Physical ExaminationPhysical Examination of ofthe the Lower ExtremityLower Extremity

Dr Ülkü AkarırmakDr Ülkü Akarırmak

ObjectivesObjectives

Principles of Physical ExaminationPrinciples of Physical Examination

• HipHip

• KneeKnee

• Foot & AnkleFoot & Ankle

DiagnosisDiagnosis

• Clinical EvaluationClinical Evaluation

- History- History

- - Physical ExaminationPhysical Examination

• Laboratory EvaluationLaboratory Evaluation

- Biochemistry- Biochemistry

- Imaging (x-ray, CT, MR, US)- Imaging (x-ray, CT, MR, US)

- Electrophysiology (EMG)- Electrophysiology (EMG)

- Others: DXA - Others: DXA

Principles of MSPrinciples of MSKK Exam Exam

• Two sidesTwo sides: right and left: right and left

• Two jointsTwo joints: above and below: above and below

• Two surfacesTwo surfaces: front and back: front and back

General Examination: PostureGeneral Examination: Posture

• ..

Frolich, Human Anatomy, Lower LImb

Posterior PelvisPosterior Pelvis Surface Anatomy Surface Anatomy • Iliac crestIliac crest• Gluteus maximus Gluteus maximus • Gluteal foldsGluteal folds

Anterior LegAnterior Leg Surface Surface Anatomy Anatomy

PatellaPatellaCondyles of femurCondyles of femur

Femoral TriangleFemoral Triangle–Sartorius (lateral)Sartorius (lateral)–Adductor longus (medial)Adductor longus (medial)–Inguinal ligament (suInguinal ligament (sup)p)–Femoral aFemoral arteryrtery + v + vein+ein+ lymph nodeslymph nodes

Frolich, Human Anatomy, Lower LImb

Posterior LegPosterior Leg Surface Anatomy Surface Anatomy

• Popliteal fossaPopliteal fossa

BoundariesBoundariesBiceps femoris Biceps femoris (Semitendinosis (Semitendinosis semimembranosissemimembranosis Gastrocnemius heads Gastrocnemius heads

• Calcaneal (Achilles) Calcaneal (Achilles) tendontendon

pg 793

ExamExaminationinationof the of the Lower Extremity JointLower Extremity Jointss

1. Inspection 1. Inspection

GaitGait – Posture – Posture

2. Palpation2. Palpation

3. ROM3. ROM

4. 4. Special TestsSpecial Tests

5. 5. NeuroNeurologic + Vlogic + Vascular ascular ExaminationExamination

GaitGait

• Antalgic gaitAntalgic gait: P: Painful, short stance phaseainful, short stance phase• Trendelenburg gait: Trendelenburg gait: WWeak abductorseak abductors• Waddling gait: Waddling gait: BBilateral weak abductorsilateral weak abductors• Steppage gait: Steppage gait: FFoot dropoot drop• Toe-walkingToe-walking: I: In-toeing n-toeing / / out-toeingout-toeing• Others: Others: AAtaxic, scissoring, etc.taxic, scissoring, etc.

Hip Hip Exam Exam – – InspectionInspection

• InspectionInspection

– Leg length discrepancyLeg length discrepancy– DeformityDeformity & Asymmetry & Asymmetry – Muscle Muscle wastingwasting (atrophy) (atrophy)– SwellingSwelling– Skin changes (erythema) Skin changes (erythema) etc.etc.

HipHip Exam Exam – – PalpationPalpation

• PrinciplesPrinciples– Reference points - Reference points - painful areapainful areass– Increased temperatureIncreased temperature, swelling, tenderness, swelling, tenderness

• SitesSites– FFront: SIront: SIAAS, pubic tubercS, pubic tubercuulele– SSide: Gide: Great trochanterreat trochanter, iliotibial band, iliotibial band– BBack: SI joint, SIack: SI joint, SIPPSS

Sacroiliac joint palpation

HipHip Exam Exam – – ROMROM

• PrinciplesPrinciples– Active Active / / passivepassive ROM ROM– Feel for crepitus, excessive movement Feel for crepitus, excessive movement

(laxity), limited movement (contracture), (laxity), limited movement (contracture), painful limitationpainful limitation

• MovementsMovements– Flexion & ExtensionFlexion & Extension– Abduction & AdductionAbduction & Adduction– IR & ER IR & ER ((in flexion & extensionin flexion & extension))

Hip Joint - ROMHip Joint - ROM•

Flexion 120-135 degrees

Hip Joint - ROMHip Joint - ROM

Extension 30 degrees

Hip ROMHip ROM

Internal rotation 35 External rotation 45

Hip ROM – sitting positionHip ROM – sitting position

External Rotation Internal Rotation

Hip ROMHip ROM

Abduction 45 Adduction 20-30

Hip – MotorHip – Motor Function Function

MovementMovement Muscle(s)Muscle(s) InnervationInnervation

FlexionFlexion IliopsoasIliopsoas Lumbar plexus & Lumbar plexus & femoral nervefemoral nerve

