THE LOWER EXTREMITY EXAM FOR THE FAMILY PRACTITIONER

Transcription

1 THE LOWER EXTREMITY EXAM FOR THE FAMILY PRACTITIONER Melinda A. Scott, D.O. Orthopedic Associates of Dayton Board Certified in Primary Care Sports Medicine

2 GOALS Identify landmarks necessary for exam of the lower extremity Review techniques for a quick but thorough exam Be familiar with normal findings and range of motion Review some special maneuvers and abnormal findings Review common diagnoses

3 PRE-TEST QUESTIONS If a patient has hip arthritis, where will he or she typically complain of pain? A. Buttock B. Low back C. Lateral hip D. Groin E. Posterior thigh 10 Countdown

4 PRE-TEST QUESTIONS A positive straight leg raise test indicates that the patient s hip pain is from a A. Radicular/sciatic etiology B. Hip joint pathology C. Bursitis D. Tight Hamstrings E. Weak hip flexors 10 Countdown

5 PRE-TEST QUESTIONS A positive McMurray s tests is indicative of a possible A. ACL tear B. MCL tear C. Patellar dislocation D. Joint effusion E. Meniscus tear 10 Countdown

6 PRE-TEST QUESTIONS Anterior drawer test on the knee is performed with the knee in A. 30 degrees flexion B. 90 degrees flexion C. Full extension D. 45 degrees flexion E. 130 degrees flexion 10 Countdown

7 PRE-TEST QUESTIONS A positive squeeze test during an ankle exam is indicative of A. Syndesmotic injury B. Anterior talofibular ligament strain C. Deep vein thrombosis D. Compartment syndrome E. Deltoid ligament injury 10 Countdown

8 HIP EXAM Overview Can be very complex area to exam Long list of differential diagnoses to consider Careful history narrows down the list considerably Cannot examine the hip without examining the back Physical exam is KEY

9 HIP ANATOMY Bony Landmarks ASIS Sartorius Greater trochanter ITB Gluteus medius Pubic symphysis Adductors AIIS Rectus femoris Iliac crest Abdominal oblique Ischial tuberosity Hamstrings PSIS

10 MUSCULATURE OF THE HIP

11 Flexion 90 degrees with knee in extension 120 degrees with knee in flexion Extension 15 degrees Abduction 45 degrees Adduction 30 degrees Internal rotation 40 degrees (with knee flexed) External rotation 45 degrees (with knee flexed) HIP RANGE OF MOTION

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13 Hip flexors Rectus femoris Iliopsoas Weakness with hip joint pathology (OA) Test with hip flexed and knee extended HIP STRENGTH TESTING

14 Hip extensors Hamstrings Weakness with isolated hamstring injury or radicular etiology HIP STRENGTH TESTING

15 HIP STRENGTH TESTING External rotators Gluteus medius Trendelenburg test Have patient stand on affected leg. Unsupported hip will descend causing affected to hip to thrust outward Weakness of gluteus medius

16 HIP STRENGTH TESTING Adductors Gracilis Adductor longus Weakness with isolated muscle strain

17 HIP SPECIAL MANEUVERS Trendelenburg Straight leg raise (back) With patient supine, flex the hip with the knee in full extension through degrees Positive test Indicates radicular pain

18 Greater trochanteric bursitis Pinpoint pain over the greater trochanter Tight ITB HIP DIFFERENTIAL DIAGNOSES Sometimes pops or snaps as ITB crosses trochanter

19 HIP DIFFERENTIAL DIAGNOSES Muscle strain/tendonitis Hip flexor tendonitis Hamstring/groin strain Have pain over affected tendons Weakness/pain with strength testing

20 HIP DIFFERENTIAL DIAGNOSES Radicular pain Radiating pain following a radicular pattern Usually starts in posterior hip or low back Hip motion does not typically reproduce pain Positive SLR (in severe cases) Cannot find position of comfort (severe cases)

21 HIP DIFFERENTIAL DIAGNOSES Hip joint pathology OSTEOARTHRITIS Labral tears AVN Reproduced with internal/external rotation of the hip Groin pain is hallmark for hip joint pain Radiates to anterior/medial thigh, knee

