Hip & Thigh

HIPMNRS

Basic introduction to regional exam performed by Dr. Vizniak

video resources: palpation, muscle testingROM

regional exam forms – Rehab. & Stretching patient handouts

To learn more see our text books or take our hands on training seminars

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Allis Sign (Skyline)

Synonym: Galeazzi’s Sign, Knee Skyline Test

Patient supine with hips flexed 45° in knees flexed 90°, examiner observes the height of the patellas from the foot of the table for tibial length discrepancies, then examiner observes laterally for femoral length discrepancies

(+) One knee higher (tibia) or more anterior (femur) to the other → Leg length inequality (anisomelia)

Potential causes of leg length inequality include; functional SI malalignment, congenital, poor fracture healing, bone growth disorders, degenerative joint disease; a positive test should be followed with leg length measure &/or scanogram

Anvil Test

Patient supine, examiner flexes patient’s straight leg to 15-30°, then applies gentle long axis compression to the leg & strikes the patient’s heel

(+) Hip pain → hip joint pathology, arthritis, femoral neck or head fracture, infection

(+) Local femoral, tibial, fibular or calcaneal pain → fracture in the region corresponding to the pain

Clinician’s option: examiner may choose to repeatedly strike the heel with increasing force each time for up to 3 percussions (start lightly then gradually increase force – least to most invasive)

Prior to having patient lay down the clinician may choose to have the patient attempt to hop on one foot as a more functional test for the lower extremity

Craig's Test

Patient prone with knee flexed 90°, examiner palpates greater trochanter then proceeds to internally or externally rotate the femur until the greater trochanter is parallel with the examination table

The degree of anteversion can be estimated based on the angle of the lower limb to the vertical plane – Adult anteversion angle should be between 8°-15°

Synonyms: Ryder Method, Anteversion Test (anteversion = anterior torsion of the femoral neck; retroversion = posterior torsion of the femoral neck); femoral anteversion occurs 2:1 female:male

Dial/Log Roll Test

Patient supine or side lying examiner carefully rotates the thigh internally & externally & observes the patient for signs of discomfort, pain or excessive ROM, compare other side

(+) Excessive motion → hip joint capsule laxity (instability)

With the patient supine the test is usually easier to perform in acute presentations – test is effectively passive rotation ROM

Femoral Neck Stress FX Test

Patient seated with mid femur & knee hanging off edge of table, examiner applies pressure down on the distal knee & observes the patient for signs of pain/discomfort (mid thigh should be at edge of table)

(+) Pain → femoral neck stress fracture

Very useful test the put little pressure on the joint cartilage surface or capsule to DDx femoral neck stress fracture

Also look for history of the female athletic triad

  1. Excessive exercise (repetitive trauma)
  2. Decreased bone density (osteopenia/porosis)
  3. Nutrient or absorption or eating disorder or amenorrhea

Patrick (Fabere) Test

Synonyms: Figure-4 Test, Jansen’s Test

Patient supine, examiner instructs patient to cross legs into a “figure 4” position (ankle placed above contralateral knee, ipsilateral knee flexed 90°, ipsilateral hip abducted & externally rotated), examiner then stabilizes pelvis & applies gentle downward pressure over the flexed knee

(+) Pain or inability to perform motion → hip joint pathology, severe arthritis, sprain/strain, fracture, tight hip adductors

FABERE is an acronym for Flexion, Abduction, External Rotation & Extension of the hip joint (good general screening test) (sn: 50 sp: 29 +LR: 0.7 -LR: 1.72)

F.A.I.R (Piriformis) Test

FAIR stands for flexion, adduction & internal rotation

Patient side lying or supine with hip neutral & knee flexed ~60-90°; examiner stabilizes hip & passively flexes hip to ~60° & internally rotates femur (test is effectively a stretch of piriformis)

(+) pain in sciatic/gluteal area → sciatic nerve compression, hip joint pathology, femoral acetabular impingement, hip fracture

Anterior thigh pain can result from femoral acetabular impingement (be sure to ask where the patient feels pain)

(sn: 88 sp: 83 +LR: 5.2 -LR: 0.14)

SI Resisted Abduction

Patient side-lying with the unaffected side down & knee flexed for stability, the affected leg is straight, slightly extended & abducted; examiner applies downward pressure against the patient’s resistance on the abducted leg, test is then repeated on the opposite lower extremity

(+) Pain near the PSIS → SI joint dysfunction, ligamentous sprain

(+) Abductor muscle weakness → Muscle deconditioning, muscle strain (gluteus medius) (r: 0.63 sn: 73 sp: 46 +LR: 1.4 -LR: 0.6)14

Test is essentially resisted muscle test of hip abduction

Scour (quadrant) Test

Patient supine, examiner flexes patient’s hip to 90° & flexes knee, 3 parts

1. Take patient through passive hip ROM (circumduction & rotation) without compression

2. Examiner then applies mild long axis compression over the femur and repeats

3. If tolerated, examiner repeats test with more pressure

(+) Pain or crepitus → Hip joint pathology, osteoarthritis, transient hip synovitis, capsulitis, labral tear, acetabular impingement syndrome, SCFE, fracture

This test approximates acetabulofemoral joint structures which may be irritated in the presence of hip pathologies

(sn: 75-91 sp: 43 +LR: 1.3 -LR: 0.58)

Rectus Femoris Contracture Test

Supine patient, with leg off end of table, flexes one knee to chest while keeping the other hip straight & knee flexed 90°, examiner observes for straight hip knee extension

(+) Extension of the knee → Rectus femoris muscle contracture

Abduction of the hip may also be noted in the presence of ITB tightness or contracture

