Physical Examination of

the Lower Extremity

Dr Ülkü Akarırmak
 Objectives

Principles of Physical Examination

• Hip
• Knee
• Foot & Ankle
 Diagnosis
• Clinical Evaluation
- History
- Physical Examination

• Laboratory Evaluation
- Biochemistry
- Imaging (x-ray, CT, MR, US)
- Electrophysiology (EMG)
- Others: DXA
 Principles of MSK Exam

• Two sides: right and left

• Two joints: above and below

• Two surfaces: front and back

 General Examination: Posture
• .
 Posterior Pelvis Surface Anatomy
• Iliac crest
• Gluteus maximus
• Gluteal folds

Frolich, Human
Anatomy, Lower LImb
Anterior Leg Surface
Anatomy
Patella
Condyles of femur

Femoral Triangle
–Sartorius (lateral)
–Adductor longus (medial)
–Inguinal ligament (sup)
–Femoral artery + vein+
lymph nodes
 Posterior Leg Surface Anatomy
• Popliteal fossa

Boundaries
Biceps femoris
(Semitendinosis
semimembranosis

Gastrocnemius heads

• Calcaneal (Achilles)
tendon
Frolich, Human
pgAnatomy,
793 Lower LImb
 Examination
of the Lower Extremity Joints

1. Inspection
Gait – Posture
2. Palpation
3. ROM
4. Special Tests
5. Neurologic + Vascular
Examination
 Gait

• Antalgic gait: Painful, short stance phase

• Trendelenburg gait: Weak abductors
• Waddling gait: Bilateral weak abductors
• Steppage gait: Foot drop
• Toe-walking: In-toeing / out-toeing
• Others: Ataxic, scissoring, etc.
 Hip Exam – Inspection

• Inspection

– Leg length discrepancy

– Deformity & Asymmetry
– Muscle wasting (atrophy)
– Swelling
– Skin changes (erythema) etc.
 Hip Exam – Palpation

• Principles
– Reference points - painful areas
– Increased temperature, swelling, tenderness

• Sites
– Front: SIAS, pubic tubercule
– Side: Great trochanter, iliotibial band
– Back: SI joint, SIPS
Sacroiliac joint palpation
 Hip Exam – ROM
• Principles
– Active / passive ROM
– Feel for crepitus, excessive movement
(laxity), limited movement (contracture),
painful limitation

• Movements
– Flexion & Extension
– Abduction & Adduction
– IR & ER (in flexion & extension)
 Hip Joint - ROM
•

Flexion 120-135 degrees

Hip Joint - ROM

Extension 30 degrees
 Hip ROM

Internal rotation 35 External rotation 45

 Hip ROM – sitting position

Internal Rotation External Rotation

 Hip ROM

Abduction 45 Adduction 20-30

 Hip – Motor Function

Movement Muscle(s) Innervation

Lumbar plexus &

Flexion Iliopsoas
femoral nerve

Extension Gluteus max Inferior gluteal

Abduction Gluteus med & min Superior gluteal

Adductor magnus,
Adduction Obturator
longus & brevis
 Hip Joint – Special Tests

• Trendelenburg test: Abductor strength

• Thomas test: Hip flexion contracture

• Ober’s test: Iliotibial band tightness

• Patrick’s (FABERE) test: SI joint and

coxofemoral joint
Thomas test (-) Thomas test (+)
Ober’s Test
Patrick’s (FABERE) test
 Knee Exam - Inspection
- Gait
- Leg length discrepancy
- Deformity
varus, valgus, recurvatum
- Atrophy
- Swelling
- Skin changes
erythema,
scars etc.
Popliteal (Baker’s)Cyst /
Rupture in RA
Leg Length Discrepancy
Biomechanical Evaluation
 Knee – Palpation
• Principles
– Reference points / painful areas
– Warmth, swelling, effusion, tenderness
– Popliteal area
• Sites
– Patella: Margins and surfaces,
– Quadriceps&patellar tendon&insertion
– Bursae
– Ligaments, tendons, & ITB attachment
– Joint line - medial & lateral
– Effusion: Milking test, ballotment
 Knee - ROM
• Principles
– Active & passive ROM
– Crepitus, excessive movement (laxity), limited
movement (contracture, painful limitation)

• Movements
– Extension: Quadriceps (innerv. by femoral nerve)
– Flexion: Hamstrings (innerv. by sciatic nerve)
Range of Motion

