953418
research-article2020
SPHXXX10.1177/1941738120953418Wichman et alSports Health
vol. 13 • no. 2 SPORTS HEALTH
Physical Examination of the Hip
Daniel Wichman, BS,† Jonathan P. Rasio, BS,*† Austin Looney, MD,‡ and Shane J. Nho, MD, MS†
The hip and pelvis have a complex anatomy and are a common source of pain and injury in the athletic population. The
clinical examination of the hip requires a systematic approach to differentially diagnose hip problems with overlapping pain
referral patterns. Because of the complex anatomy of the hip, the physical examination is a comprehensive evaluation of
the 4 main pain generators of the hip from deep to superficial: the osteochondral, capsulolabral, musculotendinous, and
neurovascular elements of the hip. The hip examination begins with the standing examination and gait analysis followed
by a seated, supine, lateral, and prone examination. A targeted physical examination used in conjunction with a layered
understanding of the hip and pelvis can help guide diagnostic testing, distinguish hip-specific diagnoses from similar
presenting pathologies, and inform treatment.
Keywords: hip pain; femoroacetabular impingement syndrome; hip physical examination; hip joint
H
ip injuries are common in sports medicine, and the effect of reducing the joint reactive force by reducing the
clinicians must maintain a broad differential due to the abductor moment arm through a more favorable load
complex anatomy of the hip and overlapping pain distribution. As long as the abductors are not weak and are
referral patterns. Prior to the physical examination of the hip, a functioning normally, the pelvis remains level. This is in contrast
thorough patient history should be assessed, including the time with a waddling Trendelenburg gait in which patients shift weight
of onset, the mechanism of injury, activities that exacerbate over the affected side to accommodate insufficient abductors that
pain, and which, if any, treatment modalities have been are unable to maintain a level pelvis while the affected side is in
attempted since the onset of pain.4 The hip physical stance phase, causing the contralateral hemipelvis to dip.
examination follows a systematic approach to assess pathology With the patient standing, leg-length discrepancies are
in the different layers of the hip, including the osteochondral, assessed by comparing shoulder and iliac crest height bilaterally.
capsulolabral, musculotendinous, and neurovascular layers.1 The Trendelenberg test is performed by asking the patient to
However, some of these examination findings have limited stand on 1 leg. A drop in the pelvis by over 2 cm toward the
sensitivity and specificity for intra-articular and extra-articular nonweightbearing side is a positive test, indicating insufficient
sources. Additionally, many of these examination maneuvers gluteal abductor musculature.4 While standing, the patient may
can elicit pain in patients with an inflamed hip joint. be asked to bend forward at the trunk to assess spinal
alignment and signs of scoliosis.
Standing Examination and Gait
Supine Examination
The gait examination is performed to evaluate the kinematic
chain. At least 6 to 8 strides should be observed to evaluate foot Tenderness to palpation is assessed over bony prominences and
progression angle, stance phase, stride length, and arm swing.4 A tendon insertions. Localizing the source of the pain may help
negative foot progression angle (in-toeing) can be a focus the physical examination. With the patient in the supine
compensatory mechanism for increased femoral anteversion, position, the examiner may palpate the anterior superior iliac
while a more positive foot progression angle (out-toeing) can be spine, iliopsoas, rectus femoris, hip adductors origin, inguinal
seen with decreased anteversion or retroversion. An antalgic gait ligament, and pubic tubercle.
refers to a nonspecific limp resulting from a shortened stance The patient should be encouraged to demonstrate distinct,
phase due to pain on the affected side. Patients with hip pain provocative movements that reproduce any previously
may demonstrate a coxalgic gait, in which the upper trunk shifts described clicking, snapping, or popping sensations. The
toward the affected side during stance phase on the affected leg. circumduction clunk test for internal coxa saltans, or snapping
Similar to using a cane in the ipsilateral upper extremity, this has of the iliopsoas over the femoral head or anterior capsule of the
From †Division of Young Adult Hip Surgery, Department of Sports Medicine, Midwest Orthopaedics at Rush University, Chicago, Illinois, and ‡Department of Orthopaedic
Surgery, Georgetown University Hospital, Washington, District of Columbia
*Address correspondence to Jonathan P. Rasio, BS, Department of Orthopaedic Surgery, Rush University Medical Center, 1611 West Harrison Street, Suite 300, Chicago, IL
60612 (email: [Link]@[Link]).
