Examination Flashcards
General Inspection
-Body habitus: obesity RF joint pathology due to increased mechanical load (e.g. osteoarthritis).
-Age, frailty
-Scars: previous lower limb surgery.
-Wasting of muscles: suggestive of disuse atrophy secondary to joint pathology or a lower motor neuron injury.
-Walking aids: the ability to walk can be impacted by a wide range of knee, hip and ankle pathology. Shoes- orthoses
-Prescriptions: prescribing charts or personal prescriptions can provide useful information about the patient’s recent medications (e.g. analgesia). Oxygen, systemic illness
-Posture, malalignments
Closer inspection of hips
STAND AND TURN IN 90* INCREEMENTS
-Anterior
=Scars (iliac crest to groin), bruising (recent trauma/ surgery), swelling (asymmetry: unilateral- effusion, inflammatory arthropathy, septic A), quad wasting (diffuse atrophy, LMN), leg length discrepancy (congenital/ acquired- degenerative joint disease, trauma to epiphyseal endplate prior to skeletal maturity), pelvic tilt (scoliosis, length discrepancy, hip abductor weakness)
-Lateral
=Flexion abnormalities (fixed deformity- contractures secondary to previous trauma, inflammatory conditions or neurological disease)
=Kyphosis lordosis
=Greater trochanter scar
-Posterior
=Scars, muscle wasting, spine assessment (shoulder level, straight, pelvis level, buttock atrophy secondary to nerve damage in surgery)
Gait assessment
-Gait cycle: toe-off or heel strike
-Range of movement: often reduced in the context of chronic joint pathology (e.g. osteoarthritis, inflammatory arthritis).
-Limping: may suggest joint pain (i.e. antalgic gait) or weakness.
-Leg length: note any discrepancy which may be the cause or the result of joint pathology.
-Turning: patients with joint disease may turn slowly due to restrictions in joint range of movement or instability.
-Trendelenburg’s gait: an abnormal gait caused by unilateral weakness of the hip abductor muscles secondary to a superior gluteal nerve lesion or L5 radiculopathy.
-Waddling gait: an abnormal gait caused by bilateral weakness of the hip abductor muscles, typically associated with myopathies (e.g. muscular dystrophy).
-Antalgic gait
-Assess the patient’s footwear: unequal sole wearing is suggestive of an abnormal gait
The phases of gait cycle
- Heel-strike: initial contact of the heel with the floor.
- Foot flat: weight is transferred onto this leg.
- Mid-stance: the weight is aligned and balanced on this leg.
- Heel-off: the heel lifts off the floor as the foot rises but the toes remain in contact with the floor.
- Toe-off: as the foot continues to rise the toes lift off the floor.
- Swing: the foot swings forward and comes back into contact with the floor with a heel strike (and the gait cycle repeats).
“Feel” in hip exam
-Temperature (septic/ inflammatory A)
-Hip joint palpation (palpate greater trochanter of each leg for tenderness in trochanteric bursitis)
-Leg length assessment (true and apparent- secondary to lateral pelvic tilt)
True vs apparent leg length
-True: anterior superior iliac spine to tip of medial malleolus (tibia or femur as hip dysplasia or fracture)
-Apparent: measure and compare distance between umbilicus (or xiphisternum) and tip of medial malleolus (different in pelvic tilt and scoliosis)
Describe Trendelenburg’s gait
-Unilateral hip abductor weakness, which is typically described as ‘lurching’ in nature.
-As the pelvis sags towards the unaffected side, the trunk lurches towards the opposite side in an effort to maintain balance
-If a patient has unilateral hip abductor weakness, the pelvis will drop toward the contralateral side when the leg on that side leaves the ground (i.e. if there is left hip abductor weakness, the pelvis will drop towards the right whenever the right foot is lifted off the ground).
-It’s important to remember that the pelvis falls on the contralateral side to the weakness. This sagging of the pelvis secondary to hip abductor weakness is known as Trendelenburg’s sign.
-Unilateral hip abductor weakness is typically caused by a superior gluteal nerve lesion or L5 radiculopathy
Describe Waddling gait
-If an individual has bilateral hip abductor weakness, they typically present with a waddling gait, caused by the overuse of circumduction to compensate for gluteal weakness.
-Bilateral hip abductor weakness is typically associated with myopathies (e.g. muscular dystrophy).
