Hip Assessment for Physiotherapists: A Structured Clinical Guide
The hip is a deep, inherently stable ball-and-socket joint that is frequently overlooked in favour of the knee and shoulder. Yet hip pathology is common across all age groups â from femoroacetabular impingement (FAI) in young athletes to osteoarthritis in older adults â and accurate assessment is essential for appropriate management. This guide provides a structured approach to hip assessment, from the subjective history through to objective examination and differential diagnosis.
Subjective Assessment: Key Questions for the Hip
Area and distribution of pain â True hip joint pain is typically felt in the groin (anterior hip), deep buttock, or lateral hip. Pain in the lateral hip is more often due to greater trochanteric pain syndrome (GTPS) than true hip joint pathology. Pain radiating down the leg may indicate lumbar spine referral â always screen the lumbar spine in patients presenting with hip or groin pain.
Onset and mechanism â Insidious onset in a young, active patient suggests FAI or labral pathology. Gradual onset in an older patient is more consistent with osteoarthritis. Acute onset following a fall or direct blow raises the possibility of fracture (particularly in older patients with osteoporosis).
Aggravating and easing factors â Pain with prolonged sitting, getting in and out of a car, or putting on shoes suggests anterior hip joint pathology (FAI, OA). Pain with walking and stairs, relieved by rest, is more consistent with OA. Pain with lying on the affected side suggests GTPS.
Red flags â Unexplained weight loss, history of cancer, constant progressive pain, fever, or night sweats require urgent investigation. In children and adolescents, always consider Perthes disease, slipped upper femoral epiphysis (SUFE), and septic arthritis.
Objective Assessment: Range of Movement and Muscle Testing
Begin with the patient supine for active and passive range of movement:
Normal hip ranges of movement: - Flexion: 120â135° - Extension: 10â20° - Abduction: 40â45° - Adduction: 20â30° - Internal rotation: 30â40° - External rotation: 40â60°
Reduced internal rotation is a sensitive indicator of hip joint pathology (OA, FAI). Global restriction in a capsular pattern (flexion, abduction, and internal rotation most restricted) is characteristic of hip osteoarthritis.
Muscle testing: - Hip flexors (iliopsoas) â resisted hip flexion in sitting - Hip abductors (gluteus medius) â resisted abduction in side-lying - Hip external rotators â resisted external rotation in sitting - Trendelenburg test â single-leg stance; a positive test (contralateral pelvis drops) indicates gluteus medius weakness or hip joint pathology
Special Tests for the Hip
FABER Test (Patrick's Test) The patient lies supine with the test leg in a figure-of-4 position (hip flexed, abducted, and externally rotated). The examiner applies gentle downward pressure to the knee. Groin pain suggests hip joint pathology; posterior pain suggests SI joint involvement. - Sensitivity: 57â60% | Specificity: 71â75% for hip OA
FADIR Test (Impingement Test) With the patient supine, the examiner passively flexes the hip to 90°, then adducts and internally rotates. Anterior groin pain is a positive finding for FAI or labral pathology. - Sensitivity: 78â96% | Specificity: 10â25% - High sensitivity but low specificity â a positive FADIR is common but not diagnostic of FAI alone.
Log Roll Test With the patient supine, the examiner passively internally and externally rotates the hip with the leg extended. Pain or apprehension with internal rotation suggests intra-articular pathology.
Trendelenburg Test The patient stands on one leg for 30 seconds. A positive test (contralateral pelvis drops, or the patient leans toward the stance leg) indicates gluteus medius weakness or hip abductor dysfunction. - Sensitivity: 72% | Specificity: 76% for hip OA
Ober's Test With the patient in side-lying, the examiner passively extends and abducts the upper hip, then releases. Failure of the leg to adduct to the table suggests iliotibial band or TFL tightness, associated with GTPS.
Differential Diagnosis: Common Hip Conditions
| Condition | Key Features |
|---|---|
| Hip osteoarthritis | Older patient, insidious onset, groin pain, capsular pattern restriction, positive FABER |
| Femoroacetabular impingement (FAI) | Young active patient, anterior groin pain, positive FADIR, reduced internal rotation |
| Greater trochanteric pain syndrome | Lateral hip pain, tender over greater trochanter, worse lying on affected side |
| Labral tear | Groin pain, clicking or locking, positive FADIR, often associated with FAI |
| Iliopsoas tendinopathy | Anterior hip/groin pain, snapping with hip flexion, tender over lesser trochanter |
| Lumbar referred pain | Hip/buttock pain reproduced by lumbar movement, no restriction of hip ROM |
| Piriformis syndrome | Deep buttock pain, sciatic-type symptoms, positive FAIR test |
| Stress fracture | Young athlete or older patient with osteoporosis, localised groin pain, positive fulcrum test |
Always screen the lumbar spine and knee in patients presenting with hip pain, as referred pain from both regions is common.
Clinical Reasoning: Putting It All Together
A thorough hip assessment integrates the subjective history, objective findings, and special test results into a coherent clinical picture. Key questions to ask yourself after completing your assessment:
- Is this intra-articular (hip joint) or extra-articular (soft tissue, referred) pathology?
- Is there any evidence of neurological involvement (lumbar referral, femoral nerve)?
- Are there any red flags that require urgent investigation or referral?
- What is the patient's main functional limitation and goal?
- What are the contributing factors (biomechanics, load, activity level, psychosocial)?
Documenting your clinical reasoning clearly â including what you have ruled out and why â is as important as identifying the working diagnosis. This is particularly important in complex presentations where multiple pathologies may coexist.