Ebook Essentials of musculoskeletal care (4/E): Part 2

Section 5

Hip and Thigh
528 Pain diagram
530 Anatomy
531 overview of the Hip
and thigh

555 Fracture of the
Femoral Shaft
558 Fracture of the Pelvis

563 Fracture of the
Proximal Femur
541 Physical examination
of the Hip and thigh 568 Hip impingement
551 Dislocation of
the Hip (Acute,
traumatic)

573 inflammatory
Arthritis

576 Lateral Femoral
cutaneous nerve
Syndrome

597 Strains of the thigh

579 osteoarthritis of
the Hip

607 transient
osteoporosis of the
Hip

582 osteonecrosis of
the Hip
586 Snapping Hip
591 Strains of the Hip

604 Stress Fracture of the
Femoral neck

609 trochanteric Bursitis
614 Procedure:
trochanteric Bursitis
injection

Section Editors
Craig J. Della Valle, MD

Kathleen Weber, MD, MS

Associate Professor
Department of Orthopaedic Surgery
Rush University Medical Center
Chicago, IL

Assistant Professor
Department of Orthopaedic and Internal Medicine

Rush University Medical Center
Chicago, IL

Michael Huxford, MEd, ATC, CSCS
Sports Medicine Coordinator
Rehabilitative Services
Institute for Sports Medicine
Children’s Memorial Hospital
Chicago, IL

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

Shane J. Nho, MD, MS
Assistant Professor
Section of Sports Medicine
Department of Orthopaedic Surgery
Rush University Medical Center
Chicago, IL

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529


AnAtomy oF tHe HiP AnD tHigH
Origin of psoas major
muscle from vertebral
bodies, transverse

processes, and
intervertebral disks
(T12-L4) and origin
of psoas minor muscle
from vertebral bodies
(T12, L1)

T12

12th rib
Quadratus lumborum
muscle

L1

Transversus abdominis
muscle (cut)

L2

Iliohypogastric nerve
L3

Ilioinguinal nerve

Lumbar plexus

Psoas minor
muscle

Lumbosacral trunk

Psoas major
muscle

L4

Genitofemoral nerve

L5

Iliac crest

Anterior superior
iliac spine

Lateral cutaneous
nerve of thigh
Iliacus muscle
Femoral nerve
Superior pubic ramus

Iliopectineal bursa

Greater trochanter
of femur
Iliopsoas muscle
passes backward
to insertion on
lesser trochanter

Iliofemoral
ligament of
hip joint
(Y ligament
of Bigelow)

Shaft (body) of femur

Anterior Muscles of the Pelvis
Anterior superior iliac spine
Iliacus muscle

Iliac crest
Gluteal aponeurosis over
gluteus medius muscle

Psoas major muscle
Gluteus medius muscle
Inguinal ligament

Gluteus maximus muscle

Pubic tubercle
Iliopsoas muscle
Tensor fasciae latae muscle
Pectineus muscle

Greater trochanter

Adductor longus muscle
Semitendinosus muscle
Gracilis muscle
Sartorius muscle

Biceps femoris muscle (long head)

Rectus femoris muscle

Adductor minimus part of
adductor magnus muscle

Vastus lateralis muscle
Vastus intermedius muscle
Vastus medialis muscle
Iliotibial tract
Rectus femoris tendon (becoming part
of quadriceps femoris tendon)
Lateral patellar retinaculum
Patella
Medial patellar retinaculum
Patellar ligament
Sartorius tendon
Gracilis tendon

Semimembranosus muscle
Iliotibial tract
Gracilis muscle
Biceps femoris muscle
Short head

Long head
Semimembranosus muscle
Semitendinosus muscle
Popliteal vessels and tibial nerve
Common fibular (peroneal) nerve
Plantaris muscle
Gastrocnemius muscle
Medial head
Lateral head
Sartorius muscle

Semitendinosus tendon
Tibial tuberosity

Muscles of the Anterior Thigh
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Muscles of the Posterior Thigh and Gluteus
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Overview of the
Hip and Thigh

SECTION 5 HIP

Hip or proximal thigh pain generally comes from one of the
following sources: (1) the hip joint itself, (2) the soft tissues
around the hip and pelvis, (3) the pelvic bones, or (4) referred
pain from the lumbar spine. Diagnosing pathology involving the
hip joint and pelvis is often possible with a careful history and
physical examination combined with plain radiographs; in some
cases, however, advanced imaging studies such as MRI, CT, or
nuclear medicine scans may be required.
The hip joint, consisting of the articulation between the
cartilaginous surfaces of the femoral head and the pelvic
acetabulum, is a diarthroidal, synovial ball-and-socket joint
(Figure 1). The acetabulum is formed by the confluence of the
ilium, the ischium, and the pubis, and the articular surface that
is created is horseshoe shaped. The proximal femur consists of
the femoral head and neck and the greater and lesser
trochanters. The greater trochanter is a large bony prominence
found at the lateral base of the femoral neck; it serves as the
attachment site for the abductor musculature (the gluteus medius
and minimus). The lesser trochanter is a smaller bony
prominence located on the medial aspect of the proximal femur;

Figure 1 Bones of the hip and thigh.

