9

Examination of the Hip Joint Complex

Asst. Prof. Donald G. Manlapaz, PhD, PTRP, PT

PT Initial Evaluation

November 1, 2020
Dx: S/P THR on the ®

S> G. G, a 55 y/o, (-) Htn/DM ® handed ♀ was referred fro PT eval and Mx 2° to S/P THR on the
®. Pt c/o constant aching pain on the posterolateral aspect of the ® hip graded 8/10 on VAS (0= no
pain; 10= worst poss pain), worsened by movement (becomes 10/10). States that she finds it difficult to
move in and get out of the bed, and even just using the bedpan. Condition started 3 days ago, while Pt
was busy doing gardening. Pt suddenly tripped over a flowerpot and fell on her buttocks, and
immediately felt a “crack” on her right hip accompanied by a sharp pain. Pt called out for help as she
couldn’t move her leg, and she was carried into their car by her son. Pt was immediately brought to the
emergency room at the STUH, underwent x- ray which revealed complete, displaced Fx of the femoral
neck. MD immediately opted to do a cemented THR procedure c posterolateral approach on the same
day. Pt was then referred for in- patient PT rehabilitation and is cleared for immediate PWB. PMHx:
Unremarkable. Home Situation: Pt lives in a 2- storey house with her husband and children. Pt stays in a
2nd floor bedroom, with ~ 11 stair steps from 1st floor to 2nd floor; handrails on the ® during ascending;
States that bathroom is found outside their room, with ~ 5 steps from bedroom door to bathroom.
Lifestyle: Pt is a (-) smoker/alcoholic beverage drinker who lives an active lifestyle. Pt often helps in
various household chores, loves to tend flowers in her garden, and goes to ballroom dancing every
weekend. Pt is a retired teacher. Pt’s Goal: To be relieved of pain and to be able to move around
freely and independently again ASAP. O>

VS>
BP: 120/ 90 mmHg
PR: 75 bpm
RR: 19 cpm
T°: 37.1°C
OI> bed fast
➢ Alert, coherent, cooperative
➢ Oriented x 3
➢ Endomorph
➢ (+) IV line on dorsal aspect of (L) hand
➢ (+) gauze on posterolateral aspect of ® hip (wound not assessed 2° to dressing)
➢ Minimal swelling on the ® hip
Palpation> Normothermic on all 4’s
➢ Normotonic on all 4’s
➢ (+) grade 3 tenderness on area around incision site
➢ (+) muscle spasm on the ® hip area
➢ (-) tightness
 ➢ (-) crepitations
ROM> All major joints of (B) UE/LE, neck and trunk are WNL, actively and passively
done, pain- free and c N endfeels, except for:
AROM
® hip flex 0- 10 deg
® hip abduction 0- 15 deg
® hip IR/ER not assessed 2° to hip precautions
® hip PROM and endfeels not assessed 2° to hip precautions
MMT> All major muscles of (B) UE/LE are graded 5/5, except for:
(B) triceps: 4/5
(B) knee extensors: 4/5
® hip muscles: not assessed
Sensory Testing> No objective sensory deficits on all 4’s, neck and trunk as to light touch,
pain and pressure
DTR’s> normoreflexive on all 4’s
GA> not assessed as of IE
FA> independent in eating, grooming and wearing gown
➢ Dependent with mod +2 assist in bed mobility such as supine↔sidelying
➢ Dependent with max +1 assist in using bedpan
➢ Still unable to preform sitting dangling, but can tolerate long sitting with back support
➢ Dependent in all transfers

THE HIP JOINT

- most stable joint, least dislocated joint in the body
- formed by the acetabulum ( ½ of a sphere) and the femoral head ( 2/3 of a sphere)

❖ Angles:
• Neck shaft angle ( angle of femoral inclination)
✓ N: 125; Children: 160
✓ If there is an abnormal increase: Coxa valga
✓ If there is an abnormal decrease: Coxa vara

