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AH 325

Thigh & Hip Injuries Laboratory

  1. History
    1. Mechanism of Injury
      1. Contusion
        1. Iliac crest - very painful & disabling, may involve periosteum
        2. Sacrum -
        3. Buttocks - frequent, may also include ischial tuberosity
        4. Sciatic nerve - pain along nerve & possible referred from low back problem
        5. Pubis - from split-legged falls, over a bar in gymnastics, saddle injury in horseback riding
        6. Scrotum -
        7. Femoral triangle -uncommon, can possibly damage femoral nerve, artery, or vein resulting in quadriceps paralysis & decreased cutaneous sensation in anterior medial thigh
        8. Obturator nerve -cause referred pain to the medial thigh or knee joint
        9. Greater trochanter -from falling on the side, may result in trochanteric bursitis
      2. Fractures - rare
        1. Intertrochanteric - from falling with both direct, & indirect forces from the pull of the iliopsoas & the abductor muscles on the lesser & greater trochanters
        2. Subtrochanteric - extremely rare, but in younger athletes from direct trauma of considerable force
        3. Sacrum - rare, but usually transverse or star shaped, acutely painful, if displaced there is possibility of rectal damage
        4. Ischial tuberosity - can occur from direct trauma, more likely form avulsion of hamstrings, may have periostitis, bursitis
        5. Acetabulum - infrequent, may be along margin, may tear labrum
        6. Femoral neck - more common in older athlete with osteoporosis, considerable force needed in young athlete, can result form direct blow or a rotational force through femur. Injured limb is held in lateral rotation & leg appears in shortened.
        7. Epiphysis - can occur to proximal femur, greater trochanter, or capital femoral epiphysis
      3. Dislocation - rare, but more common than fractures, usually only occur when violent force is exerted on flexed hip & knee joint or a force is transmitted along the femur in an abducted hip position. Medical emergency. Femoral head blood supply can be disturbed, resulting in avascular necrosis of femoral head.
        1. Posterior hip dislocation - greater trochanter is prominent, femur is flexed, adducted, & internally rotated, may have an associated ring fx in adolescents, occasionally sciatic nerve may also be damaged
        2. Anterior hip dislocation - hip is abducted, externally rotated, & in slight flexion, femoral head is palpable, femoral nerve can be damaged
        3. Slipped capital femoral epiphysis - occurs in young (10-15) athlete, endomorphic build, delayed secondary sex characteristics, possibly with relatively minor trauma, pain usually in groin & anteromedial thigh, often referred to knee, develop antalgic gait & limb external rotation, capital epiphysis becomes displaced posteriorly & inferiorly while femoral neck moves anteriorly & superiorly on the capital epiphysis. As it progresses, hip loses ability to internally rotate and tends to abduct & externally rotate
      4. Bursitis
        1. Greater trochanter bursa -most commonly injured in hip area, more commonly from overuse, but can be from direct blow, can also develop secondary to contralateral gluteus medius weakness, leg-length difference, incorrect running
        2. Ischial bursa - caused from prolonged sitting or direct blow
        3. Iliopectineal bursa - usually overuse of iliopsoas muscle, can be due to direct trauma, hip assumes flexed, externally rotated position
      5. Overstretch
        1. Hip flexion with knee extension - may cause hamstring strain, avulsion of ischial tuberosity, most commonly long head of biceps femoris at origin, may result from muscle imbalance
        2. Hip extension with knee extension - causes iliopsoas strain usually at point of attachment to lesser trochanter, iliofemoral ligament sprain, inferior abdominal strain
        3. Hip extension with knee flexion - most commonly strains rectus femoris, but may also cause iliopsoas or lower abdominal strain, iliofemoral ligament sprain
        4. Hip abduction - causes strains, tears, or avulsions of hip adductors (adductor longus, magnus, brevis, gracilis, & pectineus) at ischiopubic rami most likely, possible avulsion of lesser trochanter
        5. Hip medial rotation - causes hip lateral rotator strain (piriformis, obturator internus, obturator externus, gluteus medius, gluteus maximus, quadratus femoris, & gemelli, also posterior ischiofemoral ligament sprain and/or lateral hip capsule sprain
        6. Hip lateral rotation - causes hip medial rotator strain (tensor fascia lata, gluteus medius, or anterior fibers of gluteus minimus), also sprains of iliofemoral ligament, pubofemoral ligament, medial hip capsule
        7. Trunk lateral flexion - can cause hip & abdominal strain or avulsion
      6. Overuse
        1. Trunk rotation - on a fixed pelvis causes stress to lateral & medial rotators
        2. Hip lateral rotation - repeated stress to lateral rotators leads to piriformis syndrome, piriformis myofascial trigger points, hip joint capsulitis & synovitis
        3. Hip medial rotation - repeated stress to medial rotators leads to gluteus medius tendonitis or activation of gluteus medius trigger points, hip joint capsulitis & synovitis
        4. Hip flexion - repeated hip flexion leads to tendonitis or trigger point activation of rectus femoris, sartorius, iliopsoas, or iliopectineal bursitis
        5. Hip extension & knee extension - repeated in standing position leads to greater trochanteric bursitis, tendinitis or trigger point activation of iliopsoas, rectus femoris, sartorius, or tensor fascia lata
        6. Hip and knee flexion and extension - leads to iliopsoas tendonitis or bursitis
        7. Vertical shearing forces - repeated vertical shearing to asymmetric pelvis or leg-length discrepancy leads to sacroiliitis, osteitis pubis, adductor tendinitis or strain, gluteus medius tendonitis, or quadratus lumborum tendinitis or strain
        8. Hip adduction - repeated hip adduction leads to adductor tendinitis (especially adductor longus), osteitis pubis
        9. Greater trochanteric bursitis - caused by running, particularly if the runner has a wide pelvis, lack of iliotibial band and/or quadratus lumborum flexibility, increased subtalar supination, excessive wear on posterolateral heel of running shoes, leg-length difference, hip adductor/abductor muscle imbalance, gluteus medius weakness, abnormal running mechanics (especially cross-over gait), running on banked or slippery surfaces
        10. Ischial bursitis - can develop in adolescent runners doing hill or speed work, also may develop hamstring strains or syndrome (tendinous fibrotic band of biceps femoris at insertion irritating sciatic nerve
        11. Stress fractures - relatively uncommon, usually in long-distance runner, ischial pubic ramus, iliac crest or epiphysis of anterior iliac crest, lesser trochanter, femoral neck, or proximal femur
        12. Others - runners with functional or structural leg-length discrepancy can develop sacroiliitis, osteitis pubis, or adductor tendinitis