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OVERVIEW OF THE HIP AND THIGH

it serves as the attachment site for the iliopsoas tendon (a
powerful hip flexor).
Radiographic examination of the hip should include an AP
radiograph of the pelvis and either a frog-lateral view of the
pelvis or AP and lateral radiographs of the involved hip.
Radiographs should be evaluated carefully for displaced or
nondisplaced fractures, degenerative changes of the hip joint
(including joint space narrowing), hip dysplasia, and changes in
bony architecture, such as lytic or blastic lesions that could
suggest a primary or metastatic tumor.

SECTION 5 HIP

Type of Pain

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Pain arising from the hip joint may be secondary to
osteoarthritis, osteonecrosis, inflammatory conditions such as
rheumatoid arthritis, septic arthritis, fractures of the proximal
femur or pelvis, or dislocations of the femoral head. Patients
with these conditions usually report pain in the groin or the
anterior aspect of the proximal thigh, but pain may be present in
the buttock or lateral aspect of the thigh or may be referred to
the supracondylar region of the knee. Hip joint pathology is
often associated with a decrease in range of motion that in

degenerative conditions is associated with difficulty in activities
such as putting on shoes. A limp also may be present, and
patients with traumatic injuries (such as proximal femoral or
pelvic fractures) are typically unable to bear weight on the
extremity and are unable to perform a straight-leg raise.
Problems involving the bony pelvis include traumatic highenergy fractures, insufficiency fractures associated with
osteoporosis, avulsion fractures from attached tendons, and
primary or metastatic tumors. Problems involving both the hip
joint and bony pelvis often manifest as pain in the groin,
buttock, or lateral thigh.
Conditions that affect the soft tissues around the hip, such
as trochanteric bursitis, lateral femoral cutaneous nerve
impingement, and snapping hip syndrome, typically cause pain
on the lateral or anterolateral aspect of the proximal thigh.
Patients with an injury of the adductor muscles will note pain in
the groin; hamstring injuries are associated with pain in the
buttock or posterior aspect of the thigh.
The sacroiliac (SI) joint is relatively immobile. Some
individuals have been found to experience more SI mobility than
others and may experience SI pain. High-energy injuries such as
high-energy pelvic ring disruption can lead to significant SI
pain. Other conditions that involve the SI joint, such as
seronegative arthritides or traumatic arthritis, can cause buttock
and posterior thigh pain but are unlikely to restrict function.
Pathology in the lumbar spine may present as referred pain to
the buttock and posterior thigh or as pain that radiates down the
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ipsilateral extremity in a radicular pattern. Patients with
degenerative problems of the lumbar spine or strains of the
lumbar musculature may have pain limited to the buttock,
whereas disorders that cause entrapment of the spinal nerves
(such as disk herniations) will cause pain that radiates in a
dermatomal pattern. With these conditions, patients typically do
not have symptoms referable to the groin, significant discomfort
with rotation of the hip, or limited range of motion of the hip
joint, although they often present with what they describe as
“pain in the hip.”
Nonmusculoskeletal pathology may present as groin or hip
pain, and if the source of pain is obviously not the hip joint,
these etiologies must be explored. Constitutional symptoms such
as fever, chills, and weight loss should be explored to rule out
malignancy or infection. Inguinal or abdominal hernias and
rectus abdominus strains may present with pain in the groin or
anterior thigh and may be difficult for the patient to distinguish
from hip pathology. Gastrointestinal disorders such as
inflammatory bowel disease, diverticulosis, diverticulitis, or
appendicitis may mimic hip pain. Pain from abdominal aortic
aneurysms may mimic groin pain. Urinary tract infections or
nephrolithiasis also may cause pain referred to the hip region.
Pathology of the reproductive system also may present as
pain in the groin or hip area. Prostatitis, epididymitis,
hydroceles, varicoceles, testicular torsions, and testicular
neoplasms all have been known to cause groin pain in men.
Ectopic pregnancy, dysmenorrhea, endometriosis, and pelvic

inflammatory disease may cause pain in this location in women.
Pelvic floor muscles that are weak or too tight can produce hip,
buttock, or groin pain. If any of these disorders are suspected, a
referral should be made to the appropriate specialists.

