Musculoskeletal examination of the hip and groin

INTRODUCTION — Hip and groin pain are common complaints among active adults and pose a diagnostic challenge to clinicians due to the complex anatomy and biomechanics of the region. Effective evaluation of the hip and groin depends upon an understanding of local anatomy and function and the proper performance of a focused physical examination.

The clinical anatomy and examination of the hip and groin are reviewed here. The diagnostic approach to hip and groin pain and discussions of specific injuries and conditions involving structures in the hip and groin are discussed separately. (See "Approach to the adult with unspecified hip pain" and "Approach to hip and groin pain in the athlete and active adult".)

ANATOMY AND BIOMECHANICS — The pelvis is a bony ring-like structure that provides postural support when stationary and during movement (figure 1 and figure 2) [1]. In addition, the pelvis provides a stable platform for the hip (picture 1), a ball and socket joint positioned at each inferolateral aspect of the pelvis that enables rotation, flexion, extension, abduction, adduction, and rotation of each lower extremity. The bones forming the hip include the ilium, pubis, and ischium bones. The hip joint consists of the femoral head (ball) and the acetabulum (socket), a cavity created by the hips bones. The depth of the acetabulum is increased by a triangular fibrocartilage structure called the labrum that attaches along its outer rim.

Posteriorly the ilium articulates with the sacrum. This sacroiliac joint provides a stable connection between the pelvis and the lower spine. This allows force transmitted down the spine to be transferred in part to the pelvis. Conversely, forces absorbed during impact with the ground and transmitted up the lower extremities, during such activities as running and jumping, can be dissipated through the pelvis and spine. The sacroiliac joint is considered an amphiarthrosis, as it is an intermediate between a synarthrosis and diarthrosis permitting only minimal movement [2]. The ilial surface is slightly convex and the sacral surface slightly concave, which increases stability and limits motion. Motion is only approximately 3 degrees in both the longitudinal and transverse planes but appears important for normal rotation of the hemipelvis and for flexion and extension of the hip. Below the sacrum, the coccyx forms the distal portion of the spine (figure 3) [3].

The pelvis must support the entire torso and upper extremities, and support of the bony articulations is provided by powerful ligaments (figure 4 and figure 5). At the same time, pelvic motion is a critical aspect of normal walking and running so the left and right hemipelvis have articulations at the sacroiliac joint that allow some rotation and both flexion and extension of the trunk. The sacroiliac ligaments, as well as the sacrotuberous and sacrospinal ligaments, prevent anterior translation of the hemi-pelvis and help to stabilize the joint during motion. The iliolumbar ligament assists in stabilizing the posterior pelvis. The sacroiliac joint is a stress point during motion and thus a frequent location for injury. Anteriorly, the pelvis has a strong ligament that encompasses a disk lying between the superior pubic rami and forms the symphysis pubis (figure 2). Together the symphysis pubis and sacroiliac joint allow a small degree of anterior translation of the hemipelvis. Combined with posterior translation of the opposite hemipelvis, this motion is sufficient to allow for pelvic rotation in an anteroposterior plane, thereby enabling efficient walking and running.

Key muscular attachments to the hip and pelvis include those for muscles that stabilize and move the hip joint (figure 6). On the anterior surface of the hip, the iliacus and psoas descend from the ilium and lumbar vertebrae respectively and fuse to form the iliopsoas muscle, a major hip flexor (figure 7). The iliopsoas tendon attaches to the lesser trochanter of the proximal femur. Just medial to the iliopsoas on the anterior surface is the pectineus muscle that arises from the anterior aspect of the superior pubic ramus. The pectineus inserts on the superior femur along the pectineal line. The rectus femoris is part of the quadriceps complex but also an important hip flexor. Its major tendinous attachment is found at the antero-inferior iliac spine. Superficial anterior hip muscles include the Sartorius, which arises from the antero-superior iliac spine and crosses the thigh to attach at the pes anserine area. The sartorius is a weak hip flexor and assists with external rotation of the thigh. The tensor fascia lata muscle lies just superior and anterior to the hip and attaches to the iliotibial band [4].

Muscles at the medial surface of the hip control adduction of the hip and thigh and assist with hip flexion (figure 8). These include the adductor longus, adductor brevis, adductor magnus, and gracilis.

