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Hip examination frequently appears in OSCEs.  You’ll be expected to pick up the relevant clinical signs using your examination skills. This hip examination OSCE guide provides a step by step approach to examining the hip joint. Check out the hip examination mark scheme here.



Introduction

Wash hands

Introduce yourself

Confirm patient details – name / DOB

Explain examination:
“Today I need to examine your hip joints, this will involve looking, feeling and moving the joints.”

Check understanding and gain consent:
“Does everything I’ve said make sense?  Are you happy for me to examine your hips?”

Ask if the patient has had a hip replacement (if so internal rotation, adduction and flexion greater than 90° should be avoided due to risk of dislocation)

Expose patient appropriately

Position patient standing

Ask if the patient currently has any pain


Look

Look around bed for any aids or adaptationswalking stick / wheelchair 

Inspect patient from all angles

Front – scars / pelvic tilt /quadriceps wasting / foot deformity

Side – assess lumbar lordosis – normal / hyperlordosis

Behind – scoliosisgluteal wasting / pelvic tilt

  • Inspect the lower hip joint, pelvis and lower limb.

Gait

Observe the patient’s gait from multiple angles

Assess speed /smoothness /turning

Note any evidence of antalgic gait or Trendelenburg gait

Assess the patient’s footwear – unequal sole wearing – abnormal gait

  • Observe the patient's GAIT.

Feel

Ask patient to lay down on the examination couch

Palpate the tissues overlying the hip joint for tenderness/warmth – inflammation/infection

Palpate the greater trochanter – tenderness (often indicative of greater trochanteric bursitis)

Assess leg length

Measure apparent leg length – umbilicus to the tip of the medial malleolus

Measure true leg length – anterior superior iliac spine to the tip of the medial malleolus 

  • Assess & compare hip joint temperature.

Move

Active movements

Place your hand under the lumbar spine to detect masking of hip movement by the pelvis / lumbar spine.

Flexion  – “bring your knee towards your chest” – normal ROM is 120°

Passive movements

Flexion – assess the degree of flexion in each hip individually – normal ROM is 120°

 

Internal rotation:

This can be assessed with the hip and knee joint flexed at 90°

  • Rotate the foot laterally 
  • Normal ROM 40°

 

External rotation:

This can be assessed with the hip and knee joint flexed at 90°

  • Rotate the foot medially
  • Normal ROM 45°

 

ABduction – whilst stabilising the contralateral iliac crest, use your other hand to abduct the hip until you feel the pelvis begin to tilt –  normal ROM is 45°

ADduction – whilst stabilising the contralateral iliac crest, use your other hand to adduct the patient’s leg across the midline as far as possible – normal ROM is 30°

  • Assess active HIP FLEXION

Position patient prone

Hip extension (passive):

  • Place a hand on the pelvis to assess for movement
  • Lift one leg at a time to assess range of extension
  • Normal ROM is 10-20°
  • Assess HIP EXTENSION

Special tests

Thomas’s test

1. Place a hand under the patient’s spine.

2. Passively flex the unaffected leg (hips/knees) as far as you are able to.

3. Your hand should detect that the lumbar lordosis is now flattened.

4. With the unaffected leg flexed, the contralateral leg should be flat on the bed

5. Repeat the test to assess the contralateral hip joint.

The test is positive (abnormal) if the affected thigh raises off the bed, indicating a loss of extension in the hip. This would suggest a fixed flexion deformity in the affected hip.

DO NOT PERFORM ON PATIENTS WITH HIP REPLACEMENTS – can cause dislocation!

  • Passively flex both hips as far as possible (ensuring the lumbar lordosis is eliminated).

Trendelenburg’s sign

1. Place hands on the iliac crests on either side of the pelvis.

2. Ask the patient to stand on one leg for 30 seconds.

3. Observe your hands to see which moves up or down.

4. Normally the iliac crest on the side with the foot off the ground should rise up.

5. Repeat the test on the opposite side.

The test is deemed positive (abnormal) if the pelvis falls on the side with the foot off the ground.

This abnormal result suggests weak hip abductors on the contralateral side of the pelvis.

This video demonstrates a positive Trendelenburg’s sign [LINK]

  • Perform Trendelenburg's test.

To complete the examination

Thank patient

Wash hands

Summarise findings

 

Suggest further assessments and investigations

  • Full neurovascular examination of both lower limbs 
  • Examine the joint above and below – lumbar spine/knee
  • Consider further imaging if indicated – e.g. X-ray / CT / MRI

Further reading

Arthritis research UK provides some excellent free guides to musculoskeletal examination and history taking [LINK]


REVIEWED BY 

Mr Tejas Yarashi

Trauma & Orthopaedic Surgeon (ST7)


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