Lower limb examination

An introductory lecture

STANDARD APPROACH

LOOK

FEEL

MOVE

SPECIAL TESTS

Regional approach

• Hip

• Knee

• Foot (diabetic)

HIP

LOOK

• Gait…

In hip: short limb gait

trendelenburg gait

antalgic gait

• Scars, sinuses, skin changes, deformities

• Trendelenburg test

Standing on affected leg: pelvis falls to unaffected

side, body swerves to affected side to compensate

FEEL

• Temperature

• Joint palpation (tenderness)

– GT

– ASIS

– Joint line

– Pubic symphisis

MOVE

• Flexion: 0 – 140

– Thomas test

Right Thomas test positive

100

• Abduction: 0 – 45

• Adduction: 0 – 30

• Internal rotate: 0 – 40

• External rotate: 0 – 50

SPECIAL TESTS

Limb length measurement

• To determine site of shortening

• Start with galeazzi test

• Then proceed with Bryant’ triangle

• Measure apparent length:

– Umbilicus to medial malleolus

• Measure true length:

– ASIS to medial malleolus

Summary hip

• Look

• Feel

• Move

• Special test

+ Trendelenburg test

+ Thomas test

+ LLD measurement

KNEE

LOOK

• Gait patterns: antalgic, lateral thrust

• Front, side, back:

– Deformities, swellings, wasting, sinus,

scars, skin changes

• Sit at side of table:

– Assess patella tracking (inverted J)

– Measure Q – angle • ♂ - 14 ♀ - 17

FEEL

• Temperature

• Effusion assessment

– Cross fluctuation – large

– Patella tap – medium

– Bulge test – little

– Hollow test – minimal

• Joint line tenderness

– may suggest meniscus involvement

MOVE

• Flexion: active, passive

• Extension: active, passive

SPECIAL TESTS

Aims

• To determine internal knee

structures integrity

• To assess patellofemoral joint

stability

Knee integrity

• Posterior sagging sign – PCL

• Drawer’s test – anterior and posterior

• Lachman’s test – ACL

• Varus and valgus test – MCL, LCL

• McMurray test – ?

Done in 0 and

30 degrees

PFJ assessment

• Palpate the patella and its

undersurface – tenderness

• Patella apprehension test

Summary knee

• Look

• Feel

• Move

• Special test

+ patella tracking, Q angle

+ effusion assessment

+ internal knee integrity

+ PFJ assessment

FOOT (DIABETIC)

• Vasculopathy

• Immunopathy

• Neuropathy

– Motor

– Sensory

– Autonomic

LOOK

• Wounds, ulcer, gangrene

• Deformities

• Immunopathy – cellulitis features

• Vasculopathy – loss of hair

• Neuropathy

– Motor – claw toes,

callosities

– Autonomic – dry skin

FEEL

• Immunopathy – warmth, tender

• Vasculopathy – pulses, cold

peripheries, CRT

MOVE

• Ankle – active and passive

• Tightness of tendon Achilles

– Due to glycolisation products

deposition

SPECIAL TESTS

• Neuropathy

– Sensory – glove and stocking

– Monofilament – assess protective

sensation

• Ankle-brachio systolic index (ABSI) –

0.8 – 1.0 ratio

King’s classification

• Stage 1 – normal foot

• Stage 2 – foot at risk

• Stage 3 – ulcerated foot

• Stage 4 – infected foot

• Stage 5 – necrotic foot

• Stage 6 – major amputation

Summary foot (diabetic)

• Aim to detect features of:

– Vasculopathy

– Immunopathy

– Neuropathy

• Classify the foot (King’s)

THANK YOU