation4 /f true shortening e,uals apparent 9 there is ?8
compensation4 /f -R=E shortening more than apparent 9 part of it is
compensated by fixed abduction deformity4 /f -R=E shortening is less than
apparent it indicates fixed adduction deformity and no compensation4
-otal limb length : emoral component E -ibial Component
emoral Component : +upratrochanteric length E /nfratrochanteric length
+upratrochanteric measurements :
CryantFs -riangle : Identify greater trochanter and ASIS. 0oin ASIS and greater
trochanter. 8rop a vertical from ASIS and !oin tip of greater trochanter with this
vertical lin at =* degrees. This line forms the ase of the %ryants triangle. This is
a measure of supratrochanteric length and is to e compared with the normal
side. $ypotenuse of the %ryants triangle forms a part of the :elatons line.
&A''A9A 7 8iscrepant results in ilateral affection of the hip !oint.
$raw on both sides
C : elevation of trochanter
C : anteropsterior movement
of trochanterG ?80
5ost dislocation
Morris Citrochanteric -est 7 'ines drawn connecting Symphysis puis and
greater trochanter and thy should measure e-ual normally. In supratrochanteric
shortening this is decreased.
ChieneFs -est : Two lines drawn, one !oining oth ASIS B other line !oining oth
greater trochanters. :ormally these lines are parallel. They intersect on the
affected side.
+hoema6erFs (ine : 'ines drawn %C' from ;T to ASIS should dissect at the
umilicus in the midline. In case of shortening this decussation is displaced
towards the unaffected side.
?elatonFs (ine : The patient lies on his sound side. 'ine drawn from ischial
tuerosity to ASIS, the tip of the greater trochanter !ust touches this line normally.
In supratrochanteric shortening tip will e aove this line.
+5EC/%( -E+-+
-rendelenburg +ign: The test is performed with the patients ack to the
examiner. The model stands on the normal leg and flexes the knee of the other
leg to a right angle. The pelvis should remain level or tilt slightly upwards on the
unsupported side. The model then stands on the affected leg and flexes the knee
of the other leg. If the pelvis tilts downwards on the unsupported side, then this
confirms a positive Trendelenerg sign. @atient made to stand at least D*
seconds to rule out any muscle weakness disorder.
$elayed positive -rendelenburg sign: Several people have an initial negative
test, ut after standing for a short time, with the non"stance side of the pelvis
raised, the pelvis gradually falls and they are not ale to maintain their initial
posture. This has een called a delayed positive Trendelenurgs sign. The time
at which the pelvis egins to drop should e calculated. In such people, the gait
can e normal ut when they are asked to walk -uickly, it ecomes apparen
t that they egin to fatigue easily, and a
limp with all the characteristics of a trendelenurgs gait ecome ovious.
5re Re,uisites of -rendelenberg -est:
" &633 A%8/9TIO:C A88/9TIO: O& )* 83;.
" A%'3 TO STA:8 O: A&&39T38 'I.% &O6 E D* S39.
" A;3 E F A3A6S.
/sed to assess the aility of the hip aductors to stailise the pelvis on the
femur. A positive test demonstrates that the hip abductors are not functioning.
Causes7
8isturance in pivotal mechanism < dislocation or suluxation of hip,
shortening of femoral neck
Geakness of the hip aductors e.g. myopathy, neuropathy
&allacies 7
Intact Huadratus 'umorum can produce &alse positive Test
SI 0oint involvement due to pain may produce pseudo positive
trendelenberg test
.edial shift of axis of the lim elow the knee e.g. ow knee etc can produce
a pseudo positive test
9auses of false negatives include 7 use of supra pelvic muscles, use of
psoas and rectus femoris, wide lateral translocation of trunk to allow alance
over the hip as a fulcrum.
(eg (ength -ests 1;eber Carstow Maneuver3 @ross emur (ength2@ross
-ibia (ength :
@atient supine with hips flexed IF deg and knees =* deg. 3xaminer palpates
medial malleolus with the thums. @atient lifts the pelvis of the couch and
returns. 3xaminer passively extends the legs, a difference in the level indicates
asymmetry.