      7. Explosive muscle contraction - causes muscle strains, tears, or avulsions, may (in adolescents) avulse ASIS or crest, AIIS, ischial tuberosity, lesser trochanter, iliac crest from abdominal (external oblique) contraction
      8. Reenacting the mechanism - movement, weight bearing or not, force direction
      9. Nature & forces of the sport - nature & sport mechanics
      10. Insidious onset - may be slipped capital femoral epiphysis, pain in groin, medial thigh, or knee, loss of medial hip rotation
    2. Pain
      1. Location
        1. Local - usually indicates more superficial lesion involving skin or superficial fascia, superficial muscles or tendons, superficial ligaments, greater trochanteric & iliopectineal bursa, periosteum, nerves
        2. Diffuse - often caused by deep somatic or neural injuries
        3. Referred - true hip joint pain is referred to groin, front of thigh, occasionally down front of leg along L3 dermatome
          1. Myotome - deep muscle injury can refer pain to that myotome & may be caused by gluteus medius, lateral rotators (piriformis), deep adductors, pectineus
          2. Sclerotome - deep capsular injury, fracture, genitofemoral pain of hip osteoarthritis refers pain into thigh & eventually even knee stiffness in the morning
          3. Deep & cutaneous nerves - can refer pain along nerves, usually distal, deep may be sciatic, femoral, obturator. Cutaneous may be lateral, medial, posterior, obturator, anterior, cluneal, ilio-inguinal
          4. Groin, medial thigh, hip, or knee pain - Other conditions may cause pain to radiate to hip or groin area including
            1. inguinal or femoral hernia
            2. inflammation or infection of abdominal organs
            3. gynecological or urinary infection or disease
            4. tumors, osteoma, metastatic disease of femur or lower pelvis
            5. enlarged lymphatic vessels in triangle area
            6. inflammatory conditions (ankylosing spondylitis, Reiter syndrome, rheumatoid arthritis
            7. circulatory problems of femoral artery
            8. iliopsoas abscess
            9. tubercular disease of hip
            10. slipped capital femoral epiphysis
            11. Pain in medial thigh, groin, and pubic area may be caused by pubic symphysis instability, osteitis pubis, pubic ramus stress fx, femoral neck stress fx, or adductor tendinitis
          5. Posterior buttock & thigh pain - may be caused by lumbar spine nerve root irritation, facet, ligamentous capsular lesion, intervertebral disc herniation, chronic posterior thigh compartment syndrome, piriformis syndrome, hamstring strain or syndrome, ischiogluteal bursitis, sciatic nerve contusion
      2. Type of pain
        1. Sharp - can be caused by injury to skin, fascia, ligaments, superficial muscle, periosteum
        2. Dull - can be caused by injury to joints, deep muscles, chronic muscle problems
        3. Aching - can be caused by injury to deep muscles, deep bursa, deep ligament, fibrous capsule, ventral nerve root, deep or peripheral nerve
        4. Pins & needles - sensation caused by injury to dorsal nerve root (L2, L3, L4, L5, S1) or nerve trunk
        5. Numbness - caused by injury to dorsal nerve root (L2-S1)
      3. Timing of pain - pain that occurs suddenly & remains intense suggests a more severe injury, pain that returns later indicates synovial swelling
      4. When the pain occurs
        1. All the time - usually indicates a more severe injury, active inflammatory state, or disease process
        2. Repeating mechanism pain with repeated mechanism suggests local lesion, either ligamentous or muscular, repetitive movements suggest bursitis or tendinitis
        3. Morning - accompanied by stiffness suggest intracapsular swelling that builds overnight, common with arthritic or degenerative joint pathology
        4. End of the day - suggests inflammation due to too much stress during daily or sports activities
        5. Weight-bearing - suggests articular or muscular injury
      5. Degree of pain - usually the worse the pain, the more severe the injury, but complete muscular or ligamentous tears may be painless
    3. Swelling
      1. Location
        1. Local
          1. Intracapsular - cannot be determined by history, observations , or palpations. Functional testing will indicate capsular pattern
          2. Intramuscular - lump within muscle usually in midbelly during manual resistance testing
          3. Bursal - very localized, most commonly greater trochanteric bursa
        2. Diffuse
          1. Intermuscular - swelling tracking down thigh due to gravity, around iliac crest from hip pointer
      2. Time of swelling - immediate swelling indicates more severe injury including hemarthrosis, fracture, local hemorrhage
    4. Function
      1. Activities - what makes it worse: standing, walking, running, sitting, forward bending
        1. Athlete’s function post-injury
          1. How well could athlete function after injury?
          2. Continued play?
          3. Weight bearing?
          4. Limping?
          5. Carried off field or court?
          6. Comfortable positions?
        2. Pain alleviating & aggravating positions
      2. Sensations
        1. Numbness or hypersensitivity - see dermatomes or local cutaneous nerve supply
        2. Snapping or clicking - at lateral aspect due to bursal thickening at greater trochanter, gluteus maximus can snap over greater trochanter, other causes may be psoas tendon slipping over iliopectineal eminence of pubis or lesser trochanter, iliofemoral ligament slipping over anterior hip capsule or femoral head, hip joint subluxation, loose body, or osteochondromatosis (rare)
        3. Popping sensation - if after sudden explosive contraction, may be muscle strain or tear
        4. Tightness or tension - may be presence of swelling or protective muscle strain
        5. Joint stiffness - suggest osteoarthritic rheumatoid arthritic changes
      3. Particulars - history, previous medical exams, treatments, chronic recurring conditions include hamstring strains, adductor strains, greater trochanteric bursitis, iliopsoas tendinitis, iliopectineal bursitis
  2. Observation
    1. Standing
      1. Anterior view
        1. Anterior superior iliac spines & iliac crests - should be level, if unlevel could be leg-length difference
        2. Leg-length discrepancy - could lead to problems with:
          1. sacroiliac joint
          2. symphysis pubis
          3. facet & intervertebral joints of lumbar spine
          4. muscle imbalances (quadratus lumborum, iliopsoas, adductors)
          5. facet joints of thoracic or cervical if scoliosis occurs
        3. Coxa Varum (Genu valgum) - angle of inclination, with one axis through head & neck of femur, and other down the femoral shaft, should be 1250. If less than then coxa varum exist, may be caused by slipped capital femoral epiphysis, trauma, arthritis, rickets, or congenital. Usually bilateral, if unilateral there will be leg-length difference with affected side of pelvis being lower, may cause back or sacroiliac dysfunction. Coxa varum causes genu valgum leading to patellofemoral problems.
