Hip Dysplasia

Clinical Signs and Physical Examination

Findings

Jason Syrcle, DVM

KEYWORDS
 Hip dysplasia  Hip laxity  Hip subluxation  Hip osteoarthritis  Ortolani test

KEY POINTS
 Hip dysplasia is a common developmental disorder of the dog consisting of varying de-
grees of hip laxity, progressive remodeling of the structures of the hip, and subsequent
development of osteoarthritis.
 Hip dysplasia is a juvenile-onset condition, with clinical signs often first evident at 4 to
12 months of age.
 A presumptive diagnosis of hip dysplasia can be made by collection of a thorough history
and performance of a comprehensive physical examination.
 The Ortolani test is a valuable screening tool for hip dysplasia, particularly in the juvenile
patient.

INTRODUCTION

Hip dysplasia is a common developmental disorder of the dog, consisting of varying

degrees of hip laxity, progressive remodeling of the structures of the hip, and subse-
quent development of osteoarthritis. Hip dysplasia may initially be suspected from
signalment, history, and physical examination findings. This article outlines the typical
clinical presentation of hip dysplasia and physical examination methods that can be
used to help diagnose the condition and rule out other problems.

SIGNALMENT
Breed
Any size or breed of dog can be affected with hip dysplasia but the condition is most
commonly diagnosed in large and giant breed dogs. Breeds with the most evaluations
by the Orthopedic Foundation for Animals for hip dysplasia over the last 40 years

The author has nothing to disclose.

Small Animal Surgery, Department of Clinical Sciences, College of Veterinary Medicine, Missis-
sippi State University, PO Box 6100, Mississippi State, MS 39762, USA
E-mail address: syrcle@cvm.msstate.edu

Vet Clin Small Anim - (2017) -–-

http://dx.doi.org/10.1016/j.cvsm.2017.02.001 vetsmall.theclinics.com
0195-5616/17/ª 2017 Elsevier Inc. All rights reserved.
2 Syrcle

include Labrador Retrievers (12.2% dysplastic), Golden Retrievers (20.1%), German

Shepherds (20.4%), and Rottweilers (21.3%). Breeds with particularly high reported
prevalence of dysplasia include the Bulldog (73.4%), Pug (69.7%), and St. Bernard
(49.2%).1 These numbers do not indicate a true prevalence because breeders typically
will not submit radiographs from dogs that are obviously dysplastic. Although certain
dog breeds are predisposed, mixed-breed dogs can also develop hip dysplasia. In
one large study, purebreds and mixed-breed dogs were equally likely to develop
hip dysplasia.2

Sex
Multiple large prevalence studies show no sex predilection associated with hip
dysplasia.3–6 However, several studies suggest that male neutered dogs may be at
increased risk for development of hip dysplasia, especially when neutered early.7–10
Definitions of early neutering associated with increased incidence of hip dysplasia in
these studies included dogs that were younger than 5.5 months, 6 months, and
12 months of age at the time of neutering.

Age
Juvenile patients
Hip dysplasia is by definition a juvenile-onset condition. Clinical signs of hip dysplasia
are often first evident at 4 to 12 months of age.11–13 Onset of signs is typically gradual
and progressive, although an acute onset of signs may be seen, most often in juvenile
patients. Dogs with this acute onset of signs are typically more severely affected, with
pain thought to be caused by stretching and tearing of joint capsule and other sup-
porting structures, along with acetabular microfracture.13 Evidence of hip laxity is
not present at birth but may be detectable as early as 7 weeks of age.11 Clinical signs
noted by the owner are listed in Table 1.11–14

Adult patients
Several reasons may exist for initial presentation of dysplastic patients older than
12 months of age. The patient may have had signs as a puppy that went unnoticed
by the owner, undiagnosed by the family veterinarian, or there was a delay in referral.
Alternatively, some dogs may not exhibit clinical signs until later in the disease pro-
cess, often associated with progression of osteoarthritis. These cases may exhibit
clinical signs similar to juvenile patients but clinical signs in older patients are often

