Hip Assessment PDF

ASSESSMENT OF THE HIP MAGEE -- CHAPTER 11 - One of the largest and most stable joints in the body fig 12.1 - Injury or pathology is usually immediately perceptible during walking - Important to test SI and L spine as well because hip pain can be referred from these areas **ANATOMY...

ASSESSMENT OF THE HIP MAGEE -- CHAPTER 11 - One of the largest and most stable joints in the body fig 12.1 - Injury or pathology is usually immediately perceptible during walking - Important to test SI and L spine as well because hip pain can be referred from these areas **ANATOMY** - Multiaxial ball and socket - Femur is anteverted in the acetabulum (fig 11.2) to allow sufficient movement and proper alignment +-----------------------------------+-----------------------------------+ | Resting Position | 30° flex, 30° ABD, slight lateral | | | rotation | +===================================+===================================+ | Closed packed position | Full extension, medial rotation, | | | and abduction | +-----------------------------------+-----------------------------------+ | Capsular pattern | Flexion, abduction, medial | | | rotation | | | | | | (in any order) | +-----------------------------------+-----------------------------------+ - Has a labrum - Strong capsule - Very strong muscles that control hip movement fig 11.1, 11.3 - Supported by 3 strong ligaments - Iliofemoral - Strongest in body - Prevent excessive extension - Significant role in stabilizing, maintaining upright position while limiting anterior translation - Ischiofemoral - Weakest of the 3 - Stabilizes hip while in extension - Pubofemoral - Prevents excessive ABD of the femur - Limits extension - All 3 limit medial rotation - Ligamentum teres physical attachment of head of femur to acetabulum - Weight bearing = pelvis moves on femur - Non weight bearing = femur moves on pelvis - Fig 11.4 **OBSERVATION** - Table 11.1, p. 770 clues about hip pain - Table 11.3, p. 773 causes of hip snapping symptoms (details are written in the text) - Gait is important - If a hip is affected, weight is lowered carefully on that side and knee bends slightly to absorb shock - Length of step on affected side is shortened - Pathology of the hip can lead to tight: - Adductors - Iliopsoas - Piriformis - Tfl - Rectus femoris - Hamstrings - But also weak: - Gluteals - Can lead to Trendelenburg gait or 'abductor lurch' - These imbalances can lead to pelvic tilts or rotations in the femur - Cane is to be used on the opposite side - Note the following from front, side, and behind - Posture - Level of pelvis (PSIS is normally at S2\*\*\*\*) - Unequal leg length - Muscle imbalance - Scoliosis - Hip flexion deformity - How weight is distributed over both legs - Balance - Ask them to balance on the good leg, and then the affected leg - Note differences - Eyes closed will test loss of proprioception (nervous system) - Look for Trendelenburg sign (dropping of opposite hip) - Limb positions should be equal and symmetrical - May indicate the type of pathology - Talked about traumatic dislocations and fractures - Obvious shortening of a leg - Colour and texture of skin - Scars or sinuses (dents/divots) - Swelling (difficult to see) - Client's willingness to move - Pain or difficulty controlling the movement **EXAMINATION** - pain might be referred from pelvis or lumbar spine - often, all 3 regions need to be assessed ACTIVE RANGE OF MOTION - Fig 11.11 - Supine -- flexion (with knee flexed), abduction, adduction, rotation - Prone -- extension, rotation - Watch for muscle recruitment from other areas ex, spine extension rather than hip extension - Pure movements would mean that the ASIS and PSIS do not move (fig 11.12) - Otherwise extra muscle recruitment due to imbalance Flexion 110-120° ------------------ ---------- Extension 10-15° Abduction 30-50° Adduction 30° Lateral rotation 40-60° Medial rotation 30-40° - Flx -- supine, knee bent; pay attention to ASIS as well - If sharp anterior groin pain that may refer to the gluteal or trochanteric region is elicited on full flexion, adduction and medial rotation = pain may be result on