It’s not “What you do” but “How you do it” that counts. Don’t forget the 5 P’s.

Introduction

This is a fairly comprehensive overview of clinical examination of the hip. We wanted to get away from the usual bullet point revision overview of hip examination that can be found in a lot of FRCSOrth related material

The aim is to highlight areas that are not well-covered or explained in standard textbooks. It is sometimes “just assumed” that one knows various facts which can occasionally lead to candidates having a nasty surprise on the day of the clinicals.

Some candidates may argue (with some justification) that by including esoteric areas of hip examination we are making the whole process too complicated. However we are working on the premise that it is better to have more up your sleeve than less and it is surprising how often esoteric points end up getting discussed with the examiners during a clinical case. Moreover the pitch of this text is not aimed at medical students but candidates preparing for a senior orthopaedic exit examination.

During an exit fellowship examination a candidate will have to demonstrate not only that he/she knows how to examine the hips of a patient but also ensure that the examiner is able to see and appreciate each part of the examination. It will become immediately apparent to the examiner if the candidate has a routine for examining the hip. It is useful to have a set standard system that is second nature to you so that you appear competent and no steps are forgotten.

Examination of the hip in the 2 months prior to the FRCS Orth exam should become a subconscious act to you. This means that even during the most stressful of situations in the real exam it will flow naturally, without one having to think about what comes up next or worry that one has missed some vital test out. If you are able to achieve this competency in your examination technique you will be more relaxed during the real thing and will be able to appreciate the significance of the clinical findings that you elicit.

It its most evolved form this involves anticipating expected clinical findings based on what you have already uncovered clinically and formulating ideas about the possible diagnosis as you go along. This is impossible if you can’t remember what comes up next in your examination and become tongue tied with the examiners.

By all means develop your own routine that works best for you but don’t stray too far from the norm. Just as important do not jump around and get the order of the hip examination out of sync. This is particularly annoying to examiners and suggests a disordered thought process and a lack of a systematic approach in your clinical practice.

During a hip short case examination you will almost certainly be asked to demonstrate just one or two specific clinical tests to the examiners. Classically these would include Trendelenburg’s test, measurement of leg lengths, Thomas test and range of movement of both hips. One must be able to perform these tests with ease and confidence or else one will invariably fail at the first hurdle

In the intermediate case you would need to examine the hip more fully covering most if not all of the examination in the 5 set minutes allowed. It is quite common to be presented with more unusual or complex hip problems. Unfamiliar clinical situations may be encountered and interfere with your standard hip examination routine. For example what to do if the knee has a fixed flexion deformity interfering with the examination of the hip.

Examples may include:

  • What to do if the knee has a fixed flexion deformity interfering with the examination of the hip.
  • How to take into account of a valgus knee when examining leg lengths.
  • What to do if the hip has an adduction contraction present

One would need to let the examiners know that you have recognised an unusual clinical issue and that your examination technique has taken this into account. It is much easier to talk your way through these scenarios if you are aware of their existence before the exam and worked out a plan of action. Let the examiners know what you are doing and why.

Coming across these scenarios for the first time in the FRCS Orth exam not knowing what to do or say to the examiners and having to refine your examination technique from first principles could seriously jeopardise your chances of passing the intermediate case.

The point is best illustrated by the following story. One candidate was asked to examine a patient with an arthrodesis of the right hip due to old tuberculosis. This patient also had a flexion deformity of the right knee. The candidate was unable to modify correctly his hip examination technique to take into account the knee flexion deformity. After the examiners had played around with him, thoroughly confused him and made him look silly they took great delight in demonstrating how to examine the hip in the presence of a fixed flexion deformity of the knee “His examination technique of the hip was poor” It wasn’t, he just hadn’t come across this particular clinical situation beforehand and in the heat of the battle was unsure and nervous of how to proceed forward with his examination technique.

