- With the patient standing, assess for muscle wasting (gluteal muscle bulk in particular).
- With the patient lying flat and face up, observe the legs, comparing one side with the other – is there an obvious flexion deformity of the hip?
- If there is a suggestion of leg length disparity, assess true leg lengths using a tape measure. Measurements are taken from the anterior superior iliac crest to the medial malleolus of the ankle on the same side. Compare the measurements. In a fractured neck of femur the leg is shortened and externally rotated.
- Check for scars overlying the hip.
- Palpate over the greater trochanter for tenderness.
- With the knee flexed at 90º, assess full hip flexion, comparing one side with the other and watching the patient’s face for signs of pain.
- Assess for a fixed flexion deformity of the hip by performing Thomas’ test. Keep one hand under the patient’s back to ensure that normal lumbar lordosis is removed. Fully flex one hip and observe the opposite leg (see Figure 13). If it lifts off the couch then there is a fixed flexion deformity in that hip. (As the pelvis is forced to tilt a normal hip would extend allowing the leg to remain on the couch.)
- With the hip and knee flexed at 90º, assess internal and external rotation of both hips. This is often limited in hip disease.
- Assess the hip and proximal (gluteal) muscle strength by performing the Trendelenberg test. This involves the patient alternately standing on each leg alone. In a negative test the pelvis remains level or even rises. In an abnormal test the pelvis will dip on the contralateral side. (See Figure 14.)
- Ask the patient to walk – look for an antalgic or Trendelenberg gait. An antalgic gait simply means a painful gait, normally resulting in a limp. A Trendelenberg gait results from proximal muscle weakness and commonly results in a ‘waddling’ walk.
Examination of the hip: checklist
- Introduce yourself/gain consent to examine
With the patient lying on couch:
- Look for flexion deformity and leg length disparity
- Check for scars
- Feel the greater trochanter for tenderness
- Assess full hip flexion, internal and external rotation
- Perform Thomas' test
With the patient standing:
- Look for gluteal muscle bulk
- Perform the Trendelenberg test
- Assess the patient's gait
CMC(J) carpometacarpal (joint); CT computerized tomography; DEXA dual-energy x-ray absorptiometry; DIP(J) distal interphalangeal (joint); ESR erythrocyte sedimentation rate; GALS gait, arms, legs and spine; MCP(J) metacarpophalangeal (joint); MRI magnetic resonance imaging; MTP(J) metatarsophalangeal (joint); NSAID non-steroidal anti-inflammatory drug; OA osteoarthritis; PIP(J) proximal interphalangeal (joint); RA rheumatoid arthritis; REMS regional examination of the musculoskeletal system.