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Examination of the Lower Limbs

Examination of the Lower Limbs

Examination of the lower limbs involves assessment of the hips, knees, ankles, and feet to evaluate for signs of pathology. The examination includes inspection, palpation, assessment of range of movement, and provocative maneuvers. A good history should be taken and concurrently used with the exam findings to obtain a presumptive diagnosis.

Last updated: Feb 21, 2023

Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

Contents

Overview

Initial steps

  • Briefly explain each step of the examination to the individual and obtain consent.
  • Place the individual in the appropriate position.
  • Expose the leg Leg The lower leg, or just “leg” in anatomical terms, is the part of the lower limb between the knee and the ankle joint. The bony structure is composed of the tibia and fibula bones, and the muscles of the leg are grouped into the anterior, lateral, and posterior compartments by extensions of fascia. Leg: Anatomy completely, especially the thigh Thigh The thigh is the region of the lower limb found between the hip and the knee joint. There is a single bone in the thigh called the femur, which is surrounded by large muscles grouped into 3 fascial compartments. Thigh: Anatomy, knee, ankle, and foot Foot The foot is the terminal portion of the lower limb, whose primary function is to bear weight and facilitate locomotion. The foot comprises 26 bones, including the tarsal bones, metatarsal bones, and phalanges. The bones of the foot form longitudinal and transverse arches and are supported by various muscles, ligaments, and tendons. Foot: Anatomy.
  • Ensure good lighting.

Components of the examination

  • Inspect/observe stance.
  • Inspect/observe gait Gait Manner or style of walking. Neurological Examination.
  • Note any leg Leg The lower leg, or just “leg” in anatomical terms, is the part of the lower limb between the knee and the ankle joint. The bony structure is composed of the tibia and fibula bones, and the muscles of the leg are grouped into the anterior, lateral, and posterior compartments by extensions of fascia. Leg: Anatomy length discrepancy Length Discrepancy Blount’s Disease.
  • Palpate bony landmarks, tendons, ligaments, muscles.
  • Test both active and passive range of motion Range of motion The distance and direction to which a bone joint can be extended. Range of motion is a function of the condition of the joints, muscles, and connective tissues involved. Joint flexibility can be improved through appropriate muscle strength exercises. Examination of the Upper Limbs.
  • Perform special tests.
  • Test strength against resistance Resistance Physiologically, the opposition to flow of air caused by the forces of friction. As a part of pulmonary function testing, it is the ratio of driving pressure to the rate of air flow. Ventilation: Mechanics of Breathing.
  • Perform both generalized and dermatomal Dermatomal Dermatologic Examination sensory Sensory Neurons which conduct nerve impulses to the central nervous system. Nervous System: Histology testing.
  • Check deep tendon reflexes Deep Tendon Reflexes Neurological Examination (DTRs).

Anatomy

The lower limb is divided into 4 regions:

  • Hip region
  • Thigh Thigh The thigh is the region of the lower limb found between the hip and the knee joint. There is a single bone in the thigh called the femur, which is surrounded by large muscles grouped into 3 fascial compartments. Thigh: Anatomy
  • Leg Leg The lower leg, or just “leg” in anatomical terms, is the part of the lower limb between the knee and the ankle joint. The bony structure is composed of the tibia and fibula bones, and the muscles of the leg are grouped into the anterior, lateral, and posterior compartments by extensions of fascia. Leg: Anatomy
  • Foot Foot The foot is the terminal portion of the lower limb, whose primary function is to bear weight and facilitate locomotion. The foot comprises 26 bones, including the tarsal bones, metatarsal bones, and phalanges. The bones of the foot form longitudinal and transverse arches and are supported by various muscles, ligaments, and tendons. Foot: Anatomy

 The joints involved include:

  • Hip joint Hip joint The hip joint is a ball-and-socket joint formed by the head of the femur and the acetabulum of the pelvis. The hip joint is the most stable joint in the body and is supported by a very strong capsule and several ligaments, allowing the joint to sustain forces that can be multiple times the total body weight. Hip Joint: Anatomy
  • Knee joint Knee joint The knee joint is made up of the articulations between the femur, tibia, and patella bones, and is one of the largest and most complex joints of the human body. The knee is classified as a synovial hinge joint, which primarily allows for flexion and extension with a more limited degree of translation and rotation. Knee Joint: Anatomy
  • Ankle joint Ankle joint The ankle is a hinged synovial joint formed between the articular surfaces of the distal tibia, distal fibula, and talus. The ankle primarily allows plantar flexion and dorsiflexion of the foot.
  • Tibiotalar joint
  • Proximal tibiofibular joint Proximal tibiofibular joint Leg: Anatomy
  • Distal tibiofibular Distal tibiofibular Ankle Joint: Anatomy joint
  • Tarsometatarsal joints
  • Metatarsophalangeal joints
  • Proximal interphalangeal joints Interphalangeal joints Hand: Anatomy
  • Distal interphalangeal joints Interphalangeal joints Hand: Anatomy

These joints are surrounded and supported by many muscles, tendons, ligaments, and fibrocartilaginous structures to ensure support and stability and to absorb shock Shock Shock is a life-threatening condition associated with impaired circulation that results in tissue hypoxia. The different types of shock are based on the underlying cause: distributive (↑ cardiac output (CO), ↓ systemic vascular resistance (SVR)), cardiogenic (↓ CO, ↑ SVR), hypovolemic (↓ CO, ↑ SVR), obstructive (↓ CO), and mixed. Types of Shock during locomotion.

Anterior view of the pelvis

Anterior view of the pelvis, featuring the supporting ligaments of the joints of the pelvic girdle

Image by BioDigital, edited by Lecturio.
Knee ligaments

Knee ligaments tested using special tests to ensure stability

Image by Lecturio.
Lateral ankle

Lateral ankle showing the ligaments of the ankle joint that stabilize the joint

Image by BioDigital, edited by Lecturio
Ligaments

Ligaments supporting the medial aspect of the ankle joint

Image by BioDigital, edited by Lecturio
Superior view of the right foot featuring the bones of the foot and the tarsus

Superior view of the right foot featuring the bones of the foot and the tarsus

Image by Lecturio.
Medial view of the foot

Medial view of the foot featuring the arches of the foot

Image by Lecturio.

Hip Examination

Inspection Inspection Dermatologic Examination

  • Observe the individual walking and standing.
  • Observe alignment:
    • Determined by measurement of the angle formed between the head and neck Neck The part of a human or animal body connecting the head to the rest of the body. Peritonsillar Abscess of the femur:
      • A line is extended through the center of the shaft of the femoral neck Neck The part of a human or animal body connecting the head to the rest of the body. Peritonsillar Abscess. 
      • Another line is extended through the center of the shaft of the long axis of the femur. 
      • The intersection of these 2 lines is normally approximately 120‒135 degrees.
    • Angular deformities:
      • Coxa varum (> 135 degrees)
      • Coxa valgus (< 120 degrees)
  • Scars or redness Redness Inflammation
  • Swelling Swelling Inflammation or ecchymosis Ecchymosis Extravasation of blood into the skin, resulting in a nonelevated, rounded or irregular, blue or purplish patch, larger than a petechia. Orbital Fractures 
  • Muscle (quadriceps) wasting
  • Observe the inguinal region Inguinal region Anterior Abdominal Wall: Anatomy for swelling Swelling Inflammation (e.g., lymphadenopathy Lymphadenopathy Lymphadenopathy is lymph node enlargement (> 1 cm) and is benign and self-limited in most patients. Etiologies include malignancy, infection, and autoimmune disorders, as well as iatrogenic causes such as the use of certain medications. Generalized lymphadenopathy often indicates underlying systemic disease. Lymphadenopathy, inguinal hernia Hernia Protrusion of tissue, structure, or part of an organ through the bone, muscular tissue, or the membrane by which it is normally contained. Hernia may involve tissues such as the abdominal wall or the respiratory diaphragm. Hernias may be internal, external, congenital, or acquired. Abdominal Hernias).
  • Observe the hip capsule Capsule An envelope of loose gel surrounding a bacterial cell which is associated with the virulence of pathogenic bacteria. Some capsules have a well-defined border, whereas others form a slime layer that trails off into the medium. Most capsules consist of relatively simple polysaccharides but there are some bacteria whose capsules are made of polypeptides. Bacteroides for effusion.

