>> Plain radiographs are a standard test to diagnose hip osteoarthritis.
But four in five patients who have radiographic evidence of osteoarthritis are asymptomatic.
This video illustrates how to perform an informative hip examination,
which can help clinicians avoid unnecessary imagining and provide important information
about the clinical significance of findings of osteoarthritis on hip x-rays.
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Dr. Irsk Anderson is evaluating his 62 year old patient for hip osteoarthritis.
She has right hip pain and recalls having it ever
since she fell off the ladder seven years ago.
Will use her physical examination to estimate her risk
of having any hip osteoarthritis and severe hip osteoarthritis.
>> When I started to get concerned about osteoarthritis is in patients who are 60 years
or older and especially if they're complaining about pain in the anterior portion of the hip.
These patients will often complain about pain when they're getting out of a chair
from a seated position, walking up and down stairs
or really just walking on any flat ground whatsoever.
When the pain is located in the anterior hip, that's more concerning for osteoarthritis.
Our patients are going to come in and say they have hip pain and they will point
to the lateral portion of the hip, as well as the posterior portion of the hip.
In that situation you need to be concerned about osteoarthritis as well,
or at least do the appropriate examination to rule it out.
>> Without giving an exhaustive list, some differentials to consider for anterior,
lateral and posterior hip pain are listed here.
For all patients presenting with hip pain you want to be sure to do a gate assessment.
There are a few things you're looking for in a gate assessment.
One is if the patient has a limp, which can also be described as an antalgic gate.
The patient will alter their gate to compensate for any presence of hip pain.
Another is to observe for abductor weakness.
With full abductor strength the patient is able to keep the pelvis parallel to the floor.
Whereas, with abductor weakness, the contralateral pelvis will dip toward the floor.
Hip descent contralateral to pain on walking is also called the Trendelenburg sign.
Our patient has a negative Trendelenburg sign.
>> The physical exam maneuver with the highest likelihood ratio
to detect osteoarthritis on imaging is the squat test.
For the squat test, first, have the patient put their feet about 8 inches apart.
Their hands must be on their hips, they cannot be holding
onto anything to do this maneuver correctly.
Have the patient keep their back straight and squat down as far as they can go.
The exam is over either when the heel comes off the ground or the patient is in pain.
Are you having any pain?
>> Yes.
>> Where do you feel it?
>> Right here.
>> Pain in the posterior region during the squat test is highly indicative of osteoarthritis.
You may stand up.
Next we're going to do a test called the Trendelenburg test,
which is looking for abductor strength.
Have the patient stand on the affected leg, with the other leg bent and off the ground.
Somebody who has strung abductors they should be able to keep the hips parallel to the ground,
whereas, if they have weakness of the abductors you will see the hips dip
to the opposite or contralateral side.
You may stand.
>> Dr. Anderson has asked the patient to indicate with one finger
where she feels the pain the most.
And in her case, the anterior groin.
Check if there's tenderness on palpation of the inguinal ligament,
which can be consistent with osteoarthritis.
>> Now we're going to test for range of motion.
Whenever you test for range of motion you always want to compare to the opposite side.
The other way you can measure for range of motion differences is
by using what's called a goniometer, which is a measuring tool to measure angles across joints.
The first maneuver is going to be hip flexion.
We're going to have the patient bend the knee to about 90 degrees,
you're going to try to flex as far as you can.
Normal is about 120 degrees.
Is there any pain with that maneuver?
>> Yes.
>> So she has a little bit of reduction in range of motion and pain,
which can go along with osteoarthritis.
Next we're going to check for hip flexor strength.
To do this and isolate away from the rectus femoris you want
to keep the knee bent at 90 degrees.
By doing this you take out the rectus femoris muscle and hip flexion
and you really isolate the Sartorius and iliopsoas.
Please keep your leg up and don't let me push.
Excellent, she has five out of five strength.
Just as a reference, zero out of five strength indicates there is no strength in that limb.
Three out of five strength means the patient can move the limp against gravity alone.
Four out of five strength means there's some minimal weakness of that limb.
While five out of five is full strength.
We're going to relax the leg down.
Next we're going to look at abduction and adduction of the hip.
For abduction you want to move the leg out laterally away from the body.
What you're looking for is range of motion, which normal is 45 degrees,
as well as, any evidence of pain.
Does that hurt?
>> No.
>> She does not have any pain, which would be indicative of osteoarthritis.
Next we're going to move the hip into adduction, where we move the leg across the body
and you're looking for about 20 to 30 degrees of range of motion.
You also want to ask about any pain?
>> Just a little.
>> A little bit.
If she had pain with either adduction or abduction,
that too is indicative of osteoarthritis.
>> Groin pain on adduction or abduction and posterior pain
on squat test are comparably predictive.
With similar positive likelihood ratios for detecting osteoarthritis on hip radiographs.
>> Next we're going to check for abductor and adductor strength.
I'm going to keep your leg up off the table and don't let me push.
