Sports Medicine Research: In the Lab & In the Field: The Accuracy of Hip Special Tests (Sports Med Res)


Wednesday, September 5, 2012

The Accuracy of Hip Special Tests

Diagnostic Accuracy of Clinical Tests of the Hip: A Systematic Review with Meta-Analysis

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


Alyson said...

As a recent undergraduate, I am always looking for ways to develop my evaluation skills. The hip is a daunting joint, much like the shoulder. With this in mind, hip evaluation skills can always be improved upon. During my lower extremity evaluation class, we had one of our leading orthopaedic surgeons come talk to us about hip specific findings during an eval. "Groin pain" and the athlete pointing to just lateral of the inguinal like, describing it as "deep" pain that increases with end ROM hip flex, were all key signs for a hip pathology. I like this article because it bring together 5 key tests that could be used to assess hip injuries. The fact that all of them have high specificity and sensitivity is also a confidence builder for any evaluator examining a hip. The important thing to remember is the idea that we have the notion of always have a "toolbox" to work with. Like the Ottawa Ankle rules, this is a part of that tool box, that helps your make an educated decision about fx of an ankle. If this same thing could be done for patients with hip pain, this could lead to better patient care and outcomes. This systematic review is a start and has a great future to help clinicians.

Thank you for this article. It was very interesting to read about.

Nicole Cattano said...

Alyson-thank you for your comment. I couldn't.agree with you more. As clinicians we need to make sure that we have the best tools in our toolbox. The hip is an area that we need to improve upon. This systematic review is great place to start.

Anonymous said...

As a recent newly certified ATC, I can really relate to Alyson and her level of experience and point of view when it comes to hip joint pathologies. I completely agree with her comment and I appreciate the effort put forth to create this article. Even though I have not worked with many athletes with hip pathologies thus far, I will definitely keep this article in my inventory for future reference. It was a fantastic read and I appreciate the work that was put forth to make this systematic review/meta-analysis possible.

Kate said...

I am currently working with a collegiate track & field team so I am no stranger to hip injuries. It can be a real challenge to determine a definite diagnosis when it comes to the hip. I am definitely glad to see that these widely used tests can be relied upon to help in the differential diagnosis process because I use them often. People often refer to impressiveness of knee tests and say that we still don't have a hip or shoulder test that is like the Lachman's in regards to specificity and sensitivity. However, I don't think we will ever get a test like that in other joints because it would be extremely difficult to isolate a structure in the hip like in the knee. The structures in the knee just as the ACL and PCL can be easily distinguished based on the position of the knee and the direction of pull. However in the hip many different structures share similar origins and insertions and work in numerous ways to resist various directions of pull. Therefore, I don't believe we will ever get a test that diagnoses a condition as accurately as the lachman's tests the ACL. I do agree though that we should create a checklist criteria such as the Ottawa Rule in regards to hip pathologies because hip MRIs can be extremely pricey so it would be nice to better be able to diagnose hip injuries instead of sending every hip injury on for further imaging.

Nicole Cattano said...

Kate- great points! MRIs of the hip especially get expensive when you factor in the frequent needs for an MRI Arthrogram or a different series of angles view when looking for things like sports hernias.

Within he hip, what are you seeing a lot of in your track athletes? Have you anecdotally seen any series of tests or symptoms that seem to line up with certain pathologies?

Brian Sabb said...


This is a great discussion! Hip evaluation is not only difficult clinically (as highlighted in the original text and the comments), but it is also many times difficult to evaluate the hip by MRI. Many MRI centers and radiologists are not familiar with all the planes of imaging (as alluded to above) and the diverse pathology in the hip.

Even when the rad is familiar with the pathologies and has the right images, the assessment can still be difficult because of the subtle appearance of some injuries and the normal variants (eg labral sulcus) that can be mistaken for true pathology.

MRI is best obtained after a thorough work up has been performed and the patient is not responsive to conservative measures. Of course, there are circumstances when an early MRI makes sense: r/o fracture, tumor, AVN OR in a high level athlete that needs to RTP.

Happy New Year,

Brian Sabb

Nicole Cattano said...

Thanks for your comments Brian! You add a very critical piece to this, in that there is the possibility of human error in interpretation of the MrIs by the radiologists. I think this adds to the value of finding a set of special tests that appear to be accurate in the ruling out/in of pathologies. MRI may not always be the gold standard.

Becca Burkhart said...

As Alyson said I think that the hip joint can be just as complicated as the shoulder. When we look at the ankle or the knee there are many special tests that have been proven accurate. It surprises me that there aren't more special tests or evaluation skills that can help in the diagnosis process of the hip. I think more research is the only way to help increase the accuracy of athletic trainer differential diagnosis.

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