Examination of the Lower Extremities PDF

Examination of the Lower Extremities Lee Scott, MD, FAAP Learning Objectives Describe the basic anatomy of the lower extremities Describe what can be found on inspection of the lower extremities and how to verbalize findings Explain the technique for inspection of the lower extremities Describe what...

Examination of the Lower Extremities Lee Scott, MD, FAAP Learning Objectives Describe the basic anatomy of the lower extremities Describe what can be found on inspection of the lower extremities and how to verbalize findings Explain the technique for inspection of the lower extremities Describe what can be found on palpation of lower extremities and how to verbalize findings Describe how to adequately palpate the lower extremities Describe how to test range of motion of the lower extremities Describe how to test strength in the lower extremities Describe the clinical significance of normal abnormal lower extremity physical exam findings Document the lower extremity physical exam findings Lower Extremity Skills Inspection – Lower Extremity Size Muscle Wasting Fasciculations The venous pattern Gait: Stance and swing Venous enlargement Pigmentation Joint concavities that are usually evident adjacent and Symmetry Swelling Rashes Scars superior to each side of the patella Ulcers Alignment of the knees Genu varum Genu valgum Calluses Corns Deformities Color/texture of the skin Nodules Color of the nail beds Distribution of hair on the lower legs, feet, and toes Skinfolds Always look at BOTH sides, all aspects. Bruising Verbalize your findings: “No significant asymmetry noted, no skin changes or muscle wasting.” “I don’t see any joint swelling or redness.” Inspection - Hip Inspection of the hip begins with careful observation of the patient's gait. Observe the two phases of gait: Stance—when the foot is on the ground and bears weight (60% of the walking cycle) Swing—when the foot moves forward and does not bear weight (40% of the cycle) Inspect the gait for the width of the base The width of the base should be 2 to 4 inches from heel to heel. the shift of the pelvis Normal gait has a smooth, continuous rhythm, achieved in part by contraction of the abductors of the weight-bearing limb. Abductor contraction stabilizes the pelvis and helps maintain balance, raising the opposite hip. flexion of the knee The knee should be flexed throughout the stance phase, except when the heel strikes the ground to counteract motion at the ankle. Inspection. - Hip A wide base suggests cerebellar disease or foot problems. Pain during weight bearing or examiner strike on the heel occurs in femoral neck stress fractures. Hip dislocation, arthritis, unequal leg lengths, or abductor weakness can cause the pelvis to drop on the opposite side, producing a waddling gait. Lack of knee flexion, which makes the leg functionally longer, interrupts the smooth pattern of gait, causing circumduction (swinging the leg out to the side). Inspection - Hip Inspect the lumbar portion of the spine for the degree of lordosis and, with the patient supine, assess the length of the legs for symmetry. Inspect the anterior and posterior surfaces of the hip for any areas of muscle atrophy or bruising. The joint is too deeply situated to detect swelling. We will not actually inspect the hip in lab or FOSCE/OSCE. Inspection - Knee Inspect the gait for a smooth rhythmic flow as previously discussed. The knee should be extended at heel strike and flexed at all other phases of swing and stance. Stumbling or “giving way” of the knee during heel strike suggests quadriceps weakness or abnormal patellar tracking. Check the alignment and contours of the knees. Observe any atrophy of the quadriceps muscles. Bow-legs (genu varum) and knock-knees (genu valgum) are common. Quadriceps atrophy signals hip girdle weakness in older adults. Inspection - Knee Inspect for any loss of the normal hollows around the patella, a sign of swelling in the knee joint and suprapatellar pouch; note any other swelling in or around the knee. Swelling over the patella occurs in prepatellar bursitis (housemaid's knee). Swelling over the tibial tubercle suggests infrapatellar or, if more medial, anserine bursitis. Inspection – Ankles / Feet Observe all surfaces of the ankles and feet, noting any deformities, nodules, swelling, calluses, or corns. Inspection – Ankles / Feet Inspection – Ankles / Feet Inspection – Ankles / Feet Inspection – Ankles / Feet Palpation Skin Fascia Muscles Arteries Nodes Bones Joints Bursae Palpation Note Abnormalities: Heat Tenderness (ask the patient!) Swelling Crepitus (move the joint to appreciate this) Abnormal Muscle Tone Masses Verbalize: “Please let me know if any of this causes pain.” “I don’t feel any masses or swelling”. “No warmth, no crepitus.” Palpation - Temperature Reminder: Assess the temperature of the feet and legs with the backs of your fingers. Compare one side with the other. Bilateral coldness is usually caused by a cold environment or anxiety. Palpation – Hip – Bones and Joints On the anterior surface of the hip, locate the following: The iliac crest at the level of L4 The iliac tubercle The anterior superior iliac spine