MusculoSkeletal Exam

Chapter 11 The Hip

Table 11.1 Muscle, innervation, and root levels of the hip.

Movement	Muscles		Innervation	Root levels
Flexion of hip	1 Psoas		L1–L3	L1, L2, L3
	2	Iliacus	Femoral	L2, L3
	3	Rectus femoris	Femoral	L2, L3, L4
	4	Sartorius	Femoral	L2, L3
	5	Pectineus	Femoral	L2, L3
	6	Adductor longus	Obturator	L2, L3
	7	Adductor brevis	Obturator	L2, L3, L4
	8	Gracilis	Obturator	L2, L3
Extension of hip	1 Biceps femoris		Sciatic	L5, S1, S2
	2	Semimembranosus	Sciatic	L5, S1
	3	Semitendinosus	Sciatic	L5, S1, S2
	4	Gluteus maximus	Inferior gluteal	L5, S1, S2
	5	Gluteus medius (posterior)	Superior gluteal	L4, L5, S1
	6	Adductor magnus	Obdurator and sciatic	L3, L4
Abduction of hip	1	Tensor fascia lata	Superior gluteal	L4, L5, S1
	2	Gluteus medius	Superior gluteal	L4, L5, S1
	3	Gluteus minimus	Superior gluteal	L4, L5, S1
	4	Gluteus maximus	Inferior gluteal	L5, S1, S2
	5	Sartorius	Femoral	L2, L3
Adduction of hip	1 Adductor magnus		Obturator and sciatic	L3, L4
	2	Adductor longus	Obturator	L2, L3
	3	Adductor brevis	Obturator	L2, L3, L4
	4	Gracilis	Obturator	L2, L3
	5	Pectineus	Femoral	L2, L3
Internal (medial)	1 Adductor longus		Obturator	L2, L3
rotation of the hip	2 Adductor brevis		Obturator	L2, L3, L4
	3	Adductor magnus	Obturator and sciatic	L3, L4
	4	Gluteus medius (anterior)	Superior gluteal	L4, L5, S1
	5	Gluteus minimus (anterior)	Superior gluteal	L4, L5, S1
	6	Tensor fasciae latae	Superior gluteal	L4, L5, S1
	7	Pectineus	Femoral	L2, L3
	8	Gracilis	Obturator	L2, L3
External (lateral)	1 Gluteus maximus		Inferior gluteal	L5, S1, S2
rotation of hip	2 Obturator internus		Nerve (N) to obturator internus	L5, S1, S2
	3	Obturator externus	Obturator	L3, L4
	4	Quadratus femoris	N to quadratus femoris	L4, L5, S1
	5	Piriformis	L5–S2	L5, S1, S2
	6	Gemellus superior	N to obturator internus	L5, S1, S2
	7	Gemellus inferior	N to quadratus femoris	L4, L5, S1
	8	Sartorius	Femoral	L2, L3
	9	Gluteus medius (posterior)	Superior gluteal	L4, L5, S1

providing sensation in the hip region are shown in Figure 11.64.

The lateral femoral cutaneous nerve (Figure 11.65) is of clinical significance, as it may be compressed at the waist, where it crosses the inguinal ligament. Pain, numbness, or tingling in the proximal lateral aspect

of the thigh may be due to compression of this nerve. This is called meralgia paresthetica.

Many common abnormal gait patterns result from dysfunction in the muscles about the hip. These abnormal gait patterns are described in Chapter 14.

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The Hip Chapter 11

Key sensory area for L1

L1

L3 L2

L1

	Key sensory
L2	area for L2

S3

S4

S3

S3

S4

Posterior

Figure 11.63 The dermatomes of the hip. Note the key areas for testing sensation in the L1 and L2 dermatomes.

Iliohypogastric nerve

Subcostal nerve

Subcostal nerve

Genitofermoral

L1, L2, L3 nerve roots

	Illoinguinal nerve
		S1, S2, S3 nerve roots
	Lateral femoral cutaneous	Lateral cutaneous nerve
	nerve of thigh
		of thigh
	Medial intermediate cutaneous
	nerve of thigh (femoral nerve)	Posterior femoral cutaneous
	Obturator nerve	nerve
		Obturator nerve
		Medial cutaneous nerve
		of thigh (femoral nerve)
Anterior view	Posterior view

Figure 11.64 The peripheral nerves and their sensory territories.

