Hip Examination

Original Editor - Laura Ritchie Top Contributors - Samuel Adedigba, Kim Jackson, Rachael Lowe, Laura Ritchie, Vidya Acharya, Admin, 127.0.0.1, Kai A. Sigel, Tony Lowe, Naomi O'Reilly and Wanda van Niekerk

Introduction[edit | edit source]

The Hip Joint

The Hip joint is one of the most important joints in the body because of the vital role it plays in locomotion. It is the second largest weight-bearing joint in the body, after the knee joint. It is a ball-and-socket synovial joint formed between the os coxa (hip bone) and the femur. The rounded head of the femur forms the ball, which fits into the acetabulum (socket in the pelvic bone) and ligaments connect the ball to the socket, thereby providing tremendous stability to the joint. Functionally, the hip joint enjoys a very high range of motion.

All of the various components of the hip mechanism assist in the mobility of the joint. Damage to any single component can negatively affect range of motion and ability to bear weight on the joint. In hip injury, as with other traumatic presentations, age distribution is bimodal with high-energy trauma in the younger population and potentially trivial mechanisms of injury in the older population, e.g. a simple fall.[1]

Subjective Examination[edit | edit source]

Patient Intake[edit | edit source]

The first step during the examination is the patient interview, during which the clinician gets a description of the presenting symptoms from the patient. Research suggests patient history plays a vital role in the differential diagnosis of hip pain and, in some cases, can be superior to objective tests and measures[2]. Taking the history is a vital component of the subjective examination as it helps the clinician develop a hypothesis about the mechanism of injury, type of the injured structures and extent of the injury or damage. Details like the location of the pain, nature of the pain, 24-hour pattern of the pain, activities that trigger the pain, pain aggravating and relieving factors etc., are gotten from the patient during the interview. According to new systematic review published in the Archives of Physical Medicine and Rehabilitation, thigh/groin pain and constant back/buttock pain are better indicators of hip OA  than stand-alone tests and reported hip crepitus is a strong indicator of intra-articular hip pathology. [2]

The patient's past medical history, as well as their social/family history is also important as this helps the clinician rule out hereditary conditions. Any surgical histories that are specific to the hip region is also vital, for example, a patient who had a hip joint replacement surgery and is currently complaining of pain at the hip joint. The patient's drug history and current medications they are on should also be documented as well as any allergies they might have. The effects of the condition on the patient' functional status and Activities of Daily Living (ADLs) should be well assessed and documented.

In the elderly it is also worth considering whether a fall was the result of a simple trip, or secondary to another reason, e.g. seizure, cardiovascular trigger, stroke or loss of consciousness. Relevant assessment of the cardiovascular or neurological system may be required with additional tests, e.g. ECG, CT brain.[1]

Special Considerations[edit | edit source]

Red Flags[3]

  • Sudden onset of pain.
  • A history of trauma
  • Any swelling
  • Any deformity
  • An inability to bear weight
  • Any lumps or bumps felt in the groin
  • Night pain
  • Any noticeable groin pulsations
  • Constipation or vomiting
  • Haematuria
  • Fever
  • Lower limb neurological symptoms - weakness, numbness or tingling
  • History of steroid use
  • Testicular swelling
  • Night sweats, unintentional weight loss, appetite loss
  • History of malignancy
  • High-risk sexual activity

Other Flags

It is also important to screen for other (yellow, orange, blue and black) flags as these may interfere with physiotherapy interventions.

Investigations[edit | edit source]

The first investigation of choice in a patient with hip pain following trauma is a hip x-ray. This will be an AP radiograph of the pelvis and a lateral radiograph of the painful hip. Fractures are not always identified on initial x-ray imaging. If there is a clinical concern for a hip fracture, but the x-ray is normal, further imaging is required. Both CT and MRI can be used to look for a radiographically occult fracture - MRI is more sensitive, but CT is usually easier to organise and in many institutions is the second-line investigation of choice.[1]

In complex fractures, CT can be helpful to get additional preoperative information that can be used to plan surgery and aid discussion about consent and prognosis. It is also worthwhile considering that interpretation of a hip x-ray will be complicated in the elderly by the present of other conditions, e.g. secondary osteoarthritis.[1]

Objective Examination[edit | edit source]

Observation[edit | edit source]

Upon conclusion of the patient interview, the clinician proceeds to the objective examination. A Pain VAS is administered to determine the patient's baseline pain level and then the examiner observes and documents the following:

  • Bony deformity / Bony alignment[4]
    1. Gait pattern: There are several types of abnormal gait patterns associated with hip pathologies which the clinician needs to look out for such as Antalgic gait, Trendelenburg gait, Arthrogenic gait and Lurching gait.
    2. Weight Bearing
    3. Balance and Posture
    4. In Standing: Lumbar spine, Level of iliac crests (To rule out pelvic/SIJ dysfunction)
    5. Lying Supine: Leg length (apparent and real leg lengths), External rotation of leg.
  • Colour changes e.g. bruising, inflammation, infection, rash.
  • Muscle wasting, muscle spasm and muscle bulk
  • Swelling, scarring, skin changes (wounds)

Palpation[edit | edit source]

During palpation, the examiner checks[4]:

  • Vascular System – Distal pulses, capillary refill
  • Sensation (Neurological Examination) – Peripheral nerve skin sensation and power
  • Temperature – Infection / Inflammation
  • Swelling – Effusion, Synovial thickening, Extra capsular
  • Tenderness
    • Lumbar spine
    • Pelvis: Iliac crest, ASIS, Pubic rami, Symphysis pubis, PSIS, SIJ, Ischial tuberosity, Sacrum, Coccyx
    • Greater trochanter
    • Inguinal ligament
    • Femoral triangle (hip joint)
    • Knee
[5]

Neurologic Assessment[edit | edit source]

  • Manual Muscle Testing: The strength of the muscle groups surrounding the hip joint, namely the hip extensors, flexors, abductors, adductors, internal and external rotators should be graded and documented.
  • Straight Leg Raise
  • Dermatome Testing
  • Skin sensation test

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Movement Testing[edit | edit source]

The available ranges of motion at the hip joint (Active and Passive) are measured using a goniometer and documented. These measurements serve as baseline readings and help determine if the intervention is yielding results.

Special Tests[edit | edit source]

[6]
[7]
[8]
[9]
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[11]
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[14]

Differential Diagnosis[edit | edit source]

Orthopaedic/rheumatological causes[3]

Pathological causes

Hernias, aneurysms and benign lumps

  • Inguinal lymphadenopathy secondary to multiple causes
  • Inguinal hernia
  • Femoral hernia
  • Femoral artery aneurysm
  • Lipoma
  • Sebaceous cyst

Malignant causes

  • Osteosarcoma
  • Metastatic disease such as prostate cancer or pelvic tumours

Miscellaneous

  • Renal calculus (loin to groin pain)
  • Iliopsoas abscess

Outcome Measures[edit | edit source]

Resources[edit | edit source]

