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 . Toes
POST-TEST QUESTIONS
If a patient has hip arthritis, where will he 20% 20% 20% 20% 20% 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 If a patient has hip arthritis, where will he or she typically complain of pain?
20% Buttock 20%
20% Low back 20%
20% Lateral hip 20%
20% Groin 20%
20% Posterior thigh 20%
First Slide Second Slide POST-TEST QUESTIONS
A positive straight leg raise test indicates that the patient’s hip pain is from a 20% 20% 20% 20% 20%
A. Radicular/sciatic etiology B. Hip joint pathology C. Bursitis D. Tight Hamstrings E. Weak hip flexors
10
Countdown A. B. C. D. E. A positive straight leg raise test indicates that the patient’s hip pain is from a
20% Radicular/sciatic etiology 20%
20% Hip joint pathology 20%
20% Bursitis 20%
20% Tight Hamstrings 20%
20% Weak hip flexors 20%
First Slide Second Slide POST-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 A. B. C. D. E. Countdown A positive McMurray’s tests is indicative of a possible
20% ACL tear 20%
20% MCL tear 20%
20% Patellar dislocation 20%
20% Joint effusion 20%
20% Meniscus tear 20%
First Slide Second Slide POST-TEST QUESTIONS
Anterior drawer test on the knee is 20% 20% 20% 20% 20% performed with the knee in
A. 30 degrees flexion B. 90 degrees flexion C. Full extension D. 45 degrees flexion E. 130 degrees flexion
10 A. B. C. D. E.
Countdown Anterior drawer test on the knee is performed with the knee in
20% 30 degrees flexion 20%
20% 90 degrees flexion 20%
20% Full extension 20%
20% 45 degrees flexion 20%
20% 130 degrees flexion 20%
First Slide Second Slide POST-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
Countdown A. B. C. D. E. A positive squeeze test during an ankle exam is indicative of
20% Syndesmotic injury 20%
Anterior talofibular 20% ligament strain 20%
20% Deep vein thrombosis 20%
20% Compartment syndrome 20%
20% Deltoid ligament injury 20%
First Slide Second Slide THANK YOU!