Examination of the Hip

by Stephen Holt, MD, MS

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    00:01 But now, let's move on to examining the hips, because the hips are definitely a common source of "low back pain" so it's worth us including that in our examination of the spine.

    00:12 So when examining the hip I like to break this into three different sections, there're causes of posterior hip pain, causes of lateral hip pain, and then causes of interior hip pain.

    00:23 When we're thinking about posterior hip pain, the three diagnoses that I tend to focus on are issues with the lumbosacral spine which we've already talked about to some extent already whether its lumbosacral muscles or lumbosacral spondylosis; diseases of the SI joints, the sacroiliac joints; and then piriformis syndrome which we'll take a look at can also cause pain in the posterior lumbosacral spine or even into the buttock area that patients may mix up and think that it's a hip pain itself.

    00:54 So we've already talked about lumbosacral disease, so let's move on to the SI joints.

    00:58 The sacroiliac joints are very readily palpable in our patients.

    01:02 There's a bony ridge that lies right here and it's the junction between the sacrum and the lateral parts of the hip joint, the hip bone, the ala of the hips and there's one on either side.

    01:18 If the patient has tenderness in those areas, we're going to be thinking about sacroiliac disease.

    01:22 Sacroiliac disease is relatively common in patients who have, members of the spondyloarthritides so for example reactive arthritis, ankylosing spondylitis and sometimes even psoriatic arthritis, so it is worth making sure you know how to identify sacroiliac joint disease.

    01:39 And now we're going to change him around and have a look at some provocative maneuvers which can bring out sacroiliac disease.

    01:47 So let's have you roll over and lie on your back, Shaun.

    01:54 So the test that we're going to use to assess for SI join disease are the FABER and the sacral compression test.

    02:02 FABER is actually just an acronym that tells me what I'm supposed to do for this test.

    02:06 It's an acronym for flexion, abduction, and external rotation of the hip.

    02:12 If you put the first letter from each of those words together you get FABER.

    02:16 So flexion, A-B-duction which is moving the hip away and then external rotation and it essentially forms the figure four, and I'm going to have you just bring your knee down to the table as far down as you can go.

    02:30 And what we're trying to do here is to see if the strain that I'm applying especially when I pull push here on the other hip, the strain that I'm applying isn't reproducing any pain in the sacroiliac joints posteriorly.

    02:44 If doing this just causes pain in the patient's groin that's got nothing to do with the SI joints, it's more likely either tight hamstrings or some potentially disease of the hip itself, but when we're doing this test, we're trying to see if this reproduces posterior pain.

    02:57 The second test that we're going to do is the sacral compression test and I'll have you roll over unto your left hip, please.

    03:06 The sacrum essentially looks like two wings that are joined together at the sacrum and or at the two joints, the SI joints; and by pushing down on his hips we are flexing and putting tension on the junction between the ala, the wings of the hips and the SI joints.

    03:25 So simply finding this anterior-superior iliac spine which is here, just part of his hips, part of his pelvic bone, I'm going to push down and we're trying to see if this motion reproduces any pain at the SI joints which I am flexing by pushing down on his sacrum like that.

    03:46 Keep in mind that if this just causes pain where I'm applying pressure, that has nothing to do with the SI joints.

    03:53 So those are the two test for the sacroiliac disease, now I want to do one quick test for piriformis syndrome.

    03:59 This is called the active piriformis test.

    04:01 So with piriformis syndrome what's happening is that as the sacral nerves from the sacral plexus and most notably, the sciatic nerve, exits the pelvis you're passing around the piriformis muscle which, if it's inflamed or very tight, can cause inflammation and ultimately entrapment of the sciatic nerve causing pain most notably in the buttock area, particularly when you're just talking about small branches of the sciatic nerve.

    04:31 So this test is designed to activate the piriformis muscle, to have it contract and if that reproduce the patient's buttock pain, it supports the diagnosis of piriformis syndrome.

    04:42 So what I want to have you do is lift up your leg put your shoe down on the table and I want you to apply downward pressure like you're driving your foot into the table while I push away like this.

    04:52 So these two actions that are happening here, I'm resisting external rotation and abduction of his hip while he's driving down his foot into the table, this is essentially contracting his piriformis muscle - you can relax now.

    05:05 If that were to reproduce pain back here on his buttock area where the piriformis muscle is very deep to the gluteus maximus, that would support the diagnosis of piriformis syndrome.

    05:15 Since we're in this position, now we can talk about lateral causes of hip pain.

    05:21 The most notable and the most common of which is certainly trochanteric bursitis.

    05:26 I'm going to grab my model here demonstrate this.

    05:32 So to this is a right hip and again this is the entire pelvic bone and this is the femur and this is the greater trochanter of that femur so if we line this up with his anatomy here's the pubic symphysis which would wrap around to there and this is the anterior superior iliac spine.

    05:48 Patients oftentimes reports that they have hip pain but actually it's nothing to do with the hip joint instead it's inflammation over this greater trochanter where there's a bursa, your trochanteric bursa, that can commonly get inflamed as tendons and muscles like the tensor fasciae latae, course across it - particularly if somebody has, let's say an ankle injury or a knee injury and they start walking funny, more specifically an antalgic gait.

    06:17 The mechanics of their ambulation start to impact how muscles and tendons are aligned and that malalignment can cause irritation over the bursa over the greater trochanter and so they'll have pain right in that area; and luckily, it's extremely easy to diagnose.

    06:34 You're basically just going to look for the most prominent, the bony prominence over the lateral thigh and you'll find that bony prominence very easily and just pushing on that area, you'll see if that reproduces the patient's "hip pain" and then you know you've got your diagnosis.

    06:51 It's also very easy to treat, you simply you're going to inject some steroids right into that area and you'll - not only confirm your diagnosis but you'll have long lasting relief, typically.

