Introduce yourself, confirm the patient’s name and date of birth. Explain the examination, obtain consent and a chaperone and then proceed to wash hands.
Ask whether the patient is in any pain, especially in the hip, and ask them to report if they have pain at any point of the examination. Expose both lower limbs entirely, allowing the patient to keep their undergarments on.
For all orthopaedic examinations remember: Look Feel Move Test.
Check if the patient is comfortable at rest. Assess their body habitus; obesity is an increased risk factor for disease of the weight bearing joints. Look around the bed for any walking aids.
It is recommended that you carry out the exercises which require standing first, before proceeding to examine the patient on the bed.
Assessment of gait
Ask the patient to walk 5m, first using any walking aids, and then without them, if it is possible.
Analysis of gait can help identify whether there are any symptoms of pain, weakness, limited range of movement, instability or discrepancy in leg length that you need to be aware of for the examination.
Antalgic gait: Also known in layman’s terms as a limp. The patient walks in a manner to avoid pain. They will have a shortened "swing phase" and will attempt to reduce weight bearing on the affected leg.
Trendelenburg’s gait: If there is injury to the hip abductors on one side, for example due to trauma to the muscles or the corresponding superior gluteal nerve, then, when the patient raises their contralateral leg (the side without the lesion), their hip will unilaterally drop on the uninjured side (sound side sags). This phenomenon, known as Trendelenburg’s sign, will produce a special gait known as Trendelenburg's gait.
Waddling gait: If both hip abductors are affected then there will be a bilateral hip drop leading to a waddling gait. Patients with proximal myopathy may experience this.
Ask the patient to stand still whilst you move 360° around the them to assess for knee alignment deformities and asymmetry, muscle wasting, swelling and scars.
A good acronym to remember what to look for is DAWSS. This stands for deformity, asymmetry, wasting, swelling or scars.
Alternatively, you can ask the patient to turn 90° at a time so that you do not need to circle them to inspect.
When performing an examination of both limbs, it is usually best practise to start by examining the “good” limb first, as this way you gain an appreciation for what is considered as “normal” for that patient.
Look for any obvious leg length discrepancy. This may be congenital, post-trauma or due to disease during childhood.
Examine the pelvis for a pelvic tilt. This describes the position of the pelvis in relation to its neutral position. The precise causative mechanisms are unclear, but muscle imbalances are believed to play a major role. There are three types of pelvic tilt:
Anterior pelvic tilt: The anterior aspect of the pelvis moves inferiorly whilst the posterior aspect moves superiorly.
Posterior pelvic tilt: The anterior aspect of the pelvis moves superiorly whilst the posterior aspect moves inferiorly.
Lateral pelvic tilt: Lateral tilt of the pelvis such that one side is elevated above the other. This may occur with scoliosis.
Observe the quadriceps femoris muscle for any wasting. Muscle wasting may be due to injury or nerve damage, but most commonly occurs with underuse of the muscle.
Finally check for any incisional scars, which are present following hip surgery.
When examining, you will need to move the patient’s undergarments to have a complete view. Remember to inform the patient of your actions and maintain patient dignity.
If you see a scar, identify its precise anatomical location, size, shape (if nonlinear), contour and appearance of surrounding skin.
There are two main approaches to hip surgery.
Anterior approach: A straight incision is made between the iliac crest and the superior aspect of the thigh. This is a complex surgery which avoids muscle and nerve damage and hence is often described as “minimally invasive” hip surgery. The patient often has a fast recovery, decreased risk of dislocation and good range of movement. The patient must be of a low body weight and have healthy bone.
Posterior approach: A curved incision is made just posterior to the greater trochanter. This traditional surgery is performed by splitting the fascia lata and gluteus maximus muscle, followed by the external rotators of the hip. This enables the surgeon to have a much better view of the acetabular joint and hence can be performed in obese patients or those with complex disease.
Other techniques may involve a lateral, anterolateral or posterolateral approach, or may attempt minimally invasive technique with a posterior approach.
This will give a better view of some incisional scars.
Observe the gluteus maximus, medius and minimus for any wasting. Once again, check for any scars.
At this point, whilst the patient is standing, you may wish to perform one of the “special tests” and check for Trendelenburg’s sign.
Set the bed flat and ask the patient to lay down with their knees fully extended. Once again look for any muscle wasting and any obvious leg length discrepancy. Perform a closer inspection for any swellings or scars. Swelling at the hip is suggestive of hip bursitis.
Inflammation of any of the bursa (fluid-filled sac) in the area surrounding the acetabular joint. This may be caused by muscle overuse or inflammatory pathologies such as rheumatoid arthritis and osteoarthritis.
Assessment of leg length discrepancy
It is important to distinguish between a true leg length discrepancy and a false one, the latter of which may be due to a lateral pelvic tilt.
Use a measuring tape on each limb to compare the distance between the anterior superior iliac spine and the medial malleolus. This distance is the true leg length, and therefore if there is a difference then there is a true leg length discrepancy.
Next, record and compare the distance between the xiphisternum and the medial malleolus on either limb. If there is a difference, and the true leg lengths are the same, then there is a false leg length discrepancy, which is most likely due to a lateral pelvic tilt.
