physical examination of the lower extremity dr Ülkü akarırmak
TRANSCRIPT
Physical ExaminationPhysical Examination of ofthe the Lower ExtremityLower Extremity
Dr Ülkü AkarırmakDr Ülkü Akarırmak
ObjectivesObjectives
Principles of Physical ExaminationPrinciples of Physical Examination
• HipHip
• KneeKnee
• Foot & AnkleFoot & Ankle
DiagnosisDiagnosis
• Clinical EvaluationClinical Evaluation
- History- History
- - Physical ExaminationPhysical Examination
• Laboratory EvaluationLaboratory Evaluation
- Biochemistry- Biochemistry
- Imaging (x-ray, CT, MR, US)- Imaging (x-ray, CT, MR, US)
- Electrophysiology (EMG)- Electrophysiology (EMG)
- Others: DXA - Others: DXA
Principles of MSPrinciples of MSKK Exam Exam
• Two sidesTwo sides: right and left: right and left
• Two jointsTwo joints: above and below: above and below
• Two surfacesTwo surfaces: front and back: front and back
General Examination: PostureGeneral Examination: Posture
• ..
Frolich, Human Anatomy, Lower LImb
Posterior PelvisPosterior Pelvis Surface Anatomy Surface Anatomy • Iliac crestIliac crest• Gluteus maximus Gluteus maximus • Gluteal foldsGluteal folds
Anterior LegAnterior Leg Surface Surface Anatomy Anatomy
PatellaPatellaCondyles of femurCondyles of femur
Femoral TriangleFemoral Triangle–Sartorius (lateral)Sartorius (lateral)–Adductor longus (medial)Adductor longus (medial)–Inguinal ligament (suInguinal ligament (sup)p)–Femoral aFemoral arteryrtery + v + vein+ein+ lymph nodeslymph nodes
Frolich, Human Anatomy, Lower LImb
Posterior LegPosterior Leg Surface Anatomy Surface Anatomy
• Popliteal fossaPopliteal fossa
BoundariesBoundariesBiceps femoris Biceps femoris (Semitendinosis (Semitendinosis semimembranosissemimembranosis Gastrocnemius heads Gastrocnemius heads
• Calcaneal (Achilles) Calcaneal (Achilles) tendontendon
pg 793
ExamExaminationinationof the of the Lower Extremity JointLower Extremity Jointss
1. Inspection 1. Inspection
GaitGait – Posture – Posture
2. Palpation2. Palpation
3. ROM3. ROM
4. 4. Special TestsSpecial Tests
5. 5. NeuroNeurologic + Vlogic + Vascular ascular ExaminationExamination
GaitGait
• Antalgic gaitAntalgic gait: P: Painful, short stance phaseainful, short stance phase• Trendelenburg gait: Trendelenburg gait: WWeak abductorseak abductors• Waddling gait: Waddling gait: BBilateral weak abductorsilateral weak abductors• Steppage gait: Steppage gait: FFoot dropoot drop• Toe-walkingToe-walking: I: In-toeing n-toeing / / out-toeingout-toeing• Others: Others: AAtaxic, scissoring, etc.taxic, scissoring, etc.
Hip Hip Exam Exam – – InspectionInspection
• InspectionInspection
– Leg length discrepancyLeg length discrepancy– DeformityDeformity & Asymmetry & Asymmetry – Muscle Muscle wastingwasting (atrophy) (atrophy)– SwellingSwelling– Skin changes (erythema) Skin changes (erythema) etc.etc.
