Evidence-Based Examination of the Hip

Alexis Wright, PT, PhD, DPT, FAAOMPT

Course Materials
 Module 1:
Introduction of the Hip
Alexis A. Wright PT, PhD, DPT,
FAAOMPT
 Objectives
• Define Hip and/or Groin pain
• Gain an understanding of hip related pain
patterns
 Hip/Groin Pain – Defined
• Pain suffered near the hip and/or groin can arise
from a number of different sources including
lumbar spine, pelvis, and sometimes knee.
• Primarily, true hip pathologies are of intra-
articular origin (OA, labral tears) and will exhibit
symptoms in the buttock and/or groin with
referral to the knee
• However, it is not unusual for the hip joint to
refer pain outside the immediate hip and/or groin
area
DeAngelis, NA & Busconi BD. Assessment and Differential Diagnosis of the Painful Hip.
Clin Orthop Relat Res. 2003;406:11-18
 Lumbar Spine Referral Patterns
• Discogenic referred
pain patterns

Low
• Primary pain zones: Back
low back (including
hip/buttock), proximal Thigh

leg (thigh), and lower

leg (below the knee) Lower
Leg

O’Neill, CW et al. Disc stimulation and Patterns of Referred Pain. Spine. 2002;27:2776-2781
 Lumbar Spine Referral Patterns
• Lumbar
zygapophyseal
1
referred pain
6
patterns
2
– Sites 2-6 3
represent
referred pain 4
5
patterns from
L2-S1

Fukui, S. et al. Distribution of Referred Pain from the Lumbar Zygapophyseal Joints and Dorsal Fami. Clin J Pain. 1997;13:303-307
 Hip Pain - Prevalence
• Hip pain associated with OA is the most common
cause of hip pain in older adults with prevalence
rates reported anywhere from 0.4% to 27%.
• In patients between the ages of 60 to 90 years,
23.8% reported pain in the hip.
• 27.7% reported functional limitations secondary
to the hip
• Symptoms increased with age and were more
prevalent in women
Cibulka et al. Hip pain and mobility deficits – hip osteoarthritis. J Orthop Sports Phys Ther. 2009;39
Quintana JM et al. Prevalence of symptoms of knee or hip joints in older adults from the general population. Aging Clin Exp Res.
2008;20:329-36.
 Hip Pain - Prevalence
• Hip pain accounts for 0.61% of all visits to family
practitioners or about 1 in every 164 encounters
• Runners report an average yearly hip or pelvic injury
rate of 2% to 11%
• 14.3% of patients aged 60 years and older reported
significant hip pain on most days over the previous 6
weeks
• In younger patients, sports injuries about the hip and
pelvis are most common in ballet dancers, soccer
players, and runner (incidence of 44%, 13%, and 11%,
respectively)
National Ambulatory Medical Care Survey. Hyattsville, Md: National Center for Health Statistics; 1995. CHS CD-ROM series 13, no.
11. Issued July 1997.
Van Mechelen W. Running injuries. A review of the epidemiological literature. Sports Med 1992;14:320–335.
Christmas C, Crespo CJ, Franckowiak SC, Bathon JM, Bartlett SJ, Andersen RE. How common is hip pain among older adults?
Results from the Third National Health and Nutrition Examination Survey. J Fam Pract 2002;51:345–348.
Scopp JM, Moorman CT. The assessment of athletic hip injury. Clin Sports Med 2001;20:647–659.
 Hip Joint Referral Pain Patterns
Frequency of pain referral to the buttock,
groin, leg, knee, and foot
Anatomic Region Percentage of
Patients with Pain
Buttock 71
Thigh 57
Anterior 27
Lateral 27
Posterior 24
Medial 16
Groin 55
Leg 16
Lateral 8
Posterior 8
Anterior 4
Medial 2
Foot 6
Knee 2

Lesher, JM et al. Hip Joint Pain Referral Patterns: A Descriptive Study. Pain Medicine (Spine Section). 2008;9:22-25
 The Hip Complex
• The hip joint is a
synovial, ball-and- Capsular tissue

socket,
acetabulofemoral joint
enveloped in dense
capsular tissue
• The Y-shaped triradiate
cartilage acetabulum
covers 170 degrees of Acetabulum
the femoral head
Articular surfaces of the Hip Joint
• The hip joint is formed
between the head of
the femur and the
acetabulum
• The fibrous capsule of
the hip joint consists of
two types of fibers
– Circular
• Forms internal part
– Longitudinal
• Forms external part
 Acetabular labrum anatomy
• Fibrocartilaginous structure
• Capsular side
– Dense connective tissue
• Articular side
– Type II collagen fibrocartilage
• Transverse acetabular
ligament
• Anastomotic ring surrounding
the capsular attachment of the
labrum provides blood supply
• Obturator nerve and branch of
the nerve to the quadratus
femoris

Freehill, MT & Safran, MR. The labrum of the hip: diagnosis and rationale for surgical correction. Clin Sports Med. 2001;30:293-315.
Groh, MM & Herrera, J. A Comprehensive review of hip labral tears. Curr Rev Musculoskelet Med. 2009;2:105-117
 Ligaments of the hip joint
• 5 major ligaments
– Iliofemoral
– Pubofemoral
– Ischiofemoral
Anterior view
– Transverse acetabular
– Ligamentum Teres

Posterior view
 Blood supply of the hip joint
• Obturator
artery
• Medial
circumflex
artery
• Superior and
inferior gluteal
arteries
Nerve supply to the hip joint
• Femoral nerve and
muscular branches
• Sciatic nerve
• Others include
– Obturator nerve
– Accessory
obturator nerve
– Nerve to quadratus
femoris
– Superior gluteal
nerve
 Hip musculature
• Hip flexion • Extension
– Psoas major – Gluteus
maximus
– Iliacus
– Hamstring
• Abduction • Medial
– Gluteus rotation
med/min – TFL
– TFL – Glut
– Sartorius med/min
• Adduction • Lateral
– Adductor
rotation
longus, – Gemelli
brevis, – Quadratus
magnus femoris
Hip Bursae

• Iliopsoas
• Gluteus medius
• Trochanteric
• Ischiogluteal
 Self-limiting problem
• Hip pathologies can be a major source of
functional limitation as primary complaints
often include:
– Difficulty walking
– Difficulty stairclimbing
– Difficulty with prolonged sitting
– Difficulty squatting
– Sport limitation
 Module 2:
Patient History and
Outcomes Measures
Alexis A. Wright PT, PhD, DPT,
FAAOMPT
 Objectives
• Discuss key components of patient history
during a hip examination
• Discuss the “best” forms of self reported
patient reported outcome measures for hip
pain and function
• Discuss reported Minimally Clinical Important
Difference scores for self reported outcome
measures related to the hip
 Record a body chart
• Site (area and depth)
• Type of symptoms
– Sharp, shooting, dull,
ache, clicking, popping?
– Constant or
intermittent?
• Clear other areas
• Determine the
relationship between
areas
 Nature of symptoms
• It is important to • Identifying pain type
identify all areas of pain helps to further narrow
to help rule in/rule out down hypothesis when
specific hypotheses considering differential
– Bilateral, below the diagnosis
knee? – i.e. burning pain is more
typical of nerve
pathology versus a dull
ache is most often
associated with
intraarticular pathology
(hip OA)
 Patient History - Irritability
• Aggravating Factors
– What activities make your symptoms worse?
• Sitting, Squatting, Rotation, Stairs, shoes
– What is the pain level during these activities?
– Does it worsen immediately or over time?
– After stopping the activity, how long before your
pain level returns to normal?
• Relieving Factors
– As above
 Characteristic Hip Symptoms
• Symptoms worse with activities
• Twisting, such as turning or changing directions
• Seated positions secondary to prolonged periods of hip
flexion
• Rising from seated position
• Difficulty stairclimbing
• Increased symptoms with
entering/exiting automobile secondary
to hip flexion in combination with
twisting maneuver
• Difficulty don/doff shoes, socks Femoroacetabular Impingement

