MusculoSkeletal Exam

the iliotibial band places too great a functional demand on the remaining muscular soft tissues (gluteus medium, gluteus minimus, hip capsule) to efficiently stabilize the pelvis during unilateral support stance.

Observation

The examination should begin in the waiting room before the patient is aware of the examiner’s observation. Information regarding the degree of the patient’s disability, level of functioning, posture, and gait can be observed. The clinician should pay careful attention to the patient’s facial expressions with regard to the degree of discomfort the patient is experiencing. The information gathered in this short period can be very useful in creating a total picture of the patient’s condition.

Note the manner in which the patient is sitting in the waiting room. If the patient is sitting reclined posteriorly, he or she may have decreased range of motion in hip flexion. If the patient is leaning to one side, this may be due to pain in the ischial tuberosity secondary to bursitis; sacroiliac dysfunction; or radiating pain from the low back. Pain may be altered by changes in position so watch the patient’s facial expression to give you insight into their pain level.

Observe the patient as he or she assumes the standing position. How difficult is it to go from flexion to extension? Can the patient evenly distribute weight between both lower extremities? Once the patient starts to ambulate, a brief gait analysis should be initiated. Note any gait deviations and whether the patient requires or is using an assistive device. Details and implications of gait deviations are discussed in Chapter 14.

Subjective Examination

The hip is an extremely stable joint. Therefore, complaints and dysfunctions are usually limited to problems relating to trauma or deterioration. You should inquire about the nature and location of the complaints, their duration and intensity. The course of the pain during the day and night should be addressed. This will give you information regarding how the pain responds to changes in position, activity, and swelling.

Chapter 11 The Hip

The patient’s disorder may be related to age, gender, ethnic background, body type, static and dynamic posture, occupation, leisure activities, hobbies, and general activity level. It is important to inquire about any change in daily routine and any unusual activities that the patient has participated in. If an incident occurred, the details of the mechanism of injury are important to help direct your examination.

The location of the symptoms may give you some insight into the etiology of the complaints. Pain that is located over the anterior and lateral aspects of the thigh may be referred from L1 or L2. Pain into the knee may be referred from L4 or L5 or from the hip joint. The patient may complain about pain over the lateral or posterior aspect of the greater trochanter, which may be indicative of trochanteric bursitis or piriformis syndrome. (Please refer to Box 2.1, p. 18 for typical questions for the subjective examination.)

Paradigm for osteoarthritis of the hip due to congenital hip dysplasia (CDH)

A 40-year-old female patient presents with a complaint of left groin pain. She gives no history of injury now or in the past. She was the product of a breech birth and achieved normal developmental milestones. About 1 year ago she began to notice episodic discomfort in her left groin which radiated to the inner aspect of her thigh. Pain was in proportion to her level of weight bearing activity. She was beginning to notice a slight limp on walking more than 15 minutes or standing for more than 30 minutes. She is having difficulty entering and exiting her new sports car; and has difficulty in cutting her toenails. She reports no pain at rest, but does report stiffness on arising in the morning and after prolonged periods of sitting. She does not perceive any noises with movement; and does not report symptoms of “pins and needles” or tingling in the lower extremity. There are no other family members so affected, and she has no other significant medical history.

Physical exam demonstrates a well developed, well nourished woman who walks with a slight abductor limp. Her stride lengths are equal as are her leg lengths. She uses no assistive devices. She has a positive Trendelenburg sign, with no significant weakness in either lower extremity. She mounts and dismounts from the examining table easily and independently. Her musculoskeletal exam is otherwise unremarkable except for a significant lack of internal and external rotation of the left hip.

X-rays confirm a markedly shallow acetabulum with narrowing of the articular “space” and periarticular osteophyte formation.

This is a paradigm for secondary osteoarthritis of the hip because of:

The patient’s young age Her being female

The involvement of the left hip The history of breech birth

No history of trauma or excessive loading to the hip

Gentle Palpation

The palpatory examination is started with the patient in the supine position. You should first examine for areas of localized effusion, discoloration, birthmarks, open sinuses or drainage, incisional areas, bony contours, muscle girth and symmetry, and skinfolds. You should not have to use deep pressure to determine areas of tenderness or malalignment. It is important to use firm but gentle pressure, which will enhance your palpatory skills. If you have a sound basis of cross-sectional anatomy, you will not need to physically penetrate through several layers of tissue to have a good sense of the underlying structures. Remember that if you increase the patient’s pain at this point in the examination, the patient will be very reluctant to allow you to continue, or may become more limited in his or her ability to move.

Palpation is most easily performed with the patient in a relaxed position. Although palpation can be performed standing, the supine, side-lying, or prone positions are preferred for stability and ease of examination.

Anterior Aspectcthe Patient is

Positioned in Supine

Bony Structures

Iliac Crest

The iliac crest is superficial, very prominent, and easy to palpate. Place your extended hands so that the index fingers are at the waist. Allow your hands to press medially and rest on the superior aspect of the iliac crests. Iliac crests that are uneven in height may be due to a leg length difference, a pelvic obliquity, a bony anomaly, or a sacroiliac dysfunction (Figure 11.4).

