542 | september 2008 | volume 38 | number 9 | journal of orthopaedic & sports physical therapy

[ RESEARCH REPORT ]
1
Associate Professor, US Army-Baylor University Doctoral Program in Physical Therapy, San Antonio, TX.
2
Doctoral student, US Army-Baylor University Doctoral Program in
Physical Therapy, San Antonio, TX.
3
Chief, Musculoskeletal Section, Department of Radiology and Radiology Residency Program Director, Brooke Army Medical Center, San
Antonio, TX.
4
Assistant Professor, US Army-Baylor University Doctoral Program in Physical Therapy, San Antonio, TX.
5
Assistant Professor and Director of Research, US Army-
Baylor University Doctoral Program in Physical Therapy, San Antonio, TX. The protocol for this study was approved by The Institutional Review Board of Brooke Army Medical
Center. The opinions or assertions herein are the private views of the authors and are not to be construed as ofcial or as reecting the views of the United States Army or the
Department of Defense. Address correspondence to Thomas G. Sutlive, US Army-Baylor University Doctoral Program in Physical Therapy, 3150 Stanley Road, Room 1303, ATTN:
MCCS-HMT, Fort Sam Houston, TX 78234. E-mail: thomas.sutlive@amedd.army.mil
THOMAS G. SUTLIVE, PT, PhD, OCS hAIhk P. L0PZ, DPT 0AN| . 56hN|Ikk, DPT 5AkAh . YAwN, DPT
k08kI J. hALL, DPT L|N I. NAN5F|L0, MD k08kI . 80YL5, PT, DSc, OCS, FAAOMPT
4
J0hN 0. 6h|L05, PT, PhD, MBA, OCS, FAAOMPT
5
Development of a Clinical Prediction
Rule for Diagnosing Hip Osteoarthritis in
Individuals With Unilateral Hip Pain
O
steoarthritis (OA) is the most common form of arthritic
disorders and one of the most common reasons for visiting
a health care practitioner.
27
The estimated annual cost of
managing OA in the United States is immense, accounting for
billions of dollars in healthcare expenditures.
11,13,17
The hip is a common
site for OA, afecting 10% to 25% of the population over the age of
55.
13,41
In addition to the economic impacts, decreased function
associated with hip OA can have a substantial detrimental efect on
quality of life. Although there is no cure
for hip OA, various forms of nonsurgi-
cal treatment have proven efective, in-
cluding weight reduction, exercise, and
manual therapy interventions.
20-22,43
Therefore, accurate diagnosis and timely
intervention is essential to minimize the
deleterious efects of OA and to maximize
functional abilities.
9,25,40
Radiographs represent the current
gold standard for diagnosing hip OA.
37
Osteoarthritis severity is determined
based on the presence of hallmark radio-
graphic ndings, such as joint space nar-
rowing, osteophytes, bony changes at the
joint margins, and alterations of subchon-
dral bone, according to the Kellgren and
Lawrence scale.
26,37
Although radiographs
are relatively inexpensive, understanding
the diagnostic accuracy of key clinical ex-
amination ndings would assist the clini-
cian in expediting the evaluation process,
initiating early management, and making
appropriate referrals to specialty provid-
ers, and may obviate unnecessary radia-
tion exposure.
Altman and colleagues
1
identied sev-
eral elements of the clinical examination
that are diagnostic of hip OA in patients
with hip pain. Although these criteria have
proven to be valuable for decision mak-
5Iu0Y 05|6N: Prospective cohort/predictive
validity study.
08J6I|: To determine the diagnostic ac-
curacy of common clinical examination items and
to construct a preliminary clinical prediction rule
for diagnosing hip osteoarthritis (OA) in individuals
with unilateral hip pain.
8A6k6k0uN0: The current gold standard for
the diagnosis of hip OA is a standing anteroposte-
rior (AP) radiograph of the pelvis. Other than for
Altmans criteria, little research has been done to
determine the accuracy of clinical examination
ndings for diagnosing hip OA.
NIh005 AN0 NA5uk5: Seventy-two
subjects completed the study. Each subject
received a standardized history, physical examina-
tion, and standing AP radiograph of the pelvis.
Subjects with a Kellgren and Lawrence score of 2
or higher based on the radiographs were consid-
ered to have denitive hip OA. Likelihood ratios
(LRs) were computed to determine which clinical
examination ndings were most diagnostic of hip
OA. Potential predictor variables were entered
into a logistic regression model to determine the
most accurate set of clinical examination items for
diagnosing hip OA.
k5uLI5: Twenty-one (29%) of the 72 subjects
had radiographic evidence of hip OA. A clini-
cal prediction rule consisting of 5 examination
variables was identied. If at least 4 of 5 variables
were present, the positive LR was equal to 24.3
(95% condence interval: 4.4-142.1), increasing
the probability of hip OA to 91%.
60N6Lu5|0N: The preliminary clinical predic-
tion rule provides the ability to a priori identify pa-
tients with hip pain who are likely to have hip OA.
A validation study should be done before the rule
can be implemented in routine clinical practice.