Gaenslen's Test

Patient supine, examiner flexes knee & thigh of affected leg to patient’s abdomen, then examiner slowly hyperextends the opposite leg & observes the patient for signs of discomfort or pain, the test is then repeated on the opposite extremity

(+) Sacroiliac or anterior thigh pain → sacroiliac joint pathology (ligamentous sprain, instability) (r: 0.6-0.72 sn: 50-71 sp: 26-77 +LR: 1-2.2 -LR: 0.65-1.1)

(+) Elevation of extended hip → iliopsoas contracture

(-) No sacroiliac pain → possible lumbar or hip pain origination (if the leg hanging off the table starts to straighten look for iliopsoas contracture)

Hamstring Contracture Test

Patient seated on examination table with one hip abducted & knee fully flexed & the other leg straight, examiner instructs patient to flex trunk & touch toes of straight leg; test is repeated bilaterally

(+) Inability to touch toes → Tight hamstring muscle group (contracture)

Some individuals have a genetic predisposition towards congenitally shortened hamstring muscles & will perform poorly on this test

Hip Telescoping Test

Synonyms: Piston Test, Dupuytren’s Test, Axial Distraction

Patient supine with hip & knee flexed 90°, examiner first applies downward pressure towards the examination table, then examiner applies long axis distraction on the femur lifting the leg from the examination table

(+) Excessive motion, pain or apprehension → Hip dislocation, instability, ligament damage

Test is often described as a pediatric orthopedic test but it does have similar application in adults

Acetabular Labral Tear Test

Patient supine, 3 parts to test

Examiner applies P-A force over distal thigh & asks patient to flex hip (rectus femoris originates from the anterior acetabulum & if the anterior labrum is torn the pull from contraction may cause pain – similar to O’brien’s or Biceps load test II in the shoulder – both of which show excellent statistical values)

Patient in Gaenslen’s test position, examiner pushes hanging leg into extension (compression of the posterior labrum may cause pain if damaged)

With patients knee bent, examiner flexes patient hip into full flexion & internal rotation with over pressure (sn: 94-98 sp: 8-25 +LR: 1.1-1.3 -LR: 0.12-0.46)

(+) Pain or apprehension → acetabular labral teat, joint capsule impingement – MRI is the confirmatory test for acetabular labral tears

Leg Length Evaluation

 

Patient supine or standing with leg straight & feet together, two different procedures:

Actual leg length test (more accurate): examiner measures bilaterally from the ASIS to the most inferior point of the medial malleolus

Apparent leg length test: examiner measures bilaterally from umbilicus or xiphoid process to the most inferior point of the medial malleolus

 

Interpretation

 

(+) Leg length inequality → congenital bone growth discrepancy (tibia, femur), sacroiliac joint dysfunction (anterior or posterior tilt of the ilium), coxa vara, coxa valga, SCFE, Legg-Calves-Perthes disease, loss of articular cartilage (DJD, infection, arthritis), femoral neck fracture, femoral dislocation

Standing leg length evaluation is a more functional assessment, as leg length inequality only becomes an issue with lower extremity weight bearing ambulation

 

Ober's Test

Patient side-lying with affected lower extremity up, examiner stabilizes pelvis with one hand & grasps ankle & flexes patient’s knee to 90°, slightly abducts & extends hip, examiner then proceeds to internally rotate the hip (lift the ankle up)

(+) Hip pain → Hip joint pathology

(+) Trochanteric pain → Trochanteric bursitis (r: 0.94)22, 23

Clinicians should use caution when performing this test on individuals with known knee pathologies as this test may increase stress on the knee

Clinician’s option: examiner may also palpate the greater trochanter while rotating the thigh to possibly further irritate the trochanteric bursa

Ober's Modified Test

Patient side-lying with affected lower extremity up, examiner stabilizes the patient’s pelvis & adducts affected leg behind opposite leg, observing for pain, discomfort, ROM and end feel

(+) Hip pain → Hip joint pathology

(+) Trochanteric pain → Trochanteric bursitis

(+) Decreased ROM → ITB contracture

Synonym: Posterior Adduction Test, ITB stretch test; this maneuver may also be used as a stretch for the ITB

Patellar Public Percussion

Patient supine; examiner places stethoscope over patient’s pubic symphysis, examiner taps or places tuning fork on patient’s patella & notes presence of sound, test is repeated on opposite side

(+) Decreased sound, pain with percussion → Hip or femur fracture (r: 0.89 sn: 89-96 sp: 82-95 +LR: 5-20 -LR: 0.06-0.8)

Test is essentially part of a normal fracture screen, patient history & initial presentation should point the examiner toward the diagnosis of fracture

Follow HIP MNRS with every patient encounter – History, Inspection, Palpation – Motion, Neurovascular, Referred, Special Tests

Make sure you have a detailed anatomy understanding and can create a list of potential pain generators (muscle, bone, joint, ligament, cartilage, blood vessels, nerves, viscera & lymphatics) – any competent practitioner should be able to give a detailed list of the anatomy below their hand and the tissues they are stretching, compressing or activating

Clinicians performing regional exams must realize that no one sign is of absolute significance in isolation, each individual finding should be evaluated only in the context of other findings & the patient as a whole; this is particularly important with diagnostic procedures that may result in “soft” signs, which are difficult to reproduce & may have a large subjective bias in their interpretation.

When recording test results it is not enough to write “test-X positive.” Record any findings associated with the test (reproduction of symptoms, pain, muscle guarding, numbness & tingling, decreased flexibility, clicking, etc) – more information results in a more accurate assessment & better treatment. Remember assessment is therapeutic!

To learn more see our textbooks or take our hands on training seminars