Byrd, JWT. Clinical Commentary. Evaluation of the Hip: History and Physical Examination. NAJSPT. 2007;2:231-240
 History of Present Illness
• When and how did this start?
• How long have you been suffering from these
symptoms?
• Do you have a previous history of these
symptoms?
• Have you undergone any imaging?
• Course of symptoms
– Are you better, worse, or the same?
• Have you undergone any previous treatment?
– Was it effective?
 Medical History
• Do you suffer from any other health problems?
– Heart
– Lungs
– Diabetes
– Cancer
– Osteoporosis
– Blood disorder
– Cholesterol
– Blood pressure
• Have you undergone any previous surgeries?
• Do you smoke, drink?
 Social History
• Are you currently working?
• Look for yellow, blue, and black flags!
• What is your current living situation?
– Do you have stairs in your home, rugs, stool chair?
• Do you have family support?
– How much help does this patient have in the
home?
 Yellow Flags
• Factors that may affect treatment plan
• Psychosocial factors
– Patient’s beliefs
– Coping strategies
– Distress/illness behavior
– Willingness to change
– Patient’s social, occupational and economic status
• Occupational component can further be
delineated into Blue and Black Flags
 Blue Flags
• Features of work generally associated with
increased rate of symptoms
• Derived out of the stress literature
– High demand and low control
– Unhelpful management style
– Poor social support from colleagues
– Perceived time pressure
– Lack of job satisfaction
 Black Flags
• Established policy concerning work conditions
– Rates of pay
– Negotiated entitlements
– Sickness policy
– Restricted duties policy
– Organization size and structure
– Trade union support
– Also ergonomics (posture, lifting, etc)
– Temporal characteristics (length of shift)
 Special Questions – non
mechanical in origin
• Do you notice any feelings of numbness or pins
and needles bilaterally?
• Have you suffered any recent weight loss?
• Do you ever feel as though you are stumbling
while walking
• Have you suffered any recent bowel/bladder
changes?
• Do you suffer from any pins/needle like feelings
in the inner groin area?
 Patient specific goals
• Identify patient specific goals to help guide
your decision making process!
SELF REPORTED OUTCOMES
MEASURES
 Outcome Measures: Clinical
Practice
• (Standardised) Measurement of health status
• Setting Goals for Treatment
• Monitoring change over time (progress)
• Informing clinical decision making (management)

Also:
• Evidence to patient and users
• Reimbursement
• Quality assurance and enhancement
(Clinician & Provider)
 Outcome Measures: Other Issues
• Inform Patient choice
• Enhance communication and interaction between physical
therapists and patients

• Inform Funders and Third Parties

• Inform health-care policy

• Improve quality of health services
• Provide evidence of health and need in groups

• Essential component of research assessing effectiveness*

Jenkinson et al 2009; Black 2008
 Outcome Measures: Importance
• Well accepted
• Endorsed by various stakeholders
• ‘Required’ professional competence
• Databanks of options for OMs
• Central feature of patient-centred care
(PROMS)
• (What’s not to like?)
Outcome Measures: Required
• Standardised Measurement
• Validity
• Reliability
• Able to detect change (when it has occurred)
MCID or Minimum clinically important difference
• (Acceptability to patients and others)
Self-Reported Outcome Measures
• It is important to remember that outcome
measures can only be generalized to the
specific target population from which they
were derived
• In other words, a validated outcome measure
in a hip OA population may not be appropriate
to use in a younger population with a hip
labral tear
Thorborg, K. et al. Validity, reliability and responsiveness of patient-reported outcome questionnaires when assessing hip
and groin disability: a systematic review. Br J Sports Med. 2010;44:1186-1196
Self report measures - Strengths
• Ease of administration
• Less time consuming
• Inexpensive
• Multidimensional
Validity, Reliability, and Response of Patient-Reported
Outcome Questionnaires when Assessing Hip and
Groin Disability
K Thorburn, EM Roos, EM Bartels, J Petersen, P Holmich

• Psychometric properties of questionnaires can only be generalized to the specific

target population and the context in which it has been applied; information
regarding the target population and the context in which it is applied is just as
important as the overall rating of the instrument
• Based on previously mentioned criteria, the HOS and the HOOS received the best
ratings for their psychometric properties (6/8)
• Authors report that HIP DYSFUNCTION AND OSTEOARTHRITIS OUTCOME SCORE
(HOOS) has adequate psychometric properties when assessing patients with hip
OA undergoing conservative treatment or THR
• HIP OUTCOME SCORE (HOS) has adequate psychometric properties when
assessing young patients (< 50 years) undergoing hip arthroscopy
• OHS and PASI showed adequate test-retest and inter-tester reliability but more
information on internal consistency, floor and ceiling effects, and responsiveness is
needed.
• INGUINAL PAIN QUESTIONNAIRE (IPQ) was the only identified questionnaire
evaluating groin disability and DOES NOT contain adequate measurement qualities
 Hip Dysfunction and Osteoarthritis
Outcome Score
• The HOOS has been found to demonstrate
adequate psychometric properties when
assessing patients with hip OA undergoing
conservative treatment or THR
• 40 item instrument
– Scored on a 0 to 4 scale with 0 indicating extreme
difficulty and 4 no difficulty
– 100- (___/160) = %
• 10-15 minutes to complete
• A higher percentage score represents a higher
level of function
Nilsdotter, A. & Bremander, A. Measures of Hip Function and Symptoms. Arthritis Care & Research. 2011;63:S200-207.
 Hip Outcome Score
• Has adequate psychometric properties when assessing
young patient (<50 years) undergoing hip arthroscopy
• 26 item instrument
– 17 item ADL subscale
– 9 item Sport Subscale
• Responses are scored from 4 to 0 with 4 being no
difficulty and 0 being unable to do
• If all questions completed (X/104) x 100 = %
– If one question missed (X/100)
• Higher scores represent a higher level of physical
function

Martin, RL, & Philippon, MJ. Evidence of reliability and responsiveness for the hip outcome score. Arthroscopy. 2008;24:676-682.
 Lower Extremity Functional Scale
• 20 item
instrument
• Test- retest
reliability
– ICC = 0.98
• Internal
consistency
– Cronbach’s
alpha = 0.96
• Responsiveness
– Area under the
curve = 0.77
Watson, CJ et al. Reliability and responsiveness of the lower extremity functional scale and the anterior knee pain scale in patients
with anterior knee pain. JOSPT. 2005; 35:136-146
 Weakness of Self Report Measures
• Do not always differentiate between whether or why a
specific task is not done or can’t be done
• Do not accurately characterize or quantify the impact
of the health condition nor a change in that impact
• Errors in memory or judgment, impaired cognition,
willingness and ability to answer accurately
• Poor correlation between self-report and PPM
• Appear to be highly reflective of changes in pain (and
what the patient is experiencing) and less reflective of
changes in function.
Simmonds MJ. Measuring and managing pain and performance. Man Ther. 2006;11:175-179
Wright, AA. Measurement of function in hip osteoarthritis: developing a standardized approach for physical performance
measures. Physio Theory Pract. 2011;27:253-62.
Stratford PW, Kennedy DM. Performance measures were necessary to obtain a complete picture of osteoarthritis patients. J
Clin Epidemiol. 2006;59:160-167.
 Global ratings of change (groc)
The GROC is a 15-point global rating scale ranging from -7 (“a very great
deal worse”) to 0 (“about the same”) to +7 (“a very great deal better”).

