PHYSICAL EXAMINATION OF THE LOWER EXTREMITY MUSCULOSKELETAL SYSTEM

Question 1

Components and findings of a HIP examination

(1) Inspection

Answer 1

(a) Gait
(b) Pelvic and Hip alignment
1) Anterior and Posteriorly
(c) Skin and subcutaneous tissue
(d) Surrounding musculature
1) Atrophy or wasting
2) Hypertrophy

Question 2

Components and findings of a HIP examination

(2) Palpation
(a) Major landmarks

Answer 2

1) ASIS
2) PSIS
3) Greater Trochanter
4) Iliac Crest
5) Ischial Tuberosity

Question 3

Components and findings of a HIP examination

(3) Assess ROM
(a) Flexion: expect ___ degrees
(b) Extension: expect ___degrees
(c) Abduction: expect ___degrees
(d) Adduction: expect ___degrees
(e) Internal rotation: expect ___degrees
(f) External rotation: expect ___degrees

Answer 3

(a) Flexion: expect 120 degrees
(b) Extension: expect 30 degrees
(c) Abduction: expect 45 degrees
(d) Adduction: expect 30 degrees
(e) Internal rotation: expect 40 degrees
(f) External rotation: expect 45 degrees

Question 4

Components and findings of a HIP examination

(4) Assess Muscle Strength
(a) Flexion
(b) Extension: what muscle
(c) Abduction: what muscle
(d) Adduction: what muscle
(e) External & Internal Rotation

Answer 4

(a) Flexion
(b) Extension: Gluteus Maximus
(c) Abduction: Gluteus Medius
(d) Adduction: Adductor Longus / Brevis / Magnus
(e) External & Internal Rotation

Question 5

Components and findings of a HIP examination

(5) Neurovascular

Answer 5

(a) Femoral pulses

(b) Sensation to light touch

Question 6

Components and findings of a HIP examination

(6) Special Tests
(a) Trendelenburg Test

Answer 6

(a) Trendelenburg Test
1) Detects gluteus medius muscle weakness
a) While observing the PSIS levels, have the patient stand on one leg
1 The test is positive if the PSIS on the unsupported side descends

Question 7

Components and findings of a HIP examination

(6) Special Tests
(b) Faber test aka Figure of 4 test, Patrick test, Jansen test

Answer 7

1) Detects hip and sacroiliac pathology
2) Patient is supine with affected hip in flexion, abduction and external rotation with foot
on opposite knee
3) Stabilize pelvis with hand on contralateral ASIS and press down on thigh of affected
side
4) A positive test results in pain to the hip or sacroiliac joint

Question 8

Components and findings of a HIP examination

(6) Special Tests
(c) Log Roll Test

Answer 8

1) Performed to detect acetabular or femoral neck pathology such as osteoarthritis or
osteonecrosis
2) With patient supine, internally and externally rotate the relaxed lower extremity
3) Pain in the hip or groin, particular with internal rotation is positive

Question 9

Components and findings of a HIP examination

(6) Special Tests
(d) Piriformis Test

Answer 9

1) Tests for a tight piriformis impinging the sciatic nerve
2) With patient lying on the unaffected side and the knee and hip flexed to 90 degree,
stabilize the pelvis with one hand and use the other hand to apply lexion, adduction
and internal rotation pressure at the knee by pushing into the exam table
3) If the test is positive then pain will be produced in the buttock and even down the leg

Question 10

Components and findings of a HIP examination

(6) Special Tests
(e) Scour Test

Answer 10

1) Test for labral pathology, loose body, or other internal derangement of the hip
2) With patient supine and the hip flexed and adducted, use the patient’s knee and thigh to
apply a posterolateral force through the hip as the femur is rotated in the acetabulum
3) Passively flex, adduct and internally rotate the hip while longitudinally compressing to
scour inner aspect of the joint
4) To scour the outer aspect, abduct and externally rotate the hip while maintaining
flexion with longitudinal compression
5) Pain or grating sensation or sensation is positive

Question 11

Components and findings of a HIP examination

(6) Special Tests
(f) Hamstring Flexibility

Answer 11

1) With patient supine and contralateral hip and knee maintained in full extension,
instruct patient to flex hip to 90 degree
2) While maintaining this position, actively extend knee fully
3) If patient is unable to obtain within 10 degree of full knee extension are considered to
have hamstring tightness

Question 12

Components and findings of a HIP examination

(6) Special Tests
(g) Thomas Test

Answer 12

1) Detects flexion contractures or tightness of the hip
2) With your hand under the small of the patients back, have him fully flex his hips
(notice his lumbar curve should flatten into your hand). Instruct the patient to hold
onto his knee as you passively extend the other leg
3) The test is positive if the hip does not fully extend or lumbar curve arches (lordosis)

Question 13

Components and findings of a KNEE examination.