[4]
Related articles
Shoulder Examination - Physiopedia Shoulder Examination Lift off test: Subscapularis The prerequisite for any treatment in the shoulder region of a patient with pain is a precise and comprehensive picture of the signs and symptoms as they occur during the assessment and as they existed until then. Because of its many structures (most of which are in a small area), its many movements, and the many lesions that may occur either inside or outside the joints, the shoulder complex is difficult to assess. Having a systematic and structured approach to the shoulder history and examination ensures that key aspects of the condition are elicited and important conditions are not missed. Information gathered in this process can help guide decisions about the need for special tests or investigations and ongoing management. Note, the evaluation strategies based on clinical tests and diagnostic imaging has been challenged over time, with clinical tests appearing unable to clearly identify the structures that generated pain. The interpretation of diagnostic imaging is also still controversial. [1] Relevant Anatomy[edit | edit source] Shoulder Anatomy The range of motion (ROM) of the arm relative to the trunk does not just come from the glenohumeral joint. Movement also occurs in the acromioclavicular (a.c.) joint, sternoclavicular (s.c.) joint and the upper costosternal and costovertebral joints. Another prerequisite for normal movement is that the scapula should be able to move freely, relative from the dorsal thorax wall. The glenohumeral joint is a multiaxial, ball-and-socket, synovial joint with a relatively shallow socket: the cavitas glenoidalis. The joint depends primarily on the muscles and ligaments for its support, stability and integrity.[2] The ring of firbocartilage labrum (glenoid labrum), surrounds and deepens the glenoid cavity of the scapula about 50%.[3] Stability is mostly offered by the periarticular muscles, that originate from the scapula and insert on the caput humeri. This rotator cuff includes the m.supraspinatus, m. infraspinatus and m. subscapularis. The spina scapulae is a bony ridge on the dorsal side and is the insertion location of the m. trapezius and m. deltoideus. The spina scapulae broadens on the lateral side, shaping the acromion. The space between the acromion and humerus head is called the subacromial space. In this space you'll find the tendons of the rotators and the bursa subacromialis (= bursa subdeltoidea). The tuberculum minus and tuberculum majus are divided by the sulcus intertubercularis, where the tendon of the caput longum m. biceps brachii runs. This tendon continues into into the joint and has its insertion on the top ridge of the cavitas glenoidalis (labrum glenoidale). For a full overview of shoulder anatomy, please read this page on the shoulder. Anamnesis/Medical History[edit | edit source] Anamnesis refers to the client's account of their past medical history. The anamnesis is a significant part of the assessment of patients with musculoskeletal dysfunction. Different anamnestic elements are collected including Characteristics of symptoms Mechanisms of pain Expectations, preferences and psychosocial factors of patients (yellow flags) These elements are all weighted and included in the clinical reasoning process to guide the subsequent physical examination Patient History[edit | edit source] Listen carefully to the patient’s past medical history, this may well rule out red flags and guide the shoulder examination History of presenting condition, how long have the complaints persisted, how did it develop, was there a trauma-moment? Pain distribution and severity: disturbed sleep, can de patient lie on the affected side, degree of hindrance in daily living at home and at work Self care and other treatments the patient has tried Shoulder complaints in the past: course, treatment and result of the treatment Relation between the complaints and work situation Relation between the complaints and sports activities Try to get an impression of the location of the complaints, ask about[edit | edit source] The location of the pain, radiation in the arm Aggravating activities, e.g. difficulty with overhead activities, lifting objects, activities of daily living, sports or recreational activities Painful limitation when moving the upper arm in one or more directions Feeling of instability Added complaints in the neck Questions to ask to determine possible pathologies[edit | edit source] Does moving your neck change your symptoms? Do you ever feel unstable during arm movement? When you do actions with your arms over your head, does this aggravate your pain level? Is it difficult to move your arm? When performing actions with your arms over your head, do your arms feel heavier?[4] Mechanism of Injury[edit | edit source] Asking about the mechanism of any specific injury is critical, particularly about three factors relating to the time of injury: anatomical site, limb position and subjective experiences. Take care to clarify the patient’s description of the anatomical site. A description of the arm position at the time of the injury is also valuable. For example, falling on an abducted and externally rotated arm increases the risk of shoulder dislocation or subluxation. Finally, exploring the subjective experiences of the patient at the time of injury can be useful. For example, a snapping or cracking sound may be related to a bone or ligament breaking; feeling something ‘pop out’ may suggest a joint dislocation or subluxation. Physical Examination[edit | edit source] Clear the Cervical Spine[edit | edit source] The cervical spine can refer pain to the shoulder/scapular region. It is imperative that the cervical spine be screened appropriately as it may be contributing to the patient’s clinical presentation. See Cervical Examination Objective[edit | edit source] Observation[edit | edit source] The key principle with this phase of the shoulder examination is symmetry. The shape, position and function of each shoulder should be relatively similar. Some differences can occur due to shoulder dominance; the dominant shoulder may sit lower and may appear somewhat larger due to larger muscle mass. Also look at position of scapula and or winging and any abnormal postures of swellings/injuries. [5] [6] [7] Palpation[edit | edit source] Palpation of the shoulder region may provider the physical therapist with valuable information. The physical therapist should note the presence of swelling, texture, and temperature of the tissue. Additionally the physical therapist may observe asymmetry, sensation differences, and pain reproduction. Key palpable structures include: Acromioclavicular Joint Sternoclavicular Joint Rotator Cuff Muscle Insertions Long Head of the Biceps Tendon Tenderness and altered sensation (subjective) local or referred Surface temperature, texture (objective) - a hot tense surface may indicate infection, inflammation/synovitis, recent trauma or tumour Swelling - may indicate effusion, tumour, nodule or bone changes Crepitus with movement - occurs in osteoarthritis, tendinopathy and fracture[8] Neurologic Assessment[edit | edit source] A comprehensive neurological examination may be warranted in patients that present with a primary complaint of shoulder pain. The presence of neurological symptoms including numbness and tingling may warrant this examination. Myotomes[edit | edit source] C4 – Shoulder Elevation/Shrug C5 – Shoulder Abduction C6 – Elbow Flexion, Wrist Extension C7 – Elbow Extension, Wrist Flexion C8 – Thumb Abduction/Extension T1 – Finger Abduction Dermatomes[edit | edit source] C4 – Top of Shoulders C5 – Lateral Deltoid C6 – Tip of Thumb C7 – Distal middle Finger C8 – Distal 5th Finger T1 – Medial Forearm Pathological Reflexes[edit | edit source] Hoffmann’s Reflex Inverted Supinator Reflex Deep Tendon Reflexes[edit | edit source] Biceps Brachii – C5 Nerve Root Brachioradialis – C6 Nerve Root Triceps – C7 Nerve Root [9] [10] [11] [12] Movement Testing[edit | edit source] The patient performs active movements in all functional planes for the shoulder. This includes flexion, extension, abduction, adduction and internal and external rotation. Estimate the range of movement or measure with a goniometer and compare the affected with the unaffected shoulder and with the normal expected range.[8][13] Active Range of Motion (ROM)[edit | edit source] Active movements of the shoulder complex[14] Active movements of the shoulder complex ROM Elevation through abduction 170°-180° Elevation through forward flexion 160°-180° Elevation through the plane of the scapula 170°-180° Lateral (external) rotation 80°-90° Medial (internal) rotation 60°-100° Extension 50°-60° Adduction 50°-75° Horizontal adduction/abduction (cross-flexion/ cross-extension) 130° Circumduction 200° Scapular protraction Scapular retration Combined movements (if necessary) Repetitive movements (if necessary) Sustained positions (if necessary) Dysfunction - affecting movements. Which movements are limited, as this can help isolate the problem. Consider the following if movements are limited by: Pain: tendinopathy, impingement, sprain/strain, labral pathology Mechanical block: labral pathology, frozen shoulder (see MRI image to the right) Night pain (lying on affected shoulder): rotator cuff pathology, anterior shoulder instability, ACJ injury, neoplasm (particularly unremitting) Sensation of ‘clicking or clunking’: labral pathology, unstable shoulder (either anterior or multidirectional instability) Sensation of stiffness or instability: frozen shoulder, anterior or multidirectional instability Passive ROM[edit | edit source] May include each of the motions stated in the active ROM section. The therapist may opt to include overpressure to further stress the joint. Muscle Length Assessment[edit | edit source] Assessment of the flexibility of certain muscles may be warranted in patients with shoulder pain. These muscles may include, but are not limited to: Latissimus Dorsi Pectoralis Minor/Major Levator Scapulae Upper Trapezius Scalenes (anterior/middle/posterior) Muscle Strength[edit | edit source] Resistive testing of the shoulder muscles typically includes the following motions: Shoulder Flexion Shoulder Extension Shoulder Abduction Horizontal Abduction Horizontal Adduction Internal Rotation External Rotation Resistive testing of the scapular stabilisation muscles may include: Upper trapezius Middle trapezius Lower trapezius Serratus Anterior Rhomboids Levator Scapulae Joint Mobility Assessment[edit | edit source] Assessment of the mobility of the joint may indicate hypomobility within the joint and/or reproduce symptoms. Glenohumeral Anterior Posterior Inferior Distraction Acromioclavicular Anterior Posterior Sternoclavicular Anterior Posterior Superior Inferior Scapulothoracic Elevation Depression Upward/downward rotation Protraction/Retraction Special Tests[edit | edit source] Several special tests exist for particular disorders of the shoulder. Below are links to the specific pages for each pathology that describe the special tests: Subacromial Related Shoulder Pain [15][16][17] Biceps Tendinopathy [18][19] Labral Tears [20][21][22] Laxity/Instability [23][24][25] Outcome Measures[edit | edit source] Shoulder Pain and Disability Index (SPADI) Disabilities of the Arm Shoulder and Hand (DASH) Constant-Murley Shoulder Outcome Score (CMS) University of Pennsylvania Shoulder Score (U-Penn) Visual Analogue Scale Patient Specific Functional Scale Special Questions[edit | edit source] Patients with shoulder pain should be questioned for the presence of red or yellow flags. A thorough medical history and possibly the use of a medical screening form is the initial step in the screening process. The chart below highlights some of the most common red flag conditions for patients with shoulder pain. Red Flags[edit | edit source] Red flags are sign and symptoms alerting the physiotherapist on a possible presence of a non-musculoskeletal, life-threatening pathology, fracture, infection, tumor and inflammatory rheumatic conditions. Examples include:[1][26] Polymyalgia rheumatica. Often presents as bilateral shoulder pain and weakness. These patients must be assessed for temporal arteritis Acute compartment syndrome. May result from significant limb swelling following an injury or an excessively tight bandage or cast. The pain is disproportionate to the injury. Pulselessness of the limb does not usually occur, or is a very late sign. This condition is a surgical emergency[8] Open fractures Fractures with nerve or vascular compromise Skin, but more particularly joint infections Neoplasia Serious and life threatening conditions that present with symptoms mimicking shoulder pain, such as referred ischaemic cardiac pain Left Shoulder- -MI 68.7% of patients reported shoulder pain during an acute myocardial infarction[27] Yellow Flags[edit | edit source] To assess for yellow flags, if suspected these tools may be used; The Fear Avoidance Belief Questionnaire (FABQ) Depression Screening tools such as the Beck Depression Inventory (BDI) or the Depression Anxiety Screening Scale (DASS) are useful in screening patients for depression. The Pain Catastrophizing Scale, helps determine if the patient is exaggerating their pain and symptoms and the severity of the situations as a whole. Fractures[edit | edit source] Fractures may result from trauma such as falls onto an outstretched hand. These are known as FOOSH injuries. Commonly fractured within the shoulder region are: Humeral Fractures Clavicle Fractures[28] Fractures of the clavicle usually result from a direct blow to the shoulder giving axial compression. The middle 1/3 of the clavicle is most often broken with an incidence of ~80%. Distal clavicle fractures have an incidence of 10-15% and medial clavicle fractures have and incidence of 3 to 5%. Significantly displaced fractures are managed surgically. Mid-shaft clavicle fractures have a lower rate of mal-union and better functional outcomes at one year.