Download Hip Evaluation

Thigh, Hip, Pelvis Evaluation
1. History
• Chief Complaint:
A. What happened?
B. Is it a sharp or dull pain?
C. How long have you had the pain?
D. Can you pinpoint the pain?
E. Do you have any numbness or tingling?
• Mechanism:
A. How did it happen?
B. What was felt or heard?
• Previous History:
A. Have you injured this before?
2. Observation
• Swelling
• Discoloration
• Deformity
A. Hip dislocation: You will see the knee flexed and hip internally rotated
B. Hip fracture: You will see the knee extended and leg externally rotated
C. Pelvic obliquity: Measure the Anterior Superior Iliac Spine (ASIS). It should be
level
• Gait
A. Abduction Lurch: Affects gluteus medius. Falls to the effected side
B. Extensor Lurch: Affects gluteus maximus. The athlete arches their back and
thrusts forward at the hip on the effected side
C. Steppage Gait: The athlete has to pick their foot high up because dorsiflexors
(specifically the peroneal nevre) are not functioning.
• Q-Angle
• Muscle tone/Atrophy
• Angle of Torsion
A. Femoral neck anteversion
− Also called “pigeon toed” gait. This occurs when the angle of the neck of the
femur is greater than 135º, causing excessive anterior angulation resulting a
toe in gait
Copyright © 2004, Yoshiyuki Shiratori. All right reserved.
•
B. Femoral neck retroversion
− Also called “duck feet” gait. This occurs when the angle of the neck of the
femur is less than 120º, causing excessive posterior angulation resulting a toe
in out
Leg length discrepancies
A. True leg length measurement
− Measuring to see if there is any anatomical discrepancy.
− Measurement
♦ Patient is supine
♦ ASIS to the medial malleoli
B. Apparent leg length measurement
− Measurement is to see if the discrepancy factor is due to other factors than
femoral or tibial leg length.
− Always perform after there is a negative true leg length discrepancy
− Measurement
♦ Patient is supine
♦ Umbilicus to the medial malleoli
♦ Cause: pelvic obliquely or from a flexion or adduction deformity
3. Check the bone for fracture
• Proper location and palpation
A. Anterior aspect
− Anterior Superior Iliac Spine (ASIS)
− Iliac crest
− Greater trochanter
− Iliac tubercle
− Pubic tubercle
− Head of femur
B. Posterior aspect (pateint should lie on their side with the top hip flexed)
− Posterior Superior Iliac Spine (PSIS)
− Greater trochanter
− Ischial tuberosity
C. Sacrum
− Sacroiliac (SI) joint
Copyright © 2004, Yoshiyuki Shiratori. All right reserved.
D. Acetabulum
E. Coccyx
F. Femur
− Shaft
− Greater trochanter
4. Check the ligaments and cartilage
A. Inguinal ligament
− Top of the femoral triangle. Between the ASIS and the pubic tubercle
− Only palpable hip ligament. Place the athlete in a figure 4.
B. Iliofemoral ligament
− Also called the “Y-ligament of Bigelow”
− The longest ligament in body which is non-palpable
− Prevents hyperextension of the hip
C. Ligamentum teres
− From the acetabulum to the head of the femur
D. Iliopectineal ligament
− Prevents hyperextension
E. Transverse acetabular ligament
− Completes the acetabular labrum inferiorly
F. Ischiofemoral ligament
− Limits medial rotation of the hip
5. Check the muscle tendon and soft tissue
• Anterior aspect: flexor group
A. Iliopsoas
B. Sartorius
C. Rectus Femoris
• Posterior aspect: extensor group
A. Gluteus Maximus
B. Hamstrings
C. Ischial Bursa
− Over the ischial tuberosity
− Ischial Bursitis
♦ Excessive friction causes pain and inflammation. Pain with passive hip
flexion and active/resistive hip extension.
• Medial aspect: adductor group
Copyright © 2004, Yoshiyuki Shiratori. All right reserved.
A.
B.
C.
D.
E.
F.
•
Gracilis
Pectineus
Adductor Longus
Adductor Magnus
Adductor Brevis
Femoral Triangle
− The triangle is formed by the inguinal ligament, sartorius muscle, and
adductor longus muscle
− Evaluate in a figure 4 position
− Underlying structures (Lateral⇒Medial)
♦ Femoral nerve
♦ Femoral artery
♦ Femoral vein
♦ Lymph nodes
Lateral aspect: abductor group
A. Gluteus Medius
B. Gluteus Minimus
C. Tensor Fascia Latae
D. Iliotibial Band
− Snapping hip syndrome
♦ IT band rides over the greater trochanter and inflamed bursa during hip
flexion and extension. Ask if the snapping elicits pain.