Muscles lateral to the hip include the gluteus medius and gluteus minimus (figure 9). The tensor fascia lata forms the anterior border of the lateral hip and the anterior fibers of the gluteus maximus form the posterior aspect of the lateral hip. While the gluteus medius is the strongest pure hip abductor, the gluteus minimus and tensor fascia lata assist with abduction when the hip is flexed. Similarly, the gluteus maximus assists with hip abduction when the hip is in extension.

Muscles at the posterior hip include the gluteus maximus, the major hip extender (figure 10 and figure 11). Deep to gluteus maximus are smaller muscles that assist in stabilizing the hip during single leg stance and perform hip external rotation (figure 12). These include the piriformis, superior and inferior gemellus, obturator internus, and quadratus femoris muscles.

Large muscles that attach to pelvis play important roles in providing postural stability and determining pelvic position. At the antero-superior aspect of the pelvis, these muscles include the rectus abdominis and lateral abdominal obliques (figure 13). The antero-inferior attachments include the adductor muscles and hip flexors. Posteriorly, the thoracolumbar fascia, latissimus dorsi, erector spinae, and quadratus lumborum muscles all contribute to stability and position of the pelvis. The hamstrings attach to the ischial tuberosity inferiorly (figure 14).

There are approximately 18 bursae in the hip region; some important ones are shown in the following picture (figure 15). The deep trochanteric bursa (also referred to as the gluteus medius bursa) lies between the tendon of the gluteus maximus and the posterolateral prominence of the greater trochanter and is a common source of inflammation and hip pain [5]. A more superficial bursa directly over the greater trochanter may also become inflamed and tender (figure 16). Other bursa that can become a source of hip pathology include the iliopsoas bursa, located between the psoas tendon and the hip capsule, and the ischiogluteal bursa, located between the gluteus maximus muscle and the ischial tuberosity.

The neuroanatomy of the hip and groin region is complex. The lumbosacral plexus is formed by the ventral rami of T12 to S3 (figure 17). The major nerves that emanate from the plexus include the femoral, obturator, superior and inferior gluteal, and sciatic nerves. The femoral nerve (figure 18) serves the sartorius, pectineus, and quadriceps musculature, and is most commonly injured by direct trauma. The obturator nerve (figure 19) originates from the L2 to L4 nerve roots and provides motor innervation to the obturator externus, gracilis, and adductor musculature, and sensory innervation to the medial thigh (figure 20). The superior gluteal nerve originates from the L4 to S1 nerve roots and provides motor innervation to the gluteus medius, gluteus minimus, and the tensor fascia lata. Injury to this nerve can result in a Trendelenburg gait (picture 2). The inferior gluteal nerve innervates the gluteus maximus. The sciatic nerve (figure 21) arises from nerve roots L4 to S3 and divides into the tibial and peroneal branches, providing motor innervation to the hamstrings and much of the musculature of the lower leg. The sciatic nerve can be injured by compression at the sciatic notch, possibly by tight piriformis or gluteus muscles [6,7].

TIPS FOR A PRODUCTIVE EXAMINATION — The following tips may be helpful for performing the hip and groin examination effectively and efficiently:

●Observe the patient closely, noting their posture, ability to bear weight, and gait.

●Observe the patient walking, looking for Trendelenburg shift (picture 2), uneven pelvis, inability to flex the hip, or a limp. Sagging of the contralateral hip may be due to weakness of the hip abductors.

●Evaluate the asymptomatic side for accurate comparison. Examination of the asymptomatic side first allows the patient to know what to expect and may reduce guarding in the affected extremity.

●Assess for leg length inequality.

●Palpate the key bony landmarks listed below as well as soft tissue structures to assess for tenderness.

●Systematically test adduction, abduction, flexion, and extension strength of the hip, positioning the patient so the results can be compared from side to side.

●Before formally assessing hip range of motion, allow the patient to demonstrate their active mobility at the hip and pelvis to see if there are likely to be limitations during your examination.

●Assess muscular endurance around hip and groin region.

Explaining each step of the planned examination may allow patients who have had significant pain to be more relaxed. Particularly for older adults, consider skipping tests that are likely to cause discomfort or modify them so they are easier for the patient to perform.

