Lower Limb

Foot & Ankle Exam

Look

 

Aids

Shoes - raises / wear patterns

Stigmata generalised disease

Hands - RA, CMT

 

Front

 

Knee alignment

Forefoot - Hallux & Lesser toes 

Scars

Circulatory changes

 

Medial Side

 

Turn affected side away & ask to step foot forward

Flexed attitude of knee

Medial arch - planus / cavus

 

Behind

 

Spine - scoliosis / spinal dysraphism

Hindfoot varus / valgus

Forefoot (Too many toes)

Scars

 

Calf wasting

 

Double heel raise 

- Heel swings into varus or remains in valgus

- ? mobile subtalar joint

- ? Medial arch restoration

 

Single heel raise

- Must put patient close to blank wall half a foot length from the wall

- otherwise will cheat by pushing up or leaning forward against wall 

 

Lateral side

 

Haglund's

Peroneal tendons

 

Gait

 

Ankle

- Stiff / Fixed equinus 

- Weak / Foot drop

- Painful / Antalgic

 

Foot Progression angle

Tip toe - strong S1

Heel walk - strong L4

 

Sit

 

On edge of bed with legs hanging

- examiner sits on chair

 

Screen active ROM AKJ and STJ bilaterally

 

Look at sole

- normal distribution weight pattern

- callosities

- lumps / plantar fibromatosis

 

Feel

" Where is it painful?"

 

Lateral aspect

- lateral malleolus

- lateral ligament complex

- Peroneal tendons

- sinus tarsi

- base of 5th 

 

Posterior aspect

- tendo-achilles

- insertional / non insertional

 

Medially

- deltoid ligament

- tibialis posterior

- MT joints

- sustenaculum tali

 

Anterior

- ankle joint tenderness / effusion

- AITLF

 

Sole

- fat pad

- insertion of plantar fascia

 

Midfoot

 

Forefoot

- hallux rigidus

- sesamoids

- metatarsalgia

- Mulder test / interdigital tenderness

 

Move

 

DF - active and passive range 20o

 

PF - active and passive range 50o

 

Subtalar joint motion 

- ankle in 90° DF

- thumb on talar neck to detect talar movement 

- opposite hand cups heel and inverts & everts 

- Inversion 10-15o

- Eversion 0-5o

 

Midtarsal joint

- Foot at 90 to lock ankle mortise

- Adduct foot 20o

- abduct foot 10o

- dorsiflex

- plantarflex

 

T Ach

- Tenderness along tendon /Insertion, ? lump

- test power / pain

 

Foot Exam Tibialis AnteriorFoot Exam Tibialis PosteriorFoot Exam Peroneals

 

Tibialis posterior

- Prominent with plantarflexion and inversion

- Thickening

- Tenderness

- Check power if abnormal

 

Peroneus brevis & longus

- thickening

- Tenderness

- Dislocation (resisted eversion)

- active eversion

 

Tibialis anterior

- Prominent with dorsiflexion and inversion

- Insertion

 

EHL & EDL - Dorsiflex toes

 

Special tests

 

Instability

 

Anterior drawer

- Due to complete tear of ATFL

- Grasp lower tibia and cup calcaneum

- "clunk" or draw

- compare with other side > 3 mm

 

Lateral instability

- Inversion stress

- Gaping of soft tissues

- Talar tilt (may occur in normal & must compare with other side)

- Needs to be confirmed on stress views

- > 20o

 

Medial instability

- Eversion stress

- Gaping / widening

- Needs to be confirmed on stress views

 

Gastrocnemius /soleus contracture

 

Test if limited dorsiflexion

 

Silverskiold Test

- Extend knee - dorsiflexion limited by both soleus & gastrocnemius contracture

- Flex knee - gastrocnemius relaxed (crosses knee joint)

- If dorsiflexion still limited it is due to soleus contracture

- If limited in extension & not in flexion then due to gastrocnemius contraction

 

Pes cavus

 

Claw toes - flexible / fixed

 

Individual power compared with other side

- Tibialis anterior (inversion in DF)

- Tibialis posterior (inversion in PF)

- Peronei

 

Coleman block test

- Dynamic visualisation of hindfoot correction

- Stand on 2cm block

 

Passive correction of plantar-flexed 1st MT

 

Spine / Neuro Exam

 

Hallux valgus

 

MTPJ Painful / limited range

- flexion 45o

- extension 70-90o

- redo range with correction

 

IPJ

- hallux interphalangeus

- extension / flexion

 

Lesser toes

- fixed / mobile

- dislocated

 

