Examination of the Lower Limbs

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 joint Distal tibiofibular joint Leg: Anatomy
• 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.

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 Axis The second cervical vertebra. Vertebral Column: Anatomy 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: 
  • Iliopsoas bursa Iliopsoas bursa Hip Joint: Anatomy
  • Ischial bursa Ischial bursa Hip Joint: Anatomy 
  • Trochanteric bursa Trochanteric bursa Hip Joint: 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 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 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 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

• Active movements 1st
• Flexion Flexion Examination of the Upper Limbs:
  • Bring the knee up to the chest while supine.
  • Normal range: 0–120 degrees
  • Assesses hip flexor 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: 
  • Passively carry the hip into extension Extension Examination of the Upper Limbs/hyperextension from the lateral decubitus or prone position,
  • Normal range: 0–15 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
• Abduction Abduction Examination of the Upper Limbs: 
  • Passively carry the hip into abduction Abduction Examination of the Upper Limbs from the supine position.
  • Normal range: 30–50 degrees
  • Assesses hip abductor 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
• Adduction Adduction Examination of the Upper Limbs:
  • Passively carry the hip into adduction Adduction Examination of the Upper Limbs from the supine position.
  • Normal range: 20–30 degrees
  • Assesses hip adductor 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
• Internal rotation Rotation Motion of an object in which either one or more points on a line are fixed. It is also the motion of a particle about a fixed point. X-rays:
  • Passively carry the hip into internal rotation Rotation Motion of an object in which either one or more points on a line are fixed. It is also the motion of a particle about a fixed point. X-rays from the supine position.
  • Normal range: 30–40 degrees
  • Assesses hip internal rotator 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
• External rotation Rotation Motion of an object in which either one or more points on a line are fixed. It is also the motion of a particle about a fixed point. X-rays:
  • Passively carry the hip into external rotation Rotation Motion of an object in which either one or more points on a line are fixed. It is also the motion of a particle about a fixed point. X-rays from the supine position.
  • Normal range: 40–60 degrees
  • Assesses hip internal rotator 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

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:
  • Localized midline pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways with flexion Flexion Examination of the Upper Limbs (forward bending) or lateral flexion Flexion Examination of the Upper Limbs (side 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
  • Localized midline pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways with cough or sneeze (i.e., Valsalva)
  • Discogenic pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways may or may not be associated with nerve root (i.e., radicular) pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways. 
• 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: Anatomy 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: Anatomy (extended at the knee) into hip flexion Flexion Examination of the Upper Limbs. A positive test causes pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways to radiate into the lower limb (typically in a dermatomal Dermatomal Dermatologic Examination pattern).
  • Associated sensory Sensory Neurons which conduct nerve impulses to the central nervous system. Nervous System: Histology ( dermatomal Dermatomal Dermatologic Examination) and motor Motor Neurons which send impulses peripherally to activate muscles or secretory cells. Nervous System: Histology (myotomal) findings in the affected lower limb(s)

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 Axis The second cervical vertebra. Vertebral Column: Anatomy 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:

• Due to periosteal irritation associated with tight hamstrings (proximal attachment Attachment The binding of virus particles to virus receptors on the host cell surface, facilitating virus entry into the cell. Virology of the hamstrings is in the ischial tuberosity Ischial Tuberosity Chronic Apophyseal Injury)
• Ischial bursitis ( ischial bursa Ischial bursa Hip Joint: Anatomy overlies the ischial tuberosity Ischial Tuberosity Chronic Apophyseal Injury): from activities required repetitive or prolonged squatting
• Exam findings ( ischial tuberosity Ischial Tuberosity Chronic Apophyseal Injury): 
  • 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 ischial tuberosity Ischial Tuberosity Chronic Apophyseal Injury/ ischial bursa Ischial bursa Hip Joint: Anatomy
  • 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 squatting/restricted hip extension Extension Examination of the Upper Limbs (hamstring contraction)

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

• Spasm/ hypertonicity Hypertonicity Volume Depletion and Dehydration/injury to the piriformis Piriformis Vagina, Vulva, and Pelvic Floor: Anatomy muscle
• Compensatory overstretching of the piriformis Piriformis Vagina, Vulva, and Pelvic Floor: Anatomy muscle due to abnormal pelvic mechanics
• Pseuodosciatica: irritation of the sciatic nerve Sciatic Nerve A nerve which originates in the lumbar and sacral spinal cord (l4 to s3) and supplies motor and sensory innervation to the lower extremity. The sciatic nerve, which is the main continuation of the sacral plexus, is the largest nerve in the body. It has two major branches, the tibial nerve and the peroneal nerve. Gluteal Region: Anatomy as it passes under (or through, anatomic variant) the belly of the piriformis Piriformis Vagina, Vulva, and Pelvic Floor: Anatomy
• Exam findings ( piriformis Piriformis Vagina, Vulva, and Pelvic Floor: 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 and/or hypertonicity Hypertonicity Volume Depletion and Dehydration of the piriformis Piriformis Vagina, Vulva, and Pelvic Floor: Anatomy muscle
  • Positive active piriformis Piriformis Vagina, Vulva, and Pelvic Floor: Anatomy 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 Adduction Examination of the Upper Limbs of the hip against the individual’s active effort to abduct.
    • Note: The piriformis Piriformis Vagina, Vulva, and Pelvic Floor: Anatomy is an abductor and external rotator of the hip when the hip is flexed.