E. Trochanteric Bursa
− Between the greater trochanter and soft tissue
− Trocanteric Bursitis
♦ Caused by overuse, trauma, leg length discrepancy, and larger Q-angle
♦ Demonstrating a running motion with one leg and extending their hip will
recreate the pain
6. Compare ROM
• Compare bilaterally
• Stabilize both legs when testing
• AROM:
A. Hip Flexion: 120º
− Primary muscle: Iliopsoas
♦ Patient is seated with knee flexed
− Secondary muscle: Rectus Femoris, Sartorius
Copyright © 2004, Yoshiyuki Shiratori. All right reserved.
•
♦ Rectus Femoris: Patient is seated or supine with knee extended
B. Hip Extension: 30º
− Primary muscle: Gluteus Maximus
♦ Patient is prone, with knee bent
− Secondary muscle: Hamstring
♦ Patient is prone, with knee straight
C. Hip Abduction: 45º
− Primary muscle: Gluteus Medius
− Secondary muscle: Gluteus Minimus, Tensor Fascia Latae
♦ Patient is supine. Use of goinometer or tape measure will be easier for
comparison
D. Hip Adduction: 20º
− Primary muscle: Adductor Longus
− Secondary muscle: Adductor Brevis, Adductor Magnus, Gracilis, Pectinius
♦ Patient is supine. Effected leg should be moved underneath the opposite
raised leg
E. Hip Internal Rotation: 35º
− Gluteus Medius, Gluteus Minimus
− Patient is seated and knees bent. Bring the leg laterally.
− Look at the patella, not the foot
F. Hip External Rotation: 45º
− Piriformis, Quadratus Femoris, Obturator Internus, Obturator Externus,
Gemellus Superior, Gemellus Inferior
− Patient is seated and knees bent. Bring the leg medially
− Look at the patella, not the foot
PROM: Perform the same motion as AROM
7. Resistive ROM
• Stabilize both legs when testing
• Compare bilaterally, starting with the non injured ankle
• Performed both concentric and eccentric (break) tests
A. Hip flexion
− Iliopsoas: Patient is sitting with the knee flexed
− Rectus Femoris: Patient is sitting or supine with knee extended
B. Hip extension
− Gluteus Maximus: Patient is prone with knee flexed
− Hamstrings: Patient is prone with knee extended
Copyright © 2004, Yoshiyuki Shiratori. All right reserved.
C. Abduction
− Patient is on the side
♦ Stabilize the pelvis by placing one hand over the iliac crest and tubercle
and one hand on the lateral side of the knee
− Patient supine
♦ Have the patient abduct their leg about 20º
♦ Place hands on the lateral sides of the knee
D. Adduction
− Patient is on the side
♦ Have the patient abduct their leg. Stabilize the pelvis by placing one hand
over the iliac crest and tubercle and one hand on the medial side of the
knee.
− Patient supine
♦ Have the patient abduct their leg
♦ Place hands on the medial sides of the knee or your body between their leg
E. Internal rotation
− Position: Patient is seated with knees bent
− Hand placement: Stabilize the knee with one hand and the other hand placed
on the lateral malleolus
− Procedure: Have the patient rotate their leg laterally
F. External rotation
− Position: Patient is seated with knees bent
− Hand placement: Stabilize the knee with one hand and the other hand placed
on the medial malleolus
− Procedure: Have the patient rotate their leg medially
8. Orthopedic Special Tests
• Test for sacroiliac dysfunction
A. Patrick test
− This test is used to identify limited mobility of the hip (iliopsoas spasm), or
sacroiliac (SI) dysfunction. The test is also called the FABER (Flexion,
ABduction, External Rotation) test.
♦ Position: Patient is supine with the involved leg in a figure 4 at the leg
♦ Hand placement: Place one hand on the opposite ASIS, and the other hand
on the medial aspect of the involved leg
♦ Procedure: Push the knee passively into abduction (into the table), while
stabilizing the opposite ASIS.
Copyright © 2004, Yoshiyuki Shiratori. All right reserved.
♦ Positive sign: Thigh remains elevated above the opposite leg
B. Gaenslen’s Test
− This test assess the general pathology of the hip or the SI or an L4 nerve lesion
♦ Position: Patient lies supine, with both knees is flexed against the chest
and the involved buttock off the edge of the table.