Concealed

 

Spine

Neuro exam

Vascular exam

Ligamentous laxity

 

 

Gait Exam

Definition

 

Limp - asymmetrical gait pattern

Note:  Children assume adult walking patterns by the age of eight

 

Normal Gait

 

1.  Rate

- increased, decreased or normal

 

2.  Rhythm

- normal or limp

- limp is a disturbance in normal rhythm

- numerous causes - see below

 

3. Gait cycle

- individual cycle

- from one foot strike to the same foot strike

- stance 60% swing 40%

 

Phases

 

Initial contact - knee extended

 

Loading response - knee flexed, ankle DF

 

Mid stance

 

Terminal stance - hip extends, heel rise

 

Pre swing - ankle PF

 

Initial swing 

- need foot clearance 

- knee flexed, ankle DF

 

Mid swing

 

Terminal swing

 

Elements of gait asymmetry

 

STRAWS

 

Short 

Trendelenburg (gait or lurch)

Rigid -  hip / knee / ankle

Antalgic - painful, shortened stance phase

Weak - hip (trendelenberg), knee (back knee gait), ankle (high stepping)

Supratentorial (CNS - spastic / ataxic / toe walking / crouch / jump)

 

Gait Examination

 

Examine in coronal plane (from front) and in sagittal plane (from side)

 

Foot

 

Coronal

- foot progression angle

- bilateral in / out toeing

- old SUFE (walk with ER)

 

Sagittal (F/E)

- should have 3 rocker phases (might have just one or two)

- Heel Strike / Plant / Toe off

- nil heel strike in toe walker / cp - equinus may be fixed or not

- high stepping gait if weak

- equinus if LLD (shouldn't be fixed)

 

Knee

 

Coronal

- varus / valgus malalignment & thrust

- squinting / medially facing patella secondary increase PFA

 

Sagittal (F/E)

- achieving full extension in stance (not in a cp)

- back leg gait (weak knee extensors eg polio)

- may hold flexed in LLD

 

Hip

 

Coronal

- abductor lurch

- scissoring (adductor tightness in cp, increased PFA)

 

Sagittal (F/E)

- hyperflexion / FFD (hyperlordosis)

- weak hip flexors - back extension

 

Pelvis

 

Coronal

- pelvic asymmetry secondary to LLD / scoliosis

 

Sagittal

- hyperlordosis (hip FFD)

 

Trunk

 

Coronal - swaying side to side

 

Head - up and down with LLD

 

UL

- a hemiplegic will swing only one arm

 

Specific Gait patterns

 

Short 

- head and shoulders drop as patient steps onto short limb (bobbing up & down of head and shoulders in sagittal plane)

- Pelvis drops on affected side with heel strike and exaggerated head motion in sagittal plane

- vaulting gait

- flexion knee, equinus ankle 

 

Stiff

 

Hip 

- head & torso sways front to back in sagittal plane as walks

- Decreased hip flexion on swing phase and lumbar motion increases (AP sway)

 

Knee

- hip circumducts

- little flexion / extension through stance

 

Ankle

- may turn foot out to use STJ

- limitation F/E in sagittal plane

- DDX unilateral fixed equinus

- Tight TA / Hemiplegic CP / Short leg / Foot drop

 

Pain

- shortened stance phase

 

Weak

 

Hip

- Trendelenberg / abductor lurch

- head and shoulders sway side to side

 

Knee

- weak quads

- back knee gait

 

Ankle

- Foot drop gait

- High stepping gait

 

Neuromuscular

 

Spastic gait 

 

Diplegic

1.  Equinus gait - nil heel strike in rocker phases

2.  Jump gait - ankle equinus, knee flexion

3.  Crouch gait - ankle / knee + hip flexion

4.  Scissoring gait

 

Hemiplegic

- unilateral loss heel strike, knee held flexed

- nil movement of arm in swing

 

Ataxia 

- broad based gait

 

 

 

Hip Exam

Look

 

Walking aid

 

Footwear - shoe raises

 

Front

- Overall alignment of Lower Limb

 

Side

- lumbar lordosis

- flexed attitude of hip / knee

- scars

 

Back

- lumbar spine

- buttock wasting

- popliteal creases

- examine ROM

- try to differentiate spine and hip

 

Functional Leg Length

 

Attain symmetrical stance

- knees extended

- feet flat on ground

- check levels of ASIS

- comment on

 

A.  Pelvis is level / not level

B.  Stance is symmetrical

C.  Coronal plane deformity - Knee is flexed, ankle is in equinus 

 

Situations

 