HipHip Exam Exam – – PalpationPalpation
• PrinciplesPrinciples– Reference points - Reference points - painful areapainful areass– Increased temperatureIncreased temperature, swelling, tenderness, swelling, tenderness
• SitesSites– FFront: SIront: SIAAS, pubic tubercS, pubic tubercuulele– SSide: Gide: Great trochanterreat trochanter, iliotibial band, iliotibial band– BBack: SI joint, SIack: SI joint, SIPPSS
Sacroiliac joint palpation
HipHip Exam Exam – – ROMROM
• PrinciplesPrinciples– Active Active / / passivepassive ROM ROM– Feel for crepitus, excessive movement Feel for crepitus, excessive movement
(laxity), limited movement (contracture), (laxity), limited movement (contracture), painful limitationpainful limitation
• MovementsMovements– Flexion & ExtensionFlexion & Extension– Abduction & AdductionAbduction & Adduction– IR & ER IR & ER ((in flexion & extensionin flexion & extension))
Hip Joint - ROMHip Joint - ROM•
Flexion 120-135 degrees
Hip Joint - ROMHip Joint - ROM
Extension 30 degrees
Hip ROMHip ROM
Internal rotation 35 External rotation 45
Hip ROM – sitting positionHip ROM – sitting position
External Rotation Internal Rotation
Hip ROMHip ROM
Abduction 45 Adduction 20-30
Hip – MotorHip – Motor Function Function
MovementMovement Muscle(s)Muscle(s) InnervationInnervation
FlexionFlexion IliopsoasIliopsoas Lumbar plexus & Lumbar plexus & femoral nervefemoral nerve
ExtensionExtension Gluteus maxGluteus max Inferior glutealInferior gluteal
AbductionAbduction Gluteus med & minGluteus med & min SupSupeerior glutealrior gluteal
AdductionAdduction Adductor magnus, Adductor magnus, longus longus && brevis brevis OObturatorbturator
HipHip Joint Joint – – Special TestsSpecial Tests
• Trendelenburg testTrendelenburg test:: AAbductor strengthbductor strength
• Thomas testThomas test: : HHip flexion contractureip flexion contracture
• Ober’s testOber’s test: : IIliotibial band tightnessliotibial band tightness
• Patrick’s (FABERPatrick’s (FABEREE) test) test: : SI jointSI joint and and coxofemoral jointcoxofemoral joint
Thomas test (-) Thomas test (+)
Ober’s TestOber’s Test
Patrick’s (FABERE) test
KneeKnee Exam Exam - - InspectionInspection - Gait- Gait
- - Leg length discrepancyLeg length discrepancy-DeformityDeformity
varus, valgusvarus, valgus, recurvatum, recurvatum
- - AAtrophytrophy
- - SwellingSwelling
- - Skin changesSkin changes erythema, erythema, s scarscars etc. etc.
Popliteal (Baker’s)Cyst / Popliteal (Baker’s)Cyst / Rupture in RARupture in RA
Leg Length Discrepancy Leg Length Discrepancy
Biomechanical EvaluationBiomechanical Evaluation
Knee – Knee – PalpationPalpation• PrinciplesPrinciples
– Reference points / Reference points / painful areapainful areass– WWarmth, swelling, effusion, tendernessarmth, swelling, effusion, tenderness– Popliteal areaPopliteal area
• SitesSites– Patella: Patella: MMargins and surfaces, argins and surfaces, – QQuadriceps&patellar tendon&insertionuadriceps&patellar tendon&insertion– BBursaeursae– Ligaments, tendons, & ITB attachmentLigaments, tendons, & ITB attachment– Joint linJoint line - e - medial & lateralmedial & lateral– Effusion: Effusion: MMilking test, ballotmentilking test, ballotment
Knee - Knee - ROMROM
• PrinciplesPrinciples– Active Active & & passivepassive ROM ROM– CCrepitus, excessive movement (laxity), limited repitus, excessive movement (laxity), limited
movement (contracture, painful limitationmovement (contracture, painful limitation))
• MovementsMovements– Extension: Extension: QQuadriceps uadriceps (innerv. (innerv. by by ffemoremoral nerve)al nerve)– Flexion: Flexion: HHamstrings amstrings (innerv. (innerv. by sciaticby sciatic nerve) nerve)
