CLIN SKILLS: Lower Limb Exam

Question 1

general process for hip exam

Answer 1

• introduction
• inspection
• palpation
• move
• measure (true and apparent leg length)
• special test: Thomas test

Question 2

inspection for hip exam

Answer 2

• general appearance
• muscle bulk
• abnormal gait
• skin
• swelling
• deformity: trendelenburg

Question 3

trendelenburg test

Answer 3

• stand behind Pt
• get them to stand on one leg (flexing the knee) then the other
• normally, non-weight-bearing hip will rise
• if non-weight-bearing hip sags, this indicates weakness in the abductors (gluteus medius) on the WEIGHT-BEARING hip

Question 4

a positive Trendelenburg sign indicates weakness in what muscle?

Answer 4

• glutes medius

Question 5

palpation for hip exam

Answer 5

• bony landmarks: anterior (ASIS, iliac crests, iliac tubercle, greater trochanter, pubic tubercle) and posterior (PSIS, ischial tuberosity)
• effusion
• swelling
• skin
• tenderness
• temperature

Question 6

normal ROM for hip movements

Answer 6

• flexion w/ knee extended - 90˚
• flexion w/ knee flexed - 120˚
• extension - 30˚
• internal and external rotation - 45˚
• abduction - 50˚
• adduction - 45˚

Question 7

true vs apparent leg length and how to interpret

Answer 7

• true: from ASIS to medial malleolus. Any differences indicate hip disease on shorter side
• apparent: from umbilicus to medial malleolus. Differences indicate pelvic tilt

Question 8

Thomas test

Answer 8

• Pt lying supine
• place hand under lumbar spine on one side and ask them to fully flex the OTHER hip w/ knee flexed
• if the straightened leg hip lifts off couch = fixed flexion deformity (compensatory lordosis)

Question 9

general process for knee exam

Answer 9

• introduction
• inspection
• palpation
• move
• special tests: stability, ligaments, menisci

Question 10

inspection for knee

Answer 10

• general appearance
• muscle bulk: hamstrings, quads, calves
• abnormal gait
• skin
• swelling: check popliteal fossa for baker’s cyst
• deformity: varus/valgus OR fixed flexion deformity (check w/ Pt lying supine)

Question 11

palpation for knee

Answer 11

• bony landmarks (knee in slight flexion lying supine): quadriceps tendon, borders of patella, tibial tuberosity, joint line, tibial and femoral condyles, head of fibula, hamstrings tendon, popliteal pulse
• effusion: patellar tap (large) + bulge sign (small)
• temperature

Question 12

patellar tap test vs bulge sign

Answer 12

• patellar tap test (LARGE effusion): slide hand down to empty pouch and push down on patella to see if it bounces back
• bulge sign (SMALL effusion): slide hand down to empty pouch, stroke upwards on medial side and downwards on lateral side

Question 13

normal ROM for knee movements

Answer 13

• flexion 135˚
• extension 5˚

Question 14

special tests for knee

Answer 14

• patello-femoral stability: flex and extend knee, then slide patella sideways on femoral condyles
• patellar apprehension test (ASK IF THEYVE HAD A DISLOCATION): Push patella laterally and flex knee
• Valgus stress test (MCL): flex knee to 30˚, apply valgus stress (towards medial). Repeat in full extension
• Varus stress test (LCL): flex knee to 30˚, apply varus stress (towards lateral). Repeat in full extension.
• Anterior and posterior draw test (ACL and PCL): flex knee to 90 degrees, pull tibia anteriorly and posteriorly
• lachman test (ACL): flex knee to 20-30˚, draw tibia forwards whilst applying posterior pressure to femur
• Menisci (McMurray’s Test): flex knee to 90˚, grip heel w/ R hand, use left to press on medial joint line w/ index finger. Extend leg while externally rotating. For lateral joint line, extend leg while internally rotating.

Question 15

Thessaly test

Answer 15

• tests for meniscal tear (medial pain = medial meniscus tear and vice versa)
• stand on one leg at a time w/ knees slightly flexed, rotating over tibia internally and externally

Question 16

general process for ankle/foot exam

Answer 16

• introduction
• inspection
• palpation
• move
• special tests (Thompson)

Question 17

inspection for foot/ankle

Answer 17

• general appearance
• muscle bulk
• abnormal gait
• skin
• swelling
• deformity: flat foot, hallux valgus, calluses, nail changes, rheumatoid nodules over Achilles, clawing/crowding of the toes

Question 18

palpation for foot/ankle

Answer 18

• bony landmarks: medial malleolus, lateral malleolus, calcaneus, MTP joints, PIPs and DIPs, Achilles tendon
• effusion
• swelling
• tenderness
• temperature

Question 19

normal ROM for ankle/foot movements

Answer 19

• dorsiflexion 20˚
• plantar flexion 50 ˚
• eversion and inversion 5˚

Question 20

achilles test (Thompson test)

Answer 20

• hang foot off bed, lying prone
• squeeze gastroc and foot should plantar flex then go back to normal