Gait
A brief examination of the patient’s gait can be very helpful in
making a diagnosis. Ask the patient to walk briskly up and
down the hall several times at a brisk pace. An abductor or
gluteus medius lurch is manifested by a lateral shift of the body
to the weight-bearing side with ambulation. This type of gait
often occurs in patients who have intra-articular hip pathology
(osteoarthritis, inflammatory arthritis, or osteonecrosis of the
hip). Pain associated with a limp suggests pathology around the
pelvis or hip and requires further investigation.

SECTION 5 HIP

OVERVIEW OF THE HIP AND THIGH

Musculoskeletal Conditioning of the Hip
A conditioning program consists of three basic phases: stretching
exercises, to improve range of motion; strengthening, to improve
muscle power; and proprioception, to enhance balance and
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OVERVIEW OF THE HIP AND THIGH

agility. In addition, the exercise session should begin with an
active warm-up, and plyometric exercises may be added for
power after basic strength and flexibility have been achieved.
Patient handouts are provided here for the stretching and
strengthening exercises. Advanced proprioceptive exercises and
plyometric exercises should be done under the supervision of a
rehabilitation specialist or other exercise professional.
The goal of a conditioning program is to enable people to
live a more fit and healthy lifestyle by being more active. A
well-structured conditioning program also will prepare the
individual for participation in sports and recreational activities.
The greater the intensity of the activity that the individual
wishes to engage in, the greater the intensity of the conditioning
that will be required. If the individual participates in a
supervised rehabilitation program that provides instruction in a
conditioning routine—instead of using only an exercise handout
such as provided here—the focus should be on developing and
committing to a home exercise fitness program. A conditioning
program for the body as a whole that includes exercises for the
shoulder, knee, foot, and spine as well as the hip is described in
Musculoskeletal Conditioning: Helping Patients Prevent Injury
and Stay Fit, beginning on page 183.
The muscles of the hip and pelvis are important in walking

and running activities. Both the shoulder and the hip are balland-socket joints, but because of its anatomy, the hip is more
stable than the shoulder. An exercise program for conditioning
of the hip should include an active warm-up; stretching,
strengthening, and proprioceptive exercises; and, once basic
stretching and strengthening have been achieved, plyometrics
for power.

Active Warm-Up
The hip muscle groups are large and require an adequate warmup, such as riding on a stationary bicycle or jogging for
10 minutes to raise the core body temperature. In addition,
dynamic stretching exercises such as leg swings can be used to
warm up the synovial fluid in the hip joint and actively stretch
the muscles before activity.

Strengthening Exercises
Exercises that isolate muscle contraction and do not stimulate
co-contractions are important for strengthening the hip muscles.
In general, weight-bearing exercises produce co-contractions,
and non–weight-bearing exercises do not. Co-contractions are
important for stabilizing the joint that is being strengthened.
Strengthening of the large hip muscle groups requires heavier
weights and few (6 to 12) repetitions. After beginning with a
weight that allows the patient to perform 6 to 8 repetitions
initially, working up to 12 repetitions should be the goal of the

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OVERVIEW OF THE HIP AND THIGH

strengthening phase. The exercises described below isolate the
gluteus medius (posterior fibers), the gluteus maximus, and the
internal and external rotators, which often are weak and
therefore contribute to hip pathology.

Static Stretching Exercises
Static stretching should be done to increase the flexibility of the
muscles surrounding the hip. A static stretch is performed at the
end of the available range of painless motion of the muscle and
joint.

In addition to strength, the athlete requires balance and power.
Neuromuscular training, which improves communication
between the muscles and the proprioceptors, includes balance
and perturbation exercises as well as plyometrics. Balance
involves the visual, vestibular, and proprioceptive systems. With
balance training, the athlete consciously attempts to hold a
posture for 30 to 60 seconds. These exercises might include
balancing on one leg or balancing on one leg while touching the
other foot to different points on the ground within reach. With
perturbation training, the athlete stands on an unstable surface
such as a balance board while it is being perturbed by an
outside force. Jumping exercises, such as jumping forward and
backward over a barrier, are a basic form of plyometrics. These

should be attempted only by individuals with full range of
motion and adequate strength in the hip, pelvic and abdominal,
and back muscles. These types of plyometric and proprioceptive
exercises should be supervised by a rehabilitation specialist or
other exercise professional.