Please rate the overall condition of your back from the time that you began
treatment until now (check only one):

-7 -6 -5 -4 -3 -2 -1 0 1 2 3 4 5 6 7
A very About the A very
great deal same great deal
worse better
 A very great deal worse  About the same  A very great deal better
 A great deal worse  A great deal better
 Quite a bit worse  Quite a bit better
 Moderately worse  Moderately better
 Somewhat worse  Somewhat better
 A little bit worse  A little bit better
 A tiny bit worse (almost  A tiny bit better (almost
the same) the same)
 Not longitudinally stable

Cook C, Garrison. The Global Rating of Change Score (GRoC) Poorly Correlates with Functional Measures and is
Not Temporally Stable: A Clinimetrics Corner
Correlations between self-report and PPM
Table 3: Pearson Correlation Coefficients Between Dependent (outcome) and Independent (explanatory)
Variables
Variables WOMAC Pain WOMAC Function RAND-36 Physical Function
Pathophysiologic variables
Kellgren-Lawrence grade of hip OA .027 .016 -.018
BMI (kg/m2) .137 .252 -.290
Comorbidities .369 .313 -.220
Duration of knee pain (y) .198 .195 -.104
Personal factors
Age (y) .123 .149 -.138
Education (y) -.276 -.264 .291
BDI .196 .131 -.184
Life Satisfaction Scale .299 .204 -.319
Smoking (y) -.102 -.097 -.019
Duration of sport activities (y) .163 .079 .101
Performance measures
Leg extensor power (W/kg) -.191 -.277 .256
Passive hip flexion (deg) -.261 -.286 .239
Passive hip internal rortation (deg) .050 -.010 .090
Sock test .134 .243 -.303
10MWT .233 .208 -.338
TUG test .251 .282 -.344
6MWT -.277 -.286 .417
Juhakoski et al 2008
 Self-report functional outcome measures –
functional performance or perceived performance?

Physical Functioning Before and After Total Hip

Arthroplasty: Perception and Performance
Inge van der Akker-Scheek, Wiebren Zijlstra, Johan W Groothoff, Sjored K Bulstra, Martin
Stevens. Phys Ther. 2008

• CONCLUSIONS:
– “The influence of pain on self-reported physical
functioning serves as an explanation for the poor
relationship between self-reported and performance-
based physical functioning”

Van den Akker-Scheek et al, 2008

 Hip example– womac

Wright, AA. Relationship between the Western Ontario and McMaster Universities Osteoarthritis Index Physical
Function Subscale and Physical Performance Measures in Patients with Hip Osteoarthritis. Arch Phys Med Rehabil
2010;91:1558-64
 ersity, 1400 Main Street West, Hamilton, Ontario L8N 1C7, Canada
abilitation Science, McMaster University, Hamilton, Ontario, Canada
Orthopaedic and Arthritic Institute of Sunnybrook and Women’s College Health Sciences Centre,
Performance measures were necessary to obtain a
Physical Therapy, University of Toronto, Toronto, Ontario, Canada
Accepted 3 July 2005

complete picture of osteoarthritic patients

Paul W. Stratford, Deborah M. Kennedy
d performance measures represent two methods for assessing physical function. A recurring
toperformancemeasures. Thisstudy investigated theassociation between threeperformance
n, and timeor distance; for self-paced walk, stair test, timed up-and-go, 6-minute walk) with
Physical Function subscale and LEFS) and the association between the change scores of the
t measures.
e and self-report measures were administered three times (presurgery and at | 1 week and
who underwent total hip or knee arthroplasty. Components of the performance tests were
measures. Multiple regression analyses were applied. Independent variables were perform-
were self-report measures. Standardized regression coefficients described the cross-sectional

ant of WOMAC Physical Function subscale scores. Pain, exertion, and time or distance were
second, andthird assessments, respectively. Changeinpainwasmost strongly associated with

st the isolated use of self-report assessments of physical function. Ó 2006 Elsevier Inc.

function; Health status; Validity; Outcome

without providing operational definitions or distinguishing

between methods of assessment, the OMERACT III group
ormance measures
specified that the assessment of physical function is essen-
e physical function
tial for PhaseIII clinical trials, but theevaluation of perfor-
or knee, and of pa-
mance is optional [1]. Many investigators, however, use
rring theme is that performance measures as a patient-centered assessment of Stratford et al, 2006
over performance
physical function [3–8]. Adding to theconfusion isthat in-
ionalefor and val-
vestigatorsdo not typically clarify theintended meaning of
thetermdifficulty, whichappearsonmany self-report meas-
 Performance measures were necessary to obtain a
complete picture of osteoarthritic patients
Paul W. Stratford, Deborah M. Kennedy

• AUTHORS’ CONCLUSIONS:
– Pain was the principal determinant of WOMAC physical
Function subscale scores
– Pain, exertion, and time or distance were strongly
associated with the LEFS
– Change in pain was most strongly associated with
change in self-reported physical function

Stratford et al, 2006

 Factors Affecting Self-Reported Pain and Physical
Function in Patients with Hip Osteoarthritis
Riikka, Juhakoski, MD, Seppo Tenhonen, MD, Tapia Anttonen, MD, Timo Kauppinen, MD, Jari P. Arokoski, MD,
DMedSc

• AUTHORS’ CONCLUSIONS:
– Educational level, life satisfaction, and number of comorbidities were
identified as significant factors for both self-reported pain and physical
functioning in patients with hip OA
– Performance measures are better predictors of physical function than pain
– Factors explaining disability and pain in hip OA are multidimensional

Juhakoski et al, 2008

 Presenters’ thoughts
• Because assessment of function is multidimensional,
indexes of functional disability have been considered
misleading without considering the patients’ values
and preferences, thus reflecting the important role of
self-report measures
• The patient’s subjective evaluation serves to represent
patient perception, an essential aspect to consider
when determining functional change
• Self-report used in isolation may overestimate patients’
functional status due to the high correlations with pain
An Overview
PHYSICAL PERFORMANCE
MEASURES
 Physical Performance Measures
(PPM)
• An observed functional
task or a group of
functional tasks with
defined beginning and
end points that is scored
in some fashion.

• PPM’s are used to

document a change in
status for either
outcomes or predictive
purposes
Physical Performance Measures –
strengths
• Can be used to characterize and quantify the impact
of selected conditions.
• Can be used to guide and refine treatment
• May be less influenced by pain
• Lesser influence of psychological factors and
cognitive impairments which may results in recall
bias
MORE ON PHYSICAL
PERFORMANCE MEASURES IN
MODULE 8
THE MINIMUM CLINICALLY
IMPORTANT DIFFERENCE SCORE
 Minimal Clinically Important
Difference (MCID)
• The MCID is defined as the smallest difference in an outcome
measure’s score that patients perceive as beneficial and which
would, therefore, mandate a change in the patient’s management
• MCID scores are utilized by healthcare practitioners to determine
patient response to treatment, either positively or negatively
• Currently, the reported MCID’s for the outcome measures described
are:
– Hip Outcome Score
• ADL subscale 9 points
• Sport Subscale 6 points
– Hip Dysfunction and Osteoarthritis Outcome Score
• None Reported
– Lower Extremity Functional Scale
• 9 points
Jaeschke R, Singer J, Guyatt GH. Measurement of health status: ascertaining the minimal clinically important difference. Control
Clin Trials. 1989;10:407-15.
Martin RL, Philippon MJ. Evidence of reliability and responsiveness for the Hip Outcome Score. Arthroscopy. 2008;24(6):676-82.
 MCID ≠ MDC
• The minimal detectable change is the smallest
change in score than can be detected beyond
random error and is dependent upon sample
distribution.
• MCID can occur on either side of any
statistical threshold and is determined by the
patients in quality of life measures

Turner D. The minimal detectable change cannot reliably replace the minimal important
difference. J Clin Epidemiol 2010;63:28-36.
 Example
• QuickDASH
– MDC 11.2 % points
– MCID 8.1 % points

Mintken, PE. Psychometric properties of the shortened disabilities of the Arm, Shoulder,
and Hand Questionnaire (QuickDASH) and Numeric Pain Rating Scale in patients with
shoulder pain. J Shoulder Elbow Surg 2009; 18:920-6
 Minimum Clinically Important Difference
(MCID)
• Smallest change in score perceived as beneficial

• Differentiates between improved and not improved

• Determined using various methods (distribution vs

anchor-based)

• cf: Minimum Detectable Change (MDC):

– The smallest change in score attributable to true change, over and above
measurement error
 Methods
Anchor based Distribution based
• Sensitivity and specificity • Standard error of
based approach measurement
• Within-patients score • Minimal detectable change
change • Standard deviation
• Between-patients score • Effect size
change
• Social comparison approach