Palpation Palpation Application of fingers with light pressure to the surface of the body to determine consistency of parts beneath in physical diagnosis; includes palpation for determining the outlines of organs. Dermatologic Examination and percussion Percussion Act of striking a part with short, sharp blows as an aid in diagnosing the condition beneath the sound obtained. Pulmonary Examination

  • Joint palpation Palpation Application of fingers with light pressure to the surface of the body to determine consistency of parts beneath in physical diagnosis; includes palpation for determining the outlines of organs. Dermatologic Examination:
    • Best done with a neutral or flexed hip
    • Palpate the anterior joint line along the inguinal fold. 
  • Palpate along the joint to feel for sponginess ( synovitis Synovitis Inflammation of the synovial membrane. Rheumatoid Arthritis) or bony growth (osteophytes).
  • Palpate for joint crepitus Crepitus Osteoarthritis (during active or passive range of motion Range of motion The distance and direction to which a bone joint can be extended. Range of motion is a function of the condition of the joints, muscles, and connective tissues involved. Joint flexibility can be improved through appropriate muscle strength exercises. Examination of the Upper Limbs).
  • Bursae:
  • Feel for warmth of the skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions across the gradient (above and below the inguinal fold).
  • Percussion Percussion Act of striking a part with short, sharp blows as an aid in diagnosing the condition beneath the sound obtained. Pulmonary Examination:
    • Along the femoral neck Neck The part of a human or animal body connecting the head to the rest of the body. Peritonsillar Abscess to detect femoral neck Neck The part of a human or animal body connecting the head to the rest of the body. Peritonsillar Abscess (stress) fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures
    • Medial to the anterior superior iliac spine Anterior Superior Iliac Spine Chronic Apophyseal Injury to detect lateral femoral cutaneous nerve entrapment

Motor Motor Neurons which send impulses peripherally to activate muscles or secretory cells. Nervous System: Histology and strength function

Hip pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways evaluation

“Hip pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways,” as referred to by the layperson, is a common term that may be due to pathology in numerous structures. This pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways should be further clarified by the examiner as to whether the pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways is: 

  • Posterior
  • Lateral
  • Anterior

Tests for posterior hip pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways

Low lumbar spine Spine The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column: Anatomy/lumbosacral spine Spine The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column: Anatomy:

  • Would typical emanate from:
    • L4–L5 or L5– S1 S1 Heart Sounds facet
    • L4–L5 or L5– S1 S1 Heart Sounds disk
    • L4, L5, or sacral nerve roots
    • Muscular/tendinous/ligamentous elements related to these structures
  • Presents as localized pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways at or just below the waistline that may be referred (or radiate) to the buttocks, proximal lower limb, and/or distal lower limb
  • Facet disease:
    • Generalized pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways with extension Extension Examination of the Upper Limbs (backward bending) of the lumbar spine Spine The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column: Anatomy
    • Positive Kemp test: localized pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways (over the specific facet joint(s) affected) with extension Extension Examination of the Upper Limbs of the lumbar spine Spine The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column: Anatomy
    • Tenderness to palpation Palpation Application of fingers with light pressure to the surface of the body to determine consistency of parts beneath in physical diagnosis; includes palpation for determining the outlines of organs. Dermatologic Examination directly over the facet joint(s)
  • Disk disease:
  • Nerve root disease:

Sacroiliac joint Sacroiliac Joint The immovable joint formed by the lateral surfaces of the sacrum and ilium. Pelvis: Anatomy:

  • Significant (and commonly missed) cause of “low back” pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways
  • Common in individuals with spondyloarthropathies (e.g., ankylosing spondylitis Ankylosing spondylitis Ankylosing spondylitis (also known as Bechterew’s disease or Marie-Strümpell disease) is a seronegative spondyloarthropathy characterized by chronic and indolent inflammation of the axial skeleton. Severe disease can lead to fusion and rigidity of the spine. Ankylosing Spondylitis, psoriatic arthritis Psoriatic Arthritis A type of inflammatory arthritis associated with psoriasis, often involving the axial joints and the peripheral terminal interphalangeal joints. It is characterized by the presence of hla-b27-associated spondyloarthropathy, and the absence of rheumatoid factor. Psoriasis)
  • Also common in the general population
  • Presents as localized pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways at or just below the waistline that may be referred (or radiate) to the buttocks and/or proximal lower limb (rarely past the knee).
  • Positive Fortin finger point sign: Individual points within 2 cm of the posterior superior iliac spine Spine The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column: Anatomy when asked to identify the source of their pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways. 
  • Tenderness to palpation Palpation Application of fingers with light pressure to the surface of the body to determine consistency of parts beneath in physical diagnosis; includes palpation for determining the outlines of organs. Dermatologic Examination over the posterior superior iliac spine Spine The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column: Anatomy
  • Provocative testing (designed to recreate the presenting pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways):
    • FABER test Faber Test Ankylosing Spondylitis (also known as Patrick test Patrick Test Back Pain or figure 4 test):
      • Individual is in the supine position.
      • The affected hip is carried into passive Flexion, ABduction, and External Rotation by the examiner.
      • Followed by a downward force to the medial knee applied by the examiner. 
    • Pelvic compression Compression Blunt Chest Trauma test:
      • Individual is in the lateral decubitus position.
      • Examiner compresses the innominates by applying a downward force through the anterior superior iliac spines.
    • Pelvic distraction test:
      • Individual is in the supine position.
      • Examiner separates (distracts) the innominates by applying a distractive force between the anterior superior iliac spines.
    • Thigh Thigh The thigh is the region of the lower limb found between the hip and the knee joint. There is a single bone in the thigh called the femur, which is surrounded by large muscles grouped into 3 fascial compartments. Thigh: Anatomy thrust test:
      • Individual is lying supine.
      • Affected hip is flexed to 90 degrees.
      • Pelvis Pelvis The pelvis consists of the bony pelvic girdle, the muscular and ligamentous pelvic floor, and the pelvic cavity, which contains viscera, vessels, and multiple nerves and muscles. The pelvic girdle, composed of 2 “hip” bones and the sacrum, is a ring-like bony structure of the axial skeleton that links the vertebral column with the lower extremities. Pelvis: Anatomy is stabilized at the opposite anterior superior iliac spines by the examiner. 
      • Examiner then applies downward pressure through the axis of the femur.
    • Gaenslen test:
      • Individual is lying supine.
      • Individual draws the nonaffected hip into full flexion Flexion Examination of the Upper Limbs and holds the position with their hands on a flexed knee while the affected limb stays lying on the table. 
      • Examiner places one hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand: Anatomy on the supine knee and the other over the hands of the individual on the flexed knee. 
      • The examiner then applies a distractive force between the 2 knees, creating torsion stress at the sacroiliac (SI) joint. 

