The Hip

Introduction

The term hip is often used by people  to describe  a region that is actually part  of their  buttock.  Pain  in that  region  may  be  from the  lower  back, pelvis,  soft tissues  in the  buttock  and  also  from the  hip joint  itself. An important  aim of the full history and examination is to determine where the problem  is located.

Anatomy of the Hip

H-1 Hip and pelvis from front H-2 Hip and pelvis from back H-3 Hip and pelvis from side

The hip is the main weight-bearing joint of the body, located  deep under layers  of powerful  supporting  muscles  and  ligaments.  It is a  ball  and socket joint with the head of the femur forming the ball which inserts into the acetabulum  of the pelvis.

Just distal to the head  and neck of the femur on the upper  portion of the femur is a bony process:  the greater trochanter,  a broad  flat process  on the lateral aspect. The trochanteric  bursa overlies the greater trochanter.

The pelvis and sacrum form an oval structure known as the pelvic girdle. The iliac crest is a ridge of bone  formed by the upper,  curved  border  of the pelvis. It can be palpated on the lateral aspect of the body just below the waist. The bony  ridge ends  in an anterior  projection known  as the anterior superior iliac spine (ASIS).

The pelvic girdle is joined  to the fused part of the spine or sacrum at the sacroiliac joint.

H-4 Diagram of hip joint structure H-5 X-ray of pelvis H-6 Diagram looking into pelvis

Problems of the Buttock and Thigh

Pain in the hip may be coming  from various structures – the lower back, pelvis, sacroiliac  joints, soft tissues in the buttock  including  bursitis and also the hip joints.

Pain from the hip joint is usually  felt in the groin or anterior  or lateral thigh. Similar pain may also be caused  by pain referred from the knee.

Buttock pain may originate  from the hip but this is more usually due to problems  in the lower back.

Pain  in  the  outer  thigh  may  arise  from  the  trochanteric bursa  or  that region.

Hip Osteoarthritis

Rheumatoid arthritis

Fracture

Bursitis Trochanteric bursitis
Infection Septic arthritis is rare
Sacroiliac  joint Mechanical
Inflammatory Ankylosing spondylitis
Back problems Pain in the buttock  may be referred from the lumbar spine
                                              .                                         .

Osteoarthritis is one  of the most common causes  of hip pain  in adults. A limp  may  develop  with  associated stiffness. In extreme  cases  a  leg may   become  shortened  and   the   hip   adopts   a   fixed  flexion   and adduction  deformity.  Total  hip  replacement  is  effective  in  relieving pain in osteoarthritis.

Hip disorders:

  • Often produce a limp.
  • Cause a reduction in the distance that can be walked.
  • Limit activities of daily living, such as getting in and out of the bath, or a car, putting on shoes and foot care.

Giving a History of Buttock and Thigh Pain

Invite the doctor to carry out a consultation by first asking you about your history  related  to the  experience you  have  of your condition. This will then be followed  by the physical  examination.

The doctor  should  first ask you ‘What  is the problem?’and you should give a short response  describing  your symptoms  and their effect on your quality of life.

Develop  a script based  on your own experience. You may still have the symptoms  or you  may  be  describing  an  episode  you  have  had  as if it were still present.

Describe  as fully as you can your own symptoms, including  where in the buttocks,  thighs or groin you feel/felt pain or discomfort.  Say if you have any stiffness, swelling or other  symptoms.  Mention  how  the problem  is having/had an impact  on your daily life, your work, or your sleep.

Remember  to describe  how  your condition affects/affected  your quality of life. Consider  self care  (e.g. ability  to wash,  dress,  toilet  and  feed), domestic   care   (e.g.   ability   to   cook,   clean,   launder,   shop),   work (e.g. ability to stand, sit, type), leisure (e.g. ability to play sports, walk, go out for meals). Explain about  the way it limits/limited  your activities and restricts/restricted  your participation in normal  life.

