Physical examination tests for hip dysfunction

and injury
Michael P Reiman, Richard C Mather III, Chad E Cook
Correspondence to ABSTRACT problem requires two primary approaches: (1) iden-
Dr Michael P Reiman, Background Physical examination tests for hip tify the most accurate-specific hip physical examin-
Department of Community and
Family Practice, Duke University dysfunction and injury of the strongest diagnostic ation (HPE) tests and (2) provide detailed
School of Medicine, 2200 W. accuracy were identified in a recent systematic review descriptions and instructions to providers to allow
Main, Durham NC 27705, with meta-analysis in the BJSM. These tests were reproduction and application of these tests. The
USA; described in this article. first was recently addressed by Reiman et al8 in a
[email protected]
Discussion A detailed description of the various systematic review and meta-analysis. This article
different tests is given, with photographs for each test encompassed a detailed execution of the HPE tests
procedure. Diagnostic interpretation of each test requires with the greatest clinical utility as outlined by that
careful consideration, with special attention to specific group. In addition, the publication discussed the
variables such as test performance and patient discrepancy in test description and reason for
population. caution in test interpretation when appropriate.

PHYSICAL EXAMINATION TESTS OF THE HIP

Click the following link test your knowledge of this Hip osteoarthritis
paper: http://learning.bmj.com/learning/module- Trendelenburg’s sign9
intro/.html?moduleId=10043037 Patient position: Standing in front of the examiner,
with both feet on ground.
INTRODUCTION Clinician position: Observing the patient from the
Diagnosis of non-arthritic hip pathology is challen- front.
ging. In the last 10 years the understanding of hip Movement: The patient is instructed to lift one leg
pathology and femoroacetabular impingement (FAI) up by flexing their hip and knee, standing on only
has exploded,1 although in the spectrum of medi- one leg (figure 1A).
cine knowledge this area is relatively new.2 As such, Assessment: The clinician assesses the weight-
expertise is often located in irregular pockets of pro- bearing leg by evaluating the degree of drop of the
viders, resulting in variable understanding and rec- contralateral pelvis once the leg is lifted. A pelvic
ognition in the larger medical community. Patients on femoral angle with ≤83° angle criteria with spe-
with intra-articular hip pathology have been cified time duration of 30 s was used as a positive
reported to see 3.3 providers on average before sign. Figure 1B shows the pelvic on femoral angle
being correctly diagnosed.3 4 Thus, it is not uncom- (angle between the two lines).
mon for a patient to undergo inappropriate imaging Diagnostic accuracy: Sensitivity (SN) 55%, specifi-
and, unfortunately, inappropriate treatments includ- city (SP) 70%, positive likelihood ratio (+LR) 1.83
ing epidural steroid injections, hernia repairs and and negative likelihood ratio (−LR) 0.82.
even lumbar spine fusion. Furthermore, long- Special note: Monitor for patient compensating by
standing hip pain results in surrounding dysfunction leaning their trunk to avoid having pelvis drop.
of the low back, pelvis and even knee, with poorer Leaning compensation constitutes a positive test as
outcomes in patients with concomitant conditions.5 well.
These factors converge to make diagnosis of hip Background: Generally considered a physical per-
pathology one of the greatest challenges currently formance test of hip strength, this test has also
facing the orthopaedic and sports medicine field. been utilised for assessment of gluteal tendinopathy
Disorders of the hip can largely be categorised as with a positive test being reproduction of spontan-
intra-articular or extra-articular. Intra-articular disor- eous pain within 30 s on involved leg compared
ders are driven by pathology at opposite ends of the with the contralateral leg during single leg stance.10
morphological spectrum; acetabular dysplasia or The use of a supporting stick was suggested in
FAI.3 6 Labral tears are recognised to be the pain gen- the hand only on the side of the weight-bearing
erator in these disease states. Extra-articular disorders hip. Alternatively, both shoulders could be sup-
include psoas tendon disorders such as internal snap- ported by the examiner so as to maintain balance
ping hip and tendinitis, peritrochanteric space disor- without a stick.11
ders such as external snapping hip and abductor
tendon tears, and deep gluteal space syndrome, previ- Commentary on hip osteoarthritis tests
ously known as piriformis syndrome.7 The Trendelenburg’s sign alters post-test probability
Whereas imaging is clearly important for correct of a diagnosis to a very small degree.8 The clinician
diagnosis, false positives with MRI and MRI with should carefully incorporate functional assessment
arthrogram (MRA) are common, requiring provi- (gait, stairs, etc) as part of the examination con-
ders to determine whether a distinct pathology is tinuum even though they have not been specifically
actually symptomatic, further relying on accurate investigated for this cohort. In addition, consider-
and efficient physical examination. Solving this ation of additional components such as (1) more

