CLIN MSK Hip, Knee, Ankle, Foot Exam

Question 1

Process of Hip Exam

Answer 1

1. HH
2. Greet pt
3. Introduce yourself
4. Identify pt
5. Explanation of examination & confidentiality
6. Discuss exposure – legs should be fully exposed (ask patient to remove clothing, except underpants).
7. Obtain consent
8. Position the pt
9. Ask whether the pt is comfortable
10. Ask the pt if they are in pain or experiencing any discomfort before the exam.
11. General Inspection
    a. Aids – specific to exam (e.g., walking frames/crutches)
    b. Posture
    c. Pain/discomfort
    d. ‘Noting body habitus’
12. Look – from front, sides & behind
    a. Symmetry
    b. Scars
    c. Rashes
    d. Bruising
    e. Erythema/redness
    f. Swelling
    g. Deformity
    i. Valgus – away from the midline
    ii. Varus – towards the midline.
    h. Muscle wasting
    i. Abnormal bone alignment
    j. Posture
    k. Contour
    l. Gait
    i. Watch the pt walk
    ii. Observe one leg at a time
    iii. Start with the ankle, then move up to the knee, hip, pelvis.
    iv. Determine possible causes of abnormal gait, pain, joint immobility, muscle weakness, abnormal limb control.
    m. Check for leg shortening.
    n. Trendelenburg Test
    i. Inform pt that you will be standing behind them
    ii. Ask pt to stand on one leg
13. Feel (normal joint first then joint of complaint)
    a. Skin warmth – w back of fingers
    i. Active synovitis – swollen & slightly warm joint
    ii. Infection
    iii. Crystal arthritis (e.g., gout).
    b. Tenderness
    i. Fibromyalgia – tenderness present over muscles
    ii. Inflammation – tenderness elicited over the margins of a joint
    c. Synovitis – soft & spongy swelling
    d. Effusion – fluctuant & mobile (can be made to shift within the joint)
    e. Bone swelling – hard & immobile (suggesting osteophyte formation/subchondral bone thickening).
    f. Bony landmarks – check both sides of pt & note whether at the same horizontal level.
14. Inguinal ligament
    ii. Anterior – w pt standing
15. Iliac crests
16. ASIS
17. Iliac tubercle
18. Greater trochanter
19. Pubic tubercle
    iii. Posterior – w pt lying on each side w knee flexed (tucked up)
20. PSIS (look for dimples on either side of the spinal cord on exposed back).
21. Greater trochanter
22. Ischial tuberosity
23. Move – pt lying down (use hand as meeting point for foot in passive movements)
    a. Active
    i. Flexion w knee extended 90
    ii. Flexion w knee flexed 120
    iii. Internal rotation 45 (foot twisted out)
    iv. External rotation 45 (foot twisted inwards)
    v. Abduction 50
    vi. Adduction 45
    b. Passive – comment on presence/absence of crepitus (be aware in presence of fracture)
    i. Flexion w knee extended 90
    ii. Flexion w knee flexed 120
    iii. Internal rotation 45 (foot twisted out)
    iv. External rotation 45 (foot twisted inwards)
    v. Abduction 50 – ensure pt’s pelvis is steady by applying one of your hands over the pt’s ASIC of the examined side/by placing forearms over both ASICs.
24. Abduct until you feel the pt’s pelvis move.
    vi. Adduction 45 - ensure pt’s pelvis is steady by applying one of your hands over the pt’s ASIC of the examined side/by placing forearms over both ASICs.
25. Adduct until you feel the pt’s pelvis move.
    vii. Extension 30 – w pt lying prone
    viii. Extension 30 – w pt lying prone & stabilise sacroiliac joint
26. Special Tests
    a. Thomas Test
    i. Slide hand beneath lordosis
    ii. Bend knee upwards (testing hip on the other side)
    iii. Ensure back and other leg remain on the bed.
    b. Leg Length
    i. True Leg Length
    ii. Apparent Leg Length
27. Thank pt
28. Redress
29. Report findings
30. Ask if any questions for pts
31. HH

