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Physical Examination

Lower Extremity
Sohail Bajammal, MBChB, MSc, FRCS(C)
November 4, 2008

Objectives

Fundamentals of Diagnosis
Principles of Physical Examination
Principles of MSK Physical Examination
MSK Physical Examination Approach:
Hip
Knee
Foot & Ankle

Fundamentals of Diagnosis
Have a list of D/D as you read the CC
VITAMIN C&D

Re-visit your D/D


Narrow your list by the end of History
Further narrow by the end of Physical
Confirm by further investigations

Principles of Physical Exam

Permission
Pre-amble
Privacy
Politeness
Passionate
Pacing

Principles of MSK Exam


Do not forget the patient
General exam, Vital signs

Two sides: right and left


Two joints: above and below
Two surfaces: front and back

Approach to MSK Exam


Any Lower Extremity Joint

General & Gait


Look, Feel & Move
Special Tests
Neurovascular Examination

General
Well or ill-looking
Cachectic
Vital signs: febrile, hemodynamic
stability

Gait
Antalgic gait: painful, short stance phase
Trendelenburg (abductor lurch) gait: weak
abductors
Waddling gait: bilateral weak abductors,
bilateral DDH
Steppage gait: foot drop
Toe-walking
In-toeing vs out-toeing
Others: ataxic, scissoring, etc.

Hip

Hip - Look
Principles:
Enough exposure
Compare both sides
Examine joint above (back) and joint below

Look for:
Leg length discrepancy: blocks vs. tape
Alignment & Asymmetry (wasting)
Swelling, Skin changes (erythema), Scars

Hip - Feel
Principles:
Start from non-painful area
Feel for warmth, swelling, tenderness

Sites:
From the front: ASIS, pubic tubercle
From the side: GT, iliotibial band
From the back: SI joint, PSIS

Examination of a Mass
6 Students and 3 Teachers go for CAMPFIRE

Site, Size, Shape, Surface, Skin, Scar


Tenderness, Temperature, Transillumination
Consistency
Attachment
Mobility
Pulsation
Fluctuation
Irreducibility
Regional lymph nodes
Edge

Hip - Move
Principles:
Active then passive
Feel for crepitus, excessive movement
(laxity), limited movement (contracture),
painful limitation
? Do the motor neurological exam now

Movements:
Flexion & Extension
Abduction & Adduction
IR & ER in flexion & extension

Hip Move (Motor)


Movement

Muscle(s)

Innervation

Flexion

Iliopsoas

Lumbar plexus &


femoral nerve

Extension

Gluteus maximus

Inferior gluteal

Abduction

Gluteus medius &


minimus

Superior gluteal

Adduction

Adductor magnus,
longus and brevis

Mainly obturator

Hip Special Tests


Trendelenburg test: for abductor strength
Thomas test: for hip flexion contracture
Obers test: for iliotibial band tightness
Patricks (FABER) test: for SI joint
Labral tear test

Knee

Knee - Look
Principles:
Enough exposure
Compare both sides
Examine joint above (hip) and joint below

Look for:
Leg length discrepancy
Alignment (varus, valgus, Q-angle)
Asymmetry (wasting)
Swelling, Skin changes (erythema), Scars

Knee - Feel
Principles:
Start from non-painful area
Feel for warmth, swelling, effusion, tenderness
Do not forget the back of the knee

Sites:
Patella: margins and surfaces, quadriceps &
patellar tendon & its insertion, bursae
Ligaments, tendons, & ITB attachment
Joint line: medial & lateral
Effusion: milking test, balloon test, ballotment

Knee - Move
Principles:
Active then passive
Feel for crepitus, excessive movement
(laxity), limited movement (contracture, locked
knee), painful limitation
? Do the motor neurological exam now

Movements:
Extension: quadriceps by femoral nerve
Flexion: hamstrings by sciatic nerve

Knee Special Tests


Patellar tests:
Patellar apprehension test
Patellofemoral grind test

Meniscal tests:
McMurray test
Apleys test

Ligaments tests: ACL, PCL, MCL, LCL,


PLC

Knee Ligaments Special Tests


ACL: Lachmans, Anterior drawer, Pivot
shift
PCL: posterior sag sign, Posterior drawer
MCL: valgus stress in neutral & 30 flexion
LCL: varus stress in neutral & 30 flexion
PLC: dial test

Foot & Ankle

Foot & Ankle - Look


Principles:
Enough exposure, Compare both sides
Examine joint above & below

In hindfoot, midfoot & forefoot, look for:


Leg length discrepancy
Alignment:

Ankle: valgus or varus,


Foot: pes planus or cavus,
Big toe: hallux valgus or varus
Toes: claw, hammer, mallet

Asymmetry (wasting)
Swelling, Skin changes (erythema), Scars

Toes

Claw Toes
Hammer Toe
Mallet Toe

Foot & Ankle - Feel


Principles:
Start from non-painful area
Feel for warmth, swelling, effusion, tenderness

Sites:
Bones: malleoli, bones of the hindfoot, midfoot
and forefoot
Ankle joint
Tendons: Achilles, posterior tibial, peroneal
Interdigital neuroma

Foot & Ankle - Move


Principles:
Active then passive
Feel for crepitus, excessive movement (laxity), limited
movement (contracture), painful limitation
? Do the motor neurological exam now

Movements:

Ankle: dorsiflexion & plantarflexion


Subtalar joint: inversion & eversion
Forefoot: abduction & adduction
Toes: extension & flexion

Foot & Ankle Move (Motor)


Movement

Muscle(s)

Innervation

Ankle DF

Tib Ant

Deep Peroneal

Ankle PF

Gastrocnemius

Tibial

Inversion

Tib Post mainly

Tibial

Eversion

Peroneus longus &


brevis

Superficial
Peroneal

Foot & Ankle Special Tests


Tendons:
Achilles Tendon: Thompson test
Posterior Tibial Tendon: Heel raise test

Instability:
Anterior drawer test
Inversion stress test
Peroneal tendon instability test

Mortons test: Mulders click

Neurovascular
Examination

Neurological Examination
If suspecting peripheral pathology, test
motor & sensory for all peripheral nerves
If suspecting spine pathology:
Dermatome sensation, myotome power
testing & deep tendon reflexes

Peripheral Nerves of Lower Extremities


Nerve

Motor

Sensory

Femoral

Knee Extension

Saphenous n

Obturator

Hip Adduction

Medial aspect of thigh

LFCN

Lateral aspect of thigh

Sciatic

Knee Flexion

According to branches

Tibial

Ankle PF

Plantar aspect of foot

Ankle DF

1st web space


dorsum of foot

Superficial
peroneal

Foot Eversion

Dorsum of foot
except 1st web space

Sural

Lateral border of foot

Saphenous

Medial border of foot

Deep
peroneal

Sensation

Dermatomes & Myotomes


Root

Sensory

Motor

L1

Inguinal ligament

Iliopsoas

L2

Anteromedial thigh

Iliopsoas

L3

Medial to patella

Quads

L4

Medial lower leg

Tib Ant

L5

Anterolateral leg, dorsum foot

EHL

S1

Posterolateral heel

Gastroc

S2

Posterior thigh

Rectal

S3-5

Perianal

Rectal

Reflexes

Patellar

Achilles

Vascular Examination
Inspection:
Pallor
Hair distribution

Palpation:

Feel pulses: dorsalis pedis, posterior tibial, popliteal, femoral


Temperature
Capillary refill
Sensation

Special Tests:
Compartments check
Ankle-Brachial Index

References

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Questions