Reiman MP, Mather RC, Cook CE. Br J Sports Med 2013;0:1–6. 1

 Figure 2 Resisted external derotation test.

Movement: Patient then actively returns the leg to neutral pos-

ition ( placing leg along the axis of the bed) against resistance
(figure 2).
If test result is negative, the test is repeated with patient lying
prone, hip extended and knee flexed to 90°.
Assessment: A positive test is spontaneous reproduction of
patient’s concordant pain.
Diagnostic accuracy: SN 88%, SP 97.3%, +LR 32.6 and
−LR 0.12.
Special note: Monitor for patient compensation of grabbing
onto table for stabilisation during test.
Background: The combination of passive stretch, followed by
active contraction is likely to provide the tensile load across the
involved structure(s).

Commentary on gluteal tendinopathy tests

Only the resisted external derotation test demonstrated the ability
to modify the post-test probability of a gluteal tendinopathy diag-
nosis.8 The sole study examining this test only had a sample size of
17 participants, with an average age of 68.1±10.8 years, thus lim-
iting the external generalisability. The Trendelenburg’s sign (as
described above in the Hip osteoarthritis section) demonstrated a
pooled SN of 61%, SP 92%, +LR 6.83 and −LR of 0.25;8 across
three studies with 78 patients.10 14 15

Impingement/labral tear/intra-articular pathology

Impingement (flexion-adduction-internal rotation) (FADDIR) test
16–20
Patient position: Supine, bilateral legs extended.
Clinician position: Standing at the side of the leg to be tested.
Figure 1 (A) Trendelenburg’s sign. (B) Angle of measurement for Movement: Clinician passively moves the patient’s leg to 90° of
Trendelenburg’s sign. hip and knee flexion. The leg is then passively adducted and
internally rotated with overpressure to both motions at end-
than one plane of motion restriction, (2) age >50 and (3) stiff- range (figure 3).
ness ≤60 min, are a necessity for clinical assessment of hip Assessment: A positive test is reproduction of concordant pain,
osteoarthritis.12 13 locking, clicking and catching.
Pooled diagnostic accuracy:
Gluteal tendinopathy (MRA criterion reference) SN 94%, SP 8%, +LR 1.02, −LR
Resisted external derotation test 0.48;8 across four studies with 128 patients.16 17 19 20
Patient position: Supine, hip flexed 90°, and in external (Arthroscopy criterion reference) SN 99%, SP 7%, +LR
rotation.10 1.06, −LR 0.15;8 across two studies with 157 patients.18 19
Clinician position: Clinician, standing just to the side of leg Special note: Monitor for patient compensation of rolling trunk
being tested, slightly decreases external rotation just enough to toward non-involved leg to avoid pain. Discordant lateral hip
relieve pain (if any was present). pain is a negative test.

2 Reiman MP, Mather RC, Cook CE. Br J Sports Med 2013;0:1–6.

 Clinician position: Standing at end of table, directly facing
patient.
Movement: Clinician passively lays the patient onto their back,
bringing bilateral knees up to patient’s chest. Patient holds non-
tested leg toward their chest with bilateral arms as the clinician pas-
sively lowers the tested leg into extension. The clinician stabilises
the ipsilateral side of the pelvis with their other arm (figure 5).

Figure 3 Flexion-adduction-internal rotation test.