Preliminaries

Preliminaries are very important in the exam setting even for the short cases where time is tight As an absolute minimum you should introduce yourself to the patient and ask their permission to examine their hip It is probably not unreasonable to ask them if their hip is painful Explain to them that you will be moving them about and will do your best not to hurt them. Make sure that you watch their face throughout the examination and avoid sudden movements. Tell the examiner that you would like to start by undressing the patient to his/her underwear including removing socks. They will probably indicate that this is not necessary At all times be careful to maintain a patient’s modesty Don’t forget to wash your hands between EVERY case Stay calm and focused and remember • Think about what you will find • Listen to what the examiner says • Look as though you know what you are doing • Appear confident to the examiners

Examine in turn

  • Inspection
  • Gait
  • Limb Length Discrepancy
  • Palpation
  • Thomas test
  • Movements
  • Neurovascular status
  • Trendelenburg test

Inspection

Inspection of the hip is very much descriptive; it is about what you see It is the LOOK part of Appley’s look,feel and move.

Look for general clues

Any walking frame, special shoes or orthosis present? Does the patient use a stick and is it in the correct hand? Ask the patient is they have a walking stick Talk to the patient; explain what you are going to do Work around the hip 360° get used to using a small space

General Inspection

Look and be seen to be looking Observe the patient first in the standing position Stand with the patient facing you. Be prepared to support the patient, as they may not be able to stand unaided. Start with a general inspection considering the patient as a whole. Consider if the patient looks well, is breathless at rest, is jaundiced or has generalised features of psorasis or rheumatoid arthritis.

There is always some debate as to include general inspection at the beginning of a short case. In everyday clinical practice it is one of the most important parts of your examination. If a patient is breathless at rest, cyanotic and can’t walk more than 10m because of COPD then perhaps listing them for THA isn’t a good idea. However the unofficial exam view is to get straight to the nub of the case and avoid general inspection. If the examiners ask you to perform Thomas test don’t start saying “the patient looks well for his/her years, is of average height and build” etc as the examiners may get annoyed and think you are wasting potential scoring opportunities. If the examiners have asked you to perform Thomas test they want you to just get on and perform Thomas test. The exam is not a real life clinic; the situation is very artificial and different.Do exactly as what the examiners direct you to do.

Observe the patient from the front, the side and then back.

Hip inspection from the Front

Does the patient stand straight and upright? Is stance comfortable? Is stance symmetrical? Are the shoulders level? “Can you stand up straight for me please” (Knees extended and both feet flat on the ground) “Can you straighten you knees for me and bring both feet together” Check the level of the ASIS .Is the pelvis symmetrical? If not level…. why not? What is causing the pelvic obliquity • Is there a leg length discrepancy • Is there a fixed deformity Ask for blocks if the pelvis is not level to access functional leg length discrepancy. The patient is asked “Do you feel level now” and the blocks are changed as necessary until the patient feels level. Is there any deformity in the coronal plane e.g.Abduction/adduction contracture of the hip An adduction contracture of the hip will cause the leg to appear short and results in ASIS on the affected side to be at a higher level. Likewise an abduction contracture of the hip will cause the leg to appear longer and may result in the ASIS on the affected side to be at a lower level Any thigh or calf wasting? Is the patient taking weight equally through both legs? Look at the feet, is the foot taking weight in a plantigrade fashion or is the ankle or foot inverted, everted or in equinus. Inspect the skin for scars, sinus, evidence of circulatory disturbance etc “Can you push your knee back fully straighten your leg”

Hip inspection from the Side

Look from the side Is there an increased lumbar lordosis or is the patient standing with a stoop? An increased lumbar lordosis suggests a compensatory mechanism to conceal a FFD of the hip Is there a flexion contracture of the hip or knee? (Deformity in the axial plane) Lift up the underpants Look at the hip area Are there any scars from previous surgery or disease? Is there a hip arthroplasty scar Is there evidence of recent bruising? Is there a sinus or dressings present? A sinus suggests chronic hip infectionAt this stage ask the patient “Can you point to where the pain is? If the patient points to the groin it is probably arising from the hip joint, if the patient points to their back or buttock it suggests possible referred pain from the spine to the hip Sometimes a patient will make a C sign with their hand over the painful hip which is a very specific sign for hip diseaseDo not forget to pull the underwear out of the way (Don’t miss an obvious scar).

Hip inspection from the Back

Look from behind Does the patient have a straight or scoliotic lumbar spine, and if so, is it compensated or not. A degenerative scoliosis may be the reason the patient is complaining of hip pain Check for any gluteal muscle (buttock) wasting Gluteal muscle wasting suggests chronic hip disease Look at the popliteal creases, are they at the same level. Alterations in the level of the popliteal fold suggest a LLD Ask the patient “Can you bend forwards please sir” You are assessing forward flexion checking the spine for symmetrical movement, normal rhyme Sum up your provisional finding from inspection at this stage Do not examine in silence • “On general inspection the patient looks well, is standing straight, the shoulders and pelvis are level, both knees extended and the stance is symmetrical”.