Range of MotionRange of Motion
• ExtensionExtension 0°- (-10°)0°- (-10°)
• Flexion Flexion
130°-140°130°-140°
Knee – Knee – Special TestsSpecial Tests
• Patellar Patellar ExamExam– Patellar apprehension testPatellar apprehension test– Patellofemoral grind testPatellofemoral grind test
• Meniscal Meniscal ExamExam– McMurray testMcMurray test– Apley’s testApley’s test
• Ligament testsLigament tests: : ACL, PCL, MCL, LCLACL, PCL, MCL, LCL
Patellofemoral grind test
Patellar apprehension test
Exam of MenisciExam of MenisciMcMurray’s testMcMurray’s test
• • Flex&ext with Flex&ext with varus&valgus and varus&valgus and int&ext rotation int&ext rotation
• • Goal is to get torn piece toGoal is to get torn piece to pop in and out of placepop in and out of place
• • (+) if pop or reproduction of (+) if pop or reproduction of painpain
Apley’s compression testApley’s compression test
• • Prone with knee flexed, Prone with knee flexed, axial load and rotationaxial load and rotation
• McMurray testMcMurray test
McMurray test Apley’s test
Knee – Ligaments Knee – Ligaments Special TestsSpecial Tests
• ACLACL:: Anterior drawer, Anterior drawer, LachmanLachman,, Pivot shift Pivot shift
• PCLPCL: Posterior drawer: Posterior drawer
• MCLMCL: : VValgus stress in neutral & 30 flexionalgus stress in neutral & 30 flexion
• LCLLCL: : VVarus stress in neutral & 30 flexionarus stress in neutral & 30 flexion
Valgus stress test Varus stress test
Foot & Ankle Foot & Ankle Exam Exam – – InspectionInspection
•HHindfoot, midfoot & forefootindfoot, midfoot & forefoot areas areas- Gait analysis- Gait analysis- - AlignmentAlignment
• Ankle: Ankle: VValgus or varus algus or varus • Foot: Foot: PPes planus or cavus es planus or cavus • Big toe: Big toe: HHallux valgus allux valgus • Toes: Toes: CClaw, hammer, malletlaw, hammer, mallet
- - Asymmetry Asymmetry - - Swelling, Swelling, sskin changes kin changes (erythema(erythema or or sscarscars))
Foot DeformitiesFoot Deformities
ToeToe Deformities Deformities
Foot & Ankle – Foot & Ankle – PalpationPalpation
• PrinciplesPrinciples
TemperatureTemperature, swelling, , swelling, effusion, effusion, painpain
• SitesSites– Bones: Bones: MMalleolialleoli and and
bones of the hindfoot, midfoot and forefootbones of the hindfoot, midfoot and forefoot– Ankle jointAnkle joint– Tendons: Achilles, posterior tibial, peronealTendons: Achilles, posterior tibial, peroneal– Interdigital neuromaInterdigital neuroma
Foot & Ankle – Foot & Ankle – ROMROM
• PrinciplesPrinciples
- - Active Active & & passivepassive ROM ROM
- C- Crepitus, excessive movement (laxity), repitus, excessive movement (laxity), contracture, painful limitationcontracture, painful limitation
• MovementsMovements
- - Ankle: dorsiflexion & plantarflexionAnkle: dorsiflexion & plantarflexion-Subtalar joint: Subtalar joint: IInversion & eversionnversion & eversion-Forefoot: Forefoot: AAbduction & adductionbduction & adduction-Toes: Toes: EExtension & flexionxtension & flexion
İnversion-Eversion İnversion-Eversion Abduction-Abduction-AdductionAdduction
Ankle & Foot - ROMAnkle & Foot - ROM
Foot & Ankle – Foot & Ankle – MotorMotor ExamExam
MovementMovement Muscle(s)Muscle(s) InnervationInnervation
Ankle DFAnkle DF TibTibialisialis a antnteriorerior Deep Deep pperonealeroneal
Ankle PFAnkle PF GastrocnemiusGastrocnemius TibialTibial
InversionInversion TibTibialis ialis ppostosteriorerior TibialTibial
EversionEversion Peroneus longus & Peroneus longus & brevisbrevis
