Hip and Sacroiliac joints

Patients often present with “hip pain” being their main complaint. “Hip pain” often means different pain to different people. It is important to localize the location of the pain. Often the pain is over the lumbar spine or sacro-iliac joint. The pain can be over the greater trochanter and radiate down the outer aspect of the leg. This is usually trochanteric bursitis. Hip joint pain is often a deep pain over the anterior aspect of the hip that radiates into the groin. It can also be felt into the thigh, the buttock and radiate down to the knee.

Sacroiliac joint pain is also a deep pain. It is often made worse by sitting and relieved by standing. The pain is usually over the sacroiliac joint.

Examination of these joints is best done together.

Begin the examination by inspecting the hip and surrounding structures. With the patient standing, look for wasting of the glutei or quadriceps muscles. Look for a fixed deformity. The most common is a flexed and laterally rotated position as this is the most comfortable position for the patient with a hip problem. Fixed flexion deformities can be masked by the patient increasing their pelvic tilt. This results in an increase in lumbar lordosis.

Examination the patient’s gait next. Observe their gait from the front, side and from behind. There are 4 patterns to observe:

1. Antalgic gait. This is caused by a painful hip. The patient tries to minimise the time spent weight bearing on the painful hip.

2. Trendelenburg gait. This occurs when there is weakness of the hip abductors due to an unstable hip. With a normal gait the hip abductors contract when the weight is beared on the same side. In a Trendelenburg gait there is weakness of the abductors. This results in the pelvis tilting. The observer will see the “sound side sagging”. If there is weakness on both sides the patient will have a waddling gait.

3. Swinging gait. The whole leg is swung around. This can be due to ankylosis of the hip joint or due to a hemiplegia.

4. Adductor gait. This results in scissoring of the legs. It is due to muscle adductor spasm. This is usually due to bilateral hip disease.

Perform a Trendelenburg test. The normal function of the hip involves contraction of the hip abductors when weight in transferred to the same side. This allows the pelvis to remain level. When there is disease of the hip there is often associated weakness of the hip abductors.

To perform the test, ask the patient to stand on both feet. Observe from behind. Ask the patient to raise one knee to approximately 90° flexion at the hip. A positive test is when the pelvic rim drops on the side that the leg was raised. This occurs because the abductors on the opposite side cannot contract sufficiently to keep the pelvis level.

Test hip movements