LL 0F |0N6: Diagnosis, level 2b.
J Orthop Sports Phys Ther 2008;38(9):542-550.
doi:10.2519/jospt.2008.2753
kY w0k05: arthritis, diagnosis, OA, predic-
tive validity
journal of orthopaedic & sports physical therapy | volume 38 | number 9 | september 2008 | 543
the diagnostic accuracy of commonly used
clinical examination procedures thought
to be suggestive of hip OA, but that may
have not previously been considered by
Altmans criteria, and to develop a prelim-
inary clinical prediction rule that maxi-
mizes the accuracy of diagnosing hip OA,
based on clinical examination ndings.
METHODS
Subjects
w
e utilized a single-group,
cross-sectional study design to
determine the diagnostic accura-
cy of selected special tests and measures
for the diagnosis of hip OA. Seventy-
eight subjects were recruited from the
military healthcare beneciary system at
Fort Sam Houston in San Antonio, TX.
Volunteers were required to be over 40
years of age and have a chief complaint
of unilateral pain in the buttock, groin,
or anterior thigh. We excluded patients
with a current diagnosis of cancer, his-
tory of hip surgery, and females who were
pregnant at the time of the study. Urine
pregnancy tests were performed on all
premenopausal females. The study was
approved by the Brooke Army Medical
Center (San Antonio, Texas) Institutional
Review Board, and all patients provided
consent prior to their participation.
xam|oat|oo Procedures
Each subject received a standardized his-
tory and physical examination by physical
therapists in the US Army-Baylor Univer-
sity Doctoral Program in Physical Thera-
py. Examiner teams were comprised of 2
physical therapist doctoral students, with
one serving as the examiner and the other
as a recorder. Examiners underwent a
standardized training regimen prior to
the beginning of data collection to de-
velop consistent measurements based on
the operational denitions for the clinical
examination procedures. Examiners com-
pleted several training sessions to stan-
dardize the measurements in accordance
with the operational denitions, followed
by a nal testing session to establish pilot
reliability data in a sample of 10 healthy
subjects. The rst 30 subjects enrolled in
the study were also assessed by teams of
2 examiner blinded to each others nd-
ings to establish denitive reliability
of the testing procedures. The physical
examination included range-of-motion
measurements, end feel testing according
to Cyriax, and 3 provocative maneuvers:
Patricks test (F|6uk I), the scour test, and
the squat test. Operational denitions of
the physical examination items are pro-
vided in the APPN0|X to facilitate replica-
tion of our study. The positional order of
testing (ie, standing, supine, prone) was
counterbalanced to mitigate the potential
for an order efect to occur.
Range of motion for hip exion, ex-
tension, abduction, and adduction were
obtained using a standard 18-cm plastic
goniometer. An inclinometer was used
to assess range of motion for hip inter-
nal and external rotation (F|6uk Z). Im-
mediately following each measurement,
subjects were asked whether the move-
ment changed their symptoms. To assess
end feels, examiners utilized standard-
ized passive range-of-motion assessment
techniques with overpressure. End feels
were recorded into 1 of 7 categories as
dened by Cyriax
10
: bone to bone, spasm,
early capsular, capsular, tissue approxi-
mation, empty, and springy. For the
purposes of data analysis, end feels were
dichotomized into capsular and noncap-
sular. According to Cyriax,
10
the end feels
of early capsular, spasm, and bone-to-
bone are considered capsular end feels
and indicative of degenerative changes of
ing,
2,21,22,35,40
their utilization may require
laboratory testing, such as erythrocyte
sedimentation rate (ESR). Additionally,
the development of these criteria did not
include several clinical examination nd-
ings commonly thought to be associated
with hip OA, such as the presence of a
capsular pattern of motion restriction,
identication of certain abnormal end
feels at the end range of passive range-
of-motion testing, and reproduction of
a patients pain with provocative testing.
Cyriax
10
stated that a capsular pattern is
a unique pattern of range-of-motion re-
strictions that is suggestive of OA. For
the hip, Cyriax stated that the capsular
pattern consisted of a gross limitation in
internal rotation, exion, and abduction.
It was also suggested that an early cap-
sular end feel, a spasm end feel (in the
absence of acute trauma), and a bone-
to-bone end feel may indicate possible
degenerative changes at the hip.
10
Clini-
cal examination procedures, such as the
Patricks test, hip exion test, scour test,
and squat test, are also commonly used
by clinicians in the assessment of patients
with hip pain
31
and designed to repro-
duce a patients symptoms (provocative
tests). These tests are frequently used to
determine the location and irritability of
a patients symptoms and to select appro-
priate treatment interventions.
Although preliminary evidence sug-
gests that positive ndings from these
procedures may be useful in diagnosing
hip OA, their diagnostic accuracy has not
been thoroughly studied. Therefore, the
purposes of this study were to determine
F|6uk I. Measurement of the Patricks test using an
inclinometer.
F|6uk Z. Measurement of passive hip internal
rotation using an inclinometer.
