1. Physical Examination Lower Extremity Sohail Bajammal, MBChB, MSc, FRCS(C) November 4, 2008

2. Principles of MSK Exam Do not forget the patientDo not forget the patient –General 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

3. Approach to MSK Exam Any Lower Extremity Joint General & GaitGeneral & Gait Look, Feel & MoveLook, Feel & Move Special TestsSpecial Tests Neurovascular ExaminationNeurovascular Examination

4. General Well or ill-lookingWell or ill-looking CachecticCachectic Vital signs: febrile, hemodynamic stabilityVital signs: febrile, hemodynamic stability

5. Gait Antalgic gait: painful, short stance phaseAntalgic gait: painful, short stance phase Trendelenburg (abductor lurch) gait: weak abductorsTrendelenburg (abductor lurch) gait: weak abductors Steppage gait: foot dropSteppage gait: foot drop Others: ataxic, scissoring, etc.Others: ataxic, scissoring, etc.

6. Hip

7. Hip - Look Principles:Principles: –Enough exposure –Compare both sides –Examine joint above (back) and joint below Look for:Look for: –Leg length discrepancy: –Alignment & Asymmetry (wasting) –Swelling, Skin changes (erythema), Scars

8. Hip - Feel Principles:Principles: –Start from non-painful area –Feel for warmth, swelling, tenderness

9. Hip - Move Principles:Principles: –Active then passive –Feel for crepitus, excessive movement (laxity), limited movement (contracture), painful limitation –? Do the motor neurological exam now Movements:Movements: –Flexion & Extension –Abduction & Adduction –IR & ER in flexion & extension

10. Knee

11. Knee - Look Principles:Principles: –Enough exposure –Compare both sides –Examine joint above (hip) and joint below Look for:Look for: –Leg length discrepancy –Alignment (varus - inward angulation of the distal segment, valgus, Q-angle) –Alignment (varus - inward angulation of the distal segment, valgus, Q-angle) –Asymmetry (wasting) –Swelling, Skin changes (erythema), Scars

12. Knee - Feel Principles:Principles: –Start from non-painful area –Feel for warmth, swelling, effusion, tenderness –Do not forget the back of the knee Sites:Sites: –Patella: margins and surfaces, quadriceps & patellar tendon & its insertion, bursae –Ligaments, tendons, & ITB attachment –Joint line: medial & lateral –Effusion: milking test, balloon test, ballotment

13. Knee - Move Principles:Principles: –Active then passive –Feel for crepitus, excessive movement (laxity), limited movement (contracture, locked knee), painful limitation –? Do the motor neurological exam now Movements:Movements: –Extension: quadriceps by femoral nerve –Flexion: hamstrings by sciatic nerve

14. Foot & Ankle

15. Foot & Ankle - Look Principles:Principles: –Enough exposure, Compare both sides –Examine joint above & below In hindfoot, midfoot & forefoot, look for:In hindfoot, midfoot & forefoot, look for: –Leg length discrepancy –Alignment: Ankle: valgus or varus,Ankle: valgus or varus, Foot: pes planus or cavus,Foot: pes planus or cavus, Big toe: hallux valgus or varusBig toe: hallux valgus or varus Toes: claw, hammer, malletToes: claw, hammer, mallet –Asymmetry (wasting) –Swelling, Skin changes (erythema), Scars

16. Foot & Ankle - Feel Principles:Principles: –Start from non-painful area –Feel for warmth, swelling, effusion, tenderness Sites:Sites: –Bones: malleoli, bones of the hindfoot, midfoot and forefoot –Ankle joint –Tendons: Achilles, posterior tibial, peroneal –Interdigital neuroma

17. Foot & Ankle - Move Principles:Principles: –Active then passive –Feel for crepitus, excessive movement (laxity), limited movement (contracture), painful limitation –? Do the motor neurological exam now Movements:Movements: –Ankle: dorsiflexion & plantarflexion –Subtalar joint: inversion & eversion –Forefoot: abduction & adduction –Toes: extension & flexion

18. Foot & Ankle – Move (Motor) MovementMuscle(s)Innervation Ankle DF Tib Ant Deep Peroneal Ankle PF GastrocnemiusTibial Inversion Tib Post mainly Tibial Eversion Peroneus longus & brevis Superficial Peroneal

19. Foot & Ankle – Special Tests Tendons:Tendons: –Achilles Tendon: Thompson test –Posterior Tibial Tendon: Heel raise test Instability:Instability: –Anterior drawer test –Inversion stress test –Peroneal tendon instability test Morton’s test: Mulder’s clickMorton’s test: Mulder’s click

20. Neurovascular Examination

21. Neurological Examination If suspecting peripheral pathology, test motor & sensory for all peripheral nervesIf suspecting peripheral pathology, test motor & sensory for all peripheral nerves If suspecting spine pathology:If suspecting spine pathology: –Dermatome sensation, myotome power testing & deep tendon reflexes

22. Peripheral Nerves of Lower Extremities NerveMotorSensory Femoral Knee Extension Saphenous n Obturator Hip Adduction Medial aspect of thigh LFCN- Lateral aspect of thigh Sciatic Knee Flexion According to branches Tibial Ankle PF Plantar aspect of foot Deep peroneal Ankle DF 1st web space dorsum of foot Superficial peroneal Foot Eversion Dorsum of foot except 1 st web space Sural- Lateral border of foot Saphenous- Medial border of foot

23. Sensation

24. Dermatomes & Myotomes RootSensoryMotorReflexes L1 Inguinal ligament Iliopsoas L2 Anteromedial thigh Iliopsoas L3 Medial to patella Quads L4 Medial lower leg Tib Ant Patellar L5 Anterolateral leg, dorsum foot EHL S1 Posterolateral heel GastrocAchilles S2 Posterior thigh Rectal S3-5PerianalRectal

25. Vascular Examination Inspection:Inspection: –Pallor –Hair distribution Palpation:Palpation: –Feel pulses: dorsalis pedis, posterior tibial, popliteal, femoral –Temperature –Capillary refill –Sensation Special Tests:Special Tests: –Compartments check –Ankle-Brachial Index

26. References US$ 65 US$ 47

27. Questions