• Angle of femoral torsion

✓ N: 13- 15
✓ If increased: anteversion
✓ If decreased: retroversion

- CPP: EABIR
- OPP: FABER (30-30-slight ER)
- Capsular Pattern: FABIR

❖ Common Conditions of the Hip

CONDITION

Hip Osteoarthritis • Middle and late adults

• Insidious onset of stiffness or pain down the thigh to the
knee after exertion; relieved with rest
• Factors: obesity, congenital hip problem,
trauma, avascular necrosis of the femoral head
• Pain
• Swelling, atrophy
Post- fracture
• Edema, muscle spasm, crepitus, stiffness
• Discoloration, scars
• Limb shortening
 – Total vs. Partial
Hip Replacement – Cemented vs. Non-cemented
– Approach: Posterolateral vs. Anterolateral
• Sciatic nerve entrapment

Piriformis Syndrome • Factors: tight piriformis and ext. rotators, hip

abductor weakness, hypomobile SI joint, lower lumbar
spine dysfunction
• Lateral femoral cutaneous nerve (L2-L3)
Meralgia Paresthetica
entrapment under the inguinal ligament

Iliopsoas Syndrome • Iliopsoas bursitis and/or tendinitis

• Caused by repetitive hip flexion: gymnasts, track
athletes, dancers
• Direct blow or by repetitive friction
Trochanteric Bursitis
• Factors: tight TFL, rectus femoris, hamstrings, weak
adductors

• Rectus Femoris
• Sprinting, kicking a ball
Quadriceps Strain
• Factors: tightness or weakness of quads, hamstring
tightness, insufficient warm-up or stretching, previous
injury, over-training
• Adductor longus and magnus
Adductor Strain • Sudden hip abduction in ER or repetitive adduction
• Factors: tight adductors, psoas, int. rotators,
hamstrings; weak hamstrings and gluteus medius
• Short Head
• Higher running speeds, eccentric overload; extreme hip
Hamstring Strain Fl with knee Ext
• Factors: Insufficient warm-up, muscle strength and
flexibility imbalance, poor muscle coordination, previous
injury

Subjective Examination

1. Patient’s Profile
❖ Initials, Age, Sex, Handedness
• Congenital Hip Dislocation - < 2 y/o girls
• Legg-Calve-Perthes Disease – 3-12 y/o boys
• Slipped Capital Femoral Epiphysis – 10-16 y/o boys
• Osgood Schlatter Disease – 10-14 y/o, M
 inflammation of tibial tuberosity
• Arthritis
✓ RA: > 30 y/o female
✓ OA: middle-aged, elderly men
• Fractures - > 50 y/o. THR, hamstrings strain, piriformis syndrome, OA/RA
• Sever’s Disease – young active teens
• Sports Injuries – young male athletes
2. Chief Complaint
❖ Pain
• Description
✓ Aching / Dull: degenerative changes
✓ Sharp & Catching: mechanical
✓ With stiffness in AM and eases with activity: arthritic
✓ During activity: subluxation, patellar tracking disorder
✓ After activity: synovial plica or early tendinitis
✓ Generalized pain: contusions, ligamental / muscle tear/sprain/strain
• Severity
- Pain scale
- VAS, SPS
❖ Discomfort – degenerative changes
❖ Dysesthesia – sensory deficits
❖ “Giving way” - instabilities
❖ Locking vs. Catching – loose bodies
❖ Swelling
✓ Synovial: avascular structures
✓ Hemarthrosis
✓ Pyogenic: infection
✓ Bursitis – inflammation of bursa
❖ Sounds:
✓ Click, grate: meniscus/bone or crepitations (degenerative changes)
✓ Snap: hip/knee - tendon
✓ Pop: ligament, meniscus – ACL or achilles tendon
❖ Functional Impairment

3. Area of Symptoms
❖ Localized vs. Diffuse
• Patellofemoral Pain Syndrome: anterior knee pain
• Plantar Fasciitis: medial heel pain
• Referred symptoms: nerve root & peripheral nerve
- Ex. Pain in groin area. Urogenital system visceral affectation referred to joint
- Back-kidney problem
• Meralgia Paresthetica: Pain and dysesthesias along the lateral thigh
- Tight pants, belt
- Lateral femoral cutaneous nerve, L2
❖ Around a joint, along a bone, in a muscle area
• Hip – groin, posterior, anterior & medial thigh
• Posterior hip:
✓ With WB – Ischial Bursitis
✓ With AROM – Hamstring muscle
✓ With PROM – Joint capsule
• Knee: leg
• Ankle: foot

