L11: Spine & LE Flashcards
Lower extremity arterial supply
- Femoral artery
- Popliteal artery
- Dorsalis pedis artery
- Posterior tibial artery
Lower Extremity Venous System
- Superficial System
- Great and Small (Lesser) Saphenous veins
- Deep System
- Femoral vein
- Communicating or perforating veins
Peripheral Vascular Disease (PVD): Arterial vs. Venous Ulcers
- Pain
- Edema
- Pulse
- Drainage
- Sores
- Skin
- Location of sores
- Treatment? Surgical treatment?
Peripheral Artery Insufficiency: Inspection
What are the signs of peripheral artery insufficiency that you would observe (inspection)?
- Pallor
- Dependent rubor
- Distal hair loss
- Atrophic skin, nail changes
- Ulcers
- Necrosis, gangrene
Peripheral Artery Insufficiency: Palpation
Which pulses to check?
Expected skin temperature?
Capillary refill time?
- Pulses:
- Femoral, popliteal, dorsalis pedis, posterior tibial
- Skin temperature:
- Cool
- Capillary refill:
- Delayed (> 2 sec)
Peripheral Artery Insufficiency: Auscultation
What are you auscultating for? Where?
- Auscultation for bruits
- Abdominal Aorta
- Femoral and popliteal arteries
Venous Insufficiency: Inspection
What would you observe (inspection) in venous insufficiency?
Dilated, tortuous superficial veins that result from defective structure and function of the valves
Venous Insufficiency: Clinical Presentation
How does venous insufficiency present?
- Dull ache or pressure sensation after prolonged standing; relieved with elevation
- Dependent ankle edema and ankle ulcerations may develop
- Superficial thrombosis/thrombophlebitis may occur
Varicose Veins
What is it? Cause?
- Venous insufficiency
- Enlarged veins
- Due to malfunction of their valves causing improper flow of blood, and pooling as a result
Stasis Dermatitis
Cause?
Brawny edema?
- Due to chronic venous insufficiency with incompetent valves and higher pressure in capillary bed.
- Tissue is damaged and inflamed.
- Brawny edema: non-pitting edema
Lymphedema
What is it?
- Lymphedema: lymphphatic obstruction
- Swelling due to due to blockage in the lymphatic system
Lower Extremity: Subdivisions
What are the subdivisions of the lower extremity?
Subdivisions:
- Hip
- Thigh
- Knee
- (Lower) Leg
- Ankle
- Foot
- Hindfoot, Midfoot, Forefoot
LE: General Inspection
What are you evaluating the lower extremity for?
Evaluate Lower extremity for the following:
- Color
- Swelling
- Masses
- Varicosities
- Grossdeformity
- Involuntarymovements
- Gait
- Symmetry
- Skin folds
- Length
- Size
- Hypertrophy v. atrophy
LE: Palpation
What are you palpating the lower extremity for?
- Palpate all lower extremity bones, joints, and surrounding muscles for the following:
- Muscle tone
- Warmth
- Tenderness
- Crepitus
- Popliteal fossa
- Pulses
- Edema
Assess for areas of tenderness
LE: Range of Motion
What are you assessing?
- Test ROM: Actively or Passively
- Both are required for a complete exam
- Watch for limitations of movement
- Assess for instability, pain, clicking, locking, crepitus
- Complete full ROM
LE: Range of Motion
What are you testing in the hip?
Knee?
Ankle/foot?
Isolate and stabilize each joint during strength testing and compare bilaterally
- Hip:
- abduction and adduction
- flexion and extension
- Internal and external rotation
- Knee:
- flexion** and **extension
- Ankle/Foot:
- dorsiflexion and plantar flexion
- inversion and eversion
- Internal and external rotation (adduction and abduction)
- toe flexion and extension
- supination and pronation
Hip Joint
What type of joint?
Allowed movements?
- Weight bearing joint with strong muscle groups:
- Freely movable joint supported
- Flexors & extensors
- Abductors & adductors
Hip & Thigh: Inspection
What position are you inspecting the patient in?
- Patient already supine (just finished abdomen and inguinal region)
- Examination of inguinal region will only be verbalized for the practical: nodes, pulses, hernias.
- Expose lower extremities
- Inspect Hips and Thighs, verbalizing landmarks
- Assess anterior and lateral for abnormality
- Evaluate for limbs ymmetry and leg length equality
Hip: Palpation
What landmarks are you palpating on the hip?
- Anterior landmarks
- Iliac crest
- Anterior superior iliac spine
- Pubic symphysis
- Posterior-lateral landmarks
- Greater trochanter
- Ischial tuberosity
- Thigh
- Quadriceps
- Hamstrings
- Femur
Hip: ROM
What ROM is being assessed?