Copay, AG. Understanding the minimum clinically important difference: a review of

concepts and methods. The Spine Journal 2007;7:541-546
 Which one do I choose?
• There are a Table 1. Ranges for MIC Value Based on the Empirical
Evidence
range of Questionnaire Scoring Range Rance of MIC Range of MIC VALUES

acceptable Values (Absolute) (% Improvement from

Baseline)

values reported VAS 0-100 2.0-29.0 points No empirical

evidence
in the literature NRS 0-10 1.0-4.5 points 30

based on the RDQ 0-24 2.0-8.6 points 30

ODI 0-100 4.0-15.0 points No empirical

methodology evidence

chosen! QBPQ 0-100 8.5-32.9 points No empirical

evidence

Ostelo, RW. Interpreting change scores for pain and functional status in low back pain. Spine
2008;33:90-94
Terwee, 2010
 Baseline Dependency of Minimal Clinically
Important Improvement
Ying-Chih Wancy, Dennis L. Hart, Paul W. Stratford, Jerome E. Mioduski

• Subjects: N = 6,651; Orthopedic knee

impairments
• Treatment: Outpatient physical therapy
• Outcome measures:
– LEFS (0-100 scale)
– GROC (15 point scale); ≥ 3
 Baseline Dependency of Minimal Clinically
Important Improvement
Ying-Chih Wancy, Dennis L. Hart, Paul W. Stratford, Jerome E. Mioduski

• Results: Based on baseline intake value

 Baseline Dependency of Minimal Clinically
Important Improvement
Ying-Chih Wancy, Dennis L. Hart, Paul W. Stratford, Jerome E. Mioduski

• Results: Based on sex, symptom acuity, and age

 Baseline Dependency of Minimal Clinically
Important Improvement
Ying-Chih Wancy, Dennis L. Hart, Paul W. Stratford, Jerome E. Mioduski

• Conclusion
– Participants who were male, younger, or had more
acute symptoms required more change to report
meaningful change
– MCII is context specific and not a fixed attribute!

Wang, Y. Baseline dependency of minimal clinically important improvement. Phys Ther

2011;91:675-688.
 Misclassification
• Most MCID estimates are extremely specific
and lack sensitivity
• At the individual patient level, this will
misclassify people below the mean as not
having experienced an important change
when in fact they have

Beaton, 2002
 Case Example
Table 4 Responsiveness Characteristics for Physical Performance Measure at
9-week Follow-up Using 3 Methods
Meausre/ Method MCII Sensitivity Specificity Percent Correctly Positive AUCI
Classified Likelihood Ratio
Timed up-and-go test s(n=64)
Method 1 -.08 55.6 (28.4, 79.7) 78.2 (73.7, 82.1) 75.0 (67.3, 81.8) 2.6 (1.1, 4.5) 0.69 (0.48, 0.90)
Method 2 -1.4 33.3 (12.8, 59.4) 87.2 (83.9, 91.5) 79.7(73.9, 87.0) 2.6 (0.8, 7.0) ---
Method 3 -12 (P=.03) 33.3 (12.8, 60.1) 85.5 (82.1, 89.8) 78.1 (72.3, 85.7) 2.3 (0.7, 5.9) ---

40-m self-paced walk test, m/s

(n=64)
Method 1 0.2 66.7 (38.3, 86.9) 85.5 (80.8, 88.8) 82.8 (74.8, 88.5) 4.6 (2.0, 7.7) 0.89 (0.76, 1.00)
Method 2 0.3 (P=.0002) 55.6 (30.2, 74.2) 94.5 (90.4, 97.6) 89.0 (81.9, 94.3) 10.2 (3.1, 31.0) ---
Method 3 .02 (P<.001) 66.7 (39.0, 86.1) 90.9 (86.4, 94.1) 87.5 (79.7. 93.0) 7.3 (2.9, 14.6) ---
30-s chair stand, n repetitions
(n=65)
Method 1 2.0 66.7 (37.3, 87.4) 67.9 (63.1, 71.2) 67.7 (59.6, 73.4) 2.1 (1.0, 3.0) 0.73 (0.55, 0.91)
Method 2 2.6 66.7 (37.3, 87.4) 67.9 (63.1, 71.2) 67.7 (59.6, 73.4) 2.1 (1.0, 3.0) ---
Method 3 2.1 (P=.06) 66.7 (37.3, 87.4) 67.9 (63.1, 71.2) 67.7 (59.6, 73.4) 2.1 (1.0, 3.0) ---
20-cm step test, n repetitions
(n=65)
Method 1 5.0 55.6 (28.9, 78.7) 87.5 (83.2, 91.2) 83.1 (75.7, 89.5) 4.4 (1.7, 9.0) 0.78 (0.63, 0.93)
Method 2 12.8 33.3 (13.7, 48.5) 96.4 (93.3, 98.9) 87.7 (82.2, 91.9) 9.3 (2.0, 43.1) ---
Method 3 16.4 33.3 (13.7, 48.5) 96.4 (93.3, 98.9) 87.7 (82.2, 91.9) 9.3 (2.0, 43.1) ---

Wright et al, 2011

 Let’s use an example
• Is manual therapy an effective treatment for improving
function in patients with hip OA?
• Outcome measure used is the WOMAC function
subscale
• MCID = 6.5 points
• 70 patients underwent MT treatment
• Mean change score = 6 points
• Conclusion: Manual therapy is ineffective in improving
function in patients with hip OA

• WHY??!?!?!?
KEY POINTS AND
RECOMMENDATIONS
 MCID Strengths
• Clinically, the MCID may be used as a threshold to
detect change beyond that of random error
signaling patient response to treatment
• When using an anchor-based approach, the MCID
is designed to bring the patient’s perspective to
prominence to help guide clinical decision making
during the course of treatment
• For the clinical researcher, the MCID is often used
to determine sample size calculations needed to
demonstrate treatment effectiveness
 MCID Weaknesses
• The MCID is not a universal fixed attribute and cannot be
transferred across patient populations or disease specific
states
• Lack of a universally accepted methodology to determine
the MCID results in a wide range of reported values for a
single outcome measure
• MCID scores reported as single point estimates based upon
the average score of a group lack associated confidence
intervals representative of the wide distribution of actual
change score values.
• Use of a single point estimate runs the risk of misclassifying
patients as not improved when, in fact, they have
 Limitations of the MCID
• There are a wide range of reported MCID scores in hip
related outcomes measures
• MCID scores are context specific and are not
transferable across different populations, genders,
treatments and joints
• A MCID is only valid in the population from which it
was originally derived
– i.e. a MCID score utilized amongst young, athletic
individuals with knee pain cannot be used amongst an
elderly population undergoing TKR.
• MCID scores should not be used in isolation when
determining patient satisfaction
 Patient rate of recovery or patient
acceptable symptom state
• Allowing patients to report their level of recovery status at
the time of the tool administration (at discharge)
• “Taking into account all the activities you have during your
daily life, your level of pain, and your functional
impairment, do you consider that your current state is
satisfactory?”
• Basically, this helps to identify whether the patient is good
versus are they better
• Better does not always equal satisfied
Tubach F et al (2005) Evaluation of clinically relevant states in patient reported outcomes in knee and hip osteoarthritis: the patient
acceptable symptom state. Ann Rheum Dis 64 (1):34-37.
Wright AA & Cook CE. Criterion validation of the rate of recovery, single alphanumeric measure, in patients with low back pain.
Physiother Res Int. 2012
 Module 3:
Observation of the Hip
Alexis A. Wright PT, PhD, DPT,
FAAOMPT
 Objectives
• Recognize selected observations that may be
associated with disease processes
 Observation (Big Picture)
• Work Big to Small, Global to Local
• Global
– Do they look healthy?
– Are they overweight?
– Are they limping?
– Do they walk in a forward flexed position?
– Do they use a cane?
• Local
– Swelling
– Bruising
 Observation
• Performed in both
standing and seated
positions
• Typically, patients
with hip pain will
attempt to alleviate
symptoms by flexing
the hip and knee to
offload the joint or
weight shifting away
from the affected
side
Byrd, JW. Evaluation of the Hip: History and Physical Examination. N Am J Sports Phys Ther. 2007;2:231-240
 Observation - Gait
• Typically the stance • Look for stride length
phase will be shortened • Stance phase
and hip flexion – Shortened?
accentuated
• Foot rotation
• Avoidance of hip – Externally rotated?
extension
• Lumbar lordosis?
• Trendelenburg gait – Secondary to hip flexion
– Abductor lurch contracture
– Hip hike
Byrd, JW. Evaluation of the Hip: History and Physical Examination. N Am J Sports Phys Ther. 2007;2:231-240
Braly, BA, Beall, DP & Martin HD. Clinical examination of the athletic hip. Clin Sports Med. 2006;25:199-210
 Functional gait adaptations in
patients with painful hip
• In a study with 26 patients with unilateral hip pain and 20 normal
age and sex-matched control, force plate data were used to
calculate joint motion, moments and intersegmental forces
• 22 patients with hip OA, 4 with avascular necrosis
• Results:
– Gait analysis shows significant reduced step length (0.66 +/- .06m)
– Reduced range of motion at the knee and ankle
– Patients with hip pain walked with decreased external extension,
adduction, and internal/external rotation moments
– Decreased hip extension significant correlated with increased level of
pain (p<.0001)
– Severe hip pain correlated with decreased hip extension range of
motion with compensatory increased anterior pelvic tilt and lumbar
lordosis