A.  Pelvis is level with symmetrical stance

- no LLD

 

B.  Pelvis is not level with symmetrical stance

- uncompensated LLD

 

C.  Pelvis is level with asymmetrical stance

- compensated LLD

 

D.  Pelvis is not level with asymmetrical stance

- partially compensated LLD

- contractures

 

Blocks 

- if pelvis not level

- to assess functional leg length discrepancy

 

Trendelenberg

 

Aim

- assess if patient's abductors can elevate ASIS on affected side

- without using trunk

 

Technique

- visualise ASIS or PSIS

- stand on good leg

- opposite ASIS should rise

- stand on bad leg

- cannot raise opposite ASIS
- either fall or have to lean trunk over

 

False negative test

- able to maintain abduction with no abductor function

- fixed abduction contracture

- arthrodesed hip in abduction

 

Invalid if

- poor balance

- generalised weakness

- lack of co-ordination or understanding

- costo-pelvic impingement

 

Causes

 

1. Pain

- painful disorder of hip

- centre over hip to decrease abductor pull

- decrease joint reaction forces  

 

2. Pivot

- dislocation or subluxation of hip

- shortening of femoral neck 

- abductors cannot work correctly

 

3. Power 

- weakness of abductors

 

Gait

 

STRAWS

 

Short 

- shoulder drops on ipsilateral side

- head up and down

 

Trendelenburg 

- abductor lurch

 

Rigid / Stiff

- hip

- knee

 

Antalgic

- shortened stance phase

 

Weak

- back knee gait

- foot drop

 

Supratentorial (CNS)

 

Supine on Examination Bed

 

Feel

 

Along line of inguinal ligament from medial to lateral

- masses (dislocated femoral head, hernias, aneurysms, lymph nodes)

- tenderness (LCFN)

 

Along posterior greater trochanter

- tenderness (trochanteric bursitis)

 

Knee

 

Exclude FFD of knee

- allows assessment of leg length (correct with pillow)

- allows assessment of FFD of hip (must put knee over bed)

 

Valgus knee

- difficulty measuring LL

- will be unable to put other leg in same position

- must measure components

 

Hip

 

Normal ROM

- Flexion / extension 140o

- adduction / abduction 400

- IR / ER

 

Thomas' Test

 

Angle through which thigh is raised from couch is angle of fixed flexion

 

Fixed flexion deformity of knee

- place patient at edge of couch

- when assessing FFD, move heel over edge of couch

- lower heel below level of couch

- to eliminate effect of knee FFD

 

Method

- passively flex both knees to 45o

- place hand behind back and

- ask patient to clutch unaffected knee to chest

- ensure lumbar lordosis eliminated

- this fixes pelvis

 

Extension

- gently extend affected hip passively

- lift heel off bed

- stop when painful

- fixed flexion deformity of (x)o

 

Flexion

- ask patient to actively flex affected hip

- gently passively maximise flexion

- comment

- flexes to (y)o

- flexion arc of (x)o FFD to (y)o

 

Abduction / Adduction in Extension

 

Position

- hip and knee extended

- fix pelvis by abducting unaffected hip so that leg dangles over edge of couch

- palpate ipsilateral ASIS

- abduction / adduction both sides

- know at extremes of limit when ASIS / Pelvis begins to move

 

Internal and External Rotation in Flexion

 

Position

- hip flexed to 90o

- hold leg with one hand

- hand in popliteal fossa

- leg resting on forearm

- assess pelvis movement with other hand

- palpate contralateral ASIS

- internal rotation, turn foot out

- external rotation, turn foot in

- examine contralateral side 

 

Leg Length

 

Make pelvis square with bed

- attempt to make legs square with pelvis and straight

- ensure buttocks not in dip in bed

- ensure normal heel height

- ensure no asymmetrical buttock wasting

 

Apparent LL 

- leg length measured without correcting for sagittal or coronal plane deformity

- from umbilicus to medial malleolus

- tape measure

 

True LL 

- leg length measured once coronal & sagittal plane deformity corrected for 

- sum of intercalated segments

- ASIS to medial malleolus

 

Correct for 

 

1.  Abduction contracture

- comment on contracture

- unable to place legs perpendicular to pelvis because of abduction contracture

- must place other leg in same position

- abduct unaffected hip same degree

- measure leg length

 

2.  Adduction contracture

- comment on contracture

- unable to place legs perpendicular to pelvis because of adduction contracture

- must place other leg in same position

- measure leg lengths sequentially

- cross one leg and measure

- cross other leg and measure

 