Background: The combination motions of flexion, adduction

and internal rotation cause an abutment between the femoral
head and anterior acetabulum.
Figure 5 Thomas test.
Flexion-internal rotation test
21–23
Patient position: Supine, bilateral legs extended. Assessment: A positive test is reproduction of painful click or
Clinician position: Standing at the side of the leg to be tested. concordant groin pain.
Movement: Clinician passively performs the combined move- Diagnostic accuracy: SN 89%, SP 92%, +LR 11.1 and −LR
ments of flexion to 90° and internal rotation (figure 4). 0.12.24
Assessment: A positive test is reproduction of concordant pain, Special note: Monitor for tightness/compensation of the lumbar
locking, clicking or catching. spine arching, tested leg abducting and externally rotating.
Pooled diagnostic accuracy: SN 96%, SP 17%, +LR 1.12, −LR Background: Although this test does not reproduce the mechan-
0.27;8 across three studies with 42 patients.21–23 ical abutment between the femoral head and acetabulum similar
Special note: Monitor for patient compensation of rolling trunk to the FADDIR or flexion internal rotation test, it does recreate
toward non-involved leg to avoid pain. hip extension, which has been shown to recreate the greatest
forces on the hip joint.25

Commentary on impingement/labral tear/intra-articular

pathology tests
In general, these tests demonstrate better screening than diag-
nostic ability.8 The one study with the least risk of bias demon-
strated that the Thomas test has value as both a screen and
diagnostic test.24 Caution should be used though as this was
only one study.24

Femoral fracture/stress fracture

Patellar-pubic percussion test
26–28
Patient position: Supine, bilateral legs extended.
Clinician position: Standing at the side of the leg to be tested.
Movement: Clinician places a stethoscope over the pubic
tubercle of the patient. Clinician taps the patella of patient’s leg
being assessed and qualitatively reports the sound. A tuning fork
Figure 4 Flexion-internal rotation test. has also been used in place of tapping (figure 6).
Assessment: A positive test is diminished percussion noted com-
Background: This test produces a likely similar abutment pared with contralateral side.
described for the FADDIR test without the end-range adduc- Pooled diagnostic accuracy: SN 95%, SP 86%, +LR 6.11, −LR
tion. In addition, moving from neutral adduction to end-range 0.07;8 across three studies with 782 patients.26–28
internal rotation could impinge an anterior labral tear. Special note: Clinician must ensure that stethoscope is placed
firmly over pubic tubercle and lateral to the pubic symphysis
joint (on the side ipsilateral to side being tested).
Thomas test Background: The sound produced with either tapping or the
Patient position: Sitting at the end of the table, feet on floor.24 tuning fork is dampened with the fracture/stress fracture.

Reiman MP, Mather RC, Cook CE. Br J Sports Med 2013;0:1–6. 3

 Commentary on fracture/stress fracture tests
The patellar-pubic percussion test has strong diagnostic value as
both a screen and diagnostic test.8 The use of stethoscope and
tuning fork has previously been demonstrated as a valid
measure for this diagnosis.31 Caution is suggested with the use
of the stress fracture test (despite demonstrated ability to func-
tion as a screening test) due to high risk bias and small subject
sizes in studies investigating this test.

Sports related chronic groin pain

Single adductor test
Patient position: Patient is supine with bilateral legs extended.32
Clinician position: Standing at patient’s foot to be assessed.
Movement: Clinician passively flexes leg to be assessed to 30°
Figure 6 Patellar-pubic percussion test.
with slight abduction and internal rotation. Patient resists the
clinicians attempt to abduct the leg to be tested, effectively con-
tracting their adductor muscles on that side (figure 8).
Fulcrum test
Patient position: Sitting on side of table with bilateral distal
29
portion of legs off the edge of the table. 30 Patient is instructed
to lean back on bilateral hands.
Clinician position: Standing or kneeling to the side of the leg to
be tested.
Movement: Clinician places one forearm under patient’s thigh
to be tested. Clinician arm is used as a fulcrum under the thigh
and is moved from the distal to the proximal thigh as gentle
pressure is applied to the dorsum of the knee with the opposite
arm (figure 7).
Assessment: A positive test is reproduction of patient’s con-
cordant discomfort/sharp pain, usually accompanied by
apprehension.
Diagnostic accuracy: SN 93%, SP 75%, +LR 3.7, −LR 0.09;29
SN 88%, SP 13%, +LR 1.0, −LR 0.92.30
Special note: The length of the femur assessed is limited due to
the ability to place the arm under the assessed femur. Figure 8 Single adductor test.
Background: Fulcrum and pressure applied in the direction
opposite creates stress force to the area of suspected stress
fracture. Assessment: A positive test involves reproduction of patient’s
concordant pain.
Diagnostic accuracy: SN 30%, SP 91%, +LR 3.3 and −LR
0.66.32
Special note: Force is applied at the ankle with the knee straight.
Background: As with the other sports related chronic groin tests,
adduction contraction elicits stress across the common origin of
the adductor muscles on the pubic symphysis region.