4. Behavior of Symptoms
❖ Aggravating & relieving factors
o OA: Insidious onset of stiffness or pain down the thigh to the knee after exertion;
relieved with rest
❖ Irritability
❖ Duration: constant or intermittent
❖ Static position vs. Activity
• Non-mechanical: tumor
 ❖ Time of day:
• Upon waking up vs. During the day
• OA: Appear in the AM and wear off during the day
• Plantar fasciitis: worse in the AM when taking the first step of the day
• Sleep disturbance
❖ With or without weight bearing
❖ With active or passive ROM
❖ Sleep disturbance: red flag sign for cancer or tumor
❖ Limitation in activities since symptoms first appeared

5. History of Present Condition

❖ Mechanism of Injury
• Force
✓ Hyperextension: ACL
✓ Flexion with posterior translation: PCL
✓ Valgus force: MCL
✓ Varus force: LCL
✓ Rotational: menisci
✓ Inversion
o With plantar flexion: Anterior Talofibular, Calcaneofibular Ligaments
o In neutral dorsiflexion: CFL
✓ Eversion: Deltoid ligaments
• WB vs. NWB
• Acceleration vs. Deceleration vs. Constant Speed
• Sudden onset: trauma
o Metatarsal/phalangeal fracture
o Ligamentous/capsular sprain
Grade Description
Grade I (Mild) Minor ligamentous disruption (stretch) with maintenance of
integrity and no signs of instability

Grade II Incomplete disruption with macroscopic tearing and swelling;

(Moderate) moderate amount of functional loss; mild or moderate
instability

Grade III (Severe) Complete rupture with swelling, discoloration and tenderness;
significant amount of functional loss with LOM, limited
weight-bearing tolerance and reduced stability

o Muscular strain
Degree Description
First Degree Overstretch with minimal disruption of musculotendinous
(Mild) unit
Signs present after the activity: cramp, tightness; pain with
motion

Second Incomplete muscle tear

Degree Immediate pain; swelling; hematoma; tenderness;
(Moderate) compromised muscle strength

Complete rupture
Third Degree Burning or stabbing pain; swelling; hematoma; palpable mass;
(Severe) loss of muscle function; inability to walk without pain
 ❖ Gradual onset:
o Overuse syndromes and chronic injuries
▪ Poor flexibility and conditioning, muscle imbalance, structural abnormalities
▪ Symptoms begin as mild, sporadic ache & gradually increasing in intensity

✓ Playing surface
✓ Training changes – distance, duration, intensity; errors in training
✓ Footwear changes

❖ Current Treatment:
• Medications
• Modalities
• Exercises
• Surgical Procedures
• Orthoses

❖ Ancillary Procedures:
• X-ray, MRI, CT Scan
• EMG-NCV
• Laboratory findings

6. Past Medical History

❖ Previous Injuries to same /related area/s
• Type
• Treatment & Medication (steroids)
• Recovery period
• Significant relief / deficits

7. Family History:
❖ RA, OA
❖ DM
❖ Neurologic disorder
❖ Flat feet
❖ Congenital disorder – hip joint in pediatric

8. Home Situation
❖ Type
❖ Stairs, ramps
❖ Available assistance
❖ Distances of areas
❖ Mode of transport

9. Lifestyle / Occupation
❖ Relation to problem
❖ Ergonomics
❖ Smoker/alcoholic beverage drinker
❖ Hobbies – varsity or recreational (position); schedule

10. Patient’s Goal/s

❖ Return to work/play
❖ Relief from pain
❖ Eliminate other symptoms
 OBJECTIVE EXAMINATION
Vital Signs
• BP
• HR
• RR
• Temperature
• “Pt. was seen but not treated d/t BP: 150/80”