“Move” in hip exam
-Assess normal leg first
-Straight leg raise: assess nerve tension signs in spine pathology, if discomfort flex hip and reduce pain as reduced nerve tension
-Active: hip flexion and extension
-Passive: flexion, internal rotational, external rotation, abduction, adduction, extension
Describe the active movement tests of the hip
-Look for restrictions in range and signs of discomfort
-Flexion: Place your hand under the lumbar spine to detect masking of restricted hip joint movement by the pelvis and lumbar spine. Normal range of movement: 120°. Ask the patient to flex their hip as far as they are able – “Bring your knee as close to your chest as you can.”
-Extension: Normal range of movement: the leg should be able to lie flat (180°). Ask the patient to extend their leg, so that it is flat on the bed – “Straighten your leg out so that it is flat on the bed.”
Describe the passive movement tests of the hip
-Assess for crepitus, discomfort, restriction
-Flexion: 120, Whilst supporting the patient’s leg, flex the hip as far as you are able, making sure to observe for signs of discomfort- another 10 to 20 degrees
-Internal rotation: 20-40, Flex the patient’s hip and knee joint to 90° and then rotate their foot laterally.
-External rotation: 30-45, Flex the patient’s hip and knee joint to 90° and then rotate their foot medially
-Abduction: 30-45, With the patient’s legs straight and flat on the bed, use one of your hands to hold the ankle of the hip being assessed and place your other hand over the contralateral iliac crest to stabilise the pelvis. Move the patient’s ankle laterally to abduct the hip until the pelvis begins to tilt
-Adduction: 20-30, With the patient’s legs straight and flat on the bed, use one of your hands to hold the ankle of the hip being assessed and place your other hand over the contralateral iliac crest to stabilise the pelvis. Move the patient’s ankle medially to adduct the hip until the pelvis begins to tilt.
-Extension: 10-20, prone position, one hand to hold ankle of leg being assessed and place other hand on ipsilateral pelvis, lift the leg to extend hip joint and assess range of extension
Special hip tests
-Thomas’s
=Fixed flexion deformity (inability to fully extend leg)
=Flat on bed, place a hand below their lumbar spine with your palm facing upwards (this helps to prevent the patient from masking a fixed flexion deformity by increasing lumbar lordosis). Passively flex the hip of the unaffected leg as far as you are able to and observe the contralateral limb. Repeat the assessment on the contralateral hip
=Positive: affected thigh raises off bed indicating loss of hip joint extension, not be performed on patients who have had a hip replacement as it can cause dislocation
-Trendelenburg’s test is used to screen for hip abductor weakness (gluteus medius and minimus, stabilise pelvis).
1. With the patient upright, stand in front of them and ask them to place their hands on your forearms or shoulders for stability.
2. Position your fingers on each side of the patient’s pelvis at the iliac crest (pelvic tilt?).
3. Ask the patient to stand on one leg and observe your fingers for evidence of lateral pelvic tilt.
4. Repeat the assessment with the patient standing on the other leg
=If abductors functioning normally pelvis should remain stable or rise slightly on side of raised leg, if pelvis drops on side of raised leg suggests contralateral hip abductor weakness
True and apparent leg length
Further assessments and investigations in hip examination
-Neurovascular examination of both lower limbs.
-Examination of the joints above and below (lumbar spine and knee joint).
-Further imaging if indicated (e.g. X-ray and MRI).
General inspection in knee examination
-Body habitus (joint pathology due to increased mechanical load)
-Scars
-Wasting of muscle (disuse atrophy secondary to joint pathology or a lower motor neuron injury)
-Walking aids
-Prescriptions
Anterior knee inspection
-Scars: arthroscopy port entry sites) or indicate previous joint trauma.
=Midline anterior incision and port sites
-Bruising: recent trauma or spontaneous haemarthrosis (e.g. patients on anticoagulants or with clotting disorders such as haemophilia).
-Swelling: asymmetry in the size of the knee joints that may suggest unilateral swelling (e.g. effusion, inflammatory arthropathy, septic arthritis, haemarthrosis). Erythema
-Psoriasis plaques: typically present over extensor surfaces and important to note due to the increased risk of psoriatic arthritis.
-Patellar position: the patella is normally located over the centre of the knee joint and any deviation from this central position may indicate patellar dislocation or subluxation (i.e. partial dislocation).
-Valgus deformity of the knee: the tibia is turned outward in relation to the femur, resulting in the knees ‘knocking’ together.
-Varus deformity of the knee: the tibia is turned inward in relation to the femur, resulting in a bowlegged appearance.
