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● Introduce yourself and get the consent of the patient or the parent of the child for examination.
● Note down the name, age, sex, race and occupation of the patient.
● The patient should be adequately exposed while making sure that external genitalia are covered
and the patient is comfortable and relaxed. Explaining why you need to expose and the steps of
examination will help in relaxing the patient and in establishing a good rapport.
● When examining a female patient make sure that you have a female nurse or assistant.
● Examine the child with the parents by the side. Very young children may be examined in the
parent’s lap.
● First examine the normal or less symptomatic side first to establish the normal range of movement
for the particular patient and to make the patient understand what is going to be done on the
painful side.
● Steps of all procedures should be explained to the patient to ensure patient comfort and
cooperation.
Patients with hip joint disease may present with pain, alteration of gait, instability, functional limitation or
limb length discrepancy as their presenting complaint. Hip symptoms may be due to intra-articular,
extra-articular or referred causes. Intra-articular conditions usually will cause deformity, limitation of
range of movement and worsening of symptoms on joint activity. Extra-articular conditions usually will
not cause restriction of range of movement, pain will be present mainly in one particular movement or
position of joint and tenderness will be localized to a specific area. Always rule out referred pain from
spine, pelvis, and sacroiliac joint or vascular causes. Rarely hip disease may present as pain referred to
the knee.
Examine the patient in standing, sitting, walking and lying down. When the patient is lying in the supine
position, always examine the patient from the right side. Make sure that the patient lies on a hard surface
to ensure that deformities are not concealed by a soft mattress.
HISTORY
Pain
● Progress – What has happened to the pain after it started? Has it increased, decreased or remain in
the same intensity. Is it constant or intermittent?
● Site- Ask the patient to pinpoint the site of pain with a single finger. Note down whether in the
groin, trochanteric area, buttocks etc. and don’t use vague terms like pain in the hip. Remember
that a patient with hip disease may present with knee pain.
● Severity- How disabling is the pain? What is its effect on routine activities, self care, locomotion,
occupation and recreational activities?
● Character – What is the nature of pain? Throbbing pain is due to inflammatory causes, burning
pain is due to neuropathic causes.
● Radiation- Pain of hip may radiate to knee or thigh. Pain radiating to the testes is suggestive of
ureteric calculi. Pain radiating below knee is due to sciatica.
● Aggravating and relieving factors- Mechanical pain due to osteoarthritis or impingement is
aggravated by activity and relieved by rest. Pain due to inflammatory arthritis is aggravated by
rest and partially relieved by activity.
● Diurnal variation- Pain of osteoarthritis is more towards the evening and less when patient gets
up in the morning. Pain of inflammatory arthritis like ankylosing spondylitis is more in the
morning and less in the evening. Nocturnal pain that interferes with sleep is an ominous sign of
malignancy or infection.
● Associated symptoms
Deformity
● Is it static or progressive?
● Associated symptoms?
● Any history of infection or trauma?
● Walking ability
○ Normal or altered
○ Restricted or unrestricted
○ Aided or unaided
Fever – Whether associated with chills and rigor, severity, continued or intermittent and the treatment
taken.
Past history
● Hypertension
● Diabetes mellitus
● Inflammatory arthropathy
● Septic arthritis
● Tuberculosis
● Umbilical sepsis
● H/o prolonged IV infusion in childhood
● Blood Dyscriasis
● Previous surgery
● Previous trauma
Personal history
● Alcohol abuse
● Smoking
● Diet
● Menstrual history
● Occupational history
● Recreational activities
Treatment History
Family history
● Similar illness
● Tuberculosis
GENERAL EXAMINATION
Head to foot examination
Eyes- Blue sclera, irirtis ,uveitis, squint, microophtalmos, cornea, pigmentation of sclera.
Nails- Pitting.
Ligamentous laxity (Wynne-Davis Criteria- 3 out of 5 needed for diagnosing generalized laxity)
Neurocutaneous markers-
LOCAL EXAMINATION
The steps of local examination are inspection, palpation, movements, measurements, gait analysis, special
tests and examination of spine and other joints and other system.
Inspection
Inspection should be done with the patient standing, walking, sitting and lying down. Look from the front,
sides and back. Look for any asymmetry when compared to the normal side.
