Quick Guide to the Hip Pain
John Port, MD
Hip exam:
Flexion - start supine, knee at 90 degrees. Last 45 degrees to chest uses pelvic and lumbar joints
Lateral/external rotation – normally up to 60 degrees
Medial/internal rotation – normally up to 45 degrees, movement most limited by OA, can test prone with knees
flexed and pushing feet apart
Abduction
Adduction
Extension - 1st movement affected by OA, tested while pt prone
Resisted movements
Resisted straight leg raise – tests rectus femoris and sartorious
Resisted flexion – hip and knee and 90 degrees, iliac fossa pain is iliopsoas pathology
Resisted lateral/external rotation – tests for piriformis syndrome (sciatica-like)
Resisted adduction - - pain with rider’s strain in athletes, or pubic bone fracture/metaplasia
Differential Diagnosis
●Anterior or “in the Groin” Hip Pain
Î reproduced by active straight leg raise
Iliopsoas tendonitis - pain w/ FABER test and resisted flexion
Rectus femoris injury – no pain with FABER test, pain with Ely test
OA – pain with passive rotation, anterior hip tenderness
Inflammatory arthritis - often multiple joints
Septic arthritis – more sudden or severe than OA
AVN of femoral head
Fracture or stress fracture – externally rotated, anterior tenderness of hip capsule
●Lateral Hip Pain
Î near greater trochanter
Iliotibial band contracture- tightness to Ober’s test, crepitation
Trochanteric bursitis – tenderness with deep palpation, “the greater pretender”,
Often not the primary disorder, but may respond to treatment anyway
Gluteus medius tendontitis – tenderness proximal to greater trochanter
●Posterior Hip Pain
Î radiates to buttock
Piriformis tendonitis or syndrome – tenderness near hook of greater trochanter,
+piriformis test
Gluteus maximus tendonitis – tenderness at inferior aspect of gluteus maximus
Herniated lumbar disc – sciatic notch tenderness, pain with nerve tension
Spinal stenosis – pain with extension of lumbar spine, loss of lordosis
Sacroiliac joint dysfunction – tenderness, pain w/ FABER test
●Hip pain presenting as leg or knee pain “false localization”
Selected Hip Tests
FABER (Flexion ABduction External Rotation) Test, a.k.a Patrick’s test - with patient supine, limb to be
examined is guided to a cross-legged (figure 4) position resting just proximal to contralateral knee. Press on
crossed knee while applying counterpressure on opposite anterior superior iliac spine. Posterior hip pain indicates
SI joint pathology. Anterior hip pain indicates hip arthritis. Iliopsoas sign – pain with FABER test, indicative of
irritation of iliopsoas sheath.
Ely test – with pt prone and knees extended, examiner passively flexes knee. With a tight rectus femoris, knee
flexion produces an involuntary flexion on hip, causing buttocks to rise off table. Effect of rectus femoris crossing
both hip and knee joints.
Ober’s test – with patient lying in lateral decubitus position and the side to be tested facing up, flex knee to 90
degrees, abduct hip 40 degrees, and extend to its limit while stabilizing hip with opposite hand. Then, gently
adduct hip toward table to touch thighs together. Inability to adduct hip past midline indicates contracture of
iliotibial band.
Piriformis test – with patient in lateral decubitus position and the side to be tested facing up, flex hip at 45 degrees
and knee at 90 degrees. Stabilize pelvis with one hand. Press flexed knee downward, internally rotating hip. Pain
is associated with tight piriformis or tendonitis. If pain radiates like sciatica, suspect piriformis syndrome
References:
Orient JM. Sapira’a Art and Science of Bedside Diagnosis, 3rd ed. 2005
Reider BR. The Orthopaedic Physical Exam. 2005