Hulet C et al. Functional gait adaptations in patients with painful hip. Rev Chir Orthop Reparatrice Appar Mot. 200;86:581-9
 Gait changes in hip OA
• 30 patients with hip OA
• Tested for static and dynamic gait parameters
• Results:
– Significant differences were observed in step
length
– Significant differences were observed for total
ground contact area between affected and healthy
leg.

Cichy, B & Wilk, M. Gait analysis in osteoarthritis of the hip. Med Sci Monit. 2006;12:CR507-513
 Observation – Walking speed
• 17 patients with hip OA matched with 17
healthy elderly subjects
• Study observing walking speed, stance phase
duration, stride length and cadence
• Results:
– Subjects with hip OA demonstrated 12.4% slower
walking speed

Watelain, E et al. Pelvic and lower limb compensatory actions of subjects in an early stage of hip osteoarthritis.
Arch Phys Med Rehab. 2001;82:1705-11
 Trendelenburg’s Sign
With normal abductor strength,
the pelvis should remain level.
With abductor weakness, the
pelvis drops toward the
contralateral side, reflecting a
positive Trendelenburg test.
(Right leg affected here)

Byrd, JW. Evaluation of the Hip: History and Physical Examination. N Am J Sports Phys Ther. 2007;2:231-240
 Observation
• Deep Squat
– Point of pain or weight shift
• Single leg hop
– Pain reproduction
• Ascend/Descend Stairs
– Which foot do they lead with
– Pain reproduction
 Module 4:
Triage and Screening of
the Hip
Alexis A. Wright PT, PhD, DPT,
FAAOMPT
 Objectives
• Identify the best tests used to diagnose red
flag conditions of the hip
• Compare and contrast different tests used for
differential diagnosis
• Identify structural screening tests to rule out
competing diagnoses
 Hip/Groin Pain - Defined
• Primarily, true hip pathologies are of intra-
articular origin (OA, labral tears) and will
exhibit symptoms in the buttock and/or groin
with referral to the knee
• Hip pain may arise from a number of sources
including the lumbar spine, pelvis, visceral
structures, and sometimes knee
 Purpose of Screening
• Scanning for
– Potential sources of the condition
– Contributing factors
– Precautions and contraindications
Screening questions common to
all patients
• Medical history
• Surgical history
• Weight loss
• Medications
• Other tests (radiographs, blood work, etc)
• Stress
 Routine Screening Questions:
Pharmacological Status
• Oral Steroids
– Prolonged use leads to bone density loss
• Anticoagulant therapy
• Aspirin
• Analgesics
• Nonsteroidal antiinflammatory drugs (NSAIDS)
• Hormone replacement therapy
• Recreational drug use
– Altered pain perception
 General Health Screen
• Smoking/drinking
• History of RA/rheumatic fever
• Ankylosing spondylitis
• Cancer
• Menstrual status
 Cord or Cauda Equina Compression
• Cord questions
– “Do you ever have pins and needles or numbness
in both arms or both legs at the same time?”
– “Do you have problems with stumbling while
walking?”
• Cauda equina questions
– “Do you have any problems/changes with bowel
and bladder?”
– “Do you ever have pins and needles or numbness
in the saddle/groin area?”
 Hip specific red flags
• Appendicitis
• Ureter
• Colon Cancer
• Femoral neck fracture
• Avascular Necrosis
 Appendicitis
Red Flag data from history Red Flags from physical exam
• Right thigh, groin,
+LR
testicular pain
Rebound tenderness 1.99 (1.61, 2.45)
• Low grade fever Percussion tenderness 2.86 (1.95, 4.21)
• Nausea and vomiting Rigidity 2.96 (2.43, 3.59)
• Anorexia

Andersson RE. Meta-analysis of the clinical and laboratory diagnosis of appendicitis. Br J Surg. 2004;91:28-37
 Palpation Appendices

QUADAS
Study Reliability Sensitivity Specificity LR+ LR-
Score (0-14)
Campbell & McPhail NT 76 NT NT NT 8
Alvarado (tenderness) NT 100 12 1.14 0.00 8
Alvarado (Blumberg’s sign) NT 55 78 2.5 0.58 8
Tzanakis et al. (tenerness) NT 90 59 2.19 0.17 9
Tzanakis et al. (Blumberg’s sign) NT 66 75 2.61 0.45 9
Soda et al. NT 87 90 8.42 0.15 9
 Visceral Referral - Ureter
• Typically at the costovertebral angle
• Radiate into lower abdomen, upper thigh, groin,
genital
• Intensity: excruciating

Goodman & Snyder, 2007

 Colon Cancer
Red Flags from History Red Flags from Physical exam
• Age > 50 • Hypoactive or high-pitched
• Blood in stool bowel sounds
• Unexplained weight loss • May have ascites
• History of colon cancer in
immediate family
• Pain unchanged by
positions or movement
• Pain > 1 month
• Smoker?
Cappell MS. The pathophysiology, clinical presentation, and diagnosis of colon cancer and adenomatous polyps. 2005;89:1-42
Deyo RA & Diehl AK. Cancer as a cause of back pain: frequency, clinical presentation, and diagnostic strategies. J Gen Intern Med.
1988;3:230-8.
Femoral neck fracture – Patellar-Pubic Percussion test
Study Sensitivity Specificity +LR -LR
Adams & Yarnold 94 95 20.4 0.06
Bache & Cross 91 82 5.1 0.11
Misurya et al 89 NT NA NA
Tiru et al 96 86 6.73 0.75
 Avascular necrosis
Red Flags from History Red Flags from Physical exam
• History of long-term • Sudden onset with rapid
corticosteroid use
progression; may refer to
• History of AVN of the
contralateral hip groin, thigh, or medial knee
• Trauma • Worse with weight bearing
• Global loss of movement
• 40-60% present with
symptoms bilaterally

Allison, GT, Bostrom, MP & Glesby MJ. Osteonecrosis in HIV disease: epidemiology, etiologies, and clinical management. AIDS.
2003;17:1-9
Gebhard KL & Maibach HI. Relationship between systematic corticosteroids and osteonecrosis. Am J Clin Dermatol. 2001;2:377-
388
Lumbar Spine Referral Patterns
• Discogenic referred
pain patterns L1
L2

L3
L4

Low
Back

Thigh

Lower
Leg L5

O’Neill, CW et al. Disc stimulation and Patterns of Referred Pain. Spine. 2002;27:2776-2781
 Lumbar Spine Referral
Patterns
• Lumbar
zygapophyseal 1
referred pain 6
patterns 2
– Sites 2-6 represent 3

referred pain
patterns from L2-S1 5
4

Fukui, S. et al. Distribution of Referred Pain from the Lumbar Zygapophyseal Joints and Dorsal Fami. Clin J Pain. 1997;13:303-307
 Lumbar Screen
• Rule out referred pain!!
– Lumbar flexion
– Lumbar extension
– Lateral flexion
– Extension quadrant
– Flexion quadrant