TELEMEDICINE EXAMINATION — An article with extensive video clips and photographs describing in detail how to perform the musculoskeletal examination of the hip, knee, spine, and shoulder remotely using telemedicine is provided in the following reference [8].

NEUROVASCULAR ASSESSMENT — Among patients without a history of trauma or neurologic complaints, a focused neurovascular examination confirming basic motor function and sensation and adequate distal blood flow is sufficient. If there is a history of trauma or a lumbar radiculopathy is suspected based upon the history, it is important to perform the relevant elements of the neurologic evaluation, including examination of the reflexes and lower extremity strength and sensation, and any specific tests relevant to the diagnosis being considered, such as the straight leg raise for lumbar radiculopathy. (See "Acute lumbosacral radiculopathy: Etiology, clinical features, and diagnosis", section on 'Clinical presentations' and "Acute lumbosacral radiculopathy: Etiology, clinical features, and diagnosis", section on 'Evaluation and diagnosis' and "The detailed neurologic examination in adults".)

PHYSICAL EXAMINATION — For most athletes or active adults, groin or hip pain that is related to activity stems from a musculoskeletal problem. Thus, the examination of such patients focuses on the soft tissues and bones most likely to be involved. However, depending upon the clinical scenario, it may be important to rule out medical or neurologic conditions (eg, inguinal hernia, urinary tract infection, lumbar radiculopathy, abscess, tumor) and an appropriate physical examination, including evaluation of the genitourinary system, may be necessary.

The patient with groin pain likely due to a musculoskeletal problem is examined using a standard approach, including: inspection, palpation, range of motion testing, strength testing, and special tests. The emphasis and scope of the examination is focused based upon the most likely diagnoses, as determined by the history. Having the patient provide a complete history and indicate the site of pain helps to direct the examination. The physical examination is tailored to the individual, and typically includes an assessment of gait, followed by an examination while standing, then lying, and finally special testing based upon the most likely presumptive diagnoses. At each stage, the basic progression of observation, palpation, range of motion testing (both passive and active), and strength testing (both active and resisted) is used.

Assessment of gait and the standing patient — Gait assessment is reviewed in detail separately, but aspects of particular importance to the examination of the hip and groin are discussed here. (See "Clinical assessment of walking and running gait".)

Begin the examination by watching the patient walk into the room or move from a seated position to lying supine on the examining table; look for signs of weakness, instability, or pain. It is useful to have the patient walk at least six to eight strides while watching for asymmetry, stride length, and internal or external hip rotation. In addition, the presence of snapping or clicking should be assessed as these can be associated with tight iliotibial band structures or intra-articular hip pathology. Trendelenburg gait consists of the trunk lurching toward the affected side during the stance phase of gait (figure 22 and picture 2), often due to weakness of the abductor muscles on the ipsilateral side that prevents the pelvis from dropping. Trendelenburg gait can also be seen in patients with hip pathology who are trying to avoid the compressive loading of the hip that occurs when the abductors contract.

Next, with the patient standing, palpate the lumbosacral spine and the sacroiliac joints for tenderness or deformity. Focal tenderness in these areas may indicate spine rather than hip or groin related pathology. Keep in mind that patients presenting with hip diseases may have coexisting spine disorders, a condition that is termed "hip-spine syndrome." Contributing factors can include leg length discrepancy, hip pain, and decreased hip motion leading to spinal misalignment. Therefore, signs of spine pathology do not rule out additional hip or groin pathology [9]. Assess for leg length discrepancy by noting the height of the iliac crests. Have the patient bend forward and touch the ground, bend to each side, and rotate and extend their spine. When the patient performs these motions, assess the segmental motion at each level of the lumbar spine: Is it smooth or is there dysfunction, pain, or loss of motion? The Trendelenburg test should be performed with the patient standing while the clinician observes from behind to look for abductor weakness. The Gillet test (picture 3) should be performed to assess for sacroiliac joint dysfunction. (See 'Special tests for specific conditions' below.)