The following author declared potential conflicts of interest: S.J.N. has received nonfinancial research support from Allosource, Arthrex, Inc, Athletico, DJ Orthopaedics,
Linvatec, Miomed, Smith & Nephew, and Stryker; is a paid consultant for Ossur and Pizot Medical; and has received royalties from Ossur and Springer.
DOI: 10.1177/1941738120953418
© 2020 The Author(s)
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Wichman et al Mar • Apr 2021
position.8 Additionally, these patients may demonstrate a
Table 1. Normative values for hip range of motion according positive Thomas test with reciprocal hip flexion when the
to standards published by the American Academy of contralateral hip and knee are pulled in toward the chest,
Orthopaedic Surgeonsa consistent with iliopsoas tightness or contracture.
The passive range of motion of both hips should be examined
Motion Value, deg, Mean ± SDb (Table 1). It is important to first measure the unaffected hip
Flexion 128.4 ± 6.7 in order to identify a standard with which to compare the
affected hip.
Extension 17.0 ± 3.9 In the supine position, flexion is measured by bringing the
knee as close to the chest as possible with the flexed knee
Abduction 33.0 ± 4.8
approximately 90°. Next, with the hip flexed 90°, internal
Adduction 13.8 ± 6.3 rotation is measured by maintaining the femur in a vertical
position while rotating the limb around the vertical axis of the
Internal rotation 42.1 ± 9.6
femur away from the midline. External rotation is measured by
External rotation 43.9 ± 8.4 rotating in the opposite direction. Abduction and adduction are
both measured with the hips and knees in a neutral extended
a
Supine position is used for flexion, abduction, adduction, internal rota- position. The leg is abducted by moving the limb away from the
tion, and external rotation. Prone position is used for extension.
b body and adducted by bringing the limb toward the midline,
As variation from the neutral, midline position.
above the contralateral leg. Subtle asymmetry in passive range
of motion may suggest mechanical impingement. Additionally,
reproduction of lateral pain when the leg is fully abducted in
neutral rotation is a positive lateral rim impingement test,
hip, is performed by asking the patient to actively flex the hip indicating possible impingement of the superolateral part of the
to 90° and circumduct the hip to an extended position. femoral neck against the posterior superior acetabular rim.
Reproduction of clunking is positive for iliopsoas snapping. Multiple examination maneuvers have been proposed to
Internal coxa saltans can also be elicited by maneuvering the differentiate the various mechanisms of impingement resulting
hip into the extension, adduction, internal rotation (EADIR) from intra- and extra-articular pathologies (Figure 1; Table 2).
Figure 1. (a) Subspine impingement test with affected hip placed in the hyperflexed position while in neutral rotation. (b) Flexion,
adduction, internal rotation test in the supine position. (c) Flexion, abduction, external rotation test with lower extremity placed in a
figure-of-4 position. (d) Ishiofemoral impingement test in the lateral position with affected hip placed in extension, adduction, and
external rotation. (e) Log roll test with extended leg manually shifted into internal and external rotation. (f) Posterior impingement
test with the patient’s legs hanging freely off the edge of the table and the affected hip placed in extension, abduction, and external
rotation.
