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

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

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.

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?

by: Nicole Cattano 
by: Jeffrey Driban


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