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ANKLE
ROTATION HANDOUT
FAMILY MEDICINE RESIDENTS
ORTHOPEDICS ROTATION
Gaetano P. Monteleone, Jr., M.D.
Dept of Family Medicine
West Virginia University School of Medicine
monteleoneg@wvuh.com
2. Talar Tilt- measure opening (in degrees)
Side-to-side (Cotton) test- place examining hand under the plantar aspect of the foot/ankle,
with your thumb under one malleolus and your
middle finger under the other malleolus. Place a
medial
and
lateral-directed
force
(not
inversion/eversion stress as in the talar tilt test) on
the ankle. Assess if translation and assess quality of
endpoint. There may be a few mm of motion with a
syndesmosis sprain. An alternative to this is to
passively externally rotate the foot. Pain with this
maneuver will occur in a syndesmosis sprain.
4. Proximal squeeze test- also for syndesmosis sprains
II.
KNEE
Palpation
a. Anterior- patella, patellar tendon, quadriceps tendon, joint line, tibial tubercle.
b. Medial- patellar retinaculum, MCL (origin and insertion), meniscus, pes
anserine tendons, pes anserine bursa, medial femoral condyle, medial facet of the
patella.
c. Lateral- patellar retinaculum, LCL, lateral meniscus, iliotibial band (inserts at
Gerdy's tubercle), lateral femoral condyle.
d. Posterior- hamstring tendons, posterior joint line (posterior horns of the
meniscus, popliteal fossa (neurovascular structures, Baker's cyst).
e. Joint line tenderness- posterior joint line tenderness more sensitive for
meniscal injury than anterior. Anterior joint line tenderness may reflect anterior
knee pain syndromes, osteochondritis dessicans, etc. In addition, joint line
tenderness is most sensitive if not associated with an ACL tear.
N.B. When palpating joint line, internal tibial rotation renders the lateral meniscus more
palpable, external tibial rotation renders the medial meniscus more palpable.
Histology/Translation
Endpoint
Good
Fair
Poor, soft
c. Anterior/posterior drawer tests- for ACL and PCL, respectively. The knee is
flexed to 90, hip at 45 with feet flat on exam table; examiner may sit on foot,
apply an anteriorly or posteriorly-directed force. Maintain thumbs at joint line.
Assess for translation and quality of endpoint. The a nterior drawer is generally
not as helpful as the Lachman and pivot shift tests for ACL integrity. In addition,
it requires more motion to an acutely injured knee. The posterior drawer test, on
the other hand, is the most helpful test for PCL integrity.
d. Pivot shift test- for ACL integrity. Start with knee straight and an examining
hand under heel of foot. Turn the foot into internal rotation with one hand, place a
valgus-directed force at the knee with the other hand. At the same time, bring the
knee from extension to flexion. A palpable clunk appreciated at 30 of flexion at
the joint line represents the tibia reducing on the femur in ACL-deficient knee.
This may be quite uncomfortable for the acutely injured patient. It requires
significant relaxation on the part of the patient, and they probably won't let you do
it a second time (so get it right the first time!). This is the most accurate test for
chronic tear of the ACL (> 6 months).
e. Posterior sag sign- have patient lying relaxed and supine, with knees in
position similar to the anterior/posterior drawer tests. In
patients with a PCL tear, the tibial tubercle will sag
posteriorly relative to the other tibial tuberosity. The
quadriceps active test- for PCL integrity involves the
same position. Active contraction of the quadriceps will
shift the tibial tubercle anteriorly (back to neutral) in a
patient with a PCL tear. Figure at right describes the
posterior sag and the quadriceps active tests.
f. Apley's distraction test- patient lying prone, knee
Ortho Rotation Handout Revised 11.4.04
flexed to 90, examiner stabilizes posterior femur in one hand and distracts the
foot upward. At the same time, the foot should be rotated internally and
externally. Reproduction of patients pain may indicate MCL/LCL sprain or tear.
A variation to this is Apley's compression test. Performed similarly to the
distraction test, the examiner produces a compression force from the heel directed
into the exam table. Again, reproduction of pain with internal/external rotation of
the foot is a positive test. This may indicate possible meniscal pathology.
Note: in patients with open growth plates, positive Lachman's test, valgus/varus tests may
actually represent opening of tibial or femoral growth plate fracture.
The value of this and other clinical exam tests for the meniscus has been questioned. The
positive predictive value approximates 85%, for audible/palpable click. The positive predictive
value is higher in the medial meniscus and lower for the lateral meniscus.
b. Apley's compression test positive for pain. Pt prone. Knee flexed to 90. The
examiner produces a compression force directed toward the exam table. Note
distraction stress may stretch the collateral ligaments and create pain. This may
distinguish MCL vs medial meniscus injury.
III.