Ischial tuberosity Ischial Tuberosity Chronic Apophyseal Injury/ ischial bursa Ischial bursa Hip Joint: Anatomy:

Piriformis Piriformis Vagina, Vulva, and Pelvic Floor: Anatomy muscle/ piriformis Piriformis Vagina, Vulva, and Pelvic Floor: Anatomy syndrome:

Palpation of the posterior superior iliac spine

Palpation of the posterior superior iliac spine:
This palpation is useful for identifying a bony landmark. In the Fortin finger point test, the individual is asked to point at the source of their pain. Localization of the individual’s fingertip near the posterior superior iliac spine is suggestive of SI joint disease. The posterior superior iliac spine is also commonly tender to palpation in SI joint disorders.

Image by Lecturio.
Faber test

The figure 4, or FABER, test:
With the individual in the supine position, the affected hip is carried into passive Flexion, ABduction, and External Rotation by the examiner, followed by a downward force applied by the examiner. This force causes stress against the SI joint(s). This provocative maneuver is designed to reproduce posterior hip pain and is associated with SI joint pathology.

Image by Lecturio.
The pelvic compression test

The pelvic compression test:
With the individual in the lateral decubitus position, the examiner compresses the innominates by applying a downward force through the anterior superior iliac spine. This force causes stress against the SI joint(s). This provocative maneuver is designed to reproduce posterior hip pain and is associated with SI joint pathology.

Image by Lecturio.
Active piriformis test

Active piriformis test:
With the individual in the lateral decubitus position with the hip and knee flexed, the examiner applies a medial force against the lateral aspect of the knee to induce adduction of the hip against the individual’s active effort to abduct (the piriformis is an abductor and external rotator of the hip when the hip is flexed). This force causes the piriformis to contract. This provocative maneuver is designed to reproduce posterior hip pain and is associated with piriformis pathology or irritation of the sciatic nerve (pseudosciatica) as it passes under (or through) the piriformis.

Image by Lecturio.

Tests for lateral hip pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways

Proximal iliotibial (IT) band/tensor fascia lata Fascia lata Femoral Region and Hernias: Anatomy:

  • Common overuse injury Overuse Injury Osgood-Schlatter Disease in endurance sports (e.g., running, cycling)
  • May alternatively present as lateral knee pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways and/or in conjunction with trochanteric bursitis
  • Exam findings:
    • Tenderness to palpation Palpation Application of fingers with light pressure to the surface of the body to determine consistency of parts beneath in physical diagnosis; includes palpation for determining the outlines of organs. Dermatologic Examination over the tensor fascia lata Fascia lata Femoral Region and Hernias: Anatomy and/or iliotibial band Iliotibial band Thigh: Anatomy (anywhere along its length, but especially over bony attachments)
    • Positive Ober test:
      • Individual is in the lateral decubitus position (affected side up) with the hip in the neutral position.
      • Examiner passively carries the hip into abduction Abduction Examination of the Upper Limbs (shortening the IT band) by lifting at the knee and then letting it fall. 
      • In the absence of IT band (or tensor fascia lata Fascia lata Femoral Region and Hernias: Anatomy) pathology, the knee will fall to its original position free of resistance Resistance Physiologically, the opposition to flow of air caused by the forces of friction. As a part of pulmonary function testing, it is the ratio of driving pressure to the rate of air flow. Ventilation: Mechanics of Breathing. 
      • If IT band pathology is present, the knee may fall slowly or may stop midway owing to contracture(s) of the IT band.

Trochanteric bursitis:

The ober test

The Ober test:
With the individual in the lateral decubitus position (affected side up) and the hip in the neutral position, the examiner passively carries the hip into abduction (shortening the IT band) by lifting at the knee and then letting it fall. In the absence of IT band (or tensor fascia lata) pathology, the knee will fall to its original position free of resistance. If IT band pathology is present, the knee may fall slowly or may stop midway owing to contracture(s) of the IT band.

Image by Lecturio.
Palpation and provocation of the greater trochanter

Palpation and provocation of the greater trochanter:


With the individual in the lateral decubitus position (affected side up), the examiner locates the greater trochanter and applies a downward provocative force. This force causes compression of the trochanteric bursa overlying the greater trochanter. This provocative maneuver is designed to reproduce lateral hip pain and is associated with pathology of the trochanteric bursa.

Image by Lecturio.

Tests for anterior hip pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways

Femoroacetabular joint:

  • Most commonly due to arthritic conditions (e.g., osteoarthritis Osteoarthritis Osteoarthritis (OA) is the most common form of arthritis, and is due to cartilage destruction and changes of the subchondral bone. The risk of developing this disorder increases with age, obesity, and repetitive joint use or trauma. Patients develop gradual joint pain, stiffness lasting < 30 minutes, and decreased range of motion. Osteoarthritis ( OA OA Osteoarthritis (OA) is the most common form of arthritis, and is due to cartilage destruction and changes of the subchondral bone. The risk of developing this disorder increases with age, obesity, and repetitive joint use or trauma. Patients develop gradual joint pain, stiffness lasting < 30 minutes, and decreased range of motion. Osteoarthritis), rheumatoid arthritis Arthritis Acute or chronic inflammation of joints. Osteoarthritis (RA))
  • Less commonly associated with avascular necrosis Avascular Necrosis Hip Fractures of the hip
  • Exam findings:

Hip flexors/iliopsoas syndrome:

  • Common in individuals who stay seated for prolonged periods (office workers), during which the hip flexors stay in the shortened position
  • Common overuse injury Overuse Injury Osgood-Schlatter Disease in the setting of repetitive hip flexion Flexion Examination of the Upper Limbs (e.g., cycling, sit-ups)
  • May occur with standing abruptly after a prolonged period of sitting
  • Exam findings:
    • Tenderness to palpation Palpation Application of fingers with light pressure to the surface of the body to determine consistency of parts beneath in physical diagnosis; includes palpation for determining the outlines of organs. Dermatologic Examination and/or hypertonicity Hypertonicity Volume Depletion and Dehydration of the iliopsoas muscle
    • Reproduction of pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways with resisted flexion Flexion Examination of the Upper Limbs of the hip:
      • Individual is in the supine position.
      • Examiner places a downward force against the individual’s distal femur while the individual resists by actively contracting the hip flexors. 
      • This provocative maneuver is designed to reproduce pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways in the anterior hip and is associated with pathology of the hip flexors.
    • Positive Thomas test:
      • Individual is in the supine position
      • Unaffected hip is passively flexed to the chest. 
      • If the iliopsoas is shortened (spasm/contracture), the affected hip will be unable to stay fully extended. 

Lateral femoral cutaneous nerve entrapment ( meralgia paresthetica Meralgia Paresthetica Mononeuropathy and Plexopathy):

  • The lateral femoral cutaneous nerve exits the anterior abdominal wall Abdominal wall The outer margins of the abdomen, extending from the osteocartilaginous thoracic cage to the pelvis. Though its major part is muscular, the abdominal wall consists of at least seven layers: the skin, subcutaneous fat, deep fascia; abdominal muscles, transversalis fascia, extraperitoneal fat, and the parietal peritoneum. Surgical Anatomy of the Abdomen just medial to the anterior superior iliac spine Anterior Superior Iliac Spine Chronic Apophyseal Injury. 
  • Entrapment/impingement/irritation may occur with:
    • Tight belt
    • Heavy belt (e.g., police belt, tool belt)
    • Abdominal pannus Pannus A genus of cyanobacteria in the family synechococcaceae that is free-floating and occurs in various water environments attaching to algae and submersed plants. Septic Arthritis (i.e., obesity Obesity Obesity is a condition associated with excess body weight, specifically with the deposition of excessive adipose tissue. Obesity is considered a global epidemic. Major influences come from the western diet and sedentary lifestyles, but the exact mechanisms likely include a mixture of genetic and environmental factors. Obesity)
    • Pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care
  • Presents with pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways/paresthesia in the distribution of the lateral femoral cutaneous nerve.
  • Exam findings:
Log roll test

Log roll test:
With the individual in the supine position, the femur is passively rotated internally and externally within the acetabulum. This provocative maneuver is designed to reproduce pain in the anterior hip (generally with internal rotation) and is associated with femoroacetabular joint pathology.