22 KNEE EXAM Overview Rely a lot on palpation and observation of alignment/gait Careful history Lots of special maneuvers to help aid in diagnosis

23 KNEE ANATOMY Bony landmarks Femoral condyles Fibular head Patella Tibial tuberosity Tibial plateau

24 KNEE ANATOMY Soft Tissue landmarks MCL LCL Popliteal fossa Patellar tendon Medial/Lateral Joint line Quad tendon Bursa (prepatellar and pes anserine) ITB

25 INSPECTION AND PALPATION OF THE KNEE Deformity Genu Varus Bow legged Medial compartment arthritis Genu Valgus Knock- kneed Lateral compartment arthritis

26 INSPECTION AND PALPATION OF THE KNEE Swelling Effusion, soft tissue swelling or bursitis? Prepatellar bursitis fluid is extraarticular Effusion is intraarticular

27 INSPECTION AND PALPATION OF THE KNEE Crepitus Peripatellar Popliteal fossa Baker s cyst

28 KNEE RANGE OF MOTION Knee is a hinged joint Flexion-extension are primary movements Normal Flexion 0 to 130 degrees Normal Extension 0 to -15 degrees

29 KNEE STRENGTH TESTING Quad VMO weakness Single leg squat Straight leg raise (for integrity of patellar retinaculum) Hamstring

30 KNEE SPECIAL MANEUVERS McMurray s test Patient supine or seated One hand holding the foot, other hand across the joint Rotate the leg externally, apply valgus stress and then slowly extend the knee Pain or palpable click over medial joint line indicates medial meniscus tear Repeat with leg internally rotated and with varus stress for lateral joint line

31 McMurray s test KNEE SPECIAL MANEUVERS

32 KNEE SPECIAL MANEUVERS Patella testing Patellar grind Patient supine with leg relaxed Push the patella distally into the patella groove and have patient tighten quad Pain indicates patellofemoral pain Patellar tracking Single leg squat Knee goes into valgus indicates VMO weakness

33 KNEE INSTABILITY TESTS Anterior Drawer Tests for laxity of the ACL Performed with the patient supine Knee flexed to 90 degrees, feet flat on table Cup your hands around the joint with thumbs over medial and lateral joint line Attempt to translate the tibia forward Positive if tibia translates forward Compare to other side

34 KNEE INSTABILITY TESTS Lachman s test - tests for laxity of the ACL Generally accepted as a more sensitive test compared to Anterior drawer Patient supine and knee in degrees flexion Stabilize thigh with one hand and try to translate tibia forward with other hand Positive test if tibia translates forward Compare to other side

35 KNEE INSTABILITY TESTS Medial and lateral instability Varus and valgus stress Hold leg with one hand and apply varus or valgus stress to the knee If the joint gaps, positive test for collateral ligament damage

36 KNEE DIFFERENTIAL DIAGNOSIS Patellofemoral pain Anterior/peripatellar pain, sitting to standing painful, stairs Ligamentous injury Injury related typically Chronic ACL tears common in older adult Meniscus tear Joint line pain, mechanical symptoms Osteoarthritis Joint line pain, stiffness Tendonitis Patellar, quad and hamstring Bursitis Prepatellar, pes anserine

37 FOOT AND ANKLE Overall Complex area Common area to injury Fractures common

38 FOOT AND ANKLE ANATOMY AND PALPATION Bony landmarks Medial and lateral malleolus Distal tibia Talus Metatarsals base of the 5 th Navicular Toes

39 FOOT AND ANKLE ANATOMY AND PALPATION Palpation/inspection Soft tissue swelling/ecchymosis/erythema Joint effusion (tibiotalar) Ligaments (ATFL, CFL, deltoid) Tendons (Achilles, posterior tibial, peroneal) Plantar fascia Pes planus/cavus deformities

40 FOOT AND ANKLE RANGE OF MOTION Ankle Dorsiflexion /Plantarflexion 20 degrees/45 degrees Foot Inversion/Eversion 40 degrees/30 degrees Foot fabduction/adduction 10 degrees/20 degrees Toe flexion/extension