● Attitude
● Deformity
● Bony contours
● Swelling
● Wasting
Attitude is the position of joint which is most comfortable to the patient. Position of comfort for the hip
joint is flexion, abduction & external rotation; as it allows maximum distension of the capsule. If the joint
is moved it can be brought to neutral position. In deformity; there is a fixed contracture of the joint which
will prevent the joint from being placed in the neutral position. A flexed attitude of the hip joint can be
corrected but a fixed flexion deformity cannot be corrected.
Normally when a person lies supine on a firm surface the lumbar spine lies flat on the table and there will
not be any gap between the lumbar spine and the couch; if there is a gap then lumbar lordosis is
exaggerated. In the case of flexion deformity of the hip (FFD) it is usually masked by forward tilting of
the pelvis, which in turn is masked by increased lumbar lordosis. Hence exaggerated lumbar lordosis is a
sign of fixed flexion deformity of the hip. Unmasking of the fixed flexion deformity of hip can be done
A coronal plane deformity such as abduction or adduction is masked by compensatory coronal tilting of
the pelvis, which can be identified by looking at the level of both anterior superior iliac spines (ASIS). In
case of an adduction deformity; the ASIS of the deformed side will be at a higher level, the affected limb
will appear to be shortened and there will lumbar scoliosis with convexity to the opposite side. In case of
abduction deformity; the ASIS of the deformed side will be at a lower level, the affected limb will appear
to be lengthened and there will lumbar scoliosis with convexity to the same side.
● Level of ASIS
● Inguinal orifices
● Widened perineum
● Contour and bulk of the thigh muscles looking for abnormal contour and wasting
Laterally:
● Position and bulk of the trochanter- Look for any superior migration and more posterior position
when compared to opposite side. Superior migration may be due to dislocation/subluxation, joint
space destruction, fracture of neck /trochanter and coxa vara. Excessive lateral prominence is
Posteriorly:
● Scoliosis
Palpation
Palpate for any local rise in temperature, tenderness, bony thickening or swelling, soft tissue mass or
defect.
Anteriorly:
point. Mid-inguinal point is the centre of a line connecting ASIS and the symphysis pubis.
● Feel the resistance over the Scarpa’s triangle. It will be reduced if the hip is dislocated and it will
be more in case of cold abscess.
● Femoral pulsations- The volume of pulse when compared to opposite side will be reduced if the
Laterally:
● Greater trochanter
Posteriorly:
● Any mass- Globular bony mass that moves with the femur is suggestive of dislocated femoral
● Posterior joint line tenderness- Located at the junction of the lateral one third and the medial two
third of a line connecting the posterior superior iliac spine (PSIS) and greater trochanter.
Movements
Look for active and passive movements in all three axes. Look for flexion & extension, abduction &
adduction and the external & internal rotation. Look for any fixed rotation deformities in both hip flexion
as well as extension.
A deformity almost always occurs in all three planes, but it will be predominantly in one or two planes. It
may occur in the sagittal plane (Flexion-Extension), coronal plane (Abduction-Adduction) or in the axial
plane (Internal rotation-External rotation). In the case of flexion deformity of the hip (FFD) it is usually
masked by forward tilting of the pelvis, which in turn is masked by increased lumbar lordosis. Hence
exaggerated lumbar lordosis is a sign of fixed flexion deformity of the hip. Normally when a person lies
supine on a firm surface the lumbar spine lies flat on the table and there will not be any gap between the
lumbar spine and the couch; if there is a gap then lumbar lordosis is exaggerated. Unmasking of the fixed
flexion deformity of hip can be done by the Thomas well leg raising test.
A coronal plane deformity such as abduction or adduction is masked by compensatory coronal tilting of
the pelvis, which can be identified by looking at the level of both anterior superior iliac spines (ASIS). In
case of an adduction deformity; the ASIS of the deformed side will be at a higher level, the affected limb
will appear to be shortened and there will lumbar scoliosis with convexity to the opposite side. In case of
abduction deformity; the ASIS of the deformed side will be at a lower level, the affected limb will appear
to be lengthened and there will lumbar scoliosis with convexity to the same side.
In order to assess the deformity, the coronal plane deformity is made manifest by correcting the coronal
Squaring of the pelvis is done by making both the ASIS at the same level. This is done by further
adducting the affected hip in presence of an adduction deformity till both ASIS are at the same level. If
there is some degree of free adduction present then the hip has to move through that free range before the
pelvis starts tilting. Hence before measuring the degree of adduction deformity, gently abduct the limb till
the free range of movement is over and pelvis just starts to tilt again. Now measure the degree of
adduction deformity by using a goniometer. The goniometer is place with the hinge over the centre of hip
and one arm is parallel to the midline of trunk and the other arm is parallel to the lower limb. Abduction
deformity is measured by further abducting the affected hip using the same principles.
