Reiman MP, Goode AP, Hegedus EJ, Cook CE & Wright AA. British Journal of Sports Medicine. July 2012; (e-pub ahead of print). doi 10.1136/bjsports2012-09135
In recent years, there has been a significant increase in the number of diagnosed hip pathologies due to greater attention to this area. “Chronic groin pain” is no longer an accepted diagnosis for athletic injuries. Therefore, we need a closer look at the accuracy of hip special tests for athletic injuries to help determine which special tests can help us make differential diagnoses. The purpose of this systematic review was to analyze the literature on hip special tests to determine the accuracy of these tests in diagnosing hip pathologies. A systematic literature search yielded 25 studies that met the inclusion criteria of a cross-sectional or cohort study that reported the special test accuracy (i.e., sensitivity/specificity) for a hip pathology. Of the 25 studies, 20 studies evaluated intraarticular or fracture pathologies (2 osteoarthritis, 12 impingement/labral/intraarticular, 5 fracture, and 1 avascular necrosis) and 5 studies evaluated extraarticular pathologies (tendinopathies). The authors reported the sensitivity and specificity for commonly utilized special tests, however, 5 special tests (i.e., FADDIR [hip flexion, adduction, internal rotation], Trendelenburg, resisted hip abduction, flexion and internal rotation, and patellar-pubic percussion tests) were explored in more detail with meta-analyses. For labral pathologies, the FADDIR and flexion and internal rotation special tests were found to have great sensitivity (99% and 95% respectively; sensitivity = ability of a special test to correctly identify a positive result when the condition exists) but overall poor specificity (special test correctly identifies a negative result when the condition does not exist). The patellar-pubic percussion test accuracy was good/excellent with 95% sensitivity and 86% specificity for femoral fracture. The authors also reported that the Trendelenburg’s and resisted abduction tests were overall good at detecting gluteal tendinopathies due to 61% and 71% sensitivity and 92% and 84% specificity, respectively.
This review identified a few commonly used tests that were accurate for the evaluation of hip pathologies; however, there is still no battery of tests we can rely on. These tests have been found to be relatively accurate in isolation, however, a broader, multi-step approach may be necessary to improve diagnoses or screening (e.g., Ottawa Ankle Rules). Sensitivity and specificity are commonly utilized measures of diagnostic accuracy. Sensitivity is the ability of a special test to yield a positive finding when the pathology exists and specificity is the ability of a special test to yield a negative finding when the pathology does not exist. Unlike the Lachman test for the knee, we still do not have an accurate test to help definitively diagnose different hip pathologies. As clinicians we need to utilize the entire picture to work through differential diagnoses of the hip, as many hip pathologies present with similar signs and symptoms. This review found 5 special tests that had good-to-excellent accuracy within 3 different hip pathologies. Clinically we should remember to keep these tests (FADDIRs, Flexion and Internal Rotation, Patellar-Pubic Percussion Test, Trendelenberg’s, Resisted Abduction) in our evaluations as they have produced favorable outcomes. This review highlighted the absence of high quality studies that report accuracy measures for hip special tests. 127 of 152 articles were excluded due to their failure to report sensitivity/specificity measures. Clinically, it is easy to do what “seems to work” in the previous encounters, but to advance the profession and improve patient care, we need to start testing these findings formally. Has anyone had any special tests or common clinical findings that you use to help make diagnosis of a specific hip pathology?
Written by: Nicole Cattano
Reviewed by: Jeffrey Driban
Related Posts:Reiman MP, Goode AP, Hegedus EJ, Cook CE, & Wright AA (2012). Diagnostic accuracy of clinical tests of the hip: a systematic review with meta-analysis. British Journal of Sports Medicine PMID: 22773321