2. Heel strike

Femoral fracture, trauma

compensatory motion in the pelvis. Limited adduction/abduction could result from a contracture of the respective musculature. Flexion is recorded by having the patient flex both thighs into the chest, flattening the lumbar spine and keeping the knee flexed to oppose any hamstring tightness. Normal flexion is 120°. Difficulties in flexion result in limited active daily living [1].

The Thomas test is performed to assess any hip flexor contracture that may be present. With the patient holding the nonaffected leg in the flexed position, lower the affected leg to the table. If the thigh cannot reach the table, this represents a positive Thomas test, and is a sign of the hip flexor contraction. Note the angle between the femoral shaft and the table [32]. If a clicking is audible during this test, it may be an indication of a labral tear [16], or coxa sultans externus. Clicking is most indicative of a tear and a louder, more audible pop, is snapping of the psoas tendon.

The McCarthy test is performed in an attempt to re-establish the discomfort felt by the patient in order to discover the underlying etiology. The cause of pain reconstructed from this test is likely a tear of the acetabular labrum. This test is relevant in that most tears occur in the anterior acetabulum, compounded in athletes who have acetabular dysplasia [39-44]. By rolling the hip in a wide arc of internal and external rotation through flexion to extension, the goal is to find a site of bony impingement that may have caused a tear [45]. A positive McCarthy sign is noted by recreation of the patients pain in a specific position.

The Patrick FABER (Flexion ABduction External Rotation) test is the classical physical examination test for the characterization of hip pain in the abducted position. The test is performed by laying the ankle of the affected leg across the thigh of the nonaffected leg proximal to the knee joint, creating a figure 4 position. This position displaces the anterior superior rim of the femoral neck to the twelve o'clock position of the acetabular rim. Pressure is applied to the knee of the affected leg, causing stress in the ipsilateral sacroiliac (SI) joint. Pain in the posterior hip should cause consideration of SI joint pathology. Pain in the groin can be caused by pathology of the iliopsoas muscle, resulting in an iliopsoas sign [32]. Pain in the lateral aspect of the hip can also be associated with lateral femoroacetabular impingement (FAI).

Because of the demands placed on the hip in sports-related activities, it is necessary to assess the hip for trauma. This assessment is made through the log roll test and the heel strike test. Rolling the leg in the Z axis on the table will reproduce pain in femoral fractures. Striking the heel of the foot will reproduce pain if the fracture has occurred in the femoral neck. Positive signs in either of these two tests should warrant radiographic investigation.

Finalizing the supine examination, bony and soft tissue structures around the pelvis should be palpated for tenderness. The abdominal examination should include inspection and palpation for fascial hernias. Fascial hernias may be difficult to detect by palpation, and the isometric contraction of the rectus abdominus and obliques can facilitate their detection. The region of the ilio-inguinal ligament should be inspected and the presence or absence of a Tinel's sign (tingling sensation in the distribution of the femoral nerve) at the level of the ilioinguinal ligament indicating femoral nerve pathology should be noted [32]. Palpation of the adductor tubercle as the patient adducts the extended leg may help identify adductor tendonitis, because point tenderness will be present in this location. Pain with palpation of the pubic symphosis is a cause for further examination of the area. Additional palpation should be continued in the lateral position.

Lateral Position

The lateral hip examination (Table 7) is performed with the patient in the lateral recumbent position lying on the unaffected hip with his shoulders perpendicular to the table. The physical examination tests in the lateral position are useful in the determination of lateral-based hip pain, and can further confirm the presence of intra-articular pathology.

Palpation for tenderness is continued, with special attention given to the SI joint, gluteus maximus origin, piriformis, sciatic nere, iliotibial band (ITB), greater trochanteric bursae, tensor fascial lata and ischial tuberosity [1,16,31, 32,46,47]. Tenderness in one of these regions warrants further examination.

Ober's test is used to assess the tightness of the 1T B and fascia lata. Three positions are examined in this test: extension, neutral, and flexion. These refer to the positions of the affected leg in respect to the nonaffected leg. In extension, the affected leg is abducted with the knee flexed. When the force abducting the leg is removed, the affected leg should adduct due to gravity. 1f the leg remains abducted, this is a positive Ober's sign. The neutral position is performed similar to extension with the knee flexed, and is a test of the gluteus medius tension. 1n flexion, the ipsilateral shoulder should be rotated posteriorly (making both shoulders come into contact with the table) and the knee extended to assess the gluteus maximus origin in cases with gluteus maximus contractures. The 1TB tension may be released by flexing the knee, and this technique can

Table 7

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