544 | september 2008 | volume 38 | number 9 | journal of orthopaedic & sports physical therapy
[ RESEARCH REPORT ]
the joint. End feels classied as noncap-
sular included soft tissue approximation,
capsular (ie, normal resistance of the
capsule at the end range of some joints),
springy block, and empty end feels. We
also recorded the efect of the movement
on the patients symptoms, such as pain
location (veried by the subject pointing
to the site of pain) and replication of pre-
vious pain for each measurement.
Cyriax
10
stated that the capsular pat-
tern of restriction for the hip was gross
limitation of internal rotation, exion,
and abduction, and that this pattern was
suggestive of hip OA. He also stated that
in very early hip arthrosis, internal ro-
tation is the rst movement to become
restricted, followed by exion.
10
Based
on Cyriaxs denitions, we determined
whether a capsular pattern of restriction
existed in our subjects based on fulll-
ment of 1 of the 2 following conditions: (1)
loss of hip internal rotation greater than
loss of hip exion greater than loss of hip
abduction, or (2) loss of hip internal ro-
tation greater than loss of hip abduction
greater than loss of hip exion. Loss of
each range of motion was expressed as a
percentage of restricted motion based on
published normal values.
15
For example,
based on a published normal value of 45,
a subject with 35 of hip internal rotation
was considered to have a 10 restriction
or a 22% (10/45) loss of motion.
15
kad|ographs
Following the physical examination, each
subject received a standing antero-poste-
rior (AP) radiograph of the pelvis (F|6uk
3). The average SD number of days be-
tween the physical examination and radio-
graphic testing was 5.8 9.5 days (range,
0-46 days), and the median was 1.5 days.
All radiographs were examined and scored
by the same staf radiologist who had more
than 15 years of experience in musculo-
skeletal imaging. Scoring was based on
the Kellgren and Lawrence scale (IA8L
1).
26
The Kellgren and Lawrence grading
scheme has proven to be reliable
16
and has
been accepted by the World Health Or-
ganization as the reference standard for
cross-sectional and longitudinal studies
of hip OA.
37
Subjects with a Kellgren and
Lawrence score of 2 or higher were consid-
ered to have hip OA.
24,34,37
The radiologist
and examiners were blinded to each oth-
ers ndings to eliminate the potential for
IA8L I
Kellgren and Lawrence Grading Scale
for Hip Osteoarthritis
26
6rade kad|ograph|c F|od|ogs
0 No evidence of joint space narrowing, osteophyte formation, or sclerosis (normal radiograph)
1 Possible narrowing of the joint space medially and possible osteophytes around the femoral head
2 Denite narrowing of the joint space, denite osteophytes, and slight sclerosis
3 Marked narrowing of the joint space, slight osteophytes, some sclerosis, and cyst formation, and deformity of
the femoral head and acetabulum
4 Gross loss of joint space with sclerosis and cysts, marked deformity of femoral head and acetabulum,
large osteophytes
IA8L Z
Demographics and Baseline
Characteristics of Subjects
Abbreviation: OA, osteoarthritis.
* Diference between groups.

Numeric pain rating scale: 0 to 10, with 0 as no pain and 10 as the worst possible pain.
A|| 5ubjects h|p 0A Preseot h|p 0A Abseot
ar|ab|e (o = 7Z) (o = ZI) (o = 5I) P Value*
Age, mean y (SD) 58.6 (11.2) 61.1 (12.7) 58.3 (10.6) .36
Gender, n (%) females 40 (56%) 7 (10%) 33 (46%) .02
Current pain, mean (SD) 2.8 (2.3) 3.4 (2.8) 2.5 (2.1) .03
Duration of symptoms, n .22
6 wk 2 0 2
6 wk-6 mo 9 0 9
6 mo-1 y 7 3 4
1-5 y 32 10 22
5 y 22 8 14
Mode of onset, n .05
Gradual 46 14 32
Sudden (minutes with no perturbation) 14 1 13
Sudden (traumatic) 12 6 6
Location of symptoms, n
Lumbar spine 45 16 29 .42
Buttock 36 14 22 .14
Groin 15 8 7 .04
Anterior thigh 19 7 12 .43
Posterior thigh 18 5 13 .38
Lower leg/foot 24 9 15 .61
F|6uk 3. Standing antero-posterior radiograph of
the pelvis, with evidence of Kellgren and Lawrence
grade 4 osteoarthritis in both hips.
journal of orthopaedic & sports physical therapy | volume 38 | number 9 | september 2008 | 545
for each of the continuous variables ac-
cording to the following equation: SD
(1 ICC). The minimum detectable
change (MDC) was calculated as SEM
1.96 (z score for 95% condence) 2.
Individual variables from the history
and physical examination were tested for
their association with the radiograph ref-
erence criterion using independent-sam-
ples t tests for continuous variables and

2
tests for categorical variables. Variables
with a signicance level of P.10 were
retained as potential predictors. A more
liberal P value was utilized to avoid elim-
inating potentially meaningful variables
during the initial screening process. For
continuous variables with a signicant
univariate relationship, sensitivity and
specicity values were calculated for all
possible cutof points and then plotted as
a receiver operator characteristic (ROC)
curve. The point on the curve nearest the
upper left-hand corner represented the
rater bias. Only clinical examination data
from the patients self-reported symptom-
atic side were considered for subjects who
were judged to have bilateral radiographic
evidence of hip OA.