Image by Lecturio.
Hip abduction and adduction

Hip abduction and adduction:
With the individual in the supine position, the examiner passively carries the hip into abduction and adduction. This provocative maneuver is designed to reproduce pain in the anterior hip and is associated with femoroacetabular joint pathology.

Image by Lecturio.
Resisted flexion of the hip

Resisted flexion of the hip:
With the individual in the supine position, the examiner places a downward force against the individual’s distal femur while the individual resists by actively contracting the hip flexors. This provocative maneuver is designed to reproduce pain in the anterior hip and is associated with pathology of the hip flexors.

Image by Lecturio.
Percussion over the lateral femoral cutaneous nerve

Percussion over the lateral femoral cutaneous nerve at its exit point from the anterior abdominal wall just medial to the anterior superior iliac spine:
This provocative maneuver is designed to reproduce pain and/or paresthesia in the distribution of the nerve and is associated with nerve entrapment.

Image by Lecturio.

Vascular exam of the hip

The femoral pulse can be palpated at the inguinal fold:

Anterior view of the thigh featuring the femoral triangle

Anterior view of the thigh, featuring the femoral triangle with its borders and contents

Image by Lecturio.

Related videos

12:19
Examination of the Hip

Knee Examination

Inspection Inspection Dermatologic Examination

  • Observe the individual walking and standing.
  • Observe alignment:
    • Determined by measurement of the Q angle:
    • Angular deformities:
      • Genu varum Genu varum Genu varum is a deformation of the knee joint(s) that creates angulation of the lower limb(s) away from the midline in the coronal plane. Children ages 1-5 years are commonly affected. Genu Varum (bowlegged)
      • Genu valgum Genu valgum Genu valgum is a deformation of the knee joint(s) that creates angulation of the lower limb(s) toward the midline in the coronal plane. Children ages 1-5 years are commonly affected. Genu Valgum (knock-kneed)
  • Scars or redness Redness Inflammation
  • Swelling Swelling Inflammation or ecchymosis Ecchymosis Extravasation of blood into the skin, resulting in a nonelevated, rounded or irregular, blue or purplish patch, larger than a petechia. Orbital Fractures 
  • Muscle (quadriceps) wasting
  • Observe the popliteal fossa Popliteal fossa The popliteal fossa or the “knee pit” is a diamond-shaped, fat-filled, shallow depression on the posterior aspect of the knee joint. The popliteal fossa is located at the dorsal aspect of the knee and contains an increased number of lymph nodes as well as structures of the neurovascular system that travel from the thigh to the lower leg. Popliteal Fossa: Anatomy for swelling Swelling Inflammation.
  • Observe the knee capsule Capsule An envelope of loose gel surrounding a bacterial cell which is associated with the virulence of pathogenic bacteria. Some capsules have a well-defined border, whereas others form a slime layer that trails off into the medium. Most capsules consist of relatively simple polysaccharides but there are some bacteria whose capsules are made of polypeptides. Bacteroides for effusion.

Palpation Palpation Application of fingers with light pressure to the surface of the body to determine consistency of parts beneath in physical diagnosis; includes palpation for determining the outlines of organs. Dermatologic Examination and percussion Percussion Act of striking a part with short, sharp blows as an aid in diagnosing the condition beneath the sound obtained. Pulmonary Examination

  • Joint palpation Palpation Application of fingers with light pressure to the surface of the body to determine consistency of parts beneath in physical diagnosis; includes palpation for determining the outlines of organs. Dermatologic Examination:
  • Palpate along the joint to feel for sponginess ( synovitis Synovitis Inflammation of the synovial membrane. Rheumatoid Arthritis) or bony growth (osteophytes).
  • Palpate for joint crepitus Crepitus Osteoarthritis (during active or passive range of motion Range of motion The distance and direction to which a bone joint can be extended. Range of motion is a function of the condition of the joints, muscles, and connective tissues involved. Joint flexibility can be improved through appropriate muscle strength exercises. Examination of the Upper Limbs).
  • The posterior fossa must also be palpated for fullness, discomfort, or the presence of a cyst (Baker cyst, also known as popliteal cyst Popliteal cyst A synovial cyst most commonly at the back of the knee. Osteoarthritis).
  • Bursae:
    • Pes PES Removal of plasma and replacement with various fluids, e.g., fresh frozen plasma, plasma protein fractions (ppf), albumin preparations, dextran solutions, saline. Used in treatment of autoimmune diseases, immune complex diseases, diseases of excess plasma factors, and other conditions. Thrombotic Thrombocytopenic Purpura anserine (upper medial aspect of the tibia Tibia The second longest bone of the skeleton. It is located on the medial side of the lower leg, articulating with the fibula laterally, the talus distally, and the femur proximally. Knee Joint: Anatomy)
    • Prepatellar bursae 
    • Suprapatellar bursa Suprapatellar bursa Knee Joint: Anatomy
  • Palpate for a popliteal pulse Popliteal pulse Popliteal Fossa: Anatomy. 
  • Feel for warmth of the skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions across the gradient (above the knee to the tibia Tibia The second longest bone of the skeleton. It is located on the medial side of the lower leg, articulating with the fibula laterally, the talus distally, and the femur proximally. Knee Joint: Anatomy)
  • Tests for effusion:
    • Patellar ballottement test/tap:
      • Extend the knee joint Knee joint The knee joint is made up of the articulations between the femur, tibia, and patella bones, and is one of the largest and most complex joints of the human body. The knee is classified as a synovial hinge joint, which primarily allows for flexion and extension with a more limited degree of translation and rotation. Knee Joint: Anatomy.
      • Empty (milk) the suprapatellar pouch (by sliding hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand: Anatomy down the thigh Thigh The thigh is the region of the lower limb found between the hip and the knee joint. There is a single bone in the thigh called the femur, which is surrounded by large muscles grouped into 3 fascial compartments. Thigh: Anatomy to the patella Patella The flat, triangular bone situated at the anterior part of the knee. Knee Joint: Anatomy).
      • Tap the patella Patella The flat, triangular bone situated at the anterior part of the knee. Knee Joint: Anatomy.
      • Note for a tapping sensation or fluid impulse on the milking hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand: Anatomy.
    • Bulge sign/ripple test:
      • Extend the knee joint Knee joint The knee joint is made up of the articulations between the femur, tibia, and patella bones, and is one of the largest and most complex joints of the human body. The knee is classified as a synovial hinge joint, which primarily allows for flexion and extension with a more limited degree of translation and rotation. Knee Joint: Anatomy.
      • Empty (milk) the suprapatellar pouch (by sliding hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand: Anatomy down the thigh Thigh The thigh is the region of the lower limb found between the hip and the knee joint. There is a single bone in the thigh called the femur, which is surrounded by large muscles grouped into 3 fascial compartments. Thigh: Anatomy to the patella Patella The flat, triangular bone situated at the anterior part of the knee. Knee Joint: Anatomy).
      • Stroke the lateral side of the joint. 
      • Note any bulge or ripple on the medial side of the joint.
  • Percussion Percussion Act of striking a part with short, sharp blows as an aid in diagnosing the condition beneath the sound obtained. Pulmonary Examination:
    • Along the tibial plateau Plateau Cardiac Physiology to detect tibial plateau Plateau Cardiac Physiology (stress) fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures
    • Along the anterior tibial shaft to detect tibial insufficiency (stress) fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures
Palpation of the pes anserine bursa

Palpation of the pes anserine bursa

Image by Lecturio.
Patellar ballottement test

Patellar ballottement test

Image by Lecturio.
Bulge sign (ripple test)

Bulge sign (ripple test)

Image by Lecturio.

