Physical Examination of
the Lower Extremity
Dr Ülkü Akarırmak
Objectives
Principles of Physical Examination
• Hip
• Knee
• Foot & Ankle
Diagnosis
• Clinical Evaluation
- History
- Physical Examination
• Laboratory Evaluation
- Biochemistry
- Imaging (x-ray, CT, MR, US)
- Electrophysiology (EMG)
- Others: DXA
Principles of MSK Exam
• Two sides: right and left
• Two joints: above and below
• Two surfaces: front and back
General Examination: Posture
• .
Posterior Pelvis Surface Anatomy
• Iliac crest
• Gluteus maximus
• Gluteal folds
Frolich, Human
Anatomy, Lower LImb
Anterior Leg Surface
Anatomy
Patella
Condyles of femur
Femoral Triangle
– Sartorius (lateral)
– Adductor longus (medial)
– Inguinal ligament (sup)
– Femoral artery + vein+
lymph nodes
Posterior Leg Surface Anatomy
• Popliteal fossa
Boundaries
Biceps femoris
(Semitendinosis
semimembranosis
Gastrocnemius heads
• Calcaneal (Achilles)
tendon
Frolich, Human
pgAnatomy,
793
Lower LImb
Examination
of the Lower Extremity Joints
1. Inspection
Gait – Posture
2. Palpation
3. ROM
4. Special Tests
5. Neurologic + Vascular
Examination
Gait
•
•
•
•
•
•
Antalgic gait: Painful, short stance phase
Trendelenburg gait: Weak abductors
Waddling gait: Bilateral weak abductors
Steppage gait: Foot drop
Toe-walking: In-toeing / out-toeing
Others: Ataxic, scissoring, etc.
Hip Exam – Inspection
• Inspection
– Leg length discrepancy
– Deformity & Asymmetry
– Muscle wasting (atrophy)
– Swelling
– Skin changes (erythema) etc.
Hip Exam – Palpation
• Principles
– Reference points - painful areas
– Increased temperature, swelling, tenderness
• Sites
– Front: SIAS, pubic tubercule
– Side: Great trochanter, iliotibial band
– Back: SI joint, SIPS
Sacroiliac joint palpation
Hip Exam – ROM
• Principles
– Active / passive ROM
– Feel for crepitus, excessive movement
(laxity), limited movement (contracture),
painful limitation
• Movements
– Flexion & Extension
– Abduction & Adduction
– IR & ER (in flexion & extension)
Hip Joint - ROM
•
Flexion
120-135 degrees
Hip Joint - ROM
Extension 30 degrees
Hip ROM
Internal rotation 35
External rotation 45
Hip ROM – sitting position
Internal Rotation
External Rotation
Hip ROM
Abduction 45
Adduction 20-30
Hip – Motor Function
Movement
Muscle(s)
Innervation
Flexion
Iliopsoas
Lumbar plexus &
femoral nerve
Extension
Gluteus max
Inferior gluteal
Abduction
Gluteus med & min
Superior gluteal
Adduction
Adductor magnus,
longus & brevis
Obturator
Hip Joint – Special Tests
• Trendelenburg test: Abductor strength
• Thomas test: Hip flexion contracture
• Ober’s test: Iliotibial band tightness
• Patrick’s (FABERE) test: SI joint and
coxofemoral joint
Thomas test (-)
Thomas test (+)
Ober’s Test
Patrick’s (FABERE) test
Knee Exam - Inspection
- Gait
- Leg length discrepancy
- Deformity
varus, valgus, recurvatum
- Atrophy
- Swelling
- Skin changes
erythema,
scars etc.