Flexion 1200
Extension 100
Abduction 400
Range of movement depends largely on the age, gender and race. Children and women have greater range
of movement. Elderly will have lesser range of motion. Asian populations have greater range of
movement.
The range of movement in all three axes should be measured using a goniometer. The hinge of the
goniometer should be at the centre of rotation of hip. The proximal arm of the goniometer should be in
the long axis of the body and the distal arm should be in the long axis of the lower limb.
2. If restricted; which movement is restricted?
Global limitation of all movements is seen with arthritis and differential limitation of abduction and
Compare with the opposite side. If the opposite side is also abnormal then compare with the normal
5. If painful; during which movement and during which part of the arc of movement?
In patients with synovitis, the range of movements is normal but the terminal part of the arc is painful. In
case of arthritis all movements are restricted to some degree and painful. Pain on one particular
movement alone with normal range of movement is suggestive of extra-articular cause of pain.
6. Is the limitation of movement due to mechanical causes or due to pain and spasm?
Normally when the hip is flexed the lower limb flexes towards the opposite shoulder. Axis deviation
during flexion can be seen in patients with slipped capital femoral epiphysis.
In presence of childhood septic arthritis (Tom Smith arthritis), dysplastic hip or post polio residual
paralysis the range of movements is exaggerated in all directions. In SCFE there will be e xaggerated
extension, adduction and external rotation and limitation of flexion, abduction and internal rotation.
Measurement
One should measure the length and circumference of the limb. Longitudinal measurement includes
measurement of the length of the entire lower extremity and measurement of segments. The segements to
measure are the leg segment, infratrochanteric segment and the supratrochanteric segment. Longitudinal
measurement of lower extremity involves measurement of apparent length and true length.
Apparent length:
Keep both lower limbs parallel to each other in line with the trunk and measure from the xiphisternum to
True length:
Square the pelvis in the method described earlier. Further adduct if there is an adduction deformity and
vice versa. True length of the affected limb is measured from the inferior edge of ASIS to the tip of
medial malleolus. Place the normal limb in exactly the same position as the affected limb and then
Segmental measurements
If there is limb length discrepancy then one should identify the anatomic region of discrepancy.
Supratrochanteric region is assessed by drawing the Bryant’s triangle, Nelaton’s line and Shoemakers’
line. Infratrochanteric region is measured from the tip of greater trochanter to lateral knee joint line. Leg
segment is measured from medial malleolus tip to medial knee joint line.
Bryant’s triangle is drawn by placing the patient in the supine position. Mark the tip of greater trochanter
and the inferior edge of ASIS with a skin pencil. Draw a line from the inferior edge of ASIS vertically to
the couch. Draw another line from the tip of trochanter to the first line and measure. Normally the greater
trochanter lies about 2-3 cm below the first line. Compare with the opposite side. In case of severe
shortening the greater trochanter may lie above the first line; in such cases shortening will be the
measured length of the line with 3 cm or normal side measurement added to it.
Nelaton’s line is drawn by placing the patient in the lateral position with affected side up. Flex the hip and
knee to 900. Draw a line connecting the inferior edge of ASIS to the most prominent portion of ischial
tuberosity. In the normal hip the tip of greater trochanter will be just touching the line. In patients with
Shoemaker’s line is drawn on both sides from the tip of trochanter to the inferior edge of ASIS and
extended further on to the abdomen. Normally the lines will cross in the midline. In case of
Girth measurement is done at the bulkiest part of thigh and calf to look for wasting of muscles. Wasting
Special tests
Special tests are done as required depending on the clinical diagnosis. They can be divided into the
following.
Procedure – Stand on the right side of the patient with one hand under the lumbar spine of the patient.
With the other hand hold the unaffected side. Flex the unaffected knee fully, then flex the unaffected hip
till the excessive lumbar lordosis disappears. Measure the angle between the thigh of the affected side and
the couch to assess the angle of fixed flexion deformity of the hip.
Interpretation- Normally the limb will lie flat on the examination table. But if there is a fixed flexion
deformity the affected side will be off the couch. The angle between the long axis of thigh and the
examination table gives the angle of flexion deformity.
Patient position- Prone with hip and knees dangling beyond the end of the examination table
Procedure- Place one hand over the sacrum to stabilise the patient and to detect pelvic motion. Gently
extend the tested lower limb till the pelvis starts to move. Measure the angle between the long axis of
Interpretation- The angle between the thigh and the table is the fixed flexion deformity.