Motor Motor Neurons which send impulses peripherally to activate muscles or secretory cells. Nervous System: Histology and strength function

  • Active movements 1st.
  • Flexion Flexion Examination of the Upper Limbs:
    • Bring the knee up to the chest while supine, bringing the knee into maximum flexion Flexion Examination of the Upper Limbs.
    • Normal range: 0–140 degrees
    • Assesses hamstring strength against resistance Resistance Physiologically, the opposition to flow of air caused by the forces of friction. As a part of pulmonary function testing, it is the ratio of driving pressure to the rate of air flow. Ventilation: Mechanics of Breathing.
  • Extension Extension Examination of the Upper Limbs:
    • Straighten the leg Leg The lower leg, or just “leg” in anatomical terms, is the part of the lower limb between the knee and the ankle joint. The bony structure is composed of the tibia and fibula bones, and the muscles of the leg are grouped into the anterior, lateral, and posterior compartments by extensions of fascia. Leg: Anatomy at the knee, bringing the knee into maximum extension Extension Examination of the Upper Limbs.
    • Normal range: 0–140 degrees
    • Assesses quadriceps strength against resistance Resistance Physiologically, the opposition to flow of air caused by the forces of friction. As a part of pulmonary function testing, it is the ratio of driving pressure to the rate of air flow. Ventilation: Mechanics of Breathing
  • Patellar reflex: tests the reflex arc involving the L3 and L4 segments of the spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord: Anatomy

Joint stability tests

Always test the unaffected knee 1st and compare the 2 knees.

Collateral ligament stability:

  • Start with the knee completely extended:
    • If stable
    • Then flex the knee to 30 degrees.
    • At 30 degrees, cruciate ligament stability is removed.
  • Valgus test:
    • Assesses the integrity of the medial collateral ligament Medial collateral ligament Knee Joint: Anatomy.
    • One hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand: Anatomy is placed on the lateral aspect of the knee while the ankle is supported by the examiner’s other arm Arm The arm, or “upper arm” in common usage, is the region of the upper limb that extends from the shoulder to the elbow joint and connects inferiorly to the forearm through the cubital fossa. It is divided into 2 fascial compartments (anterior and posterior). Arm: Anatomy.
    • Valgus force is applied to the knee while the thumb monitors the joint line.
    • Assess for excessive joint opening, ligamentous laxity, or pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways.
  • Varus test:
    • Assesses the integrity of the lateral collateral ligament Lateral collateral ligament Knee Joint: Anatomy (LCL).
    • Examiner places one hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand: Anatomy on the medial aspect of the knee while the ankle is supported by the examiner’s other arm Arm The arm, or “upper arm” in common usage, is the region of the upper limb that extends from the shoulder to the elbow joint and connects inferiorly to the forearm through the cubital fossa. It is divided into 2 fascial compartments (anterior and posterior). Arm: Anatomy.
    • Apply varus force to the knee while holding the thumb in a position to monitor the joint line.
    • Assess for excessive joint opening, ligamentous laxity, or pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways

Cruciate ligament stability:

  • Anterior cruciate ligament Anterior Cruciate Ligament A strong ligament of the knee that originates from the posteromedial portion of the lateral condyle of the femur, passes anteriorly and inferiorly between the condyles, and attaches to the depression in front of the intercondylar eminence of the tibia. Knee Joint: Anatomy ( ACL ACL A strong ligament of the knee that originates from the posteromedial portion of the lateral condyle of the femur, passes anteriorly and inferiorly between the condyles, and attaches to the depression in front of the intercondylar eminence of the tibia. Knee Joint: Anatomy) injury is assessed by the anterior drawer, Lachman, and pivot shift tests.
    • Anterior drawer:
      • With the individual supine, the knee is bent at 90 degrees while the examiner stabilizes the leg Leg The lower leg, or just “leg” in anatomical terms, is the part of the lower limb between the knee and the ankle joint. The bony structure is composed of the tibia and fibula bones, and the muscles of the leg are grouped into the anterior, lateral, and posterior compartments by extensions of fascia. Leg: Anatomy by placing their thigh Thigh The thigh is the region of the lower limb found between the hip and the knee joint. There is a single bone in the thigh called the femur, which is surrounded by large muscles grouped into 3 fascial compartments. Thigh: Anatomy on the foot Foot The foot is the terminal portion of the lower limb, whose primary function is to bear weight and facilitate locomotion. The foot comprises 26 bones, including the tarsal bones, metatarsal bones, and phalanges. The bones of the foot form longitudinal and transverse arches and are supported by various muscles, ligaments, and tendons. Foot: Anatomy. 
      • Place the hands behind the tibia Tibia The second longest bone of the skeleton. It is located on the medial side of the lower leg, articulating with the fibula laterally, the talus distally, and the femur proximally. Knee Joint: Anatomy and the thumbs over the tibial tuberosity Tibial tuberosity Leg: Anatomy.
      • Pull the tibia Tibia The second longest bone of the skeleton. It is located on the medial side of the lower leg, articulating with the fibula laterally, the talus distally, and the femur proximally. Knee Joint: Anatomy anteriorly.
      • Excessive anterior translation Translation Translation is the process of synthesizing a protein from a messenger RNA (mRNA) transcript. This process is divided into three primary stages: initiation, elongation, and termination. Translation is catalyzed by structures known as ribosomes, which are large complexes of proteins and ribosomal RNA (rRNA). Stages and Regulation of Translation indicates rupture of the ACL ACL A strong ligament of the knee that originates from the posteromedial portion of the lateral condyle of the femur, passes anteriorly and inferiorly between the condyles, and attaches to the depression in front of the intercondylar eminence of the tibia. Knee Joint: Anatomy.
    • Lachman test Lachman Test Knee Ligament Injuries:
      • With the individual supine, the knee is bent at 20–30 degrees.  
      • One of the examiner’s hands stabilizes the distal femur while the other pulls the proximal tibia Tibia The second longest bone of the skeleton. It is located on the medial side of the lower leg, articulating with the fibula laterally, the talus distally, and the femur proximally. Knee Joint: Anatomy anteriorly.
      • Excessive anterior translation Translation Translation is the process of synthesizing a protein from a messenger RNA (mRNA) transcript. This process is divided into three primary stages: initiation, elongation, and termination. Translation is catalyzed by structures known as ribosomes, which are large complexes of proteins and ribosomal RNA (rRNA). Stages and Regulation of Translation indicates rupture of the ACL ACL A strong ligament of the knee that originates from the posteromedial portion of the lateral condyle of the femur, passes anteriorly and inferiorly between the condyles, and attaches to the depression in front of the intercondylar eminence of the tibia. Knee Joint: Anatomy.
      • More sensitive and specific than the anterior drawer test.
    • Pivot shift:
      • Individual is positioned supine with the knee fully extended.
      • The examiner places an internal rotation Internal Rotation Examination of the Upper Limbs and valgus force on the proximal tibia Tibia The second longest bone of the skeleton. It is located on the medial side of the lower leg, articulating with the fibula laterally, the talus distally, and the femur proximally. Knee Joint: Anatomy while carrying the knee into passive flexion Flexion Examination of the Upper Limbs.
      • A “clunk” with flexion Flexion Examination of the Upper Limbs indicates rupture of the ACL ACL A strong ligament of the knee that originates from the posteromedial portion of the lateral condyle of the femur, passes anteriorly and inferiorly between the condyles, and attaches to the depression in front of the intercondylar eminence of the tibia. Knee Joint: Anatomy.
  • Posterior cruciate ligament Posterior Cruciate Ligament A strong ligament of the knee that originates from the anterolateral surface of the medial condyle of the femur, passes posteriorly and inferiorly between the condyles, and attaches to the posterior intercondylar area of the tibia. Knee Joint: Anatomy ( PCL PCL A strong ligament of the knee that originates from the anterolateral surface of the medial condyle of the femur, passes posteriorly and inferiorly between the condyles, and attaches to the posterior intercondylar area of the tibia. Knee Joint: Anatomy) injury is assessed by the posterior drawer and quadriceps active tests.
    • Posterior drawer test Posterior Drawer Test Knee Ligament Injuries:
      • Individual is positioned supine with the knee flexed at 90 degrees while the examiner stabilizes the leg Leg The lower leg, or just “leg” in anatomical terms, is the part of the lower limb between the knee and the ankle joint. The bony structure is composed of the tibia and fibula bones, and the muscles of the leg are grouped into the anterior, lateral, and posterior compartments by extensions of fascia. Leg: Anatomy by placing their thigh Thigh The thigh is the region of the lower limb found between the hip and the knee joint. There is a single bone in the thigh called the femur, which is surrounded by large muscles grouped into 3 fascial compartments. Thigh: Anatomy on the foot Foot The foot is the terminal portion of the lower limb, whose primary function is to bear weight and facilitate locomotion. The foot comprises 26 bones, including the tarsal bones, metatarsal bones, and phalanges. The bones of the foot form longitudinal and transverse arches and are supported by various muscles, ligaments, and tendons. Foot: Anatomy. 
      • Both of the examiner’s hands are held at the individual’s proximal tibia Tibia The second longest bone of the skeleton. It is located on the medial side of the lower leg, articulating with the fibula laterally, the talus distally, and the femur proximally. Knee Joint: Anatomy while a posterior force is applied.
      • Excessive posterior translation Translation Translation is the process of synthesizing a protein from a messenger RNA (mRNA) transcript. This process is divided into three primary stages: initiation, elongation, and termination. Translation is catalyzed by structures known as ribosomes, which are large complexes of proteins and ribosomal RNA (rRNA). Stages and Regulation of Translation indicates rupture of the PCL PCL A strong ligament of the knee that originates from the anterolateral surface of the medial condyle of the femur, passes posteriorly and inferiorly between the condyles, and attaches to the posterior intercondylar area of the tibia. Knee Joint: Anatomy.
    • Quadriceps active test Quadriceps Active Test Knee Ligament Injuries:
      • Individual is positioned supine and asked to raise the foot Foot The foot is the terminal portion of the lower limb, whose primary function is to bear weight and facilitate locomotion. The foot comprises 26 bones, including the tarsal bones, metatarsal bones, and phalanges. The bones of the foot form longitudinal and transverse arches and are supported by various muscles, ligaments, and tendons. Foot: Anatomy off the table by actively flexing at the hip (this places the distal lower limb in a gravity-dependent position).
      • The individual is then asked to actively contract the quadriceps muscle.
  • The examiner assesses for anterior tibial movement (a tibia Tibia The second longest bone of the skeleton. It is located on the medial side of the lower leg, articulating with the fibula laterally, the talus distally, and the femur proximally. Knee Joint: Anatomy in posterior subluxation Subluxation Radial Head Subluxation (Nursemaid’s Elbow) will move anteriorly, indicating PCL PCL A strong ligament of the knee that originates from the anterolateral surface of the medial condyle of the femur, passes posteriorly and inferiorly between the condyles, and attaches to the posterior intercondylar area of the tibia. Knee Joint: Anatomy rupture).