Data Analysis
All statistical analyses were performed
using SPSS software, Version 12.0 (SPSS
Inc, Chicago, IL). Descriptive statistics
and measures of central tendency and
variability were calculated to summa-
rize the demographic characteristics of
the sample. Descriptive statistics and
interrater reliability coefcients were
determined for each of the physical ex-
amination items. Interrater reliability
coefcients were calculated using Cohens
kappa coefcient and percent agreement
for categorical variables and intraclass
correlation coefcients (ICC
2,1
) for con-
tinuous variables. Standard errors of the
measurement (SEM) were determined
value with the best diagnostic accuracy,
and this point was selected as the cut-of
dening a positive test. Sensitivity, speci-
city, and positive and negative likelihood
ratios (LR) were calculated for potential
predictor variables. Potential predictor
variables were entered into a stepwise lo-
gistic regression model to determine the
most accurate set of variables for predic-
tion of diagnostic success. A signicance
level of greater than .10 was required for
removal from the equation to minimize
the likelihood of excluding potentially
helpful variables. Variables retained in
the regression model were used to for-
mulate the clinical prediction rule.
k5uLI5
S
eventy-eight volunteers were
recruited for this study. Six subjects
failed to complete their radiograph
examination. Seventy-two subjects (40
female, 32 male; mean SD age, 58.6
11.2 years) completed the study. Demo-
graphic and baseline characteristics are
shown in IA8L Z. Twenty-one of the 72
subjects were classied as having hip OA,
resulting in a pretest probability of 29%
(21/72). The number of subjects who had
Kellgren and Lawrence scores of 0, 1, 2, 3,
and 4 were 19 (26%), 32 (44%), 13 (18%),
3 (4%), and 5 (7%), respectively.
ke||ab|||ty
Interrater reliability (ICC
2,1
) and 95% con-
dence intervals (CIs) for range-of-motion
measurements, squat test, and Patricks
tests are shown in IA8L 3. Values ranged
from 0.54 to 0.90. The kappa coefcients
with 95% CIs for end feel testing ranged
from 0.21 to 0.52 (IA8L 4). Because of the
low prevalence of some end feel categories
and limited variability between examiners,
kappa coefcients might have been arti-
cially deated.
39
Therefore, we also cal-
culated percent agreement, which ranged
from 70.0% to 86.7% (IA8L 4).
39
0|agoost|c Accuracy
The sensitivity, specicity, and positive
likelihood ratios for individual variables
IA8L 3
Interrater Reliability (ICC
2,1
), SEM, and
MDC for Hip Range of Motion Measurements,
the Squat, and Patricks Test
Abbreviations: CI, condence interval; ICC, intraclass correlation coefcient; MDC, minimum detect-
able change; SEM, standard error of the measurement.
ar|ab|e |66
2,1
(95% 6|) 5N N06
Flexion 0.85 (0.64 to 0.93) 2.0 5.5
Abduction 0.85 (0.68 to 0.93) 1.6 4.4
Adduction 0.54 (0.19 to 0.81) 0.9 2.5
External rotation 0.77 (0.53 to 0.89) 1.7 4.7
Internal rotation 0.88 (0.74 to 0.94) 1.8 5.0
Extension 0.68 (0.32 to 0.85) 0.7 1.9
Squat 0.80 (0.59 to 0.91) 1.4 3.9
Patricks test 0.90 (0.78 to 0.96) 2.6 7.2
IA8L 4
Percent Agreement for Hip End
Feel Dichotomized Into Capsular and
Noncapsular End Feels
Abbreviation: CI, condence interval.
ar|ab|e kappa 6oemc|eot (95% 6|) Perceot Agreemeot
Flexion (involved side) 0.21 (0.22 to 0.64) 70.0
Internal rotation (involved side) 0.51 (0.19 to 0.83) 76.7
Scour test (involved side) 0.52 (0.08 to 0.96) 86.7
Patricks test (involved side) 0.47 (0.12 to 0.81) 76.7
Hip exion test (involved side) 0.52 (0.09 to 0.96) 86.7
546 | september 2008 | volume 38 | number 9 | journal of orthopaedic & sports physical therapy
[ RESEARCH REPORT ]
demonstrating a signicant relationship
with positive radiographic ndings are
shown in IA8L 5. The 5 variables that
emerged from the subsequent logistic re-
gression analysis were used to form the
preliminary clinical prediction rule: (1)
self-reported squatting as an aggravat-
ing factor; (2) active hip exion causing
lateral hip pain; (3) scour test with ad-
duction causing lateral hip or groin pain;
(4) active hip extension causing pain; and
(5) passive internal rotation of less than
or equal to 25 (IA8L5 6 and 7). Having at
least 3 out of the 5 predictor variables re-
sulted in a positive likelihood ratio equal
to 5.2 (95% CI: 2.6-10.9), increasing the
likelihood of having hip OA from a pre-
test probability of 29% to a 68% posttest
probability. If at least 4 out of 5 variables
were present, the positive likelihood ra-
tio was equal to 24.3 (95% CI: 4.4-142.1),
increasing the posttest probability of hav-
ing hip OA to 91%.