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Chapter 11 The Hip

Compression (causing tingling and numbness down thigh)

Lateral femoral cutaneous nerve

Referred Pain Patterns

Pain in the hip and groin region can result from urogenital or abdominal organ disease. For example, resisted hip flexion or external rotation may be painful in patients with appendicitis.

Dysfunction of the knee or diseases of the distal part of the femur can also radiate pain to the hip.

A L1 or L2 radiculopathy and sacroiliac joint dysfunction can also refer pain to the hip.

Figure 11.65 The lateral femoral cutaneous nerve (L2, L3) is a purely sensory nerve that can be compressed under the inguinal ligament at the anterior superior iliac spine, causing meralgia paresthetica.

Normal

Special Tests

Flexibility Tests

Thomas Test

This test is used to rule out a hip flexion contracture (Figure 11.66). The test is performed with the patient lying supine on the examining table. One knee is brought to the patient’s chest and held there. Make sure the lower region of the lumbar spine remains flat

Abnormal

Figure 11.66 Thomas test. Note that the patient’s knee elevates from the examination table due to a right hip flexion contracture.

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The Hip Chapter 11

Figure 11.67 Ober’s test. The test is performed with the knee in flexion. Extend the hip passively so that the tensor fascia lata (TFL) crosses the greater trochanter of the femur. The test result is positive when the knee fails to drop downward due to excessive tightness of the iliotibial band.

on the table. In the presence of a hip flexion contracture, the extended leg will bend at the knee and the thigh will raise from the table.

Ober’s Test

This test is used to assess tightness of the iliotibial band (Figure 11.67). The patient is placed in a position so as to stretch the iliotibial band. The patient lies on the unaffected side. The lower leg is flexed at the hip and knee. The upper leg (test leg) is flexed at the knee and extended at the hip while being lifted in the air by the examiner. The iliotibial band is tight and the test is abnormal when the knee cannot be lowered to the table. If the test is performed with the knee in extension, you may pick up a less obvious contracture of the iliotibial band.

Ely’s Test

This test is used to assess tightness of the rectus femoris (Figure 11.68). It is performed with the patient lying supine with the knees hanging over the edge of the table. The unaffected leg is flexed toward the

chest to stabilize the pelvis and back, and you should observe the test leg to see if the knee extends. Extension of the knee on the test side is a sign of rectus femoris tightness and is due to the fact that flexion of the opposite leg rotates the pelvis posteriorly, pulling on the rectus femoris muscle.

Piriformis Test

This test was described previously in the Resistive Testing section (p. 322).

Tests for Stability and Structural Integrity

Trendelenburg’s Test

This test is used to determine whether pelvic stability can be maintained by the hip abductor muscles (Figure 11.69). The patient stands on the test leg and raises the other leg off the ground. Normally, the pelvis should tilt upward on the non-weight-bearing side. The test finding is abnormal if the pelvis drops on the non-weight-bearing side.

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Chapter 11 The Hip

A

B

Figure 11.68 Ely’s test. (A) Negative test result is when the thigh remains in contact with the examination table. (B) Positive finding for rectus femoris tightness is when the thigh elevates and the hip flexes.

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Normal

Abnormal

Figure 11.69 Trendelenburg’s test. (A) Normally, the pelvis on the non-weight-bearing side elevates. (B) Positive finding due to left abductor weakness. Note that the pelvis is dropped on the non-weight-bearing side.

Figure 11.70 Patrick’s (Fabere) test. By applying pressure to the pelvis and the knee, you can elicit sacroiliac joint dysfunction as you compress the joint.

ASIS

Medial malleolus

Figure 11.71 (A) True leg length is measured from the anterior superior iliac spine to the medial malleolus. (B) A leg length discrepancy is illustrated.