Gait

Abnormalities of gait are usually a consequence of pain, weakness, or a difference in the lengths of the limbs “Can you walk for me please” Ask the patient to walk away and then back towards you. Don’t forget to watch the shoulders. It is essential to recognise various different gait patterns that could be present. It gives a clue to the cause of the gait abnormality and hence the diagnosis.

Antalgic gait Is the gait antalgic? In painful disorders of the hip patients will try to avoid weight bearing on the affected side. Pain in the hip on weight bearing is diminished by reducing the time spent on the affected leg(Shortened stance phase). There is a shortened stance phase of the affected limb with learning of the trunk over to the painful side. Shifting the centre of gravity of the upper body to a position closer to the femoral head reduces the counterbalancing force required in the abductor muscles,thus dramatically reducing the compressive across the painful hip joint.This is sometimes referred to as a coxalgic gait. Several textbooks confuse the issue by mentioning that with an antalgic gait a patient learns the upper body over to the sound leg.This could occur with a painful non hip related leg condition such as a heel spur or osteoarthritis of the knee.

Tredelenburg gait Does the patient walk with a Trendelenburg gait? With a Trendelenberg gait there is a drop of the pelvis on the opposite side to the affected stance limb.There is also a shift in the body’s centrer of gravity to the non weight bearing side that’s dropped down. Patients usually compensate and avoid falling over by shifting the upper body towards the weight bearing leg. This decreases the counter balancing force that needs to be exerted by the weak abductor muscles

Short leg gait Don’t forget a short leg gait. In cases where the limb has become short due to hip disease, the patient tries to bring the foot to the ground by tilting the affected half of the body down. This involves excessive shift of the centre of gravity towards the short side with a drop of the centre of gravity. It differs from the anatagic gait in that the stance phase is equal [A regular even dip on the shortened side]. This gait is only apparent if the limb is shorter than 2cm.

Drop foot gait Look for a drop foot gait The leg is lifted more in order to get clearance. The forefoot rather than heel touches the ground first.

Gluteus maximus gait This is seen in weakness or paralysis of the gluteus maximus muscle. Patients have hip extensor weakness. The gluteus maximus normally locks the hip in extension as the contra-lateral limb is advanced for the next step. A patient with a weak gluteus maximus necessitates a forward thrust of the pelvis and backward thrust of the trunk. This position places the centre of gravity posterior to the hip and therefore reduces the force that the gluteus maximus needs to generate to lock the hip in extension. Or more simply the body lurches backwards during the stance phase on the involved side

Circumduction gait When the hip is fixed in abduction there occurs an apparent lengthening of the limb. In order to walk the patient has to take the affected “long leg” in a round about fashion to take the forward step

Stiff hip gait The patient lifts the pelvis and swings it forwards with the leg as one piece. The patient walks without flexing the hip

Quadriceps lurch The patient walks by hyper-extending and therefore locking the knee

Stiff knee gait The leg is circumducted and brought forward in order to get clearance. During the swing phase the patient raises the pelvis of the affected side.

Waddling or duct gait There is increased lordosis. The body sways from side to side on a wide base. Therefore the patient lurches on both sides while walking Mostly seen in bilateral DDH.It can be quite striking

Is walking possible without the use of their stick. Get the patient to walk first with their stick and then ask them to walk without it and specifically comment to the examiners on the difference in gait [Doing this will gain you extra points and put you ahead of the average candidate].

Summarise your finding from gait to the examiners.Again do not examine in silence • “The patient is walking with a comfortable gait. It is a reciprocating gait. The trunk is moving normally and he is using the normal 3 rockers of both feet”.

Trendelenburg Testing

“I’m now going to test how well you stand on one leg. Do you think you can manage this for me? Can you do what I’m going to show you.” The Trendelenburg test is very important and one that you must be able to demonstrate well and feel at home with. Moreover be very clear about what you are testing and be able to talk your way through it as you perform it in front of the examiners.

