Special Tests for the Hip Exam
The physical examination of the hip should include a standardized exam approach as well as a series of special tests to help diagnose the cause of the patients pain. In general, a thorough physical examination will include inspection, palpation, active and passive range of motion, strength, neurovascular and special tests. The purpose of today’s post is to review some of the special tests for the hip exam that all members of the sports medicine team should be familiar with. We will review some of the more commonly used exam techniques but it is worth mentioning there are dozens of others that are not covered here. It is also worth noting that some of these examination techniques may overlap with more than one disease process.
The FABER test, so-called because it involves hip flexion, abduction and external rotation, is interesting because it can identify hip, lumbar and sacroiliac joint disease. The patient is supine on the examination table and placed in the “figure 4” position. The examiner applies pressure to the contralateral ASIS and ipsilateral knee. A positive test is pain or restriction in range of motion. This test in isolation is of limited diagnostic utility, but when taken as a cluster of other tests, can be used to help identify the source of the patients pain.
The FADIR test, standing for flexion, adduction and internal rotation test, is designed to evaluate the piriformis, gluteal muscles and hip joint as a source of pain. The patient is typically supine but can be laying on their contralateral side. The examiner passively flexes the hip into 90 degrees of flexion, while adducting and internally rotating. A positive test is reproduction of the patients pain which may be in the piriformis, down the sciatic nerve or anteriorly through the joint. A modified FADIR has been proposed which does not involve adduction.
The stinchfield test is used to help identify the cause of hip pain. It may be positive in disease states like athletic pubalgia, slipped capital femoral epiphysis and femoral acetabular impingement. It is also called the straight leg raise against resistance test. The patient is supine and the examiner asks the patient to raise their leg flexed to 20 to 45 degrees off the table with the knee in extension. The examiner applies force against the anterior thigh, forcing it back down to the table. A positive test is hip or groin pain.
Log Roll Test
The log roll test is an easy examination trick to help evaluate the hip joint as a cause of the patients pain. The patient is supine with hip and knee extended into a neutral position. The examiner grasps the mid thigh and calf. They then passively rotate the entire leg in both internal and external direction attempting to move the limb into maximal range of motion. A positive test is pain, clicking or popping suggesting intra-articular disease. Increased total range of motion compared to the unaffected hip may suggest ligamentous or capsular laxity.
The Scour test, sometimes called the quadrant test, is a technique used to evaluate the joint as a cause of hip pain. The patient is supine. The examiner flexes the hip and knee to approximately 90 degrees. They then move the hip through an arc of motion incorporation flexion/adduction and extension/abduction. They should maintain a posterior compressive force throughout the exam. A positive test is worsening pain in the same distribution
Bent Knee Stretch Test
The bent knee stretch test is used to evaluate hamstrings as a cause of pain and also hamstring mobility. The patient is supine, hip and knee are maximally flexed. The examiner slowly straightens the patients leg. Positive test is reproduction of the patients pain. The affected leg should be compared to the unaffected leg.
The Thomas test, named after Dr Hugh Owen Thomas, is used to measure the flexibility and/or assess the tightness of the hip flexors. The patient is supine, the affected limb is maximally flexed to the chest. The unaffected limb should be left in extension and resting on the examination table. This flattens out the lumbar lordosis and stabilizes the pelvis. A positive test is the patient is unable to maintain their lower back against the table, the hip has a large posterior tilt or the knee is unable to flex more than 80 degrees. Note that the Thomas test may also be abnormal with IT band and quadriceps tightness.
There are a couple modifications worth mentioning. In one modification, both knees are flexed towards the chest. The affected limb is then lowered tower the table laterally while maintaining the unaffected limb in maximal flexion. Here you can measure the length of the iliopsoas angle. A second modification involves allowing the unnaffected limb to hang over the edge of the table rather than flexxing it towards the chest.
Active Piriformis Test
The active piriformis test, sometimes called the modified pace test, can be used to evaluate the piriformis muscle as a cause of hip or buttocks pain. The patient is placed in the lateral decubitus position with the unaffected hip pointed up. The examiner places one hand on the piriformis muscle belly. The patient is then asked to flex, abduct and internally rotate the hip against resistance. A positive test is reproduction of the patients pain.
Straight Leg Raise Test
The straight leg raise test, sometimes called lasegue sign, is used in patients with hip or back pain to help evaluate for radicular features suggesting a back etiology. The patient is supine. The examiner passively flexes the hip as high as the patient will tolerate with the knee in extension. A positive test is reproduction of pain radiating down the same leg in a similar distribution.
Some modifications exist. The contralateral straight leg raise test involves raising the unaffected leg and reproducing symptoms down the ipsilateral leg. Lesegue sign involves applying ankle dorsiflexion to the hip flexion.
Single Leg Stance Test
The single leg stance test, also called the fatigue trendelenburg test, is used to evaluate the gluteal muscles and trochanteric bursa as a cause of hip pain. The patient is asked to stand on the affected leg for 30 seconds. A positive test is reproduction of the patients pain. No hip drop should be present until the patient fatigues.
Obers test is used to evaluate the tensor fasciae latae and iliotibial band. The patient lays in the lateral decubitus position on the unaffected side. The unaffected limb is in a neutral position with hip and leg slightly flexed. The examiner stabilizes the pelvis and brings the affected limb into flexion and the leg is slowly allowed to adduct with gravity. A positive test is the patients leg does not drop due to IT band tightness, increased pain with adduction or if the patient has pain with active abduction against resistance.
The fulcrum test is a special examination technique to evaluate patients with thigh pain for a femoral shaft or neck stress fracture. The patient is seated, legs hanging from the examination table. The examiner places one arm under the symptomatic thigh. The other hand applies a downwards pressure on the distal leg, using the hand under the thigh as a “fulcrum”. The hand under the thigh can be moved around to find the point of maximal discomfort. A positive test is increased pain, discomfort or even apprehension.
The hop test, or one legged hop test, can be used to evaluate for stress fractures of the lower extremity including femoral neck and shaft. The patient is asked to jump up and down 10 times on the affected limb. A positive test is significant pain localized to a specific area.