• Perform with
overpressure to clear!
 Module 5:
Movement Assessment of
the Hip
Alexis A. Wright PT, PhD, DPT,
FAAOMPT
 Objectives
• Understand the nature of the patient’s
condition
• Identify the concordant sign reproductive of
the patient’s signs/symptoms
• Perform functional testing, active and passive
physiological and passive accessory
movement examination
 Functional Testing
• Functional tests are designed to provide a
glimpse of pain provocation with various
activities
• Also, these tests serve as a “reassessment
sign” to determine response to treatment
Deep Squat
Unilateral Step-Up
 Active Physiological Movements
• The purpose of active physiological
movements are to identify the concordant
sign
• The concordant sign is the movement or
position that reproduces the patients pain
and/or limitation
• Positive findings may be used as treatment
• Overpressures are used to rule out joints
Maitland GD. Maitland’s vertebral manipulation. 6th ed. London; Butterworth-Heinemann: 2001.
Active Physiological Flexion
Active Physiological
Abduction
Active Physiological
Adduction
Active Physiological Extension
Seated Internal Rotation
Seated External Rotation
 Passive Physiological Movements
• Passive physiological movements are
necessary to identify potential noncontractile
structures that are pain generators
• The purpose of passive physiological
movements are to identify the concordant
sign
• The concordant sign is the movement or
position that reproduces the patients pain
• Positive findings may be used as treatment
Maitland GD. Maitland’s vertebral manipulation. 6th ed. London; Butterworth-Heinemann: 2001.
Flexion with Overpressure
Abduction with Overpressure
Adduction with Overpressure
Internal Rotation with
Overpressure
External Rotation with
Overpressure
Extension with Overpressure
 Passive Accessory Movements
• The purpose of passive accessory movements
are to identify the concordant sign
• The concordant sign is the movement or
position that reproduces the patients pain
• Positive findings may be used as treatment

• Typically passive accessories used to identify

intra-articular pathology
Maitland GD. Maitland’s vertebral manipulation. 6th ed. London; Butterworth-Heinemann: 2001.
Anterior-Posterior Glide
Indirect Distraction
Direct Distraction
 Lateral Glide

MacDonald et al. Clinical Outcomes Following Manual Physical Therapy and Exercise for Hip Osteoarthritis: A Case Series. JOSPT;36:588-573
Hip Quadrant
140 F (towards ipsilateral shoulder)

125 F (towards chin)

110 F (towards opposite shoulder)

95 F (towards opposite

waist)

80 F (towards
ipsilateral shoulder)
Posterior-Anterior Glide
 Module 6:
Palpation and Manual
Muscle Testing for the Hip
Alexis A. Wright PT, PhD, DPT,
FAAOMPT
 Objectives
• Perform an appropriate palpatory examination
• Perform an appropriate strength and
endurance examination
 Palpation
• No studies have been found • Greater Trochanter
which measure the • Anterior Superior Iliac Spine
reliability or validity of • Inguinal Ligament
palpation of the hip
• Pubic Symphysis
• Origin of Adductor Tendon
on Pubic Symphysis
• However, some authors • Sciatic Notch
propose the benefit of
palpation of the hip, • Origin of Hamstrings on
particularly for ruling in/out Ischial Tuberosity
greater trochanteric pain
syndrome, hip flexor muscle
pain and ischial tuberosity
bursitis
Cook CE. Orthopaedic Manual Therapy. An Evidence Based Approach. Prentice Hall; Upper Saddle River, NJ:2007.
 Palpation
• Anterior • Sciatic
Superior Notch
Iliac Spine • Greater
• Inguinal Trochanter
Ligament • Origin of
• Pubic Hamstrings
Symphysis on Ischial
Tuberosity
• Origin of
Adductor
Tendon on
Pubic
Symphysis
Cook CE. Orthopaedic Manual Therapy. An Evidence Based Approach. Prentice Hall; Upper Saddle River, NJ:2007.
Greater trochanter
 Ischial
Tuberosity

Franklyn-Miller A, et al. The gluteal triangle: a clinical patho-anatomical approach to the diagnosis of gluteal pain in athletes.
Br J Sports Med. 2009;43:460-466
 Strength Testing
• Flexion
• Abduction
• Adduction
• Internal Rotation
• External Rotation
• Extension
Resisted hip flexion
Resisted hip abduction
Resisted hip adduction
Resisted hip extension
Resisted hip IR
Resisted hip ER
 Flexibility
• Thomas Test
• Ober Test
• FABER test
Thomas Test
Ober’s Test
FABER test
• The examiner passively
positions the testing limb in
a position of hip flexion,
abduction, and external
rotation.
• The examiner assesses the
perpendicular distance from
the knee on the tested
lower extremity to the table
• An increase in this distance
or pain, when compared to
the uninvolved side, is
suggestive of intra-articular
hip pathology
 Module 7:
Special Tests for the Hip
Alexis A. Wright PT, PhD, DPT,
FAAOMPT
 Objectives
• Understand the language of diagnostic
accuracy
• Identify the most diagnostic hip oriented
special tests
• Apply the tests to the appropriate diagnoses
 Quality Special Tests
• Involves identifying or determining the
etiology of a disease or condition through
evaluation of patient history, physical
examination, and review of laboratory data or
diagnostic imaging; and the subsequent
descriptive title of that finding
• Good tests can discriminate different, similar
conditions
Whiting et al. Evidence based diagnosis. J Health Serv Res 2008 Oct;13 Suppl:57-63
 The Language of Diagnostic
Accuracy
• Sensitivity (SN): The probability of a positive
test result in someone with the pathology
• Specificity (SP): The probability of a negative
test results in someone without the pathology
Two uses of diagnostic tests:
• In the beginning of the exam as a screen
– SNnOUT
• At the end of an exam as the “icing on the
cake”
– SPpIN
 Sensitivity & specificity
Truth ___ Labral tear Labral tear
Test result ↓ (+) (-)
Quadrant
(+) A B
Type I error
Quadrant
(--) C D
Type II error
Sn = A/(A+C) Sp = D/(B+D)
 The Language of Diagnostic
Accuracy
• Positive Likelihood Ratio (LR+): The ratio of a
positive test result in people with the
pathology to a positive test result in people
without the pathology
• Negative Likelihood Ratio (LR-): The ratio of a
negative test result in people with the
pathology to a negative test result in people
without the pathology
 Bayes’ Theorem
• The LR+ is a multiplier in
Bayes’ Theorem and is
used to modify the
posttest probability

• Pretest prob = 20%

• LR+Lachman’s test = 9.0
• Posttest prob = 69%
*Likelihood Ratio Approximate Change in Probability
(%)

The higher the LR +, the better

2 +15

5 +30

10 +45

The lower the LR -, the better

.1 -45

.20 -30

.50 -15

Adapted from: McGee S. JGIM 2002

 QUADAS
• Retrospective Assessment (2006)
• Quality Assessment of Diagnostic Accuracy
Studies
• 14 items (scored 0 to 14)
– Appropriate selection of patient spectrum
– Appropriate reference standard
– Absence of review bias (both test and diagnostic)
– Clinical review bias
– Reporting of
ininterpretable/indeterminate/intermediate results
Whiting et al. BMC Medical Research Methodology. 2003, 3:25
Guidelines for “Best” Special Tests
• No fatal flaws in design
• LR+ of 5.0 or higher
• LR- of 0.2 or lower
• Sensitivity of .90 or higher
• QUADAS of 10 or higher
• A test that matters
• There is limited evidence to support the use
of hip physical examination tests as stand-
alone clinical tests for the diagnosis of hip
related pathology

Reiman et al. Diagnostic accuracy of clinical tests of the hip: a systematic review with meta-analysis. Br J Sports Med. 2012
TESTS FOR OSTEOARTHRITIS
 Composite Exam
Combination of Predictor Variables and Associated Accuracy Statistics with 95%
Confidence Intervals
Number of Sensitivity (95% CI) Specificity (95% Positive Likelihood Negative Post-test
Predictors CI) Ratio (95% CI) Likelihood Ratio Probability of
Present (95% CI) Hip OA (95% CI)
5 .14 (.04 to .37) .98 (.88 to 1.0) 7.3 (1.1 to 49.1) .87 (.73 to 1.1) 75 (25 to 96)
>4 .48 (.26 to .70) .98 (.88 to 1.0) 24.3 (4.4 to 142.1) .53 (.35 to .80) 91 (58 to 99)
>3 .71 (.48 to .88) .86 (.73 to .94) 5.2 (2.6 to 10.9) .33 (.17 to .66) 68 (51 to 82)
>2 .81 (.57 to .94) .61 (.46 to .74) 2.1 (1.4 to 3.1) .31 (.13 to .78) 46 (36 to 56)
>1 .95 (.74 to 1.0) .18 (.09 to .31) 1.2 (.99 to 1.4) .27 (.04 to 2.0) 33 (29 to 36)
*The posttest probability of diagnosis of hip OA is calculated using the positive likelihood ratio and assumes 29% of patients have hip OA (our study
prevalence) regardless of number of predictors present