3.  FFD Hip or Knee

- correct with pillows

 

4.  Equinus foot

- look below medial malleolus

- difference in effective heel height because of equinus contracture

 

5. Coronal plane deformity knees

- cannot correct for 

- must measure intercalated segments

 

Galeazzi's sign

 

Identify level of leg length discrepancy

 

Flex knees to 90o with hips and ankles at 45o

- put malleoli at same level

- any hindfoot asymmetry makes test inaccurate

 

Femurs parallel

- tibias same height

- discrepancy above knee

 

Tibias parallel

- femurs same length

- discrepancy in tibia

- knees at different levels

 

LLD above GT

 

1.  Bryant's triangle

- identify ASIS with thumb & tip of greater trochanter with forefinger

- drop imaginary lines down to floor

- distance between the lines

- difference in distance between ASIS and GT suggests discrepancy proximal to GT

- assess perpendicular distance between points with fingers of other hand

- perpendicular distance between points is different by (x) fingerwidths

 

2.  Schoemaker's line 

- line from greater trochanter thru ASIS

- projection from each side should cross proximal to umbilicus

- if shortening above gr trochanter then the lines will cross below the umbilicus

 

3.  Nelaton's line 

- ischial tuberosity to ASIS

- with patient lying on the side

- the greater trochanter should lie on the line

 

Knee Exam

Look

 

Shoes

Walking aids

 

Front

 

Knee alignment 

- physiological valgus

 

Patellar rotation 

- squinting (inwards, increased PFA) 

- grasshopper eyes (high and lateral)

 

Swelling

Quads Wasting

Scars

 

Knee effusion

 

Side

 

Knee attitude

- flexion

- recurvatum

- push knees back

 

Knee FFD Standing

 

Step foot forward and bear weight

- examine arch

 

Scars

 

Behind

 

Hindfoot valgus

Swelling popliteal fossa

Wasting of hamstrings or calf

Level popliteal creases

 

Other Side

 

Knee attitude

- flexion

- recurvatum

- push knees back

 

Step foot forward

 

Scars

 

Gait

 

Rigid / Stiff

- decreased flexion / extension range

 

Antalgic

 

Weak knee

- back knee gait

 

Medial or lateral thrust

- valgus or varus moment about the knee

 

Foot progression angle

 

Sit on Edge of Bed

 

Patella tracking

- crepitus

 

J tracking

- patellar sharply deviates laterally in terminal extension

- or travel laterally until jumps into trochlea at midrange of flexion

 

Supine

 

Look 

- quads wasting

- alignment

- scars

 

Effusion

- swipe, ballot, tap

 

Range

- FFD / Recurvatum / lift foot in air

- active extension / quads lag

- range of flexion bilaterally

 

Knee FFD LyingKnee FFD Fixed

 

FFD

- effusion

- entrapped meniscus

- ACL stump

- loose body

 

Feel

 

Flat

- Extensor mechanism

- patella

- tibial tuberosity

 

Flexed

- Joint lines, MCL, LCL

- tibial and femoral condyles

- popliteal fossa

 

Palpate distal femur for osteochondromas

 

Examine Ligaments

 

Collaterals

 

Test at 0 and 30o

- if loose at 0, loss of secondary stabilisers

 

Grading

1+   Surfaces separate 5mm or less

2+   5 - 10 mm

3+   10 mm or more

 

ACL / PCL

 

Lachmann's

- 85% sensitive awake

- 100% asleep

 

Check loss of tibial step off

- posterior sag

- MTP normally 1 cm anterior to MFC

 

Quadriceps active

- knee at 90o

- stabilise foot & ask to slide foot down bed

- N < 1mm / PCL > 3mm

 

Anterior / Posterior drawer

- restore tibial step off

 

Posterolateral drawer

- 30o IR

- tightens PLC

 

Posteromedial drawer

- 15o ER

- tightens PMC

 

Pivot Shift

- valgus stress with IR + axial compression

- knee moved from extension to flexion

- in chronic ACL deficiency, the LTC is subluxed anteriorly

- at 30o it reduces backwards

- this is when ITB passes behind axis of rotation and becomes flexor

- grade pivot glide / 1 / 2 / 3

 

Must have 4 things

- MCL to pivot about

- intact ITB

- no FFD

- ability to glide i.e. no meniscal pathology

 

PCL / Posterolateral Corner (PLC)

 

External rotation / Recurvatum

- hold big toe and assess PLC

- knee moves into recurvatum, tibia externally rotates & subtle varus

- indicates PCL + PLC + LCL

 