Superficial Superficial pperonealeroneal
Foot & Ankle – Foot & Ankle – Special TestsSpecial Tests
• TendonsTendons– Achilles Achilles ttendonendon– Posterior Posterior ttibial ibial ttendonendon
• InstabilityInstability– Anterior drawer testAnterior drawer test– Inversion stress testInversion stress test– Peroneal tendon instability testPeroneal tendon instability test
• Morton’s testMorton’s test: Mulder’s click: Mulder’s click
Thompson testThompson test
Anterior drawer test Inversion stress test
Peroneal tendon instability test
Peroneal tendon instability test
Mulder’s click
Mulder’s Sign - Morton's neuroma: Pain, by squeezing two metatarsal heads together while putting pressure on the interdigital space Pain will be localized to the plantar surface of the involved space+paresthesias radiating into affected toes
Neurological ExaminationNeurological Examination
• PPeripheraleripheral nerves nerves
• SSpinpinal al pathologypathology
- S- Sensationensation
- Muscle strength - Muscle strength testtest
- D- Deep tendon reflexeseep tendon reflexes
Dermatomes & MyotomesDermatomes & Myotomes
RootRoot SensorySensory MotorMotor ReflexesReflexes
L1L1 Inguinal ligamentInguinal ligament IliopsoasIliopsoas
L2L2 Anteromedial thighAnteromedial thigh IliopsoasIliopsoas
L3L3 Medial to patellaMedial to patella QuadsQuads
L4L4 Medial lower legMedial lower leg TibTibialisialis aantnterioerio PatellarPatellar
L5L5 Anterolat leg, dorsum footAnterolat leg, dorsum foot EHLEHL
S1S1 Posterolateral heelPosterolateral heel GastrocGastrocnemiusnemius AchillesAchilles
S2S2 Posterior thighPosterior thigh RectalRectal
S3-5S3-5 PerianalPerianal RectalRectal
Manual Muscle TestManual Muscle TestScale 5/5 - 0Scale 5/5 - 0
Vascular ExaminationVascular Examination• Inspection Inspection
– Colour - Colour - PallorPallor– Hair Hair
• PalpationPalpation– Feel pulsesFeel pulses: :
dorsalis pedisdorsalis pedis posterior tibial posterior tibialisis poplitealpopliteal femoral femoral
– TemperatureTemperature– Capillary refillCapillary refill
• Special TestsSpecial Tests– Compartments checkCompartments check– Ankle-Brachial IndexAnkle-Brachial Index
InspectionInspection
Q&AQ&A
Compartment Muscles Neurovascular structures
Anterior compartment of leg
Tibialis anterior, Extensor hallucis longus, Extensor digitorum longus, Peroneus tertius
Deep peroneal nerve, Anterior tibial vessels
Lateral compartment of leg
Fibularis/peroneus longus, Fibularis/peroneus brevis
Superficial peroneal nerve
Deep posterior compartment of leg
Tibialis posterior, Flexor hallucis longus, Flexor digitorum longus, Popliteus
Tibial nerve, Posterior tibial vessels
Superficial posterior compartment of leg
Gastrocnemius, Soleus, Plantaris
Medial sural cutaneous nerve
Compartments The (lower) leg is divided into four compartments by the, interosseous membrane of the leg, the transverse intermuscular septum and the posterior intermuscular septum
Ankle-Brachial Index Test (ABI)Measuring blood pressure at the ankle and arm while a person is at rest. Measurements are repeated at both sites after 5 minutes of walking on a treadmill.The ABI result is used to predict the severity of peripheral arterial disease (PAD) Why It Is DoneThis test is done to screen for PADResultsThe ABI result can help diagnose PAD NormalA normal resting ABI is 1.0 to 1.4. This means that blood pressure at ankle is the same or greater than pressure at arm, and suggests no significant narrowing or blockage of blood flowAbnormal: ABI is 0.9 or lower
Blood Blood SSupplyupply of Lower Extremity of Lower Extremity