Clinical Assessment and
Evaluation of the Hip.
So when assessing any sort of hip pathology,
we always start with a thorough
history and physical exam.
Within your history, you should
discern whether or not
the problem is an acute problem
or a chronic problem.
Acute problems might come more from traumas.
Chronic problems might be
problems with degeneration, wear and tear
at the hip, and osteoarthritis.
Based on the patient’s age,
you have a different index of suspicion
for different hip pathologies.
Location of the pain will
often give you an idea
of what sort of hip problem is going on.
There might be certain timing of the pain
whether or not it’s better or worse
in the morning or night.
And then also make sure to review
the different medications
that patient might be taking for it
to try to treat their hip pains.
With observation of the hip,
we want to look at how the
patient is standing,
how they’re ambulating and walking,
and whether or not they have
a leg length discrepancy.
This might be important because if someone
has a leg length discrepancy,
hey’re going to be placing more of a load
on one hip versus the other.
We want to look at range
of motion and assess
active and passive range
of motion of the hip.
A loss of range of motion might indicate
something going on with the
actual joint itself
or the muscles surrounding the hip.
We want to do strength testing with
the muscles around the hip
and examine the nerves,
then utilize any special tests to
help narrow a differential.
And then, performing an osteopathic
cueing us to any possible
that might be contributing to
hip pathology and pain.
So starting with observation of stance,
we want to look at a patient
when they’re standing,
looking at iliac crest height,
making sure that
the ASIS and PSIS are level,
looking at their lumbar lordosis,
and to observe the knees and feet.
Sometimes patient’s may have
flat feet on one side,
and again, that might change
the strain going up,
all the way up into the hip joint.
Also, look at how they stand
and whether or not the
hip naturally is more
internally or externally rotated
on one side than the other
and you can tell that by if
their toes are pointing
more laterally or medially
as during their stance phase
and whether or not that looks symmetric.
Through observation of gait, we can look
whether or not the patient is ambulating
and evenly distributing their weight.
We can see whether or not they’re in pain
or if they’re favoring one
side versus the other
that might show itself in some sort of limp
where they’re trying to prevent
putting too much weight on
one side or the painful side,
and seeing or not they’re ambulating
efficiently with their movement.
Patients with leg length discrepancies
may have increased hip pains.
And so when we’re looking at leg length,
we want to check if there’s a true
leg length discrepancy
meaning that there is a
or asymmetry of the bones in the leg.
And so we want to check from
one fixed point to another.
So usually what we do is, you
might use a tape measure
and measure from the ASIS to
the medial malleolus
and compare both sides to see if it’s equal.
The other thing you could
do is have the patient
and having them flex their knees
so their feet are resting
evenly on the table
and then you will observe the height of the
knees from the side or from the front.
And if there is a short femur
or shortened tibia,
you’ll notice that there’s an actual
height difference between the knees.
Leg length discrepancies could also
have an apparent discrepancy
meaning that there’s a difference
in leg length,
but it may not be due to
a structural problem
meaning that the femur or tibias
are of normal height,
and it’s more of asymmetry and maybe
the muscles or the innominate itself.
So if I have an innominate
where the innominate is upsheared
or if there’s a posterior to anterior
rotation of the innominate,
that will change the height
or the length of the leg on
the apparent side.
When assessing the hip for muscle strength,
what we want to do is to check
whether or not the patient
could move their hip
in different planes of motion
If the patient’s able to
move their hip in a specific plane of
motion against full resistance,
then that would be considered
normal or 5 out of 5
in terms of muscle strength.
And if a patient cannot move at all
and there’s no contractility
then that’d be a 0.
So muscle strength itself is graded
between 0 to 5, 0 being
really no motion or movement when
the patient’s instructed to contract
and 5 being normal.
Now the major discerning numbers
is between 2 and 3.
And so, muscle strength of 3 out of 5
means that I could have some
range of motion
whereas 2 out of 5
is really being able to move the
joint with gravity eliminated.
So what does that mean?
If I’m motion testing someone’s
and they are able to move against gravity—
let’s say I’m checking right hip abduction
and I have the patient lying
on their left side
and then lifting their hip up
towards the ceiling,
then if they’re able to do it fully
then that would be a 3 out of 5.
But if you ask them to do that
and they’re not able to,
but then have them lie supine
thus eliminating gravity
and having them abduct their leg,
and they’re able to do it,
then that would be a 2 out of 5.
And so when you’re grading muscle strength,
what you want to do is to grade it 0 to 5
and understand that 3
is able to move against gravity
is able to move but gravity
has been eliminated.
Neurologic innervation of the hip.