anterolateral impingement of femoral neck against acetabular rim we can't fix this (femoroacetabular impingement {FAI} -- s/s table 11.6) - Ext -- prone; pay attention to PSIS and L spine - Loads of info about possible impingements on page 781/82 (handy reference) - Abd -- make sure pelvis is level before beginning, remain still/level during range; action stops when pelvis moves; observe ASIS - If lat rot and slight flexion occurs early during abd, could be TFL is stronger than glute med/min - If happens late, could be iliopsoas or piriformis is overactive - Pelvis tilts up = overactive QL - This action may reveal adduction contractures (opposite ASIS drops early in ROM) - Add -- set pelvis to be level' watch ASIS throughout, movement stops when ASIS moves - Move leg over the other to test, or hold the opposite limb to their chest so its out of the way; OR abduct opposite leg so it is out of the way - Ipsilateral ASIS moves early in ROM = abduction contracture - Rot -- supine, prone, or seated - Loss of internal ROM is one of the first signs of an internal hip pathology - Seated = hip at 90°, supine = hip in neutral OR hip and knee at 90°; prone = hip neutral, knee bent to 90° PASSIVE RANGE OF MOTION - All supine, except extension; Be sure to not move the pelvis - Can assess iliopsoas snapping by passively (or actively) moving the hip from a flexed, abducted, and laterally rotated position to one of extension and medial rotation - Pain on flexion and medial rotation may indicate intra-articular source of problem; may be clicking and pain into groin - Flexion contracture -- if contralateral leg can't touch the table during ipsilateral flexion, contralateral leg may have the contracture Flexion Tissue approximation or tissue stretch ------------------ ---------------------------------------- Extension Tissue stretch Abduction Tissue stretch Adduction Tissue approximation or tissue stretch Lateral rotation Tissue stretch Medial rotation Tissue stretch RESISTED RANGE OF MOTION - Performed in supine (fig 11.16) - Must be able to answers these questions in regards to the hip, back, and abdominals - Can the client actively position their pelvis in neutral - Can the client hold this position statically - Can the client control dynamic movement of the pelvis - "don't let me move your hip" so the client knows not to recruit other movements - Include knee flexion and extension as well because quads and hams are two joint muscles - Hip flexors and extensors are equal in strength, but ADD are 2.5x stronger than ABD - Table 11.9 -- muscles that move the hip SPECIAL TESTS p. 791 **TESTS FOR HIP PATHOLOGY** +-------------+-------------+-------------+-------------+-------------+ | TEST | PATHOLGY/ | CLIENT | RMT | POSITIVE | | | STRUCTURE | | | | +=============+=============+=============+=============+=============+ | Hip Scour | Compressed | Supine | Flex and | Irregularit | | (Grind) | femoral | | add c's hip | y | | Test | neck | | so that hip | of movement | | (Flexion-Ad | against the | | faces c's | ('bumps') | | duction | acetabulum | | opposite | | | Test) | | | shoulder, | Pain | | | Pinches add | | to the | | | p\. 795 | long, | | point of | Apprehensio | | | pectineus, | | resistance | n | | green | iliopsoas, | | | | | | sartorius, | | Then take | Might give | | 11.31 | or TFL | | hip into | indication | | | | | abduction | as to where | | | | | while still | the | | | | | flexed | pathology | | | | | | is | | | | | | occurring | +-------------+-------------+-------------+-------------+-------------+ | Patrick's | Hip | Supine | Place foot | Lateral | | Test | | | of test leg | pain | | | Iliopsoas | | on knee of | | | (**FABER** | | | opposite | = FAI | | or Figure-4 | SI joint | | leg | | | Test) | | | | Groin pain | | | Causing | | (**F**lexio | | | aka | limitation | | n, | = | | Jansen's | of movement | | **Ab**ducti | iliopsa=oas | | Test | | | on, | pathology, | | | | | and | psoas | | p\. 