1. Ocular Inspection
❖ Manner of Arrival
• Assistive device – knee brace, (B) AD, bondage, wheelchair, dependent amb c min. +1
assist, cane
• Gait
❖ Body built
❖ Deformities / Asymmetries
• In examination: start from feet → up
• Documentation: up → down
• Muscle bulk
• Shoulder, Spine, Pelvis
• Femur
• Knee: Valgum, Varum, Recurvatum
• Patella: Alta, Baja, Squinting
• Tibia
• Malleoli
• Foot: Toeing in/out, Equinus, Planus, Cavus, Splay, Rocker-bottom, Hallux
valgus, Bunion, calluses
❖ Postural deviations
❖ Gait deviations
❖ Shoe assessment:
• type – high cut, regular rubber shoes, slipper
• worn out areas - usually medial
• creases
• material
• heels
❖ Attachment, orthosis, prosthesis
❖ Swelling
❖ Discoloration
❖ Hematoma
❖ Atrophy
❖ Wounds, ulcerations, scars: appearance, dimensions
❖ Varicosities
❖ Vasomotor changes: toenail, hair, skin, nail beds
 PELVIC TILT AND SACRAL MOVEMENT
• Anterior vs Posterior pelvic tilt
 ANTERIOR: iliac crest separates,
symphysis pubis approximates
 POSTERIOR: iliac crest approximates,
symphysis pubis separates

• Nutation vs Counternutation (SACRUM)

 NUTATION:
» sacral promontory = forward & downward
» coccyx = backward & upward
 COUNTERNUTATION:
» sacral promontory = backward & downward
» coccyx = forward & upward

 Hip flex contracture → ant pelvic tilt → counternutation → increased lumbar lordosis
 Hip extensor tightness → post pelvic tilt → nutation → decreased lumbar lordosis (flatback)

MALALIGNMENT (LE)
- Common in females: broad pelvis
- Excessive hip anteversion (N=13-18) >18
- Internal femoral torsion
- Genu valgum
- External tibial torsion**
- Pronation of the foot
- In-toeing

2. Palpation
❖ Temperature
❖ Muscle tone
❖ Tenderness: Grade 1 to 4
❖ Edema (pitting or non-pitting)
❖ Crepitations
❖ Lumps – check in groin, thigh area; there are lymph nodes here
❖ Muscle spasm
❖ Muscle guarding
❖ Contractures
❖ Tightness
❖ Peripheral pulses: femoral artery, but usually we check the distal ones - dorsal pedal,
posterior tibial arteries

3. Anthropometric Measurement:
❖ Swelling, muscle atrophy
❖ Limb girth (landmark = inches ; measurement = cm)
LANDMARK Right Left Difference
2” above
Medial tibial plateau
2” below

❖ Leg length (indicate landmarks used and difference between two sides) = true/apparent
❖ Volumetric measurement: ankle and foot
❖ Figure of eight using tape measure: ankle and foot
4. Range of Motion
❖ LOM in a joint may cause compensatory movement in other joints
❖ Active movements before passive
❖ Passive Movements
• End feels
• Presence of pain
• Capsular patterns
❖ ROM lags – extension lag usually in knee

5. Manual Muscle Testing

❖ Gross MMT: thorough MMT if (+) lesion
❖ Break test if (+) pain
❖ LE Myotomes: Nerve root
L2 - Hip flexors
L3 - Knee extensors
L4 - Ankle dorsiflexors
L5 - Toe extensors
S1 - Ankle plantar flexors

6. Sensory Testing
❖ Entrapment syndromes: Hx of DM, Neurologic dysfunction
❖ LE dermatomes: Nerve root
T12 - Inguinal Ligament
L1 - Midway between T12 and L2
L2 - Mid-anterior thigh
L3 - Medial femoral condyle
L4 - Medial malleolus
L5 - Dorsal foot
S1 - Lateral heel
S2 - Popliteal fossa
S3 - Ischial tuberosity
❖ LE peripheral nerves
❖ Deep sensation: proprioception/kinesthesia

