Diagnosis of the Hip

by Sheldon C. Yao, DO

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    1:00:01 Evaluating the Hip Joint.

    1:00:03 So the hip joint—what we want to do is to start with just looking at any sort of asymmetry.

    1:00:09 Usually when the patient is walking, you observe their gait.

    1:00:12 If there’s hip problems, usually they might limp.

    1:00:15 They might have issues when they’re ambulating or how they’re standing.

    1:00:18 If they’re crooked when they’re standing.

    1:00:20 You want to see how they’re able to maneuver and walk, how they could get on the table and get off the table.

    1:00:25 Sometimes hip pathologies could lead to and point towards back pains and back issues so we want to look at the hip first and do our observation, and then we’re going to palpate some key landmarks.

    1:00:37 So we’re going to start with the iliac crest here and then the ASIS anteriorly.

    1:00:42 Then we’re going to come down laterally and you’ll feel for the greater trochanter of the hip.

    1:00:46 You could also feel for the AIIS.

    1:00:48 That’s going to be about an inch medial and an inch below the ASIS.

    1:00:54 The AIIS is the attachments of the quadriceps muscles, and so you want to check any muscle tone around the area.

    1:01:01 Sometimes the lateral hip could have tightness of the iliotibial band as it blends into the tensor fascia latae attaching to the ASIS.

    1:01:09 So just kind of checking the hip, seeing if there’s good tone.

    1:01:14 If there’s any disruption of the bony structure and working our way down.

    1:01:18 So the hip joint is the articulation between the femur and the acetabulum.

    1:01:24 And so to motion test the area what we need to do is to move the hip in several planes.

    1:01:30 So in a sagittal plane, we have hip flexion and hip extension.

    1:01:35 Hip flexion we could perform by flexing up the leg.

    1:01:39 Now if you keep the leg straight, the hamstring muscle is going to prevent you from fully flexing the hip so you want to bend the knee here to relieve stress on the hamstring to be able to fully flex the hip.

    1:01:50 And so you want to see how far you’re able to flex the hip.

    1:01:54 Now for extension, we’re going to have the patient turn onto their stomach and now you could easily extend the hip by grabbing above the knee and slowly bringing the hip into extension.

    1:02:07 You want to note both sides and see how far they could extend.

    1:02:12 I’m going to have you turn back on your back.

    1:02:15 So that’s flexion and extension in the sagittal plane.

    1:02:19 You could motion test the hip in abduction and adduction in the coronal plane.

    1:02:23 So what we’re going to do is to support the leg here and slowly abduct the leg out and we see how far we can move.

    1:02:31 Then we could adduct the leg and you can see that in order to avoid running into the opposite leg, we could flex the leg up a little bit and come across so we could better adduct the leg.

    1:02:40 So abduction and adduction of the hip.

    1:02:45 Now to test motion in the transverse plane, we’re going to internally and externally rotate.

    1:02:50 Now if we internally and externally rotate the hip with the leg straight, it’s really hard to tell exactly how much motion you have.

    1:02:56 So a better way to do it is to flex the hip and flex the knee and have the ankle be the marker with the leg straight.

    1:03:04 So what we’re measuring is how much internal rotation by bringing the ankle laterally and then how much external rotation by bringing the ankle medially.

    1:03:16 So in this way, we could really measure the amount of rotation from neutral.

    1:03:25 So if we have a somatic dysfunction present in the hip what we’re going to note is there’s decreased range of motion in one of those planes.

    1:03:32 And so before when we tested the internal and external rotation, you could note that external rotation is fairly free here internal rotation is pretty limited.

    1:03:43 So as I move into internal rotation, there’s not as much motion as I would suspect.

    1:03:47 So the internal rotation is the restriction, so we name this for its freedoms so this would be an external rotation hip somatic dysfunction.

    1:03:56 so this would be an internal rotation hip somatic dysfunction.

    1:03:57 So based on your range of motion findings, you could find somatic dysfunctions in the joint and you want to name it for its freedom when you localize the restriction.

    1:04:08 So there are special tests we could perform to better rule in or rule out different pathologies of the hip.