[29] A trial of conservative management may be warranted for non-displaced clavicular fractures. Diagnostic Imaging Radiographs of the shoulder can be used to identify cysts, sclerosis, or acromial spurs, osteoarthritis of the acromioclavicular and glenohumeral joint, or calcific tendonitis. Common radiographic views may include (this may vary depending on medical provider): Supraspinatus Outlet View Scapular Y-View Axillary View Anterior-Posterior (AP) View Clinical Picture[edit | edit source] Presentation of different shoulder pathologies Patients with suspected glenohumeral instability or labral pathology may have feelings of “looseness or instability” particularly in abducted and externally rotated positions. Patients with suspected adhesive capsulitis may report intense global shoulder pain initially combined with a progressive loss of range of motion. Patients with suspected subacromial or rotator cuff related impairment may report feelings of weakness, heaviness and/or pain. Shoulder Osteoarthritis - progressive, activity-related pain that is deep in the joint and often localised posteriorly. As the disease progresses, night pain becomes more common This flow diagram provides an aid to diagnosis of shoulder conditions: Template:Clinical Examination - Physiopedia Subjective[edit source] Patient Intake[edit source] Self‐report Performance‐based outcome measures Region‐specific historical examination Special Questions [edit source] Red Flags Yellow Flags Investigations [edit source] Radiological Considerations Objective[edit source] Observation[edit source] Posture Movement Patterns Functional Tests [edit source] Palpation[edit source] supine prone seated Neurologic Assessment [edit source] Movement Testing[edit source] AROM, PROM, and Overpressure Passive Intervertebral Motion Muscle Strength Special Tests[edit source] Cervical Examination - Physiopedia Introduction A primary goal of diagnosis is to match the patient’s clinical presentation with the most efficacious treatment approach. A component of this decision is determining whether the patient is, in fact, appropriate for physical therapy management[1]. To do this there are three essential elements of the examination: Rule out any serious pathological condition that may require referral to a medical practitioner for further investigation or surgical intervention. Identify movement dysfunction, impaired motor control, sensorimotor impairment, and related connective and nerve tissue dysfunction and if possible rule in or out particular conditions. Identify other contributing factors that might affect deviations form expected clinical course of neck pain. Subjective[edit | edit source] Patient Intake[edit | edit source] Taking a detailed patient history is important. Listen carefully to the patient’s past medical history (PMH) and history of present illness (HPI). The narrative given by the patient contains much of the information needed to rule out red flags and guide the cervical examination. When taking the patients history it is also important to ask if they have pain or symptoms in other regions such as their thoracic spine or shoulder. Outcome measures such as the Neck Disability Index or Patient-Specific Functional Scale can also be used at this stage (See outcome measures section) Special Questions[edit | edit source] Patients with neck pain should be questioned for the presence of red flags. A thorough medical history and possibly the use of a medical screening form is the initial step in the screening process. The chart below highlights some of the most common red flag conditions for patients with neck pain. Red Flags Red Flags Cervical Myelopathy Neoplastic Conditions Upper CervicalLigamentous Instability Vertebral Artery Insufficiency Inflammatory or Systemic Disease Cervical Fracture Signs & Symptoms Sensory disturbance of the hands Age over 50 years Occipital headache and numbness Drop attacks Temperature >100 °F If there has been trauma, follow the Canadian C-Spine Rule Hand intrinsic muscle wasting Previous history of cancer Severe limitation during neck active range of motion (AROM) in all directions Dizziness Blood pressure > 160/95 mmHg Unsteady gait Unexplained weight loss Signs of cervical myelopathy Dysphasia Resting pulse>100 bpm Hoffman’s reflex Constant pain not relieved with best rest Post trauma Dysarthria Resting respiration>25bpm Babinski Night pain RA Diplopia Fatigue Clonus Down Syndrome Positive cranial nerve signs Inverted supinator sign Ataxia Hyperreflexia Nausea Bowel and bladder disturbances Multisegmental weakness Multisegmental sensory changes Yellow Flags Yellow flags are factors that increase a patient’s risk for developing long-term disability. Psychosocial factors may be contributing to a patient’s persistent pain and disability, or that may contribute to the transition of an acute condition to a chronic, disabling condition. Some attitudes and beliefs to look out for are.[2] Pain is harmful or disabling  Pain must be eliminated before returning to activity Passive attitudes towards therapy  Patient utilization of extended rest, reduced activity level and withdrawal from daily activities Patient reports of extreme pain intensity High intake of alcohol or other substances The Fear-Avoidance Beliefs Questionnaire (FABQ) is a tool to assess yellow flags among patients. The FABQ predictive validity is debatable, and is best for the FABQ-W when evaluating workers compensation patients.  The overall test-retest reliability is excellent, ICC= .97. Depression screening tools such as the Beck Depression Inventory (BDI) or the Depression Anxiety Screening Scale (DASS) are useful in screening patients for depression. Psychometric properties of the BDI: a cut-off score of ≥5 for screening, Sn = 90.9%, Sp = 17.6 %. A cut-off score of ≥22 for diagnostic utility, Sn = 27.3%, Sp = 90%. The Pain Catastrophizing Scale, helps determine if the patient is exaggerating their pain and symptoms and the severity of the situations as a whole. Cronbach alpha values reported for the total Pain Catastrophizing Scale (PCS) (α=.87) and factor scales (Rumination α=.87; Magnification α=.60; Helplessness α=.87) were found to be satisfactory. The total PCS score showed strong temporal validity[3]. In a patient population with acute whiplash there was found to be a significant moderate correlation between pain pressure threshold and the pain catastrophizing scale as well as cold pain threshold and the pain catastrophizing scale[4]. Investigations[edit | edit source] Radiological Considerations: Diagnostic Imaging Considerations: see Canadian C-spine Rules.  If patient is positive on the rule a referral for imaging is required. Cervical spine radiograph are most commonly utilized to assess for fractures; however cervical CT is more sensitive for ruling out fractures. Patients with rapidly worsening neurological signs and symptoms should be referred for a cervical MRI. Patients with red flags including a history of cancer, possible cervical arterial disease, and possible instability should be referred for diagnostic imaging procedures. Outcome Measures[edit | edit source] Neck Disability Index[5] Contains 10 items (7 related to ADLs, 2 related to pain, 1 related to concentration) Each item is scored 0 – 5 and the total score is expressed as a percentage Higher scores correspond to greater disability Minimal detectable change is 5 (10%). MCID is 9.5 (19%)—Cleland and colleagues for patients with mechanical neck disorders Moderate test re-test reliability  Valid health outcome measure in Pts with cervical radiculopathy ICC for test re-test reliability = 0.68 MCID is 19-20 percentage points The Patient-Specific Functional Scale[5] (PSFS) for patients with neck pain  This self report is a practical alternative supplement to generic and condition-specific measures. Asks patients to list 3 activities that are difficult as a result of their symptoms/injury/disorder The patient rates each activity on a scale of 0 – 10;0 represents inability to perform the activity and 10 represents the ability to perform the activity as well as they could prior to the onset of symptoms The 3 activity scores are averaged for a final score ICC test re-test reliability in patients with cervical radiculopathy is 0.82 MCID is 2.0 points Performance‐based outcome measures[5] Movement or activity limitations associated with the patient’s neck pain and be used to assess the changes in the patient’s level of function over the episode of care. These activities should be measurable and reproducible. This is commonly referred to as an asterisk sign. Have the patient perform an activity that produces their symptoms such as looking over their shoulder as if they were checking a blind spot when driving, and note at which point in the motion symptoms are elicited. After intervention this can be reassessed to see if symptoms are decreased, or range of motion is gained which would indicate an improvement in function. When evaluating a patient with neck pain over an episode of care, assessment of impairment of body function should include measures that can rule in or rule out[1]: neck pain with mobility deficits, including cervical active range of motion, the flexion rotation test, cervical and thoracic segmental mobility tests, and neck pain with radiating pain/cervical radiculopathy, including the upper limb tension test, Spurling's test, distraction test, and the Valsalva test. Cranial cervical flexion and neck flexor muscle endurance tests may be use in assessing movement coordination impairments, and algometric assessment of pressure pain threshold may be useful in staging chronicity of neck pain[1]. Objective[edit | edit source] Observation[edit | edit source] Posture Observe the patient’s posture in standing and sitting. As a part of the examination, postural deviations can be corrected to determine the effect on the patient’s signs and symptoms. Common postural deviations: Protracted cervical spine or forward head posture Protracted shoulder girdle and rounded shoulders Upper Thoracic Spine Kyphotic or Flexed Lordotic or Extended Normal Middle Thoracic Spine Kyphotic or Flexed Lordotic or Extended Normal Movement Tests[edit | edit source] Functional Movement Before anything else ask the patient to demonstrate the functional movement that most easily replicates their symptoms. The movement that the patient demonstrates can give many clues to the main cause of the problem as well as a good performance based outcome measure. Cervical AROM, PROM, and Overpressure[5] Prior to movement testing the examiner asks the patient about baseline symptom location and intensity. The examiner notes any change in location or intensity during the testing and where in the motion they occur. The examiner should assess for the presence of symptom centralisation and peripheralisation during testing. Repeated motions may be utilised as part of this assessment. All cervical AROM tests (Neck flexion, extension, rotation and side-bending) performed with the patient in seated in an upright posture Cervical ROM tests can be measured with an inclinometer. Inclinometer cervical ROM measurements have exhibited reliability coefficients ranging from 0.66 to 0.84 (ICC). A universal goniometer is used to measure cervical rotation if measured in sitting. Passive overpressure may be applied at the end of active motion to assess for pain response and end-feel. Combined motions: Upper cervical flexion and lower cervical extension is assessed with cervical retraction. Upper cervical extension with lower cervical extension is assessed with cervical protraction. The cervical quadrant involves combined cervical extension with ipsilateral rotation and sidebending. Cervical and Thoracic Segmental Mobility (PPIVMs and PAIVMs)[5] The patient is positioned in prone. Cervical and thoracic spine segmental mobility and pain response are assessed. The examiner contacts each cervical spinous process with the thumbs. The examiner applies an oscillatory posterior to anterior force. The examiner can assess mobility unilaterally by performing the same procedure over the cervical articular pillar on each side. The examiner assesses for pain provocation at each segment.  