        4. Coxa Valgum (Genu varum) - If greater than 1300 then coxa valgum exist, may be caused by previous hip dislocation, trauma, spastic paralysis, or congenital. May cause eventual osteoarthritic hip changes, increased susceptibility to trochanteric bursitis, coxa valgum causes genu varum, predisposes the hip to dislocation because of tight adductors.
        5. Femoral anteversion - angle formed by transverse axis through femoral neck & through the transverse axis of femoral condyles should be 120 to 150, ranging from 80 to 250. Femoral anteversion is > 150. Toed-in gait. Extra femoral head pressure contributing to osteoarthritis in later life. Increased susceptibility to anterior femoral dislocation, knee may have malalignment syndromes, patellar dislocations, excessive lumbar lordosis. Body may compensate by increasing external tibial torsion and/or pronating feet.
        6. Femoral retroversion - angle is < 150. Toed-out gait. Body tends to compensate by internally rotating tibia and/or supination.
      2. Lateral view
        1. Pelvic position - anterior tilt is associated with excessive lumbar lordosis, shortened hip flexors, lumbar extensors & thoracolumbar fascia, posterior tilt is combined with flat back position, hyperextended hips, lax hip ligaments, weak hip flexors
        2. Excessive lumbar lordosis (anterior pelvic tilt) - can be caused by or result in tight hip flexors, tight low back musculature, weak abdominals, weak hamstrings & glutei
        3. Flat back with hip joints hyperextended (posterior pelvic rotation) - puts a stretch on anterior hip ligaments, iliopsoas muscles, external oblique muscles. Low hamstrings are often tight & shortened, leads to facet degeneration & uneven pressure on intervertebral discs.
        4. Tight hip flexors - causes anterior tilt, excessive lumbar lordosis, anterior hip capsule tightness which progresses degenerative hip joint disease
        5. Tight hamstrings - leads to posterior pelvic tilt
        6. Abdominal muscle weakness - contributes to anterior pelvic tilt, anterior capsule & hip flexor tightness
        7. Weight distribution - any hip problems or pelvic injury will cause less weight to be placed on injured side.
      3. Posterior view
        1. Spinous process - key to determining scoliosis and possible leg-length difference
        2. Posterior superior iliac spines - may be raised by quadratus lumborum muscle spasm or weak gluteus medius, functional or structural leg-length difference. When one PSIS is higher and ASIS is lower there is functional leg-length difference or anterior iliac rotation.
        3. Gluteal folds - should be level, sag of one buttocks may be caused by L5 or S1 nerve root impingement or lesion
        4. Hamstring development -atrophy of hamstrings and gastrocnemii is a sign of S1 or S2 radiculopathy, atrophy of buttocks or hamstring can also develop from hip arthritis or previous hamstring atrophy
        5. Popliteal creases - uneven may be caused by functional or structural lower leg difference
        6. Gastrocnemii development - atrophy may be a sign of S1 or S2 nerve root irritation
        7. Calcaneal alignment - unilateral calcaneal valgus will cause a slight functional leg-length difference, calcaneal valgus can cause prolonged pronation during gait.
      4. One leg standing (stork stand) - look for balance, willingness to weight bear, dropping of unsupported side indicates gluteus medius, gluteus minimus, or tensor fascia lata weakness
      5. Local observations of the lesion site - look for swelling, ecchymosis, scars, & atrophy, asymmetrical bony & muscular development
    2. Gait - watch trunk, pelvis, & entire lower limb during walking
      1. Stance phase
        1. Heel strike & foot flat - the lateral rotators & abdominals contract to stabilize hip & pelvis. Hip extension begins & continues until heel off. At heel strike, the center of gravity is shifted over the weight-bearing leg & pelvis, which produces a closed chain hip adduction motion during heel strike & at the beginning of midstance. Hip internal rotation occurs at heel strike & foot flat, rotation is transferred down the limb. Hip extensor injury limits the force of both hip extension and push off on that side. Hip adductor or internal rotator muscle injuries may elicit pain on weight-bearing side at heel strike & foot flat.
        2. Midstance - body weight is shifted over the hip joint, hip adduction motion changes to hip abduction for the rest of the stance phase to control the weight transfer & then move the line of gravity to the opposite limb. Internal motion of the hip changes to external rotation during midstance and push off. A weak gluteus medius will cause lurching over to involved side (Trendelenburg gait). A weak gluteus maximus will cause upper body to lurch backward to maintain hip extension (gluteus maximus lurch).
        3. Push-off (Heel off-Toe-off) - Abduction & external rotation continues until toe off. Hip extensor, abductor, or lateral rotators will cause a weak, unstable push-off.