Which actions require strenght testing?
How to perform each test
-
ROM
- Abduction and adduction
- Flexion and extension
- Internal and external rotation
-
Strength testing
- Abduction, adduction, flexion
Trendelenburg Test
What is this testing?
How to perform test?
What is a positive result?
What does the positive result indicate?
- Observe the patient from behind
- Ask patient to lift leg with hip and knee flexion
Positive: pelvis drops > 2 cm and indicates weakness of the contralateral hip abductors
FADIR
What is this testing?
How to perform test?
What is a positive result?
What does the positive result indicate?
- Impingement Test
- FADIR: Flexion, Adduction, Internal Rotation
- Positive: Reproduction of anterolateral hip pain consistent with FAI
FABER
What is this testing?
How to perform test?
What is a positive result?
What does the positive result indicate?
- Patrick Test, Figure-of-Four
- FABER: Flexion, Abduction, External Rotation
- Positive: pain to groin, SI joint, or posterior hip
Knee Joint
What type of joint?
Condylar Joint
Knee: Inspection
What are you inspecting for?
- Alignment and contour of the knees
- Atrophy
- Swelling
- Patellar tracking
- Obvious deformity
Lower Leg: Inspection
What are you inspecting for?
Size and symmetry
Swelling/edema
Venous pattern
Texture of the skin
Distribution of hair
Knee: Palpation
What landmarks are you palpating?
- Palpation of landmarks:
- Quadriceps tendon
- Patella
- Patellar tendon
- Medial & lateral joint lines
- Tibial tuberosity
Popliteal Fossa: Palpation
what are you palpating for?
- Palpate for fullness or masses (cyst, aneurysm, lymphadenopathy)
- Popliteal pulse
- Knee should be flexed
- May need to press deeply
Lower Leg: Palpation
What are you papating for?
- Tibia/fibula
- Musculature
- Calf tenderness
- Swelling
- Palpable “cord” (suggestive of thrombosed vein)
- Achilles tendon
Knee: ROM
What ROM is being assessed?
Which actions require strenght testing?
How to perform each test
- Flexion: bend knee
- Extension: extend knee
- Strength Testing of the Knee
- Examine separately and compare
- Flexion:
- Knees bent
- Hand on thigh and ankle
- “Don’t let me pull your foot (away from the table)”
- Extension:
- Knees bent
- Hand on thigh and ankle
- “Push my hand away from the table with your foot”
Genus Varum vs. Genu Valgum
Genus Varum – “bow-legged”
Genu Valgum – “knock-kneed”
Baker’s Cyst
What is it also called?
Where is it?
How to assess?
- Baker’s Cyst (Popliteal Cyst)
- A synovial fluid cyst located in the popliteal space
- Palpable as fluctuant fullness
- May be painful or result in calf swelling if they leak fluid or rupture
- Extend the knee to palpate a Baker’s cyst
Popliteal Artery Aneurysm
What is it? How common?
Cause?
Age/gender?
How to diagnose?
- Usually due to atherosclerotic vascular disease
- The most common aneurysm of the peripheral vascular system.
- Bilateral over 50% of the time.
- Males >>females, > 65 years old.
- Dx: pulsatile swelling behind the knee
Patellar Glide
What is this testing?
How to perform test?
What is a positive result?
What does the positive result indicate?
- Patient supine
- Extend knee to relax quads
- Displace patella medially and laterally
Positive: Displacement < 1⁄4 or patella (tightness of retinaculum) or > 3⁄4 of patella width (hypermobility)
Patellar Apprehension Test
What is this testing?
How to perform test?
What is a positive result?
What does the positive result indicate?
- Knee flexed 30°
- Apply medial pressure to displace patella laterally
- Observe for apprehension
Positive: Patient has sensation of instability (“knee giving out”) and guards or demonstrates apprehension indicating hypermobility or patellofemoral instability
J-Sign
What is this testing?
How to perform test?
What is a positive result?
What does the positive result indicate?
- Knee flexion of 45-90°
- Slowly extend the knee
- Observe patellar tracking
Positive: Lateral tracking of the patella when approaching terminal extension indicating hypermobility or instability of the patella
Bulge Sign
What is this testing?
How to perform test?
What is a positive result?
What does the positive result indicate?
- Patient supine with leg in extension
- Sweep downward with one hand “milking” the fluid toward the patella
- Apply infrapatellar pressure to each side observing for a bulge or alternatively, stroke medial side upwards followed but the lateral side downwards
Positive: medial bulge appreciated with presence of effusion
Ballottement
What is this testing?
