Thank you, Chris, and thank you, John Kelly, for this opportunity. And obviously, most hip surgeons, as you can see on the podium, are bald because of what John just said. No, I'm just joking. So let's talk about the examination of the hip. My disclosures are not relevant. So the bottom line is that this differential diagnosis is very complex. There's a lot of non-hip, spine, core issues you've got to worry about. And then in the hip, there are a lot of issues you have to worry about. This is my kind of go-to physical exam talk I give to the residents and fellows. So when you have a complex differential diagnosis, it forces you to do something that we're getting worse and worse, or we're teaching worse and worse, is how to do a thorough history and physical exam. And I'm going to be focused on the physical exam. John did a great job about the history. So I call this the Ranawat Physical Exam. You've got to be algorithmic to elucidate a complex disorder. With a differential diagnosis, that's very, very complicated. So I break it down to six simple things, your gait, your lumbar spine exam, including your neurovascular exam, your palpation exam, where I'm throwing in athletic pubalgia, your hip range of motion, my intra-articular testing, and my special extra-articular testing. We're in New York. I talk fast. I got no hair. We move quickly. You know, Hal Martin, probably the best physical exam of our generation, does this in 45 minutes. I'm going to do this in six minutes. So first, the gait. I call this my foot progression angle walking test. I look at someone's gait and first see whether they have a coxalgia gait, do they have a lumbar avoidance gait, and then I do my thing called my FPAW test. Here's my FPAW where I first ask them to walk with their native foot progression angle. Then I ask them to walk. It's a loaded exam with internal rotation, which will help instability, and external rotation, which will worsen with instability. Likewise, with impingement, it would be the opposite. More internal rotation will worsen impingement, and more external rotation will help impinge – will alleviate impingement. Then I'll do a Trendelenburg sign, looking for not just their level of their pelvis, but also their degree of compensation. Then I'm quickly doing our lumbar spine. I look at their overall scoliosis. You got to take their shirt off. You want to look at their motion. I want to see if there's any radicular symptoms. Examine the back. A high disc will present with groin pain. I see about one or two revision hip scopes a year where they get an MRI of their back and they should have had a spine surgery, not a hip surgery. Not a win for us. So this is a basic hip exam. A basic hip exam includes the spine. You must examine the spine. Likewise, for the spine surgeons, you must examine the hip. And this is a big thing coming with hip spine syndrome. Then I get to stage three, which is my palpation exam, right? Intraarticular pathology, for the most part, is not palpable. Extraarticular pathology is. And I really want to focus on my adductor, my rectus, my ASIS, my iliac wing. I do a true hernia exam if I have central pubic pain, and obviously my trochanteric exam. And I flip them over if they have more posterior pain. My palpation exam is dependent primarily on their source of their pain, groin, lateral, posterior. But you got to palpate what you think you got to palpate. So if I think it's more anterior pain, I'm evaluating their trochanter. I'm going to evaluate their rectus, mostly the longest. You feel the longest. You hook the longest. I'm sorry, the adductors. And then I evaluate the rectus. Then I get to my hip range of motion. This is our lock of our hip joint. And I really want to look at flexion, internal rotation, external rotation. Based on hip range of motion, I am closing my eyes, and I'm predicting the X-ray. We really are over-relying on imaging, and we teach our resident fellows too much to rely on imaging. You can predict almost every X-ray and CAT scan based on their exam. So I want to first see how much flexion I have. I'm really trying to lock the pelvis. I actually axial load posteriorly into the hip joint. And then I'll put my left hand on the iliac crest to stabilize the pelvis. You have to look for subtle rocking of the pelvis. This is an exam that Brian Kelly taught me. You have to really subtly assess hip internal rotation, internal and external. And then I think of my three-pack out of respect to Dr. O'Brien and the shoulder is my impingement or my intra-articular exam, which is subspine, fader, and faber, my posterior exam, and my lateral exam. And I contrast that to my instability exam, which is my ABER, and my prone apprehension relocation test, which is another physical exam we described. Remember, the hip impingement test is not a sign of impingement. It's a sign for intra-articular pathology. If you have anything that hurts in your hip and you grind a hip really hard, it's going to hurt them more. A faber test is positive for intra-articular pathology when they have anterior pain, not posterior lateral. You want to make that distinction. And a subspine test, again, it's really hard to say it's truly for subspine pathology, and straight flexion will certainly aggravate an irritated or synovitic hip. You can do this really quickly. You quickly do a subspine, then you quickly get into a fader, and then you get into a faber. Again, you're algorithmic in your approach. Then I'm getting to instability. First, I'll do an ABER test, then I'll do my prone apprehension test, which is a new diagnosis. This is the classic GANS test, which is very specific but not very sensitive. You really got to really push hard on someone's hip to dislocate them anteriorly. So hence, for the prone apprehension, we use gravity on our side, just like our shoulder surgeon colleagues have done, and it's actually much more sensitive. We have a paper coming out with Dr. Ernie Sink, one of our PEDS colleagues. Then finally, I get to my specialty testing. I'm going to look at ischiofemoral impingement, hamstring sciatic pathology, and abductor pathology. Really, what you want to think of ischiofemoral impingement is close your eyes and figure out what's it might think is hitting the pelvis. Is it the lesser or greater trochanter? They're very different. I use the maximal internal rotation test, as well as Hal Martin's test, and here I use a lot of dynamic ultrasound. I think too many surgeons rely on inadequate tests to do big operations, taking off people's parts of their bone, without adequate diagnoses here. So here's the classic external rotation test to hit the lesser, and then you can also see Hal's test, which is a similar kind of maneuver, adduction, to get the lesser to hit the ischium and the hamstring in abduction. And then at the same time, I assess abduction in three planes, neutral, forward flexion, and extension. So, in conclusion, by the goal, by the end of this H&P, you should understand the nature of the pain, the aggravating system, whether it's intra-extraarticular diagnosis, and ultimately what the x-ray looks at. It's a complex diagnostic differential. You have to be algorithmic. You have to look for non-hip etiologies. Not everything is FAI. Extraarticular hip pain does exist. You can find it. The patient will tell you and show you everything you need to know. You just need how to listen and know how to listen with your hands. Thank you very much.

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