      2. Swing phase - watch length of stride & rhythm of gait, equal weight bearing on both sides
        1. Toed-in gait - sign of anteversion or internal tibial torsion
        2. Toed-out gait - sign of retroversion or external tibial torsion
        3. Slipped capital femoral epiphysis - walking with affected leg externally rotated
        4. Antalgic gait - (limp) may be caused by:
          1. injury to muscle, ligament, or joint in the lower extremity
          2. congenital dysplasia or hip dislocation
          3. coxa valgum or coxa varum
          4. hip joint osteoarthritis
          5. leg-length discrepancy
          6. slipped capital femoral epiphysis
          7. acute sacroiliac sprain
          8. ASIS epiphysitis (antalgic gait with listing toward involved side)
        5. Gluteus medius gait (Trendelenburg gait) - caused by:
          1. weakness or inhibition of gluteus medius
          2. congenital hip dislocation
          3. neurological problem (poliomyelitis, meningomyelocele, nerve root lesion)
          4. any occurrence causing muscle origin to move closer to insertion (coxa vara, fx trochanter, slipped capital femoral epiphysis
        6. Gluteus maximus gait - caused by:
          1. weakness or inhibition of gluteus maximus
          2. L5, S1 nerve root problem
          3. gluteus maximus muscle injury
          4. inferior gluteal nerve injury
        7. Weak psoas gait (injured) - exaggeration of pelvic movement & trunk to help thigh move into flexion, caused by:
          1. iliopsoas muscle injury
          2. psoas injury or abscess
          3. iliopsoas bursitis
          4. L2 nerve root irritation (rare)
        8. Weak adductor gait - walking with wide stance & unstable pelvis, caused by:
          1. adductor muscle injury
          2. osteitis pubis
          3. neurological problems at L2, L3, or L4 nerve roots
        9. Hip flexor tightness or contracture - compensated for by walking with anterior pelvis tilt & excessive lumbar lordosis
        10. Upper shoulder & arm movements - excessive upper body movements, arms swinging across body may be caused by faulty hip or lower limb mechanics
        11. Lumbar spine - stiffness in lower back or trunk may cause reluctance to move pelvis during gait due to pain or muscle spasm
        12. Painful hip joint - commonly held in slight flexion, abduction, & external rotation, walking speed is reduced
        13. Pelvic movements - normal pelvic movements include horizontal displacement, pelvic drop, & pelvic rotation
          1. Horizontal displacements - normally pelvis moves 1" on either side of midline toward weight-bearing side
          2. Pelvic drop - pelvis drops slightly on swing leg side, injury or weakness in contralateral abductors cause excessive drop
          3. Pelvic rotation - the pelvis rotates forward about 400 on the swing leg side, imbalance or injury cause excessive or limited rotation
  3. Palpation
    1. Palpate for tenderness, swelling, muscle spasm, masses/deficits
    2. Palpate bony & soft tissues (palpate all structures standing first, then supine, prone, etc.)
      1. Femoral triangle (figure 4 supine position)
        1. Inguinal ligament (superiorly) (figure 4 supine position)
        2. Sartorius muscle (laterally) (figure 4 supine position)
        3. Adductor longus (medially) (figure 4 supine position)
        4. Psoas bursa (midpoint of inguinal ligament) (figure 4 supine position)
        5. Palpate the femoral pulse (figure 4 supine position)
      2. Anterior superior iliac spine (supine & standing position)
      3. Rectus femoris (supine position)
      4. Crest of ilium (supine & standing position)
      5. Iliac tubercles (supine & standing position)
      6. Pubic tubercles (supine & standing position)
      7. Greater trochanter (supine & standing position)
      8. Posterior superior iliac spines (prone & standing position)
      9. Gluteus medius (prone & sidelying position)
      10. Ischial tuberosity (prone & sidelying position)
      11. Sciatic nerve (sidelying position)
      12. Hamstrings (prone & sidelying position)
      13. Gluteus maximus (prone & sidelying position)
  4. Functional tests
    1. Rule out
      1. Lumbar spine - problems here can cause referred hip pain
      2. Knee - knee pain may be referred from above, clear by supine knee flexion, heel to buttock, apply overpressure
      3. Internal organ problems - can cause hip region pain, may include gynecological problems, inguinal or femoral hernia, prostrate problems, bladder or urinary tract infections, kidney infections, appendicitis, pelvic floor myalgia
      4. Inflammatory disorders - ankylosing spondylitis, Reiter syndrome, rheumatoid arthritis
      5. Tumors or metastatic disease - malignant or benign cancers
    2. Tests in supine position
      1. Active hip flexion (1100 to 1200) - Pain, limited ROM, or weakness can be due to muscles or their nerve supply:
        1. Iliacus - femoral N (L2,L3)
        2. Psoas major - femoral N (L1, L2, L3, L4)
        3. Tensor fascia lata - superior gluteal N (L4, L5)
        4. Rectus femoris - femoral N (L2, L3, L4)
        5. Sartorius - femoral N (L2, L3)
        6. Pectineus - femoral N (L2, L3, L4)
        7. Adductor magnus or longus - obturator N (L2, L3, L4)
        8. May also come from hamstring stretch if hamstring problem or gluteus maximus strain exists
      2. Passive hip flexion (1200)
        1. knee flexed (1200 to 1400) - may be from hamstring or gluteus maximus, pain at end range, if soft suggests ischial bursitis, if hard suggest arthrosis. Overpressure causes posterior iliac rotation, then lumbar flexion.
        2. knee extended (900 to 1200) - stretches the hamstrings, also stretches the dural sleeve & can elicit pain with nerve root impingement
      3. Active hip abduction (300 to 500) - Limited abduction occurs in coxa vara due to greater trochanter against acetabulum. Pain, limited ROM, or weakness can be due to muscles or their nerve supply:
        1. Gluteus medius - superior gluteal N (L4, L5, S1)
        2. Gluteus minimus - superior gluteal N (L4, L5, S1)
        3. Gluteus maximus (upper fibers) - inferior gluteal N (L5, S1, S2)
        4. Sartorius - femoral N (L2, L3)
        5. Tensor fascia lata
      4. Passive hip abduction (500) - Pain or limitation of ROM can come from:
        1. adductors on either leg (pectineus, adductor longus, adductor brevis, adductor magnus, gracilis)
        2. sprains or partial tears of iliofemoral, ischiofemoral, or pubofemoral ligaments
        3. osteitis pubis
      5. Resisted hip abduction (Supine or sidelying position) - Pain or weakness can come from muscles or their nerve supply, also osteitis pubis, iliac crest injuries
      6. Active hip adduction (300) - Pain, limited ROM, or weakness can be due to muscles or their nerve supply:
        1. Adductor longus - obturator N (L2, L3, L4)
        2. Adductor magnus - obturator N (L2, L3, L4)
        3. Adductor brevis - obturator N (L2, L3, L4)
        4. Pectineus - femoral N (L2, L3, L4)
        5. Gracilis - obturator N (L3, L4)
      7. Passive hip adduction (300) - pain or weakness can come from compression of the iliopectineal bursa or from the greater trochanteric bursa as iliotibial band tightens over it
      8. Resisted hip adduction - Pain or weakness can come from muscles or their nerve supply. Pain may also be felt in pubic area with pubic symphysis instability, osteitis pubis, adductor avulsion (acutely painful)
    3. Testing in sitting position
      1. Resisted hip flexion (knee flexed) - Pain or weakness may be caused by iliopsoas injury or its nerve supply, iliopectineal bursitis, ASIS, AIIS, or lesser trochanter avulsion injuries
      2. Active hip internal rotation (350) - Pain, limited ROM, or weakness can be due to muscles or their nerve supply:
        1. Gluteus minimus - superior gluteal N (L4, L5, S1)
        2. Gluteus minimus - superior gluteal N (L4, L5, S1)
        3. Tensor fascia lata - superior gluteal N (L4, L5)
        4. Adductor magnus (posterior fibers) - obturator N (L2, L3, L4)
        5. Semitendinosus - tibial branch of sciatic N (L5, S1, S2)
        6. Semimembranosus - tibial branch of sciatic N (L5, S1, S2)
      3. Passive hip internal rotation - Pain or limitation of ROM may come ischiofemoral ligament or due to tension or injury of the external rotators, also slipped capital femoral epiphysis, piriformis syndrome causes pain at end range. Osteoarthritis can limit all ranges of motion, especially medial rotation & abduction
      4. Resisted hip internal rotation (350) - Pain or weakness can come from muscles or their nerve supply. Hip arthrosis causes restriction & pain in internal rotation first, then in flexion
      5. Active hip external rotation (450) - Pain, limited ROM, or weakness can be due to muscles or their nerve supply:
        1. Obturator internus - sacral plexus (L5, S1, S2, S3)
        2. Obturator externus -obturator N (L3, L4)
        3. Quadratus femoris - sacral plexus (L4, L5, S1)
        4. Piriformis - sacral plexus (L4, L5, S1)
        5. Gemellus superior - sacral plexus (L5, S1, S2, S3)
        6. Gemellus inferior - sacral plexus (L4, L5, S1, S2)
      6. Passive hip external rotation (450) - Pain or limitation of ROM may come from internal rotator injury, lateral band of iliofemoral ligament injury, pubofemoral ligament injury, femoral anteversion causes excessive hip external rotation & reduced internal rotation
      7. Resisted hip external rotation - Pain or weakness can come from muscles or their nerve supply. Weakness can be caused by L4, L5, S1 nerve root problem, piriformis syndrome may also cause pain here.
