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Physical Examination Lower Extremity. Sohail Bajammal, MBChB, MSc, FRCS(C) November 4, 2008. Objectives. Fundamentals of Diagnosis Principles of Physical Examination Principles of MSK Physical Examination MSK Physical Examination Approach: Hip Knee Foot & Ankle.

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Physical examination lower extremity

Physical ExaminationLower Extremity

Sohail Bajammal, MBChB, MSc, FRCS(C)

November 4, 2008


Objectives
Objectives

  • Fundamentals of Diagnosis

  • Principles of Physical Examination

  • Principles of MSK Physical Examination

  • MSK Physical Examination Approach:

    • Hip

    • Knee

    • Foot & Ankle


Fundamentals of diagnosis
Fundamentals of Diagnosis

  • Have a list of D/D as you read the CC

    • VITAMIN C&D

  • Re-visit your D/D

  • Narrow your list by the end of History

  • Further narrow by the end of Physical

  • Confirm by further investigations


P rinciples of physical exam
Principles of Physical Exam

  • Permission

  • Pre-amble

  • Privacy

  • Politeness

  • Passionate

  • Pacing


Principles of msk exam
Principles of MSK Exam

  • Do not forget the patient

    • General exam, Vital signs

  • Two sides: right and left

  • Two joints: above and below

  • Two surfaces: front and back


Approach to msk exam any lower extremity joint
Approach to MSK ExamAny Lower Extremity Joint

  • General & Gait

  • Look, Feel & Move

  • Special Tests

  • Neurovascular Examination


General
General

  • Well or ill-looking

  • Cachectic

  • Vital signs: febrile, hemodynamic stability


Gait

  • Antalgic gait: painful, short stance phase

  • Trendelenburg (abductor lurch) gait: weak abductors

  • Waddling gait: bilateral weak abductors, bilateral DDH

  • Steppage gait: foot drop

  • Toe-walking

  • In-toeing vs out-toeing

  • Others: ataxic, scissoring, etc.



Hip look
Hip - Look

  • Principles:

    • Enough exposure

    • Compare both sides

    • Examine joint above (back) and joint below

  • Look for:

    • Leg length discrepancy: blocks vs. tape

    • Alignment & Asymmetry (wasting)

    • Swelling, Skin changes (erythema), Scars


Hip feel
Hip - Feel

  • Principles:

    • Start from non-painful area

    • Feel for warmth, swelling, tenderness

  • Sites:

    • From the front: ASIS, pubic tubercle

    • From the side: GT, iliotibial band

    • From the back: SI joint, PSIS


Examination of a mass 6 s tudents and 3 t eachers go for campfire
Examination of a Mass “6 Students and 3 Teachers go for CAMPFIRE”

  • Site, Size, Shape, Surface, Skin, Scar

  • Tenderness, Temperature, Transillumination

  • Consistency

  • Attachment

  • Mobility

  • Pulsation

  • Fluctuation

  • Irreducibility

  • Regional lymph nodes

  • Edge


Hip move
Hip - Move

  • Principles:

    • Active then passive

    • Feel for crepitus, excessive movement (laxity), limited movement (contracture), painful limitation

    • ? Do the motor neurological exam now

  • Movements:

    • Flexion & Extension

    • Abduction & Adduction

    • IR & ER in flexion & extension



Hip special tests
Hip – Special Tests

  • Trendelenburg test: for abductor strength

  • Thomas test: for hip flexion contracture

  • Ober’s test: for iliotibial band tightness

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

  • Labral tear test



Knee look
Knee - Look

  • Principles:

    • Enough exposure

    • Compare both sides

    • Examine joint above (hip) and joint below

  • Look for:

    • Leg length discrepancy

    • Alignment (varus, valgus, Q-angle)

    • Asymmetry (wasting)

    • Swelling, Skin changes (erythema), Scars


Knee feel
Knee - Feel

  • Principles:

    • Start from non-painful area

    • Feel for warmth, swelling, effusion, tenderness

    • Do not forget the back of the knee

  • 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


Knee move
Knee - Move

  • Principles:

    • Active then passive

    • Feel for crepitus, excessive movement (laxity), limited movement (contracture, locked knee), painful limitation

    • ? Do the motor neurological exam now

  • Movements:

    • Extension: quadriceps by femoral nerve

    • Flexion: hamstrings by sciatic nerve


Knee special tests
Knee – Special Tests

  • Patellar tests:

    • Patellar apprehension test

    • Patellofemoral grind test

  • Meniscal tests:

    • McMurray test

    • Apley’s test

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


Knee ligaments special tests
Knee – Ligaments Special Tests

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

  • PCL: posterior sag sign, Posterior drawer

  • MCL: valgus stress in neutral & 30 flexion

  • LCL: varus stress in neutral & 30 flexion

  • PLC: dial test



Foot ankle look
Foot & Ankle - Look

  • Principles:

    • Enough exposure, Compare both sides

    • Examine joint above & below

  • In hindfoot, midfoot & forefoot, look for:

    • Leg length discrepancy

    • Alignment:

      • Ankle: valgus or varus,

      • Foot: pes planus or cavus,

      • Big toe: hallux valgus or varus

      • Toes: claw, hammer, mallet

    • Asymmetry (wasting)

    • Swelling, Skin changes (erythema), Scars


Toes

Claw Toes

Hammer Toe

Mallet Toe


Foot ankle feel
Foot & Ankle - Feel

  • Principles:

    • Start from non-painful area

    • Feel for warmth, swelling, effusion, tenderness

  • Sites:

    • Bones: malleoli, bones of the hindfoot, midfoot and forefoot

    • Ankle joint

    • Tendons: Achilles, posterior tibial, peroneal

    • Interdigital neuroma


Foot ankle move
Foot & Ankle - Move

  • Principles:

    • Active then passive

    • Feel for crepitus, excessive movement (laxity), limited movement (contracture), painful limitation

    • ? Do the motor neurological exam now

  • Movements:

    • Ankle: dorsiflexion & plantarflexion

    • Subtalar joint: inversion & eversion

    • Forefoot: abduction & adduction

    • Toes: extension & flexion



Foot ankle special tests
Foot & Ankle – Special Tests

  • Tendons:

    • Achilles Tendon: Thompson test

    • Posterior Tibial Tendon: Heel raise test

  • Instability:

    • Anterior drawer test

    • Inversion stress test

    • Peroneal tendon instability test

  • Morton’s test: Mulder’s click



Neurological examination
Neurological Examination

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

  • If suspecting spine pathology:

    • Dermatome sensation, myotome power testing & deep tendon reflexes





Vascular examination
Vascular Examination

  • Inspection:

    • Pallor

    • Hair distribution

  • Palpation:

    • Feel pulses: dorsalis pedis, posterior tibial, popliteal, femoral

    • Temperature

    • Capillary refill

    • Sensation

  • Special Tests:

    • Compartments check

    • Ankle-Brachial Index


References
References

US$ 65

US$ 47



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