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The Lower Extremity Exam for the Family Practitioner

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The Lower Extremity Exam for the Family Practitioner Melinda A. Scott, D.O. THE LOWER EXTREMITY Orthopedic Associates of EXAM FOR THE FAMILY Dayton Board Certified in Primary Care PRACTITIONER Sports Medicine GOALS Identify landmarks necessary for exam of the lower extremity Review techniques for a quick but thorough exam Be familiar with normal findings and range of motion Review some special maneuvers and abnormal findings Review common diagnoses PRE-TEST QUESTIONS 20% 20% 20% 20% 20% If a patient has hip arthritis, where will he or she typically complain of pain? A. Buttock B. Low back C. Lateral hip D. Groin E. Posterior thigh 10 A. B. C. D. E. Countdown PRE-TEST QUESTIONS A positive straight leg raise test indicates 20% 20% 20% 20% 20% that the patient’s hip pain is from a A. Radicular/sciatic etiology B. Hip joint pathology C. Bursitis D. Tight Hamstrings E. Weak hip flexors 10 Countdown A. B. C. D. E. PRE-TEST QUESTIONS A positive McMurray’s tests is indicative of 20% 20% 20% 20% 20% a possible A. ACL tear B. MCL tear C. Patellar dislocation D. Joint effusion E. Meniscus tear 10 Countdown A. B. C. D. E. PRE-TEST QUESTIONS Anterior drawer test on the knee is performed with the knee in 20% 20% 20% 20% 20% A. 30 degrees flexion B. 90 degrees flexion C. Full extension D. 45 degrees flexion E. 130 degrees flexion 10 Countdown A. B. C. D. E. PRE-TEST QUESTIONS A positive squeeze test during an ankle 20% 20% 20% 20% 20% exam is indicative of A. Syndesmotic injury B. Anterior talofibular ligament strain C. Deep vein thrombosis D. Compartment syndrome E. Deltoid ligament injury 10 A. B. C. D. E. Countdown HIP EXAM Overview . Can be very complex area to exam . Long list of differential diagnoses to consider . Careful history narrows down the list considerably . Cannot examine the hip without examining the back . Physical exam is KEY HIP ANATOMY Bony Landmarks . ASIS . Sartorius . Greater trochanter . ITB . Gluteus medius . Pubic symphysis . Adductors . AIIS . Rectus femoris . Iliac crest . Abdominal oblique . Ischial tuberosity . Hamstrings . PSIS MUSCULATURE OF THE HIP HIP RANGE OF MOTION Flexion . 90 degrees with knee in extension . 120 degrees with knee in flexion Extension . 15 degrees Abduction . 45 degrees Adduction . 30 degrees Internal rotation . 40 degrees (with knee flexed) External rotation . 45 degrees (with knee flexed) HIP STRENGTH TESTING Hip flexors . Rectus femoris . Iliopsoas . Weakness with hip joint pathology (OA) . Test with hip flexed and knee extended HIP STRENGTH TESTING Hip extensors . Hamstrings . Weakness with isolated hamstring injury or radicular etiology HIP STRENGTH TESTING External rotators . Gluteus medius . Trendelenburg test . Have patient stand on affected leg. Unsupported hip will descend causing affected to hip to thrust outward . Weakness of gluteus medius HIP STRENGTH TESTING Adductors . Gracilis . Adductor longus . Weakness with isolated muscle strain HIP SPECIAL MANEUVERS Trendelenburg Straight leg raise (back) . With patient supine, flex the hip with the knee in full extension through 30-80 degrees . Positive test . Indicates radicular pain HIP DIFFERENTIAL DIAGNOSES Greater trochanteric bursitis . Pinpoint pain over the greater trochanter . Tight ITB . Sometimes pops or snaps as ITB crosses trochanter HIP DIFFERENTIAL DIAGNOSES Muscle strain/tendonitis . Hip flexor tendonitis . Hamstring/groin strain . Have pain over affected tendons . Weakness/pain with strength testing HIP DIFFERENTIAL DIAGNOSES Radicular pain . Radiating pain following a radicular pattern . Usually starts in posterior hip or low back . Hip motion does not typically reproduce pain . Positive SLR (in severe cases) . Cannot find position of comfort (severe cases) HIP DIFFERENTIAL DIAGNOSES Hip joint pathology . OSTEOARTHRITIS . Labral tears . AVN . Reproduced with internal/external rotation of the hip . Groin pain is hallmark for hip joint pain . Radiates to anterior/medial thigh, knee KNEE EXAM Overview . Rely a lot on palpation and observation of alignment/gait . Careful history . Lots of special maneuvers to help aid in diagnosis KNEE ANATOMY Bony landmarks . Femoral condyles . Fibular head . Patella . Tibial tuberosity . Tibial plateau KNEE ANATOMY Soft Tissue landmarks . MCL . LCL . Popliteal fossa . Patellar tendon . Medial/Lateral Joint line . Quad tendon . Bursa (prepatellar and pes anserine) . ITB INSPECTION AND PALPATION OF THE KNEE Deformity . Genu Varus . “Bow legged” . Medial compartment arthritis . Genu Valgus . “Knock- kneed” . Lateral compartment arthritis INSPECTION AND PALPATION OF THE KNEE Swelling . Effusion, soft tissue swelling or bursitis? . Prepatellar bursitis – fluid is extraarticular . Effusion is intraarticular INSPECTION