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Table 2. Physical examination maneuvers for differentiating sources of impingement
Impingement Etiology
Patient
Position Test Maneuver Location Source of Impingement
Supine Subspine Affected hip is hyperflexed in neutral Anterior subspine Bony prominence below
impingement rotation while unaffected hip lies region anterior inferior iliac
test flat on the table spine and femoral neck
Supine or Flexion, adduction, Affected hip is flexed to 90°, Anterior and Anterior acetabular rim
lateral internal rotation internally rotated, and adducted anterolateral and femoral head-neck
junction
Supine Flexion, abduction, Affected extremity placed in figure- Posterolateral Greater trochanter and
external rotation of-4 position with hip flexed 45°, Deep posterolateral iliotibial band
abduction, and external rotation, Anterior Quadratus femoris (between
ankle resting on contralateral greater trochanter and
knee ischium)
Iliopsoas tendon and
femoral head
Supine Superolateral Affected hip is flexed to 90°, slightly Superior and Acetabular rim and femoral
impingement externally rotated, and abducted superolateral neck/head-neck junction
test
Supine DIRI (dynamic Affected hip is placed in flexion or Anterior (11 o’clock to 3 Acetabular rim and femoral
internal rotation hyperflexion and moved through o’clock) neck/head-neck junction
impingement a full arc of adduction with the
test) hip internally rotated. Maneuver
may be assisted by having the
patient flex the contralateral hip
to his/her chest to reduce lumbar
lordosis2,3
Supine DEXRIT (dynamic Affected hip is flexed to 90°, Superolateral and Acetabular rim and femoral
external rotation externally rotated and moved posterior (1 o’clock neck/head-neck junction
impingement through a full arc of abduction2,3 to 10 o’clock)
test)
Supine Scour test Variation of DIRI/DEXRIT tests Varies (generally 10 Acetabular rim and femoral
performed while applying a o’clock to 3 o’clock neck/head-neck junction
downward force at the knee to depending on
increase pressure in the hip joint technique)
while maneuvering into different
quadrants2,3
Supine Posterior rim While patient lies at the end of Posterior Acetabular rim and femoral
impingement the examination table allowing neck/head-neck junction
test the legs to hang freely, the
affected hip is placed into
extension, abduction, and
external rotation
Lateral Greater Affected hip is passively abducted Lateral Greater trochanter and ilium
trochanteric– in extended position. Positive
pelvic “gear stick sign” refers to relative
impingement increase in abduction range with
test hip in flexed position
Lateral Ischiofemoral Affected hip brought into extension, Deep posterior Quadratus femoris (between
impingement adduction, and external rotation lesser tuberosity and
test ischium)
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Wichman et al Mar • Apr 2021
It should be noted that the flexion, abduction, external are first assessed. The examiner may palpate the iliac crest,
rotation (FABER) test can elicit symptoms resulting from facets of the greater trochanter, ischium, and proximal
pathology involving the hip joint, sacroiliac joint, or iliopsoas hamstring. When palpating the greater trochanter, the examiner
tendon. Anterior/groin pain suggests iliopsoas tightness or may specifically assess the tendon insertion of the gluteus
femoral head impingement by the iliopsoas tendon. The minimus at the anteromedial facet, the tendon insertion of the
trochanteric pain sign refers to posterolateral pain from irritation gluteus medius at the superoposterior and lateral facets, and the
between the greater trochanter and the iliotibial band, though trochanteric bursa at the posterior facet.
lateral pain may also occur with various other trochanteric or Overall hip abductor strength is evaluated in the lateral
gluteal pathologies. Additionally, the FABER maneuver can elicit examination by having the patient actively abduct their leg
posterior pain due to sacroliac pathology by stressing this joint. against manual resistance. The gluteus medius strength test is
During the FABER examination, the distance from the knee to similarly performed with the patient’s knee flexed, which
the surface of the examination table can be compared between releases the gluteus maximus pull on the iliotibial band.4
sides to determine if there is significant stiffness in the hip or Snapping or clicking of the iliotibial band over the greater
iliopsoas muscle compared with the unaffected side.3,5 trochanter, or external coxa saltans, is elicited by having the
For patients in whom there is a concern for instability or patient perform a bicycle maneuver with the affected leg.
capsular insufficiency, additional examination maneuvers can be Ischiofemoral impingement is tested by extending the externally
performed to assess for excessive motion and to elicit rotated and adducted hip while placing counterpressure over
apprehension (Table 3).7 the hip and assessing for pain. The Ober test for iliotibial band
With the patient supine, the examiner may also assess for core tightness is performed by placing the hip into abduction and
muscle injury, athletic pubalgia, or “sports hernia.” The affected extension while the knee is flexed at 90° and is positive when
leg is placed in a semiflexed, externally rotated position, and the hip fails to adduct after release of knee support.
