A hip examination is a structured series of observations, movements, and hands-on tests that clinicians use to figure out why a hip hurts, clicks, or limits movement. What makes it tricky is that “hip pain” can originate from the joint itself, the tendons and muscles around it, the lower spine, or even the sacroiliac joint at the back of the pelvis. No single test reliably nails the diagnosis on its own. A large meta-analysis of hip physical examination tests found that most possess weak diagnostic properties, with the notable exception of the patellar-pubic percussion test used to detect fractures. The real clinical skill lies in combining multiple tests, matching them to the patient’s story, and knowing what each test can and cannot tell you.
Why the Patient’s Story Comes First
Before anyone touches the hip, the history does most of the diagnostic heavy lifting. Where exactly the pain is felt, when it started, what makes it worse, and what makes it better narrow the list of suspects dramatically. Pain felt deep in the groin usually points toward the hip joint itself. Pain along the outside of the thigh tends to implicate the tendons and bursae around the greater trochanter. Pain in the buttock or radiating down the back of the leg raises suspicion for spinal or sacroiliac causes. And numbness or burning along the front or outer thigh, rather than deep ache, suggests a nerve like the lateral femoral cutaneous nerve might be compressed.
Clinicians also ask about mechanical symptoms. Catching or locking during movement can signal a labral tear. An audible or palpable snap during hip flexion points toward snapping hip syndrome. Stiffness that worsens after sitting and improves with walking may suggest early arthritis, while pain that steadily worsens with any weight-bearing raises concern for a stress fracture. Getting this narrative right means the physical tests that follow can be chosen and interpreted in context, rather than applied as a checklist.
Watching You Stand and Walk
A surprising amount of information comes from simply watching a person stand and walk. The clinician looks at pelvic alignment, checks whether one leg appears shorter, and observes gait. One classic observation is the Trendelenburg test, where you stand on one leg while the examiner watches whether the opposite side of your pelvis drops. The idea is that if the hip abductor muscles on the standing leg are weak, the pelvis will tilt downward on the unsupported side.
The Trendelenburg test has a long history but a complicated reputation. Research using three-dimensional motion analysis found poor agreement between what a clinician observed and what the motion sensors actually measured, along with no meaningful correlation between hip abductor strength and pelvic drop in healthy young adults.
A separate study experimentally weakened participants’ hip abductors by about half using a nerve block and still found no consistent change in pelvic mechanics during the Trendelenburg test. The researchers concluded the test should not be used as a screening tool for abductor weakness unless that weakness is severe, below roughly 30% of body weight.
That said, the Trendelenburg sign does have value in specific clinical scenarios. In patients with lateral hip pain who may have a gluteal tendon tear, the Trendelenburg sign showed a sensitivity of about 73% and specificity of about 77% for predicting a tear on MRI, making it the most accurate of the physical signs tested in that context.
Range of Motion Testing
Measuring how far the hip moves in different directions is one of the most informative parts of the examination. The clinician typically tests flexion, extension, internal and external rotation, abduction, and adduction, comparing both sides. Restrictions or pain at end-range in specific directions help localize the problem.
Internal rotation is the motion clinicians pay closest attention to. A systematic review pooling data from over 1,500 hips found that people with femoroacetabular impingement syndrome had roughly eight fewer degrees of internal rotation compared to healthy controls when tested at 90 degrees of hip flexion. A study comparing patients with known impingement to healthy volunteers found that internal rotation averaged about 12 degrees in the patient group versus 28 degrees in healthy controls, a substantial and measurable difference. Cam morphology, acetabular coverage, and femoral version together accounted for about three-quarters of the variation in internal rotation between patients.
External rotation, interestingly, tends to be preserved or even slightly increased in impingement patients. This asymmetry between reduced internal rotation and maintained external rotation is itself a useful diagnostic clue. When clinicians find a “capsular pattern” of restriction, where multiple motions are limited in a predictable ratio, it can help differentiate hip joint pathology from problems originating in the lumbar spine, though this approach needs more research to confirm its reliability.
Provocation Tests for Impingement and Labral Tears
Provocation tests are designed to reproduce the patient’s pain by putting the hip into positions that stress particular structures. The two most commonly used are the FADIR test and the FABER test.
The FADIR test involves flexing the hip, then pushing it into adduction and internal rotation. This compresses the front of the hip joint and is the go-to test for anterior impingement and labral pathology. For labral tears, one systematic review found the FADIR test had a sensitivity as high as 100%, meaning it catches almost everyone who has a tear. The catch is its specificity. In one study focused on cam and pincer morphology, the FADIR’s specificity was just 11%, meaning it frequently flags people who do not actually have the condition. Another study found specificity around 24 to 51% for various impingement tests.