Reverse pivot shift 

- with valgus and ER

- flexion to extension

- in flexion, the LTP is posteriorly subluxed

- ITB become extensor

- reduces as extend

- must compare with other side

- present in 30% normal population especially ligamentous lax

 

Dial test / Prone

- measure thigh foot angle

- examiner holds knees together

- increase at 30o only  - PLC

- increases at 30 then again at 90 - PLC + PCL

- isolated PCL - no increase

- >10o compared with normal side

 

Meniscus

 

McMurray

- Flexion to extension

- Full IR - LM

- Full ER - MM

- i.e. test meniscus heel is pointing towards

- positive test is palpable / audible thud, snap, click

 

Squat test

- feet IR and ER

 

4Cs

 

Concealed / popliteal fossa

 

Cephalad / Hip

- rotation in flexion

- adduction / abduction in extension

 

Circulation

 

Collagen

 

PFJ Exam

Look

 

Stigmata Generalised disease

- Marfan's

 

Ligamentous laxity Wynne Davies

- positive if 3/5 pairs

- thumb touches volar forearm

- fingers parallel to forearm dorsally

- elbow hyperextends past 0o

- knee hyperextends past 0o

- ankle dorsiflexes > 45o

 

Front

 

VMO bulk

Swelling

Scars of previous surgery i.e. TTT

 

Planovalgus Feet / Hyperpronation

 

Genu Valgum

 

Squinting patella 

- Proximal Femoral Anteversion  (PFA)

- patellae point inwards when standing

 

Grasshopper eyes 

- patellas sit high & lateral

- due to patella alta 

- patella subluxed laterally 

 

Side

 

Flexed attitude Knee

Scars

 

Back

 

Level Popliteal creases

Valgus Heels

 

Gait 

 

Foot Progression Angle

- Normal 10° (0-30°)

- any in-toeing

- indicative of PFA

 

Sit on ege of Bed

 

Patella Tracking

- J sign

- lateral subluxation in terminal extension

 

Crepitus

 

Supine

 

Effusion

 

3 signs in Extension

 

1.  Tenderness

- tibial tuberosity

- lateral patella retinaculum

- patella

- Bassett's sign (MPFL on med epicondyle)

- pain with patella grind (compression)

 

2.  Clark's test

- gentle pressure on superior pole

- patient asked to contract quadriceps

- compare with other side

 

3.  Patellar Tilt Test

- Patient supine and relaxed with knees extended

- Trans- epicondylar axis placed parallel to table

- Lateral edge of patella elevated & medial edge depressed

- normal is lateral tilt 0-20°

- Abnormal if unable to tilt to horizontal

- indicated lateral retinaculum tightness

 

3 Signs in 30o Flexion

 

1.  Q angle 

- Knee at 30° flexion so patella engages femoral sulcus

- ASIS to centre of patella to tibial tuberosity

- abnormal > 15° in males 

- abnormal > 20° in female

 

2.  Patellar glide test (Sage Mobility)

-  Graded by number of 1/4 widths that patella displaces

- > 3 insufficient medial restraints

- < 1 tight lateral retinaculum

- > 3 insufficient lateral restraints

 

3.  Apprehension test

- patient supine and relaxed

- patella pushed laterally while knee flexed 30o

- positive if patient uncomfortable (pain or apprehension)

 

Prone / Rotational profile

 

Best is all assessed prone

 

1.  Lateral border of foot

- metatarsus adductus

 

2.  Tibial Torsion

- thigh foot angle > 15o

- trans-malleolar axis > 30o

 

3.  Femoral anteversion 

- excessive IR

- increased Gage's trochanteric angle

 

 

 

Sciatic Nerve Exam

Look

 

Wasting of anterior & lateral compartments leg

Scars at fibula head

Masses

Feet for dystrophic changes

Back - surgery / dystrophic changes

Hip - scars

 

Gait

 

Foot drop gait, high stepping, slapping

 

Feel 

 

Along CPN

 

Tinel’s

 

Sensation Tibial nerve

- sole of foot

 

Sensation CPN

- SPN dorsum of foot

- DPN 1st webspace

 

Move

 

Tibial nerve

- hamstrings

- T. Ach

- FHL

- FDL

 

CPN

- T. Ant (L4)

- EHL (L5) – often 1st damaged as most prox br

- EDL (L5,S1) – isolated with ankle in DF

- PL & PB (L5,S1) – eversion & palpate

 

DDx

 

L5 v Sciatic / Tibial

- examine Abductors (L5)

 

CPN above knee v below knee

- short head biceps EMG