Squeeze test
Patient position: Supine with bilateral hips flexed 45° and knees
flexed 90° so that bilateral feet are flat on table.32
Clinician position: Standing at patient’s bilateral knees, placing
fist between knees.
Movement: Patient is asked to contract maximally both adductor
muscles simultaneously to ‘squeeze the fist’ effectively (figure 9).
Assessment: Reproduction of patient’s concordant pain is con-
sidered a positive test.
Diagnostic accuracy: SN 43%, SP 91%, +LR 4.8 and −LR
0.63.32
Special note: Monitor for patient compensation of lower trunk
rotation.
Background: As with the other sports-related chronic groin tests,
adduction contraction elicits stress across the common origin of
Figure 7 Fulcrum test. the adductor muscles on the pubic symphysis region.

4 Reiman MP, Mather RC, Cook CE. Br J Sports Med 2013;0:1–6.

 DISCUSSION
Clinical testing of the hip is not nearly as comprehensively
investigated as other body part regions such as the shoulder and
the knee. As such the collection of clinical tests available to
diagnostic clinicians is somewhat underwhelming in context.
This may be one of the reasons patients with hip problems fre-
quently undergo inappropriate imaging and inappropriate treat-
ments, and have a delayed proper diagnosis.3 4
This manuscript focuses on the detailed execution of 10
index tests for the hip joint. Each is described in sufficient detail
using the sentinel reference when available. The tests were
selected from the recent systematic review and meta-analysis
from Reiman et al,8 because to our knowledge, this study is the
most comprehensive investigation of the diagnostic accuracy of
the hip joint.
And added benefit of a description paper is that the execution
Figure 9 Squeeze test.
of the tests can be standardised across future studies. When pos-
sible, we used the sentinel references for the description of each
index test. Variation in test performance is a form of bias that
Bilateral adductor test
has been recognised in the original QUADAS33 and QUADAS
Patient position: Patient is supine with bilateral legs extended.32
II34 quality assessment instruments. Consistent use of these tests
Clinician position: Standing at patient’s bilateral feet, directly
in future well designed studies should more efficiently determine
facing patient.
the true value of these tests during examination of the hip joint.
Movement: Patient is asked to contract maximally both adductor
muscles simultaneously, thereby attempting to bring bilateral
legs together (figure 10).
What is already known on this topic

▸ Hip joint examination is becoming increasingly popular with

improving technology regarding examination and treatment.
▸ Multiple studies have been describing various hip physical
examination (HPE) tests. Currently, reviews have only
focused on labral pathology. Reiman et al8 in the British
Journal of Sports Medicine is the only systematic review to
examine the clinical utility of HPE tests for all hip pathology.
▸ Description of the various HPE tests is quite variable
dependent on the study.

What this study adds

Figure 10 Bilateral adductor test. ▸ This study describes the correct performance of the best HPE
tests as described by Reiman et al8 The variable description
in multiple studies for similar tests requires a detailed
Assessment: Reproduction of patient’s concordant pain is con- description (and photograph) of the test procedure for each
sidered a positive test. relevant hip pathology.
Diagnostic accuracy: SN 54%, SP 93%, +LR 7.7 and −LR
0.49.32
Special note: Monitor for compensations of patient grabbing
Acknowledgements The authors would like to thank Carly Reiman for
onto table and/or bending knees. participating in the photographs.
Background: As with the other sports related chronic groin tests,
Contributors MPR provided idea, design, writing, review of manuscript and
adduction contraction elicits stress across the common origin of overall content of material; Mather and Cook provided writing, review and overall
the adductor muscles on the pubic symphysis region. content of manuscript.
Competing interests None.
Provenance and peer review
Commentary on sports related chronic groin pain tests
The bilateral adductor test was the most diagnostic of these
tests, with the potential to alter post-test probability to a moder-
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