Question 2

Process of Feel for Hip

Answer 2

a. Skin warmth – w back of fingers
i. Active synovitis – swollen & slightly warm joint
ii. Infection
iii. Crystal arthritis (e.g., gout).
b. Tenderness
i. Fibromyalgia – tenderness present over muscles
ii. Inflammation – tenderness elicited over the margins of a joint
c. Synovitis – soft & spongy swelling
d. Effusion – fluctuant & mobile (can be made to shift within the joint)
e. Bone swelling – hard & immobile (suggesting osteophyte formation/subchondral bone thickening).
f. Bony landmarks – check both sides of pt & note whether at the same horizontal level.
1. Inguinal ligament
ii. Anterior – w pt standing
1. Iliac crests
2. ASIS
3. Iliac tubercle
4. Greater trochanter
5. Pubic tubercle
iii. Posterior – w pt lying on each side w knee flexed (tucked up)
1. PSIS (look for dimples on either side of the spinal cord on exposed back).
2. Greater trochanter
3. Ischial tuberosity

Question 3

Process of General Inspection for Hip

Answer 3

a. Aids – specific to exam (e.g., walking frames/crutches)
b. Posture
c. Pain/discomfort
d. ‘Noting body habitus’

Question 4

Process of Look for Hip

Answer 4

12. Look – from front, sides & behind
    a. Symmetry
    b. Scars
    c. Rashes
    d. Bruising
    e. Erythema/redness
    f. Swelling
    g. Deformity
    i. Valgus – away from the midline
    ii. Varus – towards the midline.
    h. Muscle wasting
    i. Abnormal bone alignment
    j. Posture
    k. Contour
    l. Gait
    i. Watch the pt walk
    ii. Observe one leg at a time
    iii. Start with the ankle, then move up to the knee, hip, pelvis.
    iv. Determine possible causes of abnormal gait, pain, joint immobility, muscle weakness, abnormal limb control.
    m. Check for leg shortening.
    n. Trendelenburg Test
    i. Inform pt that you will be standing behind them
    ii. Ask pt to stand on one leg

Question 5

Process of Move for Hip

Answer 5

a. Active
i. Flexion w knee extended 90
ii. Flexion w knee flexed 120
iii. Internal rotation 45 (foot twisted out)
iv. External rotation 45 (foot twisted inwards)
v. Abduction 50
vi. Adduction 45
b. Passive – comment on presence/absence of crepitus (be aware in presence of fracture)
i. Flexion w knee extended 90
ii. Flexion w knee flexed 120
iii. Internal rotation 45 (foot twisted out)
iv. External rotation 45 (foot twisted inwards)
v. Abduction 50 – ensure pt’s pelvis is steady by applying one of your hands over the pt’s ASIC of the examined side/by placing forearms over both ASICs.
1. Abduct until you feel the pt’s pelvis move.
vi. Adduction 45 - ensure pt’s pelvis is steady by applying one of your hands over the pt’s ASIC of the examined side/by placing forearms over both ASICs.
1. Adduct until you feel the pt’s pelvis move.
vii. Extension 30 – w pt lying prone
viii. Extension 30 – w pt lying prone & stabilise sacroiliac joint

Question 6

Special Tests for Hip

Answer 6

a. Thomas Test
i. Slide hand beneath lordosis
ii. Bend knee upwards (testing hip on the other side)
iii. Ensure back and other leg remain on the bed.
b. Leg Length
i. True Leg Length
ii. Apparent Leg Length

Question 7

Causes of shortening in True Leg Length Test

Answer 7

Bone shortening.

Question 8

Causes of shortening in Apparent Leg Length Test

Answer 8

Pelvic tilt.