The FABER test, which involves flexion, abduction, and external rotation, stresses both the hip joint and the sacroiliac joint. For labral tears, one review found it had the highest specificity at 100% in certain comparisons, but its sensitivity was lower, meaning it misses some true cases. This makes FADIR and FABER somewhat complementary: FADIR is good at catching problems (sensitive), while FABER is better at confirming them (specific).
Research suggests that combining the results of multiple tests improves accuracy. One study found that when impingement test results were combined with range-of-motion measurements, diagnostic accuracy improved over using any single test alone. In practice, a clinician who finds a positive FADIR, reduced internal rotation, and groin pain provoked by deep flexion has a much stronger case for impingement than any one of those findings would provide individually.
The False-Positive Problem
One of the more important things to understand about hip provocation tests is that they frequently trigger positive results in people with no hip problems whatsoever. A study of over 1,100 healthy young adults found that about 7% of men and 5% of women had a positive anterior impingement test despite being completely asymptomatic. In a separate study of college freshman athletes, roughly 12 to 15% reported pain during the FADIR test, with no significant difference between males and females.
These numbers matter because imaging studies show that the bony shapes associated with impingement, particularly cam morphology, are common in the general population and often cause no symptoms at all. A positive physical exam test in someone without pain or functional limitation does not mean they need treatment. This is why clinicians are taught to interpret test results in the context of the whole picture rather than reacting to any single finding.
Lateral Hip Pain and Greater Trochanteric Pain Syndrome
Pain along the outside of the hip, over the bony prominence you can feel at the top of your thigh, is one of the most common hip complaints, particularly in middle-aged women and runners. This is often diagnosed as greater trochanteric pain syndrome, which encompasses gluteal tendinopathy, bursitis, and sometimes partial tendon tears.
The examination approach here differs from testing for joint problems. Two tests in sequence have proven especially useful. First, the clinician presses directly on the greater trochanter (gluteal tendon palpation). If that is negative, followed by a negative resisted hip abduction test, the probability of greater trochanteric pain syndrome drops from about 59% to 14%. Conversely, if both tests are positive, the probability climbs to 96%. This sequential testing approach gives clinicians a practical way to either rule the condition in or out with reasonable confidence.
Resisted hip flexion and direct palpation of the iliopsoas tendon and muscle belly are also useful when the pain seems to come from the front-inner aspect of the hip. The iliopsoas is a common source of pain in athletes, and its involvement is often missed when the examination focuses only on joint-level tests. Snapping hip syndrome, where the iliopsoas tendon catches over a bony prominence during movement, can often be diagnosed simply by having the patient reproduce the snap during specific hip motions.
Telling Hip Pain Apart from Sacroiliac Pain
The sacroiliac joint sits right behind the hip and can mimic hip pathology in annoying ways. Patients with sacroiliac dysfunction often point to the buttock and sometimes the groin, overlapping significantly with hip joint pain referral patterns. A set of provocation tests exists specifically for the sacroiliac joint, including compression, distraction, thigh thrust, Gaenslen’s test, and the sacral thrust.
The diagnostic rule of thumb is that three or more positive sacroiliac provocation tests raises suspicion for the sacroiliac joint as a pain source. One older but widely cited analysis reported that three or more positive tests yielded a sensitivity of 91% and specificity of 78%, with specificity climbing to 87% in patients whose symptoms could not be centralized toward the spinal midline. However, a more recent meta-analysis tempered that optimism, finding that a positive sacroiliac test cluster gives only about 35% certainty that the sacroiliac joint is truly the source. The stronger finding was on the negative side: a negative cluster allows the clinician to rule out the sacroiliac joint with about 92% confidence.
In practice, this means sacroiliac provocation tests are better at excluding the sacroiliac joint than confirming it. When the tests are negative, the clinician can more confidently turn attention to the hip joint or spine. When they are positive, further investigation, often including a diagnostic injection, is needed to be sure.
Hip Examination in Infants and Children
The hip examination takes a completely different form in newborns and young children. The primary concern in this age group is developmental dysplasia of the hip, where the socket does not develop properly and the femoral head may be partially or fully dislocated. The classic screening maneuvers are the Ortolani test (gently abducting the flexed hip to feel for a “clunk” as a dislocated hip reduces back into the socket) and the Barlow test (adducting and pushing posteriorly to see if the hip can be dislocated).
These tests are performed on virtually every newborn in countries with universal screening programs, but their accuracy is limited. A meta-analysis found the combined Ortolani-Barlow test had a pooled sensitivity of only 36% with a specificity of 98%. That means the test catches barely a third of affected hips but is excellent at correctly identifying normal hips. A study of referred infants found that the positive predictive value of the Ortolani test ranged from 39 to 61%, and the Barlow test performed worse, with a positive predictive value of just 4 to 16% depending on how a true positive was defined. Another study reported a somewhat higher sensitivity of 58% and specificity of 73%, but overall the picture is consistent: these maneuvers are highly specific but miss many cases.
