Lower Limb
Core
High Yield
Hip Examination
Master the comprehensive hip examination with Thomas test, Trendelenburg assessment, FADIR/FABER tests, and evaluation of osteoarthritis, FAI, and AVN.
Hip Examination
Examiner Favorite
The hip examination is a core clinical station. Examiners expect you to begin with gait assessment, perform Thomas test for fixed flexion deformity, demonstrate Trendelenburg test, and systematically assess ROM and special tests. Common scenarios include osteoarthritis, FAI, and DDH.
Quick Reference One-Pager
Hip Examination Summary
High-Yield Exam Summary
Look
- •Gait assessment first
- •Scars (anterior, lateral, posterior)
- •Leg length (real vs apparent)
- •Pelvic tilt, lumbar lordosis
- •Muscle wasting (quadriceps, glutei)
Feel
- •Greater trochanter
- •Inguinal ligament (hip deep)
- •Adductors
- •Iliac crest, ASIS, PSIS
Move
- •Flexion 0-120°
- •Extension 0-30°
- •Abduction 0-45°
- •Adduction 0-30°
- •Internal rotation 0-45°
- •External rotation 0-45°
Special Tests
- •Thomas test (FFD)
- •Trendelenburg test
- •FADIR (impingement)
- •FABER (SI joint/hip)
- •Log roll (synovitis)
Introduction and Setup
Before You Start
Start with Gait: Always begin hip examination by observing the patient walking
Patient Positioning:
- Standing for Trendelenburg
- Supine for ROM and most special tests
- Prone for extension and posterior structures
Exposure: Both legs exposed from waist to feet, patient in shorts or gown
Consent Script: "I'd like to examine your hips. I'll start by watching you walk, then examine both sides lying down. Please let me know if anything is painful."
Gait Assessment
Observe Patient Walking
Ask patient to walk normally across the room and back:
| Gait Pattern | Description | Indicates |
|---|---|---|
| Antalgic | Short stance phase on affected side | Hip pain (OA, AVN, fracture) |
| Trendelenburg | Pelvis drops on swing side | Abductor weakness |
| Compensated Trendelenburg | Trunk leans over affected hip | Abductor weakness (compensated) |
| Short leg | Dipping on one side | Leg length discrepancy |
| Stiff hip | Reduced hip motion, circumduction | Arthritis, fusion |
Additional Gait Tests:
- Heel walking: L5 (dorsiflexion)
- Toe walking: S1 (plantarflexion)
- Single leg stance: Assess balance and abductors
Look (Inspection)
- Posture: Pelvic obliquity, lumbar lordosis, scoliosis
- Muscle bulk: Gluteal wasting (compare sides)
- Alignment: Genu varum/valgum, foot progression angle
- Scars: Anterior (direct anterior approach), lateral (lateral/posterolateral), posterior
- Skin changes: Bruising, sinuses
Leg Length Assessment
Measuring Leg Length
True (Anatomical) Leg Length:
- Measure from ASIS to medial malleolus
- Legs in neutral position, equal abduction
- Ensure pelvis is square
Apparent (Functional) Leg Length:
- Measure from xiphisternum or umbilicus to medial malleolus
- Affected by pelvic obliquity, adduction contracture
Galeazzi Test (Block Test):
- Patient supine, knees flexed to 90°
- Compare knee heights (femoral shortening) and tibia (tibial shortening)
| Type | True Length | Apparent Length | Cause |
|---|---|---|---|
| True shortening | Short | Short | Femoral/tibial fracture, AVN, DDH |
| Apparent shortening | Equal | Short | Fixed adduction contracture |
| Apparent lengthening | Equal | Long | Fixed abduction contracture |
Feel (Palpation)
Systematic Palpation
Anterior Structures:
- ASIS: Bony landmark, sartorius origin
- Inguinal ligament: Deep palpation over hip joint
- Femoral triangle: Pulse, lymph nodes
