Musculoskeletal LQ Week 6 - Hip Physical Examination

Static Observation - Posture

• Static observation involves assessing a patient's posture, while dynamic observation focuses on their gait and functional movements.
• Static observation assesses the patient in a standing position, noting symmetry and weight distribution.
• Muscle mass or wasting should be symmetrical on both sides.
• Excessive toeing out may indicate external hip neck retroversion or slipped capital femoral epiphysis (SCFE) or pelvic torsion.
• Posteriorly rotated innominate bone can cause lateral rotation of the leg.
• Leg spraying outward, toeing in could be due to femoral neck anteversion.
• Pelvic obliquity can stem from unequal leg length, muscle contractures, or scoliosis.
• Assess the patient's ability to achieve a neutral pelvis and self-correct, which informs exercise strategies.
• Evaluate balance, including single leg stance, from anterior, posterior, and lateral perspectives.

Posture Assessment for Pelvis and Hips

• In an anterior view, assess the level or tilt of the pelvis.
• Check the hips for coxa vara or valga and anteversion or retroversion.
• Observe femur alignment and torsion
• In a lateral view, look for increased or decreased lumbar lordosis and anterior or posterior pelvic tilt.
• In a posterior view, check for level hips and the sacrum's base and inferior lateral angles.

Dynamic Balance - Gait

• Observe the patient's walking pattern, looking for abnormalities.
• Assess step length and stance time, ensuring they are equal on both sides.
• Antalgic gait involves shortened stance time due to pain.
• Trendelenburg gait is characterized by an abductor lurch.
• Note any excessive rotation during gait.

Functional and Gait Assessment

• Functional testing is done if irritability is low and no neurological deficit is expected.
• Observe function first by asking the patient to demonstrate movements like donning/doffing shoes and lifting.
• Functional testing helps in hypothesis testing and differential diagnosis.
• Functional reassessment is a patient-meaningful test and retest.
• Start with a big picture view of gait, then focus on specific regions like the lower leg, ankle, and foot.
• Understanding normal gait is crucial for identifying abnormalities.
• Determine if observed gait abnormalities are related to the patient's symptoms.
• Functions of the foot and ankle during gait: base of support, mobile adaptor for weight acceptance, and rigid lever arm during pre-swing.
• Subtalar joint locking and the windlass mechanism are important for gait.

Functional Testing - Gait Views

• Views for gait assessment include frontal plane (front and rear) and sagittal plane.
• Observe gait with shoes on and barefoot, noting deviations at the ankle/foot due to specific impairments.
• Squat: Assess how the patient squats, noting weight distribution and potential causes like dorsiflexion limitations.
• Single Leg Stance: Evaluate base of support and muscle activation.
• Single Leg Squat: Assess talocrural joint range of motion and stability at the hip, pelvis, and lumbar spine.
• Lateral Step Down: Assesses dynamic balance, knee movement, and reliance on arm support.
• The choice of functional tests depends on symptom irritability and ability level.

Functional Testing - Stairs and Hopping

• Stairs: Identify problematic aspects of stair climbing, such as ascending vs. descending and specific gait cycle phases.
• Running: If symptoms occur during running, perform a running gait analysis.
• Jumping & Hopping: Analyze movement quality and assess symptoms as load increases on the lower leg, ankle, and foot.

Palpation - Soft Tissue

• Soft tissues to palpate include the gluteus maximus, glute medius, piriformis, tensor fasciae latae/iliotibial band, and adductors.
• Gluteus maximus is superficial, while the piriformis is deep.
• Gluteus medius is below the gluteus maximus and is often implicated in greater trochanteric pain.
• Tensor Fasciae Latae is an anterolateral structure.
• Palpation of the adductor is important for identifying adductor strains causing medial hip pain.

Palpation - Bony Landmarks

• Bony landmarks to palpate include the anterior superior iliac spine, iliac crest, posterior superior iliac spine, ischial tuberosity, and greater trochanter of the femur.
• Anterior Superior Iliac Spine: Attachment site for sartorius and tensor fasciae latae.
• Iliac Crest: Attachment site for gluteal and abdominal muscles.
• Posterior Superior Iliac Spine: Attachment point for gluteus maximus.
• Ischial Tuberosity: Attachment site for hamstring muscles.
• Greater Trochanter: Attachment site for gluteus medius, gluteus minimus, and piriformis; pain can indicate greater trochanteric pain syndrome.

Active Range of Motion (AROM)

• AROM involves the patient actively moving their limb against gravity.
• Passive range of motion (PROM) involves the clinician moving the patient's limb while the patient relaxes.
• Discrepancies between AROM and PROM can aid in diagnosis, such as differentiating a muscle strain from a joint issue.
• Axis at greater trochanter, movement arm towards lateral epicondyle, stationary arm mid-axillary line.
• Palpate to ensure range of motion is purely hip and not pelvic movement.
• The axis, stationary arm, and movement arm are the same as flexion

AROM - Abduction and Adduction

• Both abduction and adduction performed supine.
• Axis at the ipsilateral ASIS, stationary arm between both ASISs, movement arm along femur to patella center.
• Abduction moves away from the body, adduction moves towards the body.

AROM - Hip Internal and External Rotation

• Both can be tested in seated and prone positions.
• Axis at the center of the anterior patella.
• Stationary arm perpendicular to the floor, movement arm along the anterior tibia midline.