It is not an easy task to perform and interpret correctly a test whilst at the same time explaining what you are doing, why you are doing it and the significance of your clinical findings to the examiners. As well do not forget that there is a patient in front of you. It is easy to get confused with this happening all together at once but in reality this is an aspect of what the clinical examination is setting out to assess. Do not under perform by concentrating too hard eliciting the physical sign whilst at the same time struggling to remember how one is going to explain it to the examiners. Practice this test beforehand to get slick during the exam

In 1895 Friedrich Trendelenburg described observations on the gait of congenitally dislocated hip patients. Later he went on to describe the pelvic inclination on single leg weight bearing, which became known as the Trendeleburg test. This test has been modified repeatedly since the original description.

The Trendelenburg test can be performed either with the examiner in front or behind the patient. The original test was described with the examiner behind the patient so that the dimples overlying the posterior superior iliac spines could be seen to move up and down when the test was performed. Most candidates are more familiar performing Trendeleburg test from the front. We believe testing from the front is more practical and simpler in an examine situation. Furthermore unless somebody is actually facing the patient, they are reluctant to stand on one leg particularly if the hip is painful.

By all means perform a test as you have always have done especially if it works for you but at least do it properly.1

In practice it is easier if you first demonstrate Trendeleburg test to the patient showing them what you want them to do. It avoids any misunderstanding There are several methods of performing Trenedeleburg test. Learn one method well and stick to it

Method 1 Stand in front of the patient and ask them to hold their hands out in front and place their hands in your hands for balance. Ask the patient to stand on their normal leg first and then the affected side The examiner can feel how much pressure the patient is using in order to maintain balance. When the left foot is lifted the right abductor muscles are being tested, when the right foot is lifted the left abductor muscles are being tested 2 A patient standing on his right leg would be Trendelenburg positive for the right if the left side dipped.3

The test is negative (normal) is the pelvis stays level or even rises slightly with the trunk staying over the pelvis and this can be maintained for 30 seconds. The test is positive (abnormal) if the patient is unable to hold the pelvis level and maintain this for 30 seconds If all things fail remember the SOUND SIDE SAGS

Method 2 The examiner kneels down and asks the patient to place their hands on his/her shoulder The examiner places his/her hands on the anterior superior iliac spine The patient is then asked to first stand on the good leg and then the bad leg The examiner will feel the pelvis dipping down on the affected side and appreciate downward pressure on the shoulder

Trendelenburg’s test is done to assess the integrity of the abductor mechanism of the hip, which constitutes of the fulcrum, lever arm and power. With the fulcrum at the hip joint, normal lever arm of the head, neck and shaft of the femur intact and power in the controlling group of muscles

True positive Power failure (weakness of abductors) • Polio, neuromuscular condidtions, • Gluteal muscle paralysis or weakness (superior gluteal nerve injury) • Generalised neurological weakness (Spinal cord lesions, myelomeningocele) • Post THR exposure with failure of adequate repair • Trochanteric osteotomy Lever (pivot) failure • #NOF; #ITF, short neck in coxa vara, DDH Fulcrum failure • Perthes.If there is femoral head incongruity or hinge abduction the test may become posi¬tive • Osteoarthritis

False positives Gluteal inhibition due to pain secondary to • OA • AVN Hip pain makes proper assessment of these cases difficult If pain is not considered a true positive It has been suggested that a 10% rate of false positives occur

False negative • Arthrodesed or ankylosed hip Able to maintain abduction with no abductor function

False-positive and false-negative responses may occur, but their interpretation can be clarified if the test is properly performed

Invalid if • Poor balance • Lack of co-ordination • Unable to understand instructions

The presence of pain, poor balance and either lack of co-operation or understanding by the patient can lead to false-positive tests, because the test cannot he properly performed. The reason for false-negative tests is that the subject uses muscles above the pelvis to elevate the non-weight-bearing side of the pelvis, or shifts the torso well over the weight-bearing side; these can be called “trick movements”.