Do  not  tell  him  everything  spontaneously  –  just  the  important   part. He  will  then  need  to  ask  further  questions  to  fully characterise your problem.  Develop  a set of answers  with  your  trainer  to the  following points. Prompt them if they omit important  questions.

Pain is usually present  and questions  should  establish:

  • How the pain started and developed.
  • The nature of the pain.
  • The exact distribution of the pain.
  • Whether the pain has increased or decreased over time.
  • Whether it affects sleep.
  • Whether anything  exacerbates or relieves the pain.

Stiffness may be a symptom  and questions  should  establish:

  • If you are stiff at all?
  • When it is worse?
  • What improves it?

Swelling may be a symptom  and questions  should  establish:

  • If you have noticed any swelling and where.
  • If it is always present.
  • If it is painful or tender.
  • If it is increasing.

They need  to ask about  the  pattern  of all the  symptoms  – where  they started and if they have spread  anywhere.

You may prompt  the doctor  (if you have not already  told them) to make sure that they include  the following information:

  • Your age, occupation and hobbies.
  • Your general health.
  • Your past medical history.
  • Whether  you  have  any  symptoms  such  as  tingling,  numbness  or weakness  in your legs.
  • Whether there  is any impairment of function  and  how  this impacts on your daily activities and quality of life.
  • Hip problems   typically  cause  difficulty  in  walking,  sitting  down, rising from a seated  position,  putting on socks and shoes.
  • Whether you have  had  previous  treatment  and  if so whether  it was successful.

The effect of any problem  depends on your personal  circumstances. The doctor  needs  to know about  what you need  to do in the home,  at work, your leisure interests and your expectations.

You may  have  symptoms  affecting  other  parts  of your  musculoskeletal system.  You may prompt the doctor to ensure he has asked whether  you have any other problems  affecting your muscles,  joints, neck or back.

You may go into further details about  how your problem  affects your life and  the  treatment  you  have  received  at  the  end  of the  session  when discussing  the findings.

Example of a Script

You should  develop  something  like this, based  on your own story. First you need  to ask me:

What is your problem?

“I  started  getting  pain  in  my  groin  4  months  ago  when  standing  or walking for any length of time and it is beginning  to stop me doing what I want to do.”

You should then respond  to questions,  guiding and prompting  the doctor through  the information  as listed above.

directional  terms  you  have  learnt.  You  can  use  your  knowledge  of anatomy   best  when   the  doctor   is  feeling  the  joint  and  periarticular structures.

“I  would  now  like  to  invite  you  to  find out  a little  bit more  about my problems,  by role play, using me as your patient and examining me.

Hip Examination Script

Describe   the  examination  to  the  doctor   using  the  anatomical and directional  terms  you  have  learnt.  You  can  use  your  knowledge  of anatomy   best  when   the  doctor   is  feeling  the  joint  and  periarticular structures.

“I  would  now  like  to  invite  you  to  find out  a little  bit more  about my problems,  by role play, using me as your patient and examining me.

Look

Standing

Observe  the patient  walking  to see if they have  a normal  gait. Look at them from the front and back when  standing  (or lying if they are unable to stand) for any asymmetry  or muscle  wasting.

What do you see?

Feel

Standing

With  the  patient   standing   if  possible,   palpate   the  buttocks   for  any tenderness to try and locate  where  the pain is.

With  the  patient   standing   if  possible,   feel  for  tenderness  over  the sacroiliac   joints  which   may  be  located   approximately  1” (2.5  cm)

laterally from the Dimples of Venus, or by drawing a finger from the ASIS back    to    the    spine    and    then    moving    fingers    laterally    1-2” (2.5 – 5cm).