(1) Inspection

Answer 13

(a) Patellar tracking
(b) Watch movement of the patella while patient flexes and extends the knee
(c) Patella normally moves in a gentle arch from a relatively lateral position when knee is
extended to a more medial position as the knee is flexed
(d) With patellar instability the arch is increased and may make an inverted J shaped when
knee nears full extension
(e) Skin and subcutaneous tissues
(f) Surrounding musculature
(g) VMO definition

Question 14

Components and findings of a KNEE examination.

(2) Palpation

Answer 14

(a) Joint line
(b) Major landmarks
(c) Patellar tendon
(d) Infrapatellar bursa
(e) Tibial tuberosity
(f) Fibular Head
(g) Pes Anserine Bursa
(h) Iliotibial Band

Question 15

Components and findings of a KNEE examination.

(3) Assess ROM
(a) Flexion: expect ___ degrees
(b) Extension: expect ___ degrees

Answer 15

(a) Flexion: expect 135 - 145 degrees

(b) Extension: expect 0 degrees

Question 16

Components and findings of a KNEE examination.

(4) Assess Muscle Strength
(a) Flexion: ___
(b) Extension: ___

Answer 16

(a) Flexion: Hamstrings
1) Knee flexion against resistance
(b) Extension: Quadriceps
1) Seated while applying opposing force to tibia

Question 17

Components and findings of a KNEE examination.

(5) Neurovascular

Answer 17

(a) Deep tendon reflexes

(b) Light touch

Question 18

Components and findings of a KNEE examination.

(6) Special Tests
(a) Patellar Apprehension Sign

Answer 18

1) Tests for Patellar instability
2) With patient supine and knee relaxed and slightly flexed, use thumbs to displace
patella laterally
3) Positive would be absence of a firm end feel or patient apprehension

Question 19

Components and findings of a KNEE examination.

6) Special Tests
(b) Patellar Grind Test (Clarke

Answer 19

1) Assesses for cartilage degeneration.
2) Patient is supine with knee extended.
3) Place one hand superior to patella and push inferiorly.
4) Ask patient to tighten quadriceps.
5) Positive would be pain and/or grinding sound.

Question 20

Components and findings of a KNEE examination.

(6) Special Tests
(c) McMurray Test

Answer 20

1) Evaluates the health of the menisci.
2) With patient supine, flex knee to the maximally pain free position. Hold leg in that
position while externally rotating the foot and then gradually extend the knee while
maintaining the tibia in external rotation.
3) Stresses medial meniscus.
4) The same maneuver performed while rotating the foot internally will stress the lateral
meniscus.
5) Joint line clicking and or pain is positive for possible meniscus tear.

Question 21

Components and findings of a KNEE examination.

(6) Special Tests
(d) Thessaly

Answer 21

1) Not referenced, but is increasing reliable for detecting meniscus tears.

Question 22

Components and findings of a KNEE examination.

(6) Special Tests
(e) Varus and Valgus Stress Test

Answer 22

1) Varus Stress evaluates the integrity of the lateral collateral ligament.
2) Valgus Stress evaluates the integrity of the medial collateral ligament.
3) With the patients knee flexed 30 degrees or fully extended, apply varus or valgus stress
on the knee.
4) The test is positive if the patient complains of pain and/or there’s instability.

Question 23

Components and findings of a KNEE examination.

(6) Special Tests
(f) Lachmans

Answer 23

1) Detects instability of the anterior cruciate ligament.
2) With the patients knee flexed 30 degrees, grasp patient’s proximal tibia with one hand
and stabilize distal femur with the other. Pull lower leg sharply creating anterior
translation of the tibia on the femur.
3) Focus on the amount of bony translation of the tibia relative to the femur and the
presence or absence of a firm end point upon reaching full anterior translation.
4) The absence of a firm end point is indicative of an anterior cruciate ligament tear.
5) Increased anterior translation indicated partial or complete tear.

Question 24

Components and findings of a KNEE examination.

(6) Special Tests
(g) Posterior Drawer

Answer 24

1) Assess posterior cruciate ligament stability.
2) With patient supine and foot supported on the table, flex the knee to 90 degrees.
3) Grasp the proximal tibia with both hands and place your thumbs on top of the medial
and lateral tibial plateaus.
4) Push the tibia posteriorly.
5) If the PCL is injured the proximal tibia falls back.