The mobility of the segments is judged to be normal, hypermobile, or hypomobile. Interpretation of mobility is based on the clinician’s perception and experience.  Psychometric data for combined pain provocation and mobility assessment: Sensitivity = 0.82 (negative Likelihood Ratio = 0.23) Specificity = 0.79 (positive Likelihood Ratio = 3.9) Pain ICC = 0.42 – 0.79 (For patients who have cervical neck pain) Presence of upper cervical Joint dysfunction in patients with headaches ICC = 0.78 – 1.0. Passive OA Joint testing (flexion/extension) Patient positioned in supine with head on or off the treatment table Therapist is in standing at the head of the patient Motion testing (Right OA joint) Rotate head 20 – 30 to right side to orient the right facet into the sagittal plane Translate occiput anteriorly on the superior facet of C1 to asses for OA extension restriction Translate the occiput posteriorly to assess for OA flexion restriction. Repeat to the Left side. AA Mobility Testing (Cervical Rotation in Flexion) Cradle head with both hands Contact the posterior aspect of C1 with finger tips Flex cervical spine Assess amount of rotation to each side Maintain flexion while rotating Muscle Strength Testing in supine or seated position. Palpation[edit | edit source] Supine Palpate bilateral sternoclavicular joints for mobility assessment or tenderness. Palpate acromioclavicular joint for mobility assessment or tenderness. Palpate suboccipital muscles, upper trapezius, levator scapula and pectoralis minor to assess shortness or   tenderness. Prone Central and peripheral Cervical and Thoracic Spine Palpate ribs 1 – 7 of the upper and mid thoracic region Ribs 1 - 7 posterior to anterior accessory motion Seated Palpate for tissue texture changes down medial groove of cervical and thoracic spine Palpate for tissue texture changes on either side of the spinous processes of the cervical and thoracic spine Palpate for any scoliotic deviations Neurologic Assessment[edit | edit source] A neurological examination should be performed if the patient reports numbness or tingling in the back, shoulder, or more distal upper extremities, or if the patient has focal weakness that would indicate nerve involvement. Reflexes[2] C5 - C6 – biceps C5 – C6 – brachioradialis C7 – triceps Manual muscle testing Elbow Flexion (C5,C6) Extension (C7) Shoulder Flexion (C5) Extension (C6, C7, C8) Abduction (C5) Wrist Flexion (C6 – 7) Extension (C6 – 7) Finger Flexion (C7 – C8) Extension (C7 – C8 Abduction (T1) Sensory examination C3 – Occiput C4 – Supraclavicular space C5 – Anterior shoulder  C6 – Lateral shoulder C7 – Posterior arm C8 – Phalanxes 4 – 5 T1 – Medial arm and axilla Cranial Nerve Assessment[6] Vestibular and Optic cranial nerve screen for cranial nerves 2,3,4,6 and 8 Snellen Eye Chart to test visual acuity Test each eye separately (covering the untested eye); test at a distance of 20 feet. O’Sullivan, Chapter 8, Examination of motor function Pupillary reaction, (constriction) is tested by shining a light in the left eye and right eye. If there is an absence of constriction this indicates abnormal function of the optic or oculomotor nerve. Extraocular movements are tested by asking the patient to follow a moving finger in a horizontal, vertical and horizontal plane. If they eyeball deviates from it’s normal conjugate position, eye movements are impaired or the patient reports double vision, there is dysfunction of the oculomotor, trochlear and/or abducens nerve(s). Trigeminal Nerve Sensory: Test noxious and light touch sensations on forehead, cheeks and jaw of the patient. Loss of facial sensations or numbness are reported with a trigeminal nerve lesion Motor: Test the muscles of mastication by asking the patient to clench their teeth. Weakness, wasting of muscles or unilateral jaw deviation indicate a trigeminal nerve lesion. Facial Nerve Facial expression is tested by asking the patient to raise eyebrows, frown, show teeth, smile, close eyes tightly and puff out both cheeks. Paralysis is indicated by the patient’s inability to close eye, drooping corner of the mouth or difficulty with speech articulation. Unilateral LMN: Bell’s Palsy (Peripheral nerve injury) Bilateral LMN: Guillain-Barre Unilateral LMN: Stroke Glossopharyngeal and Vagus and Hypoglossal nerve Listen to voice quality and articulation Dysphonia: Hoarseness denotes vocal cord weakness; nasal voice quality indicates palatal weakness. Dysarthria: Poor speech articulation. Spinal Accessory Nerve Have the patient shrug both shoulders upward against resistance. An inability to shrug bilateral shoulders upward against resistance may indicate a lesion to the spinal accessory nerve. Special Tests[edit | edit source] Cranial Cervical Flexion Test[5] The patient is positioned in supine in hook lying with the head and neck in mid-range neutral. Towels may be needed under the occiput to achieve this neutral position. A pneumatic pressure device, such as a pressure biofeedback unit, is inflated to 20 mmHg to fill the space between the cervical lordotic curve and the surface of the table. While keeping the occiput stationary (not lifting or pushing down), the patient performs the CCF in a graded fashion in 5 increments (22,24,26,28 and 30mmHg) and aims to hold each position for 10 seconds. 10 seconds rest is provided between stages. CCF is performed by the patient gently nodding the head as though they were saying “yes” with the upper neck. This motion should flatten the cervical lordosis and subsequently change the pressure in the pneumatic device. While the patient is performing CCF, the therapist palpates the neck to monitor for unwanted activation of more superficial cervical muscles such as sternocleidomastoid.  The test is graded according to the pressure level the patient can achieve with concentric contractions and accurately sustain isometrically. The test is terminated when the pressure is decreased by more than 20% or when the patient cannot perform the proper CCF movement without substitution strategies. A normal response is for the pressure to increase between 26 – 30 mmHg and be maintained for 10 seconds without utilizing superficial cervical muscle substitution strategies. An abnormal response is where the patient: Is unable to generate an increase in pressure of at least 6 mmHg Is unable to hold the generated pressure for 10 seconds Uses superficial neck muscles to accomplish the CCF or Uses a sudden movement of the chin or pushing (extending) the neck forcefully against the pneumatic pressure device. ICC = 0.81, performance index ICC = 0.93 Neck Flexor Muscle Endurance Test[5] The patient is positioned in supine, in hook lying. The chin is maximally retracted and maintained isometrically while the patient lifts the head and neck until the head is approximately 2.5cm (1 in) above the plinth while keep the head retracted to the chest. The therapist focuses on the skin folds along the patient’s neck and places a hand on the table just below the occipital bone of the patient’s head. The therapist gives verbal commands such as “tuck your chin” or “hold your head up” whenever the skin folds begin to separate or the patient’s occiput touches the therapist’s hand. The test is terminated if the skin fold(s) is/are separated due to loss of chin tuck or the patient’s head touches the clinician’s hand for more than 1 second. Reliability Subjects without neck pain: ICC = 0.67 – 0.91, SEM 8.0 – 15.3 seconds Subjects with neck pain: ICC = 0.67, SEM 11.5 seconds Upper Limb Tension Test (ULTT)[5] The patient is positioned in supine. During the ULTT that places a bias towards testing the patient’s response to tension placed on the median nerve, the examiner sequentially introduces the following movements to the symptomatic upper extremity. Scapular depression Shoulder abduction to approximately 90 degrees with the elbow flexed Forearm supination, wrist and finger extension Shoulder lateral rotation Elbow extension Contralateral then ipsilateral cervical side-bending A positive test is indicated by the presence of any of the following findings: Reproduction of all or part of the patient’s symptoms Side-to-side differences of greater than 10 degrees of elbow or wrist extension On the symptomatic side, contralateral cervical side-bending increases the patient’s symptoms, or ipsilateral side-bending decreases the patient’s symptoms Sensitivity = 0.97 Specificity = 0.22 + Likelihood Ratio = 1.3 -Likelihood Ratio = 0.12 Spurling’s Test[5] The patient is seated and asked to sidebend and slightly rotate head to the painful side. The clinician places a compressive force of approximately 7 kg through the top of the head in an effort to further narrow the intervertebral foramen. The test is considered positive when it reproduces the patient’s symptoms. The test is not indicated if the patient does not have upper extremity or scapular region symptoms. Sensitivity = 0.50 Specificity = 0.86 + Likelihood Ratio = 3.50 –Likelihood Ratio = 0.58 Distraction Test (used to identify cervical radiculopathy)[5] The patient is positioned in supine. The examiner grasps under the chin and occiput, flexes the patient’s neck to a position of comfort, and gradually applies a distraction force of up to approximately 14 kg. A positive test occurs with the reduction or elimination of the patient’s upper extremity or scapular symptoms. The test is not indicated if the patient has no upper extremity or scapular region symptoms. Sensitivity = 0.44 Specificity = 0.90 + Likelihood Ratio = 4.40 – Likelihood Ratio = 0.62 Valsalva Test[5] The patient is seated and instructed to take a deep breath and hold it while attempting to exhale for 2 – 3 seconds. #A positive response occurs with reproduction of symptoms. Sensitivity = 0.22 Specificity = 0.94 + Likelihood Ratio = 3.50 – Likelihood Ratio = 0.83 Differential Diagnosis[edit | edit source] 3 diagnostic questions[7] Are the patient’s symptoms reflective of a visceral disorder or a serious or potentially life-threatening illness? This may indicate non-mechanical conditions such as: Cervical Myelopathy Cervical Instability Fracture Neoplastic conditions Vascular compromise Systemic/visceral disease From where is the pain arising? The therapist seeks to understand characteristics about the pain source and thus select appropriate tests and measures early in the physical examination to rule out conditions. What has gone wrong with this person as a whole that would cause the pain experience to develop and persist? The therapist considers what other variables are present that serve to maintain or perpetuate the pain experience such as depression, passive coping, central pain hypersensitivity, and fear. Classification[edit | edit source] ICF Impairment-based category: Neck Pain with Mobility Deficits or ICD categories: Cervicalgia or Pain in the Thoracic Spine[5] Cervical AROM Cervical segmental mobility Thoracic Segmental mobility ICF Impairment-based category: Neck Pain with Headaches or ICD categories: Headaches or Cervicocranial Syndrome[5] Cervical AROM Cervical segmental mobility Cranial cervical flexion test Headache produced or aggravated with provocation of the ipsilateral posterior cervical myofascia and joints Restricted cervical ROM Restricted cervical segmental mobility Abnormal/Substandard performance on the cranial cervical flexion test ICF Impairment-based category: Neck Pain with Movement Coordination Impairments or ICD category: Sprain and Strain of Cervical Spine[5] Cranial Cervical Flexion test Deep neck flexor endurance test Longstanding neck pain (duration >12 weeks) Abnormal/substandard performance on the cranial cervical flexion test Abnormal/substandard performance on the deep flexor endurance test Coordination, strength, and endurance deficits of neck and UE muscles (longus colli, middle trapezius, lower trapezius, serratus anterior) Flexibility deficits of the UE muscles (anterior/middle/posterior scalenes, upper trapezius, levator scapulae, pectoralis minor, pectoralis major) Ergonomic inefficiencies with performing repetitive activities ICF Impairment-based category: Neck Pain with Radiating Pain or ICD category: Spondylosis with Radiculopathy or Cervical Disc Disorder with Radiculopathy[5] Upper Limb Tension Test Spurling’s test Distraction test UE symptoms, usually radicular or referred pain, that are produced or aggravated with Spurling’s maneuver and upper limb tension tests, and reduce with the neck distraction test Decreased cervical rotation (<60 degrees) toward the involved side Signs of nerve root compression Success with reducing UE symptoms with initial examination and intervention procedures ICD diagnosis of Cervicalgia or pain in the thoracic spine associated with the ICF diagnosis of neck pain with mobility deficits: Age <50 years Acute neck pain (duration <12 weeks) Symptoms isolated to the neck Restricted cervical ROM Overview of Hip Assessment - Physiopedia Introduction Hip pain represents a substantial contributor to the global burden of musculoskeletal disability. The complexity of the hip assessment stems from the variety of structures that can generate symptoms, including bones, ligaments, tendons, bursae, and nerves. Furthermore, the interconnected relationship between trunk and hip mobility, combined with the potential for referred pain from both the lumbar spine to the hip, and from the hip to the lower back and medial knee[1], necessitates a comprehensive and systematic approach to assessment.