Physical Exam: Hip Hip

Having gotten (literally) to the end of the upper extremity (what civilians call the \”arm\”), we now leg down to the lower extremity.  Technically, we are dealing with the transitional zone between leg and torso: the hip.
Hip, not hip or hip

Now, the word \”hip\” creates quite a bit of confusion.  I know many of my readers think of me as one hip dude.  Why do they think I am so hip?  Maybe it is my sick writing skilz.  Maybe it\’s my overuse of a tired gag about a South American quadruped.  Maybe it\’s because my mom has bribed them with a Dutch pastry that is light yet satisfying.  Whatever the case, I am not talking about anything related to my hipness.

I am definitely not talking about the fruit of the rose.  I didn\’t even know roses had fruit.

But the real confusion comes from what most people call their hips. When people say their hips hurt, they are talking about this:

When a person complains about having fat hips, they are not talking about adipose tissue in their hip joint.  They are also not (usually) talking about the fruit of roses.  They are talking about their trochanteric region.  I guess it wouldn\’t sound good for a guy to say about a woman: \”she\’s got a great trochanteric region (bilaterally).\”   Some guys might say that kind of thing, but they wouldn\’t get very far with those ladies.  I\’ve found that most women are repelled by the word \”trochanteric.\”

This doctor is pretending to do something to the
trochanteric region.  Doctors like to pretend like that.

No, when I\’m talking about the hip, I am talking about the ball-joint between the pelvis and the femur (the big leg bone above the knee).  We as doctors are used to translating \”my hip hurts\” to \”I have a pain in the trochanteric region,\” so you don\’t have to worry about jeopardizing your care by creating confusion.  Still, it is an important distinction as real pain in the hip joint doesn\’t occur in the place people think of as the hip, it happens here:

I chose the picture of Elvis because he\’s so hip.

Hip pain happens more in the groin than the hip.  It confuses people when you tell them their hip pain is not hip pain and their groin pain is hip pain.  I suppose any pain Elvis would have would be hip pain, which is why I am glad I wasn\’t his doctor.

Examination of the Hip

The exam of the hip is guided by the complaint the person has.  If the person says they have hip pain (which is, in fact, trochanteric pain), the most likely cause is trochanteric bursitis.  Trochanteric bursitis is diagnosed by poking on the outside of the leg over the hip that\’s not really the hip.  If the person says \”ouch,\” \”yow,\” \”#@%$!!,\” or punches you, it\’s probably bursitis.

It is much easier to diagnose if the words \”Trochanteric bursitis\” are written around the level of the 4th lumbar vertebra, but I am not usually so lucky.  A bursa is a small sack that is sometimes full of fluid, but usually sits there waiting to cause trouble.  Putting ice on it, doing certain exercises, taking anti-inflammatory medications, and sometimes getting a cortisone injection are the means by which trochanteric bursitis is fixed.

So then what about the hip that\’s not thought of as a hip but rather the groin (but\’s really the hip)?  Well, that\’s really what this post is about.  That\’s a much more interesting exam than the highly complex task of pushing on the side of a person\’s leg.  The hip joint (see above) is a ball-in-socket joint, which allows for a wide range of movement.

  • Flexion – bending at the hip to bring the knee toward the head.
  • Extension – opposite of flexion; straightening the hip out.
  • Abduction – spreading the legs so the knees are apart from each other.
  • Adduction – moving of the knees together, and even crossing the legs at the knees (which some errantly see as bad for you).
  • Internal rotation – with hip flexed, rotating the leg so that feet move apart from each other.
  • External rotation – opposite of internal rotation (duh); the action more commonly associated with crossing the legs.
  • Hip Hop – can\’t touch this, gangsta.

Problems with the Hip

I don\’t regularly examine the hip (except in infants), so the main thing that moves me to do so is pain.  Lots of things can cause hip pain (that\’s actually in the groin), so I will highlight the common causes.

Hip Flexor Injury is an injury to the …uh…hip flexors.  These are the muscles right at the front of the hip joint itself.  It is a common soccer, running, and football injury.  Sometimes guys who are old enough to know better take up a martial art and injure their hip flexors when trying to do a kick, causing them to limp around pathetically for several weeks (not that I would know anything about that).

Arthritis of the hip is the most common cause of hip pain, although it often presents with only a decrease in range of motion – especially in rotation.  If it causes pain, it is a pain in the acetabulum, which is the cup part of the pelvis that holds the ball part of the femur.  Osteoarthritis causes narrowing of the joint and spurring to occur (extra bone tissue) on the ball of the femur and the acetabulum.

