Physical Examination of Lower Extremity

Objective 1. Principles of Physical Examination 2. Physical Examination Approach: - Hip & Thigh - Knee - Foot & Ankle

Principles of Physical Examination 1. Do not forget the patient - General examination, Vital signs 2. Two sides: right and left 3. Two joints: above and below 4. Two surfaces: front and back

Approach to Examination (Any Lower Extremity Joint) 1. General & Gait - General: Well or ill-looking - Vital signs: febrile, hemodynamic stability - Gait cycle - Abnormal gait: antalgic gait, Trendelenburg gait, steppage (foot drop) gait 2. Look (Inspection), Feel (Palpation) & Move (Motion) 3. Special Tests 4. Neurovascular Examination

Hip & Thigh 1. Inspection for: - Leg length discrepancy - Alignment & Asymmetry (wasting) - Swelling, Skin changes (erythema), Scars

2. Palpation sites: - From the front: ASIS, pubic tubercle - From the side: greater trochanter - From the back: SI joint, PSIS

3. Motion: Hip Flexion: - Preferred Position: Supine with hips and knees in neutral rotation - Stabilization: Pelvis is stabilized by manual fixation - Goniometer Axis: Femoral Greater Trochanter - Reference (Stationary) Arm: Parallel to midaxillary line of the trunk - Movement (Movable) Arm: Parallel to longitudinal axis of the femur in line with lateral femoral condyle

Hip Extension: - Preferred Position: Prone with hips & knees in neutral and feet extending off end of the table - Stabilization: Pelvis is stabilized by manual fixation - Goniometer Axis: Femoral Greater Trochanter - Reference (Stationary) Arm: Parallel to midaxillary line of the trunk - Movement (Movable) Arm: Parallel to longitudinal axis of femur in line with lateral femoral condyle

Hip Abduction: - Preferred Position: Supine with hips and knees in neutral and pelvis level - Stabilization: Pelvis is stabilized by manual fixation - Goniometer Axis: ASIS on measured side - Reference (Stationary) Arm: Along a line between the two anterior superior iliac spines - Movement (Movable) Arm: Parallel to the long axis of the femur

Hip Adduction: - Preferred Position: Supine with the opposite extremity abducted - Stabilization: Pelvis is stabilized by manual fixation - Goniometer Axis ASIS on measured side - Reference (Stationary) Arm: Along a line between the two anterior superior iliac spines - Movement (Movable) Arm: Parallel to the long axis of the femur

Hip Internal and External Rotation: - Preferred Position: Supine or sitting with the hip and knee flexed 90°. Opposite extremity abducted and resting on a foot stool - Stabilization: prevent thigh abduction/adduction - Goniometer Axis: mid-patella - Reference (Stationary) Arm: Perpendicular to the floor

Alternate Test Position for Hip Internal/External Rotation: - Position: prone with knees flexed 90° - Stabilization: manual fixation of pelvis

4. Special tests: - Trendelenburg test: for abductor strength - Thomas test: for hip flexion contracture - Patrick’s (FABER) test: for SI joint - Anvil test & Rolling test: for hip pain

Knee 1. Inspection for: - Leg length discrepancy: true leg length, apparent leg length - Alignment (varus, valgus) - Asymmetry (wasting): thigh circumference 3

- Swelling, Skin changes (erythema), Scars

2. Palpation sites: - Patella: margins and surfaces, quadriceps & patellar tendon & its insertion, bursae - Ligaments: medial & lateral collateral ligaments - Joint line: medial & lateral - Effusion: ballotment

3. Motion: Knee Flexion: - Preferred Position: Supine or reclined with hip and knee in neutral rotation - Stabilization: Trunk and pelvis stabilized by body weight and position - Goniometer Axis: Lateral epicondyle of the femur - Reference (Stationary) Arm: Parallel to the long axis of the femur & pointing at the greater trochanter - Movement (Movable) Arm: Parallel to the long axis of the fibula and pointing at the lateral malleolus Alternate Position: Prone lying with the femur stabilized. Knee flexion motion may be decreased as the rectus femoris is now stretched over two joints. Prevent substitute motion of hip abduction and/or hip flexion.

Knee Extension: - Preferred Position: Supine with hips and knees in neutral rotation; distal leg on bolster - Stabilization: Trunk and pelvis stabilized by body weight and position - Goniometer Axis: Lateral Epicondyle of the femur - Reference (Stationary) Arm: Parallel to the long axis of the femur & pointing at the greater trochanter - Movement (Movable) Arm: Parallel to the long axis of the fibula and pointing at the lateral malleolus Alternate Position: Prone lying heel height technique

4. Special tests: - Ligaments tests: Anterior drawer test, Posterior drawer test, Varus stress test, Valgus stress test - Meniscal tests: McMurray test

Foot & Ankle 1. Inspection for: - Alignment: i. Ankle: valgus or varus, ii. Foot: pes planus or cavus, iii. Big toe: hallux valgus or varus iv. Toes: claw, hammer, mallet - Asymmetry (wasting) - Swelling, Skin changes (erythema), Scars

2. Palpation sites: - Bones: malleoli, bones of the hindfoot, midfoot and forefoot - Ankle joint - Tendons: Achilles, posterior tibial, peroneal - Ligaments: anterior talofibular ligament, calcaneofibular ligament

3. Motion: - Ankle: dorsiflexion & plantarflexion - Subtalar joint: inversion & eversion

4. Special tests: - Achilles Tendon: Thompson test