Iliac Tubercle

The iliac tubercle is the widest portion of the iliac crest. After you have located the crest, palpate anteriorly and medially along the outer lip. You will find the widest portion approximately 3 in. from the top of the crest (Figure 11.5).

Anterior Superior Iliac Spines

Place your hands on the iliac crests and allow your thumbs to reach anteriorly and inferiorly on a diagonal toward the pubic ramus. The most prominent protuberance is the anterior superior iliac spine. Place your thumb pads in a superior orientation so that

Iliac crest

L4

L5

Figure 11.4 Palpation of the iliac crest.

Iliac tubercle

Figure 11.5 Palpation of the iliac tubercle.

they can roll under the anterior superior iliac spines for the most accurate determination of position. This area is normally superficial but can be obscured in an obese patient. Differences in height may be due to an iliac rotation or shear (Figure 11.6).

Anterior superior iliac spine

Figure 11.6 Palpation of the anterior superior iliac spines.

Umbilicus

Chapter 11 The Hip

Pubic Tubercles

Place your hands so that your middle fingers are on the umbilicus and allow your palms to rest over the abdomen. The heel of your hands will be in contact with the superior aspect of the pubic tubercles. Then move your finger pads directly over the tubercles to determine their relative position. They are located medial to the inguinal crease and at the level of the greater trochanters. The pubic tubercles are normally tender to palpation. If they are asymmetrical either in height or in an anterior posterior dimension, there may be a subluxation or dislocation, or a sacroiliac dysfunction (Figure 11.7).

Greater Trochanters

Place your hands on the iliac crests and palpate distally along the lateral aspect of the pelvis until you reach a small plateau. Allow your extended hands to rest on top of the greater trochanters to determine their height. They are located at the same level as the pubic tubercles. The superior and posterior aspects of the greater trochanters are superficial and easily palpable. The anterior and lateral aspects are covered by the attachments of the gluteus medius and tensor fasciae latae, making the bony prominence more difficult to

The Hip Chapter 11

Greater

Trochanter

Figure 11.8 Palpation of the greater trochanters.

Femoral artery and vein

Sartorius

locate. You can confirm your hand placement by having the patient medially and laterally rotate the lower extremity. A difference in height may be secondary to a malalignment following a hip fracture, a congenitally dislocated hip, or a congenital anomaly. If the patient is examined in a weight-bearing position, a height difference could be secondary to a leg length difference. If tenderness is noted in this area the patient may have a trochanteric bursitis or a piriformis syndrome (Figure 11.8).

Soft-Tissue Structures

Femoral Triangle

The femoral triangle is located in the area directly caudal to the crease of the groin. The base of the triangle is formed by the inguinal ligament. The lateral border is the medial aspect of the sartorius and the medial border is the adductor longus. The floor is trough-like and is comprised of the iliacus, psoas major, adductor longus, and pectineus. The femoral vessels are located superficial to the floor and consist of the femoral artery, vein, and nerve and some lymph nodes. The tissues can be most easily accessed by placing the patient’s lower extremity in a position of flexion, abduction, and external rotation (Figure 11.9).

Inguinal ligament

Adductor longus

Femoral triangle

Inguinal ligament

Figure 11.10 The inguinal ligament.

Femoral artery

Chapter 11 The Hip

Inguinal Ligament

The inguinal ligament attaches to the anterior superior iliac spines and the pubic tubercles and is found under the inguinal crease of the groin. This ligament feels cordlike as you run your fingers across it. If a bulge is found, the patient may have an inguinal hernia (Figure 11.10).

Femoral Artery

The femoral pulse can most easily be detected at the midway point between the pubic tubercles and the anterior superior iliac spines. This is a valuable pulse to assess and is normally strong, but if a weak pulse is detected, occlusion of the aorta or the iliac arteries should be considered (Figure 11.11). If the patient is obese, a hand-over-hand technique may be useful.

Femoral Vein

The femoral vein is located medial to the femoral artery at the base of the femoral triangle. It is not easily palpable in the normal individual. This area may be inspected for enlarged lymph nodes, which may indicate an infection or systemic disease (Figure 11.12).

Femoral Nerve

The femoral nerve is located on the lateral aspect of the femoral artery. This very important structure is not normally palpable.

The Hip Chapter 11

Sartorius muscle

Figure 11.13 Palpation of the sartorius muscle.

Adductor longus

Figure 11.14 Palpation of the adductor longus muscle.

Sartorius Muscle

The sartorius muscle can be visualized by asking the patient to flex, abduct, and laterally rotate the hip and to flex the knee. It is most easily palpable at the proximal anteromedial aspect of the thigh (Figure 11.13). It is the longest muscle in the body.

Adductor Longus Muscle

The adductor longus muscle can be visualized by asking the patient to abduct the lower extremity and then resist adduction. The tendon is palpable at the proximal medial aspect of the thigh inferior to the pubic symphysis. The adductor longus muscle may be injured during athletic activities (e.g., soccer) (Figure 11.14).