The patient should be asked to stand on one leg with the other knee flexed, and then to bend backwards, first on one side then the other. This can help to determine if the sacroiliac joints are functioning normally, and may identify pain or weakness of the pelvic girdle. Significant lumbar pain with one-legged hyperextension may indicate a stress injury of the pars interarticularis (spondylolysis), a common injury among gymnasts, or other posterior elements of the spine. Hyperextension is important to the examination as stronger athletes may compensate using muscle strength and not develop pain until they hyperextend. (See "Spondylolysis and spondylolisthesis in child and adolescent athletes: Clinical presentation, imaging, and diagnosis".)

Examination with the patient supine

Inspection and palpation — With the patient lying supine, inspect the skin for obvious swelling, scars, lesions, ecchymosis, and erythema or other discoloration. Compare the hips and lower extremities looking for asymmetries. Assess potential leg length discrepancy with the patient supine by measuring the distance from the anterior superior iliac spine (ASIS) to the medial malleolus. Alternatively, determine whether the ASIS are level (on the same line in the frontal plane) and compare this with how the medial malleoli align. Repeating the assessment of the leg length with the patient going from lying to sitting is useful in excluding a fixed pelvic rotation or sacroiliac joint dysfunction (which can give the false impression of a leg length discrepancy).

Bone and soft tissue structures that are best evaluated with the patient lying supine include the following:

●ASIS

●Greater trochanter of the hip

●Iliac crest

●Lower lateral border of the rectus abdominis

●Iliopsoas

●Adductor tendons (picture 4)

●Rectus femoris and sartorius muscles and tendons

●Pubic symphysis

●Conjoint tendon

Palpating the pubic symphysis for tenderness as well as the muscle regions below and above the inguinal ligament can help to determine the source of pain. The adductor tendon, lateral rectus abdominis muscle border, and the iliac crest can all be palpated easily with the patient lying supine.

Passive range of motion — Range-of-motion assessments are used to determine mobility and to detect asymmetries or pain. Evaluating passive abduction of the hip is easiest with the patient supine. Abduct one leg by lifting at the ankle, while keeping the other ankle fixed in place. Normal abduction is approximately 45 degrees. Adduction is tested using the same grips by bringing one leg across the body, and is normally 20 to 30 degrees, though motion can be limited by tight abductors. Hip flexion is evaluated by having the patient bring both knees towards their chest; normal is approximately 120 degrees. Evaluating internal and external rotation of the hip is performed passively by flexing both the hip and knee to 90 degrees, and then internally and externally rotating the hip. Normal hip internal rotation is 20 to 35 degrees; normal external rotation is 30 to 70 degrees. Another technique is to passively “log-roll” the fully extended lower limb such that the hip internally and external rotates.

Excessive hip rotation raises the possibility of joint hypermobility in adults. Studies have identified microinstability in the hip as a potential cause of painful hip conditions, and generalized laxity may predispose to such microinstability [10]. Generalized ligamentous laxity is more common in patients who are younger, female, and have a lower body mass index. Normally, the hip can internally rotate about 10 degrees in this position without pain. Asymmetry may indicate arthritis, joint effusion, or other internal derangements, including femoroacetabular impingement (FAI). The FADDIR test can be used to assess further for FAI (picture 5). (See 'Special tests for specific conditions' below.)

Active range of motion, strength, and muscle assessment — After evaluating for passive hip motion, it is useful to evaluate for active and resisted range of motion of the lower extremities to assess for strength as well as pain. The iliopsoas, rectus, adductors, and abductors are often easiest to test with the patient supine. Assess the hip flexors by having the patient perform a straight leg raise with the knee in full extension (picture 6). If they can perform this easily without pain, have them lift the leg again against resistance. Both the iliopsoas and rectus femoris are assessed with this maneuver. The rectus femoris is also a knee extensor and can be tested by resisting knee extension (patient straightens their knee while the examiner resists). The Stinchfield test is used to assess the strength of the iliopsoas, while the Thomas test is used to assess hip flexor tightness (picture 7). Tight hip flexors can contribute to a number of hip and groin problems, including tendinopathy, rectus femoris tears, and avulsion fractures particularly of the AIIS.