HIP
Physical Exam
Palpation- Anteriorly palpate the ASIS, AIIS, pubic symphysis, neurovascular structures
(femoral artery, vein and nerve), musculature; Laterally palpate the iliac crest, greater
trochanteric bursa; posteriorly palpate the PSIS, gluteal muscles, greater sciatic notch,
ischial tuberosity and bursa, SI joint, L-spine.
Special testsa. FABER test (Flexion, ABduction, External Rotation at the hip)- Pt places leg in
figure of four position. Place the examining ankle on the contralateral knee and relax the
knee out with external rotation of the hip. Tests for hip muscle flexibility, SI joint
pathology.
b. Trendelenberg sign- have pt stand on affected leg. Normal and negative test is an
inclination of the contralateral PSIS. An abnormal (positive) test results in a drooping of
the contralateral PSIS. May indicate gluteus medius weakness.
c. Ortolanis and Barlows hip clunk for developmental dislocation of the hip (DDH).
Ortolanis opening of the hips (abduction/external rotation) reduces a dislocated hip;
Barlows closure of the hips (adduction/internal rotation) dislocates the hip again. These
tests are best performed during the first few weeks of life. After that, false negative tests
can occur due to muscular spasm, etc.
d. Limb length discrepancy- measure ASIS to medial malleolus in cm. Compare both
sides. Some discrepancy is normal. Correct for more than 1.0-1.5 cm. Most (90%)
discrepancies due to soft tissue tightness, inflexibility rather than actual difference in
bone length.
e. Neurovascular assessment-. Femoral artery, nerve; nerve roots L1-S1.
f. L-spine exam- a good hip exam includes an L-spine exam as well.
IV.
BACK
Physical Exam
Inspection- deformities, scoliosis, erythema, ecchymosis, gait, heel and toe walking
N.B. Signs of slow deliberate gait, decreased lumbar lordosis and limited range of motion
are important. However, they have low diagnostic utility, since many causes of acute low
back pain will manifest these signs.
Neurovascular Assessment (most important is L4-S1): individually test heel and toe
walking. Minor asymmetry is common. A positive test should show marked asymmetry.
Nerve Root
Sensory
Reflex
Motor
L4
Anterolateral thigh
Medial ankle
Patellar
Tibialis anterior
L5
Posterolateral thigh
Dorsum of ankle
? Posterior tibialis
Extensor hallucis
longus
S1
Lateral ankle
Achilles
Peroneus
Special Tests
a. Straight leg raise (SLR) + ankle dorsiflexion: pt supine, raise leg to 30-60; + test is
pain that radiates into the calf. Also, crossed SLR = SLR in unaffected limb exacerbates
radicular pain in affected limb.
b. Modified SLR (? Lasegue's test): hip flexed to 90, knee flexed to 90, this should
not cause pain if HNP; examiner then extends the knee until nerve root is stretched. Pain
with knee extension may indicate nerve root irritation demonstrated with HNP or
impingement with OA.
c. Bowstring sign: SLR until pain, then flex the knee. This should reduce/extinguish pain
if nerve root irritation.
Ortho Rotation Handout Revised 11.4.04
d. Seated straight leg raise: With pt seated, examiner passively extends the knee; + test
produces radicular pain.
e. FABER test = Flexion ABduction External Rotation of the hip: this position posterior
may cause pain in SI joint pathology.
f. One-leg extension (or Arabesque) test: pt stands on one leg with back in extension
(examiner supports); + test of pain may indicate spondylolysis.
g. Hamstring flexibility- pt supine, hip and knees both at 90 flexion; examiner attempts
to passively straighten leg.
h. Leg length evaluation- measure from ASIS to medial malleolus (in cm).
V.
SHOULDER
The physical exam will confirm or eliminate diagnostic possibilities suggested by the
history. Each clinician should develop a systematic approach to their examination. The various
components include the following. The various tests can be focused depending on the presenting
history.
Range of motion- abduction, forward flexion, internal and external rotation. Compare
with unaffected side. Remember that in repetitive overhand athletes, external rotation is
increased and internal rotation is slightly decreased in the throwing shoulder.
Palpation- systematic palpation of bones and joints (SC joint, AC joint, clavicle,
acromion, scapula, greater tuberosity of humerus). Palpation of muscles groups of the
shoulder. Direct palpation of the insertion of the supraspinatus is best achieved by
palpating the anterior shoulder with the humerus in slights extension.
Special testsa.
b.
c.
d.
e.
f.
g.
h.
i.
j.
