Hip Osteoarthritis Care Pathway

Date of last update: October, 2024

7. Physical Examination

A comprehensive clinical examination should consider the biopsychosocial aspects of the patient’s condition, cultural considerations, and the necessity of obtaining informed consent. This approach is crucial for both new and existing patients, especially when they present with new complaints. Obtaining informed consent involves explicitly addressing the purpose and process of the examination, ensuring the patient understands and agrees to the procedures. Special care should be taken when contact is made in sensitive areas, prioritizing the patient’s comfort and understanding throughout the examination. Additionally, cultural awareness is essential in healthcare, as a patient's cultural background can significantly influence their perception and response to treatment. Practitioners should adapt their examination techniques and interactions to be respectful and sensitive to cultural differences, tailoring their approach to meet the specific needs and considerations of each patient.

Observation: Abnormalities, asymmetries, bony enlargement, posture, movements, apparent leg length discrepancy, muscle atrophy.

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Gait: Assess normal gait, balance (e.g., tandem gait, Romberg’s), walking capacity (measured by distance or time).

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Range of Motion:

• Lumbar spine's active, passive, and resisted ROM in all planes (flexion, extension, lateral flexion, and rotation).

• Hip active, passive, and resisted ROM in all planes (flexion, extension, abduction, adduction, internal/external rotation). Reproduction of symptoms may indicate hip pathology. Hip OA often presents with reduced hip internal rotation and hip internal rotation with hip flexion.

• Consider regional and segmental hypomobility, hypermobility and aberrant movement patterns.

Palpation: Identify areas of tenderness in the hip region and surrounding musculature, feel for crepitus or grinding sensations when moving the hip joint.

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Neurological Examination:

Motor Strength:

• Key Observations: Check for asymmetry or weakness indicating nerve root involvement:

  • L2: Hip flexors (hip flexion).

  • L3: Quadriceps (knee extension).

  • L4: Tibialis anterior (foot dorsiflexion).

  • L5: Extensor hallucis longus (big toe extension).

  • S1: Gastrocnemius (plantar flexion).

  • S2: Hamstrings (knee flexion).

• Record the clinical findings for each. E.g., L5: Extensor hallucis longus (EHL) strength: L5: EHL – L 3/5, R 5/5.

Sensory Examination: 

• Key Observations: Check for sensory deficits in lower extremities, corresponding to specific dermatomal distributions:

  • L1: Inguinal region.

  • L2: Anterior mid-thigh.

  • L3: Medial thigh at the knee.

  • L4: Medial side of the calf.

  • L5: Top of the foot and toes.

  • S1: Lateral side of the foot and little toe.

• Record the clinical findings for each. E.g., "Patient reports that they perceive the same for sharp, light, and vibration for L3, L4, L5, and S1." "Patient reports a loss of perception of sharp and light for S1 on the right with all other sensations intact."

Reflexes: 

• Key Observations: Asymmetry or absence of reflexes can indicate nerve root compression or other neurological conditions.

  • L4: Patellar reflex.

  • L5: Medial hamstring reflex.

  • S1: Achilles reflex.

• Record the clinical findings for each. E.g., L5: R 2/4, L 3+/4.

Lower Motor Neuron Signs:

• Key Observations: Muscle atrophy, fasciculations, reduced muscle tone, symmetrical loss of function. May indicate a systemic neurological condition (e.g., radiculopathy, peripheral neuropathy, ALS, spinal muscular atrophy).

• Record as: E.g., "LMN signs: Atrophy (yes/no), Fasciculations (yes/no), Muscle tone (reduced/normal), Function loss (symmetrical/asymmetrical)"

Upper Motor Neuron Signs:

• Key Observations: Increased muscle tone, hyperreflexia, pathological reflexes (e.g., Babinski sign, Clonus). May indicate conditions affecting the central nervous system (e.g., cervical spondylotic myelopathy, multiple sclerosis, stroke, spinal cord injuries).

