Clinical 5: Lower Limb Examination

Question 1

What should you always ask the patient before starting the lower limb examination?

Answer 1

Are they in any pain?
Any previous joint replacements?

Question 2

What are you assessing when the patient is walking?

Answer 2

Looking for abnormal gait
Assess symmetry and turning
Note any signs of discomfort.

Question 3

When assessing the hip what should you be looking for?

Answer 3

Ask the patient to walk to the end of the examination room and back whilst observing them.
Gait - limp etc
Inspect in anatomical position from in front and behind
Skin - scars
Soft tissue - gluteal wasting
Bone - very little to see due to deep location of hip joint

Question 4

What should you feel for during the hip examination?

Answer 4

Skin - assess light touch sensation over the anterior thigh and lower leg (femoral and sciatic nerve)
Soft tissue - palpate peripheral pulses in the foot
Bone - in hip joint (below the femoral pulse), greater trochnater (tenderness associated with trochanteric bursitis)
Leg length discrepancy - apparent leg length from umbilicus to medial malleolus
- assess true leg length from ASIS to tip of medial malleolus

Question 5

What movements should be assessed in the hip examination?

Answer 5

The modified Thomas Test
Hip abduction - hold ankle and move laterally
Hip adduction - hold ankle of hip being assessed and support hip on opposite side, move ankle medially until pelvis beings to tilt
Hip internal rotation - flex hip to 45 degrees and knee to 90 , move tibia laterally.
Hip external rotation - hip to 45, knee to 90, move tibia medially.

Question 6

How do you complete the modified Thomas Test?

Answer 6

Ask patient to pull knees to chest - so maximum passive hip and knee flexion
Watch for patient reaction - carefully push further into flexion and compare movement bilaterally
Ask patient to hold affected limb in flexion by hand around shin
Ask to extend non-affected leg as far as possible and not difference between flexed and extended
Repeat with the other leg
Ask patient to relax both legs into a comfortable position.

Question 7

What special tests may be performed in the hip examination?

Answer 7

Trendelenburg test
Pastry rolling test

Question 8

What happens in the trendelenburg test?

Answer 8

Patient standings
Stand in front of them and ask to place their hands palm downwards on your palms facing upwards
Ask to stand on their non-affected leg then affected leg
Is the test is positive you should feel form downward pressure to the hand contralateral to the affected limb.

Question 9

How do you complete the pastry rolling test?

Answer 9

Position patient lyining on the examination couch.
Place one paml of your hand on the patient shin and the other on their thigh
Keep your hands flat and fingers straight and roll the leg as one under hand
Resistance to the movement or pain is suggestive of hip joint pathology.

Question 10

What are you looking for in the knee examination?

Answer 10

Gait - limp
Standing - inspect from all four sides
Skin - scats
soft tissue - brusing, swelling, quadriceps wasting, popliteal swelling
Bone - Valgus and varus knees, extension abnormalities, flexion abnormalities

Question 11

What should you feel for in the knee examination?

Answer 11

Soft tissue - assess and compare joint temperature, measures quadriceps bulk using a tape measure
Bone - palpate the borders of the petalla and the patellar ligament
Palpate the medial and lateral joint lines of the knee including collateral ligament
Repeat palpations with the knee is flexed to 90 degrees
Patellar tap test
Sweep test

Question 12

How do you complete the patellae tap test?

Answer 12

Fully extend the knee
Empty suprapatella pouch by sliding hand down the thigh to upper border of patella
Keep this hand in position, with the other hand press donwards on the patella
Is fluid is present will feel a distinct tap as patella bumps against femur

Question 13

How do you complete the sweep test?

Answer 13

Position in supine with lef relaxed and knee extended
Empty suprapatella pouch by sliding left hand downwards (keep hand here)
Stroke the medial side of joint to move any excess fluid across to the lateral side
Stroke the lateral side which will cause any excess fluid to move back across into the emptied medial side.
This will cause the appearance of a bulge or ripple on medial side

Question 14

What special tests should be performed in the knee examination?

Answer 14

Anterior drawer test
Posterior drawer test
Lateral collateral ligament assessment

Question 14

What movements should be assessed in the knee examination?

Answer 14

passive - knee flexion and knee extension
Active - knee felxion and knee extension
Look for evidence of pain or restricited motion
Feel for crepitus and tenderness in passive movements.

Question 15

How do you perform the anterior draw test?

Answer 15

Position patient supine with knee flexed to 90
Wrap hands around proximal tibia with fingers behind int eh joint
Rest forearm down patient lower leg to fix in position
Position thumbs over tibial tuberosity
Ask matient to keep legs relaxed
Pull the tibia anteriorly and feel for any anterior moveement of the tibia on the femur

Question 16

How do you perform the posterior drawer test?

