Hip examination: A complete clinical guide for practitioners

Key Takeaways

Hip examination follows a systematic sequence: history, inspection, palpation, range of motion, special tests, and neurovascular assessment.

The FADIR test has approximately 88% sensitivity for femoroacetabular impingement and acetabular labral tears, making it one of the highest-yield provocation tests.

Normal hip ROM values differ by direction: flexion 0-120 degrees, extension 0-30 degrees, abduction 0-45 degrees, internal and external rotation 0-45 degrees each.

Practice management software like Pabau helps physical therapy and orthopedic practices capture structured hip examination findings, including digital forms and AI-assisted clinical documentation, at every appointment.

Hip pain is one of the most common musculoskeletal complaints across all age groups. A misattributed diagnosis at the first clinical encounter can delay treatment by an average of several months. A rigorous hip examination identifies whether pain originates intra-articularly, from periarticular structures, or is referred from the lumbar spine or sacroiliac joint, and that distinction changes the management plan.

This guide walks through each component of the hip examination in sequence, from history taking through to documentation. It covers normal values, special test interpretation, and the clinical decision points that determine referral and imaging.

What the hip examination is designed to assess

A hip examination is a structured clinical assessment of the hip joint and surrounding soft tissues. Its purpose is to narrow a differential diagnosis that spans intra-articular pathology (femoroacetabular impingement, labral tears, osteoarthritis), periarticular conditions (greater trochanteric bursitis, iliotibial band syndrome, hip flexor tendinopathy), and referred pain from lumbar and sacroiliac sources.

The physical therapy EMR and orthopedic communities use the same systematic framework, which makes it a shared language across disciplines. Understanding its logic, not just its steps, makes the clinician faster and more accurate.

Hip examination: Taking the clinical history

The history directs every subsequent examination component. Before touching the patient, a clinician should know the location, character, and onset of pain, aggravating and relieving factors, functional limitations, and any red flags.

• Location: Groin pain suggests intra-articular pathology (FAI, labral tear, OA). Lateral hip pain points to greater trochanteric bursitis or IT band syndrome. Posterior pain raises the possibility of sacroiliac joint involvement or referred lumbar pathology.
• Character: A deep, catching groin pain worsened by hip flexion and rotation is characteristic of FAI or labral tears. Aching lateral pain after prolonged walking fits greater trochanteric bursitis.
• Onset and mechanism: Traumatic vs insidious onset significantly narrows the differential. Young athletes with insidious groin pain are a different population from elderly patients reporting gradual stiffening.
• Red flags: Night pain not relieved by position change, unintentional weight loss, history of malignancy, fever, and age over 50 with acute onset warrant urgent investigation before routine examination proceeds.
• Functional impact: Ask specifically about stairs, rising from chairs, putting on shoes, and walking tolerance. These tasks quantify disability and set a functional baseline for treatment monitoring.

The PMC systematic review on hip physical examination confirms that history-taking alone can reliably predict intra-articular pathology in a majority of cases when pain is located in the groin and worsened by hip loading activities.

Inspection during the hip examination

Inspection begins before the patient removes their clothing. Watch how they walk in, how they transition to sitting, and how they undress. Antalgic gait (shortened stance phase on the affected side) and Trendelenburg gait (contralateral pelvic drop) are both visible before formal assessment begins.

Standing inspection

With the patient standing, assess pelvic height, spinal alignment, and muscle bulk symmetry. Pelvic obliquity may indicate limb length discrepancy (LLD) or compensatory scoliosis, coded as M41.9 in ICD-10. Gluteal wasting on one side suggests chronic disuse or superior gluteal nerve compromise.

Gait assessment

Two gait patterns are clinically significant. An antalgic gait (rapid offloading of the painful limb) indicates pain-limited weight-bearing. A Trendelenburg gait (pelvis drops to the opposite side during single-leg stance) indicates gluteus medius weakness or superior gluteal nerve palsy on the stance side.

Asking the patient to walk 10 meters and return takes under a minute, and it can identify both patterns reliably.

Supine inspection

With the patient supine, check for resting limb position (fixed external rotation suggests femoral neck fracture in trauma), skin changes over the hip, and apparent versus true limb length discrepancy.

True LLD is measured from the anterior superior iliac spine (ASIS) to the medial malleolus. Apparent LLD, measured from the umbilicus to the medial malleolus, reflects pelvic obliquity rather than a true difference in bone length.

Palpation of the hip region

Palpation maps tenderness to anatomical structures and guides interpretation of subsequent special tests. Work systematically from anterior to lateral to posterior.

• Anterior: ASIS (avulsion fracture in adolescents), inguinal ligament, femoral triangle (femoral nerve, femoral artery, femoral vein), with the femoral head and hip joint palpable deep to the triangle, and the adductor tendon insertion at the pubic symphysis.
• Lateral: Greater trochanter and trochanteric bursa (tenderness here with lateral hip pain is the hallmark of greater trochanteric pain syndrome), iliotibial band along the femoral shaft.
• Posterior: Sacroiliac joint line, piriformis muscle belly (deep posterior buttock tenderness may indicate piriformis syndrome or sciatic nerve irritation), ischial tuberosity (hamstring origin, relevant in proximal hamstring tendinopathy).