♦ Procedure: Supporting the involved leg, slowly lower (extend) the leg off
the table.
♦ Positive sign: Pain in the SI region
C. Pelvic Compression/Distraction Test
− This test is used to stress the anterior and posterior SI ligament
♦ Position: Patient lies supine
♦ Hand placement: Both hands are placed
On the iliac crest for the compression test
On the ASIS. When you place your hand cross you arm.
♦ Procedure: Apply pressure
For the compression test⇒ down and inward
For the distraction test⇒ down and outward
♦ Positive sign: Pain in the SI joint
•
Neuromuscular Pathology Tests
A. Trendelenburg Test
− This test is to see hip stability and gluteus medius weakness
♦ Position: Have the patient stand on one leg
♦ Procedure: Stand behind the patient and observe the hip
♦ Positive sign: Non weight bearing hip drops
B. Thomas Test
− This test assesses the flexibility of the hip flexor muscle
♦ Position: The patient is supine
♦ Hand placement: Place one hand underneath the patient‘s back (only
when the athlete is curling their back)
♦ Procedure: Have the patient pull one knee up toward the chest and flatten
her back on the table. If the athlete has a hard time flattening their back,
place your hand underneath the spine curvature. You are to look the
extended leg for any signs
Copyright © 2004, Yoshiyuki Shiratori. All right reserved.
♦ Positive sign: If the extended leg is flexed
C. Rectus Femoris Contracture Test (Kendall Test)
− This test assesses the hip flexor and rectus femoris tightness
♦ Position: Patient is supine with their leg (mid-thigh) off the table
♦ Procedure: Have the patient pull one knee up toward the chest
♦ Positive sign: The leg off the table is going to extend (normal sign⇒ knee
should be at 90º)
D. Ober’s Test
− This test assess the tensor fascia latae and IT band tightness
♦ Position: Patient lies on their side, with the bottom leg slightly flexed for
stability. The top leg is abducted and the knee is kept in full extension
♦ Hand placement: Place one hand on the pelvis and the other hand
supporting the top leg
♦ Procedure: Slowly lower the top leg into adduction
♦ Positive sign: Leg remains abducted or if the pelvis move before the leg
when adducted
E. Noble’s Test
− This test assess a IT band friction syndrome
♦ Position: Patient is supine, with the injured knee flexed at 90º and the hip
flexed at 90º
♦ Hand placement: One hand is placed at the lateral femoral condyle and the
other hand at the leg or the heel to move the leg
♦ Procedure: Apply pressure at the lateral femoral condyle while extending
the knee passively or actively
♦ Positive sign: Pain over the lateral femoral condyle at 30º of knee flexion
F. Piriformis Test
− This test checks the tightness of the piriformis muscle
♦ Position: Patient lies on the uninvolved side with the top leg in knee
flexion and 60º hip flexion
♦ Hand placement: One hand is placed on the pelvis for stabilization, and
the other hand on the top knee
♦ Procedure: Apply downward pressure to the knee
♦ Positive sign: Pain in the piriformis muscle
Copyright © 2004, Yoshiyuki Shiratori. All right reserved.
•
Test for neuropathy
A. Femoral Nerve Traction Test
− This test assesses femoral nerve pathology that is caused from the
lumbosacral plexus
♦ Position: Patient lies on the unaffected side with the lower leg flexed for
stability. The top hip and knee are placed in extension and the head in
slight flexion
♦ Hand placement: Stabilize the hip with one hand the other hand at the
lower leg to move the knee passively
♦ Procedure: With the hip maintained at 15º of extension, the knee is
passively flexed
♦ Positive sign: Pain, numbness, or tingling in the anterior thigh
•
Neurological Test
A. Hamstring Tendon Reflex
− To test the L3-5 and S1 and S2 nerve
♦ Position: Patient is prone on the table and is relaxed
♦ Hand placement: Place your thumb over the tendon
♦ Procedure: Place the athlete in to slight knee flexion. Tap over the thumb,
which is placed over the medial or lateral hamstring tendon
B. Dermatomes
− L1 to L3 (see knee eval)
C. Myotomes
− L1-S2 (see ankle eval)
•
Functional testing (sports specific)
− Walking
− Jogging
− Toe walk
− Heel walk
− Figure 8 running
− Cutting
Copyright © 2004, Yoshiyuki Shiratori. All right reserved.