DISCUSSION
T
he ability to identify patients
with hip OA based on key clinical ex-
amination ndings is useful to guide
diagnostic decision making and to assist
clinicians in determining which patients
require further testing and evaluation,
and when to initiate early management,
which may minimize the deleterious ef-
fects of hip OA and maximize function.
Improving the clinical diagnosis of hip
OA may also minimize the costs asso-
ciated with unnecessary radiographic
procedures and avoid the risks of radia-
tion exposure. Each variable retained in
the nal clinical prediction rule demon-
strated moderate to good reliability,
29,36
falling within the ranges of those previ-
ously reported.
9,12,18,23
We chose to report
the positive likelihood ratio because the
purpose of this study was to maximize the
potential of making an accurate diagnosis
of hip OA, while minimizing the potential
of false positive ndings.
6,14
Furthermore,
requiring that subjects had at least Kell-
gren and Lawrence grade 2 radiographic
changes increased the likelihood that
they would experience clinically relevant
symptoms and might benet from non-
surgical management.
Twenty-one of the 72 subjects in our
study had a Kellgren and Lawrence score
of equal or greater to 2, based on their
radiographs. Thus the pretest probabil-
ity of having hip OA in our sample was
29%. If a subject exhibited only 1 or 2 of
the predictor variables, the posttest prob-
ability of having hip OA only increased
to 33% and 46%, respectively (IA8L 6).
However, if a subject had at least 3 pre-
dictors present, the likelihood of having
hip OA increased from 29% to 68%. If a
subject exhibited at least 4 of the 5 pre-
dictors, the posttest probability increased
further to 91%. However, this latter com-
IA8L 5
Sensitivity, Specificity, and Likelihood Ratios (95% CI) for Individual Variables
With a Significant Relationship With Positive Radiographic Findings
Abbreviations: CI, condence interval; IR, internal rotation; LBP, low back pain.
ar|ab|e 5eos|t|v|ty 5pec|hc|ty Pos|t|ve L|ke||hood kat|o Negat|ve L|ke||hood kat|o
Gender 0.67 (0.43 to 0.85) 0.65 (0.50 to 0.77) 1.9 (1.1 to 3.0) 0.52 (0.28 to 0.96)
Constant LBP/buttock pain 0.52 (0.30 to 0.74) 0.92 (0.80 to 0.97) 6.4 (2.4 to 17.4) 0.52 (0.33 to 0.81)
Groin pain same side 0.29 (0.12 to 0.52) 0.92 (0.80 to 0.97) 3.6 (1.2 to 11.0) 0.78 (0.59 to 1.00)
Self-reported squatting as aggravating factor 0.76 (0.52 to 0.91) 0.57 (0.42 to 0.70) 1.8 (1.2 to 2.6) 0.42 (0.19 to 0.93)
Squat causing posterior pain 0.24 (0.09 to 0.48) 0.96 (0.85 to 0.99) 6.1 (1.5 to 25.6) 0.79 (0.62 to 1.00)
Active hip exion causing lateral pain 0.43 (0.23 to 0.66) 0.88 (0.75 to 0.95) 3.6 (1.5 to 8.7) 0.65 (0.44 to 0.94)
Scour with adduction causing lateral or groin pain 0.62 (0.39 to 0.81) 0.75 (0.60 to 0.85) 2.4 (1.4 to 4.3) 0.51 (0.29 to 0.89)
Passive IR 25 0.76 (0.52 to 0.91) 0.61 (0.46 to 0.74) 1.9 (1.3 to 3.0) 0.39 (0.18 to 0.86)
Patricks 60 0.57 (0.34 to 0.77) 0.71 (0.56 to 0.82) 1.9 (1.1 to 3.4) 0.61 (0.36 to 1.00)
Active hip extension causing hip pain 0.52 (0.30 to 0.74) 0.80 (0.66 to 0.90) 2.7 (1.3 to 5.3) 0.59 (0.37 to 0.94)
Abduction or adduction causing groin pain 0.33 (0.15 to 0.57) 0.94 (0.83 to 0.98) 5.7 (1.7 to 18.6) 0.71 (0.52 to 0.96)
IA8L 6
The Number of Subjects in
Each Group at Each Level*
Abbreviation: K & L, Kellgren and Lawrence.
* The 5 variables forming the clinical prediction rule are (1) self-reported squatting as an aggravating
factor, (2) scour test with adduction causing groin or lateral pain, (3) active hip exion causing lateral
pain, (4) active hip extension causing hip pain, and (5) passive hip internal rotation less than or
equal to 25. Scores are n (%).
