Clinical 5: Lower Limb Examination Flashcards
What should you always ask the patient before starting the lower limb examination?
Are they in any pain?
Any previous joint replacements?
What are you assessing when the patient is walking?
Looking for abnormal gait
Assess symmetry and turning
Note any signs of discomfort.
When assessing the hip what should you be looking for?
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
What should you feel for during the hip examination?
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
What movements should be assessed in the hip examination?
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.
How do you complete the modified Thomas Test?
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.
What special tests may be performed in the hip examination?
Trendelenburg test
Pastry rolling test
What happens in the trendelenburg test?
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.
How do you complete the pastry rolling test?
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.
What are you looking for in the knee examination?
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
What should you feel for in the knee examination?
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
How do you complete the patellae tap test?
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
How do you complete the sweep test?
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
What special tests should be performed in the knee examination?
Anterior drawer test
Posterior drawer test
Lateral collateral ligament assessment
What movements should be assessed in the knee examination?
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.
How do you perform the anterior draw test?
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
How do you perform the posterior drawer test?
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
How do you assess the lateral collateral ligament of the knee?
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.
How do you assess the medial collateral ligament in the knee exam?
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
What should you look for in the ankle exam?
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.
What should you feel for in the ankle exam?
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
What movements should be done when testing the ankle?
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.
What special test should be performed in the ankle examination?
Simmonds test
How do you perform simmonds test of the ankle?
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.