Posterior Aspectcthe Patient is

Positioned in Prone

Bony Structures

Posterior Superior Iliac Spines

The posterior superior iliac spines can be found by placing your extended hands over the superior aspect of the iliac crests and allowing your thumbs to reach on a diagonal in an inferior medial direction until they contact the bony prominences. Have your thumbs roll towards a cranial orientation to more accurately determine the position of the posterior superior iliac spines. Many individuals have dimpling, which makes the location more obvious. However, you should be careful because not everyone has dimpling and if it is present, it may not coincide with the posterior superior iliac spines. With your fingers on the posterior superior iliac spines, if you move your thumbs at a medial and superior angle of approximately 30 degrees, you will come in contact with the posterior arch of L5. If you move your thumbs medially in a caudad and inferior angle of approximately 30 degrees, you will come in contact with the base of the sacrum. If you are having difficulty, you can also locate the posterior superior iliac spines by following the iliac crests posteriorly until you arrive at the spines (Figure 11.15).

Sacroiliac Joint

The actual joint line of the sacroiliac joint is not palpable because it is covered by the posterior aspect of the innominate bone. You can get a sense of its location by allowing your thumb to drop medially from the posterior superior iliac spine. The sacroiliac joint is located deep to this overhang at approximately the second sacral level (Figure 11.16).

Sacroiliac

joint

L4

L5

S2

Figure 11.16 Palpation of the sacroiliac joint.

Ischial Tuberosity

You can place your thumbs under the middle portion of the gluteal folds at approximately the level of the greater trochanters. Allow your thumbs to face superiorly and gently probe through the gluteus maximus until your thumbs are resting under the ischial tuberosity. Some people find it easier to perform this palpation with the patient in the side-lying position with the hip flexed; with this position the ischial tuberosity is more accessible because the gluteus maximus is pulled up, reducing the muscular cover. If this area is tender to palpation, it may be indicative of an inflammation of the ischial bursa (Figure 11.17).

Side-Lying Position

Soft-Tissue Structures

Piriformis Muscle

The piriformis muscle is located between the anterior inferior aspect of the sacrum and the greater trochanter. This muscle is very deep and is normally not palpable. However, if the muscle is in spasm, a cordlike structure can be detected under your fingers as you palpate the length of the muscle (Figure 11.18). The piriformis

The Hip Chapter 11

Greater trochanter

Sciatic nerve

Piriformis muscle

Figure 11.18 Palpation of the piriformis muscle.

is able to influence the alignment of the sacrum by pulling it anteriorly by virtue of its attachment. The sciatic nerve runs either under, over, or through the muscle belly. Compression of the nerve can occur when the muscle is in spasm.

Sciatic Nerve

The sciatic nerve is most easily accessed with the patient in the side-lying position, which allows the nerve to have less muscle cover since the gluteus maximus is flattened. Locate the midposition between the ischial tuberosity and greater trochanter. The sciatic nerve emerges from the internal pelvis, exiting via the greater sciatic notch and foramen under the piriformis muscle. You may be able to roll the nerve under your fingers if you take up the soft-tissue slack. Tenderness in this area can be due to an irritation of the sciatic nerve

Greater trochanter

Sciatic nerve

Piriformis muscle

Figure 11.19 Palpation of the sciatic nerve.

secondary to lumbar disc disease or piriformis spasm (Figure 11.19).

Trigger Points

Most muscles about the hip can develop myofascial dysfunction and have trigger points within them. Common trigger point locations for the gluteus maximus, gluteus medius, piriformis, tensor fascia lata, and iliopsoas muscles are illustrated in Figures 11.20 through 11.24.

While myofascial dysfunction can result in a sciaticalike pain syndrome, it should be noted that true sciatic nerve damage is associated with sensory loss, muscle weakness, or loss of reflexes. These findings do not occur in myofascial pain syndromes.

Active Movement Testing

You should have the patient perform the following movements: flexion and extension on the frontal axis, abduction and adduction on the sagittal axis, and medial and lateral rotation on the longitudinal axis.

These should be quick, functional tests designed to clear the joint. If the motion is pain free at the end of the range, you can add an additional overpressure to “clear” the joint. If the patient experiences pain during any of these movements, you should continue to explore whether the etiology of the pain is secondary to contractile or noncontractile structures by using passive and resistive tests.

Figure 11.23 A trigger point, X1, in the tensor fascia lata muscle. The referred pain pattern is noted by the dark and stippled areas. Adapted with permission from Travell J, Rinzler SI. The myofascial genesis of pain. Postgrad Ped 1952; 31: 425–431.

Flexion

The patient, in the supine position, is instructed to bend the hip and bring the knee toward the chest as far as he or she can without causing a posterior pelvic rotation (Figure 11.25).

Extension

The patient, in the supine position, is instructed to return the lower extremity to the table (Figure 11.26).

Abduction

The patient, in the supine position, is instructed to bring the lower extremity out to the side as far as possible without creating an obliquity of the pelvis (Figure 11.27).

Adduction

The patient, in the supine position, is instructed to return the lower extremity to the midline from the abducted position (Figure 11.28).

Iliopsoas