Be clear why a test is positive. The examiners will want to know why the pelvis dips down and the causes of a positive test! Normally the pelvis on the non-weight bearing leg rises slightly (Trendelenburg negative) due to contraction of the abductors of the weight-bearing limb. However if the pelvis dips on the side of the non-weight bearing leg or cannot be held steady for 30 seconds the test is positive A delayed positive test occurs if the pelvis eventually dips after continued leg rising for 30 seconds to one minute. This indicates abnormal fatigability of the hip abductors. Some authors have questioned the clinical value of a delayed Trendelenburg test. Any painful hip condition will be positive after the patient has been performing the test for 30 seconds or so

A Trendelenburg test is positive for two main reasons either a • Neuromuscular condition • or Mechanical disadvantage

Neurological causes can be generalised or more specifically localised. Generalised motor weakness is seen in conditions such as spinal cord lesions or myelomeningocele. Specific localised neurological causes could include superior gluteal nerve dysfunction secondary to previous hip surgery. The mechanical group includes conditions that affect the abductor muscle lever arm, which place them at a mechanical disadvantage. This includes conditions such as coax vara, hip fractures etc. These conditions shorten the length of the muscles and this significantly weakens their strength. When standing on one leg the body automatically brings its centre gravity over the weight bearing leg. Because the pelvis dips away from weight bearing leg the upper body may have to swing in an exaggerated manner to achieve a position with the centre of gravity of the body over the weight-bearing limb

If the test is negative it is significant—it means that the subject does not have abnormal hip mechanics

With patient lying supine on couch

“Could you come and lie down for me, please sir.” Notice how the patient gets onto the examination couch and whether they appear in pain. Do they clutch the painful leg with both hands and struggle to get on the couch? More importantly comment on this to the examiners. Make sure the examination couch is flat Make a particular point of demonstrating that the pelvis is square on the couch (Anterior Superior Iliac Spines are level) even if they are straight-it demonstrates that you are checking “The pelvis is level, both ASIS are straight and the legs are square and straight with the pelvis.” If the pelvis cannot be squared up then there is a fixed adduction or abduction deformity at one or both hips. Again comment on this problem to the examiners Wparticular look for asymmetry, deformity, and rotational alignment of the legs Any obvious shortening should be commented on With a fixed deformity mirror the opposite leg in the same position as the affected leg

Leg Shortening

This topic is covered in more detail in a separate section The legs are put in equivalent positions Check the level of the malleoli Measure from ASIS to the medial malleolus Difficulty may be encountered with fixed deformities of either the hips or knees. If necessary sequentially measure from ASIS, greater trochanter, medial joint line knee and tip medial malleolus.

Galleazzi’s test If there is shortening in a limb a candidate should go on and perform Galleazzi’s test. Candidates should know this test and be prepared to demonstrate it to the examiners if clinically indicated). 4 This test demonstrates whether the shortening is in the femur or tibia Flex the hips to 45º and the knees up to 90º. Place the malleoli together (The test is inaccurate if you are unable to do so) Comment on whether the knees are level or at a different level and on the parallelism of the femora and tibia. Normally both knees are at the same level When one knee projects farther forwards than the other,either that femur is longer or more usually the contra-lateral femur is shorter When one knee is higher than the other,either the tibia of that side is longer or the contra-lateral tibia is shorter Femoral shortening is apparent in a decreased prominence of the tibial tubercle. Tibial shortening shows similarly at the superior pole of the patella

Bryant’s triangle This test measures supratrochanteric shortening This test may form part of the limb shortening series of tests that you may need to demonstrate to the examinerAgain candidates should know this test and be prepared to demonstrate it to the examiners. The patient should lie supine with the pelvis square and limbs in identical positions. • Identify the ASIS with the thumb and the tip of the greater trochanter with the main finger • Comment on any difference in the distance between ASIS and greater trochanter, which suggests a discrepancy proximal to the greater trochanter. • Assess the perpendicular distance between points with the index finger of the other hand

This is not strictly Bryants triangle test- it is a test for proximal migration of the greater trochanter. 3 Bryants triangle test involves officially drawing out with pen various lines on the pelvis

A perpendicular line is dropped from the anterior superior iliac spine (ASIS) onto the bed. From the tip of the greater trochanter another perpendicular line is dropped onto the first line (Base of the triangle). The tip of the greater trochanter is joined to the ASIS’s on the respective sides (Hypotenuse6). This forms a triangle ABC.Each side of the triangle is compared with its counterpart on the opposite side The length of BC line is compared between the two sides. Relative shortening on one side indicates that the femur is displaced upwards as a result of a problem in or near the hip joint. If the problem is bilateral, Bryant’s triangle is unhelpful.

Shortening above the trochanter may be caused by destruction of the femoral head or acetabulum or both, a dislocated hip, coxa-vara deformity of a mal-united inter-trochanteric fracture.

