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

2. Objectives 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: –Hip –Knee –Foot & Ankle

3. Fundamentals 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&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

4. Principles of Physical Exam PermissionPermission Pre-amblePre-amble PrivacyPrivacy PolitenessPoliteness PassionatePassionate PacingPacing

5. 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

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

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

8. Gait Antalgic gait: painful, short stance phaseAntalgic gait: painful, short stance phase Trendelenburg (abductor lurch) gait: weak abductorsTrendelenburg (abductor lurch) gait: weak abductors Waddling gait: bilateral weak abductors, bilateral DDHWaddling gait: bilateral weak abductors, bilateral 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.

9. Hip

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

11. Hip - Feel Principles:Principles: –Start from non-painful area –Feel for warmth, swelling, tenderness Sites:Sites: –From the front: ASIS, pubic tubercle –From the side: GT, iliotibial band –From the back: SI joint, PSIS

12. Examination of a Mass “ 6 Students and 3 Teachers go for CAMPFIRE” Site, Size, Shape, Surface, Skin, ScarSite, Size, Shape, Surface, Skin, Scar Tenderness, Temperature, TransilluminationTenderness, Temperature, Transillumination ConsistencyConsistency AttachmentAttachment MobilityMobility PulsationPulsation FluctuationFluctuation IrreducibilityIrreducibility Regional lymph nodesRegional lymph nodes EdgeEdge

13. 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

14. Hip – Move (Motor) MovementMuscle(s)Innervation FlexionIliopsoas Lumbar plexus & femoral nerve Extension Gluteus maximus Inferior gluteal Abduction Gluteus medius & minimus Superior gluteal Adduction Adductor magnus, longus and brevis Mainly obturator

15. Hip – 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

16. Knee

17. 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, valgus, Q-angle) –Asymmetry (wasting) –Swelling, Skin changes (erythema), Scars

18. 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

19. 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

20. Knee – Special Tests Patellar tests:Patellar tests: –Patellar apprehension test –Patellofemoral grind test Meniscal tests:Meniscal tests: –McMurray test –Apley’s test Ligaments tests: ACL, PCL, MCL, LCL, PLCLigaments tests: ACL, PCL, MCL, LCL, PLC

21. Knee – Ligaments Special Tests ACL: Lachman’s, Anterior drawer, Pivot shiftACL: Lachman’s, Anterior drawer, Pivot shift 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

22. Foot & Ankle

23. 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

24. Toes Claw Toes Hammer Toe Mallet Toe

25. 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

26. 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

27. 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

28. 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

29. Neurovascular Examination

30. 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

31. 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

32. Sensation

33. 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

34. 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

35. References US$ 65 US$ 47

36. Questions