Variables included: squatting as aggravating factor; scour test with adduction causing
groin or lateral pain; active hip flexion causing lateral pain; passive internal rotation ≤ 25
degrees; active hip extension causing hip pain
Sutlive et al. Development of a clinical prediction rule for diagnosing hip osteoarthritis in individuals with unilateral hip pain.
JOSPT.2008;38:542-550
TESTS FOR FRACTURE OF THE
HIP OR FEMUR
 Patellar-pubic percussion test
• Sensitivity: 95
• Specificity: 86
• LR+ = 6.11
• LR- = 0.07

Reiman et al. Diagnostic accuracy of clinical tests of the hip: a systematic review with meta-analysis. Br J Sports Med. 2012
Borgerding, L. Use of the Patellar-Pubic Percussion Test in the Diagnosis and Management of a Patient with a non-displaced hip fracture.
JMMT 2007; 15.
 Stress Fracture Fulcrum Test
• Sensitivity: 100
• Specificity: 0
• LR+ = 1.0
• LR- = NA

Cook, CE & Hegedus, EJ. Orthopedic Physical

Examination Tests: An Evidence Based
Approach.Pearson Education;
Upper Saddle River, NJ: 2013.
Caesar, BC & Roberts, SJ. Stress Fractures of the
Femoral Diaphysis. Operative Techniques in Sports
Medicine. 2009:17;94-99.
TESTS FOR
FEMOROACETABULAR
IMPINGEMENT AND/OR LABRAL
TEAR
 Flexion Internal Rotation
• Sensitivity: 96
• Specificity: 17
• LR+ = 1.12
• LR- = 0.27
Impingement Provocation Test
• Sensitivity: 97 • LR+ = 1.1
• Specificity: 11 • LR- = 0.27

Reiman et al. Diagnostic accuracy of clinical tests of the hip: a systematic review with meta-analysis. Br J Sports Med. 2012
 Thomas Test
• Sensitivity: 89
• Specificity: 92
• LR+ = 11.1
• LR- = 0.12

Reiman et al. Diagnostic accuracy of clinical tests of the hip: a systematic review with meta-analysis. Br J Sports Med. 2012
Hip Scour Test
• Sensitivity: 50
• Specificity: 29
• LR+ = 0.70
• LR- = 1.72
TESTS FOR A TEAR OF THE
GLUTEUS MEDIUS OF THE HIP
 Trendelenburg’s Sign
• Sensitivity: 23
• Specificity: 94
• LR+ = 3.6
• LR- = 0.82

Reiman et al. Diagnostic accuracy of clinical tests of the hip: a systematic review with meta-analysis. Br J Sports Med. 2012
TESTS FOR GREATER
TROCHANTER PAIN SYNDROME
 Single leg stance for 30 seconds
• Sensitivity: 100
• Specificity: 97.3
• LR+ = 37
• LR- = 0.0

Cook, CE & Hegedus, EJ. Orthopedic Physical Examination Tests: An Evidence Based Approach.Pearson Education;
Upper Saddle River, NJ: 2013.
Resisted External Derotation Test
• Sensitivity: 88
• Specificity: 97.3
• LR+ = 32.6
• LR- = 0.12

Lequesne, M. et al. Gluteal Tendinopathy in refractory greater

trochanter pain syndrome: diagnostic value of two clinical tests.
Arthritis Rheum. 2008;59:241-246.
Reiman et al. Diagnostic accuracy of clinical tests of the hip: a
systematic review with meta-analysis. Br J Sports Med. 2012
TESTS FOR SPORTS RELATED
CHRONIC GROIN PAIN
 Bilateral adductor test
• Sensitivity: 54
• Specificity: 93
• LR+ = 7.7
• LR- = 0.49

Verrall GM, et al. Description of pain provocation tests used for the diagnosis of sports-related chronic groin pain: relationship
of tests to defined clinical (pain and tenderness) and MRI (pubic bone marrow oedema) criteria. Scan J Med Sci Sports 2005;15:36-42
 Squeeze test
• Sensitivity: 43
• Specificity: 91
• LR+ = 4.8
• LR- = 0.63

Verrall GM, et al. Description of pain provocation tests used for the diagnosis of sports-related chronic groin pain: relationship
of tests to defined clinical (pain and tenderness) and MRI (pubic bone marrow oedema) criteria. Scan J Med Sci Sports 2005;15:36-42
 Single adductor test
• Sensitivity: 30
• Specificity: 91
• LR+ = 3.3
• LR- = 0.66

Verrall GM, et al. Description of pain provocation tests used for the diagnosis of sports-related chronic groin pain: relationship
of tests to defined clinical (pain and tenderness) and MRI (pubic bone marrow oedema) criteria. Scan J Med Sci Sports 2005;15:36-42
TEST FOR ILIOTIBIAL BAND
RESTRICTION
Ober Test
• Sensitivity: NT
• Specificity: NT
• LR+ = NA
• LR- = NA
 Module 8:
Physical Performance
Measures for the Hip
Alexis A. Wright PT, PhD, DPT,
FAAOMPT
 Objectives
• Understand the different constructs of
function
• Understand the strengths and weaknesses of
self report measures and the need for physical
performance measures of function
• Identify the best physical performance
measures by condition
How do we measure it?

PHYSICAL FUNCTION
Physical Function is a multidimensional construct

Cognitive
Evaluative Behavioral

Affective Physical

Sensory Function Social

Self Report Outcome Measures

Patient
Perception
Physical Performance Measures

Observed
Performance
 PPM vs SROM
Characteristic SROM PPM
Ease of admin. √
Lower cost √
Time to issue √ √?
Ease to issue √
Ability to capture the √
domain “function”
More stable over the √
course of a disease
Affected by affect √√ √
Clinical use √ √
 Weakness of Self Report Measures
• Do not always differentiate between whether or why a specific task
is not done or can’t be done
• Do not accurately characterize or quantify the impact of the health
condition nor a change in that impact
• Errors in memory or judgment, impaired cognition, willingness and
ability to answer accurately
• Poor correlation between self-report and PPM
• Appear to be highly reflective of changes in pain (and what the
patient is experiencing) and less reflective of changes in function.

Simmonds MJ. Measuring and managing pain and performance. Man Ther. 2006;11:175-179
Wright, AA. Measurement of function in hip osteoarthritis: developing a standardized approach for physical performance
measures. Physio Theory Pract. 2011;27:253-62.
Stratford PW, Kennedy DM. Performance measures were necessary to obtain a complete picture of osteoarthritis patients. J
Clin Epidemiol. 2006;59:160-167.
 General Thoughts
• Because assessment of function is multidimensional,
indexes of functional disability have been considered
misleading without considering the patients’ values
and preferences, thus reflecting the important role of
self-report measures
• The patient’s subjective evaluation serves to represent
patient perception, an essential aspect to consider
when determining functional change
• Self-report used in isolation may overestimate patients’
functional status due to the high correlations with pain
 Physical Performance Measures
(PPM)
• An observed functional
task or a group of
functional tasks with
defined beginning and
end points that is scored
in some fashion.

