Differentials
| Presenting Feature | What might it be? | What might I find? | |
| Atraumatic hip pain |
Osteoarthritis |
Older patient, history of manual work, high BMI.
Gradual onset of pain and stiffness affecting ROM. Reduced ROM, stiffness and crepitus on examination. |
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Trochanteric bursitis |
Middle-aged women, history of overuse, surgery, trauma.
Lateral hip pain over greater trochanter, worse at night. Pain on palpation of greater trochanter and lying on side. |
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Iliotibial band syndrome |
Runners, cyclists, athletes using repetitive movements.
Activity related pain in knee/thigh radiating up to lateral hip. |
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Meralgia paraesthetica (lateral femoral cutaneous nerve) |
Recent weight gain, trauma or surgery to thigh, pregnancy.
Lateral thigh pain, burning, tingling and numbness in same distribution. |
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| Traumatic hip pain |
Neck of femur fracture |
Frail patient, history of osteoporosis, post-menopause.
Hip pain and inability to weight-bear after fall/hip trauma. Affected leg shortened and externally rotated. |
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| Paediatric hip pain |
Slipped upper femoral epicondyle |
Most commonly boys 8-15 years old, overweight, growing.
May be associated with history of mild trauma. Hip pain, limp, reduced range of movement at hip. Reluctance and pain on internal rotation. |
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Perthe’s disease |
Most commonly boys aged 5-8 years old.
Gradual onset atraumatic hip discomfort and limp. |
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Transient synovitis (irritable hip) |
Children aged 3-10.
May have been recently unwell with viral illness i.e. URTI. Hip/groin pain, reluctance to weight-bear, limp. Well child with normal observations and no fever. |
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Septic arthritis |
Any age child but more common <4 years old.
Hot, red, swollen, painful joint and refusal to weight-bear. Unwell child, tachycardia, fever, lethargy. |
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Checklist
| Preparation | Wash – Name – Explain | |
| Position patient standing | ||
| Appropriate exposure of legs | ||
| General Inspection | Systemic appearance (well/unwell) | |
| Body habitus | ||
| Pain | ||
| Joint support | ||
| Footwear/tread | ||
| Clues in bed space | ||
| Look (standing) | Examination from all aspects (anterior/lateral/posterior) | |
| Gait | ||
| Asymmetry | ||
| Swelling | ||
| Scars | ||
| Muscle wasting | ||
| Pelvic tilt | ||
| Look (lying) | Reposition to reclining 45° | |
| Examination from all aspects (anterior/lateral) | ||
| Asymmetry | ||
| Swelling | ||
| Scars | ||
| Muscle wasting | ||
| Skin colour | ||
| Fixed flexion deformity | ||
| External rotation of foot | ||
| Measure true leg length | ||
| Measure apparent leg length | ||
| Feel | Check for pain | |
| Temperature | ||
| ASIS | ||
| Anterior joint | ||
| Greater trochanter | ||
| Move | Pinroll | |
| Active flexion | ||
| Active extension | ||
| Active abduction | ||
| Active adduction | ||
| Passive flexion | ||
| Passive extension | ||
| Passive abduction | ||
| Passive adduction | ||
| Passive internal rotation | ||
| Passive external rotation | ||
| Special Tests | Thomas test | |
| Trendelenburg test | ||
| Finishing | Neurovascular examination | |
| Examine joint above & below | ||
| Re-cover patient | ||
| Wash hands |
Explanation
Preparation
Wash, name, explain:
- Wash your hands
- Introduce yourself by name and role
- Check the patient’s name and date of birth
- Explain the procedure and get consent
“I have been asked to examine your hips. This involves looking, pressing and moving your hips. You can ask me to stop at any time. Are you happy for me to do that?”
Ask the patient to expose their legs to above the knee (e.g., removing trousers and wearing small shorts/underwear).
Ask them to stand for the initial part of the examination.
General Inspection
Look at the patient and around the bed space for useful signs:
- Body habitus e.g., overweight or underweight
- Pain e.g., holding or protecting joint
- Joint support e.g., brace or cast
- Clues around the bed space e.g., medication packets, walking aids
Look at the patient’s footwear e.g., asymmetrical tread indicating a gait abnormality, build-ups/lifts indicating leg length discrepancies.