ExtensionExtension Gluteus maxGluteus max Inferior glutealInferior gluteal

AbductionAbduction Gluteus med & minGluteus med & min SupSupeerior glutealrior gluteal

AdductionAdduction Adductor magnus, Adductor magnus, longus longus && brevis brevis OObturatorbturator

HipHip Joint Joint – – Special TestsSpecial Tests

• Trendelenburg testTrendelenburg test:: AAbductor strengthbductor strength

• Thomas testThomas test: : HHip flexion contractureip flexion contracture

• Ober’s testOber’s test: : IIliotibial band tightnessliotibial band tightness

• Patrick’s (FABERPatrick’s (FABEREE) test) test: : SI jointSI joint and and coxofemoral jointcoxofemoral joint

Thomas test (-) Thomas test (+)

Ober’s TestOber’s Test

Patrick’s (FABERE) test

KneeKnee Exam Exam - - InspectionInspection - Gait- Gait

- - Leg length discrepancyLeg length discrepancy-DeformityDeformity

varus, valgusvarus, valgus, recurvatum, recurvatum

- - AAtrophytrophy

- - SwellingSwelling

- - Skin changesSkin changes erythema, erythema, s scarscars etc. etc.

Popliteal (Baker’s)Cyst / Popliteal (Baker’s)Cyst / Rupture in RARupture in RA

Leg Length Discrepancy Leg Length Discrepancy

Biomechanical EvaluationBiomechanical Evaluation

Knee – Knee – PalpationPalpation• PrinciplesPrinciples

– Reference points / Reference points / painful areapainful areass– WWarmth, swelling, effusion, tendernessarmth, swelling, effusion, tenderness– Popliteal areaPopliteal area

• SitesSites– Patella: Patella: MMargins and surfaces, argins and surfaces, – QQuadriceps&patellar tendon&insertionuadriceps&patellar tendon&insertion– BBursaeursae– Ligaments, tendons, & ITB attachmentLigaments, tendons, & ITB attachment– Joint linJoint line - e - medial & lateralmedial & lateral– Effusion: Effusion: MMilking test, ballotmentilking test, ballotment

Knee - Knee - ROMROM

• PrinciplesPrinciples– Active Active & & passivepassive ROM ROM– CCrepitus, excessive movement (laxity), limited repitus, excessive movement (laxity), limited

movement (contracture, painful limitationmovement (contracture, painful limitation))

• MovementsMovements– Extension: Extension: QQuadriceps uadriceps (innerv. (innerv. by by ffemoremoral nerve)al nerve)– Flexion: Flexion: HHamstrings amstrings (innerv. (innerv. by sciaticby sciatic nerve) nerve)

Range of MotionRange of Motion

• ExtensionExtension 0°- (-10°)0°- (-10°)

• Flexion Flexion

130°-140°130°-140°

Knee – Knee – Special TestsSpecial Tests

• Patellar Patellar ExamExam– Patellar apprehension testPatellar apprehension test– Patellofemoral grind testPatellofemoral grind test

• Meniscal Meniscal ExamExam– McMurray testMcMurray test– Apley’s testApley’s test

• Ligament testsLigament tests: : ACL, PCL, MCL, LCLACL, PCL, MCL, LCL

Patellofemoral grind test

Patellar apprehension test

Exam of MenisciExam of MenisciMcMurray’s testMcMurray’s test

• • Flex&ext with Flex&ext with varus&valgus and varus&valgus and int&ext rotation int&ext rotation

• • Goal is to get torn piece toGoal is to get torn piece to pop in and out of placepop in and out of place

• • (+) if pop or reproduction of (+) if pop or reproduction of painpain

Apley’s compression testApley’s compression test

• • Prone with knee flexed, Prone with knee flexed, axial load and rotationaxial load and rotation

• McMurray testMcMurray test

McMurray test Apley’s test

Knee – Ligaments Knee – Ligaments Special TestsSpecial Tests

• ACLACL:: Anterior drawer, Anterior drawer, LachmanLachman,, Pivot shift Pivot shift

• PCLPCL: Posterior drawer: Posterior drawer

• MCLMCL: : VValgus stress in neutral & 30 flexionalgus stress in neutral & 30 flexion

• LCLLCL: : VVarus stress in neutral & 30 flexionarus stress in neutral & 30 flexion

Valgus stress test Varus stress test

Foot & Ankle Foot & Ankle Exam Exam – – InspectionInspection

•HHindfoot, midfoot & forefootindfoot, midfoot & forefoot areas areas- Gait analysis- Gait analysis- - AlignmentAlignment

