Hip Anatomy and Examination

By admin On Jan 28, 2024

Ovid: 5-Minute Orthopaedic Consult

Editors: Frassica, Frank J.; Sponseller, Paul D.; Wilckens, John H.

Title: 5-Minute Orthopaedic Consult, 2nd Edition

> Table of Contents > Hip Anatomy and Examination

Hip Anatomy and Examination

Timothy S. Johnson MD

Lawrence A. McGuigan PA-C, MMS

Basics

Description

Bones (Fig. 1):
- Pelvis and femur bone
- The acetabulum is the “socket.”
Muscles:
- Flexors: Iliopsoas, sartorius, rectus femoris
- Extensors: Gluteus maximus, hamstring muscles
- Abductors: Gluteus medius, gluteus minimus
- Adductors: Gracilis, pectineus, adductor longus, adductor brevis, adductor magnus
Nerves:
- Femoral: Hip flexors
- Obturator: Adductors
- Superior gluteal: Abductors
Ligaments:
- Sacroiliac: Sacrum to ilium
- Sacrotuberous: Sacrum to ischial tuberosity
- Sacrospinous: Sacrum to ischial spine
  
  Fig. 1. AP radiograph of a left hip.

Diagnosis

Signs and Symptoms

History

Thorough history of the mechanism of injury and nature of pain

Physical Exam (1)

Initial procedures:
- Have the patient disrobe.
- Examine the lumbar spine.
- Examine the knee.
- Check the neurovascular status.
Standing inspection:
- Compare the height of the iliac crests in the horizontal plane. (Asymmetry suggests leg-length discrepancy.)
- Look for muscle atrophy and correlate with gait inspection, if possible.
Gait inspection (2):
- Observe for asymmetry between left and right.
- Antalgic gait: Shortened stride and decreased stance phase on the affected leg
- Make note of pain and endurance.
- Trendelenburg limp:
  
  Fig. 2. AP radiograph of a right hip with osteoarthritis.
  - Evaluate for pelvic tilt during the stance phase of gait.
  - Positive finding occurs when the patient
    leans to the affected side, placing the center of gravity over the hip
    and effectively unloading the abductor muscles.
Supine examination:
- Look for leg-length discrepancy (measure
  from the inferior edge of the anterior superior iliac spine to the
  inferior edge of the medial malleolus on both sides).
- Compare active and passive ROM.
  - Hip flexion: 110–120°
  - Hip extension: 10–15°
  - Abduction: 45–50°
  - Adduction: 20–30°
  - Internal rotation: 15–45°
  - External rotation: 40–65°
  - Extension: 30°
  - Note guarding, pain, and spasm.
Antalgic gait may be caused by hip, back, or other lower limb problems.
Weakness, muscle atrophy, decreased sensation, and asymmetric deep tendon reflexes suggest spine abnormality.
Osteoarthritis of the hip (3) (Fig. 2):
- Typically presents with start-up pain, morning stiffness, and deep groin pain
- Hip flexion with simultaneous internal rotation reproduces groin pain.
- Presents with decreased active and passive ROM:
  - Hip flexion contracture is common
- Radiographs: Joint space narrowing and osteophyte formation
Greater trochanteric bursitis:
- Typically presents as lateral hip pain
- Patients are exquisitely tender to palpation of greater trochanter.
- Resisted hip abduction reproduces lateral hip pain.
Buttock and posterior hip pain:
- Indicates lumbar spine abnormality until proven otherwise
- Radicular pain produced by deep palpation of the sciatic nerve differentiates sciatica from intra-articular abnormality.
  
  P.179
  - With the patient in the lateral decubitus position, flex the hip and knee to 90°.
  - Palpate the nerve midway between the greater trochanter and the ischium.
Labral tears/femoroacetabular impingement (4) (Fig. 3):
- Young athletic patients
- Typically presents as groin pain during or after activity
- Hip flexion with simultaneous internal rotation reproduces groin pain.
- Radiographs may be normal.
- MRI can confirm diagnosis.
- Examine for and rule out inguinal hernia.
  
  Fig. 3. Arthroscopic photograph of a labral tear.

Tests

Trendelenburg test (to evaluate strength of the gluteus medius muscle):
- Have the patient perform a single-leg stand on the affected side and try to maintain the pelvis level with the floor.
- If the pelvis tilts to maintain the
  single-leg stand, it is a sign of abductor weakness or hip joint pain,
  and the test is positive.
Thomas test (to evaluate flexion contracture):
- With the patient supine, place your hand under the lumbar spine and bring 1 leg up into full flexion.
- Have the patient hold it there by grasping the knee with both hands.
- Bring the other leg into full extension.
- Any loss of extension is a flexion contracture.

References

1. DeAngelis NA, Busconi BD. Assessment and differential diagnosis of the painful hip. Clin Orthop Relat Res 2003;406:11–18.

2. Perry J. Pathologic gait. Instr Course Lect 1990;39: 325–331.

3. Hoaglund FT, Steinbach LS. Primary osteoarthritis of the hip: etiology and epidemiology. J Am Acad Orthop Surg 2001;9:320–327.

4. Scopp JM, Moorman CT, III. The assessment of athletic hip injury. Clin Sports Med 2001;20: 647–659.

Additional Reading

Hoppenfeld S. Physical examination of the hip and pelvis. In: Physical Examination of the Spine & Extremities. Norwalk, CT: Appleton & Lange, 1976:143–169.

Hoppenfeld S, deBoer P. The hip and acetabulum. In: Surgical Exposures in Orthopaedics: The Anatomical Approach, 3rd ed. Philadelphia: Lippincott, Williams & Wilkins, 2003:365–453.

Moore KL, Dalley AF, II. Lower limb. In: Clinically Oriented Anatomy, 4th ed. Philadelphia: Lippincott Williams & Wilkins, 1999:503–663.

Miscellaneous

FAQ

Q: What is the most common cause of lateral hip pain?

A: Greater trochanteric bursitis.

Q: Arthritis of the hip joint usually presents with complaints of pain in which area of the hip?

A: The groin.