Physical Examination of the Lower Extremity Dr lk

Physical Examination of the Lower Extremity Dr Ülkü Akarırmak

Objectives Principles of Physical Examination • Hip • Knee • Foot & Ankle

Diagnosis • Clinical Evaluation - History - Physical Examination • Laboratory Evaluation - Biochemistry - Imaging (x-ray, CT, MR, US) - Electrophysiology (EMG) - Others: DXA

Principles of MSK Exam • Two sides: right and left • Two joints: above and below • Two surfaces: front and back

General Examination: Posture • .

Posterior Pelvis Surface Anatomy • • • Iliac crest Gluteus maximus Gluteal folds Frolich, Human Anatomy, Lower LImb

Anterior Leg Surface Anatomy Patella Condyles of femur Femoral Triangle – Sartorius (lateral) – Adductor longus (medial) – Inguinal ligament (sup) – Femoral artery + vein+ lymph nodes

Posterior Leg Surface Anatomy • Popliteal fossa Boundaries Biceps femoris (Semitendinosis semimembranosis Gastrocnemius heads • Calcaneal (Achilles) tendon Frolich, Human pg. Anatomy, Lower LImb 793

Examination of the Lower Extremity Joints 1. Inspection Gait – Posture 2. Palpation 3. ROM 4. Special Tests 5. Neurologic + Vascular Examination

Gait • • • Antalgic gait: Painful, short stance phase Trendelenburg gait: Weak abductors Waddling gait: Bilateral weak abductors Steppage gait: Foot drop Toe-walking: In-toeing / out-toeing Others: Ataxic, scissoring, etc.

Hip Exam – Inspection • Inspection – Leg length discrepancy – Deformity & Asymmetry – Muscle wasting (atrophy) – Swelling – Skin changes (erythema) etc.

Hip Exam – Palpation • Principles – Reference points - painful areas – Increased temperature, swelling, tenderness • Sites – Front: SIAS, pubic tubercule – Side: Great trochanter, iliotibial band – Back: SI joint, SIPS

Sacroiliac joint palpation

Hip Exam – ROM • Principles – Active / passive ROM – Feel for crepitus, excessive movement (laxity), limited movement (contracture), painful limitation • Movements – Flexion & Extension – Abduction & Adduction – IR & ER (in flexion & extension)

Hip Joint - ROM • Flexion 120 -135 degrees

Hip Joint - ROM Extension 30 degrees

Hip ROM Internal rotation 35 External rotation 45

Hip ROM – sitting position Internal Rotation External Rotation

Hip ROM Abduction 45 Adduction 20 -30

Hip – Motor Function Movement Muscle(s) Innervation Flexion Iliopsoas Lumbar plexus & femoral nerve Extension Gluteus max Inferior gluteal Abduction Gluteus med & min Superior gluteal Adduction Adductor magnus, longus & brevis Obturator

Hip Joint – Special Tests • Trendelenburg test: Abductor strength • Thomas test: Hip flexion contracture • Ober’s test: Iliotibial band tightness • Patrick’s (FABERE) test: SI joint and coxofemoral joint

Thomas test (-) Thomas test (+)

Ober’s Test

Patrick’s (FABERE) test

Knee Exam - Inspection - Gait - Leg length discrepancy - Deformity varus, valgus, recurvatum - Atrophy - Swelling - Skin changes erythema, scars etc.

Popliteal (Baker’s)Cyst / Rupture in RA

Leg Length Discrepancy

Biomechanical Evaluation

Knee – Palpation • Principles – Reference points / painful areas – Warmth, swelling, effusion, tenderness – Popliteal area • Sites – Patella: Margins and surfaces, – Quadriceps&patellar tendon&insertion – Bursae – Ligaments, tendons, & ITB attachment – Joint line - medial & lateral – Effusion: Milking test, ballotment

Knee - ROM • Principles – Active & passive ROM – Crepitus, excessive movement (laxity), limited movement (contracture, painful limitation) • Movements – Extension: Quadriceps (innerv. by femoral nerve) – Flexion: Hamstrings (innerv. by sciatic nerve)

Range of Motion • Extension 0°- (-10°) • Flexion 130°-140°

Knee – Special Tests • Patellar Exam – Patellar apprehension test – Patellofemoral grind test • Meniscal Exam – Mc. Murray test – Apley’s test • Ligament tests: ACL, PCL, MCL, LCL

Patellofemoral grind test Patellar apprehension test

Exam of Menisci Mc. Murray’s test • Flex&ext with varus&valgus and int&ext rotation • Goal is to get torn piece to pop in and out of place • (+) if pop or reproduction of pain Apley’s compression test • Prone with knee flexed, axial load and rotation

