Updated by Ahmed Dinah, May 2004
Patient must be suitably undressed (down to underwear)
First examine patient standing and then lying down.
Look, feel, move and special tests.
1. PATIENT STANDING
Look
- Front and back of pelvis/hips and legs: any ischaemic or trophic changes
- Swelling (e.g. lipoma) Scars (previous surgery)
- Sinuses (infection/neuropathic ulcers)
- Wasting (old polio, Carcot-Marie-Tooth) or hypertrophy (e.g. calf pseudo-hypertrophy in muscular dystrophy)
- Deformity (leg length inequality, pes cavus, scoliosis)
Feel (Not a lot!)
- Assess any swellings
- Assess pelvic tilt by palpating iliac crests
Move
- Gait:
- Trendelenburg (pelvic sway/tilt, aka waddling gait if bilateral)
- Broad-based (ataxia)
- High-stepping (loss of proprioception/drop foot)
- Antalgic (mention "̢ہ"with reduced stance phase on left/right side)
- Smooth progression of phases of gait cycle: stance, toe-off, swing and heel-strike
- In-toeing (persistent femoral anteversion: most PFA is not clinically significant as both Monica Selles and Andre Agassi manage quite well with theirs!)
- Appropriate stride length
- Sufficient flexion/extension at hip/knee ankle and foot: Any fixed contractures?
- Observe arm-swing and balance on turning around
- Trendelenburg test/sign:
- Make sure pelvis is horizontal by palpating iliac crests/ASIS.
- Ask patient to stand on one leg and then on the other.
- Assess any pelvic tilt by keeping an index finger on each ASIS.
- Normal (Trendelenburg negative): In the one-legged stance, the unsupported side of the pelvis remains at the same level as the side the patient is standing on. In fact, the unsupported side may even rise a little, because of powerful contraction of hip abductors on the stance leg.
- Abnormal (Trendelenburg positive): In the one-legged stance, the unsupported side of the pelvis drops below the level as the side the patient is standing on. This is because of (abnormal) weakness of hip abductors on the stance leg. The latter hip joint may therefore be abnormal. In addition, the patient may try to compensate for this pelvic tilt by swinging his/her torso away from the unsupported side, i.e. towards the abnormal hip.
If balance is a problem, face the patient and ask them to place their hands on yours to support him/her as he/she does alternate one-legged stance. Increased asymmetrical pressure on one hand indicates a positive Trendelenburg test, on the side of the abnormal hip.
A 'delayed' Trendelemburg has also been described, where the pelvic tilt appears after a minute or so: this indicates abnormal fatiguability of the hip abductors.
- Romberg's test (for sake of completeness!)
This assesses proprioception/balance (dorsal columns of spinal cord/spino-cerebellar pathways).
Ask the patient to stand with heels together and hands by the side (Remember: heels together). Ask the patient to close his/her eyes and observe for swaying for about 10 seconds. Most people sway a bit but then quickly decrease the amplitude of swaying. If however, the swaying is not corrected, or the patient opens the eyes or takes a step to regain balance, Romberg's test is positive. When doing this test, stand facing the patient with your arms outstretched and hands are at the level of the patient's shoulders to catch or stabilise him/her in case of a positive Romberg's test. DO NOT LET THE PATIENT FALL!
2. PATIENT LYING DOWN
Look
- Observe the patient climb onto the examination couch, assessing hip/knee/ankle flexion and extension.
- Assess attitude of joints for any fixed flexion deformity.
Feel
- Assess any swellings.
- Palpate the groin, and greater trochanter area for tenderness.
- Measurement can be done here or at the end.
- Measure true and apparent leg lengths (ASIS to medial malleolus, and then umbilicus or xiphisternum to medial malleolus). This is inherently inaccurate, especially if you can't find the ASIS or medial malleolus because of generous adipose tissue. Also, many people have asymptomatic leg length inequality of up to 1cm.
- If there is a true leg length discrepancy, determine which bone/segment of the lower limb is short.
- It may be below or above the knee (See Galeazzi test below).
- If above the knee, it may be above or below the greater trochanter. Drop a perpendicular from the side of the ASIS and measure distance from greater trochanter to this line.
- If above the trochanter, it may be the femoral neck (varus/valgus neck) or head (DDH): Don't forget to ask yourself "Is the hip in joint?" as a dislocated hip will cause a positive Trendelenburg and leg length inequality. It is difficult to do Ortolani or Barlow's test in older children and well nigh impossible in adults! However, inability to feel a femoral pulse on one side may indicate that the femoral head is out of the (true) acetabulum.
Move
1. Galeazzi test (If leg length discrepancy has been detected on measurement)
Ask the patient to flex hips to about 45 o and knees to about 90 o . Make sure the heels are together on the couch, with medial malleoli touching. Look at the knees from the side to see if they are at the same level. If one is proximal to the other, there is femoral shortening; if one is distal to the other there is tibial shortening.
2. Range of movements: Patients can appear to have good range of movements in spite of stiff hips, by tilting the pelvis. To detect this 'trick' movement, place a finger on the ASIS contralateral to the hip being examined: true hip movement ends when the pelvis begins to move (similar to differentiating true gleno-humeral from scapular movements in the shoulder)
- Flexion can be assessed with the patient supine, but extension is best assessed with the patient in the lateral position.
Can the patient flex hip in a straight line or does the leg roll into external rotation with flexion? This may be a retroverted femoral neck or a slipped proximal femoral epiphysis.
- Internal and external rotation can be assessed with the hip in extension (watch patella, not foot) or in flexion (flex knee and use tibia as goniometer).
Rotation is often the first movement to be limited by pain in degenerative/inflammatory conditions
Femoral neck anteversion presents with limited external rotation (can't sit cross-legged) and increased internal rotation (television position), allowing patellae to 'kiss' (hip extended) or allowing flexed knees to touch couch. Internal and external rotation can be done with the patient prone, but beware not to confuse internal and external rotation. In the prone position, thigh-foot angle (tibial torsion) can also be assessed.
- Abduction/Adduction
Remember to distinguish true hip movements from pelvic tilt.
- Thomas test: To detect fixed flexion deformity of the hip
FFD of the hip means that the patient cannot lay the back of the thigh on the couch when resting supine, but this can also be due to a FFD on the knee. If the knee has no FFD, the patient can lay the leg flat on the couch by a trick movement of 'extension' of the pelvis, resulting from increased lumbar lordosis. Abolishing this lumbar lordosis will therefore unmask this FFD, and this is the basis of the Thomas test.
Place your hand behind the small of the patient's back, between it and the couch. There is normally a small gap here due to normal lumbar lordosis. Abolish the lumbar lordosis by asking the patient to flex the hip ("̢ہ"Bring you knee up to your chest and hold it there with your hands, please), and feel the lumbar spine flatten out onto your hand. When you are happy that the lumbar spine is flat, see if the patient's other knee is flat on the couch. If not, measure the angle of (fixed) hip flexion. Then repeat the test asking the patient to clasp his/her other knee up against his/her chest and observe for FFD in the previously flexed hip. (NOTE: Tight trousers will give a false impression of FFD, so make sure the patient is undressed to underwear!)
Finally, it is often worth examining the back in patients with any lower leg problem.
Trendelenburg Test from: Hardcastle & Nade. JBJS(B): 67-B(5):741-6
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