Number oI Pred|ctor ar|ab|es Preseot k & L 6rade Z k & L 6rade 2
5 1 (1.4%) 3 (4.2%)
4 1 (1.4%) 10 (13.9%)
3 7 (9.7%) 15 (20.1%)
2 20 (27.8%) 17 (23.6%)
1 42 (58.3%) 20 (27.8%)
0 9 (12.5%) 1 (1.4%)
journal of orthopaedic & sports physical therapy | volume 38 | number 9 | september 2008 | 547
bination of predictors was associated
with a wide 95% CI, creating uncertainty
as to the stability of this point estimate.
If the intent is to conservatively estimate
when to order imaging studies, refer pa-
tients to specialty providers, or to initiate
appropriate nonsurgical management, a
reasonably sufcient degree of diagnostic
accuracy exists based on the presence of
at least 3 predictors.
Altman and colleagues
1
described
clinical examination variables that are
commonly used for establishing a diag-
nosis of patients with hip OA. According
to their study, a patient was classied as
having hip OA if they presented with hip
pain and either (1) hip internal rotation
greater than or equal to 15, pain present
on internal rotation of the hip, morning
stifness of the hip for less than or equal to
60 minutes, and an age of greater than 50
years, or (2) hip internal rotation of less
than 15 and an ESR less than or equal
to 45 mm/h. If no ESR was obtained, hip
exion less than or equal to 115 was sub-
stituted. Either of these sets of criteria had
a sensitivity of 86%, a specicity of 75%,
and a positive likelihood ratio of 3.4 for
the diagnosis of hip OA, with radiographs
serving as the reference standard. Howev-
er, Altman et als criteria were based on a
limited examination and did not consider
a number of routinely used tests and mea-
sures that are thought to be diagnostic of
hip OA. Therefore, we believed that it was
necessary to examine the diagnostic accu-
racy of these additional clinical examina-
tion procedures. Hip pain and limited hip
internal rotation were common predictors
of hip OA in both our study (IA8L 6) and
the clinical criteria reported by Altman
and colleagues.
1
Although a limitation
of hip exion range of motion was one of
Altman et als criteria, it was not retained
as a variable in our nal rule. However,
active hip exion that reproduced symp-
toms was predictive of hip OA.
Cyriax
10
proposed that each joint
might have a characteristic proportional
pattern of motion restriction that, when
detected, indicates the presence of a cap-
sular pattern, which is suggestive of a
lesion to the synovial membrane of the
joint. Cyriax described the capsular pat-
tern of the hip to be a marked limitation
of internal rotation followed by losses of
exion and abduction. He further postu-
lated that in the early onset of hip OA,
internal rotation is the rst movement to
be measurably restricted, followed by a
slight exion limitation.
10
The emphasis
on internal rotation followed by exion
appears to correlate with the results of
recent studies on clinical indicators of
hip joint OA.
1,42
While limited hip in-
ternal rotation emerged as a predictor
of hip OA in our study, the presence of
a capsular pattern of restriction did not
emerge in the nal rule. This nding is
consistent with previous reports ques-
tioning the concept of a capsular pattern
of restriction of the hip.
4,28
Klassbo and
colleagues
28
examined 168 patients with a
variety of hip disorders and found no evi-
dence to support the existence of a capsu-
lar pattern in their subjects who had hip
OA. Similarly, Bijl et al
4
examined the
validity of the concept of a capsular pat-
tern in patients with a clinical diagnosis
of hip or knee OA, and concluded that the
capsular pattern cannot be regarded as a
valid test for the diagnosis of OA in either
of these patient populations.
To our knowledge, no previous inves-
tigation has determined reliability for
the end feel assessment of hip motions.
Prior studies have shown that intrarater
reliability for the determination of knee
and shoulder end feels is moderate and
that interrater reliability is low.
5,19
Ches-
worth et al
5
reported moderate intrarater
kappa coefcients and substantial inter-
rater kappa values for the assessment of
shoulder lateral rotation in patients with
shoulder disorders. Hayes and Petersen
5,19
reported kappa values ranging from 0.01
to 0.70 in their study of subjects with uni-
lateral knee or shoulder pain. However,
their values for percent agreement were
generally high, which was consistent with
our ndings for end feel assessment of
hip internal rotation and exion (IA8L 3).
Although end feel assessment of hip in-
ternal rotation or exion did not emerge
as a predictor of hip OA, the interrater
reliability established in this study may
help to improve the clinicians condence
in utilizing these techniques during the
examination of patients with hip pain.
Our study includes several limitations.
It is important to note that the diagnostic
accuracy of the rule actually diminished
when all 5 predictors were present. How-
ever, only 4 subjects had all 5 criteria
IA8L 7
Combination of Predictor Variables and Associated Accuracy
Statistics With 95% Confidence Intervals
Abbreviations: CI, condence interval; OA, osteoarthritis.
* The posttest probability of diagnosis of hip OA is calculated using the positive likelihood ratio and assumes 29% of patients have hip OA (our study preva-
lence) regardless of number of predictors present.