Question 9

Lordosis

Answer 9

Lower back curve

Question 10

Kyphosis

Answer 10

Upper back curve

Question 11

Process of Knee Exam

Answer 11

1. HH
2. Greet pt
3. Introduce yourself
4. Identify pt
5. Explanation of examination & confidentiality
6. Discuss exposure – legs should be fully exposed (ask patient to remove clothing, except underpants).
7. Obtain consent
8. Position the pt
9. Ask whether the pt is comfortable
10. Ask the pt if they are in pain or experiencing any discomfort before the exam.
11. General Inspection
    a. Aids – specific to exam (e.g., walking frames/crutches)
    b. Posture
    c. Pain/discomfort
    d. ‘Noting body habitus’
12. Look – from front, sides & behind
    a. Symmetry
    b. Scars
    c. Rashes
    d. Bruising
    e. Erythema/redness
    f. Swelling
    i. Check for Baker’s cyst presence
    ii. Check for Bursitis presence
13. Prepatellar bursa (of Housemaid’s Knee)
    g. Deformity
    i. Valgus – towards the midline (knock knee)
    ii. Varus – away the midline (bow legs)
    h. Muscle wasting
    i. Check Quadriceps
    i. Abnormal bone alignment
    j. Posture
    k. Contour
    l. Gait
    i. Watch the pt walk
    ii. Observe one leg at a time
    iii. Start with the ankle, then move up to the knee, hip, pelvis.
    iv. Determine possible causes of abnormal gait, pain, joint immobility, muscle weakness, abnormal limb control.
14. Feel (normal joint first then joint of complaint)
    a. Skin warmth – w back of fingers
    i. Active synovitis – swollen & slightly warm joint
    ii. Infection
    iii. Crystal arthritis (e.g., gout).
    b. Tenderness
    i. Fibromyalgia – tenderness present over muscles
    ii. Inflammation – tenderness elicited over the margins of a joint
    c. Synovitis – soft & spongy swelling
    d. Effusion – fluctuant & mobile (can be made to shift within the joint)
    e. Bone swelling – hard & immobile (suggesting osteophyte formation/subchondral bone thickening).
    f. Bony landmarks – check both sides of pt
    i. Borders of quadriceps
    ii. Quadriceps
    iii. Femoral condyles
    iv. Patella
    v. Borders of patella
    vi. Joint line (aided by flexing knee)
    vii. Tibial condyles
    viii. Fibula head
    ix. Tibial tuberosity
    x. Tibia
    xi. Borders of quadriceps
    xii. Insertion of hamstrings
    xiii. Popliteal pulse (assessed by flexing knee)
15. Note presence/absence of Baker’s cyst
    g. Check for fixed flexion deformity.
    i. Asses w pt lying supine and look at knee from sides.
16. Move – pt sitting on bed
    a. Active
    i. Flexion 135
    ii. Extension 0-5
    b. Passive – comment on presence/absence of crepitus (be aware in presence of fracture)
    i. Flexion 135
    ii. Extension 0-5 (gently hyperextend)
17. Special Tests
    a. Patella Tests
    i. Patellar Tap Test (Knee Effusions)
18. Push on suprapatellar pouch
19. Push on knee cap
    ii. Bulge Sign (Knee Effusions)
20. Push on suprapatellar pouch and keep hand on pouch for duration of test
21. Push on medial side of knee
22. Push on lateral side of knee and look for fluid bulge in medial recess
    iii. Patello-Femoral Joint Stability
23. Wiggle patella side-to-side
    iv. Patellar Apprehension Test
24. Push patella laterally
25. Flex knee whilst watching pt’s face
    b. Ligament Tests
    i. Varus Stress Test (Lateral Collateral Ligament Tear)
26. Push hand laterally from medial side, whilst pushing lower leg medially – test at 30 then 0.
    ii. Valgus Stress Test (Medial Collateral Ligament Tear)
27. Push hand medially from lateral side, whilst pulling lower leg laterally – test at 30 then 0.
    iii. Lachman’s Test (Anterior Cruciate Ligament)
28. Thumb on fibula/rest thigh on your thigh with knee in slight flexion
29. Pull upwards on tibia
    iv. Anterior Drawer Test (Anterior Cruciate Ligament)
30. Sit on foot
31. Thumbs on joint line
32. Pull tibia forward with fingers from back of knee
    v. Posterior Drawer Test (Posterior Cruciate Ligament)
33. Sit on foot
34. Thumbs on joint line
35. Push tibia backwards with palms from anterior knee.
    c. Menisci Tests
    i. McMurray’s Test
36. For medial meniscus
    a. Place hand over joint line – feeling for crepitus/popping
    b. Hyperflex knee
    c. Externally rotate
    d. Extend out
37. For lateral meniscus
    a. Place hand over joint line – feeling for crepitus/popping
    b. Hyperflex knee
    c. Internally rotate
    d. Extend out
    ii. Thessaly’s Test
38. Pt standing up and provide balance point
39. Flex knee 5
40. Twist 3 times internally
41. Twist 3 times externally
42. Repeat above at 20
43. Thank pt
44. Redress
45. Report findings
46. Ask if any questions for pts
47. HH

