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 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, 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.
• Ensure good lighting.

Components of the examination

• Inspect/observe stance.
• Inspect/observe gait.
• 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 length discrepancy.
• Palpate bony landmarks, tendons, ligaments, muscles.
• Test both active and passive range of motion.
• Perform special tests.
• Test strength against resistance.
• Perform both generalized and dermatomal sensory testing.
• Check deep tendon reflexes (DTRs).

Anatomy

The lower limb is divided into 4 regions:

• Hip region
• Thigh
• Leg
• Foot

 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
• 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
• 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. Ankle Joint
• Tibiotalar joint
• Proximal tibiofibular joint
• Distal tibiofibular joint
• Tarsometatarsal joints
• Metatarsophalangeal joints
• Proximal interphalangeal joints
• Distal interphalangeal joints

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.

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Hip Examination

Inspection

• Observe the individual walking and standing.
• Observe alignment:
  • Determined by measurement of the angle formed between the head and neck of the femur:
    • A line is extended through the center of the shaft of the femoral neck. 
    • 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
• Swelling or ecchymosis 
• Muscle (quadriceps) wasting
• Observe the inguinal region for swelling (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 Inguinal hernia An abdominal hernia with an external bulge in the groin region. It can be classified by the location of herniation. Indirect inguinal hernias occur through the internal inguinal ring. Direct inguinal hernias occur through defects in the abdominal wall (transversalis fascia) in hesselbach's triangle. The former type is commonly seen in children and young adults; the latter in adults. Inguinal Canal and Hernias).
• Observe the hip capsule for effusion.

Palpation and percussion

• Joint palpation:
  • 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) or bony growth (osteophytes).
• Palpate for joint crepitus (during active or passive range of motion).
• Bursae: 
  • Iliopsoas bursa
  • Ischial bursa 
  • Trochanteric bursa
• 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. Structure and Function of the Skin across the gradient (above and below the inguinal fold).
• Percussion:
  • Along the femoral neck to detect femoral neck (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 to detect lateral femoral cutaneous nerve entrapment

Motor and strength function

• Active movements 1st
• Flexion:
  • Bring the knee up to the chest while supine.
  • Normal range: 0–120 degrees
  • Assesses hip flexor strength against resistance
• Extension: 
  • Passively carry the hip into extension/hyperextension from the lateral decubitus or prone position,
  • Normal range: 0–15 degrees
  • Assesses hamstring strength against resistance
• Abduction: 
  • Passively carry the hip into abduction from the supine position.
  • Normal range: 30–50 degrees
  • Assesses hip abductor strength against resistance
• Adduction:
  • Passively carry the hip into adduction from the supine position.
  • Normal range: 20–30 degrees
  • Assesses hip adductor strength against resistance
• Internal rotation:
  • Passively carry the hip into internal rotation from the supine position.
  • Normal range: 30–40 degrees
  • Assesses hip internal rotator strength against resistance
• External rotation:
  • Passively carry the hip into external rotation from the supine position.
  • Normal range: 40–60 degrees
  • Assesses hip internal rotator strength against resistance

Hip pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain evaluation

“Hip pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain,” as referred to by the layperson, is a common term that may be due to pathology in numerous structures. This pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain should be further clarified by the examiner as to whether the pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain is: 

• Posterior
• Lateral
• Anterior

Tests for posterior hip pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain

Low lumbar spine/lumbosacral spine:

• Would typical emanate from:
  • L4–L5 or L5–S1 facet
  • L4–L5 or L5–S1 disk
  • L4, L5, or sacral nerve roots
  • Muscular/tendinous/ligamentous elements related to these structures
• Presents as localized pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain 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 Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain with extension (backward bending) of the lumbar spine
  • Positive Kemp test: localized pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain (over the specific facet joint(s) affected) with extension of the lumbar spine
  • Tenderness to palpation directly over the facet joint(s)
• Disk disease:
  • Localized midline pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain with flexion (forward bending) or lateral flexion (side bending) of the lumbar spine
  • Localized midline pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain with cough or sneeze (i.e., Valsalva)
  • Discogenic pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain may or may not be associated with nerve root (i.e., radicular) pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain. 
• Nerve root disease: 
  • Positive straight 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 raise test (Lasègue) test: With the individual in the supine position, the examiner passively raises a straight 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 (extended at the knee) into hip flexion. A positive test causes pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain to radiate into the lower limb (typically in a dermatomal pattern).
  • Associated sensory (dermatomal) and motor (myotomal) findings in the affected lower limb(s)

Sacroiliac joint:

• Significant (and commonly missed) cause of “low back” pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain
• 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)
• Also common in the general population
• Presents as localized pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain 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 when asked to identify the source of their pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain. 
• Tenderness to palpation over the posterior superior iliac spine
• Provocative testing (designed to recreate the presenting pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain):
  • FABER test (also known as Patrick test 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 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 thrust test: 
    • Individual is lying supine.
    • Affected hip is flexed to 90 degrees.
    • Pelvis 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 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 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 bursa:

• Due to periosteal irritation associated with tight hamstrings (proximal attachment of the hamstrings is in the ischial tuberosity)
• Ischial bursitis (ischial bursa overlies the ischial tuberosity): from activities required repetitive or prolonged squatting
• Exam findings (ischial tuberosity): 
  • Tenderness to palpation directly over the ischial tuberosity/ischial bursa
  • Reproduction of pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain with squatting/restricted hip extension (hamstring contraction)

Piriformis muscle/piriformis syndrome:

• Spasm/hypertonicity/injury to the piriformis muscle
• Compensatory overstretching of the piriformis muscle due to abnormal pelvic mechanics
• Pseuodosciatica: irritation of the sciatic nerve as it passes under (or through, anatomic variant) the belly of the piriformis
• Exam findings (piriformis):
  • Tenderness to palpation and/or hypertonicity of the piriformis muscle
  • Positive active piriformis test: 
    • Individual is in the lateral decubitus position, with the hip and knee flexed.
    • 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.
    • Note: The piriformis is an abductor and external rotator of the hip when the hip is flexed.

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Tests for lateral hip pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain

Proximal iliotibial (IT) band/tensor fascia lata:

• Common overuse injury in endurance sports (e.g., running, cycling)
• May alternatively present as lateral knee pain Knee Pain Knee pain is a common presentation to primary care physicians. The diagnosis can be challenging as the pain may arise from the joint, surrounding tissues, or referred to the joint from distant structures. The differential diagnosis of knee pain is broad and categorizing the various diagnoses related to the timing (acute or chronic) is useful. Knee Pain and/or in conjunction with trochanteric bursitis
• Exam findings:
  • Tenderness to palpation over the tensor fascia lata and/or iliotibial band (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 (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.

Trochanteric bursitis:

• Common overuse injury in endurance sports (e.g., running, cycling)
• Common injury associated with abnormal gait mechanics (e.g., injured back, hip, knee, or ankle associated with an antalgic gait)
• Exam findings: tenderness to palpation directly over the greater trochanter/trochanteric bursa

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Tests for anterior hip pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain

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), rheumatoid arthritis Rheumatoid arthritis Rheumatoid arthritis (RA) is a symmetric, inflammatory polyarthritis and chronic, progressive, autoimmune disorder. Presentation occurs most commonly in middle-aged women with joint swelling, pain, and morning stiffness (often in the hands). Rheumatoid Arthritis (RA))
• Less commonly associated with avascular necrosis of the hip
• Exam findings:
  • Antalgic gait
  • Positive log roll test: 
    • Individual is in the supine position.
    • The femur is passively rotated internally and externally within the acetabulum. 
    • This provocative maneuver is designed to reproduce pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain in the anterior hip (generally with internal rotation) and is associated with femoroacetabular joint pathology.
  • Reproduction of pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain with hip abduction and adduction:
    • Individual is in the supine position.
    • Examiner passively carries the hip into abduction and adduction. 
    • This provocative maneuver is designed to reproduce pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain in the anterior hip and is associated with femoroacetabular joint pathology.

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 in the setting of repetitive hip flexion (e.g., cycling, sit-ups)
• May occur with standing abruptly after a prolonged period of sitting
• Exam findings:
  • Tenderness to palpation and/or hypertonicity of the iliopsoas muscle
  • Reproduction of pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain with resisted flexion 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 Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain 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):

• The lateral femoral cutaneous nerve exits the anterior abdominal wall Anterior abdominal wall The anterior abdominal wall is anatomically delineated as a hexagonal area defined superiorly by the xiphoid process, laterally by the midaxillary lines, and inferiorly by the pubic symphysis. Anterior Abdominal Wall just medial to the anterior superior iliac spine. 
• Entrapment/impingement/irritation may occur with:
  • Tight belt
  • Heavy belt (e.g., police belt, tool belt)
  • Abdominal pannus (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 Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-HCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care
• Presents with pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain/paresthesia in the distribution of the lateral femoral cutaneous nerve.
• Exam findings:
  • Sensory disturbance (loss of sensation, altered sensation, allodynia) in the receptive field of the lateral femoral cutaneous nerve
  • Reproduces pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain and/or paresthesia in the distribution of the nerve with percussion medial to the anterior superior iliac spine

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Vascular exam of the hip

The femoral pulse can be palpated at the inguinal fold:

• Midway between the anterior superior iliac spine and the pubic tubercle
• Inferior to the inguinal ligament/inguinal fold

Knee Examination

Inspection

• Observe the individual walking and standing.
• Observe alignment:
  • Determined by measurement of the Q angle:
    • A line is extended through the center of the patella to the ipsilateral anterior superior iliac spine. 
    • Another line is extended from the tibial tubercle through the center of the ipsilateral patella. 
    • The intersection of these 2 lines is the Q angle.
    • Normal alignment (valgus angulation) of the knee is at 8–14 degrees for men and 11–20 degrees degrees for women.
  • 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
• Swelling or ecchymosis 
• 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 for swelling.
• Observe the knee capsule for effusion.