How to perform test?
What is a positive result?
What does the positive result indicate?
- Patient supine
- Leg fully extended
- Compress suprapatellar pouch
- Press patella toward the femur
- Oscillate for motion and observe for fluid return to suprapatellar pouch
Positive: Fluid present beneath the patella
Valgus Stress Test
What is this testing?
How to perform test?
What is a positive result?
What does the positive result indicate?
Valgus Stress Test (MCL)
- Patient supine
- Stabilize at lateral joint line, medial ankle
- Apply lateral to medial force at joint line while restricting axial rotation
- Complete exam at 0 and 30 degrees of flexion
Positive: pain or medial joint space laxity
Varus Stres Test
What is this testing?
How to perform test?
What is a positive result?
What does the positive result indicate?
Varus Stress Test (LCL)
- Patient supine
- Stabilize at medial joint line, lateral ankle
- Apply medial to lateral force at joint line while restricting axial rotation
- Complete exam at 0 and 30 degrees of flexion
Positive: pain or lateral joint space laxity
Posterior Drawer Sign
What is this testing?
How to perform test?
What is a positive result?
What does the positive result indicate?
- Patient supine
- Flex hips and knees to 90°
- Stabilize foot flat on table
- Thumbs on medial and lateral joint line with fingers on hamstring insertions
- Pull tibia back checking for excessive posterior movement
Positive: posterior translation without firm endpoint
Posterior Sag Sign
What is it?
Posterior Sag Sign: PCL
- Note the amount of posterior sag relative to the other leg
- The anterior tibial surface normally lies 1 cm anterior to the femoral surface
- This is checked in both extension & 90° of flexion with both internal & external rotation
Lachman
What is this testing?
How to perform test?
What is a positive result?
What does the positive result indicate?
Lachman (ACL)
- Patient in supine position
- Kneeflexionto20-30°
- Stabilize the distal femur with one hand while attempting to displace tibia anteriorly with the other hand
Positive: anterior translation without firm endpoint
Anterior Drawer
What is this testing?
How to perform test?
What is a positive result?
What does the positive result indicate?
Anterior Drawer (ACL)
- Patient supine
- Flex hips and knees to 90°
- Stabilize foot flat on table
- Thumbs on medial and lateral joint line with fingers on hamstring insertions
- Pull tibia forward checking for excessive forward movement
Positive: anterior translation without firm endpoint
Pivot-Shift Test
What is this testing?
How to perform test?
What is a positive result?
What does the positive result indicate?
Pivot-Shift (Pivot) Test
Assesses for instability associated with ACL injury
- Flex hip to 20-30 degrees with knee extended
- Hip should be slightly abducted to relax the IT band allowing rotation of the tibia
- Internal rotation of the lower leg with valgus stress
- Slowly flex and then extend the knee looking for subluxation
McMurray Test
What is this testing?
How to perform test?
What is a positive result?
What does the positive result indicate?
McMurray Test
- Start with flexed knee: grasp heel with one hand & joint line of knee with thumb and index finger.
- Medial meniscus
- Externally rotate at heel, flex maximally, then slowly extend the knee while providing (valgus) stress to knee
- Lateral meniscus
- Internally rotate at the heel, flex maximally, then slowly extend the knee while providing (varus) stress to knee
Apley Grind Test
What is this testing?
How to perform test?
What is a positive result?
What does the positive result indicate?
Apley Grind (Distraction and Compression) Test
-
Meniscus Assessment:
- Patient prone
- Knee flexed 90°
- Stabilize thigh with examiner’s knee
- Provide longitudinal distraction while gripping the ankle
- Apply downward force to foot and rotate internally and externally
-
Positive: Pain/clicking with compression indicates possible meniscus injury which should resolve with distraction.
- *Pain with distraction testing may indicate ligament injury
Ankle Joint
Type of joint
Joints involved
- Ankle:
- Weight-bearing joint
- Absorb impact of the gait
- Hinge joint
- Tibiotalar joint.
- Subtalar (talocalcaneal)
Foot Joint
- Tarsal/metatarsal joint
- PIP/DIP joint
Ankle & Foot: Inspection
What are you inspecting for?
- Deformities
- Nodules or other masses
- Swelling
- Callus
- Nails
Pes Planus
Flatfoot
Pes Cavus
High Arch
Neuropathic Ulcer
Neuropathic Ulcer
associated with diabetic neuropathy
Ankle & Foot: Palpation
What landmarks are you papating for?
How to assess for pitting?