Evaluate the adductors and abductors with the knees fully extended, then repeat with the knees flexed. Alternatively, hip abduction can be tested while the patient lies on their side or by having them perform repeated lateral straight leg raises, which isolates the gluteus medius and may help to identify subtle weakness. Decreased hip adductor strength increases the risk of groin injury [11]. An inside straight leg lift with the patient lying on their side and lifting the lower leg against resistance can isolate pure adduction. An adductor squeeze test, performed with the supine patient's feet on the examination table and hips flexed to 45 degrees, allows further assessment of adductor strength. Test the right sartorius muscle by having the patient place their right heel on their opposite ankle, externally rotate their right hip, and then bring their right heel up to their knee. This motion can be tested with or without resistance. The sartorius can also be tested from a seated position with the examiner applying resistance to an internally rotated lower leg with the hip and knee in slight flexion and external rotation.

Hamstring inflexibility contributes to pelvic dysfunction and abnormal pelvic tilt. Since the hamstrings attach to the ischial tuberosity, excessive tightness may pull the inferior pelvis posteriorly and cause the pelvis to rotate if this is unilateral or if bilateral to tilt anteriorly. Hamstring flexibility may be assessed with the patient lying supine by assessing the popliteal angle (picture 8). With the hip flexed to 90 degrees, and the knee flexed to 90 degrees, the lower leg is slowly lifted in an attempt to straighten the leg completely. If this is possible, the popliteal angle is 0 degrees. Anything short of this is given a positive value. As an example, a popliteal angle of 10 degrees exists when the patient lacks 10 degrees of full knee extension. Hamstring tightness may contribute to knee and low back dysfunction in some athletes. A similar test is used to assess recovery following hamstring injury. (See "Hamstring muscle and tendon injuries", section on 'Return to work or sport'.)

Faber test and sacroiliac joint — With the patient lying supine, the sacral compression and FABER tests (figure 23 and picture 9) can be performed to assess sacroiliac function. The sacral compression test consists of pushing down on both sides of the pelvis simultaneously. Lack of motion on one side suggests a fixed sacroiliac joint. A positive FABER (or Patrick) test is associated with sacroiliac dysfunction and osteoarthritis of the hip, but sometimes pain is caused by conditions like degenerative disc disease of the lumbar spine, iliopsoas contracture, or femoroacetabular impingement.

Pain patterns differ with the FABER test depending upon the condition causing the limitation. As an example, sacroiliac joint dysfunction may occur at the joint tested or at the contralateral side. Lumbar spine pathology may lead the patient to arch or rotate their lumbar region as the motion of the test becomes uncomfortable. Osteoarthritis and iliopsoas contracture both may cause excessive tightness during this test. FAI can occur from several different anatomic abnormalities and whether the FABER test elicits pain will depend on the nature of the abnormality [12]. Patients with FAI may present with both hip muscle weakness and reduced joint motion [13]. (See "Femoroacetabular impingement syndrome".)

Sports hernia and conditions at pubic symphysis — While the patient is supine, it may be useful to evaluate for sports hernia, also called athletic pubalgia, and other abnormalities around the pubic symphysis. Palpate the inguinal ligament, pubic symphysis, adductor origins, and conjoined tendon. Patients often feel pain just below the inguinal ligament close to the conjoint tendon but may also experience pain at the insertion of the rectus abdominis and origin of the adductor muscles at the pubic symphysis. (See "Sports-related groin pain or 'sports hernia'".)

Other pathologies that can present with pain in or near this location include:

●Osteitis pubis (see "Osteitis pubis")

●Direct or indirect hernia (see "Classification, clinical features, and diagnosis of inguinal and femoral hernias in adults")

●Iliopsoas strain or tendinosis

●Adductor strains or tendinosis (see "Adductor muscle and tendon injury")

●Rectus abdominis strains

●Pubic rami stress fractures

●Septic arthritis of the pubic symphysis

Sports hernia (ie, athletic pubalgia) can sometimes be exacerbated by the combined motions of resisted adduction and straight leg raising or with trunk flexion. If the examiner has the patient bring their legs together against resistance and then asks the patient to lift both legs up off the table, pain is often elicited on the side of the sports hernia. Having the patient find the location of maximal pain, and pushing down on this location and then repeating the maneuver can sometimes be associated with decreased pain. Another sign of sports hernia is pain elicited when palpating the inguinal ring through the scrotum in a male (ie, inguinal hernia examination). The area is often tender on the side of sports hernia but not painful on the uninvolved side.