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Reflex
C5
Biceps
C6
Brachioradialis
C7
Triceps
C8
T1
Motor
Sensory
Deltoid, Biceps
Lateral Arm
Lateral Forearm,
Thumb/index finger
Middle finger
----
Interossei, Finger
Flexion
Medial Forearm,
Ring/pinky finger
----
Interossei
Medial Arm
Peripheral nerve
Motor
Sensory
Radial nerve
Wrist Extension
Ulnar nerve
Abduction pinky
Median nerve
Axillary nerve
Musculocutaneous nerve
Deltoid
Lateral Arm
Biceps
Lateral Forearm
LOWER EXTREMITY
Root
Reflex
Motor
Sensory
L4
Patellar
Anterior Tibialis
L5
Lateral Leg,
Dorsum Foot
S1
Achilles
Peroneus L & Br
Lateral Foot
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1
2
1
2
1
2
B. Adduction
pectoralis major (C5-T1) med & lat anterior thoracic n.
latissimus dorsi (C6-8) thoracodorsal n.
teres major
ant deltoid
C. Flexion (0-180)
ant deltoid (C5) axillary n.
coracobrachialis (C5-6) musculocutaneous n.
pectoralis major (clavicular head)
biceps
ant deltoid
D. Extension (0-60)
latissimus dorsi (C6-8) thoracodorsal n.
teres major (C5-6) lower subscapular n.
post deltoid (C5-6) axillary n.
teres minor
triceps (long head)
E. Internal (medial) rotation (0-70)
subscapularis (C5-6) upper & lower subscapular nn.
pectoralis major (C5-T1) med & lat anterior thoracic n.
latissimus dorsi (C6-8) thoracodorsal n.
teres major (C5-6) lower subscapular n.
ant deltoid
F. External (lateral) rotation (0-90)
infraspinatus (C5-6) suprascapular n.
teres minor (C5) br of axillary n.
post deltoid
G. Scapular elevation
Ortho Rotation Handout Revised 11.4.04
13
trapezius CN XI
levator scapulae (C3-4)
rhomboids
H. Scapular Protraction
serratus anterior (C5-7) long thoracic n.
I. Scapular Retraction
rhomboids (C5) dorsal scapular n.
II.
1
2
1
2
Elbow
A. Flexion (0-150)
biceps (C5-6) musculocutaneous n.
brachialis (C5-6) musculocutaneous n.
brachioradialis
supinator
B. Extension
triceps (C7) radial n.
anconeus
C. Supination
biceps (C5-6) musculocutaneous n.
supinator (C6) radial n.
D. Pronation
pronator teres (C6) median n.
pronator quadratus (C8-T1) anterior interosseous n.
III.
1
Wrist
A. Flexion (0-80)
flexor carpi radialis, FCR (C7) median n.
flexor carpi ulnaris, FCU (C8) ulnar n.
B. Extension (0-70)
extensor carpi radialis longus, ECRL (C6) radial n.
extensor carpi radialis brevis, ECRB (C6) radial n.
extensor carpi ulnaris, ECU (C7) radial n.
Lower Extremity
Ortho Rotation Handout Revised 11.4.04
14
I.
1
2
Hip
A. Abduction (0-45)
gluteus medius (L5) superior gluteal n.
gluteus minimus
1
2
B. Adduction (0-30)
adductor longus (L2-4) obturator n.
adductor brevis & magnus
C. Flexion (0-120)
Iliopsoas (L1-3) femoral n.
Rectus femoris
1
2
D. Extension (0-30)
gluteus maximus (S1) inferior gluteal n.
hamstrings
1
2
1
2
F. Internal Rotation
adductors (L2-4) obturator n.
gluteus medius and minimus
II.
1
1
III.
1
1
2
Knee
A. Flexion (0-135)
semimembranosus (L5) tibial n.
semitendinosus (L5) tibial n. } Hamstrings
biceps femoris (S1) tibial n.
B. Extension
quadriceps (L2-4) femoral n.
Ankle
A. Dorsiflexion (0-20)
tibialis anterior (L4) deep peroneal n.
extensor hallucis longus (L5) deep peroneal n.
extensor digitorum longus (L5) deep peroneal n.
B. Plantar flexion (0-50)
gastroc/soleus (S1-2) tibial n.
peroneus longus & brevis (S1) superficial peroneal n.
flexor hallucis longus
flexor digitorum longus } (L5) tibial n.
15
tibialis posterior
C. Inversion (0-35)
tibialis anterior (L4) deep peroneal n.
D. Eversion (0-15)
peroneus longus & brevis (S1) superficial peroneal n.
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AP
Lateral
Mortise (20 internal rotation)
C-spine
AP
Lateral
Obliques X 2
? Trauma
Elbow
AP
Lateral
Optional = radial head view, obliques X 2
Foot
AP
Lateral
Oblique
Forearm
PA
Lateral
Oblique
Hand
PA
Lateral
Optional = oblique
Hip
AP pelvis
Lateral of L-spine
Frog leg lateral
Knee
Leg
AP tibia/fibula
Lateral tibia/fibula
Optional = oblique tibia/fibula
L-spine
AP
Lateral
Obliques X 2
Shoulder
Trauma
Wrist
Instability
include True AP
AC joint
18