Table 1
Clinical signs of hip dysplasia

Nonspecific Signs Hind Limb Specific Signs Gait Abnormalities

 Exercise intolerance
 Reluctance to navigate
stairs
 Difficulty lying down or
rising
 Audible click or clunk  Hind end sways when
when walking walking
 Perceived hip pain  Wobbly or ataxic-
 Hind limb muscle atrophy appearing gait, with
 Unilateral hind limb normal neurologic
lameness examination
 Walking with an arched
back
 Base-narrow or base-
wide stance of the hind
limbs
 Bunny hopping
 Hip Dysplasia 3

more referable to osteoarthritic changes, rather than signs associated with laxity and
subluxation. Because clinical signs of hip dysplasia in older patients are most often
gradually progressive, an adult patient presenting for acute onset of hind limb lame-
ness attributed to hip dysplasia should be carefully screened for other conditions.

PHYSICAL EXAMINATION FINDINGS

Lameness Evaluation
Any of the gait abnormalities referenced in Table 1 can be seen on examination.
Although hip dysplasia is typically a bilateral condition, sometimes clinical signs are
more severe on one side and a unilateral lameness may be appreciated.
Orthopedic Examination
Systematic orthopedic examination should localize discomfort to the hips. For
dysplastic patients, hip manipulation is typically painful, particularly hip extension.
Pain on hip extension should be differentiated from other conditions. Common dif-
ferential diagnoses for pain localized to the hip are listed in Table 2. In addition to
hip pain, patients with advanced osteoarthritis may also exhibit crepitus on palpa-
tion of the hip, as well as decreased coxofemoral range-of motion and muscle atro-
phy of the affected limb. Complete orthopedic evaluation is critical because
comorbidities may be present that complicate treatment recommendations. For
example, an adult dog presenting with acute-onset hind limb lameness may indeed
have hip dysplasia but the lameness may be attributable to a cranial cruciate liga-
ment rupture.
Joint Subluxation Tests
Overview
Hip laxity can be identified and quantified by several examination methods, including
the tests of Barlow, Ortolani, and Bardens.15–17 The Ortolani and Barlow tests were
developed for screening of hip dysplasia in infants. The positive Ortolani test involves
abducting a subluxated hip until palpable and/or audible reduction of the hip is
noted. This sensation is often described as a click or a clunk. The test can be per-
formed in lateral or dorsal recumbency in the dog. The Barlow test involves active
subluxation of the hip. For this test, the hip is adducted while applying a distoprox-
imal force. The subluxation can be sensed as an acute proximal displacement of the
hip with palpable loss of stability. This can also be performed in dorsal or lateral re-
cumbency. The Bardens test, described by a veterinarian in the late 1960s, involves
applying a mediolateral force to the proximal femur with 1 hand while quantifying
lateral movement of the greater trochanter with the other. This test is performed in
lateral recumbency. Any palpable reduction or subluxation with the Ortolani or
Barlow test, or lateral movement of the greater trochanter of more than about
6 mm with the Bardens test, should be considered abnormal and evidence of hip
laxity.

Table 2
Common differential diagnoses for dogs with hip pain and no history of trauma

Juvenile Adult
 Iliopsoas strain  Iliopsoas strain
 Legg-Calvé-Perthes disease (small breeds)  Lumbosacral stenosis
 Slipped capital femoral physis  Neoplasia
4 Syrcle