798 | | | **E**xterna | impingement | | | | | l | | | green | | | **R**otatio | Posterolate | | | | | n) | ral | | 11.38 | | | | pain = | | | | | Slowly | ischiotroch | | | | | lower the | anteric | | | | | test knee | impingement | | | | | toward the | | | | | | table | Positive | | | | | | requires: | | | | | | | | | | | | Pain + Knee | | | | | | remains | | | | | | above the | | | | | | opposite | | | | | | straight | | | | | | leg | | | | | | | | | | | | Could also | | | | | | indicate SI | | | | | | or lumbar | | | | | | spine | +-------------+-------------+-------------+-------------+-------------+ **TESTS FOR IMPINGEMENT** +-------------+-------------+-------------+-------------+-------------+ | TEST | STRUCTURE/ | CLIENT | RMT | POSITIVE | | | PATHOLGY | | | | +=============+=============+=============+=============+=============+ | Anteroposte | Hip | Supine | Medially | Pain | | rior | dysplasia | | rotate and | | | Impingement | | Hip flexed | adduct hip | The more | | Test | Slipped | to 90° | | flex, the | | | capital | | | more pain | | p\. 800 | femoral | Can test in | | | | | epiphysis | various | | | | yellow | | degrees of | | | | | FAI | flex | | | | 11.43A | | | | | +-------------+-------------+-------------+-------------+-------------+ | Posterioinf | Global | Supine | Quickly, | Deep seated | | erior | acetabular | | laterally | groin or | | Impingement | coverage | Legs | rotates and | buttock | | Test | (long list | hanging | abducts hip | pain | | | of issues) | over edge | | | | p\. 802 | | of table | | = | | | Posterior | | | posteroinfe | | yellow | acetabular | Hold | | rior | | | cartilage | non-test | | impingement | | 11.43B | damage | leg close | | | | | | to chest | | Anterior | | | Often | | | hip pain | | | positive in | | | | | | people who | | | = | | | place hip | | | instability | | | in extreme | | | of labral | | | ROMs | | | tear | +-------------+-------------+-------------+-------------+-------------+ **TESTS FOR LABRAL LESIONS** +-------------+-------------+-------------+-------------+-------------+ | TEST | STRUCTURE/ | CLIENT | RMT | POSITIVE | | | PATHOLOGY | | | | +=============+=============+=============+=============+=============+ | Anterior | Anterior-su | Supine | Take hip | Pain | | Labral Tear | perior | | into full | | | Test | impingement | | flexion, | Reproductio | | | syndrome | | lat rot, | n | | (FADDIR | | | full ABD to | of symptoms | | Test, | Anterior | | start | (with or | | anterior | labial tear | | | without a | | apprehensio | | | Then extend | click or | | n | Iliopsoas | | hip | apprehensio | | test, | tendinitis | | combined | n) | | Fitzgerald' | | | with med | | | s, | | | rot and ADD | Location of | | FADER Test) | | | | pain and | | | | | | symptoms | | p\. 803 | | | | should help | | | | | | determine | | green | | | | pathology | | | | | | | | 11.49 | | | | | +-------------+-------------+-------------+-------------+-------------+ | Posterior | Labral tear | Supine | Take hip | Groin pain | | Labral Tear | | | into full | or | | Test | Ant hip | | flexion, | | | | instability | | ADD, and | Patient | | (posterior | | | med rot to | apprehensio | | apprehensio | Posteroinfe | | start | n | | n | rior | | | or | | test) | impingement | | Then extend | | | | | | hip | Reproductio | | p\. 803 | | | combined | n | | | | | with ABD | of symptoms | | yellow | | | and lat rot | (with or | | | | | | without | | 11.52 | | | | click) | +-------------+-------------+-------------+-------------+-------------+ **TESTS FOR FEMORAL NECK STRESS FRACTURES** +-------------+-------------+-------------+-------------+-------------+ | TEST | PATHOLOGY | CLIENT | RMT | POSITIVE | +=============+=============+=============+=============+=============+ | Heel Strike | Femoral | Supine | Firmly | Pain in | | Test | neck stress | | strike heel | groin | | | fracture | | with to | | | p\. 804 | | | simulate | | | | | | heel strike | | | yellow | | | with | | | | | | walking | | +-------------+-------------+-------------+-------------+-------------+ **TESTS FOR MUSCLE TIGHTNESS OR PATHOLOGY** +-------------+-------------+-------------+-------------+-------------+ | TEST | PATHOLGY/ | CLIENT | RMT | POSITIVE | | | STRUCTURE | | | | +=============+=============+=============+=============+=============+ | Abduction | length of | Supine with | Observe | Affected | | Contracture | gluteus | ASISs level | | leg forms | | Test | medius & | | Attempt to | an angle of | | | minimus | Adduct hip | balance | more than | | p\. 