      8. Active knee extension - Hematoma in quadriceps may cause pain. Pain, limited ROM, or weakness can be due to muscles or their nerve supply:
        1. Rectus femoris - femoral N (L2, L3)
        2. Vastus medialis - femoral N (L2, L3)
        3. Vastus intermedius - femoral N (L2, L3)
        4. Vastus lateralis - femoral N (L2, L3)
      9. Resisted knee extension - Pain or weakness can come from muscles or their nerve supply. Weakness without pain may indicate an L3 nerve root problem (disc)
    4. Tests in prone position
      1. Active knee flexion (1200 to 1300) - Pain, limited ROM, or weakness can be due to muscles or their nerve supply:
        1. Biceps femoris - sciatic N (L5, S1, S2)
        2. Semitendinosus - sciatic N (L5, S1, S2)
        3. Semimembranosus - sciatic N (L5, S1, S2)
        4. During flexion, if the buttock on that side rises, it could be due to tight hip flexors, quadriceps hematoma, rectus femoris injury
      2. Passive knee flexion (1300) Pain or limitation of ROM may be caused by knee joint swelling or dysfunction, & lesion or tightness in rectus femoris muscle
      3. Resisted knee flexion - Pain or weakness can come from muscles or their nerve supply. Ischial tuberosity will cause pain.
      4. Active hip extension with knee extension (300) - Pain, limited ROM, or weakness can be due to muscles or their nerve supply:
        1. Gluteus maximus (upper fibers) - inferior gluteal N (L5, S1, S2)
        2. Hamstrings - sciatic N (L5, S1)
      5. Passive hip extension with knee extension (300) - Pain or limited ROM can be caused by hip flexors putting pressure on iliopectineal bursa or iliofemoral or ischiofemoral ligament injury
      6. Resisted hip extension with knee extension - Pain or weakness can come from muscles or their nerve supply.
      7. Active hip extension with knee flexion - Tests the gluteus maximus individually
      8. Passive hip extension with knee flexion - Pain will be elicited from any tightness or injury to hip flexors, iliopectineal bursitis, iliofemoral & ischiofemoral sprains, this stretches femoral nerve & will elicit pain in lateral hip or anterior thigh indicating impingement of L2 or L3 nerve roots. Lateral femoral or femoral cutaneous nerve may also be painful if impinged.
      9. Resisted hip extension with knee flexion - Weakness or pain can be caused by gluteus maximus strain or injury to inferior gluteal nerve or nerve root serving the muscle (L5, S1, S2)
    5. Special tests
      1. Tests for Hip Pathology
        1. Patrick's Test or FABER (Figure 4) (Jansen's) Test - Pt. lies supine, examiner places pt.'s leg so that the foot is on top of the opposite knee. Examiner slowly lowers the flexed knee into abduction toward the table. Test leg should lower enough to be level with opposite thigh to be negative. Positive test may indicate hip joint pathology, sacroiliac joint pathology, or iliopsoas spasm, or adductor tightness.
        2. Trendelenburg Test - Assesses stability of hip and ability of hip abductors (gluteus medius) to stabilize the pelvis on the femur. If pelvis drops on opposite side when pt. is asked to stand on one limb. Normally, opposite pelvis should elevate or at least remain level.
        3. Craig's Test - measures femoral anteversion or forward torsion of the femoral neck. Anteversion is measured by the angle made by the femoral neck with the femoral condyles. The degree of forward projection of the femoral neck from the coronal plane of the shaft. Decreases with age from about 300 at birth to about 80 to 150 at adulthood. Increased anteversion leads to squinting patellae & toeing-in. Twice as common in girls. Common to also find excessive hip internal rotation (>600) & decreased external rotation. Retroversion is when the plane of the femoral neck rotates backward in relation to the coronal condylar plane. Pt. lies prone with knee flexed 900 and examiner palpates posterior aspect of greater trochanter. Hip is then passively rotated medially & laterally until greater trochanter is parallel with examining table or reaches its most lateral position. The degree of anteversion can then be estimated, based on the lower leg's angle with the vertical.
        4. Torque Test - Pt. lies supine close to table edge with test femur extended over the edge. Test leg is extended until the pelvis begins to move. Examiner uses one hand to internally rotate to the end of its range & the other hand to apply a slow posterolateral pressure along the line of the femoral neck for 20 seconds to stress the capsular ligaments & test the stability of the hip.
        5. Stinchfield Test - Pt. lies supine & flexes the hip with the knee straight to 300 of hip flexion against resistance. Groin or hip pain is + for hip pathology. Posterior hip pain or back pain indicates lumbar or sacroiliac pathology.