Ortolani test
The author’s preference when assessing hip subluxation in juvenile patients is to
perform a combination of the Barlow and Ortolani tests (commonly referred to as
an Ortolani test), as described by Chalman and Butler18 in 1985. The patient is heavily
sedated or anesthetized and placed in dorsal recumbency. An assistant stabilizes the
thorax and head of the dog to ensure true dorsal recumbency is maintained. The
examiner is behind the patient, looking toward the head. The examiner grasps the sti-
fles and ensures the femurs are positioned perpendicular to the floor (Fig. 1). Each hip
is tested sequentially, as follows. Gentle pressure is applied down the shaft of the fe-
mur toward the acetabulum (Fig. 2A). While maintaining this downward pressure, the
hip is slowly abducted until a palpable clunk is noted. The angle of the medial aspect
of the femur with a line perpendicular to the examination table is noted at the time of
reduction of the hip and recorded as the angle of reduction (see Fig. 2B). If no
palpable or audible reduction of the hip is noted, this is a negative Ortolani test result.
The hip is then adducted until subluxation is noted, palpable as a dorsal deviation of
the proximal femur. The angle of the medial aspect of the femur with a line perpen-
dicular to the examination table is recorded as the angle of subluxation (see
Fig. 2C). The test is often repeated 2 to 3 times for each hip to ensure accuracy
and precision of the measurements. The reduction and subluxation angles, as well
as the nature of the reduction (crisp or soft) are recorded. These data may be useful
to quantify hip laxity, follow progression of changes over time and to judge candidacy
for surgical interventions such as juvenile pubic symphysiodesis or triple pelvic
osteotomy.

Evidence: Ortolani test

Dogs with a positive Ortolani test were associated with increasing distraction index
(DI) measurements in a group of dogs in one study.19 In that report, dogs were cate-
gorized as having a mild, moderate, or severe Ortolani sign, with mild being a barely
perceptible reduction and severe being a loud or obvious clunk. Increasing DI was

Fig. 1. Examination of a patient using the Ortolani test. The patient is placed in dorsal re-
cumbency with an assistant to stabilize the thorax and head. The examiner stands behind
the patient, grasping the stifles, with the femurs positioned perpendicular to the floor.
 Hip Dysplasia 5

Fig. 2. Examination of the left hip using the Ortolani test from the examiner’s perspective,
paired with drawings depicting effects of the test on the coxofemoral joint. (A) Gentle
pressure is applied down the shaft (arrow) of the left femur with the examiner’s right
hand, causing subluxation of the hip. (B) While maintaining this downward pressure
(arrow), the hip is slowly abducted (curved arrow) until a palpable clunk is noted. The
angle of the medial aspect of the femur with a line perpendicular to the examination table
is measured at the time of reduction of the hip and recorded as the angle of reduction
(angle q). (C) The hip is adducted (curved arrow) while continuing to maintain downward
pressure (arrow) until subluxation is noted, palpable as a dorsal deviation of the proximal
femur. The angle of the medial aspect of the femur with a line perpendicular to the exam-
ination table is recorded as the angle of subluxation (angle q).

associated with increasing severity of the Ortolani, suggesting increased laxity could
be semiquantified with the test. The same study showed the association between DI
and Ortolani was weaker in dogs with radiographic osteoarthritis, suggesting that
remodeling in such cases led to a negative or decreased Ortolani sign, despite laxity
of the hip. Ortolani testing has been shown to provide a 92% to 100% sensitivity for
identifying laxity in juvenile dogs older than 4 months of age that later developed radio-
graphic signs of hip dysplasia.20–22 Specificity in those studies study was 41% to 79%,
suggesting Ortolani evaluation might best be used as a screening test and other tests,
such as DI measurements, may be better for confirmation of diagnosis. However, a
study evaluating Ortolani in younger dogs (6–10 weeks of age) revealed a lower sensi-
tivity for detecting dysplastic dogs (55%), so caution should be used when proclaim-
ing a young puppy free of hip dysplasia using the Ortolani test alone.23 Additionally,
subluxation tests may become less productive as dysplasia progresses.19 As dorsal
acetabular rim wear and acetabular infilling increases in severity, reduction of the sub-
luxated hip becomes less distinct or no longer palpable. Therefore, the Ortolani and
other subluxation tests may be less valuable for evaluating older dogs with suspected
hip dysplasia.
6 Syrcle

SUMMARY

With proper attention to collection of history and physical examination findings, the
clinician can eliminate differential diagnoses and make a presumptive diagnosis of
hip dysplasia. The Ortolani test is a valuable tool for identifying juvenile dogs affected
with this condition. Further diagnostics can then be prioritized, contributing to prompt
diagnosis and appropriate treatment.

ACKNOWLEDGMENTS

The author would like to thank Jonathan Blakely, DVM for providing the line draw-
ings used in this article.

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