physical examination lower extremity
DESCRIPTION
Physical Examination Lower Extremity. Sohail Bajammal, MBChB, MSc, FRCS(C) November 4, 2008. 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. - PowerPoint PPT PresentationTRANSCRIPT
Physical ExaminationPhysical ExaminationLower ExtremityLower Extremity
Sohail Bajammal, MBChB, MSc, FRCS(C)Sohail Bajammal, MBChB, MSc, FRCS(C)
November 4, 2008November 4, 2008
Principles of MSK ExamPrinciples of MSK Exam
• Do not forget the patient Do not forget the patient – General exam, Vital signsGeneral exam, Vital signs
• Two sides: right and leftTwo sides: right and left
• Two joints: above and belowTwo joints: above and below
• Two surfaces: front and backTwo surfaces: front and back
Approach to MSK ExamApproach to MSK ExamAny Lower Extremity JointAny Lower Extremity Joint
• General & GaitGeneral & Gait
• Look, Feel & MoveLook, Feel & Move
• Special TestsSpecial Tests
• Neurovascular ExaminationNeurovascular Examination
GeneralGeneral
• Well or ill-lookingWell or ill-looking
• CachecticCachectic
• Vital signs: febrile, hemodynamic Vital signs: febrile, hemodynamic stabilitystability
GaitGait
• Antalgic gait: painful, short stance phaseAntalgic gait: painful, short stance phase
• Trendelenburg (abductor lurch) gait: weak Trendelenburg (abductor lurch) gait: weak abductorsabductors
• Steppage gait: foot dropSteppage gait: foot drop
• Others: ataxic, scissoring, etc.Others: ataxic, scissoring, etc.
Hip - LookHip - Look• Principles:Principles:
– Enough exposureEnough exposure– Compare both sidesCompare both sides– Examine joint above (Examine joint above (backback) and joint below) and joint below
• Look for:Look for:– Leg length discrepancy: Leg length discrepancy: – Alignment & Asymmetry (wasting)Alignment & Asymmetry (wasting)– Swelling, Skin changes (erythema), ScarsSwelling, Skin changes (erythema), Scars
Hip - FeelHip - Feel• Principles:Principles:
– Start from non-painful areaStart from non-painful area– Feel for warmth, swelling, tendernessFeel for warmth, swelling, tenderness
Hip - MoveHip - Move• Principles:Principles:
– Active then passiveActive then passive– Feel for crepitus, excessive movement Feel for crepitus, excessive movement
(laxity), limited movement (contracture), (laxity), limited movement (contracture), painful limitationpainful limitation
– ? Do the motor neurological exam now? Do the motor neurological exam now
• Movements:Movements:– Flexion & ExtensionFlexion & Extension– Abduction & AdductionAbduction & Adduction– IR & ER in flexion & extensionIR & ER in flexion & extension
Knee - LookKnee - Look• Principles:Principles:
– Enough exposureEnough exposure– Compare both sidesCompare both sides– Examine joint above (Examine joint above (hiphip) and joint below) and joint below
• Look for:Look for:– Leg length discrepancyLeg length discrepancy– Alignment (varus - inward angulation of the Alignment (varus - inward angulation of the
distal segmentdistal segment , valgus, Q-angle), valgus, Q-angle)– Asymmetry (wasting)Asymmetry (wasting)– Swelling, Skin changes (erythema), ScarsSwelling, Skin changes (erythema), Scars
Knee - FeelKnee - Feel• Principles:Principles:
– Start from non-painful areaStart from non-painful area– Feel for warmth, swelling, effusion, tendernessFeel for warmth, swelling, effusion, tenderness– Do not forget the back of the kneeDo not forget the back of the knee
• Sites:Sites:– Patella: margins and surfaces, quadriceps & Patella: margins and surfaces, quadriceps &
patellar tendon & its insertion, bursaepatellar tendon & its insertion, bursae– Ligaments, tendons, & ITB attachmentLigaments, tendons, & ITB attachment– Joint line: medial & lateralJoint line: medial & lateral– Effusion: milking test, balloon test, ballotmentEffusion: milking test, balloon test, ballotment
Knee - MoveKnee - Move• Principles:Principles:
– Active then passiveActive then passive– Feel for crepitus, excessive movement Feel for crepitus, excessive movement
(laxity), limited movement (contracture, locked (laxity), limited movement (contracture, locked knee), painful limitationknee), painful limitation
– ? Do the motor neurological exam now? Do the motor neurological exam now
• Movements:Movements:– Extension: quadriceps by femoral nerveExtension: quadriceps by femoral nerve– Flexion: hamstrings by sciatic nerveFlexion: hamstrings by sciatic nerve
Foot & Ankle - LookFoot & Ankle - Look• Principles:Principles:
– Enough exposure, Compare both sidesEnough exposure, Compare both sides– Examine joint above & belowExamine joint above & below
• In hindfoot, midfoot & forefoot, look for:In hindfoot, midfoot & forefoot, look for:– Leg length discrepancyLeg length discrepancy– Alignment:Alignment:
