Start the hip examination by watching the patient walk, then look, feel and move with the patient supine. Test internal rotation with the hip flexed, because NICE Clinical Knowledge Summaries identify painful restriction of internal rotation with the hip flexed as the sign of hip osteoarthritis, and finish with leg length and function.

Key takeaways

  • NICE CKS gives normal passive hip movement as about 130 degrees of flexion, extension to 15 degrees beyond neutral, and roughly 45 degrees of internal and external rotation.
  • Painful restriction of internal rotation with the hip flexed points to hip osteoarthritis, according to NICE CKS.
  • In a Trendelenburg gait NICE CKS describes a lurch towards the affected hip with the pelvis tilting down on the unaffected side.
  • NICE CKS says hip pain can refer to the lateral thigh, buttock, anterior thigh, knee and ankle, so always examine the knee.
  • The Thomas test detects a hip flexion contracture, but published work shows the modified version is only valid when pelvic tilt is controlled.

What is the examiner marking at the hip station?

The Intercollegiate blueprint marks a physical examination station out of 20 across four domains: clinical and technical skill carries 8 marks, and clinical knowledge and its application, communication and professionalism carry 4 marks each. The station also gets a separate global rating of pass, borderline or fail.

More than half the marks therefore sit outside your knowledge of the condition, so a silent but technically correct examination scores poorly. You are signalled at six minutes of the nine to present your findings, so the sequence has to finish inside six.

The examiner is marking whether you start with gait and finish with function, and whether your findings add up to a diagnosis. A hip examination performed only on the couch loses marks immediately.

Narrate your findings as you go: a candidate who says what a sagging pelvis means scores above one who simply performs the test.

How should you start the hip examination?

Introduce yourself, gain consent, expose the patient from the waist down while preserving dignity, and ask about pain.

Then watch the patient walk, turn and walk back. NICE CKS notes that observing gait, the ability to walk and pain behaviour is part of the assessment, and that a high-stepping gait with an inability to lift the foot suggests weak ankle dorsiflexion.

Which gait patterns should you be able to name?

Name the pattern you see and its implication, briefly.

  • Antalgic gait, with a shortened stance phase on the painful side
  • Trendelenburg gait, a lurch towards the affected hip with the pelvis tilting down on the unaffected side, which NICE CKS attributes to wasting and weakness of the gluteal and anterior thigh muscles in advanced hip osteoarthritis
  • High-stepping gait, which NICE CKS links to weakness of ankle dorsiflexion
  • Broad-based unsteady gait, which suggests a neurological cause rather than a hip problem

**The Trendelenburg test** is a standing single-leg test of the hip abductors of the weight-bearing leg, so a pelvis that drops on the lifted side indicates a problem on the side being stood on.

What am I looking for on inspection of the hip?

Look from the front, side and behind with the patient standing, then again supine.

  • Scars, including posterior scars that are only visible from behind
  • Muscle wasting of the gluteal muscles, quadriceps and hamstrings
  • Deformity, with NICE CKS describing a fixed flexion external rotation deformity, compensatory lumbar lordosis and pelvic tilt in advanced hip osteoarthritis
  • Apparent limb shortening, which NICE CKS notes can be significant in advanced disease

Which movements should you test, and what is normal?

Test passive movement supine, stabilising the pelvis with your other hand so the lumbar spine does not supply the range.

  • Flexion, normally about 130 degrees per NICE CKS
  • Extension to about 15 degrees beyond neutral
  • Internal and external rotation, roughly 45 degrees each, tested with the hip and knee flexed to 90 degrees
  • Abduction and adduction, with a hand on the opposite iliac crest to detect pelvic movement

NICE CKS notes that pain during any of these passive movements suggests hip pathology, which is the sentence to say as you test.

Which special tests are worth doing at the hip?

The Thomas test for a fixed flexion deformity, and the Trendelenburg test for abductor function. Flex both hips to flatten the lumbar lordosis, hold one flexed and lower the other; residual flexion is the contracture.

Say the limitation aloud. Published biomechanical work shows the modified Thomas test is not a valid measure of hip extension unless pelvic tilt is controlled, so interpret it alongside the rest of your findings.

What are the most common mistakes at the hip station?

  • Examining the hip on the couch without ever watching the patient walk
  • Failing to stabilise the pelvis, so lumbar movement is recorded as hip movement
  • Reporting a Trendelenburg test on the wrong side, since the fault lies on the standing leg
  • Missing referred pain, when NICE CKS lists knee and ankle among the sites hip pain refers to
  • Leaving out leg length measurement and function, which complete the station

How should you finish the hip examination?

Measure true and apparent leg length, examine the joint above and below, and assess neurovascular status.

State how you would confirm osteoarthritis. NICE CKS supports a clinical diagnosis without imaging in a person aged 45 or over with activity-related joint pain and either no morning stiffness or stiffness lasting no longer than 30 minutes.

The MRCS Part B Questions bank has a hip examination station at /Sample-Questions.