Hip Examination: History Taking and Clinical Examination

The hip joint is a deep ball-and-socket synovial joint that plays a vital role in weight-bearing and mobility. Because pain arising from the hip may be referred to the groin, thigh, knee, or buttock, a systematic clinical examination is essential for identifying the underlying pathology.

A complete hip examination includes:

• History taking
• Inspection
• Palpation
• Assessment of range of motion
• Special tests
• Neurovascular examination
• Examination of adjacent joints (lumbar spine, pelvis, knees, ankles, and feet)

History Taking

A thorough history often provides the diagnosis before the physical examination begins.

Pain

Pain is the most common presenting complaint. Important aspects include:

• Onset
  • Acute pain suggests trauma, septic arthritis, reactive arthritis, muscle injury, or fracture.
  • Insidious onset suggests osteoarthritis, inflammatory arthritis, osteonecrosis, tuberculosis, or tumors.
• Duration
  • Sudden onset usually indicates trauma or infection.
  • Chronic pain favors degenerative or inflammatory conditions.
• Character
  • Sharp, stabbing pain is common after trauma.
  • Dull aching pain occurs in early osteoarthritis or avascular necrosis.
  • Throbbing pain is often associated with infection.
• Diurnal variation
  • Morning stiffness suggests inflammatory arthritis such as rheumatoid arthritis or ankylosing spondylitis.
  • Night pain may occur with infection, tumors, or tuberculosis.
  • Pain during the first few steps after resting is typical of arthritis.
  • Pain appearing after prolonged activity is more suggestive of early osteonecrosis or overuse conditions.
• Progression
  • Gradually worsening pain suggests degenerative disease.
  • Sudden worsening after a chronic course may indicate femoral head collapse in osteonecrosis or a pathological fracture.

Pain Location

The site of pain provides useful diagnostic clues:

Patients with persistent knee pain should always undergo a hip examination because hip disorders commonly present with referred knee pain.

Limp

Limp is one of the most reliable indicators of hip pathology.

Determine:

• Time of onset
• Relation to pain
• Progression
• Need for walking aids

Important considerations include:

• Tuberculosis of the hip often presents with limp before pain.
• Painless limp suggests:
  • Developmental dysplasia of the hip (DDH)
  • Coxa vara
  • Cerebral palsy
  • Poliomyelitis
  • Healed hip infection with deformity
  • Ankylosis

Stiffness

Ask about:

• Difficulty getting out of bed
• Difficulty putting on shoes or socks
• Morning stiffness
• Duration of stiffness

Stiffness may result from:

• Muscle spasm
• Synovitis
• Inflammatory arthritis
• Osteoarthritis
• Prolonged immobilization

Morning stiffness lasting more than 30–60 minutes strongly suggests inflammatory arthritis.

Deformity

Ask whether the patient has noticed:

• Limb shortening
• Rotational deformity
• Flexion deformity
• Progressive deformity

Patients usually recognize limb shortening more readily than rotational deformities.

Swelling

Because the hip joint lies deep beneath muscles, swelling is uncommon.

Ask about:

• Progressive swelling
• Groin masses
• Gluteal swelling
• Previous abscesses
• Sinus formation

Large swellings may occur with:

• Tuberculosis
• Septic arthritis
• Soft tissue tumors
• Iliopsoas abscess

Trauma History

If trauma occurred, document:

• Mechanism of injury
  • Road traffic accident
  • Fall from standing height
  • Fall from height
  • Sports injury
  • Crush injury
  • Slip or twisting injury
• Site of impact
• Ability to walk after injury
• Ability to bear weight
• Associated injuries
• Initial treatment received

Functional Disability

Assess current functional limitations, including:

• Walking distance
• Stair climbing
• Sitting cross-legged
• Squatting
• Getting into a car
• Wearing shoes and socks
• Need for walking aids

Also determine the patient’s pre-injury mobility.

Important Negative History

Always ask about:

• Fever
• Weight loss
• Night sweats
• Tuberculosis exposure
• Pain in other joints
• Back pain
• Pregnancy
• Previous tuberculosis treatment
• Symptoms in the opposite hip
• Ipsilateral and contralateral knee
• Ankle and foot symptoms

Past Medical History

Include:

• Previous tuberculosis
• Previous hip trauma
• Hip surgery
• Congenital hip disorders
• Developmental dysplasia
• Osteoporosis
• Diabetes mellitus
• Hypertension
• Renal disease
• Liver disease
• Respiratory disease
• Neurological disorders
• Connective tissue disorders
• Hematological disorders
• Organ transplantation

Also assess fitness for anesthesia if surgery is anticipated.

Personal History

Ask about:

• Occupation
• Activity level
• Sports participation
• Diet
• Smoking
• Alcohol consumption
• Recreational drug use

Family History

Ask about:

• Developmental dysplasia of the hip
• Inflammatory arthropathies
• Storage disorders
• Hereditary skeletal dysplasias

Inspection

Observe the patient while standing, walking, and lying supine.