        6. Nelaton's Line - an imaginary line drawn from the ischial tuberosity of the pelvis to the ASIS of the pelvis on the same side. If the greater trochanter is palpated well above the line it is an indication of a dislocated hip or coxa vara. Compare bilaterally.
        7. Bryant's Triangle - Pt. lies supine. Examiner imagines a perpendicular line from ASIS to table. Second imaginary line is projected up from tip of greater trochanter to meet the first line at a right angle. Line is measured & two sides are compared. Differences may indicate conditions such as coxa vara or congenital dislocation of hip. Can be done with radiographs.
        8. Relational Deformities - Rotational deformities can occur anywhere between hip and foot. Many deformities are hereditary. Pt. lies supine with lower limbs straight while examiner looks at patellae. Squinting patallae possibly indicate internal rotation of femur or tibia. If patallae face up, out, and away from each other (grasshopper or frog eyes), possibly indicates external rotation of femur or tibia. If tibia is affected, feet face in for internal rotation & face out more than 100 for excessive external rotation of tibia. Normal is facing out 5-100 (Fick angle).
        9. Thomas test – see Tests for Muscle Tightness or Pathology
        10. Ober’s test - Patient lies on uninvolved side with lower leg flexed at hip & knee. Abduct the upper thigh as far as possible & slightly extend hip so that tensor fascia lata & iliotibial band are over greater trochanter. Then release thigh while maintaining pelvis stabilized with opposite hand. If thigh remains abducted, test is positive indicating tight iliotibial band
        11. Piriformis test - Patient lies on side so that hip & knee are flexed to 900. Stabilize pelvis with one hand and use other hand to apply pressure at knee, pushing it to the table. If tightness in piriformis is impinging on the sciatic nerve, pain may be produced in the buttock and even down the leg
        12. Scouring test (Quadrant test) - Patient is supine with hip flexed & adducted comfortably. Grasp knee and apply posterolateral force through the hip as the femur is rotated in acetabulum. Femur is then passively flexed, adducted, & internally rotated while longitudinally compressed to scour inner aspect of joint. To scour outer aspect, hip is abducted & externally rotated while maintaining flexion during longitudinally compression. A positive test occurs with a grating sound or sensation, or if pain is elicited.
        13. Hip Distraction & Compression test
      2. Tests for Muscle Tightness or Pathology
        1. Sign of the Buttock - Pt. lies supine & examiner performs SLR. If there is limitation on SLR, examiner flexes pt.'s knee to see whether further hip flexion is possible. If the hip can not be flexed further, the lesion is in the buttock & not in the hip, sciatic nerve, or hamstring muscles. There may also be some limited trunk flexion. + tests may be caused by ischial bursitis, neoplasm, or buttocks abscess.
        2. Thomas Test - used to assess hip flexion contracture (most common in hip). Pt. lies supine while examiner checks for excessive lordosis (usually associated with tight hip flexors). Examiner then flexes one of pt.'s hips to the chest which also should flatten out lumbar spine. Position is held while examiner observes as to whether opposite leg remains on table. If contralateral hip flexes without knee extension that iliopsoas is tight. If knee extends and/or hip flexes rectus femoris is tight. (Rectus Femoris Contracture Test Method 1). If hip abducts, tensor fascia lata is tight. Pt. lies supine with knees flexed over end of
        3. Ely's Test (Tight Rectus Femoris, Method 2) - Pt. lies prone while examiner slowly flexes knee as far as possible to put heel on buttocks. If the buttocks & hip rise up before knee flexes 900 it indicates rectus femoris tightness.
        4. Ober's Test - Patient lies on uninvolved side with lower leg flexed at hip & knee. Abduct the upper thigh as far as possible & slightly extend hip so that tensor fascia lata & iliotibial band are over greater trochanter. Then release thigh while maintaining pelvis stabilized with opposite hand. If thigh remains abducted, test is positive indicating tight iliotibial band.
        5. Adduction Contracture Test - Pt. lies supine with ASISs level. If contracture is present, affected legs form an angle of less than 900 with the line joining ASISs. Examiner then attempts to balance the lower limb with pelvis, pelvis shifts up on affected side or down on unaffected side and balancing is not possible it indicates contracture leading to functional shortening of the limb. If unable to abduct more than 300 then adductor tightness is present.
        6. Abduction Contracture Test - Pt. lies supine with ASISs level. If contracture is present, affected legs form an angle of more than 900 with the line joining ASISs. Examiner then attempts to balance the lower limb with pelvis, pelvis shifts down on affected side or up on unaffected side and balancing is not possible it indicates contracture leading to functional lengthening of the limb.
        7. Noble Compression Test - Determines whether iliotibial band friction syndrome exists near the knee. Pt. lies supine & knee is flexed to 900 accompanied by hip flexion. Examiner then applies pressure with thumb to lateral femoral epicondyle and just above by 1 or 2 cm. While pressure is maintained pt. slowly extends knee. If the pt. complains of pain over lateral femoral condyle at approximately 300 of flexion it indicates a + test which is usually same pain that occurs during running.
        8. Piriformis Test – see Tests for Hip Pathology
        9. Hamstrings Contracture Test (Method 1) - Pt. long sits with one knee flexed against the chest to stabilize pelvis. The other knee is extended and pt. attempts to flex trunk & touch toes of extended leg with fingers. Observe how close pt. comes to touching toes.
        10. Tripod Sign (Hamstrings Contracture Test, Method 2) - Pt. seated with both knees flexed to 900 over edge of table. Examiner then passively extends one knee while observing to see if pt. extends trunk to relieve tension in hamstrings.
        11. 90-90 Straight Leg Raising Test (Hamstrings Contracture Test, Method 3) - Pt. is supine & flexes hip to 900 with knee bent. Pt. holds thigh just proximal to knee to stabilize hip at 900 flexion. Pt. then extends one knee & then the other to determine hamstring tightness. Should be within at least 200 of full extension.
        12. Phelp's Test - Pt. lies prone with knees extended while examiner passively abducts both thighs as far as possible. Then flex knees to 900 & try to abduct hips further. If abduction increases further, test is positive for gracilis contracture.
      3. Other
        1. Fulcrum test - used to assess for possible femoral shaft stress fx. Examiner places an arm under pt.'s thigh to act as a fulcrum. Move fulcrum arm form distal to proximal as pressure is applied to dorsum of knee with opposite hand. Pt. complain of pain along a certain spot when fulcrum arm is under a specific area indicates possible stress fx in that site.