[2] Therefore, rehabilitation providers must have a thorough understanding of hip anatomy and both the subjective and objective assessment of the hip to accurately diagnose and effectively manage these conditions. Subjective History[edit | edit source] The L-M-N-O-P-Q-R-S-T mnemonic outlines the essential aspects to cover when taking a patient’s history. The following subjective reports are useful in pinpointing the source of hip related pain:[3] Symptoms worse with activity Twisting, such as turning, changing directions Seated position might be uncomfortable, especially with hip flexion Rising from seated position often painful (e.g. catching or popping) Difficulty ascending/descending stairs Symptoms with entering and exiting an automobile Dyspareunia (painful sexual intercourse) Difficulty donning/doffing footwear (e.g. shoes, socks, hosiery) L: location of symptoms and level of functional impairment The location of symptoms can help you develop hypothetical diagnoses based on which tissues are in the area. Consider the following pain locations and their associated pathologies:[1][4] Table 1.0. Hip and Groin Pain: Location-Based Differential Diagnosis[1][4] Location of Pain Local Pathology Referred pain sources Clinical Considerations Anterior hip (groin area) Hip adductor strains Iliopsoas strains Osteoarthritis (OA) Femoroacetabular impingement (FAI) syndrome Acetabular labral tears Hip microinstability Femoral head osteonecrosis Femoral neck fractures (if trauma or fall occurred) Hernias (differential diagnosis requiring referral) Lumbar spine pathology Sacroiliac joint dysfunction Femoral nerve entrapment Ilioinguinal nerve entrapment Genitofemoral nerve entrapment "C" sign commonly indicates intra-articular pathology Clinical Pearl: the "C" sign: where the patient cups their hand over the front or side of the hip to show the location of pain. This is because the pain is typically felt deep in the groin, which is a region innervated by nerves from the hip joint, and the "C" shape of the hand represents the area of discomfort.[5] Insidious/gradual onset typical May progress from unilateral to bilateral Screen lumbar spine with repeated movements Assess sacroiliac joint with Sacroiliac Joint Special Test Cluster Consider age: OA in older adults; FAI/labral tears in younger, active patients Pubic region / symphysis Pubic symphysis dysfunction (pubic-related groin pain) Rectus abdominis strain (pubic attachment) Adductor origin pathology Pubic bone marrow oedema Osteitis pubis Hip intra-articular pathology Obturator nerve entrapment Pubic symphysis tenderness has high sensitivity for ruling out pubic-related pain Squeeze test at 0° hip flexion associated with pubic aponeurosis injury "Crossover test" ( also known at the cross-body adduction test) assesses shear forces across pubic symphysis Common in sports with kicking/twisting movements Multiple clinical entities may coexist Lateral hip/buttock Trochanteric bursitis (greater trochanteric pain syndrome) Tendinopathy of hip abductors (gluteus medius/minimus) Tendinopathy of external rotators at greater trochanter Lumbar spine pathology (L4-L5, L5-S1) Sacroiliac joint dysfunction Often related to gluteal muscle weakness May involve lateral hip snapping Consider lumbar radiculopathy differential Assess pelvic girdle function Anterior thigh Quadriceps strain Rectus femoris strain/tendinopathy Femoral nerve entrapment Hip intra-articular pathology (FAI, OA) Lumbar spine pathology (L2-L4 nerve roots) Femoral head osteonecrosis Femoral nerve tension test performed prone with passive knee flexion Consider hip flexor complex assessment (modified Thomas test) Deep progressive inguinal pain with axial loading suggests osteonecrosis Screen for red flags (corticosteroid use, alcohol consumption) Medial thigh/ adductor region Adductor strains (adductor-related groin pain) Adductor tendon origin pathology Obturator nerve entrapment Hip osteoarthritis Pubic symphysis pathology Lumbar spine pathology Most common groin pain entity in kicking sports Adductor origin tenderness has excellent inter-rater reliability (κ > 0.80) Absent adductor tenderness has high sensitivity (93%) to rule out adductor pathology Test resisted adduction at multiple hip positions (0°, 45°, 90° flexion) MRI correlation with clinical findings recommended Posterior hip/deep buttock Piriformis syndrome Deep gluteal syndrome Hamstring origin tendinopathy Ischiofemoral impingement Lumbar spine pathology (particularly L5-S1) Sacroiliac joint dysfunction Hip intra-articular pathology (posterior labral tears) External rotation in neutral hip position primarily limited by posterior impingement between greater trochanter and ischium Screen lumbar spine and pelvic girdle systematically Consider sciatic nerve involvement You should also ascertain how a patient's pain is affecting their ability to perform activities of daily living and other work-, school-, and sport-related tasks.[1] M: medical factors (medications) and mechanism of injury We need to find out what medications a patient is taking (including supplements) and what co-morbidities they may have. We also want to determine when and how the injury occurred (specific trauma, overuse, etc). If there was a traumatic injury that initiated the hip pain, determine whether neurological symptoms (numbness, tingling, sharp or burning pain) were present at the time of trauma.[1] Red flags: sudden onset of severe pain without incident or accident, neurological symptoms at the time of trauma N: Neurological symptoms Neurological symptoms include numbness, tingling, paraesthesias, and sharp or burning pain. When neurological symptoms are present, we need to determine if they are constant or intermittent, if they follow a dermatomal pattern (suggesting lumbar spine origin) or if they follow a peripheral nerve pattern (femoral or sciatic nerve), and if the symptoms are related to specific positions or movements.[1] Red flag: Sock-like numbness affecting multiple dermatomes (also consider multiple peripheral nerve involvement) O: Occupation including limitations Are there any work- or activity-related factors that are relevant? Is there a possibility of overuse? Does the patient perform any repetitive tasks? Consider sport-specific demands and occupational requirements.[1] P: What palliates or provokes symptoms? Find out what increases or worsens symptoms and how long it takes for symptoms to decrease once aggravated. This information provides insight into tissue irritability.[1] Red flags: constant, unrelenting symptoms; symptoms that never calm down regardless of activity or rest; nothing alleviates the symptoms Q: Quality of symptoms / pain Find out if symptoms are sharp, dull, stabbing, aching, or electric shock-like and if there is any numbness, tingling, or a feeling of weakness/clumsiness.[1] Clinical note: Mechanical symptoms including clicking or popping are commonly reported in patients with labral tears (frequently present alongside catching and locking sensations). However, these symptoms also occur in numerous other hip conditions including loose bodies, degenerative joint disease, and osteonecrosis, limiting their diagnostic specificity. The absence of clicking/popping may be more clinically useful for ruling out labral pathology, though specific likelihood ratios for this symptom in isolation are not well-established in the literature. Clicking should be considered alongside other clinical findings (anterior groin pain, positive FADIR test, limited hip rotation) and imaging rather than as an isolated diagnostic indicator.[6][7] R: Radiation of symptoms Questions to ask relating to radiating symptoms:[1] Where do the symptoms radiate to? Are radiating symptoms provoked by activities or position? How long do radiating symptoms last? Red flag: Radiating symptoms affecting multiple dermatomes (remember to check peripheral nerve sensory patterns if more than one dermatome appears to be affected) S: Severity of symptoms Scales such as the Visual Analogue Scale or the Numeric Pain Rating Scale can be used, but also consider how symptoms affect function and activities. Does the patient have to modify or stop activities due to symptoms?[1] Red flag: Sudden onset of severe pain without incident or accident T: Timing of symptoms Find out the timing of symptoms over a 24-hour period and in relation to activity. How do symptoms present from morning through daily activities, work, activities of daily living, and into the evening? This provides a complete timeframe of symptom behaviour.[1] Red flags: symptoms that interrupt sleep or are worse at night; constant, unrelenting pain that remains the same throughout the day regardless of activity Additional Red Flags[edit | edit source] It is important to screen for additional red flags, or constitutional symptoms (symptoms or health issues that affect the entire body rather than a specific part). Red Flags Requiring Immediate Referral to Medical Doctor or Emergency Department:[4] History of trauma with suspected fracture Fever with joint pain Unexplained weight loss Night pain unrelieved by rest Prolonged corticosteroid use (osteonecrosis risk) History of cancer Burning during urination Progressive neurological deficit Self-Assessment Questionnaires for Hip Pain[edit | edit source] Lower Extremity Functional Scale: The most commonly used generalised scale for the entire lower extremity (similar to the DASH for the upper extremity) Hip disability and Osteoarthritis Outcome Score (HOOS): Condition-specific scale for osteoarthritis Hip Outcome Score (HOS): Hip-specific outcome measure International Hip Outcome Tool (iHOT): Hip-specific outcome measure Objective Assessment[edit | edit source] Observation[edit | edit source] Remember to look at the entire lower quarter (hip, knee, and ankle/foot complex) and the lumbar spine. Observe both sides of the body to allow for a comparison. Assessment should include observation of both the weight-bearing joint function and static posture:[1] Table 2.0. Examples of Clinical Observational Assessment for the Hip[1][8] Observational Assessment Important Assessment Areas Posture assessment Seated posture Standing posture Note whether the patient bears weight equally on both legs or shifts weight off one side Observe whether the patient sits evenly on both ischial tuberosities Gait analysis Observe walking pattern Note any antalgic gait, Trendelenburg gait, or compensatory patterns Look for hip hiking to clear the lower extremity (may indicate increased quadratus lumborum tone) Examples of standardised assessments: Timed-Up-and-Go test (TUG) 6-minute walk test Functional screening These functional screens provide information about range of motion limitations, balance deficits, and overall functional capacity before formal testing. Trunk flexion (remember this involves hip flexion in standing) Trunk extension (involves hip extension in standing) Single-leg stance for balance assessment (also evaluates weight-bearing tolerance) Squat assessment (if appropriate for patient's functional level) Sit-to-stand (partial squat) if full squat is not appropriate Palpation[edit | edit source] Table 3.0. Key Palpation Points at the Hip[1][9][10][11] Anterior structures Anterior superior iliac spine (ASIS): compare symmetry between sides; attachment site for sartorius muscle Anterior inferior iliac spine (AIIS): attachment site for rectus femoris Anterior hip joint: located just lateral to the groin; tenderness may suggest osteoarthritis, fracture, or avascular necrosis Inguinal ligament: palpate from ASIS to pubic tubercle Pubic symphysis: assess for symmetry with ASIS; tenderness suggests osteitis pubis or core muscle injury Adductor tubercle and adductor origins: palpate for tenderness, particularly with groin pain Hip flexor muscle group (iliopsoas, rectus femoris): tenderness indicates potential strain or tendonitis Femoral artery: passes under inguinal ligament at its midpoint, halfway between ASIS and pubic