Question 12

Process of General Inspection for Knee

Answer 12

a. Aids – specific to exam (e.g., walking frames/crutches)
b. Posture
c. Pain/discomfort
d. ‘Noting body habitus’

Question 13

Process of Look for Knee

Answer 13

a. Symmetry
b. Scars
c. Rashes
d. Bruising
e. Erythema/redness
f. Swelling
i. Check for Baker’s cyst presence
ii. Check for Bursitis presence
1. Prepatellar bursa (of Housemaid’s Knee)
g. Deformity
i. Valgus – towards the midline (knock knee)
ii. Varus – away the midline (bow legs)
h. Muscle wasting
i. Check Quadriceps
i. Abnormal bone alignment
j. Posture
k. Contour
l. Gait
i. Watch the pt walk
ii. Observe one leg at a time
iii. Start with the ankle, then move up to the knee, hip, pelvis.
iv. Determine possible causes of abnormal gait, pain, joint immobility, muscle weakness, abnormal limb control.

Question 14

Process of Feel for Knee

Answer 14

a. Skin warmth – w back of fingers
i. Active synovitis – swollen & slightly warm joint
ii. Infection
iii. Crystal arthritis (e.g., gout).
b. Tenderness
i. Fibromyalgia – tenderness present over muscles
ii. Inflammation – tenderness elicited over the margins of a joint
c. Synovitis – soft & spongy swelling
d. Effusion – fluctuant & mobile (can be made to shift within the joint)
e. Bone swelling – hard & immobile (suggesting osteophyte formation/subchondral bone thickening).
f. Bony landmarks – check both sides of pt
i. Borders of quadriceps
ii. Quadriceps
iii. Femoral condyles
iv. Patella
v. Borders of patella
vi. Joint line (aided by flexing knee)
vii. Tibial condyles
viii. Fibula head
ix. Tibial tuberosity
x. Tibia
xi. Borders of quadriceps
xii. Insertion of hamstrings
xiii. Popliteal pulse (assessed by flexing knee)
1. Note presence/absence of Baker’s cyst
g. Check for fixed flexion deformity.
i. Asses w pt lying supine and look at knee from sides.

Question 15

Process of Move for Knee

Answer 15

a. Active
i. Flexion 135
ii. Extension 0-5
b. Passive – comment on presence/absence of crepitus (be aware in presence of fracture)
i. Flexion 135
ii. Extension 0-5 (gently hyperextend)