Assessment of temperature
Using the back of your hands, palpate both hip at the same time. Crudely assess for any increase in temperature on either side, as this may suggest an underlying inflammatory process such as septic arthritis, or reactive arthritis.
Septic arthritis is joint inflammation due to infection, most commonly by bacteria such as staphylococci, streptococci or Neisseria gonorrhoeae. The joint will be warm, painful and swollen, with the patient often having a fever. The joint pain can be so severe that the patient is unwilling to move it.
Reactive arthritis is a sterile joint inflammation which occurs due to a bacterial infection taking place elsewhere in the body. The infection will result in cross-reactivity resulting in a warm, painful and swollen joint. Often there will be multiple extra-articular features such as conjunctivitis or urethritis which are also due to cross-reactivity.
Palpate the greater trochanter on either side for any tenderness. If present, this suggests trochanteric bursitis, inflammation of the bursa at the greater trochanter.
Range of movement
Test the active range of movement of each hip, remembering to start with the “good” hip.
Flexion: Ask the patient to bring their knee towards their chest. Expect an acute angle of 60° or lesser
Extension: Ask the patient to completely straighten out their limb and then press your hand down into the bed.
Passively move each limb individually with one hand, attempting to elicit maximum flexion.
Next flex the knee joint to 90°. Keep one hand on the knee and the other on the patient’s heel in order to assess the rotation of the hip. Start with the “good” hip.
Internal rotation: Rotate the patient’s foot laterally such that the knee points medially. There should be roughly 45° of internal rotation.
External rotation: Rotate the patient’s foot medially such that the knee points laterally. There should be roughly 45° of external rotation.
Straighten out both limbs, and again starting with the “good” hip, place one hand on their ankle and the other on their contralateral iliac crest. Assess both abduction and adduction at each hip.
Abduction Move the ankle laterally until the pelvis begins to tilt. Expect up to 45° of abduction.
Adduction: Move the ankle medially over the other limb until the pelvis begins to tilt. Expect up to 25° of adduction.
Finally ask the patient to lie prone and assess hip extension, starting with the “good” hip. Place one hand on the ankle and the other on the pelvis. Lift the limb. Expect up to 20o of extension.
You may wish to perform the special test “Thomas’ test” before assessing extension in order to minimise patient discomfort.
With the patient lying flat on the bed, place one hand below the lumbar spine. This minimises movement of the lumbar spine and the risk of a false positive.
Passively flex the “good” hip to full flexion and observe the contralateral limb. The limb should remain flat on the bed. If the thigh raises off the bed, then this suggests a fixed flexion deformity of the hip in that contralateral limb.
Repeat Thomas’ test by flexing the remaining hip.
Be aware that Thomas’ test may cause dislocation of the hip in patients who have had a hip replacement and therefore should not be performed in these patients.
A deformity in which the acetabular joint is fixed in a flexed position. This may be caused by inflammatory pathologies such as osteoarthritis.
Perform Trendelenburg’s test to assess the functionality of the hip abductors, the gluteus minimus and medius. To do this, begin by requesting the patient to stand, whilst you stand directly facing them. Ask them to place their hands on your shoulders for stability.
Using your index and middle fingers, palpate the patient’s left and right anterior superior iliac spines at the same time. Ask the patient to raise one leg and feel for a lateral pelvic tilt. Do the same with the other leg. If the ipsilateral pelvis drops when the leg is raised, that means that there is a defect in the abductor muscles, or otherwise the superior gluteal nerve which innervates them, on the contralateral side.
The phrase “sound side sags” is a reminder that when there is failure of hip abduction, it is the intact side, the sound side which will have hip drop.
Conclude your examination and offer to help the patient get dressed. Wash your hands. Offer to take a full history, examine the spine and knee, look at any old radiographs and assess the neurovascular status of each lower limb.
When assessing each other, please click on each list item as you go along. Doing so will turn the list item green. Make careful note of any steps missed at the end.
We recommend completing any examination or procedure in under 10 minutes, but you can adjust the timer to suit your needs.
Introduction: “Hello, I’m SimpleOSCE and I am a medical student. I've been asked to examine your hip today, would that be ok? Can I confirm your name and DOB? Thank you.”
"For the purpose of this examination the examiner will act as a chaperone."
Ask if the patient is in any pain and identify which is their “good” and “bad” hip.
Wash your hands.
For all steps, where appropriate, examine the “good” knee first.
Assess the patient’s body habitus and inspect around the bed for any paraphernalia such as walking aids.
Ask the patient to walk 5m and assess gait.
With the patient standing, observe for any DAWSS (deformity, asymmetry, wasting, swelling or scars).
Perform a closer inspection of the hips with the patient lying flat.
Use a measuring tape to record the true and false leg lengths.
Using the back of your hands, crudely assess the temperature of each hip.
Palpate the greater trochanter for tenderness.
Assess active hip flexion and extension.
Assess passive hip internal and external rotation.
Assess passive hip abduction and adduction.
Assess passive hip flexion and extension.
Special tests ("test")
Perform Thomas’ test to look for a fixed flexion deformity.
Perform Trendelenburg’s test to assess the hip abductors.
"To complete my assessment I would like to examine the spine and knee joints, look at any old knee radiographs and assess the neurovascular status of each lower limb."
Patient manner: Enquire about pain at all appropriate points of the examination.