Palpation and percussion

• Joint palpation:
  • Best done with a flexed knee.
  • Palpate the lateral and medial joint lines. 
  • Palpate the tibiofemoral joint.
• Palpate along the joint to feel for sponginess (synovitis) or bony growth (osteophytes).
• Palpate for joint crepitus (during active or passive range of motion).
• The posterior fossa must also be palpated for fullness, discomfort, or the presence of a cyst (Baker cyst, also known as popliteal cyst).
• Bursae: 
  • Pes anserine (upper medial aspect of the tibia)
  • Prepatellar bursae 
  • Suprapatellar bursa
• Palpate for a popliteal pulse. 
• 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. Structure and Function of the Skin across the gradient (above the knee to the tibia)
• Tests for effusion:
  • Patellar ballottement test/tap:
    • Extend the knee joint.
    • 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 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 to the patella).
    • Tap the patella.
    • 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.
  • Bulge sign/ripple test:
    • Extend the knee joint.
    • 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 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 to the patella).
    • Stroke the lateral side of the joint. 
    • Note any bulge or ripple on the medial side of the joint.
• Percussion:
  • Along the tibial plateau to detect tibial plateau (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

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Motor and strength function

• Active movements 1st.
• Flexion:
  • Bring the knee up to the chest while supine, bringing the knee into maximum flexion.
  • Normal range: 0–140 degrees
  • Assesses hamstring strength against resistance.
• Extension: 
  • 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 at the knee, bringing the knee into maximum extension.
  • Normal range: 0–140 degrees
  • Assesses quadriceps strength against resistance
• 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

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.
  • 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 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.
  • Valgus force is applied to the knee while the thumb monitors the joint line.
  • Assess for excessive joint opening, ligamentous laxity, or pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain.
• Varus test: 
  • Assesses the integrity of the lateral collateral ligament (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 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.
  • 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 Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain

Cruciate ligament stability:

• Anterior cruciate ligament (ACL) 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 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 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. 
    • Place the hands behind the tibia and the thumbs over the tibial tuberosity.
    • Pull the tibia 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.
  • Lachman test:
    • 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 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.
    • 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 and valgus force on the proximal tibia while carrying the knee into passive flexion.
    • A “clunk” with flexion indicates rupture of the ACL.
• Posterior cruciate ligament (PCL) injury is assessed by the posterior drawer and quadriceps active tests. 
  • Posterior drawer test: 
    • 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 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 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. 
    • Both of the examiner’s hands are held at the individual’s proximal tibia 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.
  • Quadriceps active test: 
    • 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 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 in posterior subluxation will move anteriorly, indicating PCL rupture).

Patellar stability: patellar apprehension test

• Tests for patellofemoral pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain syndrome
• With the individual supine, the knee is fully extended.
• The patella is passively distracted laterally by the examiner while slowly carrying the knee into passive flexion. 
• If the individual resists flexion and shows discomfort, the test is positive.

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Special tests

Tests for meniscal tears:

• McMurray test:
  • Medial meniscus:
    • The examiner passively flexes the knee while applying varus stress and externally rotating the ankle.
    • The examiner then extends the knee smoothly while palpating the joint line.
    • Audible/palpable crepitus (click or pop) or excessive discomfort indicates medial meniscus injury. 
• 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 (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 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 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 applies compression through the tibia to the knee while passively carrying the ankle into internal and external rotation. 
  • Excessive discomfort indicates meniscal injury.

Tests for iliotibial band 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: 

• Noble test:
  • Individual is positioned in the lateral recumbent position with the injured side up.
  • The examiner supports the ankle 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 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 palpates the lateral epicondyle of the femur while passively carrying the knee through flexion and extension (0–90 degrees).
  • A test is positive when pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain is produced at the lateral epicondyle as the IT band passes over the bony landmark with dynamic movement. 
• Ober test:
  • Individual is positioned in the lateral recumbent position with the injured side up.
  • With the knee flexed, the examiner carries the hip into passive abduction and releases. 
  • Failure of the hip to passively fall into adduction or excessive pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain at the lateral knee with adduction indicates IT band contracture.