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SECTION 5 HIP

Proprioceptive Conditioning and Plyometrics

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OVERVIEW OF THE HIP AND THIGH

Home Exercise Program for Hip Conditioning
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Before beginning the conditioning program, warm up the muscles and the hip joint by riding a
stationary bicycle or jogging for 10 minutes and performing leg swings as follows: While

standing, swing one leg forward and backward 10 times and then side-to-side 10 times. Repeat
with the opposite leg. Place one hand against a wall for balance if needed.
When performing the stretching exercises, you should stretch slowly to the limit of motion,
taking care to avoid pain. If you experience pain with the exercises, call your doctor.
After performing the active warm-up and strengthening exercises, static stretching exercises
should be performed to maintaining or increase flexibility.

Exercise

Muscle Group

Number of Repetitions/Sets

Number of Days
per Week

SECTION 5 HIP

Strengthening

536

Hip extension (prone)

Gluteus maximus

6 to 8 repetitions, progressing to
12 repetitions

2 to 3

Side-lying hip abduction

Gluteus medius

6 to 8 repetitions, progressing to
12 repetitions

2 to 3

Internal hip rotation

Medial hamstrings

6 to 8 repetitions, progressing to
12 repetitions

2 to 3

External hip rotation

Piriformis

6 to 8 repetitions, progressing to
12 repetitions

2 to 3

Seat side straddle

Adductor muscles
Medial hamstrings
Semitendinosus
Semimembranosus

4 repetitions/2 to 3 sets

Daily

Modified seat side straddle

Hamstrings
Adductor muscles

4 repetitions/2 to 3 sets

Daily

Leg stretch

Hamstrings

4 repetitions/2 to 3 sets

Daily

Sitting rotation stretch

Piriformis
External rotators

Internal rotators

4 repetitions/2 to 3 sets

Daily

Knee to chest

Posterior hip muscles

4 repetitions/2 to 3 sets

Daily

Leg crossover

Hamstrings

4 repetitions/2 to 3 sets

Daily

Cross overstand

Hamstrings

4 repetitions/2 to 3 sets

Daily

Iliotibial band stretch

Tensor fascia

4 repetitions/2 to 3 sets

Daily

Quadriceps stretch (prone)

Quadriceps

4 repetitions/2 to 3 sets

Daily

Stretching

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OVERVIEW OF THE HIP AND THIGH

Strengthening Exercises
Hip Extension (Prone)
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Lie face down with a pillow under your hips
and one knee bent 90°. Elevate the leg off the
floor, lifting the leg straight up with the knee
bent.
Lower the leg to the floor slowly, to a count of
5. Ankle weights should be used. Start with
weight light enough to allow 6 to 8 repetitions
and work up to 12 repetitions.
Repeat on the other side.
Perform the exercise 2 to 3 days per week.
Once you have worked up to 12 repetitions, add
as much weight as can be lifted only 8 times,
working up to 12 repetitions again. Continue
this cycle of adding weight and increasing
repetitions.

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Lie on your side while cradling your head in
your arm. Bend the bottom leg for support.
Slowly move the top leg up and back to 45°,
keeping the knee straight. Lower the leg slowly,
to a count of 5, and relax it for 2 seconds.
Ankle weights should be used, starting with
weight light enough to allow 6 to 8 repetitions,
working up to 12 repetitions.
Repeat on the other side.
Perform the exercise 2 to 3 days per week.
Once you have worked up to 12 repetitions, add
as much weight as can be lifted only 8 times,
working up to 12 repetitions again. Continue
this cycle of adding weight and increasing
repetitions.

Internal Hip Rotation
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Lie on your side on a table with a pillow
between your thighs. Bend the top leg 90° at the

hip and 90° at the knee.
Start with the foot of the top leg below the level
of the top of the table; lift to the finish position,
which is rotated as high as possible.
Lower the leg slowly, to a count of 5. Ankle
weights should be used, starting with weight
light enough to allow 6 to 8 repetitions, working
up to 12 repetitions.
Repeat on the other side.
Perform the exercise 2 to 3 days per week.
Once you have worked up to 12 repetitions, add
as much weight as can be lifted only 8 times,
working up to 12 repetitions again. Continue
this cycle of adding weight and increasing
repetitions.

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SECTION 5 HIP

Side-Lying Hip Abduction

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OVERVIEW OF THE HIP AND THIGH

External Hip Rotation
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Lie on your side on a table with the bottom leg
bent 90° at the hip and 90° at the knee.
Start with the foot below the level of the top of
the table; lift to the finish position, which is
rotated as high as possible.
Lower the leg slowly, to a count of 5. Ankle
weights should be used, starting with weight
light enough to allow 6 to 8 repetitions, working
up to 12 repetitions.
Repeat on the other side.
Perform the exercise 2 to 3 days per week.
Once you have worked up to 12 repetitions, add
as much weight as can be lifted only 8 times,
working up to 12 repetitions again. Continue
this cycle of adding weight and increasing
repetitions.

