1 Lower Limb Orthopaedic Examination Workshop Mr Venu Kavarthapu, Mr Patrick Li General Tips Movements: Hip- passive only. Knee-passive and active. Foot and ankle- passive and active. Spine- active only. Always consider examining (screening) the joint above and below as appropriate ______________________________________ Hip Examination (Common pathological conditions: Young adults: Sports injuries, Hip Impingement, Hip Dyspasia. Middle aged: Sports injuries, Hip Impingement, Hip Dyspasia, Osteoarthritis. Older patients: Osteoarthritis.) Pitfalls: Hip pain is generally felt in the groin, trochanter (lateral), anterior thigh, buttock (posterior trochanter) and knee regions. It is important to identify conditions such as Hip Dysplasia and Hip Impingement in young patients before they become severely symptomatic as the treatment is less invasive if identified early. Look for other sources of pain such as lower back, sacro-iliac joint, inguinal hernia etc. Standing Look from front Shoulder level Pelvis level Leg alignment (knee) Leg lengths Look from side Spine alignment Gluteal muscle bulk Attitude of hip and knee joints Look from behind Spine alignment Hindfoot Gait Antalgic gait Trendelenburg’s sign Spine screening Sitting Knee screening Look spine Supine Non-weight bearing alignment of legs Apparent leg length measurement True leg length measurement 2 Tenderness over trochanter, anterior hip region, other tender areas Movements: Thomas’ test (for fixed flexion deformity) Internal rotation and external rotation in hip flexion Internal rotation and external rotation in hip extension (look at knee caps) Abduction Adduction Prone position Hip extension Sacro-iliac joint tenderness Special situations Young Patient: Young patients with hip pain may have Hip Impingement Syndrome. Hip Impingement sign may be the only positive finding. Knee examination (Common pathologies: Young adults: Sports injuries, Chondromalacia Patella. Patello- femoral instability. Middle aged: Sports injuries, Patello-femoral degenerative conditions, Osteoarthitis. Older patients: Osteoarthritis) Standing Look from front Shoulder level Pelvis level Leg alignment (knee) Leg lengths Look from side Spine alignment Gluteal muscle bulk Popliteal fossa Attitude of hip and knee joints Look from behind Spine alignment Hindfoot Gait Antalgic gait Sitting Hip screening Patellar tracking Supine Non-weight bearing alignment of legs Effusion tests: Moderate effusion (obliteration of gutters) - patellar tap test Minimal effusion- swipe test Patello-femoral examination: tenderness, laxity, apprehension, Clark’s test Feel for tenderness: Systematic. Knee in 60-90 degrees Move- active first Special tests Collateral ligaments Cruciates- posterior sag test. Anterior and posterior draw tests. Lachman’s test Menisci- Mc Murray’s test Hip and Ankle examination 3 Foot and Ankle (Common pathologies (numerus). Young adults: Physiological flat foot. Painful flat foot (tarsal coalition), Juvenile hallux valgus. Sports ankle injuries. Sports Achillies tendon pathologies. Middle aged: Painful flat foot (Tibialis posterior tendon deficiency), Hallux valgus. Metatarsalgia (Morton’s neuroma), Sports ankle injuries, Osteoarthitis. Heel pain (Achilles tendonitis, plantar fasceitis). Older patients: Osteoarthritis, Painful flat foot (Tibialis posterior tendon deficiency) Pitfalls: Painful normal looking foot (with no deformities) need to be examined for possible pathologies in addition to early arthritis, such as Forefoot: Morton’s neuroma, tarsal tunnel syndrome, stress fracture. Plantar heel: Plantar fascietis, tarsal tunnel syndrome. Posterior heel: insertional Achillis tendonitis, non-insertional Achillis tendonitis Patients presenting with high arched feet, always examine spine quite often this is associated with neurological conditions Standing Look from front Shoulder level Pelvis level Leg alignment (knee) Leg lengths Forefoot Midfoot Look from side Attitude of hip and knee joints Foot Arches Ankle and foot Look from behind Spine inspection Arms Hindfoot- Normal and Tip toeing Gait Shoes Sitting Callocities Corns Deformities- describe in terms of hindfoot, midfoot and forefoot Feel Tenderness- systematic Degree of passive correction of deformities Active movements Passive movements Power of local muscles Tibialis and peroneals Special tests: Morton’s neuroma (Mulder Click), Tight Gastrocnemius (Silverskoild test) _____________________________________ .