Physical ExaminationPhysical ExaminationLower ExtremityLower Extremity

Sohail Bajammal, MBChB, MSc, FRCS(C)Sohail Bajammal, MBChB, MSc, FRCS(C)

November 4, 2008November 4, 2008

ObjectivesObjectives

• Fundamentals of DiagnosisFundamentals of Diagnosis

• Principles of Physical ExaminationPrinciples of Physical Examination

• Principles of MSK Physical ExaminationPrinciples of MSK Physical Examination

• MSK Physical Examination Approach:MSK Physical Examination Approach:– HipHip– KneeKnee– Foot & AnkleFoot & Ankle

Fundamentals of DiagnosisFundamentals of Diagnosis

• Have a list of D/D as you read the CCHave a list of D/D as you read the CC– VITAMIN C&DVITAMIN C&D

• Re-visit your D/DRe-visit your D/D

• Narrow your list by the end of HistoryNarrow your list by the end of History

• Further narrow by the end of PhysicalFurther narrow by the end of Physical

• Confirm by further investigationsConfirm by further investigations

PPrinciples of Physical Examrinciples of Physical Exam

• PermissionPermission

• Pre-amblePre-amble

• PrivacyPrivacy

• PolitenessPoliteness

• PassionatePassionate

• PacingPacing

Principles of MSK ExamPrinciples of MSK Exam

• Do not forget the patient Do not forget the patient – General exam, Vital signsGeneral exam, Vital signs

• Two sides: right and leftTwo sides: right and left

• Two joints: above and belowTwo joints: above and below

• Two surfaces: front and backTwo surfaces: front and back

Approach to MSK ExamApproach to MSK ExamAny Lower Extremity JointAny Lower Extremity Joint

• General & GaitGeneral & Gait

• Look, Feel & MoveLook, Feel & Move

• Special TestsSpecial Tests

• Neurovascular ExaminationNeurovascular Examination

GeneralGeneral

• Well or ill-lookingWell or ill-looking

• CachecticCachectic

• Vital signs: febrile, hemodynamic Vital signs: febrile, hemodynamic stabilitystability

GaitGait

• Antalgic gait: painful, short stance phaseAntalgic gait: painful, short stance phase• Trendelenburg (abductor lurch) gait: weak Trendelenburg (abductor lurch) gait: weak

abductorsabductors• Waddling gait: bilateral weak abductors, Waddling gait: bilateral weak abductors,

bilateral DDHbilateral DDH• Steppage gait: foot dropSteppage gait: foot drop• Toe-walkingToe-walking• In-toeing vs out-toeingIn-toeing vs out-toeing• Others: ataxic, scissoring, etc.Others: ataxic, scissoring, etc.

HipHip

Hip - LookHip - Look• Principles:Principles:

– Enough exposureEnough exposure– Compare both sidesCompare both sides– Examine joint above (Examine joint above (backback) and joint below) and joint below

• Look for:Look for:– Leg length discrepancy: blocks vs. tapeLeg length discrepancy: blocks vs. tape– Alignment & Asymmetry (wasting)Alignment & Asymmetry (wasting)– Swelling, Skin changes (erythema), ScarsSwelling, Skin changes (erythema), Scars

Hip - FeelHip - Feel• Principles:Principles:

– Start from non-painful areaStart from non-painful area– Feel for warmth, swelling, tendernessFeel for warmth, swelling, tenderness

• Sites:Sites:– From the front: ASIS, pubic tubercleFrom the front: ASIS, pubic tubercle– From the side: GT, iliotibial bandFrom the side: GT, iliotibial band– From the back: SI joint, PSISFrom the back: SI joint, PSIS

Examination of a MassExamination of a Mass “ “6 6 SStudents and 3 tudents and 3 TTeachers go for eachers go for CAMPFIRE”CAMPFIRE”

• SSite, ite, SSize, ize, SShape, hape, SSurface, urface, SSkin, kin, SScarcar• TTenderness, enderness, TTemperature, emperature, TTransilluminationransillumination• CConsistencyonsistency• AAttachmentttachment• MMobilityobility• PPulsationulsation• FFluctuationluctuation• IIrreducibilityrreducibility• RRegional lymph nodesegional lymph nodes• EEdgedge

Hip - MoveHip - Move• Principles:Principles:

– Active then passiveActive then passive– Feel for crepitus, excessive movement Feel for crepitus, excessive movement

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

– ? Do the motor neurological exam now? Do the motor neurological exam now

• Movements:Movements:– Flexion & ExtensionFlexion & Extension– Abduction & AdductionAbduction & Adduction– IR & ER in flexion & extensionIR & ER in flexion & extension