• Extension
0°- (-10°)

• Flexion
130°-140°
 Knee – Special Tests

• Patellar Exam
– Patellar apprehension test
– Patellofemoral grind test

• Meniscal Exam
– McMurray test
– Apley’s test

• Ligament tests: ACL, PCL, MCL, LCL

 Patellofemoral grind test

Patellar apprehension test

Exam of Menisci
McMurray’s test
• Flex&ext with
varus&valgus and
int&ext rotation
• Goal is to get torn piece to
pop in and out of place
• (+) if pop or reproduction of
pain
Apley’s compression test
• Prone with knee flexed,
axial load and rotation
• McMurray test

McMurray test Apley’s test

 Knee – Ligaments Special Tests

• ACL: Anterior drawer,

Lachman, Pivot shift

• PCL: Posterior drawer

• MCL: Valgus stress in neutral & 30 flexion

• LCL: Varus stress in neutral & 30 flexion

Valgus stress test Varus stress test
 Foot & Ankle Exam – Inspection
• Hindfoot, midfoot & forefoot areas
- Gait analysis
- Alignment
• Ankle: Valgus or varus
• Foot: Pes planus or cavus
• Big toe: Hallux valgus
• Toes: Claw, hammer, mallet
- Asymmetry
- Swelling, skin changes
(erythema or scars)
Foot Deformities
Toe Deformities
 Foot & Ankle – Palpation

• Principles
Temperature, swelling,
effusion, pain
• Sites
– Bones: Malleoli and
bones of the hindfoot, midfoot and forefoot
– Ankle joint
– Tendons: Achilles, posterior tibial, peroneal
– Interdigital neuroma
 Foot & Ankle – ROM

• Principles
- Active & passive ROM
- Crepitus, excessive movement (laxity),
contracture, painful limitation
• Movements
- Ankle: dorsiflexion & plantarflexion
- Subtalar joint: Inversion & eversion
- Forefoot: Abduction & adduction
- Toes: Extension & flexion
İnversion-Eversion
Abduction-Adduction
Ankle & Foot - ROM
 Foot & Ankle – Motor
Exam
Movement Muscle(s) Innervation

Ankle DF Tibialis anterior Deep peroneal

Ankle PF Gastrocnemius Tibial

Inversion Tibialis posterior Tibial

Peroneus longus & Superficial

Eversion
brevis peroneal
 Foot & Ankle – Special Tests

• Tendons
– Achilles tendon
– Posterior tibial tendon

• Instability
– Anterior drawer test
– Inversion stress test
– Peroneal tendon instability test

• Morton’s test: Mulder’s click

Thompson 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 Examination

• Peripheral nerves

• Spinal pathology

- Sensation
- Muscle strength test
- Deep tendon reflexes
 Dermatomes & Myotomes
Root Sensory Motor Reflexes
L1 Inguinal ligament Iliopsoas
L2 Anteromedial thigh Iliopsoas
L3 Medial to patella Quads
L4 Medial lower leg Tibialis anterio Patellar
L5 Anterolat leg, dorsum foot EHL
S1 Posterolateral heel Gastrocnemius Achilles
S2 Posterior thigh Rectal

S3-5 Perianal Rectal

Manual Muscle Test
Scale 5/5 - 0
 Vascular Examination
• Inspection
– Colour - Pallor
– Hair
• Palpation
– Feel pulses:
dorsalis pedis
posterior tibialis
popliteal
femoral
– Temperature
– Capillary refill
• Special Tests
– Compartments check
– Ankle-Brachial Index
Inspection
Q&A
 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

Compartment Muscles Neurovascular structures

Tibialis anterior, Extensor

Deep peroneal
Anterior compartment of hallucis longus, Extensor
nerve, Anterior
leg digitorum
tibial vessels
longus, Peroneus tertius
Fibularis/peroneus
Lateral compartment of Superficial
longus, Fibularis/peroneu
leg peroneal nerve
s brevis
Tibialis posterior, Flexor
Tibial
Deep posterior hallucis longus, Flexor
nerve, Posterior
compartment of leg digitorum
tibial vessels
longus, Popliteus
Superficial posterior Gastrocnemius, Soleus, Medial sural
compartment of leg Plantaris cutaneous nerve
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 Done
This test is done to screen for PAD
Results
The ABI result can help diagnose PAD
Normal
A 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 flow
Abnormal: ABI is 0.9 or lower
Blood Supply of Lower Extremity