810 | | | lower limb | 90° with a | | | Can lead to | | with pelvis | line | | yellow | functional | | | joining the | | | leg | | Observe | ASISs = | | | lengthening | | | contracture | | | | | | present | | | | | | | | | | | | Pelvis will | | | | | | shift down | | | | | | on affected | | | | | | side or up | | | | | | on | | | | | | unaffected | | | | | | side when | | | | | | trying to | | | | | | make ASIS | | | | | | level | | | | | | | | | | | | ASIS moves | | | | | | before 30° | | | | | | with muscle | | | | | | stretch | +-------------+-------------+-------------+-------------+-------------+ | Adduction | Length of | Supine with | Observe | Affected | | Contracture | adductor | ASISs level | | leg forms | | Test | longus, | | Balance | an angle of | | | brevis, and | Abduct Hip | pelvis | less than | | p\. 722 | magnus | | | 90° with a | | | | | Observe | line | | yellow | Pectineus | | | joining the | | | | | | ASISs = | | 11.66 | Can lead to | | | contracture | | | functional | | | | | | leg | | | Pelvis will | | | shortening | | | shift up on | | | | | | affected | | | | | | side or | | | | | | down on | | | | | | unaffected | | | | | | | | | | | | ASIS moves | | | | | | before | | | | | | 30-50° with | | | | | | muscle | | | | | | stretch | | | | | | felt | +-------------+-------------+-------------+-------------+-------------+ | Bent-Knee | Proximal | Supine | Flex hip | Pain at | | Stretch for | portion of | | and knee | ischial | | Proximal | hamstrings | | maximally | tuberosity | | Hamstrings | | | | | | | (hypertonic | | Extend knee | \*need to | | p\. 811 | ity) | | slowly | rule out | | | | | (could | neurologica | | yellow | | | extend knee | l | | | | | quickly as | tissues for | | fig 11.72 | | | well) | it to truly | | | | | | be positive | +-------------+-------------+-------------+-------------+-------------+ | Ely's Test | Tight | Prone | Passively | Spontaneous | | | rectus | | flex knee | flexion of | | p\. 811 | femoris | | | hip on same | | | | | | side | | yellow | | | | | | | | | | | | 11.73 | | | | | +-------------+-------------+-------------+-------------+-------------+ | Hip -Lag | Glute Med | Side-lying | Abduct to | Cannot hold | | Sign | tear | | 45° | position | | | | Hold | | (drops, | | p\. 813 | | position | Medially | medial rot | | | | | rotate hip | decreases) | | green | | For 10 | | | | | | seconds | Extend hip | | | 11.78 | | | | | +-------------+-------------+-------------+-------------+-------------+ | 90-90 | Hamstrings | Supine | Observe | Not within | | Straight | | | | 20° of full | | Leg Raising | (this | Hips at 90° | | extension | | Test | section | (can | | | | | includes | support | | Angle of | | (Hamstring | variations | with their | | tibia and | | Contracture | to test the | hands) | | femur, less | | ) | length of | | | than 125° | | | glute max, | Extend | | | | p\. 813 | as well as | knees one | | (may elicit | | | strength of | at a time | | nerve root | | green | all glutes | | | symptoms) | | | ) | | | | | 11.81 | | | | | +-------------+-------------+-------------+-------------+-------------+ | Noble | IT Band | Supine | Apply | Extreme | | Compression | friction | | pressure | pain over | | Test | syndrome | Knee at 90° | with thumb | condyle at | | | (at knee) | flex | to lateral | about 30° | | p\. 814 | | | femoral | of flexion | | | | Hip flexed | condyle or | | | yellow | | | 1-2cm | Will be a | | | | | proximal to | familiar | | 11.84 | | | it | pain | | | | | | | | | | | Ask C to | | | | | | slowly | | | | | | extend knee | | +-------------+-------------+-------------+-------------+-------------+ | Ober's Test | IT Band/TFL | Sidelying | Stabilize | Leg remains | | | contracture | | pelvis | abducted -- | | p\. 