Professional Documents
Culture Documents
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
Permission
Pre-amble
Privacy
Politeness
Passionate
Pacing
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
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
Muscle(s)
Innervation
Flexion
Iliopsoas
Extension
Gluteus maximus
Inferior gluteal
Abduction
Superior gluteal
Adduction
Adductor magnus,
longus and brevis
Mainly obturator
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
Meniscal tests:
McMurray test
Apleys test
Asymmetry (wasting)
Swelling, Skin changes (erythema), Scars
Toes
Claw Toes
Hammer Toe
Mallet Toe
Sites:
Bones: malleoli, bones of the hindfoot, midfoot
and forefoot
Ankle joint
Tendons: Achilles, posterior tibial, peroneal
Interdigital neuroma
Movements:
Muscle(s)
Innervation
Ankle DF
Tib Ant
Deep Peroneal
Ankle PF
Gastrocnemius
Tibial
Inversion
Tibial
Eversion
Superficial
Peroneal
Instability:
Anterior drawer test
Inversion stress test
Peroneal tendon instability test
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
Motor
Sensory
Femoral
Knee Extension
Saphenous n
Obturator
Hip Adduction
LFCN
Sciatic
Knee Flexion
According to branches
Tibial
Ankle PF
Ankle DF
Superficial
peroneal
Foot Eversion
Dorsum of foot
except 1st web space
Sural
Saphenous
Deep
peroneal
Sensation
Sensory
Motor
L1
Inguinal ligament
Iliopsoas
L2
Anteromedial thigh
Iliopsoas
L3
Medial to patella
Quads
L4
Tib Ant
L5
EHL
S1
Posterolateral heel
Gastroc
S2
Posterior thigh
Rectal
S3-5
Perianal
Rectal
Reflexes
Patellar
Achilles
Vascular Examination
Inspection:
Pallor
Hair distribution
Palpation:
Special Tests:
Compartments check
Ankle-Brachial Index
References
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Questions