7. DTR’s
❖ Patellar (L3-L4), Achilles (S1-S2)

8. Special Tests:
HIP
Pediatric Tests Hip Pathology Muscle Tightness or
Pathology
• Ortolani’s – • Patrick’s / • Sign of the Buttock –
relocation test Jansen’s – F Ab ischial bursitis
• Barlow’s – ER • Rectus Femoris
dislocation test • Trendelenberg’s ContractureTest
• Telescoping Sign – gluteus • Ely’s Test – rectus
Sign (Piston) medius weakness femoris tightness
• Galleazi / Allis • Craig’s – angle of • Thomas Test – hip
Test femoral flexion contracture
anteversion (8-15’) • Ober’s Test – TFL
contracture
• Noble Compression
Test – ITB syndrome
• Piriformis Test –
sciatica
• Tripod Sign –
hamstring tightness
9. Postural Analysis
❖ Relation of hip, knee and ankle
❖ WB vs. NWB positions
❖ Deviations:
• Trunk: Scoliosis
• Hip: Coxa valgus vs. varus (N: 120-135’)
• Femoral anteversion: 8-15’
• Knee: Genu valgus vs. varum (N: 6’ valgus)
• Q-angle: 13-18’
• Ankle: Pronation vs. supination
• Foot: In-toeing vs. out-toeing (Fick angle: 5-18’)
• Arches

10. Functional Analysis

❖ Assistive device used
❖ Level of difficulty (maximum, moderate, minimum); amount of assistance required (+1)
❖ Amount of assistance required (+1, +2)
❖ BADL’s
• Self care activities
• Bed mobility
• Transfers
• Locomotion
• Stair negotiation

Sitting
Shoe tying
Stooping
Squatting
Crossing legs
Ascending/descending stairs
Putting on trousers
Stand on toes, heels
Walk on toes, heels
Stand on one foot
Walking vs running
Jumping
Hopping
Single leg squat

❖ IADLs
❖ Balance
❖ proprioception
❖ tolerance/Endurance
❖ single leg hop/triple hop/timed hop
❖ outcome measure tools
• LEFS
• Berg balance scale (BBS)
• Timed Up and Go Test (TUG)
• WOMAC
❖ Functional Testing (esp if pt is athlete)
• Overhead squat
• Single leg squat
• FMS (functional movement screen)
11. Gait Analysis
❖ Gait pattern (stance phase, swing phase)
❖ Gait deviation
❖ Weight-bearing status (NWB, PWB, FWB)
❖ Assistive device used
❖ Terrain
❖ Distance covered
❖ Gait parameters (temporal/spatial)
 Gait Assessment >
Indep amb s/c assist device on levelled surface ~10 m c the following gait deviations:
• spatial parameters – step length, stride length
• temporal - stride duration, cadence, step duration

*red – related to hip, the rest are neurologic cases

TYPE OF GAIT DESCRIPTION
Antalgic Gait (painful gait) Stance phase of affected is shorter
Swing phase of unaffected is shorter
Shorter step length
Listing towards painful side
Arthrogenic Gait (Stiff hip or Plantarflexed with pelvis elevation of affected
knee gait) Circumducting gait
Ataxic Gait Broad base due to poor balance
All movements are exaggerated
Foot slap and pt looking at feet
Equinus Gait Weight bear on dorsolateral or lateral side of foot
Stance phase is shorter
Limp is present
Pelvis and femur are in ER
Gluteus Maximus Gait Patient thrust the thorax during initial contact
Backward lurching
Gluteus Medius Gait Excessive lateral listing
If (B): chorus girl swing
Maybe in dislocation of hip or coxa vara
Hemiplegic Gait or Circumducting gait (swinging the leg ahead)
Hemiparetic Gait Affected upper limb is carries across the trunk for balance
Parkinsonian Gait Shuffling or short rapid steps
Arms are held stiff
Patient leans forward
Plantarflexor Gait Decrease or absence of push off
Stance phase is less and shortened step length on unaffected
Psoatic Gait Limp with exaggerated trunk and pelvic movement
LE in FADER