Tenderness directly over the femoral head (anterior groin, deep to the inguinal ligament) is a reliable indicator of intra-articular pathology and should always be correlated with ROM and special test findings.

Range of motion assessment

ROM assessment distinguishes restricted, hypermobile, and painful arc findings. Test active ROM first (patient-initiated movement), then passive ROM (clinician-guided movement). Pain occurring only at end range of passive movement differs clinically from pain throughout the arc.

The table below shows normal adult hip ROM values as reported across Stanford Medicine 25 and the PMC hip examination review. Values reflect typical adult norms, and natural variation by age and sex should be expected.

Internal rotation loss is the single most sensitive ROM marker for early hip osteoarthritis and for cam-type femoroacetabular impingement. When a patient loses more than 10 degrees of internal rotation compared to the contralateral side, that finding alone justifies further investigation even before special tests.

Special tests in hip examination

Special tests are provocation maneuvers designed to stress specific anatomical structures. No single test is definitive on its own. Their value lies in raising or lowering the probability of a diagnosis when interpreted alongside history, inspection, and ROM findings. The table below summarizes the five most clinically used tests, with approximate sensitivity ranges reported in the orthopedic literature.

FADIR test technique

With the patient supine, flex the hip to 90 degrees, then adduct and internally rotate. A positive FADIR test reproduces anterior hip or groin pain.

It is the highest-sensitivity test in the hip examination battery for FAI and labral pathology, though specificity is lower. A negative result rules out impingement more reliably than a positive result rules it in.

FABER test technique

Place the tested limb in flexion, abduction, and external rotation so the ankle rests on the contralateral knee (figure-4 position). Apply gentle downward pressure on the flexed knee. Pain in the groin or anterior hip indicates intra-articular pathology, while pain in the posterior hip or sacrum indicates SI joint involvement.

The Ober test, performed in the lateral decubitus position, assesses IT band tightness when lateral hip symptoms predominate alongside a positive FABER.

Thomas test technique

Ask the patient to draw both knees fully to their chest while supine, flattening the lumbar lordosis. Then release one leg. If the released thigh rises off the table, hip flexion contracture is present on that side. The degree of rise estimates the contracture magnitude. This test is relevant after any patient reporting difficulty achieving full hip extension during gait.

Understanding the return-to-running protocol requires accurate contracture screening. A missed Thomas test positive is a common cause of recurrent hip flexor loading injuries. Once contracture and impingement findings clear, functional return-to-sport testing, such as the yo-yo intermittent recovery test, confirms conditioning before an athlete resumes full training load.

Neurovascular examination relevant to hip pathology

Hip pain commonly has a neurological component, either from lumbar nerve root compromise (L2-L4 commonly referencing to the anterior thigh and groin) or from local nerve entrapment. A brief neurological screen prevents misattributing lumbar radiculopathy to a primary hip condition.

• Dermatome screen: L2 (anterior thigh), L3 (medial knee), L4 (medial shin), L5 (dorsal foot), S1 (lateral foot/heel). Compare light touch bilaterally along each dermatome.
• Myotome screen: Hip flexion (L2/L3), knee extension (L3/L4), ankle dorsiflexion (L4/L5), great toe extension (L5), ankle plantarflexion (S1/S2).
• Reflexes: Patella (L3/L4), Achilles (S1). Asymmetry indicates nerve root compromise rather than primary hip joint pathology.
• Vascular screen: Palpate femoral, popliteal, and dorsalis pedis pulses. Absent femoral pulse in a patient with hip and buttock claudication suggests aortoiliac occlusive disease rather than musculoskeletal pathology.

When the physiotherapy clinic management software used in practice allows templated neurovascular screening sections within the clinical record, clinicians are more consistent in completing and documenting this component. Skipping it is the most common examination omission in busy outpatient settings.

Common conditions identified through the hip examination

Examination findings cluster around recognizable patterns. Knowing the pattern accelerates clinical reasoning.

Snapping hip syndrome (coxa saltans) presents clinically in two forms. External snapping involves the iliotibial band or gluteus maximus snapping over the greater trochanter during hip flexion and extension. Internal snapping involves the iliopsoas tendon over the iliopectineal eminence. Both are identified by observing and palpating the hip during active arc movement, not during passive testing.

Good patient care management workflows ensure that snapping hip findings are recorded consistently across clinicians treating the same patient, preventing repeated first-presentation examinations.

Hip examination in special populations

Standard adult examination protocols require modification for newborns and elderly patients. Both populations present frequently in mixed-specialty practices, so it’s worth covering each separately.