• Ankle: valgus or varus, Ankle: valgus or varus, • Foot: pes planus or cavus, Foot: pes planus or cavus, • Big toe: hallux valgus or varus Big toe: hallux valgus or varus • Toes: claw, hammer, malletToes: claw, hammer, mallet
– Asymmetry (wasting)Asymmetry (wasting)– Swelling, Skin changes (erythema), ScarsSwelling, Skin changes (erythema), Scars
Foot & Ankle - FeelFoot & Ankle - Feel• Principles:Principles:
– Start from non-painful areaStart from non-painful area– Feel for warmth, swelling, effusion, tendernessFeel for warmth, swelling, effusion, tenderness
• Sites:Sites:– Bones: malleoli, bones of the hindfoot, midfoot Bones: malleoli, bones of the hindfoot, midfoot
and forefootand forefoot– Ankle jointAnkle joint– Tendons: Achilles, posterior tibial, peronealTendons: Achilles, posterior tibial, peroneal– Interdigital neuromaInterdigital neuroma
Foot & Ankle - MoveFoot & Ankle - Move• Principles:Principles:
– Active then passiveActive then passive– Feel for crepitus, excessive movement (laxity), limited Feel for crepitus, excessive movement (laxity), limited
movement (contracture), painful limitationmovement (contracture), painful limitation– ? Do the motor neurological exam now? Do the motor neurological exam now
• Movements:Movements:– Ankle: dorsiflexion & plantarflexionAnkle: dorsiflexion & plantarflexion– Subtalar joint: inversion & eversionSubtalar joint: inversion & eversion– Forefoot: abduction & adductionForefoot: abduction & adduction– Toes: extension & flexionToes: extension & flexion
Foot & Ankle – Move (Motor)Foot & Ankle – Move (Motor)
MovementMovement Muscle(s)Muscle(s) InnervationInnervation
Ankle DFAnkle DF Tib AntTib Ant Deep PeronealDeep Peroneal
Ankle PFAnkle PF GastrocnemiusGastrocnemius TibialTibial
InversionInversion Tib Post mainlyTib Post mainly TibialTibial
EversionEversion Peroneus longus & Peroneus longus & brevisbrevis
Superficial Superficial PeronealPeroneal
Foot & Ankle – Special TestsFoot & Ankle – Special Tests
• Tendons:Tendons:– Achilles Tendon: Thompson testAchilles Tendon: Thompson test– Posterior Tibial Tendon: Heel raise testPosterior Tibial Tendon: Heel raise test
• Instability:Instability:– Anterior drawer testAnterior drawer test– Inversion stress testInversion stress test– Peroneal tendon instability testPeroneal tendon instability test
• Morton’s test: Mulder’s clickMorton’s test: Mulder’s click
Neurological ExaminationNeurological Examination
• If suspecting peripheral pathology, test If suspecting peripheral pathology, test motor & sensory for all peripheral nervesmotor & sensory for all peripheral nerves
• If suspecting spine pathology:If suspecting spine pathology:– Dermatome sensation, myotome power Dermatome sensation, myotome power
testing & deep tendon reflexestesting & deep tendon reflexes
Peripheral Nerves of Lower ExtremitiesPeripheral Nerves of Lower Extremities
NerveNerve MotorMotor SensorySensory
FemoralFemoral Knee ExtensionKnee Extension Saphenous nSaphenous n
ObturatorObturator Hip AdductionHip Adduction Medial aspect of thighMedial aspect of thigh
LFCNLFCN -- Lateral aspect of thighLateral aspect of thigh
SciaticSciatic Knee FlexionKnee Flexion According to branchesAccording to branches
TibialTibial Ankle PFAnkle PF Plantar aspect of footPlantar aspect of foot
Deep Deep peronealperoneal Ankle DFAnkle DF
1st web space 1st web space
dorsum of footdorsum of foot
Superficial Superficial peronealperoneal Foot EversionFoot Eversion
Dorsum of foot Dorsum of foot
except 1except 1stst web space web space
SuralSural -- Lateral border of footLateral border of foot
SaphenousSaphenous -- Medial border of footMedial border of foot
Dermatomes & MyotomesDermatomes & Myotomes
RootRoot SensorySensory MotorMotor ReflexesReflexes
L1L1 Inguinal ligamentInguinal ligament IliopsoasIliopsoas
L2L2 Anteromedial thighAnteromedial thigh IliopsoasIliopsoas
L3L3 Medial to patellaMedial to patella QuadsQuads
L4L4 Medial lower legMedial lower leg Tib AntTib Ant PatellarPatellar
L5L5 Anterolateral leg, dorsum footAnterolateral leg, dorsum foot EHLEHL
S1S1 Posterolateral heelPosterolateral heel GastrocGastroc AchillesAchilles
S2S2 Posterior thighPosterior thigh RectalRectal
S3-5S3-5 PerianalPerianal RectalRectal
Vascular ExaminationVascular Examination
• Inspection: Inspection: – PallorPallor– Hair distributionHair distribution
• Palpation:Palpation:– Feel pulses: dorsalis pedis, posterior tibial, popliteal, femoralFeel pulses: dorsalis pedis, posterior tibial, popliteal, femoral– TemperatureTemperature– Capillary refillCapillary refill– SensationSensation
• Special Tests:Special Tests:– Compartments checkCompartments check– Ankle-Brachial IndexAnkle-Brachial Index