the adductor tendon origin on the pubis is palpated while the
patient attempts to adduct against resistance. Next, the patient Prone Examination
should be instructed to perform a sit-up against manual The prone examination is useful to palpate bony prominences in
resistance. Pain with either of these examinations may be a the posterior aspect of the hip and pelvis, especially the lumbar
positive indicator of a core muscle injury. spine, coccyx, posterior superior iliac spine, sacroiliac joint, and
Several supine tests can be performed to assess for piriformis posterior iliac crest. Additionally, the examiner may palpate the
syndrome. In the Freiberg test, the affected leg is passively greater trochanter, the ischium, and proximal hamstring. Proximal
maximally internally rotated while the patient lies with the hips hamstring pain may be reproduced by palpating over the ischium
and knees extended. Resisted external rotation in this position
with the knee bent and instructing the patient to flex the knee
may also re-create symptoms. The Pace sign refers to
against resistance. Some range of motion measurements may be
reproduction of symptoms with resisted abduction with the hip
performed during the prone examination such as hip extension,
and knee flexed, feet resting on the examination table, in the
internal rotation, and external rotation with the knee flexed to
position used to test abduction strength. Finally, the piriformis
90°. However, normative values for hip rotation measured in the
test or piriformis stretch test is performed by asking the patient prone position will differ from hip rotation measured in the
to pull the knee of the affected side toward the contralateral supine position. In patients with hip impingement, hip internal
chest. Variations of this test can be performed with the patient rotation may be more restricted when measured in flexion rather
in the lateral position or seated. than prone. Additionally, hip external rotation measured in the
Strength assessment in the supine position consists of prone position has limited intrarater reliability.6
abduction, adduction, and hip flexion. Abduction and adduction The gluteus maximus can be examined by having the patient
are examined while the patient is supine with the knees in 90° of extend the hip and lift the whole leg off the table. The Ely test
flexion and both feet flat on the examination table. Resisted hip for tightness/contracture of the rectus femoris is performed by
abduction and resisted adduction are assessed by applying lateral passively flexing the knee with the other hand in the posterior
pressure over the medial or lateral aspect of the distal femur. The superior iliac spine region to note any rise of the pelvis.
patient’s legs are then placed flat on the table and resisted hip Restriction in further knee flexion or the hemipelvis lifting off
flexion is assessed by applying downward pressure over the the table is a positive test.
distal femur while instructing the patient to perform a straight leg
raise. In certain situations, hip flexion strength may also be Summary
assessed with the patient seated on the edge of the examination
table, with the hips and knees flexed to 90°, which reduces the Appropriate assessment of the hip requires observation of gait,
contribution of rectus femoris and better isolates the iliopsoas. station, and examination in the supine, lateral, and often prone
positions. The basic examination will generally include gait and
station, palpation of commonly painful areas, and assessments
Lateral Examination
of strength, range of motion, and basic impingement testing.
For the lateral examination, the patient is asked to lie on the The examination should be tailored with additional tests and
unaffected limb, and the bony prominences of the lateral pelvis maneuvers when there is clinical concern for conditions such as
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Table 3. Physical examination maneuvers for identifying hip instability or capsular insufficiency
Positioning Test Maneuver Positive Findings Differential Diagnosis
Supine Log roll test Extended leg is manually shifted into Groin pain Intra-articular hip
internal and external rotation pathology, including
femoral neck stress
fracture
Supine Dial test Examiner passively rotates the Foot reaches a resting Anterior capsular
patient’s foot to maximal internal position in greater instability
rotation and lets go, allowing the external rotation that
foot to spontaneously return to an the contralateral
externally rotated position side, or foot forms an
angle of <20° with
the examination table
Supine Axial distraction Examiner places his/her knee against Apprehension, pain,
test the patient’s ischium, flexes the and instability
hip to 30°, and applies an axially
distracting force7
Supine Posterior Hip and knee are flexed to 90° and Posterior pain or Posterior capsular
apprehension examiner internally rotates and apprehension instability
test abducts the hip, applying a downward
and posteriorly directed force
Supine HEER While patient lies at the end of the Anterior pain or Anterior capsular
(hyperextension examination table allowing the legs apprehension instability
external rotation to hang freely, the examiner applies
test) a downward force on the knee and
externally rotates the hip7
Lateral Abduction- Affected leg is abducted to 30°, Anterior pain or Anterior capsular
extension– extended, and then externally apprehension instability
external rotation rotated
test
Prone Prone external Knee of affected limb is flexed to 90° Anterior pain or Anterior capsular
rotation test and the hip is externally rotated by apprehension instability
bringing the leg across the midline,
then a downward force is applied
behind the greater trochanter
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