- Adductor longus origin: Pubic tubercle
Lateral Structures:
- Greater trochanter: Tenderness (bursitis), prominence
- Gluteus medius insertion: Superior trochanter
- IT band: Snapping, tightness
Posterior Structures (Prone):
- PSIS: Pelvic landmarks
- Sacroiliac joint: Tenderness
- Ischial tuberosity: Hamstring origin
- Sciatic nerve: Tenderness (piriformis syndrome)
Move (Range of Motion)
| movement | normalRange | technique | keyPoints |
|---|---|---|---|
| Flexion | 0-120° | Knee to chest, stabilize pelvis | Pelvis starts to move at end range |
| Extension | 0-30° | Prone, lift straight leg | Thomas test position better |
| Abduction | 0-45° | Stabilize opposite ASIS, leg slides out | Pelvis tilts at end range |
| Adduction | 0-30° | Leg crosses over other leg | Cross over opposite limb |
| Internal Rotation | 0-45° | Hip and knee at 90°, foot outward | Most sensitive for pathology |
| External Rotation | 0-45° | Hip and knee at 90°, foot inward | Lost early in OA |
Key Concept
Internal Rotation: The first and most sensitive movement lost in hip pathology. In OA, there is a capsular pattern: internal rotation > abduction > flexion > extension.
Special Tests
Fixed Flexion Deformity
Thomas Test
Detect fixed flexion deformity
Technique
- 1Patient supine, flex opposite hip fully to flatten lumbar lordosis
- 2Press lumbar spine onto bed (or examiner's hand under lumbar spine)
- 3Observe if tested leg lifts off bed
Positive Sign
Tested hip lifts off bed and cannot be fully extended
Indicates
Fixed flexion deformity (measure angle from horizontal)
Diagnostic Accuracy
Sensitivity89%
Ability to detect true positives
Specificity92%
Ability to exclude false positives
Abductor Function
Trendelenburg Test
Hip abductor function
Technique
- 1Patient stands on affected leg (one leg stance)
- 2Observe pelvis from behind
- 3Hold for 30 seconds to detect fatigue
Positive Sign
Pelvis drops on the unsupported (swing) side
Indicates
Abductor weakness (gluteus medius): pain inhibition, muscle weakness, short neck/coxa vara, nerve injury
Diagnostic Accuracy
Sensitivity73%
Ability to detect true positives
Specificity77%
Ability to exclude false positives
Click to expand
Impingement Tests
FADIR Test (Flexion-Adduction-Internal Rotation)
Femoroacetabular impingement
Technique
- 1Patient supine
- 2Flex hip to 90°
- 3Adduct across midline and internally rotate
Positive Sign
Groin pain reproduced
Indicates
Femoroacetabular impingement (CAM or Pincer), labral pathology
Diagnostic Accuracy
Sensitivity96%
Ability to detect true positives
Specificity17%
Ability to exclude false positives
FABER Test (Flexion-Abduction-External Rotation)
Hip and SI joint pathology
Technique
- 1Patient supine
- 2Place ankle on opposite knee (figure-of-4)
- 3Gently press down on flexed knee toward bed
Positive Sign
Groin pain = hip pathology; SI region pain = SI joint pathology
Indicates
Hip arthritis, SI joint dysfunction, iliopsoas pathology
Diagnostic Accuracy
Sensitivity77%
Ability to detect true positives
Specificity41%
Ability to exclude false positives
Other Tests
Log Roll Test
Hip joint irritability/synovitis
Technique
- 1Patient supine, leg extended and relaxed
- 2Gently roll the leg internally and externally by rolling the foot
Positive Sign
Pain or guarding with gentle rotation
Indicates
Hip joint synovitis, effusion, acute pathology (fracture, septic arthritis)
Diagnostic Accuracy
Sensitivity90%
Ability to detect true positives
Specificity50%
Ability to exclude false positives