Question 16

Special Tests for Knee

Answer 16

a. Patella Tests
i. Patellar Tap Test (Knee Effusions)
1. Push on suprapatellar pouch
2. Push on knee cap
ii. Bulge Sign (Knee Effusions)
1. Push on suprapatellar pouch and keep hand on pouch for duration of test
2. Push on medial side of knee
3. Push on lateral side of knee and look for fluid bulge in medial recess
iii. Patello-Femoral Joint Stability
1. Wiggle patella side-to-side
iv. Patellar Apprehension Test
1. Push patella laterally
2. Flex knee whilst watching pt’s face
b. Ligament Tests
i. Varus Stress Test (Lateral Collateral Ligament Tear)
1. Push hand laterally from medial side, whilst pushing lower leg medially – test at 30 then 0.
ii. Valgus Stress Test (Medial Collateral Ligament Tear)
1. Push hand medially from lateral side, whilst pulling lower leg laterally – test at 30 then 0.
iii. Lachman’s Test (Anterior Cruciate Ligament)
1. Thumb on fibula/rest thigh on your thigh with knee in slight flexion
2. Pull upwards on tibia
iv. Anterior Drawer Test (Anterior Cruciate Ligament)
1. Sit on foot
2. Thumbs on joint line
3. Pull tibia forward with fingers from back of knee
v. Posterior Drawer Test (Posterior Cruciate Ligament)
1. Sit on foot
2. Thumbs on joint line
3. Push tibia backwards with palms from anterior knee.
c. Menisci Tests
i. McMurray’s Test
1. For medial meniscus
a. Place hand over joint line – feeling for crepitus/popping
b. Hyperflex knee
c. Externally rotate
d. Extend out
2. For lateral meniscus
a. Place hand over joint line – feeling for crepitus/popping
b. Hyperflex knee
c. Internally rotate
d. Extend out
ii. Thessaly’s Test
1. Pt standing up and provide balance point
2. Flex knee 5
3. Twist 3 times internally
4. Twist 3 times externally
5. Repeat above at 20

Question 17

Process of Ankle/Foot Exam

Answer 17

1. HH
2. Greet pt
3. Introduce yourself
4. Identify pt
5. Explanation of examination & confidentiality
6. Discuss exposure – legs should be fully exposed (ask patient to remove clothing, except underpants).
7. Obtain consent
8. Position the pt
9. Ask whether the pt is comfortable
10. Ask the pt if they are in pain or experiencing any discomfort before the exam.
11. General Inspection
    a. Aids – specific to exam (e.g., walking frames/crutches)
    b. Posture
    c. Pain/discomfort
    d. ‘Noting body habitus’
    e. Check shoes (e.g., orthotics…).
12. Look – from front, sides & behind
    a. Symmetry
    b. Scars
    c. Rashes
    d. Bruising
    e. Erythema/redness
    f. Swelling
    i. Rheumatoid nodules over Achilles tendon (RA)
    g. Deformity
    i. Sausage-shaped toes/Dalyctisis (Psoriatic Arthritis)
    ii. Calluses
    iii. Nail pitting (Psoriatic Arthritis)
    h. Muscle wasting
    i. Check calf muscle
    i. Abnormal bone alignment
    i. Clawing/crowding of the toes (RA)
    ii. Hallux valgus/bunion (generally of 1st metartarsal)
    j. Posture
    i. Flat foot
13. Too many toes test
    a. Stand in centre behind patient and compare number of digits able to be seen on either side
    k. Contour
    l. Gait
    i. Watch the pt walk
    ii. Observe one leg at a time
    iii. Start with the ankle, then move up to the knee, hip, pelvis.
    iv. Determine possible causes of abnormal gait, pain, joint immobility, muscle weakness, abnormal limb control.
    m. Check for leg shortening.
14. Feel (normal joint first then joint of complaint)
    a. Skin warmth – w back of fingers
    i. Active synovitis – swollen & slightly warm joint
    ii. Infection
    iii. Crystal arthritis (e.g., gout).
    b. Tenderness
    i. Fibromyalgia – tenderness present over muscles
    ii. Inflammation – tenderness elicited over the margins of a joint
    c. Synovitis – soft & spongy swelling
    d. Effusion – fluctuant & mobile (can be made to shift within the joint)
    e. Bone swelling – hard & immobile (suggesting osteophyte formation/subchondral bone thickening).
    i. Squeeze 1st & 5th metartarsals
    f. Bony landmarks – check both sides of pt & note whether at the same horizontal level.
    i. Achilles tendon
    ii. Medial malleolus
    iii. Lateral malleolus
    iv. Calcaneus (inferior aspect)
    v. Metatarsophalangeal joints
    vi. PIP & DIPs
15. Move – pt sitting down (use hands to show pt)
    a. Active
    i. Dorsiflexion 20
    ii. Plantarflexion 50
    iii. Eversion 5
    iv. Inversion 5
    v. Toe flexion
16. Ask pt to curl toes
    vi. Toe extension
17. Ask pt to straighten toes
    b. Passive – comment on presence/absence of crepitus (be aware in presence of fracture)
    i. Dorsiflexion 20
    ii. Plantarflexion 50
    iii. Eversion 5
    iv. Inversion 5
    v. Toe flexion
18. Ask pt to curl toes
    vi. Toe extension
19. Ask pt to straighten toes
20. Special Tests
    a. Achilles tendon integrity tests (Achilles tendon rupture)
    i. Pt prone
    ii. Flex knee 90
    iii. Squeeze calf
    iv. Observe plantarflexion
21. Thank pt
22. Redress
23. Report findings
24. Ask if any questions for pts
25. HH