tubercle Lateral structures Iliac crest: palpate from anterior to posterior along the rim Greater trochanter: locate and assess for tenderness; most prominent when hip is in neutral rotation Trochanteric bursa: comprises three bursae (gluteus maximus bursa is the principal one); tenderness suggests trochanteric bursitis Gluteus medius insertion: lnserts into lateral portion of greater trochanter Iliotibial band: palpable over lateral aspect of thigh Posterior structures Posterior superior iliac spine (PSIS): located at the level of the second sacral vertebra; visible as dimples; commonly tender with sacroiliac joint dysfunction (Fortin finger sign) Ischial tuberosity: assess pelvic symmetry in sitting and standing Sciatic nerve: located midway between the greater trochanter and ischial tuberosity Piriformis: deep to gluteus maximus Sacrum: palpate midline and sacral sulcus (dimples at PSIS level) Sacroiliac joints: located medial to PSIS; note that the joint itself is anatomically inaccessible to direct palpation due to overlying tissues and its medially facing position Lumbar and lumbopelvic structures Lumbar spinous processes: palpate for tenderness and alignment Iliac crest height: a horizontal line connecting the highest points of both iliac crests crosses the vertebral column at L4-L5 interspace or L4 vertebra Quadratus lumborum: assess for increased tone, particularly in patients demonstrating hip hiking during gait Paraspinal muscles: assess for tenderness and muscle tone The following optional video provides an overview for palpating the major landmarks of the hip region, and gives clinical insights on common pathologies. [12] Neurological Screen[edit | edit source] Dermatomes: assess sensation in lumbar nerve root distributions Myotomes: test key muscle groups for lumbar nerve root function Straight leg raise: screen for sciatic nerve involvement Femoral nerve tension test: screen for femoral nerve involvement[1] Range of Motion[edit | edit source] It is important to assess both active and passive range of motion, including with overpressure. For more information on the range of motion assessment, please see: Assessing Range of Motion. Table 4.0: Hip Range of Motion and End Feel (AAOM = American Academy / Association of Orthopedic Medicine) Movement AAOM Values[13] Research-Based Range[14][15] Typical End Feel[16] Flexion 120° 110–125° Soft tissue approximation Extension 20° 10-30° Capsular/firm tissue stretch Abduction 40° 30-50° Capsular/firm tissue stretch Adduction 20° 20-30° Soft tissue approximation Internal Rotation at 90° hip flexion 45° 30-45° Capsular/firm External Rotation at 90° hip flexion 45° 40-60° Capsular/firm Internal Rotation (neutral/prone) 45° 30-40° Capsular/firm External Rotation (neutral/prone) 45° 40-50° Firm The spinopelvic femoral complex (SPFC) refers to the interaction between the lumbar spine, pelvis, and hips, which together maintain upright posture, trunk balance, and efficient lower limb movement. In healthy individuals, these regions move harmoniously to allow smooth transitions between positions (e.g. sit to stand and vice versa). When standing, the pelvis tilts anteriorly (anteversion), increasing lumbar lordosis and hip extension; when sitting, the pelvis tilts posteriorly (retroversion), reducing lordosis and allowing hip flexion. This dynamic relationship enables the acetabulum to change its orientation: opening anteriorly during sitting to accommodate femoral movement, and closing during standing to provide joint stability.[17] Therefore lumbar spine plays an important role in determining hip range of motion through its influence on hip mobility.[1] A flexible lumbar spine allows the pelvis to rotate freely, thereby reducing the mechanical demand on the hip joint during movements such as flexion and extension. Conversely, when the lumbar spine becomes stiff or fused, pelvic mobility is restricted. This limitation forces the hip to compensate with greater movement, often increasing stress on the joint and predisposing to impingement or instability.[17] Table 5.0. Hip and Trunk Mobility Differentiation[1] Movement Common Hip/Lumbar Spine Combined Movements Flexion assessment Trunk flexion in standing: assesses combined trunk and hip mobility Trunk flexion in sitting: assesses combined trunk and hip mobility Hip flexion in sitting: assesses hip mobility with some trunk involvement Hip flexion in supine: isolates hip mobility as the trunk remains in neutral on the table Extension assessment Trunk extension in standing: assesses combined trunk and hip mobility Hip extension in standing: includes lumbar extension (patient will arch their lower back) Hip extension in side-lying or prone: reduces trunk involvement Clinical note: When assessing hip extension in side-lying, palpate the lumbar spine to ensure you are not getting compensatory lumbar lordosis Resisted Testing[edit | edit source] Assess the strength of the hip flexors (Iliopsoas, Tensor Fasciae Latae, Sartorius, and Rectus Femoris), extensors (Gluteus Maximus, Semitendinosus, Semimembranosus, and Biceps Femoris), abductors (Gluteus Medius and Gluteus Minimus), adductors (Adductor Magnus, Adductor brevis, Adductor Longus, Pectineus, and Gracilis), external rotators (Gluteus Maximus, Piriformis, Quadratus Femoris, Obturator Externus, Obturator Internus, Gemellus Superior, and Gemellus Inferior), and internal rotators (anterior fibres Gluteus Minimus, anterior fibres Gluteus Medius, and Tensor Fasciae Lata).[18] For more information on the strength assessment, please see Assessing Muscle Strength. Accessory Movements / Joint Mobility Testing[edit | edit source] Table 5.0. Accessory Movements of the Hip[1] Type of Movement When to Test / Use Longitudinal distraction General mobility test Useful for pain inhibition or reduction Lateral distraction General mobility test Useful for pain inhibition or reduction Inferior glide Check for hip flexion and abduction mobility Posterior glide Check for hip flexion and internal rotation mobility Anterior glide Check for hip extension and external rotation mobility Special Tests[edit | edit source] Table 6.0. Special Tests for General Hip Pathology [19][20][21][22][23][24] Name of Test and Purpose Procedure Precautions Positive Result Reliability/Validity Log Roll TestPurpose: Screening test for general hip pathology and intra-articular pathology Patient positioned supine Therapist places both hands on the upper thigh Passively rolls the leg internally and externally through available range Avoid excessive force in patients with acute hip pathology Not appropriate in suspected fracture May provoke symptoms in multiple hip conditions (low specificity) Pain provocation or restriction in movement during rolling motion Limited research on diagnostic accuracy Generally used as a screening tool rather than diagnostic test Often positive in multiple hip pathologies, limiting specificity Hip Quadrant Test/Scour TestPurpose: Identify hip joint as source of symptoms; assess for intra-articular pathology, labral tears, or osteoarthritis Patient supine Hip placed into 70° flexion and full adduction Compression force applied through femoral shaft Hip moved from 70° to 140° flexion while maintaining compression Test repeated in abduction Alternative method: full flexion and adduction with compression, then scour into abduction Contraindicated in acute fracture or dislocation Use caution with severe osteoarthritis Avoid in patients with hip replacement May provoke significant pain Reproduction of patient's hip pain during the manoeuvre Moderate sensitivity (59-69%) for intra-articular pathology Poor to moderate specificity Better used in combination with other tests Pain location important: groin pain more indicative of intra-articular pathology Table 7.0. Special Tests for Labral Pathology and Femoroacetabular Impingement (FAI) Name of Test and Purpose Procedure Precautions Positive Result Reliability/Validity FADIR Test (Flexion-Adduction-Internal Rotation) Assess for hip labral tears, femoroacetabular impingement (FAI), or intra-articular pathology Patient supine Hip flexed to 90° Hip maximally adducted and internally rotated Overpressure applied at end range Avoid in acute hip dislocation or fracture Use caution post-operatively Not appropriate with hip replacement May reproduce significant groin pain Groin pain provocation (anterior hip pain suggests labral tear or FAI) High sensitivity: 78-100% for labral tears and FAI (varies by study and reference standard) Low specificity: 8-33% Positive likelihood ratio: moderate More useful for ruling out pathology when negative Sensitivity varies with imaging reference: 8-100% (x-ray), 33-100% (MRI), 90% (CT) Best used in combination with other clinical tests and imaging FABER Test (Flexion-Abduction-External Rotation) / Patrick's Test Screen for hip pathology (labral tears, FAI, osteoarthritis), sacroiliac joint dysfunction, or iliopsoas pathology Patient supine Hip flexed, abducted, and externally rotated (figure-4 position) Lateral ankle placed above opposite patella Pelvis stabilised at contralateral ASIS Hip slowly lowered into maximal abduction and external rotation 3-5 small amplitude oscillations at end range Avoid in acute hip pathology or fracture Use caution with hip replacement Pain may arise from multiple structures (hip, SI joint, lumbar spine) Ensure patient relaxation to avoid muscle guarding Groin pain = intra-articular hip pathology Posterior pelvic/buttock pain = sacroiliac joint dysfunction Restricted range without pain = soft tissue restriction Sensitivity for hip labral tears: 41-97% (highly variable) Specificity: 18-100% (highly variable) For FAI: sensitivity 77%, specificity 17% Inter-rater reliability: moderate (κ = 0.63) 88% sensitive for general hip pathology as screening test More reliable when combined with other tests in a cluster Validity questioned in some systematic reviews due to low quality of evidence Better as screening tool than definitive diagnostic test Fitzgerald Test (Dynamic Labral Test)Assess integrity of acetabular labrum (anterior and posterior portions) Anterior labrum assessment: Patient supine Hip moved from full flexion, external rotation, and abduction into extension, internal rotation, and adduction Posterior labral assessment: Hip moved from full flexion, adduction, and internal rotation into extension, abduction, and external rotation Avoid in acute hip pathology Not appropriate with hip replacement Requires significant hip mobility to perform adequately Pain with or without audible click during the movement arc Limited research on diagnostic accuracy No robust sensitivity/specificity data available Mechanism targets labral compression during dynamic movement Clinical utility requires further validation Table 8.0. Special Tests for Hip Abductor Integrity Name of Test and Purpose Procedure Precautions Positive Result Reliability/Validity Trendelenburg TestAssess integrity and strength of hip abductor muscles (gluteus medius and minimus) Patient standing Asked to stand on one leg for 30 seconds without leaning to either side May hold light support for balance if needed Observe pelvis position Fall risk in patients with poor balance Provide standby assistance Not suitable for non-weight-bearing patients Acute hip pain may limit test performance Pelvis drops on the unsupported (contralateral) side Indicates weakness of hip abductors on the stance (supported) side Trunk lean towards stance side (compensation) Intra-rater reliability: Very strong when assessed with goniometry (ICC 0.95-0.99) Inter-rater reliability: Variable, often poor (κ = 0.22-0.25) Test-retest reliability: Good (κ > 0.75) in chronic low back pain population Sensitivity for hip OA: 55% Specificity for hip OA: 70% Validity concerns: Weak correlations found between hip abductor strength and pelvic drop in healthy populations Poor agreement between practitioner observation and 3D motion analysis Should not be used as primary screening measure for hip abductor strength in populations with strength >30% body weight More reliable in pathological populations than healthy individuals Caution advised when using to assess hip abductor weakness in absence of intra-articular hip pathology Table 9.0. Special Tests for Hip Flexor Length Name of Test and Purpose Procedure Precautions Positive Result Reliability/Validity Modified Thomas TestAssess muscle length of hip flexors (iliopsoas, rectus femoris, tensor fasciae latae, sartorius) Patient stands at end of bed with gluteal folds at edge Patient lies back onto bed while flexing both knees to chest Non-testing leg held in 90° hip flexion to flatten lumbar spine Therapist stabilises ASIS on testing side Testing leg slowly lowered as far as possible Observe position at end range Avoid in acute hip flexor strain or hip pathology Not appropriate with hip replacement (risk of dislocation) Requires adequate knee flexion range Not