Newborn hip examination for DDH

Developmental dysplasia of the hip (DDH) is screened using two maneuvers in the neonatal period. The Barlow maneuver (posterior pressure on a flexed, adducted hip) attempts to dislocate an unstable hip. The Ortolani maneuver (abduction and anterior lift of the proximal femur) attempts to reduce a dislocated hip. A palpable clunk, not a soft click, is the positive finding.

These tests are technique-sensitive and safety-critical. Clinicians performing them on newborns for the first time should do so under supervised training, as per NICE newborn screening guidance. Sports medicine software used in mixed-specialty settings benefits from configurable examination templates that can accommodate these pediatric-specific maneuvers alongside standard adult assessments.

Elderly patients

In older adults, global ROM restriction is the norm rather than a diagnostic finding in isolation. Focus shifts to comparing bilateral symmetry, identifying acute-on-chronic presentations, and screening for red flags such as fracture risk after a fall or avascular necrosis in steroid users.

As a practical guideline in this population, immediate X-ray is appropriate when the patient cannot weight-bear or when there is focal bony tenderness over the femoral neck after any fall mechanism. Where mobility is already limited, seated exercises can help maintain hip range of motion between formal rehabilitation sessions.

When to refer and what imaging to request

Not every abnormal examination finding warrants immediate specialist referral or imaging. A structured threshold prevents both under-investigation and unnecessary investigations.

• Immediate (same-day) referral or imaging: Suspected femoral neck fracture (inability to weight-bear, shortened and externally rotated limb), acute septic arthritis (fever, elevated CRP, warm erythematous joint), or suspected avascular necrosis in high-risk patients (steroid use, alcohol excess, sickle cell disease).
• Urgent (within 2 weeks) referral: Positive red flags in history (unexplained weight loss, night pain, prior malignancy), progressive neurological deficit, failed conservative management after 6 weeks with positive special tests.
• Routine referral: Persistent symptoms beyond 3 months, confirmed FAI or labral pathology on examination, candidates for hip arthroplasty.

Imaging choice depends on what the examination suggests:

• Plain AP and lateral X-ray: first-line modality for most hip presentations.
• MRI with arthrogram: gold standard for labral pathology and early cartilage changes.
• Ultrasound: preferred for dynamic assessment of snapping hip and for guiding bursal injections.
• CT: reserved for detailed bony morphology in FAI surgical planning.

These thresholds align with AAOS clinical practice guidelines on hip pathology investigation.

Streamline your clinical documentation

Pabau helps physical therapy and orthopedic practices capture structured hip examination findings, ROM measurements, and special test outcomes in digital records. No paper, no lost notes.

Book a demo

Documenting hip examination findings in clinical practice

Documentation is where a thorough hip examination either delivers its full clinical value or loses it. Unstructured free-text notes may capture findings at the time, but they fail comparison at follow-up, make handover unreliable, and leave practices exposed when outcome evidence is needed for insurance or medico-legal purposes.

Structured documentation for the hip examination should record, at minimum:

• Presenting symptoms and red flag screen results
• ROM values, active and passive, per direction, bilateral
• Special test results: test name, positive or negative, and pain location reproduced
• Gait observation findings
• Neurovascular screen results
• Working diagnosis with differential

Using digital intake forms before the appointment captures baseline pain scores, functional limitations, and relevant history electronically, feeding straight into the clinical record without re-entry. AI-assisted clinical documentation can then convert dictated examination findings into structured SOAP-format notes, cutting post-appointment admin for orthopedic and physical therapy clinicians.

Guidance on structuring safer clinical notes and a SOAP notes documentation template cover principles that carry across musculoskeletal specialties: objective, measurable findings tied to a clear assessment and plan, rather than vague descriptions.

Physiotherapy compliance requirements in several jurisdictions now specify minimum documentation standards for musculoskeletal assessments, making structured record-keeping a regulatory expectation rather than best practice alone. A client records module built for allied health supports longitudinal tracking of ROM and functional outcomes across appointments.

Conclusion

Most hip examination errors are errors of omission. Each omission removes a data point that cannot be recovered in retrospect:

• A gait assessment skipped because the corridor is short
• A neurovascular screen dropped because the appointment is running late
• A Thomas test not performed because the examiner assumed hip flexors were fine

Pabau’s structured digital forms and clinical record templates give physical therapy and orthopedic practices a consistent examination framework, so every clinician captures the same components in the same format regardless of how busy the day is. To see how Pabau handles structured musculoskeletal documentation, book a demo with the team.

Continue your research

Need a structured framework for clinical note writing? Safer clinical notes guide covers documentation principles for reducing medico-legal risk in musculoskeletal practice.

Looking for physiotherapy-specific compliance guidance? Physiotherapy compliance requirements outlines jurisdiction-specific documentation standards.

Returning an athlete to full load after hip injury? Return-to-running protocol provides a staged rehabilitation framework grounded in clinical examination findings.

Frequently asked questions