Position - for most of the exam the patient should be supine and the bed or examination table should be flat. The patient's hands should remain at their sides with the head resting on a pillow. The knees and hips should be in the anatomical position (knee extended, hip neither flexed nor extended).
Extension - done with the patient on their side. Alignment should be assessed by palpation of the ASIS, PSIS and greater trochanter.
Abduction - assessed whilst palpating the contralateral ASIS.
Adduction - assessed whilst palpating the ipsilateral ASIS.
Assessment for a hidden flexion contracture of the hip - hip flexion contractures may be occult, due to compensation by the back. They are assessed by:
Placing a hand behind the lumbar region of back
Getting the patient to fully flex the contralateral hip.
The hand in the lumbar region is used to confirm the back is straightened (flexed relative to the anatomic position). If there is a flexion contracture in the ipsilateral hip it should be evident, as the hip will appear flexed.
Normal range of motion
Internal rotation - 40°
External rotation - 45°
Flexion - 125°
Extension - 10-15°
Abduction - 45°
Adduction - 30°
Make sure pelvis is horizontal by palpating 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 or 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 isstanding on. This is because of (abnormal) weakness of hip abductors on the stance leg. The latter hip joint may therefore be abnormal.
Assisted Trendlenburg test 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’ Trendelenburg 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 This assesses proprioception/balance (dorsal columns of spinal cord/spino-cerebellarpathways).
Ask the patient to stand with heels together and hands by the side. Ask the patient to close his/her eyes and observe for swaying for about 10seconds.
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.