The greater trochanter The pubic tubercle On the posterior surface of the hip, locate the following: The posterior superior iliac spine The greater trochanter The ischial tuberosity The sacroiliac joint Palpation – Knee – Bones and Joints Ask the patient to sit on the edge of the examining table with the knees in flexion. In this position, bony landmarks are more visible, and the muscles, tendons, and ligaments are more relaxed, making them easier to palpate. Pay special attention to any areas of tenderness. Pain is a common complaint in knee problems, and localizing the structure causing pain is important for accurate evaluation. Remember the Anatomy! Knee Anatomy Palpation - Knee On the medial surface, identify the adductor tubercle the medial epicondyle of the femur the medial condyle of the tibia. On the anterior surface, identify the patella, which rests on the anterior articulating surface of the femur midway between the epicondyles, embedded in the tendon of the quadriceps muscle. This tendon continues below the knee joint as the patellar tendon, which inserts distally on the tibial tuberosity. On the lateral surface, find the lateral epicondyle of the femur the lateral condyle of the tibia the head of the fibula. Two condylar tibiofemoral joints are formed by the convex curves of the medial and lateral condyles of the femur as they articulate with the concave condyles of the tibia. The third articular surface is the patellofemoral joint. The patella slides on the groove of the anterior aspect of the distal femur, called the trochlear groove, during flexion and extension of the knee. Ankle / Foot Palpation – Ankle / Foot Palpate: Anterior ankle joint Achilles tendon Calcaneus Plantar fascia Ankle ligaments MTP joints (squeeze) Metatarsal heads. Any area patient complains of While you are there you can check: Cap refill Pulses Test for edema Capillary Refill- We’ll cover and practice in Cardio, BUT can be very important part of your extremity exam! Palpation - Nodes Palpate the superficial inguinal nodes horizontal and vertical groups Note their size, consistency, and discreteness, and note any tenderness. **Nontender, discrete inguinal nodes up to 1 cm or even 2 cm in diameter are frequently palpable in normal people. **We will not practice this in lab.** Palpation – Pulses The femoral pulse Press deeply, below the inguinal ligament and about midway between the anterior superior iliac spine and the symphysis pubis. The use of two hands, one on top of the other, may be helpful, especially in obese patients. The popliteal pulse The patient’s knee should be somewhat flexed, with the leg relaxed. Place the fingertips of both hands so that they just meet in the midline behind the knee and press them deeply into the popliteal fossa (Fig. 12-19). The popliteal pulse is more difficult to find than other pulses. It is deeper and feels more diffuse. Palpation – Pulses The DP pulse Palpate the dorsum of the foot (not the ankle) just lateral to the extensor tendon of the great toe. The DP artery may be congenitally absent or branch higher in the ankle. If you cannot feel a pulse, explore the dorsum of the foot more laterally. The PT pulse Curve your fingers behind and slightly below the medial malleolus of the ankle. This pulse may be hard to feel in a fat or edematous ankle. Palpation - Edema If swelling or edema is present, palpate for pitting edema. Press firmly but gently with your thumb for at least 2 seconds 1. over the dorsum of each foot 2. behind each medial malleolus 3. over the shins Look for pitting—a depression caused by pressure from your thumb. Normally there is none. The severity of edema is graded on a four-point scale, from slight to very marked. ** Range of Motion Demonstrate for patient or give clear instructions. Stand/Sit so that you can truly view the motion. Make sure to have patient attempt the full range. Active vs. Passive Range of Motion Motions of the hip: Flexion Extension Abduction Adduction Internal Rotation External Rotation Do not try to test with the patient standing!!! Note: Often, the examiner must assist the patient with movements of the hip. Range of Motion - Hip Flexion With the patient supine, ask the patient to bend each knee in turn up to the chest and pull it firmly against the abdomen. Note that the hip can flex further when the knee is flexed because the hamstrings are relaxed. Range of Motion - Hip Extension With the patient lying face down, extend the thigh toward you in a posterior direction. Alternatively, carefully position the supine patient near the edge of the table and extend the leg posteriorly. Range of Motion - Hip Abduction Stabilize the pelvis by pressing down on the opposite anterior–superior iliac spine with one hand. With the other hand, grasp the ankle and abduct the extended leg until you feel the iliac spine move. This movement marks the limit of hip abduction. Adduction With the patient supine, stabilize the pelvis, hold one ankle, and move the leg medially across the body and over the opposite extremity. Range of Motion - Hip Internal and External Rotation Flex the leg to 90° at hip and knee, stabilize the thigh with one hand, grasp the ankle with the other, and