Dr. Kevin Yip

Dr Kevin Yip
Orthopaedic Surgeon
MBBS(UK), FRCS(EDIN), FAM(SING), FHKCOS(ORTHO)

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Hip Anatomy and Examination

Basics
Description
  • Bones:
    • 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
Diagnosis
Signs and Symptoms
History
Thorough history of the mechanism of injury and nature of pain
 
Physical Exam
  • 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:
    • 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:
      • 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:
    • 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.
      • 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:
    • 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.
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.
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.

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