Patrick’s (Fabere) Test

This test is performed to assess possible dysfunction of the hip and sacroiliac joint (Figure 11.70). The patient is supine with the hip flexed, abducted, and externally rotated. The patient is asked to place the lateral malleolus of the test leg above the knee of the extended, unaffected leg. The test result is positive if this maneuver causes pain for the patient. The test may be amplified by your pressing downward on the test knee. Pain with downward pressure indicates a sacroiliac joint problem, as the joint is compressed in this position.

Alignment Tests

Test for True Leg Length

This test should be performed if you think the patient has unequal leg length, which may be noted on inspection and during observation of gait. A true leg length discrepancy is always noted when the patient stands with both feet on the floor. The knee of the longer leg will be flexed, or the pelvis will be dropped on the short side. A valgus deformity of the knee or ankle

Chapter 11 The Hip

may also be noted. To measure leg length accurately, it is important to make sure that the patient is lying on a flat, hard surface. Both legs should be placed in the same position with regard to abduction and adduction from the midline. Measurement is taken from the anterior superior iliac spine to the distal medial malleolus on the same side (Figure 11.71). This is then compared to the opposite side.

The true leg length discrepancy is due to shortening of either the tibia or the femur. If the patient lies supine with both knees flexed and the feet flat on the table, you can observe whether the knees are at the same height. If the knee is lower on the short side, then the difference in leg length is due to a shortened tibia. If the knee extends further on the long side than the other, then the shortening is due to a difference in the femoral length (Figure 11.72). More precise measurements can be made from radiographs.

A

B

Figure 11.72 (A) The tibia is shorter on the patient’s left.

(B) The femur is shorter on the right.

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The Hip Chapter 11

Note

Umbilicus pelvic assymetry

Medial malleolus

Figure 11.73 (A) Apparent leg length is measured from the umbilicus to the medial malleolus. (B) Here, the difference in apparent leg length is due to an asymmetrical pelvis.

Apparent Leg Length Discrepancy

This test should be performed after true leg length discrepancy is ruled out. Apparent leg length discrepancy may be due to a flexion or adduction deformity of the hip joint, a tilting of the pelvis, or a sacroiliac dysfunction.

The test is performed with the patient supine, lying as flat as possible on the table. Attempt to have both legs oriented symmetrically. Measure from the umbilicus to the medial malleolus on both sides. A difference in measurement signifies a difference of apparent leg length (Figure 11.73).

Craig Test

This test is used to measure the degree of femoral anteversion. The femoral head and neck are not perpendicular to the condyles of the femur. The angle that the head and neck of the femur make with the perpendicular to the condyles is called the angle of anteversion (Figure 11.74). This angle decreases from about 30 degrees in the infant to about 10–15 degrees in the adult. A patient with femoral anteversion of more than 15 degrees may be noted to have excessive toeing-in. Freedom of internal rotation on passive

80°

15°

A B C

Figure 11.74 (A) The angle of femoral anteversion. (B) Normal angle. (C) Excessive angle.

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Chapter 11 The Hip

Degree of anteversion

Palpate greater trochanter parallel to table

Figure 11.75 Craig test. To measure the angle of femoral anteversion, first palpate the greater trochanter and rotate the leg so that the trochanter is parallel to the examination table. Now note the angle formed by the leg and the vertical.

range of motion would also be noted, with relative restriction of external rotation. Observation of the knees may reveal medially placed patellae, also referred to as squinting patellae.

To perform the test for approximation of anteversion of the femur, the patient is placed in the prone position and the test knee is flexed to 90 degrees (Figure 11.75). Examine the greater trochanter and palpate it as you rotate the hip medially and laterally. With the trochanter being palpated in its most lateral position, the angle of anteversion can be measured between the leg and the vertical. More precise measurements can be made from radiographs.

Radiological Views

Radiological views of the hip are shown in Figures 11.76, 11.77, and 11.78.

A = Iliac crest

B= Lumbar spine

C= Symphysis pubis

D= Sacroiliac joint

E= Sacrum

Figure 11.76 Anteroposterior view of the pelvis.

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The Hip Chapter 11

Figure 11.77 “Frog-lateral” view of the hip, with the hip in	Figure 11.78 Anteroposterior view of the hip joint.
45 degrees of flexion and maximum external rotation.

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