The Hip and Pelvis
Differential Diagnosis / Special Tests
Patrick or FABERE Test/Hip-Sacroiliac Screening Test:
Have the patient lie supine and place the
foot of his involved side on his opposite knee. The hip joint is now
Flexed, ABducted, and Externally Rotated. In this position, inguinal pain
is a general indication that there is pathology in the hip joint or
surrounding muscles. To stress the sacroiliac joint, Extend the range of
motion by placing one hand on the flexed knee joint and the other hand on
the anterior superior iliac spine of the opposite side. Press down on each
of these points. If the patient complains of increased pain posteriorly,
there may be pathology in the sacroiliac joint. Anterior hip/groin pain
would continue to indicate hip involvement.
Trendelenburg Test/ Gluteus Medius Test:
This procedure evaluates the strength of
the gluteus medius muscle on the stance side. Stand behind the patient and
observe the dimples overlying the posterior superior iliac spines.
Normally, when the patient bears weight evenly on both legs, these dimples
appear level. Then ask the patient to stand on one leg. If he stands erect,
the gluteus medius muscle on the stance side should contract as soon as the
opposite leg leaves the ground, and should elevate the pelvis on the
unsupported side. This elevation indicates that the gluteus medius muscle
on the supported side is functioning properly (negative Trendelenburg
sign). If the pelvis on the unsupported side remains in position or
actually drops, the gluteus medius on the stance side is either weak or
non-functioning (positive Trendelenburg sign).
True Leg Length Discrepancy Test:
Place the patient's legs in precisely comparable positions
and measure the distance from the anterior superior iliac spines to the
medial malleoli of the ankles. Unequal distances between these fixed points
verify that one lower extremity is shorter than the other.
Apparent Leg Length Discrepancy Test:
To quickly determine where the discrepancy lies
(either in the tibia or femur), have the patient lie supine, with his knees
flexed to 90 degrees and his feet flat on the table. If one knee appears
higher than the other, the tibia of that extremity is longer. If one knee
projects further anteriorly than the other, the femur of that extremity is
Establish that there is no true leg length
discrepancy before testing for an apparent discrepancy, in which there is
no true bony inequality. Have the patient lie supine with his legs in as
neutral position as is possible, and take a measurement from the umbilicus
to the medial malleoli of the ankle. Unequal distances signify an apparent
leg length discrepancy, usually due to pelvic obliquity or from adduction
or flexion deformity in the hip joint.
Ober's Test/ Test for Shortening of the Iliotibial Band:
Have the patient lie on his side with his
involved leg uppermost. Be sure the patient does not move the pelvis
forward or backward. Abduct the leg as far as possible, flex the knee to 90
degrees, then extend the hip. Slowly release the patient's leg.
Noble Compression Test/ Test for Iliotibial Band Friction Syndrome:
If the iliotibial band is normal, the patient's thigh should drop to the
adducted position. If there is a shortening of the fascia lata or
iliotibial band, the thigh remains abducted when the leg is released
The patient is supine with the
knee flexed to 90 degrees, accompanied by hip flexion. The examiner then
applies pressure with the thumb to the lateral femoral epicondyle or one to
two centimeters proximal to it. While this pressure is maintained, the
patient slowly extends the knee. At approximately 30 degrees of flexion (0
degrees being a straight leg), if the patient complains of severe pain over
the lateral epicondyle, the test is positive.
Craig Test / Test for Femoral Torsion:
Therapists can determine the angle
of torsion of the femur using this test. Place the patient prone with knees
flexed to 90 degrees. On the side that you are testing, position the lower
extremity to the point in which the greater trochanter is most prominent
laterally (determined by internally and externally rotating the femur while
palpating the greater trochanter). Using a goniometer with the stationery
arm perpendicular to the floor (representative of the femoral neck axis)
and the moving arm perpendicular to the floor (representative of the line
between the femoral condyles) you can determine the angle of torsion of the
femur. Antetorsion: an angle of torsion greater than the upper range of
typical values; Retrotorsion: an angle less than the lower range of typical
Thomas Test/Test for Flexion Contracture of the Hip:
- The average angle of torsion in children between 4 and 7 years of age is
23 - 26 degrees (Cusick, 1990, p.94).
- Femoral torsion is complete between 8 and 16 years of age; ie: torsion
angles approach those of an adult (Cusick, 1990, p.94).
- The average angle of torsion in adults is 15 degrees (Hertling & Kessler,
1996, p. 285). Some authors place values between 8 and 15 degrees (Magee,
1997, p. 475).
The patient is supine, with his pelvis
level and square to his trunk. Stabilize the pelvis by placing your hand
under the patient's lumbar spine. Have the patient flex both his hips,
bringing his thighs up onto his trunk. Have the patient hold one leg to his
chest and let his other leg down until it is flat on the table. If the
thigh rises off the table, the test is positive for a hip flexion
contracture. This test does not differentiate between tightness of the
iliopsoas versus the rectus femoris.
Modified Thomas Test:
This utilizes the same patient position as for the Thomas Test, but
in addition, the patient scoots down the table until his knees are
approximately four inches over the edge. Have the patient perform the
maneuver for the Thomas Test. If the thigh rises off the table, attempt to
flex the knee on that side. If the knee flexes easily, the tight hip flexor
is the iliopsoas (positive test for iliopsoas). If you are unable to flex
the knee, or resistance is felt, the rectus femoris is tight (positive test
for rectus femoris).
Ely's Test/Femoral Nerve Stretch Test:
Evaluates irritation of the femoral nerve via stretching of
the nerve. The patient is prone on the table. Flex the knee to 90 degrees
or greater then passively extend the hip. Anterior and/or medial thigh pain
is positive for femoral nerve irritation.
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