Number oI Pos|t|ve L|ke||hood Negat|ve L|ke||hood Posttest Probab|||ty
Pred|ctors Preseot 5eos|t|v|ty (95% 6|) 5pec|hc|ty (95% 6|) kat|o (95% 6|) kat|o (95% 6|) oI h|p 0A (95% 6|)
5 .14 (.04 to .37) .98 (.88 to 1.0) 7.3 (1.1 to 49.1) .87 (.73 to 1.1) 75 (25 to 96)
4 .48 (.26 to .70) .98 (.88 to 1.0) 24.3 (4.4 to 142.1) .53 (.35 to .80) 91 (58 to 99)
3 .71 (.48 to .88) .86 (.73 to .94) 5.2 (2.6 to 10.9) .33 (.17 to .66) 68 (51 to 82)
2 .81 (.57 to .94) .61 (.46 to .74) 2.1 (1.4 to 3.1) .31 (.13 to .78) 46 (36 to 56)
1 .95 (.74 to 1.0) .18 (.09 to .31) 1.2 (.99 to 1.4) .27 (.04 to 2.0) 33 (29 to 36)
548 | september 2008 | volume 38 | number 9 | journal of orthopaedic & sports physical therapy
[ RESEARCH REPORT ]
investigations may also explore the best
combination of clinical factors for ruling
out the diagnosis of hip OA.
CONCLUSION
w
e have completed the rst
step in the development of a
preliminary rule that identies
patients with hip OA. We believe that
the results of this study may assist clini-
cians in expediting the evaluation pro-
cess, initiating early management, and
making appropriate referrals to specialty
providers in this patient population. Fu-
ture studies to replicate and validate our
ndings are necessary before the rule can
be recommended for widespread use in
clinical practice.

kY P0|NI5
F|N0|N65: A preliminary clinical predic-
tion rule was developed for identifying
patients with hip osteoarthritis (OA)
based on key clinical examination cri-
teria.
|NPL|6AI|0N: The clinical prediction rule
developed in this study may assist clini-
cians in expediting the evaluation pro-
cess, initiating early management, and
making appropriate referrals of patients
with hip OA.
6AuI|0N: This study involved a small
sample size (n = 72) and must be vali-
dated in replication studies in a variety
of clinical settings and populations be-
fore it can be advocated for widespread
clinical use.
present. Because 1 of these subjects did
not have hip OA, the low total number
of subjects magnied this error. Larger
studies with more individuals having all 5
criteria present would likely demonstrate
higher levels of diagnostic accuracy were
all 5 criteria present. Additionally, while
11 variables were entered into the logistic
regression analysis, only 21 subjects ex-
hibited a positive response to those vari-
ables. It is possible that the small sample
of positive ndings and the number of
variables entered into the logistic regres-
sion may have resulted in overtting of
the model, which could have led to spu-
rious ndings. However, in the develop-
ment stage of a clinical prediction rule it
is important and necessary to include all
the potential predictor variables, and any
variable that may have been identied
as a predictor should be re-examined in
future validation studies.
8
We also con-
sidered a limited number of examination
procedures performed primarily by physi-
cal therapists and other practitioners who
examine patients in a musculoskeletal or
orthopedic clinical setting. The clinical
examination procedures included in this
study were chosen because they are rou-
tinely performed during the examination
of patients with hip pain, allowing com-
parison of our results with previous work.
1
It is also possible that some of the predic-
tor variables emerged by chance. There-
fore, future studies done in a variety of
clinical practice settings and populations
are necessary to replicate and validate
our ndings before being recommended
for widespread use in clinical practice.
32
If the rule is validated, an impact analy-
sis should be conducted to determine the
impact of the rule on decreasing radio-
graphic utilization, clinical practice pat-
terns, outcomes, and costs of care. The
eventual value of the rule may be to help
clinicians determine when to initiate non-
surgical management strategies, such as
physical therapy, that have proven to be
efective for patients with hip OA.
21,22,30
Alternatively, clinicians may be interest-
ed in ruling out hip OA as a signicant
contributor to hip pain. Therefore, future
kFkN65
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@
N0k |NF0kNAI|0N
WWW.JOSPT.ORG
APPN0|X
The physical examination included range-of-motion measurements, end feel
testing according to Cyriax,
10
and provocative tests such as the scour test,
Patricks test, and squat test. Range of motion for hip exion, extension,
abduction, and adduction was obtained using a standard 18-cm plastic
goniometer.
3
An inclinometer was used to assess range of motion for hip
internal and external rotation.
12
Before each of the range-of-motion mea-
surements was taken, an assessment of mobility of the involved hip relative
to the uninvolved hip (normal, hypomobile, hypermobile) and end feel as-
sessment was made. The efect of the movement on the patients symptoms
was also recorded (pain, no pain, location of pain).
