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