      4. Sacroiliac joint tests
        1. Sacroiliac tests
          1. Active Stress Tests
            1. Kinetic test, one legged standing, begin standing evenly, palpate & locate PIIS & PSIS, then stand on one leg, flex opposite knee to chest. Non weight bearing side PSIS should move down (posterior ilium rotation). As foot moves down, the PSIS should move back up. If hypomobile, PSIS will move upward rather than down.
          2. Passive Movements
            1. Ipsilateral Prone Kinetic Test - assesses inability of ilium to flex & to rotate laterally or posteriorly. Pt. lies prone, examiner places one thumb on the PSIS & other thumb parallel to it on the sacrum. Then ask pt. to actively extend the leg on the same side. Normally, the PSIS should move superiorly & laterally. If its doesn't hypomobility with posterior rotated ilium (outflare) is indicated.
            2. Passive Extension & Medial Rotation of Ilium on Sacrum - Pt. sidelying with test side up, examiner places one hand over ASIS & other hand over PSIS so that the fingers palpate the posterior ilium & sacrum. Examiner then pulls the ilium forward with the ASIS hand & pushes the posterior ilium forward with the other hand while feeling the relative movement of the ilium on the sacrum. Repeat test for other side for comparison. If affected side moves less hypomobility with posterior rotated ilium (outflare) is indicated.
            3. Passive Flexion & Lateral Rotation of Ilium on Sacrum - Pt. sidelying with test side up, examiner places one hand over ASIS & other hand over PSIS so that the fingers palpate the posterior ilium & sacrum. Examiner then pushes the ilium backward with the ASIS hand & pulls the posterior ilium backward with the other hand while feeling the relative movement of the ilium on the sacrum. Repeat test for other side for comparison. If affected side moves less hypomobility with anterior rotated ilium (inflare) is indicated.
            4. NOTE: If both the Passive Extension & Medial Rotation of Ilium on Sacrum & Passive Flexion & Lateral Rotation of Ilium on Sacrum are positive, then an upslip of the ilium relative to the sacrum has occurred.
            5. Passive Lateral Rotation of Hip - Pt. lies supine, examiner flexes hip & knee to 900 & then externally rotates hip. Normally, this movement stresses SI joint on test side.
            6. Pelvic rocking test (Hoppenfeld 261) supine, place palms on both ASIS & push toward each other. If SI injured may be painful & injured side motion may be increased or decreased.
            7. Gapping test (Transverse Anterior Stress) - supine, cross hands over pelvis against ASIS, then push down & out, positive if causes unilateral sacroiliac or posterior leg pain, indicating sprain of anterior SI ligaments.
            8. Prone Gapping (Hibb's) Test - Stresses posterior SI ligaments. Pt must be free of hip pathology & have full ROM in hips. Pt. prone, examiner stabilizes pelvis with their chest. Pt.'s knee is flexed to 900 or > & hip is internally rotated maximally. While achieving end of internal rotation, examiner palpates on same side. Repeat test on other side for comparison of opening & quality of movement.
            9. Approximation (Transverse Posterior Stress) Test - Pt. is sidelying with examiner's hands over upper part of iliac crest, pressing toward floor to cause forward pressure on sacrum. An increased feeling of pressure in SI joints indicates a possible SI lesion or sprain of posterior SI ligaments, or both.
            10. Squish Test - Pt. supine, examiner places both hands on pt.'s ASISs & iliac crests and pushes down & in at 450 angle to test posterior SI ligaments. Pain indicates + test.
            11. Sacroiliac Rocking (Knee to Shoulder) (sacrotuberous ligament stress) Test - Pt. supine, examiner flexes pt.'s knee & hip fully, then adducts hip. SI joint is rocked by flexion & adduction of pt.'s hip. Move knee toward contralateral shoulder. Possibly internally rotate hip to maximize stress on SI joint. Simultaneously, palpate sacrotuberous ligament. Pain in SI joint indicates + test. If a longitudinal force is applied through the hip in a slow, steady manner (15-20 seconds) in an oblique & lateral direction, further stress is applied to sacrotuberous ligament. Palpate to compare slight normal movement.
            12. Sacral Apex Pressure (Prone Springing) Test - Pt. lies prone with examiner using base of hand at the apex of the pt.'s sacrum to push down, causing shear of the sacrum on the ilium. May indicate a SI joint problem if pain produced over joint. The test causes a rotational shift of the SI joints.
            13. Torsion Stress Test - Pt. lies prone while examiner palpates spinous process of L5, with one thumb holding it stable. Examiner uses other hand, placed around opposite anterior ilium & lifts it up (pulling posteriorly). This rotational movement stresses the lumbosacral junction, iliolumbar ligament, anterior sacroiliac ligament, & the SI joint.
            14. Femoral Shear Test - Pt. lies supine. Examiner slightly flexes, abducts, & laterally rotates the pt.'s thigh at approximately 450 from the midline, then applies a graded force through the long axis of the femur, which causes an anterior to posterior shear stress to the SI on the same side.
            15. Superoinferior Symphysis Pubic Stress Test - Pt. lies supine. Examiner places heel of one hand over the superior pubic ramus of one bone & the heel of the other hand over the inferior pubic ramus of the other bone. Examiner then squeezes hands together, applying a shearing force to the symphysis pubis. Pain in the symphysis pubis indicates a (+) test
          3. Sacroiliac Joint Involvement Tests
            1. Piedallu's Sign - Pt. sits on a hard, flat surface to keep the hamstrings, etc from affecting pelvic flexion symmetry & to increase the stability of the ilia. This tests the sacrum on the ilia. Examiner palpates the PSISs and compares their heights. If one PSIS, usually the painful one, is lower than the other, the pt. is asked to forward flex while sitting. If the lower PSIS becomes the higher one on forward flexion, test is positive for that side. Because the affected joint does not move properly & is hypomobile, it goes from a low to a high position, indicating abnormality in the torsion movement at the SI joint.
            2. Flamingo Test or Maneuver - Pt. is asked to stand on one leg, which should cause the sacrum to shift forward & distally with forward rotation. Ilium moves in opposite direction. On the non-weightbearing side the opposite occurs but stressed less than the weightbearing side. Pain in the symphysis pubis or SI joint indicates a + test for the painful structure. Have pt. hop on one leg to increase the stress.
            3. Hip flexion & adduction test - Supine with knee flexed, opposite leg straight, flex & adduct leg to stress Si joint on that side. May also be painful due to hip joint or S1 nerve root problem.
