1 Screening Examination of the Lower Extremities Melvyn Harrington, MD Department of Orthopaedic Surgery & Rehabilitation Loyola University Medical Center BUY THIS BOOK! • Essentials of Musculoskeletal Care • Written for Primary Care Providers • Perfect for 3rd & 4th year med students going into primary care Lower Extremity Screening Exam • Inspect, Palpate, and Examine Lower Extremities (skin, muscles, joints). • Test for ROM and muscle strength. • Observe for specific joint deformities, tenderness, soft tissue swelling, joint effusions, bony enlargement, and synovial thickening. 2 Lower Extremity Screening Exam • Skin - Special attention is given to signs of chronic arterial or venous insufficiency. – Nails – inspect for infection, color – Feet/legs - – inspect skin for signs of chronic arterial or venous insufficiency – inspect for abnormalities of position, varus or valgus angulation, symmetry of legs and joints – Note any muscle atrophy, fasciculations, or involuntary movements Lower Extremity Screening Exam • Inspect for size, length, shape, and symmetry of the legs and joints. Note any abnormalities of position, swelling, or redness. • Palpate for bony or muscle abnormalities. – Knee – patella tendon, patella, medial and lateral femoral epicondyles, proximal tibia – Hip - palpate area of greater trochanter, note any pain Lower Extremity Screening Exam • Test ROM of each joint. – Ankle: • dorsiflexion (20o) • plantarflexion (45o) • eversion (20o) • inversion (30o) – Knee: Note crepitus with ROM • flexion (130o) • extension (10o) – Hip • Flexion (120o) • Internal Rotation (40o) When the lower leg swings laterally, the femur rotates internally at the hip joint • External Rotation (45o) When the lower leg swings medially, the femur rotates externally at the hip joint. 3 Lower Extremity Screening Exam • Manual Motor Testing • Always grade muscle strength on a scale of 0 to 5: • 0—No muscular contraction detected • 1—A barely detectable flicker or trace of contraction • 2—Active movement of the body part with gravity eliminated • 3—Active movement against gravity • 4—Active movement against gravity and some resistance • 5—Active movement against full resistance without evident fatigue. This is normal muscle strength. Lower Extremity Screening Exam • Grade the following muscle strength in each leg: – Hip flexion (iliopsoas muscle – L2, L3, L4 – femoral nerve) – Knee flexion (hamstrings – L5, S1, S2 – sciatic nerve) – Knee extension (quadriceps – L2, L3, L4 – femoral nerve) – Ankle dorsiflexion (L4, L5 – peroneal nerve) – Ankle plantar flexion (S1, S2 – tibial nerve) Where is your hip? • Hip joint pain is most commonly felt in the groin and anterior thigh • Hip joint pain may radiate to the knee • Pain over the greater trochanter is typically trochanteric bursitis • The buttock is not the hip! • Buttock pain is typically from the sciatic nerve or lumbar spine 4 Musculoskeletal History • Where is the pain? • When did it start? • How bad is it? • Does it keep you awake at night? • What makes it better/worse? • What treatments have you had and did they work? Hip Specific History • How far can you walk? • Do you use any assistive devices? • Do you limp? • Can you tie your shoes , put on your socks, and clip your toenails? • Do you climb stairs normally or one at at time? Which foot first? • How long can you sit? • Do you have pain with the first steps after sitting? Gait Analysis - Hip • Abductor Lurch – Shoulder shifting gait – Moves center of gravity towards affected side to decrease forces across the hip joint • Trendelenberg Gait – Weakness of abductor muscles – Pelvis drops away from the affected side 5 Hip Exam • Palpation – Greater trochanter – bursitis – Pubic rami – fractures – Ischium – fractures, bursitis, sciatic nerve Hip Exam • Range of Motion – Flexion/ Extension – Internal/ External Rotation – Abduction/ Adduction • Check in several positions • Know where the pelvis is! • Compare with the contralateral side Hip Range of Motion • Flexion – Most pts > 90 • Flexion Contracture – Maximally flex opposite hip to fix pelvis – Thigh will not lie flat on the table 6 Hip Range of Motion • Hip Rotation • Check in several positions: – Supine with hip flexed – Supine with hip extended – Seated – Prone (most accurate) Internal Rotation External Rotation Hip Range of Motion External Rotation Internal Rotation Seated Hip Range of Motion • Palpate ASIS to feel when pelvis begins to rotate ABduction ADDuction 7 Knee History • Knee pain stays in the knee • Hip pain may be felt in the knee • The knee is more complex than the hip • More things can hurt in the knee Knee History • Mechanism of Injury – What exactly happened? – Which way did your knee go? – Did you hear or feel a pop? – Did your knee swell? • Right away or over next 24 hours? • Mechanism can often make the diagnosis • Pop and immediate swelling almost always ACL Knee History • Location – Anterior, posterior, medial, lateral – Almost every structure in the knee except for the cruciate ligaments can be directly palpated 8 Knee Exam • Observation • Alignment (standing) – Varus/valgus – Procurvatum/recurvat um • Skin – Redness – Warmth – Effusions – Lesions/wounds Gait Analysis - Knee • Antalgic (painful) Limp – Shortened stance phase of gait • Stiff-knee gait – Knee does not bend through gait cycle • Thrust – Varus or valgus bowing with each step – “trick knee” Knee Exam • Range of motion – Active and passive – Extensor lag – Extension ( 0 - -10) – Flexion (100 - 150) 9 Go Examine Yourselves!