Patellar stability: patellar apprehension test

Valgus test to assess for mcl stability at 30° flexion

Valgus test to assess for medial collateral ligament stability at 30 degrees of flexion

Image by Lecturio.
Varus test for lateral collateral ligamentlcl stability, done at 30° flexion

Varus test for lateral collateral ligament stability, done at 30 degrees of flexion

Image by Lecturio.
Anterior drawer test

Anterior drawer test

Image by Lecturio.
Lachman test for acl stability

Lachman test for anterior cruciate ligament stability

Image by Lecturio.
Posterior drawer test

Posterior drawer test

Image by Lecturio.
Patellar stability test

Patellar stability test

Image by Lecturio.

Special tests

Tests for meniscal tears:

  • McMurray test Mcmurray Test Meniscus Tear:
  • Lateral meniscus:
    • The examiner passively flexes the knee while applying valgus stress and internally rotating the ankle.
    • The examiner then extends the knee smoothly while palpating the joint line.
    • Audible/palpable crepitus Crepitus Osteoarthritis (click or pop) or excessive discomfort indicates lateral meniscus injury. 
  • Apley test:
    • Individual is placed in the prone position.
    • Knee is passively flexed to 90 degrees.
    • The examiner stabilizes the thigh Thigh The thigh is the region of the lower limb found between the hip and the knee joint. There is a single bone in the thigh called the femur, which is surrounded by large muscles grouped into 3 fascial compartments. Thigh: Anatomy with one hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand: Anatomy and with the other hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand: Anatomy applies compression Compression Blunt Chest Trauma through the tibia Tibia The second longest bone of the skeleton. It is located on the medial side of the lower leg, articulating with the fibula laterally, the talus distally, and the femur proximally. Knee Joint: Anatomy to the knee while passively carrying the ankle into internal and external rotation External Rotation Examination of the Upper Limbs. 
    • Excessive discomfort indicates meniscal injury.

Tests for iliotibial band Iliotibial band Thigh: Anatomy inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body’s defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation: 

Mcmurray test

McMurray test:
External rotation with varus stress to test for medial meniscus tear

Image by Lecturio.
Mcmurray test internal

McMurray test:
Internal rotation with valgus stress to test for lateral meniscus tear

Image by Lecturio.
Apley’s test

Apley test for meniscus tear

Image by Lecturio.
Noble test

Noble test for iliotibial band syndrome

Image by Lecturio.

Vascular exam of the knee

The popliteal pulse Popliteal pulse Popliteal Fossa: Anatomy can be palpated at the popliteal fossa Popliteal fossa The popliteal fossa or the “knee pit” is a diamond-shaped, fat-filled, shallow depression on the posterior aspect of the knee joint. The popliteal fossa is located at the dorsal aspect of the knee and contains an increased number of lymph nodes as well as structures of the neurovascular system that travel from the thigh to the lower leg. Popliteal Fossa: Anatomy:

  • Directly posterior to the joint line
  • Located between the tendons of the hamstrings muscle complex
Vascular supply of the knee (posterior view)