AND PALPATION OF THE KNEE Crepitus . Peripatellar Popliteal fossa . Baker’s cyst KNEE RANGE OF MOTION Knee is a hinged joint Flexion-extension are primary movements Normal Flexion 0 to 130 degrees Normal Extension 0 to -15 degrees KNEE STRENGTH TESTING Quad . VMO weakness . Single leg squat . Straight leg raise (for integrity of patellar retinaculum) Hamstring KNEE SPECIAL MANEUVERS McMurray’s test . Patient supine or seated . One hand holding the foot, other hand across the joint . Rotate the leg externally, apply valgus stress and then slowly extend the knee . Pain or palpable click over medial joint line indicates medial meniscus tear . Repeat with leg internally rotated and with varus stress for lateral joint line KNEE SPECIAL MANEUVERS McMurray’s test KNEE SPECIAL MANEUVERS Patella testing . Patellar grind . Patient supine with leg relaxed . Push the patella distally into the patella groove and have patient tighten quad . Pain indicates patellofemoral pain . Patellar tracking . Single leg squat . Knee goes into valgus indicates VMO weakness KNEE INSTABILITY TESTS Anterior Drawer . Tests for laxity of the ACL . Performed with the patient supine . Knee flexed to 90 degrees, feet flat on table . Cup your hands around the joint with thumbs over medial and lateral joint line . Attempt to translate the tibia forward . Positive if tibia translates forward . Compare to other side KNEE INSTABILITY TESTS Lachman’s test - tests for laxity of the ACL . Generally accepted as a more sensitive test compared to Anterior drawer . Patient supine and knee in 20-30 degrees flexion . Stabilize thigh with one hand and try to translate tibia forward with other hand . Positive test if tibia translates forward . Compare to other side KNEE INSTABILITY TESTS Medial and lateral instability . Varus and valgus stress . Hold leg with one hand and apply varus or valgus stress to the knee . If the joint gaps, positive test for collateral ligament damage KNEE DIFFERENTIAL DIAGNOSIS Patellofemoral pain . Anterior/peripatellar pain, sitting to standing painful, stairs Ligamentous injury . Injury related typically . Chronic ACL tears common in older adult Meniscus tear . Joint line pain, mechanical symptoms Osteoarthritis . Joint line pain, stiffness Tendonitis . Patellar, quad and hamstring Bursitis . Prepatellar, pes anserine FOOT AND ANKLE Overall . Complex area . Common area to injury . Fractures common FOOT AND ANKLE ANATOMY AND PALPATION Bony landmarks . Medial and lateral malleolus . Distal tibia . Talus . Metatarsals . base of the 5th . Navicular . Toes FOOT AND ANKLE ANATOMY AND PALPATION Palpation/inspection . Soft tissue swelling/ecchymosis/erythema . Joint effusion (tibiotalar) . Ligaments (ATFL, CFL, deltoid) . Tendons (Achilles, posterior tibial, peroneal) . Plantar fascia . Pes planus/cavus deformities FOOT AND ANKLE RANGE OF MOTION Ankle Dorsiflexion /Plantarflexion . 20 degrees/45 degrees Foot Inversion/Eversion . 40 degrees/30 degrees Foot fAbduction/adduction . 10 degrees/20 degrees Toe flexion/extension FOOT AND ANKLE STRENGTH TESTING Dorsiflexors . Tibial anterior . Extensor Hallucis Longus . Extensor Digitorum Longus Plantar flexors . Peroneus Longus and Brevis . Gastrocnemius and Soleus . Flexor Hallucis Longus . Flexor Digitorum Longus . Tibialis Posterior FOOT AND ANKLE STRENGTH TESTING Everters of the Foot . Peroneus Longus and Brevis Inverters of the foot . Tibialis Anterior and Posterior FOOT AND ANKLE SPECIAL MANEUVERS Drawer test – tests for instability of the ankle . Stabilize tibia with one hand and cup the calcaneus with the other hand . With foot slightly plantarflexed, slide the foot toward you . Positive test if talus translates anteriorly . Indicates tear of ATFL FOOT AND ANKLE SPECIAL MANEUVERS Squeeze test . Tests for disruption of the syndesmosis of the ankle . Compress/squeeze the proximal calf with one or two hands . Positive if causes pain at the distal syndesmosis . Causes widening of the syndesmosis distally . Indicates syndesmotic injury (anterior tibiofibular ligament) FOOT AND ANKLE SPECIAL MANEUVERS Thompson Test . Tests for rupture of the Achilles tendon . Place patient prone with foot and ankle off the edge of the table . Gently squeeze the calf which should cause the foot to plantarflex . Positive if foot does not plantarflex FOOT AND ANKLE DIFFERENTIAL DIAGNOSIS Medial/lateral ankle sprains . Lateral most common ligament injury . High ankle sprains have sprain of syndesmosis Achilles tendinosis/rupture . Rupture requires urgent orthopedic referral FOOT AND ANKLE DIFFERENTIAL DIAGNOSIS Plantar fasciitis . Pain over plantar surface of calcaneus . Pes planus deformity typically Tendonitis (peroneal, posterior tibial) FOOT AND ANKLE DIFFERENTIAL DIAGNOSIS Fractures . Base of the 5th metatarsal (Jones fracture) . Distal fibula . Stress fractures
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