“I would like now to perform Bryants triangle test to see whether there is any shortening above the trochanter (supra-trochanteric)”. When Bryants triangle is constructed the perpendicular distance is shorter by 2 finger widths between the ASIS and greater trochanter on the right side

Other tests are described that are used to roughly access the position of the greater trochanter. In clinical practice these are usually omitted as they are difficult to perform and not particularly accurate. For the exam you need to know about them so that the examiners do not catch you out.7 These tests include Nelatons line ,Schoemakers line and Chienes line. “I would like now to perform Bryants triangle test to see whether there is any shortening above the trochanter (supra-trochanteric)”. “When Bryants triangle is constructed the perpendicular distance is shorter by 2 finger widths between the ASIS and greater trochanter on the right side.”

Nelatons line The patient lies with the affected side uppermost. With the hip flexed up 900 the tip of the greater trochanter should lie on or below a line connecting the anterior superior iliac spine and ischial tuberosity. In cases of supra-trochanteric shortening the trochanter will be proximal to this line

Schoemakers line With the patient lying supine a line joining the ASIS and tip of the greater trochanter is extended on the side of the abdomen on both sides. Normally, these lines meet in the midline above the umbilicus. In the case of one of the greater trochanters migrating proximally, the lines will meet on the opposite side of the abdomen and below the umbilicus. If the problem is bilateral the lines will meet at or near the midline but below the umbilicus.

Chienes line With the patient lying supine lines are drawn joining the two ASIS and the two greater trochanters. Normally, these make two parallel lines. In the case of one trochanter moving proximally, the lines will converge on that side

Palpation

It is very easy to forget to palpate the hip during your examination .In fact examiners still like to see this performed. The hip joint is too deep to access for the presence of an effusion or synovial thickening. Access skin temperature Tenderness may be elicited in and around the joint Abnormal swelling or masses Dislocated anterior femoral head (Lump sign), lymph nodes, hernias, aneursyms Palpate the ASIS, along the inguinal ligament, femoral head, adduction longus insertion, lesser trochanter, greater trochanter [trochantric bursitis], ischial tuberosity Halfway along the inguinal ligament one can feel the femoral pulse, deep to this point is the femoral head Is there a general surgical problem? If there is a swelling you should be able to examine for a hernia. If the presentation of hip pathology is vague percussion on the heel pad in the extended position of the leg and over the trochanter usually induces discomfort and/or pain in the groin region if there is any disease or injury of the hip.]

Thomas Test

An absolute classic test that is well known to most candidates. The examiners will almost certainly ask you to demonstrate it as part of an intermediate case examination of a hip condition. The test is also well known to crop up in short case examination of the hip Candidates should practice this test and be prepared to demonstrate it well. You must be completely comfortable performing this test and be able to demonstrate it smoothly. The test is usually well described by most candidates but poorly performed under the pressure of the examination. The aim is to remove the compensatory lumbar lordosis so that the flexion deformity of the hip becomes obvious A common mistake is not to put a hand under the lumbar spine to demonstrate that the lumbar lordosis has been flattened. Another error is to be too gentle and not completely remove the lumbar lordosis. You must be sensible, do not hurt the patient flexing up the opposite hip; it may also have pathology such as a painful arthrosis. At the same time do not maximally flex the hip as this will cause the pelvis to flex and may lead to a false impression of a FFD If the patient has a total hip replacement on the opposite side do not dislocate it by flexing it up too vigorously. Some surgeons may not perform this test for fear of dislocation.

The angle subtended between the back of the thigh and the bed will be the angle of fixed flexion deformity. Severity of the flexion contraction at the hip will not be appreciated if the hip is allowed to abduct whilst the Thomas test is performed. Hugh Owen Thomas described this test in 1876.He described his test on a naked patient laid on a hard table or other hard surface.