That's testing for her abductor strength, which is five out of five, that's perfect.
Next we're going to check for adductor strength.
Keep your leg off the table, please and don't let me push.
Again, five out of five strength.
Next we're going to check for internal and external range of motion of the hip.
Again, we want to get the hip into about 90 degrees of flexion
and the knee also flexed to 90 degrees.
For internal rotation we're going to pull the leg toward you and away from the patient.
What you're looking for is overall range of motion, normal being in the 20
to 35 degree range, as well as any evidence of pain.
Does that hurt?
>> Yes.
>> And that is consistent with osteoarthritis.
Next we're going to check for external range of motion.
Normal being about 30 to 70 degrees and are you having any pain with that?
>> No.
>> Excellent.
>> An additional test to perform when the patient is supine is the scour test.
To perform a scour test raise the hip to maximal flexion, apply long axis compression
through the femur and continuing the compression force,
move the leg in an arc toward the shoulders.
A positive test will consist of bumps in movement,
pain or any patient apprehension with the motion.
>> Now that we've finished examining the patient in the supine position,
we're now going to have her role over onto her left side
to examine the right hip in the lateral position.
In the lateral position there are a couple of areas you can push on to look for tenderness.
One is over the greater trochanter, which may indicate greater trochanteric bursitis.
And ask if there's any tenderness to palpation.
Yes?
>> Yes.
>> You can also palpate along the iliotibial band for any evidence of tendonitis.
Some folks do a test called the lateral compression test
where you put a force downward toward the table on the patient's hip.
Is there any pain with that?
>> Yes.
>> what you're looking for is not so much pain over the greater trochanter,
but more posteriorly in the SI joint, which could be indicative of SI
or sacroiliac joint osteoarthritis.
Next we're going to check abductor strength.
I'm going to have the patient lift her leg off the table.
Please keep your leg up there for me and don't let me push.
And, again, here if she had weakness with her abductor strength,
that could be indicative of osteoarthritis.
Next I'd like you to bring your leg down towards your opposite leg as hard as you can.
Excellent.
And here we're looking for adductor strength, which again is normal at five out of five.
Now we'll have the patient move onto her stomach into the prone position.
In the prone position the first thing you want to check is leg extension.
You'll lift the leg up as high as you can and ask the patient to keep their leg
up if they can and don't let me push.
Any pain with that maneuver?
>> No.
>> No pain and she had five out of five strength.
By keeping the knee bent you're really limiting the muscle group to the gluteus maximus
and taking out the hamstring component of extension.
Next we're going to check for hip internal and external range of motion in the prone position.
You want to bring the patient's knees up to about 90 degrees.
And for internal range of motion you're going to let the feet fall out to the side, which, again,
should be somewhere on the order of 25 to 30 degrees normal.
Do you have any pain with that?
>> No.
>> As you can see, she has excellent range of motion in the prone position.
For external range of motion you want to cross the feet
and try to bring them down towards the table.
Is there any pain with that?
>> Yes.
>> There is some pain and there is some limitation with her external range of motion,
which, again, is normally about 30 to 70 degrees.
Next, this is a great position to test for internal and external motion strength.
If you could please keep your feet up for me.
I'm going to try to push your feet together, but don't let me.
Excellent.
She has very strong internal range of motion strength.
Next I'm going to try to push your feet out, but don't let me.
And, again, excellent external range of motion strength as well.
You can relax down.
>> Our patient has a family history of osteoarthritis,
personal history of knee osteoarthritis and hip pain with stairs and slopes.
Based on the rational clinical examination published in JAMA, patients who present
with history, signs and symptoms consistent with hip osteoarthritis have a pretest probability
of having the disease of about one third.
This is the same as the prevalence of mild to moderate hip osteoarthritis in patients
with a mean age in their early 60s who present to a primary care practitioner with hip and
or groin pain and it is the pretest probability
of hip osteoarthritis before you examine the patient.
Using the likelihood ratio calculator found at jamaevidence.com, with a pretest probability
of about one third and a likelihood ratio of about two for these features,
the patient has about a 50% probability of having osteoarthritis.
On her physical examination she had a positive squat test, pain with hip adduction,
reduced range of motion with adduction and pain with internal range of motion.
The squat test has a likelihood ratio of about six, which, going back to the calculator,
based on the pretest probability and using just the single physical examination finding
with the highest positive likelihood ratio, her post test probability
of having hip osteoarthritis is about 75%.
This patient does not meet criteria for severe hip osteoarthritis.
So she has a high probability of mild to moderate disease and there is little need
to order hip radiographs at this time.
This patient should be counseled to pursue weight loss,
develop a low impact cardiovascular exercise routine, be given analgesia
and possibly referral for physical therapy.
If these conservative therapies fail, radiographs should be ordered
and she should be referred to an orthopedist to review the findings and make recommendations
about hip injection therapies or hip arthroplasty.
Read, The Rational Clinical Exam, published in JAMA to learn more.
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