Bryan D. Springer
A wide array of tests and diagnostic tools are available to the surgeon to aid in the diagnosis of hip disease. Thorough history and physical examination, however, remain the most important tools that a physician possesses when evaluating a painful hip joint. Diagnostic tests and procedures should be used in addition to and not as a substitute for a careful history and complete physical examination.
History
Obtaining a thorough and complete history from the patient with suspected hip disease is the first and one of the most critical steps in being able to properly diagnose pathology. This can often lead to a preliminary diagnosis and will allow for a more directed physical examination. A patient with hip pathology most frequently complains of pain. True hip pathology usually presents with pain located in the groin, anterior thigh, deep buttock, and occasionally knee. Every patient who presents with knee pain or medial thigh pain should have a thorough hip evaluation to rule out hip pathology as a source of referred pain to the knee. Important questions regarding the characteristics of pain include location, severity, frequency, and radicular features. It is also important to note circumstances that aggravate or relieve the pain. Arthritic pain generally is aggravated by activity and relieved by rest. Pain that occurs at night or during rest is less common in degenerative arthritis and may indicate the presence of an inflammatory process or infection. Referred pain from the lumbosacral region is common. This type of pain is often located in the gluteal or posterior iliac crest region and may present with radicular signs and symptoms. Several other conditions may refer pain to the hip (Table 1-1). Nonarthritic hip conditions should also be evaluated (Table 1-2).
Other important details that should be obtained include the following:
Physical Examination
The evaluation should begin immediately with the first encounter. Noting how the patient rises from a chair, walks to the exam room, and assumes certain postures can provide valuable information in a non-exam-specific setting. Every patient should be disrobed and appropriately gowned to allow for a thorough inspection of the hip and surrounding areas.
Evaluation of Gait
The phases of the gait cycle include the stance phase (60%): heel strike, midstance, toe-off; and the swing phase (40%): initial, midswing, and terminal swing. Several types of abnormal gait patterns can be indicative of hip pathology and are listed in Table 1-3. Patients who experience pain with weight bearing on the affected limb (antalgic or avoidance gait) will try to minimize the time on this limb during the stance phase of gait, resulting in a limp. Abductor muscle weakness will result in the pelvis tilting away from the affected limb when that limb is in the stance phase of gait (Fig. 1-1). To compensate, patients may lean over their affected hip to shift the center of gravity, resulting in a so-called Duchenne gait. Patients with a true leg length discrepancy may circumduct the long leg during the swing phase of gait to allow for the limb to clear the floor.
Leg Length Determination
Leg lengths should be measured in all patients, but particularly those planning to undergo arthroplasty. Several different methods can be used.
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TABLE 1-1 Conditions That May Refer Pain to The HIP |
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TABLE 1-2 Nonarthritic HIP Conditions |
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TABLE 1-3 Abnormal Gait Patterns |
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Figure 1-1 The examiner places his hands on the patient's pelvis. The patient is then asked to stand on the affected limb. If the abductors are functioning properly, the pelvis will remain level. With a weak or deficient abductor mechanism, the pelvis will tilt away from the affected limb. |
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Figure 1-2 Hip flexion: Average ROM is 0 to 125 degrees. |
Inspection and Palpation
The overlying skin should be inspected and palpated to look for outward signs of trauma (swelling, ecchymosis) and infection (warmth, erythema). All previous scars should be evaluated and noted. Other sources of cutaneous pain about the hip such as lesions associated with herpes zoster should be evaluated. Palpation of soft tissue and bony landmarks around the hip is important to rule out nonarticular causes of pain such as bursitis. Important bony landmarks that may be palpated include the following:
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Figure 1-3 Hip extension: Average ROM is 0 to 25 degrees. |
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Figure 1-4 Abduction: Average ROM is 0 to 40 degrees. Note that examiner's hand stabilizes pelvis to prevent pelvic tilt. |
Range of Motion
Range of motion about the hip joint should be noted and compared with the unaffected side. Patients with osteoarthritis will have limited range of motion, and the extremes of motion may cause pain and discomfort that is similar to their symptoms. In general, patients with osteoarthritis tend to lose hip flexion and internal rotation first (Figs. 1-2, 1-3, 1-4, 1-5, 1-6, 1-7).
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Figure 1-5 Hip adduction: Normal ROM is 0 to 30 degrees. |
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Figure 1-6 Internal rotation of the hip: Normal ROM is 0 to 30 degrees. |
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Figure 1-7 External rotation of the hip: Normal ROM is 0 to 60 degrees. |
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Figure 1-8 A. NormalB. Hip flexion contracture. |
Hip-Specific Tests
Thomas Test.