Controversies At the start whether to get the patient to bend both knees to up 45° or to start by flexing up only the sound hip (Slicker but deviating from the classic Thomas test and may not go down well with an old school examiner) Whether to have the patient hold both knees up to their chest together (Uncomfortable for the elderly arthritic patient) Whether to stick to testing one hip at once or try to combine the examination to include both hips. It is difficult to perform • In the presence of an ankylosed knee (in extension) • In obese or heavy built individuals • In bilateral fixed flexion deformity of the hips Decide how you are going to do it and stick with your own method. Some examiners would suggest it is not about sticking to absolutes with this test but about attitude and appearing confident with what you are doing. If you appear hesitant and are also deviating too much from classic teaching you may get challenged by the examiners as to what exactly are you doing to the patient. Be prepared to defend your practice

Movements

Probably the most important sign. Hip movements are the key to the diagnosis of hip disease. Classically textbooks mention measuring active movements first and then passive movements afterwards. This allows a comfortable range of movement of the hip to be detected first. Passive movement beyond this range can then be sought with caution, keeping the patients face under observation so as to avoid distressing the patient (and the examiner). If movements are severely restricted in all directions think of rheumatoid arthritis, tuberculosis, septic arthritis. If hip movements are reasonably well preserved but there is pain and terminal limitation of movement think of osteoarthritis of the hip One or more movements may be more limited than others if the head is deformed in such cases as Perthes or AVN.

Fixed Deformity • Persistent muscular spasm • Persistent posture assumed to avoid pain or compensate for an obvious deformity/disparity of the limb lengths • Destructive changes in the joint • Fibrotic contractures in periarticular soft tissues May all lead to particular fixed positions of a joint from where the limb cannot be brought back to neutral but further movement in the same axis may be possible. The hip joint commonly develops a fixed deformity either singly or in combination. Combination of fixed deformities includes flexion, adduction and internal rotation, flexion, abduction and external rotation and adduction and external rotation in that order. If a joint is fixed in a particular direction the opposite movement is automatically not possible The pelvis must be fixed when testing for the range of movement. The moment the pelvis starts moving one must stop and bring the limb back to just short of this situation Even though a patient may have a fixed deformity he usually adopts some compensatory measure in order to • Conceal the deformity • Maintain equilibrium by shifting the centre of gravity • Apparently make up the disparity of limb length • Stabilise the unstable hip Therefore in most of the fixed deformities there are compensatory secondary functional (postural) deformities Fixed flexion deformity hip-lordosis at the lumbar spine Fixed abduction deformity-lowering of the pelvis on that side and scoliosis with convexity towards the affected side

Log rolling tests A very quick and simple test to judge the irritability and freedom of movements in the hip before a more formal range of movement testing. Feel for resistance on rolling the tibia Very accurate Move the patella not the foot

Internal and external rotation of the hip may be tested in both extension and 90º flexion Rotation in flexion Flex the affected hip to 90º Internal rotation occurs when the foot turns out and external rotation occurs when the foot turns in. Hold the leg with one hand and stabilise the pelvis with the other hand Do not be confused because although the foot moves laterally (externally) the hip rotates internally (medially) Do not mix up internal and external rotation of the hip which is surprisingly easy to do during the stress of the clinicals External rotation in flexion is usually slightly greater (50º) than internal rotation (40º) except in cases of excessive femoral anteversion.

Rotation in extension Rotation in extension allows a clear and convenient demonstration of restricted movement The patient needs to be placed prone on the couch Be careful if there is a fixed flexion deformity of the hip or the patient is in pain This test is probably not particularly appropriate if a patient is frail and elderly. The knee is flexed up to 900 and feet held apart to demonstrate a normal range of internal rotation of 350 and crossed over to demonstrate external rotation of 450

Abduction Hip abduction is measured with the patient lying supine Abduction can some times be difficult to quantify due to lumbar and spinal movement. The are two ways this problem can be avoided. 1. Keeping one hand over the opposite ASIS whilst moving the hip will detect any movement of the ASIS and hence pelvis. False abduction is detected when the contra-lateral ASIS moves. Make a show of feeling where the ASIS are and fix them with your forearm and access the arc of movement up to the point where the pelvis begins to move to ensure that any movement detected is not due to pelvic rock. 2. Abduct the normal hip first and leave the leg over the edge of the couch. Now abduct the abnormal leg, the normal leg will steady the pelvis. We have also seen the pelvis stabilised by placing a hand over the pubic symphysis. This method was sold as being slick way of stabilising the pelvis and allows one to move quickly from one leg to the other. Personally we are not particularly fond of it. This may relate to strong negative adverse comments made by an old school examiner the only time we ever used this method in a clinical examination. The normal range of movement is 40º