Stretching Exercises

Seat Side Straddle
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Sit on the floor with your legs spread apart.
Place both hands on the same ankle and bring
your chin as close to your knee as possible.
Hold the stretch for 30 seconds and then relax
for 30 seconds.
Repeat on the other side.
Repeat the sequence 4 times, performing 2 to 3
sets daily.

Modified Seat Side Straddle
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■

Sit on the floor with one leg extended to the
side and the other leg bent as shown.

Place both hands on the ankle of the extended
leg and bring your chin as close to your knee as
possible. Hold the stretch for 30 seconds and
then relax for 30 seconds.
Reverse leg positions and repeat on the other
side.
Repeat the sequence 4 times, performing 2 to 3
sets daily.

Leg Stretch
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538

Sit on the floor with your legs straight and your
hands grasping the calf of one leg.
Slowly lift and pull the leg toward your ear,
keeping your back straight and the other leg flat
on the floor or bent slightly if necessary for
comfort. Hold the stretch for 30 seconds and
then relax for 30 seconds
Repeat with the other leg.
Repeat the sequence 4 times.
Perform 2 to 3 sets daily.

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OVERVIEW OF THE HIP AND THIGH

Sitting Rotation Stretch
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Sit on the floor with both legs straight out in
front of you.
Cross one leg over the other, place the elbow of
the opposite arm on the outside of the thigh,
and support yourself with your other arm behind
you.
Rotate your head and body in the direction of
the supporting arm. Hold the stretch for 30

seconds and then relax for 30 seconds.
Reverse positions and repeat the stretch on the
other side.
Repeat the sequence 4 times.
Perform 2 to 3 sets daily.

Knee to Chest
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Lie on your back on the floor with your knees
bent and your heels flat on the floor.
Grasp one knee and slowly bring it toward your
chest as far as it will go. Hold the stretch for 30
seconds and then relax for 30 seconds.
Repeat with the other leg; then do both legs
together.
Repeat the sequence 4 times.
Perform 2 to 3 sets daily.

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Lie on the floor with your legs spread and your
arms at your sides.
Keeping the leg straight, bring your right toe to
your left hand.
Try to keep the other leg flat on the floor, but
you may bend it slightly if needed for comfort.
Hold the stretch for 30 seconds and then relax
for 30 seconds.
Repeat with the left leg and the right hand.
Repeat the sequence 4 times. Perform 2 to 3
sets daily.

SECTION 5 HIP

Leg Crossover

Crossover Stand
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Stand with your legs crossed, with your feet
close together and your legs straight.
Slowly bend forward and try to touch your toes.
Hold the stretch for 30 seconds and then relax
for 30 seconds.
Repeat with the position of the legs reversed.
Repeat the sequence 4 times.
Perform 2 to 3 sets daily.

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OVERVIEW OF THE HIP AND THIGH

Iliotibial Band Stretch
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Stand next to a wall for support.
Begin with your weight distributed evenly over
both feet, and then cross one leg behind the
other.
Lean the hip of the crossed-over leg toward the
wall until you feel a stretch on the outside of
the leg. Hold the stretch for 30 seconds and
then relax for 30 seconds.
Repeat on the opposite side.
Repeat the sequence 4 times.
Perform 2 to 3 sets daily.

Quadriceps Stretch (Prone)
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SECTION 5 HIP

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Lie on your stomach with your arms at your
sides and your legs straight.
Bend one knee up toward your buttocks and
grasp the ankle with the hand on the same side.

Pull on the ankle. Hold the stretch for 30
seconds and then relax for 30 seconds.
Repeat on the opposite side.
Repeat the sequence 4 times.
Perform 2 to 3 sets daily.

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Physical Ex amination
of the Hip and Thigh
Inspection/Palpation
Anterior View

Posterior View
With the patient standing, look for atrophy of the buttock and posterior thigh musculature. Note any pelvic
obliquity (one iliac crest lower than the opposite side).
Limb-length discrepancy will cause one iliac crest to
be lower than the other, but this apparent obliquity can
be corrected by placing blocks under the shorter limb.
Fixed pelvic obliquity from a spinal deformity cannot
be corrected by this maneuver. Palpate the iliac crests,
the posterior iliac spine (deep to the dimples of Venus),
and the greater trochanter. A Trendelenburg test can

be conducted at this time to determine gluteus medius
weakness. For the Trendelenburg test, the patient is
instructed to stand first on one leg and then the other
for comparison. With normal hip abductor strength, the
pelvis will stay level or the side opposite the stance leg
will elevate slightly. With abnormal abductor strength
in the stance leg, the contralateral iliac crest will drop.
This is a positive Trendelenburg test (see page 548).

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SECTION 5 HIP

With the patient standing, look for atrophy of
the anterior thigh musculature and note the
overall alignment of the hip, knee, and ankle.