Answer 16

Position the patient supine with knee flexed to 90 degrees
Wrap hands around the the proximal tibia with fingersa around the back of the knee joint
Rest forearm down the patients lower leg to fix its position
Position thumbs over the tibial tuberosity
Ask patient to relax their leg as much as possible
Push the tibia posteriorly, in a healthy individual there would be as little as possible movement

Question 17

How do you assess the lateral collateral ligament of the knee?

Answer 17

Extend the patients knee so it is fully straight
Hold patient X ankle between your X elbow and side
Position you X hand over medial aspect of knee
Position yout Y hand lower over the lateral aspect of the lower limb with fingers reaching up to palatate the lateral knee joint line.
Push steadily outwards with you X hand whilst puhsing inwards with Y hand,
Palpate the lateral knee joint line with the fingers of your hand - is there is damage to the ligament a palpable gap should be felt.

Question 18

How do you assess the medial collateral ligament in the knee exam?

Answer 18

Extend knee fully
Hold ankle between side and elbow
Position one palm over medial aspect of knee
Position other palm a little lower down over the lateral aspect.
Push steadily medially whilst pushing against with the other palm.
Whilst performing this manoeuvre palpate the medial joint line with your hand
If a gap appears in the joint line there is likley weakness in the medial collateral ligaement

Question 19

What should you look for in the ankle exam?

Answer 19

Gait obsevation
Ask to walk on tiptoes
Ask to walk on heals.
Inspect all angles of the leg.
Skin - scars
Soft tissue - bruising or swelling, muscle wasting, foot arches, calluses
Bone - fixed deformity of the toes (hammre-toe, mallet-toe), big toes misalignments.

Question 20

What should you feel for in the ankle exam?

Answer 20

Temperature - of ankle anf feet using back of hands
Pulses - posterior tibial pulse, dorsalis pedis pulse
Metatarsophalangeal joint squeeze - gently squeeze across the MTP joints and observe for signs of discomfort.
Feel for metatarsal, tarsal, tarsal joint, ankle joint, subtalar joint, calcaneum, medial/lateral malleoli, distal fibular.
Achilles tendon and gastroncnemius palpation

Question 21

What movements should be done when testing the ankle?

Answer 21

Active:
Plantarflexion
Dorsiflexion
Toe flexion
Toe extension
Inversion
Foot eversion

Passive:
Subtalar joint and Midtarsal joint - by subtarsal and mid-tarsal inversion.
Dorsiflexion, plantarflexion
Hallux flexion and extension.

Question 22

What special test should be performed in the ankle examination?

Answer 22

Simmonds test

Question 23

How do you perform simmonds test of the ankle?

Answer 23

Ask patient to kneel on a chair with their feet hanging over the edge
Squeeze each of the patients calves in turn
Healthy - plantarflexion of the foor
Achilles tendon rupture - no movement of the foot.

Question 24

What are the different types of limp?

Answer 24

Length inequality
Incoordination
Muscle weakness
Pain
Stiff

Question 25

How does a length inequality gait look like?

Answer 25

Patient bobys up and down when walking and observed from the front
However the rhythm of the gait is normal - equal time spent on each limb

Question 26

What does an incoordination limb look like?

Answer 26

Described as controlled falling.
Neuromuscular disorders often look less controlled - limp appears as tripped or intoxicated
Arms swing to act as a counterbalance
Legs frequently scissor
No rhythm to gait

Question 27

How does hip weakness present in the gait?

Answer 27

Body sways sideways to and fro when looked at from the front
Patient uses trunk muscles to lift pelvis enough to swing
Trendelenburg gait compensation - obviously lean to one side

Question 28

How does knee weakness present in the gait?

Answer 28

Weak quadriceps - lock the knee as they take weight on leg - leg extends fully before the heel strikes the ground
Keep extended as foot comes down, often requires hand to put pressure on the front of the thigh.

Question 29

How does ankle weakness present in a gait?

Answer 29

Lifts the foot very high to avoid singing the leg through without catching their toes
Foot lands with a slap on the ground becuase there is no control over it.

Question 30

How does an antalgic gait present?

Answer 30

Spend less time on teh painful limb
Bob up and down from the front
Cadence is abnormal - described as dot-dash

Question 31

How does a stiff limb joint present in the walk?

Answer 31

Sway forward and backwards when look at from the side
Hoist pelvis up as they bring hip through to stop is dragging on the ground

Question 32

How does a stiff knee present on the walk?

Answer 32

Swing leg out to the side as they walk.
To avoid catching toes on teh ground as unable to lift knee

Question 33

How do patients with a stiff ankle present in the gait?

Answer 33

Foot rocks forward from heel to toe in a very pronounced way.

Question 34

What pattern of wear is common in a shoe?

Answer 34

Corner of posteroleater heal worn off - point of heel stroke
Circular wear pattern under ball of big toe - foot drive
In very old shoes may be linked by a lin along the lateral side of sole where most weight is taken during stance phase.