• Mc. Murray test Apley’s test

Knee – Ligaments Special Tests • ACL: Anterior drawer, Lachman, Pivot shift • PCL: Posterior drawer • MCL: Valgus stress in neutral & 30 flexion • LCL: Varus stress in neutral & 30 flexion

Valgus stress test Varus stress test

Foot & Ankle Exam – Inspection • Hindfoot, midfoot & forefoot areas - Gait analysis - Alignment • Ankle: Valgus or varus • Foot: Pes planus or cavus • Big toe: Hallux valgus • Toes: Claw, hammer, mallet - Asymmetry - Swelling, skin changes (erythema or scars)

Foot Deformities

Toe Deformities

Foot & Ankle – Palpation • Principles Temperature, swelling, effusion, pain • Sites – Bones: Malleoli and bones of the hindfoot, midfoot and forefoot – Ankle joint – Tendons: Achilles, posterior tibial, peroneal – Interdigital neuroma

Foot & Ankle – ROM • Principles - Active & passive ROM - Crepitus, excessive movement (laxity), contracture, painful limitation • Movements - Ankle: dorsiflexion & plantarflexion - Subtalar joint: Inversion & eversion - Forefoot: Abduction & adduction - Toes: Extension & flexion

İnversion-Eversion Abduction-Adduction

Ankle & Foot - ROM

Foot & Ankle – Motor Exam Movement Muscle(s) Innervation Ankle DF Tibialis anterior Deep peroneal Ankle PF Gastrocnemius Tibial Inversion Tibialis posterior Tibial Eversion Peroneus longus & brevis Superficial peroneal

Foot & Ankle – Special Tests • Tendons – Achilles tendon – Posterior tibial tendon • Instability – Anterior drawer test – Inversion stress test – Peroneal tendon instability test • Morton’s test: Mulder’s click

Thompson test

Anterior drawer test Inversion stress test

Peroneal tendon instability test

Mulder’s click Mulder’s Sign - Morton's neuroma: Pain, by squeezing two metatarsal heads together while putting pressure on the interdigital space Pain will be localized to the plantar surface of the involved space+paresthesias radiating into affected toes

Neurological Examination • Peripheral nerves • Spinal pathology - Sensation - Muscle strength test - Deep tendon reflexes

Dermatomes & Myotomes Root Sensory Motor L 1 Inguinal ligament Iliopsoas L 2 Anteromedial thigh Iliopsoas L 3 Medial to patella Quads L 4 Medial lower leg Tibialis anterio L 5 Anterolat leg, dorsum foot EHL S 1 Posterolateral heel Gastrocnemius S 2 Posterior thigh Rectal S 3 -5 Perianal Rectal Reflexes Patellar Achilles

Manual Muscle Test Scale 5/5 - 0

Vascular Examination • Inspection – Colour - Pallor – Hair • Palpation – Feel pulses: dorsalis pedis posterior tibialis popliteal femoral – Temperature – Capillary refill • Special Tests – Compartments check – Ankle-Brachial Index

Inspection

Q&A

Compartments The (lower) leg is divided into four compartments by the, interosseous membrane of the leg, the transverse intermuscular septum and the posterior intermuscular septum Compartment Muscles Neurovascular structures Anterior compartment of leg Tibialis anterior, Extensor Deep peroneal hallucis longus, Extensor nerve, Anterior digitorum tibial vessels longus, Peroneus tertius Lateral compartment of leg Fibularis/peroneus Superficial longus, Fibularis/peroneu peroneal nerve s brevis Deep posterior compartment of leg Tibialis posterior, Flexor hallucis longus, Flexor digitorum longus, Popliteus Tibial nerve, Posterior tibial vessels Superficial posterior compartment of leg Gastrocnemius, Soleus, Plantaris Medial sural cutaneous nerve

Ankle-Brachial Index Test (ABI) Measuring blood pressure at the ankle and arm while a person is at rest. Measurements are repeated at both sites after 5 minutes of walking on a treadmill. The ABI result is used to predict the severity of peripheral arterial disease (PAD) Why It Is Done This test is done to screen for PAD Results The ABI result can help diagnose PAD Normal A normal resting ABI is 1. 0 to 1. 4. This means that blood pressure at ankle is the same or greater than pressure at arm, and suggests no significant narrowing or blockage of blood flow Abnormal: ABI is 0. 9 or lower

Blood Supply of Lower Extremity