Inspection from the Front

Assess:

• Overall posture
• Pelvic alignment
• Limb position
• Hip flexion deformity
• External or internal rotation
• Knee alignment
• Foot position
• Pelvic tilt
• ASIS symmetry
• Muscle wasting (especially quadriceps)
• Adductor muscle prominence or spasm
• Hernias
• Perineal widening

Inspect the skin for:

• Swelling
• Surgical scars
• Sinuses
• Loss of skin creases
• Dilated veins
• Discoloration

Inspection from the Side

Look for:

• Lumbar lordosis
• Pelvic tilt
• Hip flexion deformity
• Knee flexion
• Equinus deformity at the ankle
• Trochanteric prominence

Again inspect the skin carefully.

Inspection from Behind

Assess:

• PSIS level (dimples of Venus)
• Midline alignment
• Curvature of the spine
• Lumbar triangles
• Gluteal muscle wasting
• Gluteal fold symmetry
• Skin changes

Skin Assessment (SEADS)

Remember the mnemonic SEADS:

• S — Swelling
• E — Erythema
• A — Atrophy
• D — Discoloration
• S — Suppuration (scars or sinuses)

Palpation

Before palpation, identify the major bony landmarks:

• Anterior superior iliac spine (ASIS)
• Iliac crest
• Greater trochanter
• Pubic tubercle
• Posterior superior iliac spine (PSIS)
• Ischial tuberosity

Anterior Palpation

Assess:

• Local temperature (using the dorsum of the hand)
• ASIS level
• Groin tenderness
• Femoral pulse
• Swelling
• Abscesses
• Tenderness along the femur

The hip joint lies approximately 2 cm below and lateral to the mid-inguinal point.

Lateral Palpation

Palpate the greater trochanter for:

• Tenderness
• Superior migration
• Broadening
• Thickening

Compare iliac crest levels on both sides.

Posterior Palpation

Assess for tenderness over:

• Sacroiliac joint
• Gluteal muscles
• Short external rotators
• Coccyx
• Ischial tuberosity
• Gluteal fold

Also palpate for:

• Abscesses
• Soft tissue masses
• Posteriorly dislocated femoral head

Medial Palpation

Evaluate for:

• Adductor muscle spasm
• Tenderness over the lesser trochanter (Ludloff sign)

Assessment of Hip Movements

Always stabilize the pelvis with one hand while moving the affected limb with the other. Compare every movement with the opposite side.

Flexion

• Perform the Thomas test first to detect fixed flexion deformity.
• Then assess passive hip flexion.
• Normal flexion is approximately 120–135°.

Extension

Measure extension with the patient in the prone position.

Normal extension is approximately 10–20°.

Abduction

Square the pelvis before measuring.

Normal range:

• 40–45°

Adduction

Measure after pelvic stabilization.

Normal range:

• 20–30°

Internal and External Rotation

Assess rotation:

• With the hip extended
• With the hip flexed to 90°

Use the patella as the reference point for neutral alignment.

Normal ranges:

• Internal rotation: 30–40°
• External rotation: 40–60°

Loss of internal rotation is often the earliest clinical sign of hip osteoarthritis or femoroacetabular impingement.

Documentation Example

Document movements by comparing both hips.

Example:

• Right hip flexion: 25°–120°
• Left hip flexion: 0°–135°

Always describe the affected side relative to the normal side.

Clinical Pearls

• Groin pain usually indicates intra-articular hip pathology.
• Knee pain may be referred from the hip; always examine the hip in unexplained knee pain.
• Limp often precedes pain in tuberculous arthritis of the hip.
• Loss of internal rotation is an early indicator of hip osteoarthritis.
• Stabilizing the pelvis is essential for accurate range-of-motion assessment.
• Always examine the lumbar spine, sacroiliac joints, contralateral hip, knees, ankles, and feet during a complete hip evaluation.

Key Points

• History remains the most important component of hip assessment.
• Pain characteristics, limp, stiffness, and functional limitation guide diagnosis.
• Inspection should evaluate posture, alignment, muscle wasting, and skin changes.
• Palpation localizes tenderness and identifies deformity or swelling.
• Accurate range-of-motion testing requires pelvic stabilization and side-to-side comparison.
• A comprehensive examination includes assessment of adjacent joints and neurovascular status.

References

1. Reiman MP, Goode AP, Hegedus EJ, et al. Diagnostic accuracy of clinical tests for femoroacetabular impingement and labral pathology: a systematic review. British Journal of Sports Medicine. 2015.
2. Clohisy JC, Carlisle JC, Beaulé PE, et al. A systematic approach to the plain radiographic evaluation of the young adult hip. Journal of Bone and Joint Surgery. 2008.
3. Martin HD, Kelly BT, Philippon MJ, et al. The pattern and technique in the clinical evaluation of the adult hip. Arthroscopy. 2010.
4. American Academy of Orthopaedic Surgeons (AAOS). Clinical evaluation of hip pain.
5. Hoppenfeld S. Physical Examination of the Spine and Extremities. Appleton & Lange.