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PHYSICAL EXAMINATION OF THE HIP AND THIGH

Gait

SECTION 5 HIP

To assess gait, observe the patient walk
across the room. Hip deformities often cause
a limp that can range in severity from barely
detectable to a marked swaying of the trunk
and slowing of gait. Patients with a painful
hip joint may have an antalgic gait; that is,
they shorten the stance phase on the affected
side to avoid placing weight across the
painful joint. A Trendelenburg gait,
characterized by a lateral shift of the body
weight, is seen in patients with weakness of
the abductor musculature; this is sometimes
primary but is more often secondary to a
degenerative disorder of the hip. As the hip
joint degenerates and friction within the hip
joint increases, it becomes more difficult for
the abductor musculature to level the pelvis
during gait.

Anterior View, Supine
With the patient supine, palpate to identify any masses, abnormal adenopathy,
or tenderness in the region of the anterior superior iliac spine (ASIS) or greater
trochanter. (The examiner is palpating the ASIS in the photograph.) Patients with
avulsion of the sartorius or rectus femoris will report tenderness at or directly
inferior to the ASIS. Patients with meralgia paresthetica (entrapment of the lateral
femoral cutaneous nerve) will report tenderness immediately medial to the ASIS
and hypoesthesia over the distal lateral thigh.
Patients who report a popping sensation in the hip while ambulating most likely
have a thickened iliotibial band that snaps over the greater trochanter as the hip
moves into flexion and internal rotation. Have the patient re-create the snapping

and palpate the iliotibial band as it snaps over the greater trochanter. This may be
visible (and at times can be seen from across the room).

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PHYSICAL EXAMINATION OF THE HIP AND THIGH

Lateral View, Side-Lying
Place the patient in a side-lying position on the unaffected side to facilitate the
examination. Structures in the region of the greater trochanter may be palpated
with the patient in the supine position, but examination of this area is easier with
the patient lying on the unaffected side. Tenderness to palpation directly over the
greater trochanter reproduces pain with greater trochanteric bursitis. Tenderness
at the proximal tip of the trochanter may indicate gluteus medius tendinitis.
Tenderness at the posterior margin of the trochanter may indicate external
rotator tendinitis.

SECTION 5 HIP

Range of Motion

Flexion: Zero Starting Position
To evaluate hip flexion, the patient is supine on a firm, flat surface with the hip

not being examined held in enough flexion to flatten the lumbar spine. Flattening
the lumbar spine prevents excessive lordosis, which may camouflage a hip flexion
contracture. Avoid positioning the opposite hip in excessive flexion, as this will
rock the pelvis into abnormal posterior inclination, thereby creating a falsepositive hip flexion contracture. Instead, flex the opposite hip to a position where
the lumbar spine just starts to flatten or, more precisely, to a position where the
inclination of the pelvis is similar to that of a normal standing posture (ie, the
anterior superior iliac spine is inferior to the posterior iliac spine by only 2° to 3°).
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PHYSICAL EXAMINATION OF THE HIP AND THIGH

Maximum Flexion
Maximum hip flexion is the
point at which the pelvis
begins to rotate. Normal
hip flexion in adults is 110°
to 130°.

SECTION 5 HIP

Hip Flexion Contracture—Thomas Test
The Thomas test is used to evaluate for hip flexion contracture or psoas
tightness. Begin with the patient sitting at the end of the examination table with

the legs extending far enough that when the patient lies supine, the table edge
will not contact the posterior aspect of the calves. Have the patient then assume a
supine position, with the legs hanging off the end of the table. Instruct the patient
to pull one hip into maximum flexion. Observe the contralateral hip to see if it also
flexes off the surface of the table. A normal hip will remain on the table or flex
very slightly. Greater flexion indicates psoas tightness or a flexion contracture.

Abduction and Adduction:
Zero Starting Position
The Zero Starting Position
is with the pelvis level and
the limbs at a 90° angle to
a transverse line across the
anterior superior iliac spines.

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PHYSICAL EXAMINATION OF THE HIP AND THIGH

Abduction

SECTION 5 HIP

To assess hip abduction, a goniometer is needed. Start with the patient
supine and the limbs at a 90° angle to a transverse line across the anterior
superior iliac spines. Abduct the leg until maximum abduction is reached,
which is when the pelvis begins to tilt, a movement that you can detect by
keeping your hand on the patient’s opposite anterior superior iliac spine
when moving the leg. Normal hip abduction in adults is 35° to 50°.