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It occasionally also has the big word Osteoarthritis around the 4th lumbar vertebra, which makes the diagnosis much easier.

Hip Fracture is caused by a fracture of…the hip.  This is one of the most common fractures associated with osteoporosis, and happens on the neck of the femur, right below the ball.  It\’s actually a very serious thing, associated with a very high death rate when sustained by a person 80 or above.

In pediatric patients, there are two main causes of hip pain.  Avascular Necrosis of the Femoral head (AKA Legg-Calvé-Perthes disease), and Slipped Capital Femoral Epiphysis. These conditions show how pediatricians compensate for an overall lack of hip problems by naming them in ways that cause you to spit on your colleagues.

The first condition (the avascular thingy) happens in school-aged kids, mainly boys.  It is related to a compromised flow of blood to the bone which causes a section of bone to die.  This usually gets better with just resting the hip, although there is a chance of longer-term damage if the condition is bad enough.

The second condition (the slipped capital etc.) happens mainly to obese kids in their early teens.  As if it is bad enough to be an obese middle school student, the bone fractures at the growth plate at the end of the femur, causing the bone to slip back.  This is hard to diagnose, as it can present with minimal or vague pain, but benefits greatly from early diagnosis.  Kids with slipped etc. should go to a pediatric orthopedist if possible so they can get treatment ASAP.  Treatment often involves putting a screw in the end of the femur to stabilize the joint.

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Which is one more way that obese middle-school students can get screwed.

11 thoughts on “Physical Exam: Hip Hip”

  1. I had significant bilateral “hip pain”, increasing over the years, and figured i was headed for early bilateral hip replacements. Early, as in, I’m only 56. ( My mom and dad had severe arthritis, and my mom had 2 hips and 2 knees replaced, and her feet done, too. But she also had rheumatoid on top of osteoarthritis.) I attended a community presentation of a new type of hip replacement surgery, and made an appt. with the surgeon, and made an appt. with the surgeon to discuss it.
    Early last summer, I was totally shocked to learn that it was bilateral bursitis, not arthritis! The exam consisted of xrays, physical exam of moving my joints and finding the tender spots, and observing my gait (how i walk). The ortho doc said it was one of the most severe cases he had seen. I’d never even heard of hip bursitis!

    I was put on scheduled motrin for (ultimately) 5 months, had cortisone shots (which hurt but after a few days really help!), and did physical therapy 3x / week for a number of months. I also made significant lifestyle changes: stopped sleeping on my sides and tummy and started sleeping on my back (that was AWFUL!), with a pillow under my knees; put a 4″ foam mattress on my bed; stopped curling up on the couch or any chair (as a very short person, my feet don’t reach the ground, so i have always sat curled up); stopped crossing my legs at the knees; and i even had to stop going out for walking exercise for a number of months. In mid-winter, i also started 2-3x /week exercise class for seniors at the YMCA, modifying the exercises as i could handle them.

    I am very thankful to report that this summer, i am out walking again, pain has decreased considerably, and i can now rest on my side for short periods at night. I only have to take pain meds afew times a week at night, and if i am mindful of how i move and turn, i don’t have acute episodes of pain.

    There is life after hip bursitis.

  2. ?Internal rotation – with hip flexed, rotating the leg so that feet move apart from each other.?External rotation – opposite of external rotation (duh); the action more commonly associated with crossing the legs. Is this backwards, or am I confused (again)?

  3. Sigh. I will fix it. The internal rotation IS when the foot is rotated away from the other foot (abducted) and external is when it is moved toward the other foot (adducted). I got this backward, but I forgot to fix the “opposite of.” I guess the “duh” fits.

  4. Dr. Rob, Thank you. I had the best laughs for this week. I am so glad that you are now and entertainer. Need to go to Vegas.I needed this this morning. PC

  5. As a person with psoriatic arthritis, which affects both bone and connective tissue, this was fun to read! I learned something but was entertained. I’ve had the bursitis and the limited range of motion . . . and the hip pain that is not in the hip. It wasn’t fun walking around with pain in the uh . . groin, wondering how I was going explain this to my rheumy. I didn’t. Next time, maybe I will be able to think of something thanks to reading Dr. Rob.

  6. I had a hip scope for a labral tear three years ago…and you’re not kidding about the groin pain!

  7. So external rotation of the hip moves the foot in toward the center of the body,and internal rotation of the hip moves the foot out to the side?

    I think I’m going to go play with our skeleton to see if that helps this make more sense.

    (great post – I love your physical exam series)

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