Physical ExaminationLower ExtremitySohail Bajammal, MBChB, MSc, FRCS(C)

November 4, 2008

ObjectivesFundamentals of DiagnosisPrinciples of Physical ExaminationPrinciples of MSK Physical ExaminationMSK Physical Examination Approach:HipKneeFoot & Ankle

Fundamentals of DiagnosisHave a list of D/D as you read the CCVITAMIN 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 ExamPermissionPre-amblePrivacyPolitenessPassionatePacing

Principles of MSK ExamDo 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 ExamAny Lower Extremity JointGeneral & GaitLook, Feel & MoveSpecial TestsNeurovascular Examination

GeneralWell or ill-lookingCachecticVital signs: febrile, hemodynamic stability

GaitAntalgic gait: painful, short stance phaseTrendelenburg (abductor lurch) gait: weak abductorsWaddling gait: bilateral weak abductors, bilateral DDHSteppage gait: foot dropToe-walkingIn-toeing vs out-toeingOthers: ataxic, scissoring, etc.

Hip

Hip - LookPrinciples:Enough exposureCompare both sidesExamine joint above (back) and joint below

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

Hip - FeelPrinciples:Start from non-painful areaFeel for warmth, swelling, tenderness

Sites:From the front: ASIS, pubic tubercleFrom the side: GT, iliotibial bandFrom the back: SI joint, PSIS

Examination of a Mass 6 Students and 3 Teachers go for CAMPFIRESite, Size, Shape, Surface, Skin, ScarTenderness, Temperature, TransilluminationConsistencyAttachmentMobilityPulsationFluctuationIrreducibilityRegional lymph nodesEdge

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

Movements:Flexion & ExtensionAbduction & AdductionIR & ER in flexion & extension

Hip Move (Motor)

MovementMuscle(s)InnervationFlexionIliopsoasLumbar plexus & femoral nerveExtensionGluteus maximusInferior glutealAbductionGluteus medius & minimusSuperior glutealAdductionAdductor magnus, longus and brevisMainly obturator

Hip Special TestsTrendelenburg 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 - LookPrinciples:Enough exposureCompare both sidesExamine joint above (hip) and joint below

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

Knee - FeelPrinciples:Start from non-painful areaFeel for warmth, swelling, effusion, tendernessDo not forget the back of the knee

Sites:Patella: margins and surfaces, quadriceps & patellar tendon & its insertion, bursaeLigaments, tendons, & ITB attachmentJoint line: medial & lateralEffusion: milking test, balloon test, ballotment

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

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

Knee Special TestsPatellar tests:Patellar apprehension testPatellofemoral grind test

Meniscal tests:McMurray testApleys test

Ligaments tests: ACL, PCL, MCL, LCL, PLC

Knee Ligaments Special TestsACL: 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 - LookPrinciples:Enough exposure, Compare both sidesExamine joint above & below

In hindfoot, midfoot & forefoot, look for:Leg length discrepancyAlignment:Ankle: valgus or varus, Foot: pes planus or cavus, Big toe: hallux valgus or varus Toes: claw, hammer, malletAsymmetry (wasting)Swelling, Skin changes (erythema), Scars

ToesClaw ToesHammer ToeMallet Toe

Foot & Ankle - FeelPrinciples:Start from non-painful areaFeel for warmth, swelling, effusion, tenderness

Sites:Bones: malleoli, bones of the hindfoot, midfoot and forefootAnkle jointTendons: Achilles, posterior tibial, peronealInterdigital neuroma

Foot & Ankle - MovePrinciples:Active then passiveFeel for crepitus, excessive movement (laxity), limited movement (contracture), painful limitation? Do the motor neurological exam now

Movements:Ankle: dorsiflexion & plantarflexionSubtalar joint: inversion & eversionForefoot: abduction & adductionToes: extension & flexion

Foot & Ankle Move (Motor)

MovementMuscle(s)InnervationAnkle DFTib AntDeep PeronealAnkle PFGastrocnemiusTibialInversionTib Post mainlyTibialEversionPeroneus longus & brevisSuperficial Peroneal

Foot & Ankle Special TestsTendons:Achilles Tendon: Thompson testPosterior Tibial Tendon: Heel raise test

Instability:Anterior drawer testInversion stress testPeroneal tendon instability test

Mortons test: Mulders click

Neurovascular Examination

Neurological ExaminationIf 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

NerveMotorSensoryFemoralKnee ExtensionSaphenous nObturatorHip AdductionMedial aspect of thighLFCN-Lateral aspect of thighSciaticKnee FlexionAccording to branchesTibialAnkle PFPlantar aspect of footDeep peronealAnkle DF1st web space dorsum of footSuperficial peronealFoot EversionDorsum of foot except 1st web spaceSural-Lateral border of footSaphenous-Medial border of foot

Sensation

Dermatomes & Myotomes

RootSensoryMotorReflexesL1Inguinal ligamentIliopsoasL2Anteromedial thighIliopsoasL3Medial to patellaQuadsL4Medial lower legTib AntPatellarL5Anterolateral leg, dorsum footEHLS1Posterolateral heelGastrocAchillesS2Posterior thighRectalS3-5PerianalRectal

Vascular ExaminationInspection: PallorHair distribution

Palpation:Feel pulses: dorsalis pedis, posterior tibial, popliteal, femoralTemperatureCapillary refillSensation

Special Tests:Compartments checkAnkle-Brachial Index

ReferencesUS$ 65US$ 47

Questions

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