-Quadriceps wasting: asymmetry in the bulk of the quadriceps muscles which may be due to disuse atrophy or a lower motor neuron lesion.
Lateral inspection of knee
-Extension abnormalities: knee hyperextension can occur secondary to cruciate ligament injury.
-Flexion abnormalities: fixed flexion deformity at the knee joint may suggest the presence of contractures secondary to previous trauma, inflammatory conditions or neurological disease.
-Baker’s cyst= bulge at back of knee, OA
Posterior inspection of knee
-Scars: again look for scars indicative of previous trauma or surgery.
-Muscle wasting: inspect for any asymmetry in the muscle bulk of the posterior compartment of the thigh or lower leg suggestive of disuse atrophy or a lower motor neuron lesion.
-Popliteal swellings: possible causes include a Baker’s cyst or popliteal aneurysm (typically pulsatile).
Gait assessment in knee exam
-Gait cycle: note any abnormalities of the gait cycle (e.g. abnormalities in toe-off or heel strike).
=Antalgic
=Stiff kneed
-Range of movement: often reduced in the context of chronic joint pathology (e.g. osteoarthritis, inflammatory arthritis).
-Limping: may suggest joint pain (i.e. antalgic gait), weakness or joint instability (e.g. ligamentous injury).
-Leg length: note any discrepancy which may be the cause or the result of joint pathology.
-Turning: patients with joint disease may turn slowly due to restrictions in joint range of movement or instability.
-Height of steps: high-stepping gait is associated with foot drop, which can be caused by peroneal nerve palsy (e.g. trauma, surgery).
“Feel” exam in knee
45*
-Temp: SA, inflammatory arthritis, gout or pseudogout
-Measurement of quadriceps bulk: secondary to diffuse atrophy, circumference with tape 20cm above tibial tuberosity
-Effusion- sweep test or tap test
Palpation of extended knee
With the patient’s leg straight and relaxed, systematically palpate the joint lines and surrounding structures of each knee joint.
-Patella
1. Assess the medial and lateral border of the patella for tenderness by stabilising one side of the patella and palpating the other with a fingertip:
=Tenderness may represent injury or patellofemoral arthritis.
=If the patient appears apprehensive, developing tension in the muscles of the leg as you begin to mobilise the patella (typically in the lateral direction), it may suggest a history of recurrent patellar dislocation which the patient is anticipating (this can be formally assessed using the patellar apprehension test).
2. Palpate the patellar ligament for tenderness suggestive of tendonitis or rupture.
-Medial and lateral joint lines
1. Palpate the medial and lateral joint lines of the knee including the collateral ligaments for evidence of tenderness which may suggest:
=Fracture
=Meniscal injury (e.g. meniscal tear)
=Collateral ligament injury (e.g. rupture)
2. Palpate the quadriceps tendon for tenderness suggestive of tendonitis or rupture.
Palpation of flexed knee
With the patient’s knee flexed at 90° repeat the same process of palpation as you did when the knee was extended. Joint lines and the popliteal fossa are often easier to assess with the knee flexed.
-Patella
=Palpate the patellar ligament for tenderness suggestive of tendonitis or rupture.
-Medial and lateral joint lines
=Palpate the medial and lateral joint lines of the knee including the collateral ligaments for evidence of tenderness which may suggest:
=Fracture
=Meniscal injury (e.g. meniscal tear)
=Collateral ligament injury (e.g. rupture)
-Tibial tuberosity and the head of the fibula
=Palpate the tibial tuberosity for evidence of a bony elevation and tenderness which is typically associated with Osgood-Schlatter disease.
=Palpate the head of the fibula for tenderness which is often associated with fracture.
-Popliteal fossa
=With your thumbs placed on the tibial tuberosity, curl your fingers into the popliteal fossa and palpate for evidence of a swelling which may indicate the presence of a popliteal cyst (often referred to as a Baker’s cyst). A pulsatile mass in the popliteal fossa may represent a popliteal aneurysm.
Assess active movement of the knee
-Straight leg raise= nerve root tension, extensor mechanism, hip/ spine problems
-Active knee flexion
=0-140° (130)
=Ask the patient to flex their knee as far as they are comfortably able to – “Move your heel as close to your bottom as you can manage.”
-Active knee extension
=leg should be able to lie flat (180°)
=Ask the patient to extend their knee, so that their leg is flat on the bed – “Straighten your leg out so that it is flat on the bed.”