• PPM’s are used to

document a change in
status for either
outcomes or predictive
purposes
Physical Performance Measures –
strengths
• Can be used to characterize and
quantify the impact of selected
conditions.
• Can be used to guide and refine
treatment
• May be less influenced by pain
• Lesser influence of psychological
factors and cognitive impairments
which may results in recall bias
Performance-based methods for measuring the
hip or knee: a systematic review of
measurement properties
C.B. Terwee, L.B. Mokkink, M.P.M. Steultjens, and J. Dekker

• 26 performance measures were included

• 3/7 multi-activity tests were tested for internal consistency and 2 were rated
positively
• 14 tests were rated for reliability and 5 were rated positively
• 10 tests were rated for agreement and 1 was rated positively
• 14 tests were rated for constructed validity and 2 were rated positively
• 12 tests were rated for responsiveness and 0 were rated positively
• Iowa Level of Assistance Scale (ILAS) received the best ratings although proper
justification of the content of the test is lacking and internal consistency of the
test has not been evaluated

• CONCLUSION: NO PPM RECOMMENDATIONS CAN BE MADE SECONDARY

TO A LACK OF SUFFICIENT EVIDENCE REGARDING THE PSYCHOMETRIC
PROPERTIES OF PPM
 Measurement properties of performance-based
measures to assess physical function in hip and knee
osteoarthritis: a systematic review
F.Dobson, R.S. Hinman, M.Hall, C.B. Terwee, E.M. Roos, K.L. Bennell

• 21 performance measures were included

• 15 single activity measures
• 6 multi-activity measures
• CONCLUSION: Based on limited evidence, the 40m self paced
walk tests was the best rated walk test, the 30 second chair
stand and timed up and go were the best rated sit to stand
tests, and the Stratford Battery, Physical Activity Restrictions,
and Functional Assessment System were the best rated multi
activity measures
Dobson F. et al. Measurement properties of performance-based measures to assess physical function in hip and knee osteoarthritis:
a systematic review. Osteoarthritis Cartilage. 2012;20:1548-1562
Physical performance measures of
the hip
• Timed Up and Go • Mainly validated in
• 40m self paced walk arthritic populations
test
• 30 second chair
stand
• Stair Climb
 Timed Up-And-Go
• Rise from a standard chair, walk 3 m, then
return to the chair- timed
• Used in subjects with frailty due to aging,
OA/joint replacement, low back pain, “fallers”
• In short, anyone with mobility, balance, and
strength issues
 40 meter self-paced walk test
(SPWT)
• Walk as quickly but as safely as possible to a
mark 10m away
• Return
• Repeat for a total distance of 40m
• Subjects are timed for this test and data are
expressed as speed

Wright, AA et al. A comparison of 3 methodological approaches to defining major clinically important improvement of 4
performance measures in patients with hip osteoarthritis. JOSPT. 2011;41:319-327
 30 second chair stand
• Rise from a chair with hands folded across
chest as many times as possible in 30 seconds
• Used in frail elderly, patients with hip or knee
OA
• In short, anyone with strength, power, balance
issues
• You will also see Repeated Sit-to-Stand,
Supine-to-Stand
 Physical Activity Restrictions
• Multi-activity measure included:
– 6 minute walk test
– Five or nine stair ascent/descent
– Lift and Carry test (timed)
– Car Test (in/out car timed)

Dobson F. et al. Measurement properties of performance-based measures to assess physical function in hip and knee osteoarthritis:
a systematic review. Osteoarthritis Cartilage. 2012;20:1548-1562
 Stratford Battery
• Multi activity measure included:
– Walk 2 x 20m fast-paced
– Stand, 3 m walk, turn, return, sit
– Up and down nine stairs
– 6 min walking

Dobson F. et al. Measurement properties of performance-based measures to assess physical function in hip and knee osteoarthritis:
a systematic review. Osteoarthritis Cartilage. 2012;20:1548-1562
Functional Assessment System
• Multi-activity measure included:
– Rise from half stand max no.
– Sit to stand lowest height
– Step (max height)
– Stand one leg
– Stair climbing
– Gait speed over 65m
– Walking aid
Dobson F. et al. Measurement properties of performance-based measures to assess physical function in hip and knee osteoarthritis:
a systematic review. Osteoarthritis Cartilage. 2012;20:1548-1562
AND SOME OTHERS….
 The Stair Test
• Ascend and descend 10 stairs as quickly as is
safe for you
• Used in subjects with frailty due to aging,
cardiopulmonary dysfunction, OA/joint
replacement, low back pain
• In short, anyone with mobility/endurance
issues
• You will also see ascend stairs only, 4 flights of
stairs as quickly as possible
 SOCK TEST
• Participants are instructed to sit
on an elevated bench with their
feet off the ground. Participants
are instructed to flex the knee and
hip in the sagittal plane and reach
down toward their foot with both
hands, one on each side grabbing
the toes with the fingertips of
both hands. The foot must not
touch the bench and should be in
the air at all times during the test.

• Test-retest reliability
– Kappa = 0.79

Strand et al, 1999; Wright et al, 2010

 ILAS
• Participants are assessed on their ability to get
out of bed, stand from the bed, ambulate 15 feet,
climb up and down 3 steps, and ambulate 44 feet.
• Each activity is graded on an ordinal scale from 0
to 6 for the level of assistance required and
summed for a total score
• Test-retest reliability
– ICC = 0.82
• Responsiveness
– Guyatt’s responsiveness index = 0.75

Shields et al, 1995; Wright et al, 2010

 Functional Performance Testing of the
Hip in Athletes: A Systematic Review
for Reliability and Validity
Benjamin R. Kivlan, RobRoy L. Martin

• Author’s conclusions
– The Single leg stance, deep squat, single-leg squat, and
star excursion balance tests demonstrated evidence of
validity and normative data for score interpretation.
 Functional Performance Testing of the Hip
in Athletes: A Systematic Review for
Reliability and Validity
Benjamin R. Kivlan, RobRoy L. Martin
Summary of Functional Performance Tests with Evidence of Validity to Hip Function
Test Category Relationship to Hip Function Interpretation of Test Results
Deep Squat Movement Patients with femoroacetabular impingement Patients with Femoroacetabular Impimgement Mean Peak
demonstrated less squat depth and altered lumbo- Squat Depth – 41% of leg length
pelvic kinematics Normal Mean Peak Squat Depth = 32% of leg length
Single-Leg Movement Subjects graded as “poor” on the single leg squat test Subjects were ordinally graded (good, fair, poor) on ability
Squat exhibit weaker and slower muscle activation of the hip to maintain balance, postural control, and lower body
abductors than those graded as “good” alignment during 5 repetitions of a single leg squat to 60
Single-Leg Balance Provocation of pain during 30 second single leg stance Positive test = increase of pain within 30 seconds of single
Stance has shown sensitivity (100%) and specificity (97.3%) in leg stance
detecting tendinopathy of the gluteus medius and Normal function of the hip abductors maintains the pelvis
minimus nearly perpendicular to the femur in a single leg stance
position
Normal = 30 second of single leg stance without pain
Star ExcursionBalance Hip flexion range of motion explained 86-92% of SEBT Anterior reach difference  4 cm is 2.5 times risk for injury
Balance Tets reach distances A composit score standardized to leg length <94% is 6
Hip abduction and extension strength have a times more likely for injury
moderate correlation (r=.48-.51) to posterior-medial
and posterior-lateral reach distances
Elicits activation of the gluteus medius at 49% of
maximal volitional isometric contraction during
medial reach
 Single Leg Stance
• Reliability
– ICC: .58
• Validity
– Correlates well with 1RM
squat
• Normal = 30 seconds of
single leg stance
without pain
Deep Squat
• Normal mean peak
squat depth = 32% of
leg length
 SINGLE LEG SQUAT
• Reliability
– Intra: .61-.80
• Validity
– Good performers have
better motor control and
more hip abduction
strength
• Responsiveness
– Hold time improves after
rehab
Rate as good, fair, or poor Crossley et al.Am J Sports Med 2011
 Star Excursion Balance Test
• Reliability
– Intra = 0.84-.93
– Inter = .35-.93
• Validity
– Correlates with pain VAS
• Anterior reach
difference < 4cm >94%
of composite score
Filipa et al. Neuromuscular training improves performance on
the star excursion balance test in young female athletes. JOSPT.
2010;40:551-558
Kivlan BR & Martin RL. Functional performance testing of the hip
in athletes: a systematic review for reliability and validity. IJSPT.
2012;7:402-412
Examination of the Hip

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MedBridge Education
Evidence-Based Examination of the Hip
Alexis Wright, PT, PhD, DPT, FAAOMPT

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