814 | | Lower leg | | does not | | | Could also | flexed at | Passively | fall to | | yellow | test glute | hip and | abduct and | table | | | ,ed/min and | knee | extend | | | 11.85 | hip | | upper leg | (pain over | | | capsule, so | | with knee | greater | | | should | | straight\*\ | trochanter | | | probably | | * | could | | | test these | | or at 90° | indicate | | | as well if | | flexion | bursitis) | | | positive | | (make sure | | | | | | ITB is over | (be aware | | | | | greater | of any | | | | | trochanter) | neurologica | | | | | | l | | | | | Slowly | signs -- | | | | | lower upper | femoral N) | | | | | leg | | +-------------+-------------+-------------+-------------+-------------+ | Pace's | Piriformis | Seated | | Pain on | | (Pace and | strain | | | contraction | | Nagle) | | Abduct both | | | | Maneuver | Sciatic | legs as far | | Neurogenic | | | nerve | as possible | | pain | | p\. 815 | | | | | | | | | | | | yellow | | | | | +-------------+-------------+-------------+-------------+-------------+ | Piriformis/ | To see if | Prone | Observe | Compare how | | DLR | they are | | | far legs | | | tight | Knees bent | Hold upper | drop/don't | | Not in | | to 90° | leg by knee | drop | | book, but | Not really | | and ankle | | | kind of | a special | Let legs | | Same | | helpful | test | drop to | Allow knee | | | | | sides | to drop | Less drop = | | | | | | tight lat | | | | Sidelying | | rotators | | | | | | | | | | Bottom leg | | | | | | straight | | | | | | | | | | | | Upper leg | | | | | | bent at hip | | | | | | and knee | | | +-------------+-------------+-------------+-------------+-------------+ | Piriformis | Piriformis | Sidelying | Stabilize | Pain in the | | Test | syndrome | | hip | buttock = | | | | Hip at 60° | | muscle | | p\. 816 | | | Apply | | | | | Knee flexed | downward | Sciatic | | red | | | pressure to | pain down | | | | | knee | leg = nerve | | 11.88-90 | | | | | | | | | Could add | | | | | | resisted | | | | | | lat rot | | +-------------+-------------+-------------+-------------+-------------+ | Thomas Test | Hip flexion | Supine | Check for | Test leg | | | contracture | | excessive | raises off | | p\. 819 | | Hold knee | lordosis | table (the | | | | once it is | | straight | | yellow | | flexed | Flex one | leg) | | | | | hip by | | | 11.96 | | | bringing | If you push | | | | | the knee to | the leg | | | | | the chest | back down, | | | | | to flatten | the | | | | | lumbar | lordosis | | | | | curve | will | | | | | | reappear | | | | | | | | | | | | (if leg | | | | | | abducts | | | | | | rather than | | | | | | lifting = | | | | | | tight IT | | | | | | band on | | | | | | straight | | | | | | leg) | +-------------+-------------+-------------+-------------+-------------+ | Tightness | Medial and | Supine | Test | Medial rot | | of Hip | lateral hip | | lateral | is less | | Rotators | rotators | Knees and | rot: | than | | | | hips at 90° | | 30-40°, | | p\. 820 | | flexion | C medially | muscle | | | | | rotates | stretch end | | yellow | | | hip, add | feel | | | | | overpressur | | | 11.97 | | | e | Lateral rot | | | | | (OP) | is less | | | | | | than | | | | | Test medial | 40-60°, | | | | | rot: | musc | | | | | | stretch end | | | | | C laterally | feel | | | | | rotates | | | | | | hip, add OP | | +-------------+-------------+-------------+-------------+-------------+ | Trendelenbu | Assess | Stand on | Observe | Opposite | | rg | stability | one leg | | side of | | Sign | of hip | | | pelvis | | | | (normally, | | drops | | p\. 820 | Ability of | opposite | | | | | hip | pelvis | | \- | | green | abductors | should | | indicates | | | to | rise) and | | weak glute | | 11.98 | stabilize | hold for | | med or | | | pelvis on | 6-30 | | unstable | | | femur | seconds | | hip on | | | | | | affected/st | | | | Can | | ance | | | | increase | | side | | | | difficulty | | | | | | by adding | | | | | | one legged | | | | | | squats with | | | | | | or without | | | | | | rotation | | | | | | 11.99 | | | +-------------+-------------+-------------+-------------+-------------+ REFLEXES AND CUTANEOUS DISTRIBUTION - No reflexes to worry about - Dermatomes = fig 11.101 - Peripheral sensory distribution = fig 11.102 - Table 11.17 = peripheral nerve injuries about the hip