Because of this limited sensitivity, many screening programs supplement clinical examination with ultrasound imaging at around four to six weeks of age, particularly for infants with risk factors like breech presentation, family history, or clinical suspicion. The clinical tests remain valuable as a first-pass screen, but a normal exam does not guarantee a normal hip.
In older children and adolescents, the examination shifts to different concerns. Slipped capital femoral epiphysis, where the growth plate at the top of the thighbone shears, produces a characteristic finding called the Drehmann sign: when the hip is passively flexed, it obligatorily rotates outward rather than staying neutral. A study found that hips with a positive Drehmann sign had significantly larger alpha angles on imaging (about 86 degrees versus 63 degrees), confirming the sign’s association with bony impingement that develops after the slip.
Nerve-Related Hip Pain
Not all hip-region pain comes from musculoskeletal structures. Meralgia paresthetica, caused by compression of the lateral femoral cutaneous nerve as it passes under the inguinal ligament, produces burning, numbness, or tingling over the outer thigh. It is commonly associated with weight gain, tight clothing, or prolonged standing.
Several clinical tests can help identify this condition without the need for nerve conduction studies. The pelvic compression test, where the examiner squeezes the pelvis together to relieve tension on the nerve, showed a sensitivity of about 87% and specificity of 93%, with an overall diagnostic accuracy of 90%. Tinel’s sign, which involves tapping over the nerve near the inguinal ligament, performed similarly, with about 86% sensitivity and 88% specificity. These are remarkably strong numbers for clinical tests, making meralgia paresthetica one of the more reliably diagnosed conditions through physical examination alone.
Functional Performance Testing
Beyond individual diagnostic tests, clinicians increasingly use functional performance assessments, particularly for athletes and active individuals returning from hip injury or surgery. These involve tasks like single-leg squats, lateral step-downs, hop tests, and sport-specific movements that challenge the hip under realistic loading conditions.
An international consensus statement recommended that clinicians choose functional tests based on a graded intensity approach: low-intensity tasks like single-leg balance, medium-intensity tasks like step-downs, high-intensity tasks like hopping, and sport-specific tests that challenge speed, range of motion, and impact loading. The idea is to progressively increase demands to find the threshold at which the hip fails to perform normally.
However, the evidence base for these tests is still developing. A systematic review found that reliability of functional performance tests had not been established in patients with hip dysfunction, and called for further study to validate their use in young athletic populations. Clinicians use them anyway because they provide information that static tests cannot: whether the hip functions adequately under the stresses of daily life and sport, not just whether it hurts when pushed into a specific position on an examination table.
When the Examination Happens Through a Screen
The expansion of telemedicine during and after the COVID-19 pandemic raised a practical question: how much of a hip examination can be done remotely? Researchers have proposed modified protocols for virtual hip assessment, adapting standing inspection, gait observation, and self-guided range-of-motion measurements for video encounters. A patient can demonstrate a Trendelenburg test on camera, show their active range of motion, and perform functional tasks while the clinician observes.
What is inevitably lost is the hands-on component. Provocation tests like FADIR and FABER require the clinician to apply specific forces and feel for end-range resistance, things that cannot be replicated through a screen. Palpation of tender structures, assessment of passive range of motion, and the subtle feel of a joint reaching its limit are fundamentally in-person activities. Virtual examinations work best as a triage tool, helping clinicians decide who needs to come in for a full hands-on evaluation and who can be managed with activity modifications and monitoring.
After Hip Replacement
The hip examination does not end with surgery. For patients who have undergone total hip arthroplasty, follow-up examinations focus on different questions: Is the prosthesis stable? Is there any loosening of components? Has the range of motion improved as expected? A systematic review identified fifteen physical examination tests with moderate diagnostic utility for detecting hip fractures, symptomatic osteoarthritis, and loosening of components after hip replacement. The patellar-pubic percussion test, where the clinician taps the patella and listens over the pubic symphysis with a stethoscope, proved useful here as well, with strong sensitivity and specificity for detecting occult hip fractures in elderly patients who cannot clearly describe or localize their pain.
Post-surgical examinations also assess for complications like leg-length discrepancy, abductor weakness from the surgical approach, and signs of prosthetic joint infection. The Trendelenburg test re-enters the picture in this population, since surgical approaches that detach and reattach the gluteal muscles can leave lasting abductor weakness. Here, unlike in the general population where the test is unreliable for detecting moderate weakness, the degree of weakness after surgery is often severe enough to produce a clearly positive result.