    1:04:15 So if a patient comes in complaining of neuropathic pain where they have shooting pain going all the way down their leg that may be from a lumbar nerve root compression.

    1:04:26 And so a test that we could perform is called the straight leg raise test.

    1:04:30 So the straight leg raise test really says what we’re going to be doing.

    1:04:34 We’re going to be taking the leg, keeping it straight and raising it up.

    1:04:37 What that does is that it pulls on the nerve.

    1:04:41 As it pulls when we’re raising the leg up, it’s going to recreate the pain if there’s some sort of inflammation or some sort of impingement.

    1:04:49 We’re going to have the patient relax their leg and I’m going to slowly flex the leg up to about 70°.

    1:04:55 If there’s no pain then that would be a negative test, but if there’s pain shooting down the leg then that’s a positive test.

    1:05:02 If the patient just complains about tightness and pain behind their knee, that’s more hamstring tightness because as you flex the hip you’re stretching the hamstring also.

    1:05:10 What you want to detect is whether or not you recreate the shooting neuropathic pain going down into the feet.

    1:05:16 So a positive test is with flexion of the leg, you’re going to get pain shooting all the way down recreating the symptoms.

    1:05:25 Not just tightness posteriorly in the hamstring region.

    1:05:28 So a positive straight leg raise would increase your suspicion of having to do more diagnostic studies looking at where that nerve might be compressed, perhaps a lumbar herniated disk.

    1:05:41 If a patient has pain in the back along the tailbone in the SI joints, we could perform a test called Erichsen’s test.

    1:05:51 So Erichsen’s test is a test that is going to screen for SI joint pain and problems.

    1:05:57 And what you’re going to do is you’re going to place the palms of your hands on the ASIS and compress them together.

    1:06:03 So you’re bringing your hands together.

    1:06:05 And as you bring your hands together, if the patient has pain on either side of the SI joint, that is a positive test.

    1:06:11 Because what you’re doing is when you compress the ASIS’s together, you’re kind of bringing the innominates laterally in the back.

    1:06:19 So if there’s any sort of inflammation or problems at the SI joints, this motion should recreate pain that you have in the SI joint.

    1:06:31 Stinchfield’s test is a test that checks for intra-articular hip pathology.

    1:06:37 So what we’re going to do is to put a strain on the hip joint, and if there’s a problem intra-articularly, meaning between the pelvis and the innominates at the acetabulum and the femoral head, then that’s going to recreate pain.

    1:06:51 So what we’re going to do is have the patient, with their legs straight, push your leg up towards the ceiling.

    1:06:56 At about 30°, I’m going to push down and resist and you’re going to see if that recreates pain.

    1:07:01 You can relax.

    1:07:02 So having the patient push against your resistance will activate muscles and also activate the hip.

    1:07:09 And so if you have intra-articular hip pathology, that is going to cause pain and give you a positive Stinchfield test.

    1:07:17 So FABER’s test or Patrick’s test is a range of motion test of the hip and it also helps to test the SI joint.

    1:07:23 So FABER’s is an acronym for the motions that we’re going to be doing at the hip here.

    1:07:29 So we’re going to start by adding flexion for the F; abduction so as we abduct we’re bringing the knee down and then external rotation.

    1:07:39 So flexion, abduction, and external rotation at the same time.

    1:07:44 And the patient should be able to make ike a number 4 with their legs and that would be normal range of motion.

    1:07:49 To now also test the SI joint, we could add the extension part.

    1:07:53 So we’re going to stabilize at the opposite ASIS and then gently extend the knee and the hip a little bit more, and if that recreates pain, then that’s sensitive for SI joint pathology.

    1:08:06 So FABER’s test, you’re going to bring the leg up, make a number 4, and then when you push down on the knee that’s going to test the SI joint.

    1:08:15 If the patient is unable to create that figure 4, then there’s a restriction in hip range of motion and we need to further motion test the hip to see if there’s other pathologies that’s preventing full range of motion of the hip.

    1:08:31 A range of motion test for internal rotation and flexion is FADIR.

    1:08:37 So FADIR stands for flexion, adduction, and internal rotation.

