1. Physical Examination of the Lower Extremity
Dr.m.koushkzari
Spine felowship

2. Principles of Physical Examination
Objectives
Principles of Physical Examination
Hip
Knee
Foot & Ankle
FUNDAMENTAL:TEMEL,İLKE,KURAL
APPROACH:YAKLAŞIM

3. Diagnosis Clinical Evaluation - History - Physical Examination
Laboratory Evaluation
- Biochemistry
- Imaging (x-ray, CT, MR, US)
- Electrophysiology (EMG)
- Others: DXA
CONFİRM:DOĞRULAMAK,ONAYLAMAK

4. Principles of MSK Exam Two sides: right and left
Two joints: above and below
Two surfaces: front and back

5. General Examination: Posture.
SCİSSORİNG:MAKASLAMA

6. Posterior Pelvis Surface Anatomy
Iliac crest
Gluteus maximus
Gluteal folds
CHEEK:YANAK
CRACK:ÇATLAK
CLEFT:YARIK,ÇATLAK
FOLD:PLİ,KAT,OYUK
BOTTOM:ALT,SON,KIÇ,POPO
Frolich, Human Anatomy, Lower LImb

7. Examination of the Lower Extremity Joints
1. Inspection
Gait – Posture
2. Palpation
3. ROM
4. Special Tests
5. Neurologic + Vascular Examination

8. 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.
SCİSSORİNG:MAKASLAMA

9. Hip Exam – Inspection Inspection Leg length discrepancy
Deformity & Asymmetry
Muscle wasting (atrophy)
Swelling
Skin changes (erythema) etc.
EXPOSURE:AÇIK,İFŞA,ORTAYA ÇIKARMA

10. Hip Exam – Palpation Principles Sites Reference points - painful areas
Increased temperature, swelling, tenderness
Sites
Front: SIAS, pubic tubercule
Side: Great trochanter, iliotibial band
Back: SI joint, SIPS

11. Sacroiliac joint palpation

12. Hip Exam – ROM Principles Movements Active / passive ROM
Feel for crepitus, excessive movement (laxity), limited movement (contracture), painful limitation
Movements
Flexion & Extension
Abduction & Adduction
IR & ER (in flexion & extension)

13. 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

14. Thomas test (-)
Thomas test (+)

15. Patrick’s (FABERE) test

16. Knee Exam - Inspection - Gait - Leg length discrepancy Deformity
varus, valgus, recurvatum
- Atrophy
- Swelling
- Skin changes erythema, scars etc.

17. Popliteal (Baker’s)Cyst / Rupture in RA
Tx: Corticosteroid injection into knee joint (not cyst)

18. Leg Length Discrepancy

19. Knee – Palpation Principles Sites 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

20. Knee - ROM Principles Movements 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)

21. McMurray test
Apley’s test
McMurray test

22. 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)

23. Foot Deformities

24. Toe Deformities

25. 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

26. 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

27. Foot & Ankle – Motor Exam
Movement
Muscle(s)
Innervation
Ankle DF
Tibialis anterior
Deep peroneal
Ankle PF
Gastrocnemius
Tibial
Inversion
Tibialis posterior
Eversion
Peroneus longus & brevis
Superficial peroneal

28. Q&A