What we want to do is to make
sure that we understand
the group of muscles
and what is the range of nerves
that innervate the hip
because sometimes the nerves
could become compressed
at the lumbar spine
due to either lumbar herniations or other
sort of compressive pathologies.
Understanding the different muscle groups
and the nerves that innervate it,
and if I detect any sort of weakness,
what the pathology might be due from,
we kind of have to work backwards.
And so our primary hip flexors
are innervated by the femoral
nerve which is L1 to L3.
Our hip extensors are innervated
by the inferior gluteal nerve
which tends to be more L5 to S2.
are from the superior gluteal nerve
which is L4 to S1
and our primary adductors
is from the obturator nerve
which is L2 to L4.
As you can see, there is some overlap
and so if there’s only a single
let’s say at L5,
you might see some weakness in the
primary extensors and abductors.
So it’s important to combine our
motor strength testing
with further neurologic exam also.
The hip joint has dermatomes that
run from T10 down to S3.
Although we don’t specifically do
sensory testing around the hip,
because there’s a lot of
overlap in the region,
what we tend to do is to
do the sensory testing
specifically for the lumbar spine
and the sacral nerves more by the
lower extremity and the feet.
We do need to be aware of these dermatomes
because patients may complain
and numbness and tingling
along the hip joint itself.
There is a condition meralgia paresthetica
where if there’s too much pressure
around the ASIS.
This might happen with people
that have employment
where they have to use a heavy belt
and there’s a lot of weight
around their waist region.
And that pressure could compress
on some of those sensory nerves
and so patients can have some numbness
and tingling around the hip region.
So it’s important to be aware of
these different dermatomes
that wrap around the hip,
but the actual doing 2-point discrimination
and sensory testing
tends to be reserved more for the lower
extremity, not at the hip joint itself.
For the hip, we want to evaluate
range of motion,
so it’s good to understand the normals
of each of the range of motions of the hip.
Like we said before,
the hip being a ball-and-socket joint,
allows for motion in all planes of motion
but not as much as the
shoulder joint itself
because there is a very deep acetabulum
and there’s a lot of strong
connections that limit
the overall hip range of motion.
So in general, your hip flexion
goes to about 130°,
extension about 20°,
abduction ranges between 40° to 60°,
for adduction from 30° to 40°,
internal rotation goes between 35° to 40°
and from 40° to 50° for external rotation.
These are just general normals
for hip range of motion.
It’s important with patients when
testing range of motion
to make sure that you check both sides.
So when performing hip flexion,
it’s important to have the range
of motion of hip flexion
checked with the knee bent
because if I check hip flexion
with the knee extended,
what happens is it limits the amount
of hip flexion that could occur
because of hamstring tightness.
For hip extension,
you could usually have
the patient lying prone
and then slowly bringing the
hip up into extension,
and again, probably around 20° of motion.
you’re going to have the patient lie supine,
and again, you could bring the leg out
laterally to assess for hip abduction.
And then for hip adduction, what happens is
the other leg might be in the way
so you may have to bring
and flex the leg up just a little bit
so it clears the opposite leg.
And again, adduction to about 30° to 40°.
Internal and external rotation
should be performed
with the hip flexed to about 90°.
This will allow you to assess the amount of
internal/external rotation that occurs
by looking at how much the ankle could
swing medial and laterally.
So with the hip flexed at 90° and
the knee flexed at 90°,
if I take the ankle and bring it medially,
that would create external
rotation of the hip.
And so the hip joint is externally rotating
to about 40° to 50° would be normal.
Internal rotation—the patient
in the same position,
flexed to 90° at the hip and at the knees,
and now you’re going to bring
the ankle out laterally.
And when you bring the ankle out laterally,
what happens is you’re going to
internally rotate the hip.
When diagnosing somatic
dysfunction of the hip,
what we’re going to do is diagnosis
it based on our motion testing.
And so, if I find any restriction of the hip,
we’re going to name the somatic
dysfunction for its freedom.
So we could have 6 different somatic
dysfunctions of the hip
based on the motion testing
that we just discussed.
We could have a flexed or extended
hip somatic dysfunction,
internal or external hip
or abduction or adduction hip
So let’s practice with this test question.
I have a 55-year-old male who comes in
with right hip pain for the past 2 weeks
which has been getting progressively worse.
On physical exam, you note that there is
external rotation of his right hip to 50°
and internal rotation of
his right hip to 10°.
His left hip shows normal range of motion.
So what is the correct somatic
So here, our patient could only
internally rotate 10°
so the right hip is demonstrating
an internal rotation restriction.
Remember, we name the somatic
dysfunction for the freedom
so we have a right hip external
rotation somatic dysfunction.