Question 25

Components and findings of a KNEE examination.

(6) Special Tests
(h) Sag Test

Answer 25

1) With patient supine, flex the hip and knee of the affected knee to 90 degrees.
2) With one hand support the knee with your thumb and index fingers placed in the
medial and lateral joint line.
3) The other hand grasp the calcaneus firmly.
4) Have the patient attempt to actively extend the knee while you prevent knee joint
movement.
5) If the PCL is lax then the tibia will sag down when the knee is at rest

Question 26

Components and findings of a KNEE examination.

(6) Special Tests
(i) Ober Test

Answer 26

1) Detects iliotibial band (ITB) contractures or tightness.
2) Have the patient lie on unaffected side. Flex the knee of the affected side to 90 degrees
and passively abduct and hyperextend the hip while stabilizing the pelvis.
3) The test is positive with patient’s inability to lower knee to table or they complain of
pain at the ITB insertion site

Question 27

Components and findings of a KNEE examination.

(6) Special Tests
(j) Fibular Collateral Ligament Palpation

Answer 27

1) With patient supine, flex affected knee and place hip in flexion, abduction, and
external rotation with patient’s foot on opposite knee.
2) Observe lateral knee joint line and palpate in line with fibula for absence of
prominence of ligament.

Question 28

Components and findings of an ankle and foot examination.

(1) Inspection

Answer 28

(a) Carefully inspect
(b) Compare to opposite ankle
1) Edema
2) Ecchymosis
3) Erythema
4) Other abnormalities?

Question 29

Components and findings of an ankle and foot examination.

(2) Palpation

Answer 29

(a) ATFL
(b) CFL
(c) PTFL
(d) Anterior Tibialis

Question 30

Components and findings of an ankle and foot examination.

(3) Assess ROM

Answer 30

(a) Ankle Dorsiflexion
(b) Ankle Plantar Flexion
(c) Subtalar Inversion
(d) Subtalar Eversion
(e) Toe Flexion
(f) Toe Extension

Question 31

Components and findings of an ankle and foot examination.

(4) Muscle Strength
(a) Dorsiflexion / Inversion: What muscle
(b) Plantar Flexion: What muscle
(c) Eversion: What muscle
(d) Toe Flexion: What muscle
(e) Toe Extension: What muscle

Answer 31

(a) Dorsiflexion / Inversion: Tibialis Anterior
(b) Plantar Flexion: Gastrocnemius & Soleus
(c) Eversion: Peroneal Longus / Brevis
(d) Toe Flexion: Flexor Digitorum / Hallucis Longus
(e) Toe Extension: Extensor Digitorum / Hallucis Longus

Question 32

Components and findings of an ankle and foot examination.

(5) Neurovascular

Answer 32

(a) Cap Refill
(b) Light touch sensation
(c) Deep Tendon Reflexes
(d) Distal Pulses

Question 33

Components and findings of an ankle and foot examination.

(6) Special Tests
(a) Anterior Drawer Test

Answer 33

1) Detects anterior instability of the ankle joint
2) Grasp the patient’s heel with one hand and stabilize his tibia anteriorly with the other,
then pull the heel towards you.
3) The test is positive if the talus slides anteriorly under the ankle mortise. You may also
hear an audible “clunk”.

Question 34

Components and findings of an ankle and foot examination.

(6) Special Tests
(b) Inversion (VARUS) Stress Test

Answer 34

1) Evaluates laxity of the calcanofibular ligament.
2) With patient seated and the knee flexed at 90 degrees use one hand to stabilize the
medial aspect of the leg just above the medial malleolus.
3) Place the other hand on the inferolateral aspect of the calcaneus and invert the
hindfoot.
4) If the patient does not have an end point, then the test is positive for a CFL tear.

Question 35

Components and findings of an ankle and foot examination.

(6) Special Tests
(c) Thompson Test

Answer 35

1) Assess the integrity of the achilles tendon.
2) With the patient laying prone and foot off the table, squeeze the calf muscles.
3) The test is positive if the foot doesn’t move into plantar flexion.

Question 36

Components and findings of an ankle and foot examination.

(6) Special Tests
d) Tib/Fib Squeeze

Answer 36

1) Tests for possible Tibiofibular syndesmosis injury.
2) Squeeze the tibia and fibula together.
3) If pain is felt to the lower ankle mortise region of the ankle the test is positive.