- Palpation of landmarks:
- Achilles tendon
- Medial and lateral malleoli
- Calcaneus
- Metatarsals
- MTP and IP joints
- Press downward with thumb for a few seconds:
- Dorsum of foot, behind medial malleolus, or on shins
- Grade from 0 to 4+ edema
- May indicate how high edemarises up leg
Palpation of Pedal Pulses
Dorsalis pedis pulse
Posterior tibial pulse
-
Dorsalis pedis pulse
- Dorsum of the foot
- Approximately over the 1st-2nd metatarsals
-
Posterior tibial pulse
- Behind and slightly below medial malleolus
Grading of Pulses
Grade the amplitude of the pulse:
- 0, Absent, unable to palpate
- 1+, Diminished, weaker than expected
- 2+, Brisk, normal
- 3+, Increasing
- 4+, Bounding
Toes: ROM
What ROm are you testing?
- Flexion of the toes:
- Bend the toes
- “curl your toes under”
- Extension of the toes:
- Straighten the toes
- “lift your toes up”
Ankle: Strength Testing
What ROM are you testing?
- Dorsiflexion:
- Put hand on top of foot
- “Bend your foot up against my resistance”
- Plantar flexion:
- Put hand under ball of patient’s foot
- “Push down against my hand, like foot on the accelerator”
Anterior Drawer Test of Ankle
What is this testing?
How to perform test?
What is a positive result?
What does the positive result indicate?
- Patient supine or seated
- Stabilize the distal tibia with one hand
- Grasp the calcaneus and pull anteriorly
Positive: laxity associated with lateral collateral ligaments (anterior talofibular ligament ) instability
Thompson Test
What is this testing?
How to perform test?
What is a positive result?
What does the positive result indicate?
Thompson Test: Achilles Tear
- Patient prone or can kneel on stool
- Squeezecalf
- Observeforplantarflexion
Positive: No plantar flexion response with squeeze
Spine: Inspection
- Expose the entire back
- Note patient’s posture with feet aligned and together with arms hanging at the sides
- Is head erect?
- Are shoulders & pelvis level?
- Inspect from the side
- Evaluate spinal curvature
- Assess cervical and lumbar concavity and thoracic convexity
Spine: Inspection & Palpation
What are you inspecting for?
What landmarks you palpating?
-
Inspection
- Cervical concavity
- Thoracic convexity
- Lumbar concavity
-
Palpation
- Spinous processes
- May also do this during flexion of the spine
- Paravertebral muscles – Tenderness
- Spasm
- Palpate sciatic nerve
- Palpate sacroiliac joint
- Spinous processes
Spine: ROM
What neck & spine ROm are you testing?
- ROM of the neck
- Completed during the neck exam
- ROM of the spine (thoracic & lumbar)
- Flexion
- Extension
- Rotation
- Lateral bending
- Hunch the back
Spine ROM
-
Flexion
- Bend forward and touch toes
- Evaluate for scoliosis
- May palpate along the spinous processes during this maneuver.
-
Extension
- Bend backwards
- Stabilize the patient
- Hands on hips standing to the side
-
Rotation
- Rotate the trunk posteriorly
- Stabilize the patient
- Hands on hip or shoulders
-
Lateral Bending
- Lean to each side as far as possible
- Act like picking up a suitcase
- Stabilize the patient
- Lean to each side as far as possible
-
Hunch the back
- Assess for spinal curvature
Postural Deformities
What are the spinal postural deformities?
Adams Forward Bend Test
What is this testing?
How to perform test?
What is a positive result?
What does the positive result indicate?
Standing Examination and Adams Forward Bend Test
- Inspect from several angles and with patient bending forward
- Always evaluate for potential limb length discrepancy to determine if apparent discrepancy is from spine or if a true LLD is causing curvature.
Galeazzi Test
What is this testing?
How to perform test?
What is a positive result?
What does the positive result indicate?
Inspecting for limb length discrepancy
Comparing medial malleolus (measurement to ASIS)
Straight Leg Raise Test (SLR)
What is this testing?
How to perform test?
What is a positive result?
What does the positive result indicate?
- Specialized test for lumbosacral radiculopathy and/or sciatic neuropathy
- Most sensitive for L5-S1
- Passive ROM while supine with knees extended
- Dorsiflexion of the ankle may further increase the pain response
- Positive test: radiating pain in affected limb
- Note degrees of elevation
- *Also called Lasègue’s Test (Sign)
Seated Straight Leg Raise (SLR) Test
What is this testing?
How to perform test?
What is a positive result?
What does the positive result indicate?
Seated SLR Test (“flip sign”)
- Patient seated with hands on the table.
- Passively extend knee
Positive sign: Patient will “flip back” due to pain.
Lumbar Radiculopathy