REC-=+ EM8R/+ C8?-R%C-=RE -E+-+ :
ME-<8$ " :- The patient lies supine with the knees ent over the edge of the
examining tale. The patient flexes one knee onto the chest and holds it. The
angle of the test knee should remain at =*
*
when the opposite knee is flexed to
the chest. If it does not >i.e., the test knee extends slightly?, a contracture is
proaly present. Always palpate for muscle tightness. The two sides should e
tested and compared.
ME-<8$ * :- ElyFs -est : @atient lies prone, examiner passively flexes the
5nee 7 @OSITIJ3 sign" &lexion of the 5nee causes $ip on the same side to flex
%llis 2 @aleaHHi Manouvre : @atient supine with the knees flexed and the feet
approximated.
A difference in height of the knees K positive test >supine posture?.
5nee shifts cephalad in femoral shortening and caudad in tiial shortening. The
original Allis >aka ;alea22i? test was developed to identify gross hip deformity in
pediatric patients. The extension of this test to adults suspected of having
anatomical leg length ine-uality is prolematic, and needs refinement at the least
-elescoping -est : @atient supine , flex the hip to =* degrees, the pelvis is fixed
with one hand touching the greater trochanter. with the palm of one hand adduct
and push and pull the knee and with the other hand feel for the movement of
greater trochanter up and down. It indicates old non union fracture neck of femur,
paralytic hip or unreduced posterior dislocation of hip.
CraigFs -est 1RyderFs Method3 : @rone with 5nee flexed L =*, @alpate greater
trochanter, @assively Internally B 3xternally rotate until trochanter is parallel is
parallel to the tale. Angle etween the vertical and long axis of the leg gives
degree of anteversion.
5rone Dnee lexion -est for -ibial +hortening : Gith patient lying prone, flex
the knee y =* degrees check the levels of oth heels to determine tiial
shortenening of any etiology.
%/R 1lexion %dduction /nternal Rotation : %/R3 -est : @iriformis syndrome
is suggested y posterior hip pain caused y resisted external rotation of the hip
with the knee and hip flexed at =*+degrees, >@ace test? and y uttock or sciatic
pain exacerated y hip flexion, adduction, and internal rotation >&AI6 test?.
Anterior pain caused y resisted hip flexion and resisted straight leg raise
suggests hip flexor strain or tendinitis.
8ber -est : The Oer test is employed to test for a tight iliotiial and >IT%?, as is
often seen in patients who have trochanteric ursitis. The patient is positioned on
his or her side with the ottom leg flexed at oth the hip and knee. The top leg is
then extended and aducted. IT% contracture is present if the top leg does not
passively fall to the tale. This maneuver often exacerates pain over the greater
trochanter.
?obel Compression -est
>uadrant -est 2 +cour
Modified 8ber test : &-'
!
I 8ber test 1more abduction compared to 8berFs
-est 9 marginally improves sensitivity of the 8berFs -est3
?oble Compression -est 7 &or iliotibial band friction syndrome" @atient lies
supine with knee in =* degrees flexion and hip flexed, pressure over lateral
femoral condyle B with pressure maintained ask pt to extend the knee .
Approximately t D* degrees of flexion severe pain is felt over lateral condyle.
ErichsonFs +ign 7 Ghen iliac ones are sharply pressed towards each other pain
felt in the SI !oint region and not in the hip !oint.
<artFs +ign or (imitation of <ip %bduction -est 7 @t supine with oth hips
flexed to =* degrees B attempt to fully aduct the hips. &or a positive test
aduction is not full range. .ore useful for unilateral 88$ cases than for %ilateral
cases as assessment difficult in %C' cases.
8rtolaniFs -est : Infant supine " ;rasp thighs with thums medially B fingers
lateral at greater trochanter ;entle traction,aduction and med. directed
pressure on trochanter M9lickC9lunkN K6eduction. Jalid till "D wks. of irth B only
with dislocatedCsuluxed hips.
CarlowFs -est : .od. Of Ortolanis Test. Supine, hips =*
*
, knees extended ,
.iddle finger on ;.T., thum medial at '.T. Aduct $ip, with distal pressure on
;.T. @OSITIJ3 if MslipNC8islocation occurs. /se thum, apply post.Csup. &orce to
reduce Jalid in infants O P months. %ilateral alternate test.