Adduction True adduction can only be measured if the contra-lateral leg is in a position of abduction. If it is in a neutral position then a degree of pelvic tilt comes into play as the examined leg crosses over the contra-lateral static leg In practice most candidates move the examining leg over the good side by flexing the hip slightly to measure adduction. As with abduction, the pelvis must be stabilised when measuring the range of movement. The normal range is 30º

Lumbar spine Always examine the lumbar spine in your intermediate case. In the short cases ask to examine the lumbar spine, but expect to be told to leave it

Knees Always examine the knees in the intermediate case

Distal neurovascular status Examination for pulses and neurological deficit of the limb must always be done in a case with hip disease

Patient on their side (affected side upwards) Ask the patient to abduct the leg against gravity whilst palpating the gluteal muscles Push down for resistance Use the MRC grading of power This is an important test in patients who have had previous hip surgery to check for abductor power.

Craigs test/Ryders method for femoral anteversion The patient lies prone with the knees flexed to 900 .The examiner palpates the posterior aspect of the greater trochanter. The hip is then passively rotated medially and laterally until the greater trochanter is parallel with the examination couch or reaches its most lateral position. The degree of anteversion can then be estimated based on the angle of the lower leg with the vertical

Ober test This tests for tightness of the iliotibial tract. Abduct the hip with the knee flexed and slowly extend the knee The test is positive if the leg stays elevated (due to IT band tightness) Flex the knee (relaxing the IT band) and the leg should drop back to the couch A negative result is when the thigh falls to neutral or adduction

Apprehension test for labral pathology Not usually performed in the clinic May be useful when examining a young patient with hip pain in which the diagnosis is not entirely clear. With the patient supine, the hip is flexed gently, adducted and internally rotated. If this causes pain, there may be an anterior labral tear. MRI of the hip or hip arthroscopy may be indicated.

Patricks test This is also known as the Fabere sign (Flexion, Abduction.External Rotation and Extension) The patient is asked to place the lateral malleolus of the test leg above the knee of the extended unaffected leg. Pain during this manoeuvre is regarded as being one of the very first signs of osteoarthritis of the hip The test may be amplified by pressing downwards on the test knee. Pain with downward compression indicates a sacroiliac joint condition as this joint is compressed in this position

Telescopy Tests stability of the hip. The patient lies supine on the couch with the affected side towards the examiner. One hand stabilises the pelvis using the thenar eminence over the ASIS and the fingers on the greater trochanter. The knee and hip are flexed With the other hand holding the knee, a gentle push and pull force is applied along the long axis of the thigh An up and down movement of the greater trochanter can be felt by the fingers when the hip is unstable

Fixed Adduction deformity Commonly encountered but not always fully appreciated. Be absolutely clear what you are going to find clinically and make sure your examination technique is correct. A fixed adduction contracture would be regarded by examiners as fairly basic and if performed poorly may be the end of your intermediate case for you. The anterior superior iliac spine of the affected side is elevated as compared to the opposite side To measure the angle of fixed adduction the affected limb is adducted further leading to lowering of the anterior superior iliac spine till both anterior iliac spines are in the same horizontal plane The pelvis is thus squared up The angle of fixed adduction is between the long axis of the limb and a vertical line from the anterior superior iliac spine Squaring is not possible in a fixed scoliosis due to fixed obliquity of the pelvis Adduction makes the limb appear shorter-each 100 of fixed adduction adds a further 3 cm of apparent shortening to any real shortening which the disorder may have caused

1 Be very wary about changing your examination technique in the month or so before the exam. It is best at this stage to stick with what you have always done unless it is obviously flawed or seriously faulty! 2 Be very clear with this one. Do not get confused and mix up the side you are testing. 3 Similar to 2 but phrased differently. What ever “needs must” to remember which side you are testing 4 Ungentlemanly clinical methods This story is a few years old now but at the end of the old style long case the candidate quietly asked the patient if he had missed anything out in his examination.” “Well the last candidate did put my knees and ankles together to look for shortening of the leg” 5We are not deliberately dealing in semantics here. We may call this Bryants triangle test but it isn’t. Some candidates refer to this test as “digital Bryants triangle” to confuse the issue still further 6 The side in a right-angled triangle that is opposite the right angle 7 Debateable point. Realistically how likely are you going to be asked about this in the exam If pushed mention you are aware of these lines but do not use them in clinical practice as you find them inaccurate.