A

B

Adduction
To measure adduction, a goniometer is needed. Start with the patient supine.
Flex the opposite extremity to allow adduction of the affected extremity (A).
Maximum adduction is reached when the pelvis starts to rotate. If flexing the
opposite extremity is impractical, measure adduction by moving the affected
extremity over the top of the opposite limb (B). Normal hip adduction in adults
is 25° to 35°.

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PHYSICAL EXAMINATION OF THE HIP AND THIGH

Internal-External
Rotation in Flexion
In adults, it is more practical
to measure hip rotation with
the hips in flexion; however, this technique should
not be used in children or
when assessment of femoral
torsion or a more precise
measurement of hip rotation
in a “walking” position is
required.
To evaluate hip rotation
in flexion, with the patient
supine, flex the hip and
knee to 90°, with the thigh
held perpendicular to the
transverse line across the
anterior superior iliac spines.
Measure internal rotation by
rotating the tibia away from
the midline of the trunk, thus
producing inward rotation of
the hip (A). Measure external rotation by rotating the
tibia toward the midline of
the trunk, thus producing
external rotation at the hip
(B) (see page 1105).

SECTION 5 HIP

A

B

Muscle Testing
Hip Flexors
To assess the hip flexor
muscles, ask the seated
patient to flex the hip upward
as you resist the effort with
your hand by pushing down
on the distal thigh just above
the knee.

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PHYSICAL EXAMINATION OF THE HIP AND THIGH

Hip Extensors
To assess the hip extensor
muscles, with the patient
prone, place the knee in
approximately 90° of flexion

and ask the patient to extend
the hip as you resist the
effort with your hand by
pushing against the distal
thigh.

Hip Abductors

Hip Adductors
To assess the hip
adductors, with the
patient supine, place your
hand on the medial aspect
of the distal thigh and
ask the patient to adduct
the hip as you resist the
effort.

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To assess the hip abductors,
have the patient lie on the
unaffected side. Ask the
patient to abduct the hip as

you resist the effort with your
hand on the lateral aspect
of the thigh. Note that hip
abductor strength also can
be assessed by using the
Trendelenburg test.

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PHYSICAL EXAMINATION OF THE HIP AND THIGH

Special Tests
Trendelenburg Test
The Trendelenburg test is used to
evaluate hip abductor strength,
primarily the gluteus medius.
Stand behind the patient to
observe the level of the pelvis.
Ask the patient to stand on one
leg. With normal hip abductor
strength, the pelvis will remain
level. If hip abductor strength is
inadequate on the stance limb
side, the pelvis will drop below
level on the opposite side,
indicating a positive test.

FABER Test

SECTION 5 HIP

The FABER (flexion-abductionexternal rotation) test,
sometimes called the figure-of-4
test, Patrick test, or Jansen test,
is a stress maneuver to detect hip
and sacroiliac pathology. With
the patient supine, place the
affected hip in flexion,
abduction, and external rotation
with the patient’s foot on the
opposite knee. Stabilize the
pelvis with your hand on the
contralateral anterior superior
iliac spine and press down on the
thigh of the affected side. If the
maneuver is painful, the hip or
sacroiliac region may be
affected. Increased pain with this
test also may be a nonorganic
finding (see page 165).

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PHYSICAL EXAMINATION OF THE HIP AND THIGH

Log Roll Test

Piriformis Test
With the patient lying on the unaffected side and the hip and
knee flexed to approximately 90°, stabilize the pelvis with one
hand and use your other hand to apply flexion, adduction,
and internal rotation pressure at the knee, pushing it to the
examination table. If a tight piriformis is impinging on the sciatic nerve, pain may be produced in the buttock and even down
the leg.

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SECTION 5 HIP

With the patient supine, internally
and externally rotate the relaxed
lower extremity. Pain in the
anterior hip or groin, particularly
with internal rotation, is considered
a positive result. A positive test
may indicate acetabular or femoral
neck pathology, such as in
osteoarthritis or femoral head

osteonecrosis.

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PHYSICAL EXAMINATION OF THE HIP AND THIGH

Scouring Test
With the patient supine and the
hip flexed and adducted, use
the patient’s knee and thigh
to apply a posterolateral force
through the hip as the femur
is rotated in the acetabulum.
Passively flex, adduct, and
internally rotate the hip while
longitudinally compressing to
scour the inner aspect of the
joint (A). To scour the outer
aspect, abduct and externally
rotate the hip while
maintaining flexion during
longitudinal compression (B).
Pain or a grating sound or
sensation is a positive result
and may indicate labral
pathology, a loose body, or
other internal derangement.

A

B

Hamstring Flexibility

SECTION 5 HIP

With the patient supine
and the contralateral hip
and knee maintained in
full extension, instruct
the patient to flex the hip
to 90° and then, while
maintaining this position,
actively extend the knee
fully. Patients unable to
obtain within 10° of full
knee extension are
considered to have
hamstring tightness.