Posterior view of the vascular supply of the knee joint

Image by BioDigital, edited by Lecturio

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Ankle and Foot Examination

Inspection Inspection Dermatologic Examination

  • Observe the individual walking and standing.
  • Assess alignment of the heel (valgus/varus).
  • Assess the arch of the foot Foot The foot is the terminal portion of the lower limb, whose primary function is to bear weight and facilitate locomotion. The foot comprises 26 bones, including the tarsal bones, metatarsal bones, and phalanges. The bones of the foot form longitudinal and transverse arches and are supported by various muscles, ligaments, and tendons. Foot: Anatomy:
    • Pes PES Removal of plasma and replacement with various fluids, e.g., fresh frozen plasma, plasma protein fractions (ppf), albumin preparations, dextran solutions, saline. Used in treatment of autoimmune diseases, immune complex diseases, diseases of excess plasma factors, and other conditions. Thrombotic Thrombocytopenic Purpura cavus (exaggerated arch)
    • Pes planus Pes Planus Ehlers-Danlos Syndrome (flat foot Foot The foot is the terminal portion of the lower limb, whose primary function is to bear weight and facilitate locomotion. The foot comprises 26 bones, including the tarsal bones, metatarsal bones, and phalanges. The bones of the foot form longitudinal and transverse arches and are supported by various muscles, ligaments, and tendons. Foot: Anatomy)
  • Examine for:
    • Swelling Swelling Inflammation/ deformity Deformity Examination of the Upper Limbs:
    • Ecchymosis Ecchymosis Extravasation of blood into the skin, resulting in a nonelevated, rounded or irregular, blue or purplish patch, larger than a petechia. Orbital Fractures 
    • Scars
    • Callous
    • Wounds/ulcers (especially in the diabetic foot Foot The foot is the terminal portion of the lower limb, whose primary function is to bear weight and facilitate locomotion. The foot comprises 26 bones, including the tarsal bones, metatarsal bones, and phalanges. The bones of the foot form longitudinal and transverse arches and are supported by various muscles, ligaments, and tendons. Foot: Anatomy)

Palpation Palpation Application of fingers with light pressure to the surface of the body to determine consistency of parts beneath in physical diagnosis; includes palpation for determining the outlines of organs. Dermatologic Examination and percussion Percussion Act of striking a part with short, sharp blows as an aid in diagnosing the condition beneath the sound obtained. Pulmonary Examination

Palpatory techniques of the following structures is performed, looking for tenderness, temperature, and swelling Swelling Inflammation:

  • Proximal fibula Fibula The bone of the lower leg lateral to and smaller than the tibia. In proportion to its length, it is the most slender of the long bones. Leg: Anatomy (fibular head fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures)
  • Lateral malleolus Lateral malleolus Ankle Joint: Anatomy (and surrounding ligaments)
  • Medial malleolus Medial malleolus Ankle Joint: Anatomy and (surrounding ligaments)
  • Tarsal bones Tarsal Bones The seven bones which form the tarsus – namely, calcaneus; talus; cuboid, navicular, and the internal, middle, and external cuneiforms. Foot: Anatomy
  • Base of the 5th metatarsal (5th metatarsal fractures common)
  • 1st metatarsophalangeal joint Metatarsophalangeal Joint Foot: Anatomy ( gout Gout Gout is a heterogeneous metabolic disease associated with elevated serum uric acid levels (> 6.8 mg/dL) and abnormal deposits of monosodium urate in tissues. The condition is often familial and is initially characterized by painful, recurring, and usually monoarticular acute arthritis, or “gout flare,” followed later by chronic deforming arthritis. Gout, bunyon, arthritis Arthritis Acute or chronic inflammation of joints. Osteoarthritis, capsulitis)
  • Anterior calcaneus Calcaneus The largest of the tarsal bones which is situated at the lower and back part of the foot, forming the heel. Foot: Anatomy (tender at this point → plantar fasciitis Plantar fasciitis Inflammation of the plantar fascia (aponeurosis) on the bottom of the foot causing heel pain. The etiology of plantar fasciitis remains controversial but is likely to involve a biomechanical imbalance. Though often presenting along with heel spur, they do not appear to be causally related. Ankle and Foot Pain)
  • Posterior calcaneus Calcaneus The largest of the tarsal bones which is situated at the lower and back part of the foot, forming the heel. Foot: Anatomy/Achilles tendon (tender at this point → Achilles tendinitis Tendinitis Ankylosing Spondylitis)
  • Compress the distal tibiofibular Distal tibiofibular Ankle Joint: Anatomy joint for syndesmotic injury (indicates high ankle sprain)
  • Palpate the distal lower-extremity pulses at the:
Palpation of the deltoid ligament

Palpation of the deltoid ligament

Image by Lecturio.
Palpation of the anterior talofibular ligament (atfl) attachment

Palpation of the anterior talofibular ligament (ATFL) attachment

Image by Lecturio.
Palpation of the calcaneofibular ligament (cfl)

Palpation of the calcaneofibular ligament (CFL)

Image by Lecturio.
Palpation of the navicular bone

Palpation of the navicular bone

Image by Lecturio.
Palpation of the mtps

Palpation of the metatarsophalangeal joints

Image by Lecturio.

Motor Motor Neurons which send impulses peripherally to activate muscles or secretory cells. Nervous System: Histology strength

  • Dorsiflexion:
    • L4 nerve root 
    • Assess strength in dorsiflexion against examiner’s resistance Resistance Physiologically, the opposition to flow of air caused by the forces of friction. As a part of pulmonary function testing, it is the ratio of driving pressure to the rate of air flow. Ventilation: Mechanics of Breathing (weakness leads to foot drop Foot Drop Leprosy).
    • Normal range: 20–30 degrees
  • Plantar flexion Flexion Examination of the Upper Limbs:
  • Inversion:
    • Resisted inversion: tests the integrity of the posterior tibial tendons
    • Normal range: 0–60 degrees
  • Eversion Eversion Chronic Apophyseal Injury:
  • Achilles reflex: tests the reflex arc involving the L5 and S1 S1 Heart Sounds segments of the spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord: Anatomy

Special tests

  • Calf-squeeze test (Thompson test):
    • Assesses for rupture of the Achilles tendon
    • May be carried out with the individual sitting on the edge of the examining table or lying prone with feet hanging over the edge
    • The calf ( gastrocnemius Gastrocnemius Leg: Anatomy– soleus Soleus Leg: Anatomy complex) muscle is squeezed by the examiner.
    • Observe for plantar flexion Flexion Examination of the Upper Limbs of the ipsilateral foot Foot The foot is the terminal portion of the lower limb, whose primary function is to bear weight and facilitate locomotion. The foot comprises 26 bones, including the tarsal bones, metatarsal bones, and phalanges. The bones of the foot form longitudinal and transverse arches and are supported by various muscles, ligaments, and tendons. Foot: Anatomy.
    • If complete rupture → the foot Foot The foot is the terminal portion of the lower limb, whose primary function is to bear weight and facilitate locomotion. The foot comprises 26 bones, including the tarsal bones, metatarsal bones, and phalanges. The bones of the foot form longitudinal and transverse arches and are supported by various muscles, ligaments, and tendons. Foot: Anatomy will remain neutral or dorsiflexed.
    • If partial rupture → incomplete plantar flexion Flexion Examination of the Upper Limbs.
  • Anterior drawer test:
    • Assesses the stability of the anterior talofibular ligament Anterior Talofibular Ligament Ankle Joint: Anatomy ( ATFL ATFL Ankle Joint: Anatomy)
    • One of the examiner’s hands stabilizes the lower leg Leg The lower leg, or just “leg” in anatomical terms, is the part of the lower limb between the knee and the ankle joint. The bony structure is composed of the tibia and fibula bones, and the muscles of the leg are grouped into the anterior, lateral, and posterior compartments by extensions of fascia. Leg: Anatomy and the other applies an anterior force at the heel.
    • Excessive laxity indicates ATFL ATFL Ankle Joint: Anatomy rupture.
  • Windlass test:
    • Examiner passively dorsiflexes the toes.
    • Heel pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways with passive dorsiflexion of the toes indicates presence of plantar fasciitis Plantar fasciitis Inflammation of the plantar fascia (aponeurosis) on the bottom of the foot causing heel pain. The etiology of plantar fasciitis remains controversial but is likely to involve a biomechanical imbalance. Though often presenting along with heel spur, they do not appear to be causally related. Ankle and Foot Pain.
  • Talar tilt test:
Thompson test for achilles tendon rupture

Thompson test for Achilles tendon rupture

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Anterior drawer test of the ankle joint

Anterior drawer test of the ankle joint

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Windlass test

Windlass test:
Pain at the calcaneal attachment of the plantar aponeurosis with passive dorsiflexion of the toes indicates plantar fasciitis.