Ober's Test
Iliotibial band tightness
Technique
- 1Patient lying on unaffected side
- 2Flex lower hip and knee for stability
- 3Examiner abducts and extends tested leg, then releases
Positive Sign
Leg remains abducted and does not fall to neutral
Indicates
IT band tightness (snapping hip, lateral knee pain)
Diagnostic Accuracy
Sensitivity80%
Ability to detect true positives
Specificity90%
Ability to exclude false positives
Stinchfield Test
Intra-articular hip pathology
Technique
- 1Patient supine
- 2Flex hip to 30° with knee extended (straight leg raise)
- 3Apply resistance to further flexion
Positive Sign
Groin pain reproduced
Indicates
Intra-articular hip pathology (synovitis, labral tear, arthritis)
Diagnostic Accuracy
Sensitivity80%
Ability to detect true positives
Specificity30%
Ability to exclude false positives
Neurovascular Assessment
Neurological Examination
Motor:
| Muscle | Nerve | Root | Test |
|---|---|---|---|
| Hip flexion | Femoral | L1,2,3 | Resisted hip flexion |
| Hip extension | Inferior gluteal | L5,S1 | Prone hip extension |
| Hip abduction | Superior gluteal | L5,S1 | Side-lying abduction |
| Knee extension | Femoral | L3,4 | Resisted knee extension |
Sensory:
- L1: Inguinal region
- L2: Anterior thigh
- L3: Medial thigh/knee
- L4: Medial leg
- L5: Lateral leg, dorsum foot
- S1: Lateral foot, sole
Reflexes:
- Knee jerk: L3,4
- Ankle jerk: S1
Vascular Assessment
- Femoral pulse: Below inguinal ligament, medial to nerve (NAVY)
- Popliteal pulse: Posterior knee, deep
- Dorsalis pedis: Lateral to EHL tendon
- Posterior tibial: Behind medial malleolus
Complete the Examination
Must Know
Always state to the examiner:
"To complete my examination, I would like to:
- Examine the lumbar spine for referred pain
- Examine the knee as the joint below
- Perform neurovascular assessment of the lower limb
- Assess gait with and without walking aids
- Obtain X-rays (AP pelvis, lateral hip)"
Summary Presentation
VIVA SCENARIOStandard
Presenting Your Findings
EXAMINER
"68-year-old woman with progressive right hip pain, difficulty with stairs and putting on shoes."
KEY POINTS TO SCORE
Always start with gait assessment
Thomas test is essential for FFD
Document ROM systematically with numbers
Internal rotation is most sensitive for hip pathology
COMMON TRAPS
✗Forgetting to assess gait
✗Missing fixed flexion deformity
✗Not examining lumbar spine for referred pain
✗Confusing true and apparent leg length
Common Conditions Table
| condition | look | feel | move | specialTests |
|---|---|---|---|---|
| Osteoarthritis | Antalgic gait, FFD | Minimal tenderness | Capsular pattern (IR most limited) | Thomas +, Trendelenburg may + |
| FAI | Often normal | Deep groin | Flexion-IR restricted | FADIR +, FABER + |
| AVN | Antalgic gait | Groin tenderness | All movements painful | Log roll +, similar to early OA |
| Greater Trochanteric Pain | Normal gait | Trochanteric tenderness | Full ROM, pain on resisted abduction | Ober's + if IT band tight |
| Labral Tear | Usually normal | Deep groin | May have terminal restriction | FADIR +, clicking |
Examiner Tips
Scoring High in the Hip Examination
High-Yield Exam Summary
Do
- •Start with gait - it shows understanding
- •Perform Thomas test correctly
- •Demonstrate Trendelenburg properly
- •Measure leg lengths accurately
- •Know the capsular pattern
Don't
- •Forget to expose both hips
- •Miss the fixed flexion deformity
- •Ignore the lumbar spine
- •Confuse FADIR and FABER
- •Forget neurovascular assessment