Question 18

General Inspection for Ankle/Foot Exam

Answer 18

a. Aids – specific to exam (e.g., walking frames/crutches)
b. Posture
c. Pain/discomfort
d. ‘Noting body habitus’
e. Check shoes (e.g., orthotics…).

Question 19

Process of Look for Ankle/Foot Exam

Answer 19

a. Symmetry
b. Scars
c. Rashes
d. Bruising
e. Erythema/redness
f. Swelling
i. Rheumatoid nodules over Achilles tendon (RA)
g. Deformity
i. Sausage-shaped toes/Dalyctisis (Psoriatic Arthritis)
ii. Calluses
iii. Nail pitting (Psoriatic Arthritis)
h. Muscle wasting
i. Check calf muscle
i. Abnormal bone alignment
i. Clawing/crowding of the toes (RA)
ii. Hallux valgus/bunion (generally of 1st metartarsal)
j. Posture
i. Flat foot
1. Too many toes test
a. Stand in centre behind patient and compare number of digits able to be seen on either side
k. Contour
l. Gait
i. Watch the pt walk
ii. Observe one leg at a time
iii. Start with the ankle, then move up to the knee, hip, pelvis.
iv. Determine possible causes of abnormal gait, pain, joint immobility, muscle weakness, abnormal limb control.
m. Check for leg shortening.

Question 20

Process of Feel for Ankle/Foot Exam

Answer 20

a. Skin warmth – w back of fingers
i. Active synovitis – swollen & slightly warm joint
ii. Infection
iii. Crystal arthritis (e.g., gout).
b. Tenderness
i. Fibromyalgia – tenderness present over muscles
ii. Inflammation – tenderness elicited over the margins of a joint
c. Synovitis – soft & spongy swelling
d. Effusion – fluctuant & mobile (can be made to shift within the joint)
e. Bone swelling – hard & immobile (suggesting osteophyte formation/subchondral bone thickening).
i. Squeeze 1st & 5th metartarsals
f. Bony landmarks – check both sides of pt & note whether at the same horizontal level.
i. Achilles tendon
ii. Medial malleolus
iii. Lateral malleolus
iv. Calcaneus (inferior aspect)
v. Metatarsophalangeal joints
vi. PMPs & DMPs

Question 21

Process of Move for Ankle/Foot Exam

Answer 21

a. Active
i. Dorsiflexion 20
ii. Plantarflexion 50
iii. Eversion 5
iv. Inversion 5
v. Toe flexion
1. Ask pt to curl toes
vi. Toe extension
1. Ask pt to straighten toes
b. Passive – comment on presence/absence of crepitus (be aware in presence of fracture)
i. Dorsiflexion 20
ii. Plantarflexion 50
iii. Eversion 5
iv. Inversion 5
v. Toe flexion
1. Ask pt to curl toes
vi. Toe extension
1. Ask pt to straighten toes

Question 22

Special Tests for Ankle/Foot

Answer 22

a. Achilles tendon integrity tests (Achilles tendon rupture)
i. Pt prone
ii. Flex knee 90
iii. Squeeze calf
iv. Observe plantarflexion

Question 23

What does the Trendelenburg test test?

Answer 23

Hip abductors - gluteus maximus/minimus.