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Dislocation of the Hip
(Acute, Traumatic)
Definition

ICD-9 Codes

Dislocation of the hip occurs when the femoral head is displaced
from the acetabulum. Because of its strong capsule and deep
acetabulum, the hip is rarely dislocated in adults. The causative
injury usually is high-energy trauma, such as a motor vehicle
accident or a fall from a height. Posterior dislocations (femoral
head posterior to the acetabulum) are far more common than
anterior dislocations, accounting for more than 90% of these
injuries.

831.01
Posterior dislocation, closed
831.02
Obdurator dislocation, closed
831.03
Other anterior dislocation,
closed
831.11
Posterior dislocation, open
831.12
Obdurator dislocation, open

Clinical Symptoms
Dislocation of the hip is a severe injury. Patients have pain and
are typically unable to move the lower extremity. Patients often

have other associated musculoskeletal injuries, and there is a
high prevalence of associated head, intra-abdominal, and chest
injuries.

831.13
Other anterior dislocation, open

Tests
A posterior dislocation results in the affected limb being short,
with the hip fixed in a position of flexion, adduction, and
internal rotation (Figure 1). Assess the status of distal pulses

SECTION 5 HIP

Physical Examination

Figure 1 The clinical appearance of an individual with a posterior

dislocation of the right hip. (Reproduced with permission
from Pollak AN, Barnes L, Cioltola JA, Gulli B, eds:
Emergency Care and Transportation of the Sick and Injured,
ed 10. Rosemont, IL, American Academy of Orthopaedic
Surgeons, 2010, p 1042.)

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DISLOCATION OF THE HIP (ACUTE, TRAUMATIC)

and the function of the sciatic and femoral nerves. Sciatic nerve
palsies are common (8% to 20% incidence), with the peroneal
division of the sciatic nerve most commonly affected.
With an anterior dislocation, the hip assumes a position of
mild flexion, abduction, and external rotation. Femoral nerve
palsy may be present, but nerve injuries are less frequent with
anterior dislocations.
Inspect the extremity for abrasions about the anterior aspect
of the knee or for a knee effusion. Significant knee ligament
injuries are commonly associated with hip dislocations because
most hip dislocations typically occur from a direct blow to the
flexed hip and knee. An associated fracture of the ipsilateral
femur or acetabulum may be present.

Diagnostic Tests

SECTION 5 HIP

Radiographs should include an AP view of the pelvis and AP
and lateral views of the femur, including the knee. In the normal
pelvis, the size of the femoral heads and joint spaces will be
symmetric on AP radiographs. With a posterior hip dislocation
(Figure 2), the affected femoral head appears smaller than the
contralateral, normal femoral head; with an anterior hip
dislocation (Figure 3), the affected femoral head appears larger.

Associated fractures of the acetabulum (particularly fractures of
the posterior wall) are common; in these cases, a CT scan
should be obtained to fully define the fracture pattern
(Figure 4). Following reduction of the dislocation, it is
imperative to ensure that the reduction is completely concentric
without interposition of associated bony fragments or residual
subluxation; if there are any questions regarding these
parameters, a CT scan should be obtained.

Figure 2 Posterior dislocation

of the left hip with an
associated fracture of
the femoral head
(arrow).

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Figure 3 AP radiograph of the pelvis demonstrates an anterior

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DISLOCATION OF THE HIP (ACUTE, TRAUMATIC)

Figure 4 CT scan of the pelvis shows a displaced fracture of the

posterior wall of the acetabulum (arrow).

Differential Diagnosis
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Fracture of the acetabulum or pelvis (pain in the groin and/or
buttock)
Fracture of the hip or shaft of the femur (pain in the groin,
buttock, and thigh)

Adverse Outcomes of the Disease
Osteonecrosis of the femoral head is the most common early
complication and occurs in approximately 10% of patients.
Dislocation of the hip joint tears the hip capsule and disrupts the
blood supply to the femoral head; a delay in reduction or
incomplete reduction increases the risk of osteonecrosis.
Osteonecrosis may not be apparent for as long as 2 or 3 years
after the injury, and thus these patients require follow-up over
several years. Posttraumatic arthritis (secondary to the severe
impact to the cartilaginous surfaces), sciatic or femoral nerve
injury, and chronic pain may occur.

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Treatment

An acute traumatic hip dislocation is an emergency. A reduction
should be performed as soon as possible to decrease the risk of
osteonecrosis. The reduction should be performed in an
atraumatic fashion to avoid damage to the articular cartilage or
fracture of the femoral head or acetabulum. Associated fractures
of the femoral head or intra-articular loose bodies should be
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