Make sure to examine and compare both hips unless told otherwise by the examiner.
Look (standing)
Inspect the hips from anterior, lateral and posterior aspects, noting:
- Asymmetry e.g., obvious deformity to one leg
- Swelling
- Scars e.g., evidence of previous surgery to hip
- Muscle wasting
- Alignment of hips e.g., is there a pelvic tilt
Ask the patient to walk a short distance and observe gait for:
- Antalgic gait e.g., limping
- Reduced range of motion
- Trendelenburg gait e.g., pelvic tilt during gait cycle
Look (lying)
Reposition the patient to reclining on couch at 45° with legs extended. Observe for pain or difficulty in transferring onto the couch.
Examine from anterior and lateral aspects. Perform a closer inspection of the hips, again looking for:
- Asymmetry
- Swelling,
- Scars,
- Muscle wasting
- Skin colour e.g., erythema, bruising
Observe any fixed flexion deformity whereby hip cannot fully extend and posterior knee will not touch the couch or unilateral external rotation of the foot indicating acute or historic neck of femur fracture.
Measure leg length assessing for any significant differences in both:
- True leg length
- Apparent leg length
True leg length is measured from the ASIS to the medial malleolus and causes of a discrepancy are related to the limb itself, i.e. neck of femur fracture. Apparent leg length is measured from the umbilicus to the medial malleolus and causes of discrepancy are related to pelvic or spinal deformity, i.e. scoliosis.
Feel
Check for pain prior to palpation of joint: ask if any discomfort when palpating and look at patient’s face – are they in pain?
Feel for changes in skin temperature over the anterior joint line and the greater trochanter.
Palpate the hip, checking for swelling or tenderness of the:
- ASIS
- Anterior joint line (palpating for any deep tenderness)
- Greater trochanter
- Proximal femur
Move
Start by using a pin-rolling movement to screen for hip pain – the doctor rolls the straight extended leg from side to side assessing for any pain; positive test may indicate fracture of the hip.
Next examine active hip movement, comparing both sides looking for discomfort and range of movement (normal range):
- Flexion – ask the patient to bend the knee then bend the hip towards their chest as far as they can (120°)
- Extension – ask the patient to fully straighten their leg so it is flat on the couch and press down into the couch (180°)
NB – further extension can be assessed by asking the patient to lie prone and raise their extended leg off the couch (20°)
- Abduction – ask the patient to keep their leg straight and move it laterally as far as they are able to (45°)
- Adduction – ask the patient to keep their leg straight and move it medially across their other leg as far as able (30°)
Examine passive movements by repeating the above with doctor moving the patient’s leg with one hand and the other hand placed on patient’s hip, stabilising the pelvis with the forearm. Throughout all joint movement the doctor is checking for discomfort, crepitus and any difference in range of movement compared with active movement.
In addition to passive flexion, extension, abduction and adduction examine for internal and external rotation:
- Internal rotation – the doctor flexes the patient’s hip and knee to 90° and moves calf laterally (45°)
- External rotation – the doctor flexes the patient’s hip and knee to 90° and moves calf medially (45°)
Special Tests
The special tests for the hip are:
- Thomas test (fixed flexion deformity)
- Trendelenburg test (hip abductor weakness)
The Thomas test: with patient lying down, the doctor places an arm under the patient’s lumbar spine and passively flexes the hip and knee noting the flattening of the lumbar spinal lordosis curve. The test is positive if the contralateral thigh lifts off the couch and indicates a fixed flexion deformity.
The Trendelenburg test: with the patient standing, the doctor places both hands on the patient’s iliac crests with the patient supporting themselves by placing both hands on the doctor’s shoulders. The doctor asks the patient to stand on one leg noting the upward pelvic tilt on the side of the raised leg to compensate. The test is positive if the pelvis drops on the side of the raised leg and indicates hip abductor weakness on the side of the leg they are standing on.
Finishing
Thank the patient and allow them to cover themselves. Wash your hands.
Depending on the examination findings you may wish to carry out a full neurovascular assessment, examine the joint above and below as well as arrange further investigations including X-ray, ultrasound or MRI scanning.
Last updated Dec 2024
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