• Ankle: Ankle: VValgus or varus algus or varus • Foot: Foot: PPes planus or cavus es planus or cavus • Big toe: Big toe: HHallux valgus allux valgus • Toes: Toes: CClaw, hammer, malletlaw, hammer, mallet

- - Asymmetry Asymmetry - - Swelling, Swelling, sskin changes kin changes (erythema(erythema or or sscarscars))

Foot DeformitiesFoot Deformities

ToeToe Deformities Deformities

Foot & Ankle – Foot & Ankle – PalpationPalpation

• PrinciplesPrinciples

TemperatureTemperature, swelling, , swelling, effusion, effusion, painpain

• SitesSites– Bones: Bones: MMalleolialleoli and and

bones of the hindfoot, midfoot and forefootbones of the hindfoot, midfoot and forefoot– Ankle jointAnkle joint– Tendons: Achilles, posterior tibial, peronealTendons: Achilles, posterior tibial, peroneal– Interdigital neuromaInterdigital neuroma

Foot & Ankle – Foot & Ankle – ROMROM

• PrinciplesPrinciples

- - Active Active & & passivepassive ROM ROM

- C- Crepitus, excessive movement (laxity), repitus, excessive movement (laxity), contracture, painful limitationcontracture, painful limitation

• MovementsMovements

- - Ankle: dorsiflexion & plantarflexionAnkle: dorsiflexion & plantarflexion-Subtalar joint: Subtalar joint: IInversion & eversionnversion & eversion-Forefoot: Forefoot: AAbduction & adductionbduction & adduction-Toes: Toes: EExtension & flexionxtension & flexion

İnversion-Eversion İnversion-Eversion Abduction-Abduction-AdductionAdduction

Ankle & Foot - ROMAnkle & Foot - ROM

Foot & Ankle – Foot & Ankle – MotorMotor ExamExam

MovementMovement Muscle(s)Muscle(s) InnervationInnervation

Ankle DFAnkle DF TibTibialisialis a antnteriorerior Deep Deep pperonealeroneal

Ankle PFAnkle PF GastrocnemiusGastrocnemius TibialTibial

InversionInversion TibTibialis ialis ppostosteriorerior TibialTibial

EversionEversion Peroneus longus & Peroneus longus & brevisbrevis

Superficial Superficial pperonealeroneal

Foot & Ankle – Foot & Ankle – Special TestsSpecial Tests

• TendonsTendons– Achilles Achilles ttendonendon– Posterior Posterior ttibial ibial ttendonendon

• InstabilityInstability– Anterior drawer testAnterior drawer test– Inversion stress testInversion stress test– Peroneal tendon instability testPeroneal tendon instability test

• Morton’s testMorton’s test: Mulder’s click: Mulder’s click

Thompson testThompson test

Anterior drawer test Inversion stress test

Peroneal tendon instability 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 ExaminationNeurological Examination

• PPeripheraleripheral nerves nerves

• SSpinpinal al pathologypathology

- S- Sensationensation

- Muscle strength - Muscle strength testtest

- D- Deep tendon reflexeseep tendon reflexes

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 TibTibialisialis aantnterioerio PatellarPatellar

L5L5 Anterolat leg, dorsum footAnterolat leg, dorsum foot EHLEHL

S1S1 Posterolateral heelPosterolateral heel GastrocGastrocnemiusnemius AchillesAchilles

S2S2 Posterior thighPosterior thigh RectalRectal

S3-5S3-5 PerianalPerianal RectalRectal

Manual Muscle TestManual Muscle TestScale 5/5 - 0Scale 5/5 - 0

Vascular ExaminationVascular Examination• Inspection Inspection

– Colour - Colour - PallorPallor– Hair Hair

• PalpationPalpation– Feel pulsesFeel pulses: :

dorsalis pedisdorsalis pedis posterior tibial posterior tibialisis poplitealpopliteal femoral femoral

– TemperatureTemperature– Capillary refillCapillary refill

• Special TestsSpecial Tests– Compartments checkCompartments check– Ankle-Brachial IndexAnkle-Brachial Index

InspectionInspection

Q&AQ&A

Compartment Muscles Neurovascular structures

Anterior compartment of leg

Tibialis anterior, Extensor hallucis longus, Extensor digitorum longus, Peroneus tertius

Deep peroneal nerve, Anterior tibial vessels

Lateral compartment of leg

Fibularis/peroneus longus, Fibularis/peroneus brevis

Superficial peroneal nerve

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

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

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 DoneThis test is done to screen for PADResultsThe ABI result can help diagnose PAD NormalA 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 flowAbnormal: ABI is 0.9 or lower

Blood Blood SSupplyupply of Lower Extremity of Lower Extremity