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Talar tilt test

Talar tilt test

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Vascular exam of the ankle

  • The dorsalis pedis pulse can be palpated at the mid-dorsal foot Foot The foot is the terminal portion of the lower limb, whose primary function is to bear weight and facilitate locomotion. The foot comprises 26 bones, including the tarsal bones, metatarsal bones, and phalanges. The bones of the foot form longitudinal and transverse arches and are supported by various muscles, ligaments, and tendons. Foot: Anatomy.
  • The posterior tibial pulse can be palpated posterior to the medial malleolus Medial malleolus Ankle Joint: Anatomy.
Arterial supply of the ankle

Arterial supply to the ankle:
Note that the anterior tibial artery is shown as its continuation, the dorsalis pedis artery.

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Related videos

12:23
Examination of Foot and Ankle and Physical Findings

Clinical Relevance

Table: Overview of the most common conditions seen for knee pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways
Palpation Palpation Application of fingers with light pressure to the surface of the body to determine consistency of parts beneath in physical diagnosis; includes palpation for determining the outlines of organs. Dermatologic Examination Effusion Range of motion Range of motion The distance and direction to which a bone joint can be extended. Range of motion is a function of the condition of the joints, muscles, and connective tissues involved. Joint flexibility can be improved through appropriate muscle strength exercises. Examination of the Upper Limbs Special tests
Osteoarthritis Osteoarthritis Osteoarthritis (OA) is the most common form of arthritis, and is due to cartilage destruction and changes of the subchondral bone. The risk of developing this disorder increases with age, obesity, and repetitive joint use or trauma. Patients develop gradual joint pain, stiffness lasting < 30 minutes, and decreased range of motion. Osteoarthritis Osteophytes and tender joint line +/– Limited by pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways Plain film radiography:
  • Joint space narrowing
  • Osteophytes
Meniscus tear Meniscus tear The menisci are fibrocartilaginous wedge-shaped structures between the distal femur and proximal tibia that stabilize and dissipate weight-bearing forces at the knee joint. A meniscus tear is an injury to the meniscus caused by rotational or shearing forces across the tibiofemoral joint. Meniscus Tear Tender joint line +/– Locking sensation
Ligament injuries Tender joint line ++ ( ACL ACL A strong ligament of the knee that originates from the posteromedial portion of the lateral condyle of the femur, passes anteriorly and inferiorly between the condyles, and attaches to the depression in front of the intercondylar eminence of the tibia. Knee Joint: Anatomy tears) Limited by pain and sensation of “give-away”
Gout Gout Gout is a heterogeneous metabolic disease associated with elevated serum uric acid levels (> 6.8 mg/dL) and abnormal deposits of monosodium urate in tissues. The condition is often familial and is initially characterized by painful, recurring, and usually monoarticular acute arthritis, or “gout flare,” followed later by chronic deforming arthritis. Gout Warm joint ++ Limited by pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways Joint aspiration and analysis
Pes PES Removal of plasma and replacement with various fluids, e.g., fresh frozen plasma, plasma protein fractions (ppf), albumin preparations, dextran solutions, saline. Used in treatment of autoimmune diseases, immune complex diseases, diseases of excess plasma factors, and other conditions. Thrombotic Thrombocytopenic Purpura anserine bursitis Point tenderness Point Tenderness Chronic Apophyseal Injury at insertion (2 cm below medial tuberosity) – No limitation
Table: Most common conditions seen with ankle/ foot Foot The foot is the terminal portion of the lower limb, whose primary function is to bear weight and facilitate locomotion. The foot comprises 26 bones, including the tarsal bones, metatarsal bones, and phalanges. The bones of the foot form longitudinal and transverse arches and are supported by various muscles, ligaments, and tendons. Foot: Anatomy pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways
Palpation Palpation Application of fingers with light pressure to the surface of the body to determine consistency of parts beneath in physical diagnosis; includes palpation for determining the outlines of organs. Dermatologic Examination Special tests Notes
Ankle sprain Tilt test Ottawa ankle rules: an ankle x-ray X-ray Penetrating electromagnetic radiation emitted when the inner orbital electrons of an atom are excited and release radiant energy. X-ray wavelengths range from 1 pm to 10 nm. Hard x-rays are the higher energy, shorter wavelength x-rays. Soft x-rays or grenz rays are less energetic and longer in wavelength. The short wavelength end of the x-ray spectrum overlaps the gamma rays wavelength range. The distinction between gamma rays and x-rays is based on their radiation source. Pulmonary Function Tests is indicated for any of the following:
  • Pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways in the malleolar zone
  • Inability to bear weight for 4 steps
  • Bony tenderness along the distal 6 cm of the posterior edge of the fibula Fibula The bone of the lower leg lateral to and smaller than the tibia. In proportion to its length, it is the most slender of the long bones. Leg: Anatomy/ tibia Tibia The second longest bone of the skeleton. It is located on the medial side of the lower leg, articulating with the fibula laterally, the talus distally, and the femur proximally. Knee Joint: Anatomy of the lateral/ medial malleolus Medial malleolus Ankle Joint: Anatomy
Plantar fasciitis Plantar fasciitis Inflammation of the plantar fascia (aponeurosis) on the bottom of the foot causing heel pain. The etiology of plantar fasciitis remains controversial but is likely to involve a biomechanical imbalance. Though often presenting along with heel spur, they do not appear to be causally related. Ankle and Foot Pain Tenderness at the insertion point on the calcaneus Calcaneus The largest of the tarsal bones which is situated at the lower and back part of the foot, forming the heel. Foot: Anatomy (plantar surface) Windlass test Loss of arch might be noted
Tarsal tunnel syndrome Tarsal tunnel syndrome Entrapment of the distal branches of the posterior tibial nerve (which divides into the medial plantar, lateral plantar, and calcaneal nerves) in the tarsal tunnel, which lies posterior to the internal malleolus and beneath the retinaculum of the flexor muscles of the foot. Symptoms include ankle pain radiating into the foot which tends to be aggravated by walking. Examination may reveal tinel’s sign (radiating pain following nerve percussion) over the tibial nerve at the ankle, weakness and atrophy of the small foot muscles, or loss of sensation in the foot. Ankle and Foot Pain Palpation Palpation Application of fingers with light pressure to the surface of the body to determine consistency of parts beneath in physical diagnosis; includes palpation for determining the outlines of organs. Dermatologic Examination may reproduce symptoms of tingling Tingling Posterior Cord Syndrome/burning radiating to the soles Tinel sign
Achilles tendinitis Tendinitis Ankylosing Spondylitis/rupture Palpating along the tendon may show a gap (rupture) or tenderness at insertion (superior calcaneus Calcaneus The largest of the tarsal bones which is situated at the lower and back part of the foot, forming the heel. Foot: Anatomy). Thompson test

References

  1. Macleod J, Munro JF, Edwards CRW, University of Edinburgh. (1990). Macleod’s Clinical Examination. Edinburgh: Churchill Livingstone.
  2. Melanson SW, Shuman VL. (2021). Acute ankle sprain. StatPearls. Retrieved December 21, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK459212/

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