Hip End Feel

• Most hip motions have a firm end feel due to tendon or capsule tension.
• Hip flexion can have a soft end feel due to muscle bulk.
• Hip flexion: Soft (muscle bulk), firm (tight posterior capsule).
• Hip extension: Firm (muscle tension, anterior capsule/ligaments).
• Hip abduction: Firm (medial capsule, muscle tension/ligaments).
• Hip adduction: Firm (lateral capsule, muscle tension/ligaments).
• Hip internal/external rotation: Firm (posterior capsule, muscle tension/ligaments).

Passive Range of Motion (PROM)

• PROM assesses movement restrictions and painful arcs.
• Can determine if strength deficits limit AROM

Passive Accessory Joint Mobility Assessment

• Can be used for assessments or treatment based on the motion trying to increase.
• Anterior-Posterior Mobility: For flexion, patient is supine with hip flexed, abducted, and externally rotated; apply anterior to posterior force.
• Posterior-Anterior Mobility: For extension, patient is prone; apply posterior to anterior force near the ischial tuberosity.
• Hip Longitudinal Distraction/Caudal Glide: For pain relief when irritable.
• With patient supine, grasp the foot just above the ankle joint and pull any caudal or inferior direction
• Can be performed with a shorter lever arm (knee flexed) if knee pathology is present

Muscle Performance Testing

• Grades 3-5 are assigned when the patient can move the limb against gravity, based on resistance. Move to gravity eliminated positions if they can not.
• HHD placement is specific and reproducible making it objective across therapists

HHD (Hand-Held Dynamometry)

• HHD objectively measures hip strength with specific dynamometer placement.
• Flexors (Seated): MDC 41-54.4
• Extensors (Supine): MDC 11.4
• Abductors (Side-lying): MDC 63.5
• Adductors (Side-lying): MDC 6-.0
• Internal Rotators (Seated): MDC 14.5-28.4
• External Rotators (Seated): MDC 18.2-23.4

Special Tests for Hip Osteoarthritis

• Tests include Hip Scour and FABER
• Hip Scour: Flex hip and knee, sweep flexion-IR-adduction and flexion-ER-abduction; apply axial compression if no symptoms.
• FABER/Patrick’s Test: Place leg in figure 4, stabilize opposite ASIS, apply A-P pressure on medial knee; positive if symptoms are reproduced.

Special Tests for Non-Arthritic Hip Pain

• FADIR test: Passively flex hip/knee to 90, internally rotate, adduct; positive if symptoms are reproduced, repeat with hip flexion at end range
• Used for diagnosing femoral acetabular impingement syndrome

Special Tests for Anterior Labral Tears

• FADDIR: Flex hip, ER, abduct; then extend, IR, adduct; positive if pain/click/apprehension occurs.

Special Tests for Gluteus Medius Weakness

• Trendelenburg Sign: Pelvis drops on the opposite side when standing on one leg.

Tests for Muscle Tightness

• Tests include assessments for iliotibial band, hamstring flexibility, piriformis, and rectus femoris tightness.

Special Tests for Iliotibial Band Syndrome

• Ober’s Test: Abduct and extend hip in sidelying, then adduct while maintaining extension; measure hip adduction angle.

Special Tests for Piriformis Syndrome

• Piriformis/FAIR Test: Flex hip to 60 degrees in sidelying, then lower knee; positive if pain occurs with piriformis stretch or radiating pain into the thigh.

Special Tests for Hip Flexor Tightness

• Thomas Test: Patient lowers to back, clinician finds neutral pelvis, brings testing limb into extension, looking for iliopsoas or tensor fascia latae tightness.

Special Tests for Rectus Femoris Tightness

• Ely’s Test: Passively flex knee in prone; positive if ipsilateral hip spontaneously flexes.

Special Tests for Fractures

• Tests include the Fulcrum test and Percussion.
• Fulcrum Test: Apply pressure to the knee while using the arm as a fulcrum under the thigh.
• Patellar-Pubic Percussion Test: Percuss each patella while listening over the symphysis pubis; compare sides for pitch and loudness.

Functional Outcome Measures

• Functional outcome measures assess lower extremity conditions.
• Berg Balance Scale: Assesses static/dynamic balance (6 static, 8 dynamic tasks); max score 56; lower scores indicate fall risk.
• 30-Second Sit to Stand Test: Measures leg strength/aerobic capacity; count full stands in 30 seconds.
• Timed Up and Go Test: Assesses functional mobility/fall risk; time to stand, walk 3 meters, and sit back down.
• 6 Minute Walk Test: Sub-maximal test for exercise endurance/aerobic capacity; measure distance walked in 6 minutes.
• Tinetti Performance Oriented Mobility Assessment: Multitask test with 9 balance and 7 gait items; scores indicate fall risk levels.
• Dynamic Gait Index: Measures performance of multiple tasks, including walking, speed changes, obstacles, stairs; assesses gait ability.

Functional Gait Assessment Tool

• Measures gait ability and dynamic balance through 10 walking tests (steady state, speed changes, head turns, pivot turn, obstacles, narrow base, eyes closed, backward, stairs).
• Scoring: 0 = lowest function; total score = 30; scores ≤ 22/30 indicate fall risk.