Hip – Move (Motor)Hip – Move (Motor)MovementMovement Muscle(s)Muscle(s) InnervationInnervation

FlexionFlexion IliopsoasIliopsoas Lumbar plexus & Lumbar plexus & femoral nervefemoral nerve

ExtensionExtension Gluteus maximusGluteus maximus Inferior glutealInferior gluteal

AbductionAbduction Gluteus medius & Gluteus medius & minimusminimus Superior glutealSuperior gluteal

AdductionAdduction Adductor magnus, Adductor magnus, longus and brevislongus and brevis Mainly obturatorMainly obturator

Hip – Special TestsHip – Special Tests

• Trendelenburg test: for abductor strengthTrendelenburg test: for abductor strength

• Thomas test: for hip flexion contractureThomas test: for hip flexion contracture

• Ober’s test: for iliotibial band tightnessOber’s test: for iliotibial band tightness

• Patrick’s (FABER) test: for SI jointPatrick’s (FABER) test: for SI joint

• Labral tear testLabral tear test

KneeKnee

Knee - LookKnee - Look• Principles:Principles:

– Enough exposureEnough exposure– Compare both sidesCompare both sides– Examine joint above (Examine joint above (hiphip) and joint below) and joint below

• Look for:Look for:– Leg length discrepancyLeg length discrepancy– Alignment (varus, valgus, Q-angle)Alignment (varus, valgus, Q-angle)– Asymmetry (wasting)Asymmetry (wasting)– Swelling, Skin changes (erythema), ScarsSwelling, Skin changes (erythema), Scars

Knee - FeelKnee - Feel• Principles:Principles:

– Start from non-painful areaStart from non-painful area– Feel for warmth, swelling, effusion, tendernessFeel for warmth, swelling, effusion, tenderness– Do not forget the back of the kneeDo not forget the back of the knee

• Sites:Sites:– Patella: margins and surfaces, quadriceps & Patella: margins and surfaces, quadriceps &

patellar tendon & its insertion, bursaepatellar tendon & its insertion, bursae– Ligaments, tendons, & ITB attachmentLigaments, tendons, & ITB attachment– Joint line: medial & lateralJoint line: medial & lateral– Effusion: milking test, balloon test, ballotmentEffusion: milking test, balloon test, ballotment

Knee - MoveKnee - Move• Principles:Principles:

– Active then passiveActive then passive– Feel for crepitus, excessive movement Feel for crepitus, excessive movement

(laxity), limited movement (contracture, locked (laxity), limited movement (contracture, locked knee), painful limitationknee), painful limitation

– ? Do the motor neurological exam now? Do the motor neurological exam now

• Movements:Movements:– Extension: quadriceps by femoral nerveExtension: quadriceps by femoral nerve– Flexion: hamstrings by sciatic nerveFlexion: hamstrings by sciatic nerve

Knee – Special TestsKnee – Special Tests• Patellar tests:Patellar tests:

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

• Meniscal tests:Meniscal tests:– McMurray testMcMurray test– Apley’s testApley’s test

• Ligaments tests: ACL, PCL, MCL, LCL, Ligaments tests: ACL, PCL, MCL, LCL, PLCPLC

Knee – Ligaments Special TestsKnee – Ligaments Special Tests

• ACL: Lachman’s, Anterior drawer, Pivot ACL: Lachman’s, Anterior drawer, Pivot shiftshift

• PCL: posterior sag sign, Posterior drawerPCL: posterior sag sign, Posterior drawer

• MCL: valgus stress in neutral & 30 flexionMCL: valgus stress in neutral & 30 flexion

• LCL: varus stress in neutral & 30 flexionLCL: varus stress in neutral & 30 flexion

• PLC: dial testPLC: dial test

Foot & AnkleFoot & Ankle

Foot & Ankle - LookFoot & Ankle - Look• Principles:Principles:

– Enough exposure, Compare both sidesEnough exposure, Compare both sides– Examine joint above & belowExamine joint above & below

• In hindfoot, midfoot & forefoot, look for:In hindfoot, midfoot & forefoot, look for:– Leg length discrepancyLeg length discrepancy– Alignment:Alignment:

• Ankle: valgus or varus, Ankle: valgus or varus, • Foot: pes planus or cavus, Foot: pes planus or cavus, • Big toe: hallux valgus or varus Big toe: hallux valgus or varus • Toes: claw, hammer, malletToes: claw, hammer, mallet

