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Sh.Haghighat M.D. Assistant professor Physical Medicine & Rehab. Department Isfahan Medical College Pelvis, Hip, and Thigh Examination

The pelvis is a complex bony structure that is formed by the joining of seven individual components. On each side of the pelvis, the ilium, the ischium, and the pubis fuse together to become a pelvic, or innominate bone. The right and left pelvic bones join each other anteriorly at the pubic symphysis and join the sacrum posteriorly at the sacroiliac joints to form a closed ring

INSPECTION The most prominent feature of the pelvis is the arching superior margin of the ilium, known as the iliac crest. the anterior superior iliac spine (ASIS) is the anterior terminus of the iliac crest The hip joint itself is located 2 cm lateral and 2 cm distal to the point at which the femoral pulse is palpable beneath the inguinal ligament ANTERIOR ASPECT

The most prominent bony landmark is the greater trochanter of the proximal femur D, gluteus medius E, tensor fascia lata F. gluteus maximus LATERAL ASPECT

The posterior border of the crest is seen to curve posteriorly and medially to its point of termination, the PSIS. The PSIS overhangs the sacroiliac joint, which is located just distal to it POSTERIOR ASPECT The ischial tuberosity is not normally visible, but it is palpable in the inferior medial buttock deep to the gluteus maximus

ALIGNMENT: leg length discrepancy  Abnormalities of limb length usually result in obliquity of the pelvis; therefore, a check for pelvic obliquity is an excellent starting point to begin the alignment examination  The many possible causes of obliquity can be divided into two large groups: factors resulting in a true leg length discrepancy and factors resulting in a functional, or apparent, leg length discrepancy.

To check for a true leg length discrepancy, the examiner identifies the patient's ASIS and places the free end of a tape measure on it toward the distal tip of the medial malleolus

Femoral Versus Tibial Discrepancy

To check for a functional leg length discrepancy, the examiner measures the distance from the patient's umbilicus to the tip of each medial malleolus

GAIT With the weight of the patient's upper body bearing down on one side of the femoral head and the abductor muscles pulling at a force twice the patient's upper body weight on the other side, a compressive force of three times the weight of the patient's upper body is transmitted across the weight- bearing femoral head with every step.

A) When stepping on the unaffected side, the pelvis remains level. B) When stepping on the affected side, the pelvis tilts downward toward the unaffected side, and there is a subtle shift of the torso. Trendelenburg sign

FABER (Femoral ABduction External Rotation) or Patrick’s test If Patrick's test produces posterior hip pain, pathology of the sacroiliac joint should be suspected. An arthritic hip may also be painful when placed in this position, but the pain is normally felt in the anterior groin. The figure-four position also places the iliopsoas muscle on stretch. Pathology of the iliopsoas, such as an intrapelvic abscess irritating the iliopsoas sheath, leads to pain in this position. This is sometimes called the iliopsoas sign. Tests for acetabular pathology

Stinchfield test ‒ Ask the supine patient to raise their leg off the table, while keeping the knee in full extension, against resistance provided by the examiner pressing a hand against the lower shin. The test is positive if it elicits pain and/or weakness be due to intra-articular hip

 Snapping of the iliopsoas tendon (internal snapping hip syndrome)is a common incidental finding without clinical significance. However, the snapping can become painful and can be difficult to distinguish from an intra- articular problem  The snapping occurs as the iliopsoas tendon transiently lodges on iliopectineal eminence or femoral head

Snapping due to the iliotibial band(lateral snapping hip syndrome) is more easily distinguished from a hip joint disorder because of its lateral location. 9 9 These patients frequently present with a sensation that their hip is subluxing or dislocating. The visual appearance is created by the tensor fascia lata flipping back and forth across the greater trochanter, and not instability of the hip.

The piriformis test is performed with the patient in the lateral decubitus position with the side to be examined facing up. The patient's hip is flexed 45° with the knee flexed about 90°. The examiner stabilizes the patient's pelvis with one hand to prevent pelvic rotation The examiner's other hand then pushes the flexed knee toward the floor, thus internally rotating the hip

Tests of sacroiliac region ● Posterior shear or thigh thrust test – With the patient supine, the examiner places one hand under their sacrum and then flexes their hip and knee both to 90 degrees. With the patient in this position, the examiner applies pressure downward along the axis of the femur. Pain at the ilium or SIJ suggests SIJ dysfunction [5].5 ● Gaenslen test ● Gillet’s test ● FABER test

Gaenslen test

Gillet’s test Normally, the examiner should feel the sacrum move posteriorly on the side where the patient flexes their hip and knee; minimal movement or movement anteriorly marks a positive test.

Pt supine. Examiner applies posterolateral directed pressure to bilateral ASIS. (Reproduction of pain) pelvic distraction lest(Gapping test)

The Ober test assesses the tightness of the iliotibial band (ITB). It is performed with the patient lying on the unaffected side, with the hip and knee of the unaffected lower extremity both positioned in about 90 degrees of flexion. The examiner slightly abducts and extends the affected hip and flexes the knee. The patient is then asked to allow the affected leg to fall to the table passively, without actively adducting the hip (just letting it fall with gravity), while the examiner supports the patient's lower leg. Patients with ITB syndrome are more likely to have limited adduction of the leg with this maneuver Tests for lateral hip pain

Tests of hip flexors ● Thomas test ‒ ● Modified Thomas test ‒ From the same starting position as the Thomas test, look to see if the pelvis comes up off the table. A positive test is indicative of hip flexor tightness, involving either the tensor facia latea and/or rectus femoris. ● Ely test

Thomas test of hip flexor and knee extensor tightness

In the presence of a tight rectus femoris, full pas-sive knee flexion produces involuntary flexion at the hip, causing the buttocks to rise off the examination table