Examination with patient lying on their side — Several structures of the hip and groin are best evaluated with the patient lying on their side. These include the greater trochanter and its surrounding bursa, tensor fascia lata, gluteus musculature, and the lateral aspect of the iliac crest. The tightness of the iliotibial tract can also be assessed from this position. Resisted hip abduction while the knee is held in extension, allows the strength of the gluteus medius to be evaluated (picture 10). Ober’s test (picture 11), performed in three different positions, can be used to assess the tightness of the tensor fascia lata, iliotibial tract, and gluteus musculature respectively. Lateral compression of the pelvis, performed by pushing down on the greater trochanter and iliac crest, may produce pain if a pelvic stress fracture or osteitis pubis is present at the pubic symphysis. (See "Iliotibial band syndrome" and "Overview of stress fractures" and "Osteitis pubis".)

Examination with the patient prone — With the patient lying prone, the lower sacrum, sacroiliac joints, sciatic nerve, and lower lumbar spine can be evaluated, as well as the posterior musculature, primarily the hamstrings (biceps femoris, semitendinosus, semimembranosus), gluteals, and piriformis (figure 10). Injury or dysfunction of these muscles is not commonly a direct cause of groin pain but can contribute to posterior hip and groin pathology, and these muscles should be examined if the history and initial examination suggest such involvement. (See "Hamstring muscle and tendon injuries", section on 'Clinical presentation and examination'.)

Point tenderness at the ischial tuberosity may be due to hamstring tendinosis or bursitis. Assessment involves testing muscle strength at varying degrees of knee flexion. Tightness of the hip flexors can be assessed by extending the hip with the knee flexed (Ely test (figure 24)) looking for rectus femoris tightness, and with the knee in extension looking for tightness of both the rectus and iliopsoas (modified Thomas test (picture 7)). (See 'Special tests for specific conditions' below.)

SPECIAL TESTS FOR SPECIFIC CONDITIONS — A number of special tests for evaluating the hip and groin are used to refine the differential diagnosis and guide diagnostic testing. The tests that we have found to be most useful are described below [14,15]. The sensitivity and specificity of these tests is largely unstudied.

Special tests to perform may include the following:

Tests of hip abductors

●Trendelenburg test ‒ While observing the patient from behind, ask the patient to raise their leg (ie, flex their hip and knee simultaneously) (figure 22 and picture 2). A positive test is one where the pelvis drops more than 2 cm, and is indicative of weakness of the contralateral hip abductors. Weakness may be due to gluteus medius muscle weakness or tendinopathy, or compression of the lumbar nerves that supply these muscles (eg, impingement from protruding lumbar disc).

Tests of hip adductors — Assessment of the hip adductor muscle and tendon function includes passive stretching of the adductor muscles and adduction against resistance. Examination of the hip adductors is described in detail separately. (See "Adductor muscle and tendon injury", section on 'Physical examination' and "Adductor muscle and tendon injury", section on 'Performance of the examination'.)

Tests of hip flexors

●Thomas test ‒ With the patient lying supine and the hip and knee of one leg flexed and this leg pulled to the chest, the contralateral leg should be able to rest comfortably on the table (picture 7). A positive Thomas test occurs when the contralateral knee cannot be straightened fully, and is indicative of a tight iliopsoas muscle on that side. A painful click when the leg is lowered may represent a labral tear of the hip.

●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 iliopsoas and/or rectus femoris.

●Ely test ‒ With the patient lying prone, the examiner passively flexes the patient’s knee to about 130 degrees (figure 24). If the pelvis comes up off the table, this represents a positive test indicative of a tight rectus femoris muscle (as the rectus crosses both the knee and hip)

●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. This test may be impossible for the patient to perform if a fracture is present, but pain or weakness may be due to intra-articular hip or iliopsoas pathology.

●Adductor squeeze test – The patient lies supine with their feet planted, knees flexed to about 90 degrees, and hips flexed to about 45 degrees. The examiner then places their fist or a ball with a pressure cuff of a sphygmomanometer (or some other object such as a folded towel) between the patient's knees and asks them to perform a forceful isometric contraction of the adductor muscles [16]. The examiner documents asymmetries in strength between sides.