5ositive +ign of the Cuttoc6 : Supine# perform S'6 test, If limitations on S'6
examiner flexes patients 5nee to see if further $ip flexion can e otained. If $ip
flexion does not increase, the lesion is in uttocks or $ip, not sciatic nerve or
$amstring muscle
+cour -est of <ip 2 >uadrant -est of <ip : lex and adduct hip4 Maintain
flexion and abduct hip in scouring fashion4 Examiner applies downward pressure along
the femoral shaft while repeatedly externally & internally rotating the hip with multiple angles of flexion =se
minimal force to elicit response4
8R-8(%?/ J+ -E+- C%R(8;F+
-E+-
5ositive -est
@ain or reproduction of symptoms at the hip
5ositive -est /mplications
8efect in the articular cartilage of the femur or acetaulum
@auvainFs +ign : Sir $enry ;auvain in (=(*" In active T% of the hip !oint
rotatory movements at the hip !oint produce contraction of muscles around the
hip !oint and adomen. $olding the lower end of femur, the thigh is rotated at the
!oint inwards and outwards. After movement is checked any further sharp rotation
is met with ipsilateral !oint and adominal muscle contraction. 6eason 7
Transmission of movement from hip to the trunk.
lexion 9 %dduction -est 7 Goods and .acnicol )**( < in a normal patient
the knee should adduct to Qone (, with pathologic changes only to Qones ) or D
>limitation )
*
to pain, apprehension, or limited end range? >4? for nonspecific hip
disease
+taheli -est : 5rone hip extension test : for flexion posture of hip (hips flexed
over end of couch, support pelvis posteriorly & passively extend hip). For children
with cerebral palsy.
ulcrum -est : @atient sits on exam tale with knee extended @lace one hand
under sitting patientRs femur Other hand placed over knee apply firm pressure
upward on femur B downward on knee. @OSITIJ3 if pain is elicited . Site of pain
is usually near site of stress fracture.
%nterior (abral -ear -est : 5ositive if pain or clic6 present on external
rotation of the hip4
5osterior (abral -ear -est : 5ositive if pain or clic6 present on internal
rotation of the hip4
+(R -est 1(asKgueFs test3 : %ctive +(R- indicates anatomical integrity from
foot to hip4 <owever can be false positive in an impacted fracture nec6 of
femur4
(aguerreLs +ign : This test is done with the patient supine while the thigh and
knee are flexed to right angles. Then the thigh is aducted and rotated outward.
This forces the head of the femur against the anterior portion of the hip !oint
capsule. The sign is present when this action produces pain, tending to rule out a
lumosacral lesion, ut indicating a hip !oint lesion, iliopsoas muscle spasm or a
sacroiliac lesion.
Fabere Sign or Patricks est *+est for ,- &oint pain.
/le0ion" 1!d2ction" 30ternal 'otation. Patient is s2pine and +he knee is fle0ed" the hip is
e0ternally rotated 4ith a!d2ction Positi$e finding ( if the knee does not drop !elo4 the
le$el of the opposite h ip.
5helpFs -est >Assessment for contracture of gracilis with associated
pathology of hip !oint? 7
@rocedure 7 @rone posture with knees extended and thighs maximally
aducted >pain B resistance? " Actively flex knees ilaterally to right angle
" :ote changes in hip aduction
6ationale
(. @ositive test if knee flexion increases hip aduction
). @ositive test if knee extension decreases hip aduction
D. Test indicates contracture of gracilis muscle
(udloffFs +ign >Assessment for traumatic separation of the lesser
trochanter?
@rocedure 7
Seated posture " /nale to raise affected lim from tale along with 3cchymosis
and edema in Scarpas triangle.
REERE?CE+ :-
(? 9linical Orthopaedic 3xamination < 6onald .c6ae < F
th
edition
)? A .anual on clinical surgery < S.8as < P
th
edition
D? $oppenfield 9linical 3xamination
I? Orthopaedic @hysical Assessment " 8avid 0..aggie < I
th
edition
F? 9linical Orthopaedic Tests < @rem @. ;ogia
P? The @elvifemoral Angle , $enry .ilch < 0%0S Am (=I)#)I7(IS"(FD
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