Elevenstep Examination

Standing Examination

The initial element in the structured evaluation (Table 1) should be the general body habitus, principally gait and alignment. Because of the hip's role in

Examination

Assessment/association

Body habitus

Examination

Assessment/association

Body habitus

1. Spinal alignment

Shoulder/iliac crest heights, lordosis, scoliosis, leg length

2. Gait a. Trendelenburg b. Antelgic c. Pelvic rotational wink d. Excessive external

Abductor strength, proprioception mechanism

Trauma, fracture, synovial inflammation

Intra-articular pathology, hip flexion contracture

Femoral retroversion, increased acetabular anteversion, torsional abnormalities, effusion

Increased femoral anteversion or acetabular retroversion, torsional abnormalities, effusion iliotibial band pathology, true/false leg length discrepancy rotation e. Excessive internal rotation f. Short leg limp supporting body weight, hip pathology can often be identified in gait abnormalities [1]. An antalgic gait (one that involves a self-protecting limp caused by pain, characterized by a shortened stance phase on the painful side so as to minimize the duration of weight bearing) is an indication of hip, pelvis, or low back pain [33,34]. The gait should be observed so that the full stride length can be assessed from the front and side [30]. Common key points of evaluation should include stride length, stance phase, foot rotation (internal/external progression angle), and the pelvic rotation in the X and Y axes [1,30,32]. It is recommended that the patient walk down the hall if the room is not big enough to give the physician a chance to observe six to eight full strides.

A Trendelenburg gait is indicative of hip abductor weakness, and is often referred to as an abductor lurch. The pelvic wink displays excessive rotation in the axial plane (greater than the normal 40°) toward the affected hip to obtain terminal hip extension. This gait pattern is associated with internal hip pathology or with hip flexion contractures, especially when combined with increased lumbar lordosis or a forward-stooping posture. Special attention should be given to a limp, noting that a limp with an external foot progression could indicate effusion or traumatic condition. Consideration should also be given to any snapping or clicking the patient or physician hears, noting location as internal or external to the hip joint or derived from within the joint itself. This audible sign could be indicative of psoas contracture (coxa sultans interna), tightness of the iliotibial band (coxa sultans externa) or intra-articular pathology. Coxa sultans interna/ externa can be distinguished by the patient actively demonstrating the pop by recreating the sound as he rotates the hip.

The second aspect in observing general body habitus is alignment. Compare the patient's shoulder heights with the heights of the iliac crests to further any leg length discrepancy issues. Other palpable bony structures for pelvic alignment assessment include the anterior superior iliac spine and posterior superior iliac spine. A tilted pelvis can indicate a leg length discrepancy, which can be further investigated by measuring leg lengths manually from the anterior superior iliac spine (ASIS) to the ipsilateral medial malleolous in order to differentiate between

Table 2

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