Popliteal (Baker’s)Cyst /
Rupture in RA
Leg Length Discrepancy
Biomechanical Evaluation
Knee – Palpation
• Principles
– Reference points / painful areas
– Warmth, swelling, effusion, tenderness
– Popliteal area
• Sites
– Patella: Margins and surfaces,
– Quadriceps&patellar tendon&insertion
– Bursae
– Ligaments, tendons, & ITB attachment
– Joint line - medial & lateral
– Effusion: Milking test, ballotment
Knee - ROM
• Principles
– Active & passive ROM
– Crepitus, excessive movement (laxity), limited
movement (contracture, painful limitation)
• Movements
– Extension: Quadriceps (innerv. by femoral nerve)
– Flexion: Hamstrings (innerv. by sciatic nerve)
Range of Motion
• Extension
0°- (-10°)
• Flexion
130°-140°
Knee – Special Tests
• Patellar Exam
– Patellar apprehension test
– Patellofemoral grind test
• Meniscal Exam
– McMurray test
– Apley’s test
• Ligament tests: ACL, PCL, MCL, LCL
Patellofemoral grind test
Patellar apprehension test
Exam of Menisci
McMurray’s test
• Flex&ext with
varus&valgus and
int&ext rotation
• Goal is to get torn piece to
pop in and out of place
• (+) if pop or reproduction of
pain
Apley’s compression test
• Prone with knee flexed,
axial load and rotation
• McMurray test
McMurray test
Apley’s test
Knee – Ligaments Special Tests
• ACL: Anterior drawer,
Lachman, Pivot shift
• PCL: Posterior drawer
• MCL: Valgus stress in neutral & 30 flexion
• LCL: Varus stress in neutral & 30 flexion
Valgus stress test
Varus stress test
Foot & Ankle Exam – Inspection
• Hindfoot, midfoot & forefoot areas
- Gait analysis
- Alignment
• Ankle: Valgus or varus
• Foot: Pes planus or cavus
• Big toe: Hallux valgus
• Toes: Claw, hammer, mallet
- Asymmetry
- Swelling, skin changes
(erythema or scars)
Foot Deformities
Toe Deformities
Foot & Ankle – Palpation
• Principles
Temperature, swelling,
effusion, pain
• Sites
– Bones: Malleoli and
bones of the hindfoot, midfoot and forefoot
– Ankle joint
– Tendons: Achilles, posterior tibial, peroneal
– Interdigital neuroma
Foot & Ankle – ROM
• Principles
- Active & passive ROM
- Crepitus, excessive movement (laxity),
contracture, painful limitation
• Movements
- Ankle: dorsiflexion & plantarflexion
- Subtalar joint: Inversion & eversion
- Forefoot: Abduction & adduction
- Toes: Extension & flexion
İnversion-Eversion
Abduction-Adduction
Ankle & Foot - ROM
Foot & Ankle – Motor
Exam
Movement
Muscle(s)
Innervation
Ankle DF
Tibialis anterior
Deep peroneal
Ankle PF
Gastrocnemius
Tibial
Inversion
Tibialis posterior
Tibial
Eversion
Peroneus longus &
brevis
Superficial
peroneal
Foot & Ankle – Special Tests
• Tendons
– Achilles tendon
– Posterior tibial tendon
• Instability
– Anterior drawer test
– Inversion stress test
– Peroneal tendon instability test
• Morton’s test: Mulder’s click
Thompson test
Anterior drawer test
Inversion stress test
Peroneal tendon instability test
Peroneal tendon instability test
Mulder’s click
Mulder’s Sign - Morton's neuroma: Pain, by
squeezing two metatarsal heads together while putting
pressure on the interdigital space
Pain will be localized to the plantar surface of the involved
space+paresthesias radiating into affected toes
Neurological Examination
• Peripheral nerves
• Spinal pathology
- Sensation
- Muscle strength test
- Deep tendon reflexes
Dermatomes & Myotomes
Root
Sensory
Motor
L1
Inguinal ligament
Iliopsoas
L2
Anteromedial thigh
Iliopsoas
L3
Medial to patella
Quads
L4
Medial lower leg
Tibialis anterio
L5
Anterolat leg, dorsum foot
EHL
S1
Posterolateral heel
Gastrocnemius
S2
Posterior thigh
Rectal
S3-5
Perianal
Rectal
Reflexes
Patellar
Achilles
Manual Muscle Test
Scale 5/5 - 0
Vascular Examination
• Inspection
– Colour - Pallor
– Hair
• Palpation
– Feel pulses:
dorsalis pedis
posterior tibialis
popliteal
femoral
– Temperature
– Capillary refill
• Special Tests
– Compartments check
– Ankle-Brachial Index
Inspection
Q&A
Compartments
The (lower) leg is divided into four compartments by the, interosseous
membrane of the leg, the transverse intermuscular septum and the
posterior intermuscular septum
Compartment
Muscles
Neurovascular structures
Anterior compartment of
leg
Tibialis anterior, Extensor
Deep peroneal
hallucis longus, Extensor
nerve, Anterior
digitorum
tibial vessels
longus, Peroneus tertius
Lateral compartment of
leg
Fibularis/peroneus
Superficial
longus, Fibularis/peroneu
peroneal nerve
s brevis
Deep posterior
compartment of leg
Tibialis posterior, Flexor
hallucis longus, Flexor
digitorum
longus, Popliteus
Tibial
nerve, Posterior
tibial vessels
Superficial posterior
compartment of leg
Gastrocnemius, Soleus,
Plantaris
Medial sural
cutaneous nerve
Ankle-Brachial Index Test (ABI)
Measuring blood pressure at the ankle and arm while a person is at rest.
Measurements are repeated at both sites after 5 minutes of walking on a treadmill.
The ABI result is used to predict the severity of peripheral arterial disease (PAD)
Why It Is Done
This test is done to screen for PAD
Results
The ABI result can help diagnose PAD
Normal
A normal resting ABI is 1.0 to 1.4. This means that blood pressure at ankle is the same
or greater than pressure at arm, and suggests no significant narrowing or blockage of
blood flow
Abnormal: ABI is 0.9 or lower
Blood Supply of Lower Extremity