useful in bilateral hip flexor contractures Careful with patients who have lumbar pathology Inability to achieve normal end position indicates hip flexor tightness (specific muscles identified by movement pattern) Normal findings: Hip extended to neutral (0°) or beyond Hip in neutral or slight abduction Knee flexed to approximately 80° Interpretation of limitations: Hip extension limited + knee ≥80° flexion = iliopsoas tightness Hip abducts = tensor fasciae latae/ITB tightness Hip abducts + flexes + externally rotates = sartorius tightness No hip extension limitation + knee extends = rectus femoris tightness Hip extension limited + knee extends = rectus femoris tightness CRITICAL: Validity depends on pelvic tilt control Without pelvic control: Poor validity, sensitivity 32%, specificity 57% With pelvic control: Much improved validity (r = 0.98) Intra-rater reliability with pelvic control: Excellent (ICC 0.97-0.99) Inter-rater reliability with pelvic control: High (ICC 0.83-0.87) Standard error of measurement (SEM): 2.85° overall; 2.35° with active lumbo-pelvic stabilisation Minimal detectable change: 2.35-4.17° depending on method Pass/fail reliability limited when pelvic position not controlled Essential to maintain neutral pelvic tilt throughout test for valid results Previous reports of poor reliability likely due to inadequate pelvic stabilisation Table 10.0. Special Tests for Femoral Anteversion/Retroversion Name of Test and Purpose Procedure Precautions Positive Result Reliability/Validity Craig's Test (Trochanteric Prominence Angle Test)Estimate degree of femoral anteversion or retroversion Patient prone with knee flexed to 90° Therapist palpates greater trochanter Hip internally and externally rotated until greater trochanter most prominent laterally (parallel to table) Angle measured using goniometer along long axis of tibia relative to vertical Interpretation: Normal: 8-15° internal rotation in adults Increased anteversion = 15° internal rotation Retroversion = <8° or external rotation Requires adequate hip rotation range Examiner experience affects accuracy Difficult in obese patients (palpation challenge) Not appropriate immediately post-operative Anteversion: >15° from vertical Retroversion: <8° or external rotation from vertical Intra-examiner reliability: Good to excellent (ICC 0.74-0.90) Inter-examiner reliability: Poor to moderate (ICC 0.25-0.62; improved to 0.62 with laser-guided goniometer) Correlation with CT: r = 0.93 reported in some studies Correlation with MRI: r = 0.97 for MRI vs lower for Craig's test Validity concerns: Multiple studies show Craig's test fails to explain >75% of variance compared to CT/MRI Hip rotation ROM measurements may provide more reliable estimates of femoral version than Craig's test Better for screening than precise measurement Despite limitations, remains most commonly used clinical test for femoral version Table 11.0. Special Tests for Gluteal Tendinopathy Name of Test and Purpose Procedure Precautions Positive Result Reliability/Validity Greater Trochanter PalpationAssess for gluteal tendinopathy Patient side-lying with testing side uppermost Hips flexed to approximately 60° Therapist palpates over greater trochanter of femur Apply moderate pressure Avoid excessive pressure Other structures may also be tender (trochanteric bursa, ITB) Pain over greater trochanter area Limited research on diagnostic accuracy as isolated test Often used in combination with other tests for gluteal tendinopathy Palpation tenderness alone has poor specificity FADER Test (Flexion-Adduction-External Rotation for Gluteal Tendinopathy)Provocation test for gluteal tendinopathy Passive version: Patient supine Hip placed in 90° flexion Maximal adduction and external rotation applied Resisted version: Same position as passive Add isometric resisted internal rotation May provoke significant lateral hip pain Avoid in acute gluteal tendon tears Differentiate from trochanteric bursitis Pain over gluteal tendons (lateral hip/greater trochanter region) Limited published research on diagnostic accuracy Often used in clinical practice but requires further validation studies Table 12.0. Special Tests for Hip Instability Name of Test and Purpose Procedure Precautions Positive Result Reliability/Validity Abduction-Hyperextension-External Rotation TestAssess for anterior hip instability Patient side-lying with affected hip uppermost Top hip lifted into 30-45° abduction, extension, and external rotation Anteriorly directed force applied through posterior aspect of greater trochanter Risk of subluxation/dislocation in unstable hips Avoid in acute hip dislocation Not appropriate post-hip replacement without surgeon clearance Requires careful technique Anterior hip pain with or without apprehension Limited research on diagnostic accuracy More commonly used in post-operative assessment Clinical experience suggests utility in hypermobile patients Hyperextension-External Rotation TestAssess for anterior hip instability Patient supine at end of bed with legs dangling free Non-testing leg brought to chest and held Therapist at end of bed lowers testing hip into extension Hip externally rotated Fall risk - ensure patient safety Risk of subluxation in unstable hips Not appropriate with hip replacement Avoid in acute pathology Anterior hip pain with or without apprehension Limited published research on sensitivity/specificity Requires further validation Prone Instability TestAssess for anterior hip instability Patient prone Hip passively externally rotated maximally Anteriorly directed force applied over posterior aspect of greater trochanter Risk of subluxation Avoid in acute dislocation Not appropriate with hip replacement without clearance Anterior hip pain provocation Minimal published data on diagnostic accuracy Clinical utility requires further research Additional Resources[edit | edit source] Optional Videos[edit | edit source] The following videos provide an overview of each of the movements of the hip. Please note, the hip adduction video can only be viewed directly from the YouTube website. Please click on the link to view the video. Or click HERE. [25] [26] [27] [28] [29] [30] Elbow Examination - Physiopedia Clinical Presentation Pain and symptoms localized in or around elbow. May present with neurological symptoms local or distant to elbow. Subjective History[edit | edit source] Exact location of pain Timeline-When are the patients reported symptoms at their worst? Mechanism of the injury- In the case of a traumatic event, the mechanism of injury helps guide the diagnosis.[1] For a traumatic injuries, specific symptoms can be highly useful in determining a diagnosis. For example: patient reported numbness and/or tingling in the 5th digit may suggest ulnar neuropathy.[1] Presence of numbness or tingling? Medications? Past Medical History Diagnostic Testing/Imaging? Region Specific Historical Question[edit | edit source] These questions will help guide the examination. For example[2]: Do your symptoms change (better or worse) with any movements of the neck or shoulder?      Does your elbow ever “slip out” or feel unstable?      Does the pain change with gripping activities?      Do you ever experience numbness of tingling in the hand?     Was the elbow hyper extended during the time of injury?      Do you relate the symptoms to a throwing activity?      Environmental and Personal Factors[edit | edit source] During the initial examination, environmental and personal factors should be addressed. These issues could affect healing and return of function after an elbow injury. Table 1 outlines these issues.[1] Table 1. Patient Factors that can affect healing and return of function after elbow injury Diabetes * Immunosuppression * Infection * Multiple site injuries * Tobacco use * Excessive alcohol intake * Complications following injury or surgery(joint stiffness, heterotopic ossification, infection, joint instability) Self-Report Outcome Measures[edit | edit source] DASH (Quick Dash) Patient-Specific Functional Scale PREE and ASES: Patient-rated elbow evaluation (PREE)[1]and American Shoulder and Elbow Society evaluation(ASES)[3]are two similar scales that allow the patient to self-report their pain and disability related to their elbow pathology. The conceptual difference between the two scales is minimal and the correlation between the two scales usually exceeds 0.90.[1] P4: P4 is a 4-item pain intensity measure. The P4 asks patients to rate pain in the morning, afternoon, evening, and with activity over the past 2 days. The P4 can be particularly useful as the elbow is greatly impacted by movement and time of day.[1] SF-36: SF-36 is a generic health form. It is appropriate to address broad areas of health. For individuals with elbow dysfunction, the SF-36 is not a good tool to evaluate change in the clinic for patients with elbow disorders because it is not responsive and specific to the symptoms that the patient is reporting with. This measure can also be very time consuming and difficult to use.[1] Special Questions[edit | edit source] Red and Yellow Flags- Conditions that may require referral to appropriate health care provider.  Red Flags Infection/Inflammation Malignancy Fracture/Dislocation (Positive Elbow Extension Test) Inflammatory Arthritides Abnormal Vitals Abnormal Vascular/Neurological Exam Heterotopic Ossification (Post-Surgical Consideration) Inappropriate progress from treatment made after surgery Yellow Flags Psychosocial factors Passive coping Fear Avoidance Beliefs Investigations[edit | edit source] Normal articulations of the elbow from lateral and antero-posterior views Radiological Considerations The information from the history should be correlated with imaging findings of the elbow when available.[1] Objective[edit | edit source] Observation[edit | edit source] General posture of the upper quarter: Proximal factors should be considered which could predispose the patient to elbow symptoms. Thoracic and cervical spine including kyphosis and forward head Scapula Carrying angle: The carrying angle has a mean value of 10 degrees for men and 13 degrees for women.[4] variability occurs till age of 14 -15 Swelling/ecchymosis/deformities/muscle wasting Triangle Sign Functional Tests[edit | edit source] The goal in performing functional test is to obtain and quantify an asterisk sign to assess and reassess after intervention is performed.  Determination of an asterisk sign-(What activity increases symptoms?)  Pain-Free Grip Strength  Push-off Test: The push off test can be used to quantify a person’s ability to bear weight through the upper           extremity. This can help identify functional/occupational limitations. (ICC=0.31-0.97).[1] Functional Impairment Test-Hand, Neck, Shoulder Arm (FIT-HaNSA): Standardized physical test. Assesses gross activities of the upper extremity. Validation in elbow conditions has not yet been completed. [1] Palpation[edit | edit source] Medial/lateral epicondyle Olecranon and olecranon fossa Radial head Ulnar Collateral Ligament (UCL) of the elbow Soft tissue in upper arm and forearm/wrist for pain provocation, heat, swelling                                                                               Image 2: Anterior Elbow[4]                Image 3: Lateral Elbow[4]                             Image 4: Medial Epicondyle[4] Bicep tendon Marked                        Circle represents lateral epicondyle             Dot represents medial epicondyle Neurologic Assessment[edit | edit source] Reflexes: C5-C7 Myotomes: C5-T1 Dermatomes: C5-T1 Movement Testing[edit | edit source] Active Range Of Motion(AROM)/Passive Range Of Motion(PROM) with or without overpressure Elbow           Flexion           Extension                - Positive Elbow Extension Test may indicate fracture and referral.           Forearm pronation/supination Wrist           Flexion           Extension Cervical, Shoulder and Elbow Range of Motion with or without overpressure           Posterior-anterior glide assessment on cervical/thoracic spine for distal symptoms reproduction as well. Resistive Testing Elbow flexion/extension Forearm pronation/supination Wrist flexion/extension Pain-free grip strength Thumb Fingers Accessory motion testing Humeroulnar traction Humeroradial traction Proximal/distal radioulnar Anterior/Posterior and Posterior/Anterior glides Special Tests[edit | edit source] Cubital Tunnel Syndrome: Elbow Flexion Test Tinel's Sign Ulnar Nerve Compression Test Lateral Epicondylalgia: Passive elbow extension, pronation, wrist flexion (Mill's Test) Resisted wrist extension with radial deviation (Cozen's Test) Resisted middle finger extension (Maudley's Test) Ligamentous Tests: Varus Stress Test Valgus Stress Test Moving Valgus Stress Test Neurodynamic Tests: Median nerve bias: Upper Limb Neurodynamic Test 1 Radial nerve bias:  Upper Limb Neurodynamic Test 2b Ulnar nerve bias:  Upper Limb Neurodynamic Test 3