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Vascular exam of the knee

The popliteal pulse 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:

• Directly posterior to the joint line
• Located between the tendons of the hamstrings muscle complex

Ankle and Foot Examination

Inspection

• Observe the individual walking and standing.
  • Assess the gait.
  • Foot drop may be noticed as a steppage gait.
• 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: 
  • Pes cavus (exaggerated arch)
  • Pes planus (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)
• Examine for:
  • Swelling/deformity: 
    • Bunion (lateral deviation of the 1st metatarsophalangeal joint)
    • Swelling of the 1st metatarsophalangeal joint may indicate 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.
    • Redness/swelling of the nail bed(s) may indicate ingrown toenail.
  • Ecchymosis 
  • 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)

Palpation and percussion

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

• Proximal fibula (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 (and surrounding ligaments)
• Medial malleolus and (surrounding ligaments)
• Tarsal bones
• Base of the 5th metatarsal (5th metatarsal fractures common)
• 1st metatarsophalangeal joint ( 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, capsulitis)
• Anterior calcaneus (tender at this point → plantar fasciitis)
• Posterior calcaneus/Achilles tendon (tender at this point → Achilles tendinitis)
• Compress the distal tibiofibular joint for syndesmotic injury (indicates high ankle sprain)
• Palpate the distal lower-extremity pulses at the:
  • Dorsalis pedis artery
  • Posterior tibial artery

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Motor strength

• Dorsiflexion: 
  • L4 nerve root 
  • Assess strength in dorsiflexion against examiner’s resistance (weakness leads to 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 drop).
  • Normal range: 20–30 degrees
• Plantar flexion:
  •  L5 and S1 nerve roots
  • Assess strength in plantar flexion against examiner’s resistance.
  • Normal range: 40–50 degrees
• Inversion: 
  • Resisted inversion: tests the integrity of the posterior tibial tendons
  • Normal range: 0–60 degrees
• Eversion: 
  • Resisted eversion: tests the integrity of the fibular tendons 
  • Normal range: 0–30 degrees
• Achilles reflex: tests the reflex arc involving the L5 and S1 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

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–soleus complex) muscle is squeezed by the examiner.
  • Observe for plantar flexion 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.
  • 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 will remain neutral or dorsiflexed.
  • If partial rupture → incomplete plantar flexion.
• Anterior drawer test: 
  • Assesses the stability of the anterior talofibular ligament (ATFL)
  • 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 and the other applies an anterior force at the heel.
  • Excessive laxity indicates ATFL rupture.
• Windlass test: 
  • Examiner passively dorsiflexes the toes.
  • Heel pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain with passive dorsiflexion of the toes indicates presence of plantar fasciitis.
• Talar tilt test:
  • Tests the integrity of the ATFL
  • Performed by applying a gentle passive inversion motion at the ankle
  • A lack of a hard stop (laxity) suggests a tear to the ATFL.

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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.
• The posterior tibial pulse can be palpated posterior to the medial malleolus.

Clinical Relevance

Table: Overview of the most common conditions seen for knee pain Knee Pain Knee pain is a common presentation to primary care physicians. The diagnosis can be challenging as the pain may arise from the joint, surrounding tissues, or referred to the joint from distant structures. The differential diagnosis of knee pain is broad and categorizing the various diagnoses related to the timing (acute or chronic) is useful. Knee Pain

	Palpation	Effusion	Range of motion	Special tests
Osteoarthritis	Osteophytes and tender joint line	+/–	Limited by pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain	Plain film radiography: Joint space narrowing Osteophytes
Meniscus tear	Tender joint line	+/–	Locking sensation	McMurray test Confirmed by MRI
Ligament injuries	Tender joint line	++ (ACL tears)	Limited by pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain and sensation of “give-away”	Drawer test Lachman test Valgus/varus stress test
Gout	Warm joint	++	Limited by pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain	Joint aspiration and analysis
Pes anserine bursitis	Point tenderness at insertion (2 cm below medial tuberosity)	–	No limitation

Table: Most common conditions seen with ankle/ foot pain foot pain Ankle pain accounts for up to 20% of cases of musculoskeletal complaints in outpatient clinics. The most common etiologies of foot and ankle pain can be categorized into arthritis, trauma, sprains, and systemic causes. Ankle and Foot Pain

	Palpation	Special tests	Notes
Ankle sprain	Lateral aspect: ATFL tenderness below the lateral malleolus Medial aspect: deltoid tenderness below the medial malleolus	Tilt test	Ottawa ankle rules: an ankle x-ray is indicated for any of the following: Pain 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/tibia of the lateral/medial malleolus
Plantar fasciitis	Tenderness at the insertion point on the calcaneus (plantar surface)	Windlass test	Loss of arch might be noted
Tarsal tunnel syndrome	Palpation may reproduce symptoms of tingling/burning radiating to the soles	Tinel sign
Achilles tendinitis/rupture	Palpating along the tendon may show a gap (rupture) or tenderness at insertion (superior calcaneus).	Thompson test