Craig’s test
Procedure- One hand of the examiner is placed flat on the greater trochanter. Knee flexed to 900. Hold the
leg and gently rotate the hip in both directions till the greater trochanter is maximally prominent.
Interpretation- The amount of internal rotation needed to make the greater trochanter maximally
Trendelenberg test
Interpretation- Normally the pelvis on the opposite side will move up to shift the centre of gravity due to
contraction of gluteus medius of weight bearing side. Up to 50drop is considered normal. If more than
2cm or 50 then it is abnormal and suggests abductor insufficiency. Insufficiency may be due to abnormal
Fallacies- False positive in adduction deformity of hip, quadratus lumborum paralysis and painful lesions
Procedure- Flex the knee and hip to 900 and 100 adduction. Stabilise the pelvis with one hand. Hold the
knee and thigh with the other hand. Push and in a to and fro motion.
Ortolani test
Procedure- Flex the hip to 900 and fully flex the knees. Hold both the proximal thigh with the thumb over
the medial aspect of thigh and other fingers over the greater trochanter region. Apply pressure over the
greater trochanter and gentle longitudinal traction. Move the hip into abduction gently.
Interpretation- If the hip is dislocated; resistance to abduction will be felt at 30-400 of abduction, then a
clink will be felt as the femoral head reduces into the acetabulum slipping over the acetabular rim. Once
Barlow test
Has two parts. First step is similar to Ortolani test, but each hip is separately tested.
Procedure- Flex the hip to 900 and fully flex the knees. Hold both the proximal thigh with the thumb over
the medial aspect of thigh and other fingers over the greater trochanter region. Apply pressure over the
greater trochanter and gentle longitudinal traction. Move the hip into abduction gently.
Interpretation- If the hip is dislocated; resistance to abduction will be felt at 30-400 of abduction, then a
clink will be felt as the femoral head reduces into the acetabulum slipping over the acetabular rim. Once
Apply backward and outward pressure over the medial aspect of proximal femur with the thumb.
Interpretation- If the hip is unstable the head will be felt to dislocate with a clunk. Once the pressure is
Gouvain’s test
Procedure- Hold the femur with one hand, stabilise the pelvis. Adduct and internally rotate the hip. Look
Procedure- Flex the hip and knee to 900. Note the relative level of knees.
Interpretation- If the knee of the affected side is at a lower level there is limb length discrepancy.
Allis test
Procedure- Flex the knee to 900, flex the hip and place the foot flat on the couch. Note the relative level of
knees.
Interpretation- If the knee of the affected side is at a lower level there is limb length discrepancy. If it is
lower towards the hip side; the femoral side is shortened. If it is lower towards the leg side; the tibial
segment is shortened.
Procedure- Put the affected limb on the opposite limb in the Flexion-Abduction-External rotation
(FABER) position or Figure 4 position. Apply hand over the medial aspect of knee and force the hip into
full abduction and extension.
Interpretation- If the hip cannot be fully abducted and extended to the level of opposite limb or if there is
Scour test
During this movement apply axial load and rotate into external and internal rotation.
Procedure- Ask the patient to actively flex the hip to 30 degrees while keeping the knee in extension and
(HEABER) position.
Procedure- Put the affected limb in the Flexion-Adduction-Internal rotation (FADDIR) position. Apply
hand over the anterolateral aspect of knee and force the hip into full adduction and internal rotation.
McCarthy test
Procedure- Flex the hip to 600 and flex the knee. Stabilise the pelvis with one hand. Hold the leg with
other hand. Move the hip into adduction and internal rotation with gentle force.
Obers test
Patient position – Lateral position with the affected side up. Opposite hip and knee flexed to 900.
Procedure- Flex the hip and the knee to 900. Stabilise the pelvis with one hand. Hold the leg with other
hand. Move the hip into full abduction and external rotation. Extend the knee and hip and let the limb
Interpretation- Normally the limb should drop down and rest on the couch. If the limb is held high in
abduction, there is contracture of the iliotibial band.
Ely’s test
Examination of Gait:
Front : Look at trunk , pelvis and swinging of hand (contralateral to the hand)
Side : Excessive Lordosis, ankle plantar flexion and knee flexion, hip and knee extension.
SUMMARY
DIAGNOSIS
Pathological : Traumatic/Inflammatory/Neoplastic/Infective/Degenerative