References[edit | edit source]

  1. ↑ Jump up to: 1.0 1.1 1.2 1.3 Dr Jeremy Jones, Dr Derek Smith and Dr Craig Hacking. Investigation of hip injury (summary). 2018. Available from: https://radiopaedia.org/articles/investigation-of-hip-injury-summary (accessed 29 August 2018)
  2. ↑ Jump up to: 2.0 2.1 Wright AA, Ness BM, Donaldson M. Diagnostic accuracy of patient history in the diagnosis of hip-related pain: a systematic review. Archives of Physical Medicine and Rehabilitation. 2021 Apr 28.
  3. ↑ Jump up to: 3.0 3.1 Pipin Singh. Hip pain in adults - red flag symptoms. 2018. Available from: https://www.gponline.com/hip-pain-adults-red-flag-symptoms/musculoskeletal-disorders/article/1460668 (accessed 30 August 2018)
  4. ↑ Jump up to: 4.0 4.1 4.2 Nathan Humphries. Hip Objective Assessment. Heart of England Foundation Trust Emergency Department. Available from: http://www.heftemcast.co.uk/wp-content/uploads/2014/05/MSK-Objective-Assessments-Hip.pdf (accessed 30 August, 2018)
  5. ↑ BJSM Videos. Hip and Groin Exam (3 of 7): Patient history & palpation. Available from: http://www.youtube.com/watch?v=Y_EZvm0iSno [last accessed 25/01/14]
  6. ↑ BJSM Videos. FADDIR test. Available from: http://www.youtube.com/watch?v=3wK8JtHHAbg [last accessed 25/01/14]
  7. ↑ BJSM Videos. Flexion internal rotation test. Available from: http://www.youtube.com/watch?v=7RvaGasiWXM[last accessed 25/01/14]
  8. ↑ BJSM Videos. Thomas test. Available from: http://www.youtube.com/watch?v=lYbsVNtC1PM [last accessed 25/01/14]
  9. ↑ BJSM Videos. Trendelenburg's Sign. Available from: http://www.youtube.com/watch?v=Cewq53Wc7Jw[last accessed 25/01/14]
  10. ↑ BJSM Videos. Resisted Hip Abduction test. Available from: http://www.youtube.com/watch?v=goJXyusCCzA [last accessed 25/01/14]
  11. ↑ BJSM Videos. Resisted External Derotation Test. Available from: http://www.youtube.com/watch?v=Aq3Ripz4Jjw [last accessed 25/01/14]
  12. ↑ BJSM Videos. Single Adductor Test. Available from: http://www.youtube.com/watch?v=I21LmYARno0 [last accessed 25/01/14]
  13. ↑ BJSM Videos. Squeeze test. Available from: http://www.youtube.com/watch?v=--W5G9lP7pM [last accessed 25/01/14]
  14. ↑ BJSM Videos. Bilateral Adductor Test. Available from: http://www.youtube.com/watch?v=zOSoTz1IwWs [last accessed 25/01/14]
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