The patient is supine on the exam table (Fig. 1-8). Both knees are brought to the chest and held with the arms (this removes any lumbar lordosis). The leg to be tested is then released and allowed to come back to the table while the opposite leg remains held to the chest. A patient with a hip flexion contracture will be unable to fully extend the hip back to the exam table. Estimate the contracture by measuring the angle created by the patient's leg and the exam table.
Ely Test.
With the patient in the prone position (Fig. 1-9), the affected leg is flexed at the knee. A patient with a rectus femoris contracture will spontaneously flex at the hip.
Ober Test.
With the patient in the lateral decubitus position and the affected leg facing up (Fig. 1-10), the leg is slowly abducted with the knee flexed. From this position, the leg is released. A patient with a tight iliotibial band will remain in the abducted position whereas for those with a normal iliotibial band, the leg will fall into an adducted position.
Patrick Test or FABER Test.
With the patient in the supine position (Fig. 1-11), the affected leg is flexed, abducted, and externally rotated so the foot is placed against the contralateral knee. Pressure can then be applied by placing one hand on the opposite pelvis and pressing down the affected limb. Posterior pain indicates sacroiliac
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joint pathology, whereas anterior groin pain is indicative of hip pathology.
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Figure 1-9 A. Normal test. B. Rectus femoris contracture. |
The Stinchfield Maneuver.
With the patient in the supine position (Fig. 1-12), the hip is flexed approximately 30 degrees with the knee fully extended. The patient is then asked to resist the examiner's downward force by maintaining the hip in the flexed position. A positive test reproduces pain across the hip joint.
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Figure 1-10 Iliotibial band tightness. |
Neurovascular Examination
Every patient should undergo a directed neuromuscular and vascular examination. Palpation and documentation of pulses in both extremities is mandatory. This may include palpation of the femoral, popliteal, and posterior tibialis and dorsalis pedis pulses.
Neuromuscular examination of the hip should include muscle testing and assessment of sensation. Hip muscles can be grouped into flexors, extensors, and medial and lateral rotators. Table 1-4 lists the muscles, innervation, and nerve root derivation of the hip muscles. The strength of pertinent muscle groups should be graded and documented. Strength can be graded on a standard scale of 0 to 5:
Sensation is tested by assessment of superficial touch over dermatomes of the hip and lower extremities (Fig. 1-13). If any abnormalities are noted, a more thorough examination to include assessment of pain, temperature, and vibration may be conducted. Reflexes including the patellar (L2-4) and Achilles (S1) may be evaluated and compared with the contralateral side.
Evaluation of the Painful Total Hip Arthroplasty
When evaluating a patient with a painful total hip arthroplasty, several questions are important in evaluating the cause. Symptoms prior to surgery, dates of surgery, pain-free period after surgery and onset of new symptoms must be evaluated. Patients who never had any pain relief after surgery should be evaluated for other causes of referred pain to the hip (Tables 1-1 and 1-2). All preoperative and immediate postoperative radiographs should be obtained and evaluated. Patients with no or only a limited
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period of pain relief who continue to have discomfort that is not relieved by rest sould be evaluated for infection.
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TABLE 1-4 Actions and Innervations of the Muscles of the HIP |
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Figure 1-11 Sacral and hip joint pathology. |
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Figure 1-12 Loading hip joint in supine position. |
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Figure 1-13 Dermatomes of the upper and lower extremity. |
Patients with mechanical symptoms (i.e., loosening of the femoral or acetabular component) have generally had a pain-free period, then developed pain that has become progressive in frequency, duration, and intensity over time. Patients generally do not have pain at rest. They will often demonstrate a triphasic pain pattern, characterized by pain with initial weight bearing that subsides as they continue to walk (and the prosthesis finds a stable position) and then returns as the patient continues to bear weight.
On physical examination, patients with a painful total hip arthroplasty may demonstrate an antalgic gait or weakness of surrounding muscles. They also may demonstrate instability or apprehension at the extremes of motion.
Suggested Readings
Garvin KL, McKillip TM. History and physical examination. In: Callaghan JJ, Rosenberg AG, Rubash HE. The Adult Hip. Philadelphia: Lippincott–Raven Publishers; 1998:315–332.
Hoppenfeld S. Orthopaedic Neurology: A Diagnostic Guide to Neurologic Levels. Norwalk: Appleton and Lange; 1977.
Hoppenfeld S. Physical Examination of the Spine and Extremities. New York: Appleton-Century-Crofts; 1976.
Magee DJ. Orthopaedic Physical Assessment. 4th ed. Philadelphia: WB Saunders; 2002.
Thompson JC. Netter's Concise Atlas of Orthopaedic Anatomy. Icon Learning Systems, Teterboro, NJ; 2002.