swing the lower leg—medially for external rotation at the hip, and laterally for internal rotation. Although confusing at first, it is the motion of the head of the femur in the acetabulum that identifies these movements. Range of Motion - Knee Flexion Flexion of the knee may be tested in conjunction with hip flexion OR by asking the patient to flex the knee while standing. Extension Extension may be tested by asking the patient to straighten their leg out as much as possible while either sitting or standing. For the OSCE, do NOT test with the patient standing!!! Range of Motion – Ankle / Foot Plantar Flexion “Point your foot toward the floor.” You can also grasp the foot and move it passively. This is preferred if patient is supine and you are testing other motions passively. (See LibGuide video) Dorsiflexion “Point your foot toward the ceiling.” You can also grasp the foot and move it passively. This is preferred if patient is supine and you are testing other motions passively. (See LibGuide video) Tibiotalar (Ankle) Joint Range of Motion – Ankle / Foot Inversion/Eversion Stabilize the ankle with one hand, grasp the heel with the other, and invert and evert the foot by turning the heel inward then outward OR Ask patient to: “Bend your heel inward.” “Bend your heel outward.” Subtalar (talocalcaneal) joint Strength Testing Scale for grading Muscle Strength Muscle strength is graded on a 0 to 5 scale 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. ( 5 is normal muscle strength ) Strength Testing Hip – Flexion, Extension, Abduction, Adduction Knee – Flexion, Extension Ankle – Flexion, Extension Blue words = additions to Neuro Strength testing Pay attention to the muscles involved in each motion, not just the nerve roots now that you are in MSK. Strength Testing - Hip Test flexion at the hip (L2, L3, L4—iliopsoas). place your hand on the patient's mid-thigh ask the patient to raise the leg against your hand We tested hip flexion with the patient seated during Neuro. You can sometimes can a better test-especially if the patient is having hip pain, with the patient lying down. The picture at the left demonstrates testing with the knee extended. You can get an even better test with the knee and hip flexed as shown in the teaching video. Test extension at the hips (S1—gluteus maximus). Have the patient push the mid posterior thigh down against your hand. Strength Testing - Hip Test abduction at the hips (L4, L5, S1—gluteus medius and minimus). Place your hands firmly outside the patient's knees. Ask the patient to spread both legs against your hands. Test adduction at the hips (L2, L3, L4—adductors). Place your hands firmly on the bed between the patient's knees. Ask the patient to bring both legs together. Can do these tests with patient lying down or sitting. Can test both sides simultaneously. Strength Testing - Knee Test extension at the knee (L2, L3, L4 -quadriceps). Support the knee in flexion and ask the patient to straighten the leg against your hand. The quadriceps is the strongest muscle in the body, so expect a forceful response. Test flexion at the knee (L4, L5, S1, S2 -hamstrings). Position the patient's leg so that the knee is flexed with the foot resting on the bed. Tell the patient to keep the foot down as you try to straighten the leg. Can do these with patient lying down or sitting. Strength Testing - Ankle Test foot dorsiflexion (mainly L4, L5—tibialis anterior) at the ankle by asking the patient to pull up against your hand Test foot plantar flexion (mainly S1—gastrocnemius, soleus) at the ankle by asking the patient to push down against your hand. Heel and toe walk also assess foot dorsiflexion and plantar flexion, respectively. Can do these with patient lying down or sitting. Sample Documentation Upper Extremities: No asymmetry, redness, swelling or deformity noted. No masses. No tenderness to palpation. No tissue texture changes. Full ROM in all joints. Strength 5/5. Right elbow: Soft tissue swelling and mild erythema noted laterally. Tender to palpation along lateral epicondyle. Unable to fully flex or extend due to pain. Strength 4/5. Lower Extremities: No asymmetry, redness, swelling or deformity noted. No masses. No tenderness to palpation. No tissue texture changes. Strength and sensation intact bilaterally. Full ROM in all joints. 2+ radial pulses. Cap refill< 2 seconds. Reflexes 2+. Right knee: Appears slightly swollen anteriorly. Appears red. Tender to palpation over the patellar tendon. Flexion limited by pain and swelling. Thursday’s Skills Lab Check schedule Skills Lab attire Be prepared for bare feet! Skills: Inspection Palpation Range of Motion Strength Testing 2 Question Quiz- Bring iPad!! Watch the Lower Extremity Video PRIOR to lab. References Bickley, Lynn S., et al. Bates Guide to Physical Examination and History-Taking. 13th ed., Wolters Kluwer Health/Lippincott Williams & Wilkins, 2020. Suneja, M. (2020). DeGowin's Diagnostic Examination, 11th Edition (11th ed.). Chicago, IL: McGraw-Hill Education. Questions? General course or grading questions? ACOM PCS Course Director email: [email protected] Office hours available by appointment: Lee Scott, M.D., F.A.A.P. [email protected]