Trendelenburg Sign

Issues of Concern

The Trendelenburg sign is useful in assessing different hip dysfunctions, but the interpretation of the results remains controversial as there is no established standard for a positive test. According to Bailey et al, only 2 authors have objectively defined the point at which pelvic drop can be considered a positive Trendelenburg test result: Asayama et al established a positive Trendelenburg test result as a pelvic tilt angle of greater than 2 degrees, while Westhoff et al (2005) considered “positive” to be a pelvic drop in the non-stance limb during the single-stance phase of over 4 degrees or a maximum pelvic drop in the stance phase exceeding 8 degrees (Bailey et al, 2009).[1][5] In recent years, the Hardcastle modification of the Trendelengberg test (described above) has helped to eliminate false positives.

False positives can occur with:

• Obesity
• Fixed adduction deformity
• Medialization of lower limb axis, such as coxa vara, genu varum, and malunited supracondylar femur with varus deformity
• Non-intact quadratus lumborum (pulls the pelvis on the unaffected side up if it is not intact)
• Pain
• Poor balance
• Lack of cooperation or understanding
• Costo-pelvic impingement
• Scoliosis
• Pelvic drop can occur even in healthy individuals with normal abductor mechanisms when the abductor muscles are not working adequately.

 False negatives can occur with:

• Use of supra-pelvic muscles
• Use of psoas and rectus femoris
• Wide lateral translocation of the trunk to allow balance over the hip as a fulcrum
• In patients with early stages of osteonecrosis, despite having an abductor mechanism defect, Trendelenburg sign and, therefore, gait remain masked.[6]

Clinical Significance

The Trendelenburg sign is useful in identifying weak hip abductors and assessing other mechanical, neurological, and spinal disorders. Especially in the postoperative setting, a positive Trendelenburg sign may identify the source of patient complications. Particularly in the posterior approach to the hip, the gluteus medius is likely to be detached from its attachment at the greater trochanter. Therefore, orthopedic surgeons must be careful in their surgical approach to avoid this complication.

A positive Trendelenburg test is a finding in the following [7]:

• Any condition that brings the origin and insertion of gluteus medius together:
• Subluxation or dislocation of the hip
• Coxa vara
• Greater trochanter fractures
• Slipped femoral capital epiphysis
• Legg-Calve-Perthes disease
• Abductor paralysis or weakness:
• Polio
• Root-lesion
• Post-operative nerve damage
• Muscle-wasting disease
• Hemiplegic cerebral palsy
• Muscular dystrophy
• Any painful hip disorder that results in gluteal inhibition
• Others
• Lower back pain
• Osteoarthritis of the hip
• Greater trochanter fractures
• Femoral neck fractures
• Short leg syndrome
• The initial time following total hip replacement
• Cleidocranial dysostosis

Nursing, Allied Health, and Interprofessional Team Interventions

A patient-centered approach to care is necessary to manage and treat a patient with a positive Trendelenburg sign. A team of health care workers, including the patient’s primary care physician, specialists like orthopedics and neurologists, nurses, physical therapists, or chiropractors, all working in an interdisciplinary manner with the patient, can help find the root cause and treat the patient. Often, patients must follow up with their physical therapists and other doctors to manage their condition long-term, as it takes time to recover fully, depending on the diagnosis.

Management

Medical management of a positive Trendelenburg sign depends on the underlying cause. If the positive Trendelenburg sign is the result of pain, providers might suggest pain control through the use of over-the-counter nonsteroidal anti-inflammatory drugs. In severe cases, doctors might prescribe steroids such as cortisone injections to help reduce pain. If the patient has short leg syndrome, patients might benefit from a shoe lift to minimize the waddling gait. Other times, the clinician might suggest a harness for developmental dysplasia of the hip or a cast for Legg Calve Perthes disease. Physical therapists often recommend various exercises to strengthen the hip abductors so that the patient can maintain a midline center of gravity, preventing side-to-side motion during their gait cycle. Osteopathic manipulative treatment could result in improved gait and range of motion for individuals with somatic dysfunctions, short-leg syndrome, and lower back pain, contributing to positive Trendelenburg sign.[8] Biofeedback, through electromyography, can help patients understand how their muscles respond to specific movements and adjust their gait accordingly. This allows patients to control their muscle movements and increase their range of motion.[9]