– Asymmetry (wasting)Asymmetry (wasting)– Swelling, Skin changes (erythema), ScarsSwelling, Skin changes (erythema), Scars

ToesToes Claw Toes

Hammer Toe

Mallet Toe

Foot & Ankle - FeelFoot & Ankle - Feel• Principles:Principles:

– Start from non-painful areaStart from non-painful area– Feel for warmth, swelling, effusion, tendernessFeel for warmth, swelling, effusion, tenderness

• Sites:Sites:– Bones: malleoli, bones of the hindfoot, midfoot Bones: malleoli, bones of the hindfoot, midfoot

and forefootand forefoot– Ankle jointAnkle joint– Tendons: Achilles, posterior tibial, peronealTendons: Achilles, posterior tibial, peroneal– Interdigital neuromaInterdigital neuroma

Foot & Ankle - MoveFoot & Ankle - Move• Principles:Principles:

– Active then passiveActive then passive– Feel for crepitus, excessive movement (laxity), limited Feel for crepitus, excessive movement (laxity), limited

movement (contracture), painful limitationmovement (contracture), painful limitation– ? Do the motor neurological exam now? Do the motor neurological exam now

• Movements:Movements:– Ankle: dorsiflexion & plantarflexionAnkle: dorsiflexion & plantarflexion– Subtalar joint: inversion & eversionSubtalar joint: inversion & eversion– Forefoot: abduction & adductionForefoot: abduction & adduction– Toes: extension & flexionToes: extension & flexion

Foot & Ankle – Move (Motor)Foot & Ankle – Move (Motor)

MovementMovement Muscle(s)Muscle(s) InnervationInnervation

Ankle DFAnkle DF Tib AntTib Ant Deep PeronealDeep Peroneal

Ankle PFAnkle PF GastrocnemiusGastrocnemius TibialTibial

InversionInversion Tib Post mainlyTib Post mainly TibialTibial

EversionEversion Peroneus longus & Peroneus longus & brevisbrevis

Superficial Superficial PeronealPeroneal

Foot & Ankle – Special TestsFoot & Ankle – Special Tests

• Tendons:Tendons:– Achilles Tendon: Thompson testAchilles Tendon: Thompson test– Posterior Tibial Tendon: Heel raise testPosterior Tibial Tendon: Heel raise test

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

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

Neurovascular Neurovascular ExaminationExamination

Neurological ExaminationNeurological Examination

• If suspecting peripheral pathology, test If suspecting peripheral pathology, test motor & sensory for all peripheral nervesmotor & sensory for all peripheral nerves

• If suspecting spine pathology:If suspecting spine pathology:– Dermatome sensation, myotome power Dermatome sensation, myotome power

testing & deep tendon reflexestesting & deep tendon reflexes

Peripheral Nerves of Lower ExtremitiesPeripheral Nerves of Lower Extremities

NerveNerve MotorMotor SensorySensory

FemoralFemoral Knee ExtensionKnee Extension Saphenous nSaphenous n

ObturatorObturator Hip AdductionHip Adduction Medial aspect of thighMedial aspect of thigh

LFCNLFCN -- Lateral aspect of thighLateral aspect of thigh

SciaticSciatic Knee FlexionKnee Flexion According to branchesAccording to branches

TibialTibial Ankle PFAnkle PF Plantar aspect of footPlantar aspect of foot

Deep Deep peronealperoneal Ankle DFAnkle DF

1st web space 1st web space

dorsum of footdorsum of foot

Superficial Superficial peronealperoneal Foot EversionFoot Eversion

Dorsum of foot Dorsum of foot

except 1except 1stst web space web space

SuralSural -- Lateral border of footLateral border of foot

SaphenousSaphenous -- Medial border of footMedial border of foot

SensationSensation

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 Tib AntTib Ant PatellarPatellar

L5L5 Anterolateral leg, dorsum footAnterolateral leg, dorsum foot EHLEHL

S1S1 Posterolateral heelPosterolateral heel GastrocGastroc AchillesAchilles

S2S2 Posterior thighPosterior thigh RectalRectal

S3-5S3-5 PerianalPerianal RectalRectal

Vascular ExaminationVascular Examination

• Inspection: Inspection: – PallorPallor– Hair distributionHair distribution

• Palpation:Palpation:– Feel pulses: dorsalis pedis, posterior tibial, popliteal, femoralFeel pulses: dorsalis pedis, posterior tibial, popliteal, femoral– TemperatureTemperature– Capillary refillCapillary refill– SensationSensation

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

ReferencesReferences

US$ 65US$ 65 US$ 47US$ 47

QuestionsQuestions