    1:08:44 Here, we’re moving the ankle laterally to create internal rotation and so the FADIR test checks for range of motion of the hip. So you could flex, adduct and internally rotate and if you’re unable to do it or if you get pain in the back as you do it, then that’s a sign of potential piriformis spasm because the piriformis externally rotates so once you try to internally rotate the hip you will test that muscle also.

    1:09:07 So the FADIR test checks range of motion and also checks for possible piriformis spasms.

    1:09:15 Ober’s test is a test to check for iliotibial band contracture.

    1:09:18 So the iliotibial band is lateral leg and could sometimes cause hip and knee pains.

    1:09:25 And this is very frequent in runners and so what we want to do is to see if it’s contracted.

    1:09:30 So to test this with Ober’s test, what we’re going to do is support the leg and test the affected side.

    1:09:36 I’m going to put my hand underneath the knee to support the leg and I’m going to abduct the hip.

    1:09:42 So as I abduct the hip, it’s going to shorten the IT band, and if he does have contractures, as I release his leg down it won’t be smooth.

    1:09:51 What you’ll see is as I release the leg down, it’s going to be contracted so it’s going to ratchet down or it may even stay up based on the severity of the IT band spasms.

    1:10:03 So Ober’s test, you’re going to bring the leg up and then let it down to see if it’s smooth.

    1:10:07 If it’s not smooth, if it ratchets down or if it stays up, that’s a positive test for iliotibial band contracture.

    1:10:14 The Trendelenburg test is a test for gluteus medius weakness.

    1:10:18 So what we want to do is to test to see if the gluteus medius is weak.

    1:10:23 We’re going to have our patient lift up one side and we’re going to be testing the gluteus medius on the side that they’re standing up on.

    1:10:29 So here we’re going to have you pick up your right foot, good, and bring it back down.

    1:10:33 So if they’re able to pick up the leg and keep it up without their hip dropping down or falling over, that means that the gluteus medius is intact.

    1:10:41 You want to do this bilaterally. So pick up your left side, good, and back down.

    1:10:45 So that would be a negative test.

    1:10:48 A positive test would be if someone picks up their leg and they kind of fall over or drop down.

    1:10:52 So that would be a positive Trendelenburg test.

    1:10:55 And since it was positive picking up the right foot, and we’re testing the left gluteus medius, o that would be a positive Trendelenburg with a sign of possible left gluteus medius weakness.

    1:11:06 The hip drop test is a test that we could perform to assess lumbar sidebending.

    1:11:11 So we’re moving the hips to see how the lumbar accommodates.

    1:11:16 So we want to get eye level with the lumbar spine.

    1:11:18 I’m going to ask the patient to place his hands on his hips and we’re going to assess how the lumbar spine moves when the patient drops their hips.

    1:11:27 So first, bend this knee and keep this leg straight and you can see how that drops the hip.

    1:11:31 And I’m looking at the lumbar sidebending when he does that.

    1:11:34 We’re going to do the other side.

    1:11:36 And now bend the left knee keeping the right leg straight and that bends the left side down and you’re appreciating the curve as they’re bending the hip.

    1:11:45 Straighten up for me.

    1:11:46 The side of the greatest drop is the side of the restricted sidebending.

    About the Lecture

    The lecture Diagnosis of the Hip by Sheldon C. Yao, DO is from the course Osteopathic Diagnosis of the Hip Region.

    Included Quiz Questions

    1. Nerve root compression
    2. Muscle weakness
    3. Osteomyelitis
    4. Spondylitis
    1. Sacroiliac joint
    2. Lumbar vertebra
    3. Thoracic Lumbar junction
    4. Sacral base
    5. Thoracic vertebra
    1. Stinchfield’s test (or Stinchfield's resisted hip flexion test)
    2. Straight leg raise test
    3. Eriksen’s test
    4. Watson’s test
    1. External rotation
    2. Flexion
    3. Internal rotation
    4. Rotation
    5. Extension
    1. Ober’s test
    2. Straight leg raise test
    3. Eriksen’s test
    4. Stinchfield’s test
    5. Watson’s test

    Author of lecture Diagnosis of the Hip

     Sheldon C. Yao, DO

    Sheldon C. Yao, DO

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