Squat Test
The patient was standing with the feet aligned on a 20-cm strip of tape
placed on the oor. The big toe of each foot was positioned at each end
of the tape. With the patient in upright stance, the therapist zeroed out
the inclinometer along the tibial shaft approximately 1 to 2 cm below the
tibial tuberosity on the involved side. While looking straight ahead, patients
were instructed to keep the trunk upright, with hands on hips, and squat
as if they were trying to lower their buttocks between their feet as far as
possible, keeping the knees in line with the second toe and the heels on the
oor. Maximum squat was achieved either when the patient reported being
unable to go further due to pain limitations, was noticed to begin leaning
forward, or if the heels began to lift of the ground. Once maximum squat
was achieved, the range-of-motion measurement was recorded to the near-
est degree, and any change in symptoms was recorded.
7
5cour Iest
The subject was supine. The hip was passively exed to 90 and comfort-
able knee exion was allowed to follow. The knee was then moved toward
the opposite shoulder and an axial load was applied in a direction parallel
to the long axis of the femur. The examiner judged the test to be positive or
negative based on the provocation of the patients symptoms in the groin.
Internal rotation and axial compression and then adduction and axial com-
pression were added, with overpressure applied to the lateral surface of
0PkAI|0NAL 0F|N|I|0N5 0F I5I5 AN0 NA5uk5
550 | september 2008 | volume 38 | number 9 | journal of orthopaedic & sports physical therapy
[ RESEARCH REPORT ]
APPN0|X (60NI|Nu0)
the knee. The examiner also judged this part of the test to be positive or
negative based on the provocation of the subjects symptoms in the hip or
groin.
31
h|p F|ex|oo
The patient was supine. The hip was maintained in neutral abduction/ad-
duction and rotation. The patient was instructed to ex the knee and hip of
the opposite extremity to be measured to maintain a neutral lumbar spine
position during the measurement. The lower extremity was held in that
position, and the subject was then instructed to actively ex the tested hip
as far as possible. The examiner observed the motion, making sure that the
patient did not rotate the hips posteriorly or externally rotate at the hip. The
range of motion was measured for each hip using a universal goniometer.
The fulcrum was centered over the greater trochanter, the proximal arm
along the midline of the pelvis, and the distal arm along the midline of the
femur, in line with the lateral femoral epicondyle.
3,33
h|p Abduct|oo
The patient was supine. The hip was maintained in neutral exion/extension
and rotation. The patient was instructed to actively move his/her hip to a
position of maximum abduction. Next, the range of motion was measured
using a universal goniometer. The fulcrum was centered over the anterior
superior iliac spine (ASIS) of the side being measured, the proximal arm
along a line joining the ASIS, and the distal arm along the midline of the
thigh.
3,33
h|p Adduct|oo
The patient was supine. The hip was maintained in neutral exion/exten-
sion and rotation. The patient was instructed to actively move the hip to a
position of maximum adduction. Next, the range of motion was measured
using a universal goniometer. The fulcrum was centered over the ASIS, the
proximal arm along a line joining the ASIS, and the distal arm along the
midline of the femur. A second examiner held the untested extremity in hip
exion to allow for full motion of the measured hip.
3,33
Patr|ck's Iest
The patient was supine. The hip was moved to a position of exion, abduc-
tion, and external rotation by placing the lateral malleolus on the contral-
ateral knee. Slight overpressure was applied to stabilize the opposite ASIS.
The efect of the movement on the patients symptoms was also recorded
(pain, no pain, location of pain).
31,38
The examiner next assessed the Patricks
test in a similar manner on the involved hip. In addition to the traditional
performance of the Patricks test, an assessment of mobility of the involved
hip relative to the uninvolved hip (normal, hypomobile, hypermobile) was
made. After zeroing a bubble inclinometer against a wall, the range of mo-
tion was measured for each hip with the inclinometer placed approximately
2.5 cm proximal to the patients exed knee.
h|p |oteroa| kotat|oo
The patient was prone. The hip was maintained in neutral exion/extension
and adduction/abduction. The knee was exed to 90, and the hip was
passively moved to a position of maximum internal rotation. The examiner
noted maximal internal rotation when the patients opposite hip/buttock
began to rise from the table. The range of motion was measured for each hip
using a bubble inclinometer placed just proximal to the lateral malleolus.
12
h|p xteroa| kotat|oo
The patient was prone. The hip was maintained in neutral exion/extension
and adduction/abduction. The opposite hip was passively placed in slight
abduction to avoid impeding motion of the tested hip. The knee was exed
to approximately 90, and the hip was passively moved to a position of
maximum external rotation. The examiner noted maximal external rotation
when the patients hip began to rise from the table. The range of motion was
measured using a bubble inclinometer placed just proximal to the lateral
malleolus.
12
h|p xteos|oo
The patient was prone. The hip was maintained in neutral abduction/adduc-
tion and rotation. The knee was extended and the patient was instructed
to actively move his/her hip into a position of maximum extension, while
maintaining ASIS contact with the table. The examiner observed the mo-
tion making sure the patient did not contract his/her back musculature
when attempting maximum hip extension. The range of motion was mea-
sured using a universal goniometer. The fulcrum was centered over the
greater trochanter, the proximal arm along the midline of the pelvis, and
the distal arm along the midline of the femur, in line with the lateral femoral
epicondyle.
3,33
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