            4. Gaenslen’s Sign (Hoppenfeld 261) - supine, bilateral hip flexion followed by unilateral hip extension (make sure table edge allows for hyperextension) to rotate ipsilateral SI joint forward & posteriorly on contralateral side, causes pain if SI joint is dysfunctional or possible hip joint pathology, or an L4 nerve root lesion.
            5. Sacroiliac joint test (sidelying Gaenslen’s test) non-painful side down & locked in to hip & knee flexion by the pt., uppermost hip is extended to its limit with knee extended to apply rotary stress to upper ilium on sacrum. Painful if SI is dysfunctional or possible hip joint pathology, or an L4 nerve root lesion.
            6. Mazion's Pelvic Maneuver - Pt. stands in straddle position with unaffected side forward so that the feet are 2 to 3 ft apart. Pt. bends forward, trying to touch the floor, until the heel of the back leg lifts off the floor. If painful in lower trunk on affected side, it is considered a + test for unilateral forward displacement of ilium relative to sacrum.
            7. Laguere's Sign - Pt. lies supine. To test affected side, the examiner flexes, abducts, and externally rotates affected hip with overpressure at end range. Examiner must stabilize pelvis on opposite side by holding down the opposite ASIS. Pain in the affected SI indicates positive test. Compare sides.
            8. Gillet's (Sacral Fixation) Test - Pt. stands while examiner palpates PSISs. Pt. is asked to stand on one leg while pulling the opposite knee up toward the chest. Repeat with the other leg. If the SI joint on the side which the knee is flexed moves minimally or up, the joint is hypomobile, or blocked, indicating a + test. On the normal side, the PSIS moved down or inferiorly. Similar to test performed during hip flexion in active movement.
            9. Goldthwait's Test - Pt. lies supine. Examiner places one hand under lumbar spine so that each finger is in an interspinous space (L5-S1, L4-L5, L3-L4, & L2-L3). Examiner uses the other hand to perform SLR. If pain elicited before movement occurs at interspaces, the problem is in the SI joint. Pain during interspace movement indicates lumbar spine problem. SLR test may be positive & elicit pain referral along course of sciatic nerve if there is neurological involvement.
            10. Yeoman's Test - Pt. lies prone and examiner flexes the pt.'s knee to 900 and extends the hip. Pain localized to the SI joint indicates anterior SI ligament pathology. Lumbar pain indicates lumbar involvement and anterior thigh paresthesia indicates femoral nerve stretch.
            11. Patrick’s or Faber (Fabere) test – see Tests for Hip Pathology
            12. Supine to Sit (Long Sitting) Test - Pt. lies supine with legs straight. Examiner makes sure that medial malleoli are level and asks pt. to sit up. Examiner observes whether one leg moves proximally farther than the other. If one moves up farther, there is a functional leg length difference resulting from pelvic dysfunction caused by pelvic torsion or rotation.
            13. Sit up test for Iliosacral dysfunction - supine with body straight & legs symmetric, actively flex knees, lifts pelvis off table about 4", then drop pelvis to table. Passively extend knees & lower legs one at a time to table. Legs are then rolled medially & released. Palpate & observe level of medial malleoli, then athlete sits up & malleoli are rechecked. If one SI joint is hypomobile & blocked in posterior rotation, the sacrum & ilium will move together as unit, making the leg appear longer when sitting up compared to it appearing shorter in supine. If one SI joint is in anterior rotation that leg may appear longer or same length when supine, but get shorter when sitting up.
              1. Anterior iliac rotation
                1. ASIS in inferior, anterior, and medial to opposite ASIS
                2. PSIS is superior & anterior on that side
                3. medial sulcus (formed by ilium overlapping the sacrum) is shallow
                4. anterior iliac crest is inferior on the same side as the dysfunction
                5. posterior iliac crest is superior
                6. posterior tubercle on that side may be lower
                7. ischial tuberosity is superior
              2. Posterior iliac rotation
                1. ASIS in superior, posterior, and lateral to opposite ASIS
                2. PSIS is inferior & posterior
                3. medial sulcus is deeper
                4. anterior iliac crest is superior on the same side as the dysfunction
                5. posterior iliac crest is inferior
                6. posterior tubercle on that side may be higher
                7. ischial tuberosity is inferior
      1. Leg-length discrepancy tests
        1. Leg Length Test (True leg-length) (anatomic) - backward rotation (Nutation) of the ilium on the sacrum results in a decrease in leg length on the affected side as does anterior rotation (contranutation) of the ilium on the contralateral side. If the iliac bone on one side is lower, the leg on that side is usually longer. Pt. lies supine, flexes knees, raise pelvis about 3" & drop to table. Extend knees & make sure pt.'s lower limbs are perpendicular to the line joining the ASISs. Use a flexible tape measure to measure the distance from the ASIS to the medial or lateral malleoli. Compare to the other side. 1/2 to 1" difference is considered normal, but may be pathological. Flex knees 900 with feet together & flat on table to observe if discrepancy is within femur or tibia.
        2. Anatomic leg-length discrepancy - measure from ASIS to floor & from PSIS to floor bilaterally. May be caused by:
          1. poliomyelitis of lower limb
          2. fracture of femur or tibia
          3. bone growth problems of lower limb
        3. Functional leg-length discrepancy - Pt. stands relaxed while examiner palpates ASISs & PSISs, noting asymmetry. Pt. is then placed in correct stance (subtalar neutral, knees fully extended & toes facing straight ahead) and the ASISs & PSISs are palpated, with examiner noting whether the asymmetry has been corrected. If corrected by positioning the limb, the leg is normal length, but abnormal joint mechanics are producing a functional leg length difference. If asymmetry corrected by positioning, test is positive for functional leg length discrepancy. If ASIS is lower & PSIS is higher on same side, a functional leg-length discrepancy exists. May be caused by:
          1. one pronated foot and/or one supinated foot
          2. muscle spasm in one hip
          3. hip capsule tightness
          4. adductor muscle spasm on one side
          5. more genu valgus on one side
          6. femoral anteversion on one side ( if combined with pronated foot)
      2. Dermatome & cutaneous nerve testing - with pin check sensation from T10 to L3
      3. Circulatory tests - palpate femoral artery in femoral triangle
      4. Specific hip pointer tests - Pain will be elicited when side bending away from involved side, abduction of involved leg when sidelying on contralateral side

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