41 FOOT AND ANKLE STRENGTH TESTING Dorsiflexors Tibial anterior Extensor Hallucis Longus Extensor Digitorum Longus Plantar flexors Peroneus Longus and Brevis Gastrocnemius and Soleus Flexor Hallucis Longus Flexor Digitorum Longus Tibialis Posterior

42 FOOT AND ANKLE STRENGTH TESTING Everters of the Foot Peroneus Longus and Brevis Inverters of the foot Tibialis Anterior and Posterior

43 FOOT AND ANKLE SPECIAL MANEUVERS Drawer test tests for instability of the ankle Stabilize tibia with one hand and cup the calcaneus with the other hand With foot slightly plantarflexed, slide the foot toward you Positive test if talus translates anteriorly Indicates tear of ATFL

44 FOOT AND ANKLE SPECIAL MANEUVERS Squeeze test Tests for disruption of the syndesmosis of the ankle Compress/squeeze the proximal calf with one or two hands Positive if causes pain at the distal syndesmosis Causes widening of the syndesmosis distally Indicates syndesmotic injury (anterior tibiofibular ligament)

45 FOOT AND ANKLE SPECIAL MANEUVERS Thompson Test Tests for rupture of the Achilles tendon Place patient prone with foot and ankle off the edge of the table Gently squeeze the calf which should cause the foot to plantarflex Positive if foot does not plantarflex

46 FOOT AND ANKLE DIFFERENTIAL DIAGNOSIS Medial/lateral ankle sprains Lateral most common ligament injury High ankle sprains have sprain of syndesmosis Achilles tendinosis/rupture Rupture requires urgent orthopedic referral

47 FOOT AND ANKLE DIFFERENTIAL DIAGNOSIS Plantar fasciitis Pain over plantar surface of calcaneus Pes planus deformity typically Tendonitis (peroneal, posterior tibial)

48 FOOT AND ANKLE DIFFERENTIAL DIAGNOSIS Fractures Base of the 5 th metatarsal (Jones fracture) Distal fibula Stress fractures Toes

49 POST-TEST QUESTIONS If a patient has hip arthritis, where will he or she typically complain of pain? A. Buttock B. Low back C. Lateral hip D. Groin E. Posterior thigh 10 Countdown

50 If a patient has hip arthritis, where will he or she typically complain of pain? Buttock Low back Lateral hip Groin Posterior thigh First Slide Second Slide

51 POST-TEST QUESTIONS A positive straight leg raise test indicates that the patient s hip pain is from a A. Radicular/sciatic etiology B. Hip joint pathology C. Bursitis D. Tight Hamstrings E. Weak hip flexors 10 Countdown

52 A positive straight leg raise test indicates that the patient s hip pain is from a Radicular/sciatic etiology Hip joint pathology Bursitis Tight Hamstrings Weak hip flexors First Slide Second Slide

53 POST-TEST QUESTIONS A positive McMurray s tests is indicative of a possible A. ACL tear B. MCL tear C. Patellar dislocation D. Joint effusion E. Meniscus tear 10 Countdown

54 A positive McMurray s tests is indicative of a possible ACL tear MCL tear Patellar dislocation Joint effusion Meniscus tear First Slide Second Slide

55 POST-TEST QUESTIONS Anterior drawer test on the knee is performed with the knee in A. 30 degrees flexion B. 90 degrees flexion C. Full extension D. 45 degrees flexion E. 130 degrees flexion 10 Countdown

56 Anterior drawer test on the knee is performed with the knee in 30 degrees flexion 90 degrees flexion Full extension 45 degrees flexion 130 degrees flexion First Slide Second Slide

57 POST-TEST QUESTIONS A positive squeeze test during an ankle exam is indicative of A. Syndesmotic injury B. Anterior talofibular ligament strain C. Deep vein thrombosis D. Compartment syndrome E. Deltoid ligament injury 10 Countdown

58 A positive squeeze test during an ankle exam is indicative of Syndesmotic injury Anterior talofibular ligament strain Deep vein thrombosis Compartment syndrome Deltoid ligament injury First Slide Second Slide

59 THANK YOU!