    07:01 Keep in mind that the greater trochanter is several centimeters distal to the belt line, I oftentimes see people are looking up here and they end up on the ASIS.

    07:11 Make sure you're going down far enough down to where the greater trochanter is actually located.

    07:16 So the next one to go over since we're in this position, I'll actually have you lie on your back now, Shaun, is entrapment of a different nerve, in this case it's the lateral femoral cutaneous nerve.

    07:27 The lateral femoral cutaneous nerve, as you may remember, it passes just deep to the inguinal ligament, so I want you to envision here, the inguinal ligament lies connects between the pubic symphysis and over here, to the anterior-superior iliac spine, so there's an invisible line connecting those and the lateral femoral cutaneous nerve dives just deep to that inguinal ligament and comes out and innervates the entire anterior-lateral thigh.

    07:55 So patients who have - so patients who report that they're having paresthesia's in this lateral and anterior location and in a sort of a predictable distribution shown here, will often times simply have lateral femoral cutaneous nerve entrapment, so also known as meralgia paresthetica.

    08:15 It's relatively common particularly in folks who wear very tight-fitting jeans or tight belts.

    08:23 Backpackers who wear those tight belt so that they can carry around 40 pounds of weight on their back.

    08:28 Patients who are pregnant, folks who are obese and potentially have just extra pounds that would be pushing down on those areas as well, any of those things can cause an entrapment injury to this nerve and one typical way that you can try to identify other than simply identifying where the patient's paresthesias were located, is you actually perform a test where you tap on the location of that lateral femoral cutaneous nerve as its passes just medial to the anterior-superior iliac spine in an attempt to try and reproduce those burning paresthesias going down the thigh.

    09:03 You could also do simply pin prick testing, comparing one side to the other, or any other type of sensory testing since it is a sensory nerve, and you may be able to detect subtle differences from one side to the other.

    09:15 Lastly, let's talk about anterior hip pain.

    09:20 Acknowledging that lateral femoral cutaneous nerve entrapment is really anterolateral, but in any event, let's focus on anterior hip pain.

    09:27 Patients who actually have hip disease will typically report anterior hip pain or groin pain, that is just some discomfort at the junction where the legs meet, the perineum.

    09:41 If we're trying to look for osteoarthritis of the hip, there's a few classic maneuvers that are likely to confirm that diagnosis or certainly support that diagnosis.

    09:52 One of which is that patient who have significant osteoarthritis of the hip joints will have difficulties with internal rotation and you can simply log roll a person's leg like this to see to what extent they can inward rotate their leg.

    10:09 Patients with advance osteoarthritis may only have ten degrees of rotation which is a very small amount of rotation before they have significant discomfort or simply cannot do it, whereas most people should be able to roll in almost 45 degrees just doing a simple log roll.

    10:26 So in addition to just doing that internal rotation log roll, the remaining range of motion of the hip exam is going to include flexion, extension which oftentimes requires lying the patient on one side so you can really bring their leg behind them and then A-D-duction and A-B-duction, abduction.

    10:46 Patients with osteoarthritis will typically have their pain reproduced with abduction and adduction and that can be very useful diagnostic test.

    10:56 External rotation of the hip is performed by the turning - it's kind of counterintuitive because I'm turning the ankle inward towards the camera but in so doing I'm rotating the hip joint out, that's external rotation of the hip.

    11:11 So the last disease that I wanted to cover that involves anterior hip pain involves those very important muscle flexors, those hip flexors in the anterior area of the hip joint and those are of course, the iliopsoas muscles.

    11:27 Again, if this is my hip joints and this is my inguinal ligament attaching between the ASIS and the pubic symphysis, the iliopsoas muscle is the major muscle group that is passing just deep in the inguinal ligament and ultimately attaching further down on the femur and that's the real power that allows us to powerfully flex up our hips.

    11:47 Patients who have iliopsoas bursitis will have discomfort simply by palpating over the inguinal ligament and whether its iliopsoas bursitis or an iliopsoas muscle strain or even muscle tear, if you have them lift up their knee against resistance, lift up your thigh for me please, pushing down like that which is, again, I'm resisting their iliopsoas muscle, that should really be able to very clearly reproduce their discomfort.

    12:13 So that wraps up our examination of the hip.

    About the Lecture

    The lecture Examination of the Hip by Stephen Holt, MD, MS is from the course Examinations of the Neck and Back Region.

    Included Quiz Questions

    1. Ankylosing spondylitis
    2. Osteoarthritis of the hip
    3. Meralgia paresthetica
    4. Piriformis syndrome
    5. Scoliosis
    1. Trochanteric bursitis
    2. Sciatica
    3. Meralgia paresthetica
    4. Ankylosing spondylitis
    5. Piriformis syndrome
    1. Meralgia paresthetica
    2. Piriformis syndrome
    3. Ankylosing spondylitis
    4. Osteoarthritis of the hip
    5. Scoliosis
    1. Sciatica
    2. Ankylosing spondylitis
    3. Osteoarthritis of the hip
    4. Meralgia paresthetica
    5. Trochanteric bursitis
    1. Internal rotation of the hip joint
    2. Flexion of the hip joint
    3. Extension of the hip joint
    4. Palpation of the lateral hip
    5. Flexion of the spine
    1. Tenderness is elicited over the inguinal ligament.
    2. Tenderness is elicited over the lateral hip joint.
    3. Tenderness is elicited over the sacroiliac joint.
    4. Tenderness is elicited on palpation of the lumbar spinous processes.
    5. Tenderness is elicited over the anterior thigh muscles.

    Author of lecture Examination of the Hip

     Stephen Holt, MD, MS

    Stephen Holt, MD, MS

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