Hip Joint Assessment Essentials: Mobility, Strength, and Functional Performance Screening

1) Observation: Gait Cues and Pelvic Control

Start hip screening with simple observation because many hip-related limitations show up as movement strategies rather than isolated pain. Your goal is to identify: (a) how the pelvis controls the femur during stance, and (b) whether symptoms change with walking speed, stride length, or turning.

What to watch (quick checklist)

• Step length symmetry: shortened step on one side may reflect hip extension limitation, pain avoidance, or reduced push-off.
• Pelvic drop or trunk lean in stance: a visible drop of the opposite pelvis or a compensatory trunk lean over the stance leg can suggest reduced hip abductor capacity or pain inhibition.
• Foot progression angle: toe-out may be a strategy to avoid hip internal rotation demand; toe-in may increase internal rotation demand.
• Dynamic valgus tendency: knee moving inward during loading can be influenced by hip abductor/external rotator weakness or poor pelvic control.
• Turn and pivot behavior: “en bloc” turning (whole body turning together) may reflect hip irritability or rotation restriction.

Step-by-step: a simple gait observation sequence

1. Baseline walk: have the learner walk 10 meters out and back at a comfortable pace. Observe from front, side, and back if possible.

2. Speed change: repeat slightly faster. Note whether symptoms increase and whether compensations become more obvious.

3. Turning: ask for a 180-degree turn. Watch for guarding, reduced pivoting, or pain behaviors.

Interpretation example: If you see a trunk lean over the stance leg and the knee drifting inward during mid-stance, consider hip abductor weakness and/or pain inhibition as contributors. This observation will guide you to prioritize abductor strength testing and single-leg control tasks later.

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2) Hip AROM/PROM: Key Motions With Pelvic Stabilization

Hip motion testing is only as useful as your ability to keep the pelvis from “helping.” Many apparent hip restrictions are actually pelvic motion substitutions. Use consistent positioning, stabilize the pelvis early, and compare sides.

Flexion

AROM (supine): patient brings knee toward chest.

• Pelvic stabilization cue: watch for posterior pelvic tilt and lumbar flexion (low back flattening) that can inflate the apparent hip flexion.
• Practical tip: place one hand on the anterior superior iliac spine (ASIS) to feel pelvic motion while the other guides the leg if needed.

PROM (supine): examiner moves the hip into flexion with knee flexed.

• Common substitution: pelvis posteriorly tilts as end-range approaches.
• How to limit it: stabilize the opposite ASIS and monitor lumbar spine contact with the table.

Extension

AROM (prone or standing): patient extends the hip.

• Pelvic stabilization cue: watch for lumbar extension (arching) and anterior pelvic tilt.
• Standing option: keep the trunk upright and ask for a small, controlled leg-back motion to reduce lumbar compensation.

PROM (prone): lift the thigh slightly while stabilizing the pelvis.

• Key check: feel for anterior pelvic tilt starting before true hip extension end-range.

Abduction

AROM (supine): patient slides leg out to the side.

• Pelvic stabilization cue: watch for pelvic hiking or trunk side-bending.
• Practical tip: keep the opposite leg straight and centered to reduce pelvic roll.

PROM (supine): move the leg into abduction while stabilizing the pelvis.

• Common substitution: external rotation sneaks in (the leg turns outward) to “find” more abduction.

Internal Rotation (IR) and External Rotation (ER)

Rotation is often the most clinically informative hip motion, but it is also the easiest to contaminate with pelvic motion. Use a consistent position and a clear stabilization strategy.

Preferred setup (prone, knee flexed to 90°): rotate the hip by moving the lower leg side-to-side.

• IR: move the foot outward (laterally) which rotates the femur inward.
• ER: move the foot inward (medially) which rotates the femur outward.
• Pelvic stabilization: place a hand over the posterior pelvis (sacrum/PSIS region) to feel for pelvic lift or rotation.

Alternative setup (seated, hip and knee at 90°): useful when prone is not tolerated.

• Pelvic stabilization: ensure the patient sits tall without leaning; consider placing hands on iliac crests to detect pelvic shift.

Interpretation example: If hip IR is limited compared to the other side and you feel a firm stop while the pelvis stays quiet (no early pelvic rotation), this pattern supports a mobility restriction rather than a control issue. If IR appears limited but improves when you stabilize the pelvis more firmly, the “restriction” may have been pelvic substitution rather than true hip limitation.

3) Symptom Behavior During Testing: Stiffness vs Irritability (Practical Differentiation)

During ROM testing, track how symptoms behave: what provokes them, how quickly they settle, and whether they spread or intensify with repeated movement. This helps you decide how far to push testing and which tests to prioritize.

How to monitor symptom behavior (simple method)

• Before each motion: ask for a baseline symptom rating and location (e.g., “0–10, where do you feel it?”).
• At first onset: note the angle/position where symptoms begin.
• At end-range: note whether symptoms are tolerable, sharp, or escalating.
• After release: ask how quickly symptoms return to baseline.

