What Will My Doctor Find When He Does An Examination?

Physical examination is very helpful to your doctor in making the diagnosis of a painful hip. He or she will examine how you stand, how you walk, and how you move. He will check the alignment of your spine and pelvis and look to make sure they are level. If your pelvis is tilted, it might be a sign that your hip pain is due to a back problem. Limited motion of your spine may also suggest that your back is the real cause of your pain.

Your doctor may then ask you to lie down flat on your back on an examining table. He will first examine your legs to make sure that they appear equal. He may check the circular measurement of the thigh, the circumference, against the opposite side. If one leg is smaller or thinner than the other, it may be a sign of atrophy of the muscle, which causes thinning and weakness. This may be due to chronic hip disease. It may also be a sign of a chronic neurologic problem that has caused wasting or thinning of the muscle. Your surgeon may also want to measure the length of both of your legs. This can be done in two ways.

The first of these, apparent leg length measures the length of your leg but can be affected by the angle of your pelvis. A measurement is taken with a tape measure from your umbilicus to the  medial malleolus on the inner part of your ankle. The second measurement is called  true leg length. This measures the length of your leg without regard to any pelvic tilting or deformity. This is measured from a bony prominence on the front of your pelvis called the  anterior superior iliac spine to the same point as before, the medial malleolus, on the inner side of your ankle. Your surgeon will compare the leg lengths he measures from the right side to the left side.

If there is a difference it may be due to the fact that the hip is shortened from ongoing arthritis or disease. It may also be important when your surgeon performs your hip replacement. By knowing the difference between the two or the  leg length discrepancy, he may be able to restore your leg to its normal length. This will be very important as you walk. Leg length discrepancy may also be caused by other factors such as previous injury to the leg, an old fracture, or shortening at birth known as congenital shortening. If, however, there are no other reasons for a leg length discrepancy, then shortening may be a sign of an arthritic hip.

The shortening due to arthritis is usually in the range of 1 to 2 cm for an adult. Your doctor will next want to check to see if there is a hip flexion contracture. This means that the hip has become stiff due to arthritis and cannot fully straighten. If you have a flexion contracture, any attempts to straighten your hip and leg may cause pain or may cause your spine to move. Your surgeon will perform the  Thomas test. He will flatten your spine on the table by flexing your opposite hip. He will then attempt to straighten or extend your bad hip. If your leg cannot come fully flat on the table, it means that it is permanently flexed or has a flexion contracture.

A flexion contracture can make your leg seem shorter when you stand and walk. This is part of an apparent leg length discrepancy. Your doctor will next measure range of motion in other directions or planes. Limited range of motion may be a sign of an arthritic or diseased hip. He will first flex your hip. That is, he will attempt to bend your leg up towards the rest of your body. The point at which your hip stops bending is the range of  flexion. Typically, a hip with arthritis will have limitation of both flexion and extension. Your doctor will then check the range of  rotation. Rotation can be tested in two directions, internal and external.

Internal rotation is when the thigh is turned inward so that the foot points away from the body. External rotation is the reverse. Patients with an arthritic hip often have limitation of internal rotation. It may be both limited and painful. Your surgeon will also test the range of  adduction and abduction. Adduction is bringing your leg over the midline of your body as if it would cross the other leg. Abduction means bring your leg away from your body as if you were doing a split.

A diseased hip may show limitation of motion in both directions. Adduction is often painful. Your surgeon will look for swelling in other joints. This might be a sign of another disease process such as rheumatoid arthritis or Lyme disease. He will check the range of motion in your knees and ankles and look for any deformities in your feet. If movement of these joints causes pain in your leg, your surgeon may want to take x-rays or do further investigation.

A peripheral neurologic examination of your leg is important. This is done to make sure that there are no associated neurologic conditions causing pain. Your doctor will do a straight leg raise test and check the sensation and motor strength of your leg. He may also test the reflexes. He will feel the pulses in your legs and feet.

This is to make sure that your have adequate circulation. Poor circulation can cause pain in your thigh and leg and may limit your walking. If there are no pulses, arterial disease should be ruled out as a cause of pain. It is critical to make sure that blood circulation in the leg is adequate if surgery is being planned. Your doctor may perform a Trendelenburg test.

He will ask you first to stand and balance on your good leg and then to do the same on the bad leg. If you are unable to balance on your bad leg, your body will tip to the side. This is a positive test. It indicates weak muscles around your hip, a sign of hip disease. Your doctor will examine the way you walk and per-form an evaluation of your gait. If you have a flexion contracture, you may walk with a flexed hip and you may lean forward on your bad hip as you walk.

You may also demonstrate an abductor lurch where your body tips to the side of your bad hip. Most patients with painful hips will show a limping or antalgic gait. If disease is severe, you may require a cane or other assistive aids to walk at all. Physical findings may depend somewhat on the type of disease and degree of involvement in the hip. For example, patients with advanced osteoarthritis will have a flexion contracture and severely limited range of motion.

There may even be audible noise, or crepitus, as the hip is moved. On the other hand, patients with avascular necrosis may have severe pain with movement but relatively good range of motion until the final stages of the disease. Patients who have been treated for dislocated hips in childhood may have shortening and a leg that is internally rotated.

Others who have been treated for slipped capital femoral epiphysis during the teenage years may have an external rotation gait and turn their legs out-ward as they walk. If a patient has had polio or other neurologic disease for many years, the leg may be shortened and the muscles weak.

This may affect all joints of the leg not only the hip. Your doctor’s physical examination can provide many clues as to the nature of the problem in your hip and help him make a better diagnosis.