• Record as: E.g., "UMN signs: Muscle tone (increased/normal), Hyperreflexia (yes/no), Babinski sign (positive/negative), Clonus (yes/no)"

Special/Orthopedic Tests:

Select tests to use alongside a comprehensive clinical examination; the validity and reliability of these tests vary. Record: For all tests, note the side tested, whether the test is positive or negative, and include an observational note for the responses to the test to also inform the clinical picture. E.g., Log Roll Test R(-), L(+) patient reports pain in left hip. Tests include:

Special tests helpful to differentiate hip OA from lumbar pathology:

1. Passive Straight Leg Raise: Positive test: exacerbates leg pain at or below 45° of hip flexion.

2. Slump Test: Positive test: neurological symptoms (e.g., shooting pain, numbness, or burning down leg).

3. Femoral Nerve Traction Test: Positive test: reproduces symptoms (e.g., pain in low back, buttock, posterior thigh), indicating disc pathology.

4. Kemp’s / Quadrant / Extension-Rotation Test: Positive test: pain in the lumbar region, or referred pain into the lower extremity.

5. Thigh Thrust Test: Positive test: reproduces pain in SIJ region.

6. Compression Test: Positive test: reproduces pain in SIJ region.

7. Distraction Test: Positive test: reproduces pain in SIJ region.

8. Sacral Thrust Test: Positive test: reproduces pain in SIJ region.

9. Gaenslen’s Test: Positive test: reproduces pain in SIJ region.

Special tests helpful to differentiate hip OA from deep gluteal syndrome:

1. Trendelenburg Test: Positive test: dropping/lowering of the hip region.

2. Log-Roll Test: Positive test: reproduction of hip pain and loss of internal range of motion, possibly indicating hip OA.

3. FADDIR Test: Positive test: reproduction of hip pain, may be indicative of hip impingement.
4. FABER (Patrick’s) Test: Positive test: test leg remains above opposite leg.

5. Scour Test: Positive test: reproduction of hip pain, indicating hip pathology.

6. FADER Test: Positive test: reproduction of lateral hip pain, indicating gluteal tendinopathy.

7. Thomas Test: Positive test: affected thigh raises indicating a loss of extension in the hip.

8. Anterior Labral Tear Test: Positive test: reproduction of hip pain with or without clicking, potentially indicating a labral pathology.

9. Posterior Labral Tear Test: Positive test: reproduction of hip pain with or without clicking, potentially indicating a labral pathology.

10. Single Leg Stance Test: Positive test: reproduction of lateral hip pain, indicating gluteal muscle pathology.

11. Maximal Squat Test: Positive test: reproduction of hip or groin pain.

Functional tests to test balance and lower extremity strength:

1. ​30 Second Sit-to-Stand Test: Evaluates lower extremity strength. If patient scores below the average for their age and sex, this indicates lower extremity weakness, which increases their risk for falls.

2. Timed Up and Go Test: Evaluates fall risk. Patients who take > 12 seconds to complete is at risk of falls.

3. 4-Stage Balance Test: Evaluates fall risk. Patients who are unable to hold the stances for at least 10 seconds are at risk of falls.

4. Berg Balance Scale: Evaluates fall risk. A score of < 45 indicates a greater risk of falls.

5. Balance Error Scoring System (BESS): Evaluates balance. Lower scores indicate better balance and less errors. 

6. Single Leg Squat: Combined evaluation of mobility, strength and balance. Positive test if deviation is observed on more than one of five specific criteria.

Advanced Diagnostics:

Imaging (e.g., x-ray): Generally not recommended unless red flags are present to avoid unnecessary radiation exposure, overdiagnosis, and costs. Currently, there is insufficient evidence that routine imaging improves patient outcomes. Discuss the benefits and risks of imaging with patients, educating them on the role of imaging and reasons for deferring it initially when applicable. Imaging used in specific contexts should be discussed through shared decision-making (e.g., persistent pain and functional limitations).

Advanced Imaging (e.g., MRI, CT): Should be considered with persistent pain, functional limitations, significant neurological deficits, or when surgical intervention is being considered. These can provide detailed information to guide diagnosis and surgical management.