Practical decision rules for test intensity

• More stiffness-dominant presentation: symptoms are minimal or “stretchy,” settle quickly, and are consistent at end-range. You can usually proceed with PROM and functional tests at normal intensity.
• More irritability-dominant presentation: pain appears early, escalates quickly, lingers after release, or spreads. Reduce intensity: smaller ranges, fewer repetitions, and prioritize observation + gentle AROM over aggressive PROM.

Interpretation example: A patient reports deep anterior hip pain that appears early during flexion and remains elevated for several minutes after you stop. This symptom behavior suggests higher irritability; you would limit end-range overpressure and choose lower-load functional screens (e.g., controlled sit-to-stand) rather than step-ups or prolonged single-leg stance.

4) Strength Tests: Abductors, Extensors, External Rotators

Hip strength testing is most useful when you standardize position, minimize substitutions, and connect findings to observed movement patterns (e.g., pelvic drop, dynamic valgus). Use consistent cues and compare sides.

Hip Abductors (Gluteus Medius Emphasis)

Position: side-lying, test leg on top, hip neutral or slight extension, knee straight.

Step-by-step:

1. Align the pelvis stacked (no rolling backward).

2. Ask the patient to lift the leg straight up 20–30 cm without rotating the hip.

3. Apply resistance just above the ankle (or at the distal thigh if needed for comfort).

4. Watch for substitution: hip flexion (leg drifting forward), external rotation (toes turning up), or pelvic hiking.

Interpretation example: If the patient cannot hold against moderate resistance and you observed pelvic drop or trunk lean during gait, the abductor weakness likely contributes to reduced frontal-plane control and may be linked to dynamic valgus patterns during functional tasks.

Hip Extensors (Gluteus Maximus Emphasis)

Option A (prone knee flexed to 90°): flexing the knee reduces hamstring contribution and biases glute max.

Step-by-step:

1. Stabilize the pelvis to prevent lumbar extension/anterior pelvic tilt.

2. Ask the patient to lift the thigh slightly off the table while keeping the knee bent.

3. Apply resistance at the posterior distal thigh.

Option B (bridge hold): useful when prone is not tolerated.

• Observe: pelvic levelness, hamstring cramping, and ability to maintain without lumbar overextension.

Hip External Rotators

Position (seated, hip/knee 90°): patient rotates the lower leg outward (hip ER) against resistance.

Step-by-step:

1. Ensure upright posture; avoid trunk lean.

2. Keep the thigh stable; apply resistance at the distal leg/ankle.

3. Watch for substitution: pelvic shift, hip abduction, or foot/ankle twisting that mimics rotation.

Clinical link: weak external rotators can reduce control of femoral internal rotation during loading, contributing to inward knee drift during step-ups or sit-to-stand.

5) Functional Performance Screens: Sit-to-Stand, Step-Up Tolerance, Single-Leg Stance

Functional tests connect isolated findings (ROM/strength) to real movement demands. Choose the least provocative test first, progress only if symptoms and control allow, and always prioritize safety (stable surface, nearby support).

Sit-to-Stand (STS)

Setup: standard chair height if possible; feet hip-width; arms crossed only if safe.

Step-by-step:

1. Ask for 3–5 controlled repetitions at a comfortable speed.

2. Observe from the front and side.

3. Note pain location, symmetry of weight shift, trunk strategy, and knee alignment.

• Key cues: does the pelvis shift to one side? Does the knee collapse inward? Does the trunk lean excessively forward or to one side?

Interpretation example: If the knee moves into dynamic valgus during rising and you also found hip abductor/external rotator weakness, the STS pattern supports a hip contribution to frontal/transverse plane control deficits.

Step-Up Tolerance

Setup: low step initially (e.g., 10–15 cm), hand support available.

Step-by-step:

1. Ask the patient to step up with the test leg and step down slowly.

2. Perform 3 repetitions, then reassess symptoms.

3. Progress height or repetitions only if control and symptoms allow.

• Observe: pelvic drop, trunk lean, knee valgus, and whether the patient avoids hip extension by pushing off excessively with the trailing leg.

Pain-guided intensity: if pain is provoked early or increases with each repetition, stop and record the threshold (step height, rep number, and symptom response).

Single-Leg Stance (SLS) Time

Purpose: quick screen of pelvic control, hip abductor endurance, and balance demands that often reveal compensations not seen in non-weight-bearing tests.

Setup: stand near a stable support surface; shoes consistent between sides.

Step-by-step:

1. Ask the patient to stand on one leg, eyes open, up to a pre-set maximum (e.g., 10–30 seconds depending on ability and safety).

2. Record time and quality (not just duration).

3. Repeat on the other side.

• Quality markers: pelvic drop, trunk lean, foot wobble, or repeated tapping of the free foot.

Interpretation example: A markedly shorter SLS time on the symptomatic side with visible pelvic drop aligns with abductor endurance limitations and may explain gait deviations (e.g., trunk lean) even if isolated strength testing is only mildly reduced.

Putting It Together: Quick Interpretation Patterns (Examples)