Tests for acetabular pathology

●FADDIR (Femoral ADDuction Internal Rotation) test ‒ With the patient’s hip maximally flexed, the clinician grasps the knee and ankle of the same leg and passively flexes the knee to 90 degrees, and then adducts and internally rotates the hip (picture 5). Pain suggests femoroacetabular impingement (FAI).

The examiner can place pressure on the lateral aspect of the knee to see if that elicits pain when motion alone does not. This and similar maneuvers are sometimes called impingement provocation techniques. Alternatively, an axial load can be added to this test if the examiner pushes down on the front of the knee, applying force along the axis of the femur with one hand, while stabilizing the pelvis with the opposite hand. If axial compression causes pain as the examiner takes the knee from neutral to internal rotation, intraarticular cartilage injury or labral tear may be the source of pain. This maneuver is sometimes called the axial compression test.

●Other impingement tests ‒ Begin with the affected hip in a flexed, abducted, and externally rotated position, and then internally rotate and adduct it. A sharp, catching pain when the hip is moved in this manner constitutes a positive impingement test and suggests an anterior labral tear. A posterior labral tear (much less common) is detected by passively flexing and internally rotating the affected hip while applying pressure posteriorly [17]. Sharp pain caused by the maneuver represents a positive test.

Available published evidence suggests that no single positive examination test consistently identifies labral injury. However, if the FADDIR, flexion and internal rotation, impingement provocation, and axial compression tests of the hip are all negative, the diagnosis of a labral tear of the hip is unlikely.

●FABER (Femoral ABduction External Rotation) or Patrick’s test – Have the patient lay supine and cross the foot of the involved side over their opposite thigh, placing the involved hip in external rotation. Gradually apply pressure to increase external hip rotation (figure 23 and picture 9). Pain with the application of pressure marks a positive test, but significant tightness (limited external rotation) may be suggestive. The FABER test can cause pain in different locations, suggesting different pathologies: pain in the groin suggests osteoarthritis, iliopsoas pathology, or possibly FAI (although FADDIR test is preferred for identifying FAI); pain in the lateral hip suggests degenerative lumbar disc disease; pain posteriorly suggests pathology at the sacroiliac joint. Tight adductor muscles or iliopsoas tendon can limit motion during testing without pain.

Tests of sacroiliac region — No single test for sacroiliac joint (SIJ) dysfunction demonstrates high sensitivity or specificity. However, a combination of tests helps to confirm the diagnosis when all are positive. According to a double-blinded trial involving 40 patients with signs of SIJ pain, a combination of three clinical tests (FABER, posterior shear, and resisted abduction) demonstrated high specificity and moderately high sensitivity (ranging from 77 to 87 percent) for SIJ dysfunction [18]. The gold standard for the study was pain relieved by injection into the symptomatic SIJ under radiographic guidance.

Other tests for SIJ pain include pelvic distraction/compression, focal SIJ tenderness, seated and standing Gillet's, femoral shear, and modified Gaenslen's. The likelihood of SIJ dysfunction being the source of pain increases markedly if three or more provocation tests are positive. Other factors that suggest SIJ problems include asymmetry of the SI joints when the patient is standing, unilateral pain around the SIJ, focal pain at the sacrum without associated lumbar pain, and pain around the SIJ that increases when the patient rises from a seated position [3].

We use a combination of clinical test that typically include the four listed below.

●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 [14].

●Gaenslen test – With the patient supine, flex one hip by pushing the patient’s knee to their chest, while simultaneously extending the opposite hip joint (picture 12). This maneuver stresses both sacroiliac joints. Posterior pelvic pain indicates a positive test for sacroiliac joint dysfunction.

●Gillet’s test – With the patient standing, the examiner positioned behind the patient places each hand along the posterior superior iliac spine and extends each thumb to place them along the sacrum at the same height. Then, the patient is asked to pull one knee towards their chest and hold it there with their hands (picture 3). Both sides are compared. 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. A positive test can be seen with lumbar facet, sacroiliac joint, or pars interarticularis pathology, and may reproduce the patient’s pain on the involved side [19].

●FABER test (see 'Tests for acetabular pathology' above)

Tests for lateral hip pain

●Ober’s test and Modified Ober’s test ‒ These tests are used primarily to assess tightness of the tensor fascia lata or iliotibial band but may also indicate tightness of the gluteus medius (picture 11). They are described separately. (See "Iliotibial band syndrome", section on 'Physical examination'.)