With the patient standing,  place your hands palm down around  the waist so that they are resting laterally on the pelvic brim. Then ask the patient to stand on one leg (their best hip) and then on the leg of their affected hip. Where  there is a hip problem  the pelvis may tilt and the unaffected (non-weight   bearing)   hip  will  dip  below   the  horizontal  because  of weakness  of the gluteus medius  hip abductors. Normally  the abductors keep the individual’s  hips level. This is the Trendelenburg test.

H-7 Trendelenburg test

Lying down

Now  ask the patient  to lie down  on the examination couch,  observe  if they have any difficulty doing this. Palpate the pelvic rim and the greater trochanter for tenderness. This can  be found  approximately one  hand’s width below the ASIS on the lateral aspect  of the hips. This is usually the widest area of the hips when the patient is supine and you can recognise it as being  the hard  tissue in the lateral  buttock.  The trochanteric bursa overlies this structure.   Palpate  over both sides simultaneously.

What do you feel?

Move

Lying down

Flexion  With the patient  lying supine  on their back, place  one hand  on the distal femur around  the knee and put the other hand  under  the heel to  give  good  support  to  the  leg  to  allow  the  patient  to  relax  the  leg muscles. Now lift the leg flexing the hip and knee. It is important  that the muscles  are  relaxed  if you  are  testing  range  of movement. Use  some pressure  to flex the hip as far as it will go without  hurting  the patient. Always gradually  increase  pressure  when  moving a joint so you know if it is painful before pushing  too hard.

H-8 Hip flexion

Internal rotation Keeping one  hand  on  the  knee  and  holding  the  heel with the other hand, lift and guide the leg until both the hip and knee are at 90°. Then rotate the lower leg outwards  so that the thigh rotates inward (internally).

H-9 Internal rotation

External rotation  Now  bring  the  lower  leg  back  to  neutral  and  then rotate it inwards  so that the thigh rotates outward  (externally).

H-10 External rotation

As an  aide  memoire   to  help  remember which  way  the  hips  is being rotated  use the phrase  “foot out/hip  in, foot in/hip out”.

Adduction: Now, lower and extend the patient’s leg until it is straight but still elevated  enough  to clear the opposite  foot. Place your hand over the opposite  iliac  crest. Then  move  the  leg medially  across  the  midline  to assess the range of movement without movement of the pelvis.

H-11 Adduction of hip joint

Abduction: Then, with the hand  still over the opposite  iliac crest, move the leg laterally until there is movement of the iliac crest (often a subtle “lifting”) which  indicates  the point of abduction.

H-12 Abduction of hip joint

Leg measurement Assess whether  the legs are the same length when  the patient  is  lying  with  the  pelvis  straight  and  the  legs  outstretched by placing  your hands  around  the ankles with your thumbs  on each  of the medial  malleoli  and  feeling  if they  are  side  by side. You may  want  to measure   both  legs  from  the  ASIS  to  the  medial   malleolus   to  more formally compare leg lengths.

H-13 Measurement of leg length

What have you found?

Stress

Movement against resistance Test the quadriceps power with the patient lying with the leg extended. Place one hand  proximal  to the patella  and feel the muscle  and assess its strength when  you ask them to lift the leg against your pressure.

Listen

Crepitus   is  uncommon  but   severe   osteoarthritis   can   produce  a “clonking” of the hip joint on movement.

Special tests

There are no special  tests for use in a routine  examination of the hip.

“We have  now  come  to the end  of this mock  consultation. You should have    learned    quite    a    bit    about    my    condition   from    taking my  history  and  examining  my  joints,  however,   I  would  be  happy  to provide  you with a bit more  detail  about  the progress  of my condition

and how it affects my life, if you would  find this useful.”

[Please give a brief description  of your condition:

  • When  and how  it started.
  • Physical and psychological  affects on you.
  • Treatments  offered.
  • How  your condition progressed.
  • How this affected  your life: Home, education, work,  leisure, ability to travel, relationships etc.]

“Does anyone  have any further questions?”

“Thank  you  again  for attending   this  session.  I  hope  you  have  found it useful.”