Physical Examination Lower Extremity

1. Physical ExaminationLower Extremity Sohail Bajammal, MBChB, MSc, FRCS(C) November 4, 2008

2. Objectives • Fundamentals of Diagnosis • Principles of Physical Examination • Principles of MSK Physical Examination • MSK Physical Examination Approach: • Hip • Knee • Foot & Ankle

3. 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

4. Principles of Physical Exam • Permission • Pre-amble • Privacy • Politeness • Passionate • Pacing

5. 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

6. Approach to MSK ExamAny Lower Extremity Joint • General & Gait • Look, Feel & Move • Special Tests • Neurovascular Examination

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

8. 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.

9. Hip

10. 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

11. 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

12. 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

13. 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

14. Hip – Move (Motor)

15. Hip – Special Tests • Trendelenburg test: for abductor strength • Thomas test: for hip flexion contracture • Ober’s test: for iliotibial band tightness • Patrick’s (FABER) test: for SI joint • Labral tear test

16. Knee

17. 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

18. 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

19. 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

20. Knee – Special Tests • Patellar tests: • Patellar apprehension test • Patellofemoral grind test • Meniscal tests: • McMurray test • Apley’s test • Ligaments tests: ACL, PCL, MCL, LCL, PLC

21. Knee – Ligaments Special Tests • ACL: Lachman’s, 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

22. Foot & Ankle

23. 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

24. Toes Claw Toes Hammer Toe Mallet Toe

25. 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

26. 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

27. Foot & Ankle – Move (Motor)

28. 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 • Morton’s test: Mulder’s click

29. Neurovascular Examination

30. 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

31. Peripheral Nerves of Lower Extremities

32. Sensation

33. Dermatomes & Myotomes

34. 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

35. References US$ 65 US$ 47

36. Questions