Tests for stress fractures and minor pelvic fractures

●Lateral compression test ‒ With the patient lying on their side, compress the pelvis by pushing down on the greater trochanter and iliac crest. This test is performed to help diagnose osteitis pubis or pelvic fracture, including stress fracture.

●Fulcrum test ‒ The fulcrum test may be useful when the proximal femur or femoral neck is suspected of having a stress fracture. It is performed by placing one forearm under the area that is painful while the opposite hand applies steady pressure at the end of the femur (picture 13). This creates a fulcrum effect that stresses the site of suspected injury. Increased pain at the area in question during the test is consistent with a stress fracture.

●Hop test – The Hop test may be used to help detect stress fractures at the femoral neck. It simply involves having the patient hop on the affected leg. The test is nonspecific but should cause pain at the femoral neck in the presence of a stress fracture.

FUNCTIONAL TESTS FOR CORE STABILITY — The "Bunkie" test is used by some clinicians to assess strength and muscular endurance of the core musculature around the hip and groin regions. While a reasonable approach, the test is not well studied, nor has it been correlated with clinical outcomes.

"Bunkie" comes from a word meaning "small bench" in Afrikaans. The test involves a stable padded box approximately 25 to 30 cm (10 to 12 inches) in height on which the patient places their feet while holding five positions [20]:

●Straight single-leg supine plank

●Bent single-leg supine plank

●Lateral single-leg plank using lower leg (hip abductor emphasis)

●Lateral single-leg plank using upper leg (hip adductor emphasis)

●Straight single-leg prone plank

Each position is held for time, with a goal of 30 to 40 seconds, and assesses a different component of core strength and endurance. Patients rest at least one minute between positions [21,22].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Hip and groin pain".)

SUMMARY AND RECOMMENDATIONS

●Limitations of the hip and groin examination – Many maneuvers used to assess the hip and groin are described as if they are pathognomonic for a particular pathology. However, the diagnostic accuracy of many of these tests is limited, particularly when the results are not considered in the context of the history and other examination findings. The clinical anatomy and biomechanics necessary for performing an effective examination and tips for making the examination more productive and efficient are provided in the text. (See 'Anatomy and biomechanics' above and 'Tips for a productive examination' above.)

●Neurovascular assessment – In patients with significant hip or pelvic trauma, neurologic complaints (eg, distal weakness, paresthesias), or unusual presentations, a careful neurovascular assessment is essential; in patients without such complaints, a focused neurovascular examination confirming basic motor function and sensation and adequate blood flow is sufficient. Lumbar radiculopathy is an important consideration in patients with pain or paresthesias that radiate to or from the lumbar spine region or the involved lower extremity. (See 'Neurovascular assessment' above.)

●Importance of non-musculoskeletal causes – For most athletes or active adults, groin or hip pain that is related to activity stems from a musculoskeletal problem. Thus, the examination of such patients focuses on the soft tissues and bones most likely to be involved. However, depending upon the clinical scenario, it may be important to rule out medical or neurologic conditions (eg, inguinal hernia, urinary tract infection, lumbar radiculopathy, abscess) and an appropriate physical examination, including evaluation of the genitourinary system, may be necessary.

●Systematic physical examination – The patient with groin pain likely due to a musculoskeletal problem is examined using a standard approach, including: inspection, palpation, range of motion testing, strength testing, and special tests. The emphasis and scope of the examination is focused based upon the most likely diagnoses, as determined by the history. To assess the hip and groin in a thorough and systematic fashion, we typically organize the examination by patient position beginning with an assessment of gait and examination of the patient standing, followed by assessment of the patient while supine, on their side, and then prone. Details for each phase or described in the text. (See 'Physical examination' above.)

●Special tests for specific conditions – Once a focused differential diagnosis is established based upon the history and initial examination findings, the clinician may opt to perform special examination maneuvers to help determine the likelihood of a particular diagnosis. Special tests of muscle and tendon groups, such as the hip abductors, hip adductors, and hip flexors, and other tests to assess particular pathology, such as acetabular impingement, sacroiliac joint dysfunction, and femoral stress fracture, are described in the text. (See 'Special tests for specific conditions' above.)