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 Fascia Layers of connective tissue of variable thickness. The superficial fascia is found immediately below the skin; the deep fascia invests muscles, nerves, and other organs. Cellulitis lata:

• Common overuse injury Overuse Injury Osgood-Schlatter Disease 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 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 Fascia Layers of connective tissue of variable thickness. The superficial fascia is found immediately below the skin; the deep fascia invests muscles, nerves, and other organs. Cellulitis lata 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 Fascia Layers of connective tissue of variable thickness. The superficial fascia is found immediately below the skin; the deep fascia invests muscles, nerves, and other organs. Cellulitis lata) 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:

• Common overuse injury Overuse Injury Osgood-Schlatter Disease in endurance sports (e.g., running, cycling)
• Common injury associated with abnormal gait Gait Manner or style of walking. Neurological Examination mechanics (e.g., injured back, hip, knee, or ankle associated with an antalgic gait Antalgic Gait Legg-Calvé-Perthes Disease)
• 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 directly over the greater trochanter/ trochanteric bursa Trochanteric bursa Hip Joint: Anatomy

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 Avascular Corneal Abrasions, Erosion, and Ulcers necrosis Necrosis The death of cells in an organ or tissue due to disease, injury or failure of the blood supply. Ischemic Cell Damage of the hip
• Exam findings:
  • Antalgic gait Antalgic Gait Legg-Calvé-Perthes Disease
  • 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 An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways in the anterior hip (generally with internal rotation Rotation Motion of an object in which either one or more points on a line are fixed. It is also the motion of a particle about a fixed point. X-rays) and is associated with femoroacetabular joint pathology.
  • 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 hip abduction Abduction Examination of the Upper Limbs and adduction Adduction Examination of the Upper Limbs:
    • Individual is in the supine position.
    • Examiner passively carries the hip into abduction Abduction Examination of the Upper Limbs and adduction Adduction Examination of the Upper Limbs. 
    • 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 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 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 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. 
• 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:
  • Sensory Sensory Neurons which conduct nerve impulses to the central nervous system. Nervous System: Histology disturbance (loss of sensation, altered sensation, allodynia Allodynia Pain due to a stimulus that does not typically provoke pain. Pain Management) in the receptive field of the lateral femoral cutaneous nerve
  • Reproduces pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways and/or paresthesia in the distribution of the nerve with percussion Percussion Act of striking a part with short, sharp blows as an aid in diagnosing the condition beneath the sound obtained. Pulmonary Examination medial to the anterior 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

Vascular exam of the hip

The femoral pulse can be palpated at the inguinal fold:

• Midway between the anterior 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 and the pubic tubercle
• Inferior to the inguinal ligament Inguinal Ligament Femoral Region and Hernias: Anatomy/inguinal fold

Knee Examination

Inspection Inspection Dermatologic Examination

• 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 Patella The flat, triangular bone situated at the anterior part of the knee. Knee Joint: Anatomy to the ipsilateral anterior 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. 
    • Another line is extended from the tibial tubercle Tibial Tubercle Osgood-Schlatter Disease through the center of the ipsilateral patella Patella The flat, triangular bone situated at the anterior part of the knee. Knee Joint: Anatomy. 
    • The intersection of these 2 lines is the Q angle.
    • Normal alignment (valgus angulation Angulation Buckle or Torus Fracture) 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 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:
  • Best done with a flexed knee.
  • Palpate the lateral and medial joint lines. 
  • Palpate the tibiofemoral joint Tibiofemoral joint Knee Joint: Anatomy.
• 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

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 Rotation Motion of an object in which either one or more points on a line are fixed. It is also the motion of a particle about a fixed point. X-rays 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

• Tests for patellofemoral pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways syndrome
• With the individual supine, the knee is fully extended.
• The patella Patella The flat, triangular bone situated at the anterior part of the knee. Knee Joint: Anatomy is passively distracted laterally by the examiner while slowly carrying the knee into passive flexion Flexion Examination of the Upper Limbs. 
• If the individual resists flexion Flexion Examination of the Upper Limbs and shows discomfort, the test is positive.

Special tests

Tests for meniscal tears:

• McMurray test Mcmurray Test Meniscus Tear:
  • Medial meniscus Medial Meniscus Meniscus Tear:
    • 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 Crepitus Osteoarthritis (click or pop) or excessive discomfort indicates medial meniscus Medial Meniscus Meniscus Tear 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 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 Rotation Motion of an object in which either one or more points on a line are fixed. It is also the motion of a particle about a fixed point. X-rays. 
  • 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: 

• Noble test:
  • Individual is positioned in the lateral recumbent Lateral recumbent Airway Management 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: 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 palpates the lateral epicondyle Lateral epicondyle Arm: Anatomy of the femur while passively carrying the knee through flexion Flexion Examination of the Upper Limbs and extension Extension Examination of the Upper Limbs (0–90 degrees).
  • A test is positive when pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways is produced at the lateral epicondyle Lateral epicondyle Arm: Anatomy as the IT band passes over the bony landmark with dynamic movement. 
• Ober test:
  • Individual is positioned in the lateral recumbent Lateral recumbent Airway Management position with the injured side up.
  • With the knee flexed, the examiner carries the hip into passive abduction Abduction Examination of the Upper Limbs and releases. 
  • Failure of the hip to passively fall into adduction Adduction Examination of the Upper Limbs or excessive pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways at the lateral knee with adduction Adduction Examination of the Upper Limbs indicates IT band contracture.

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

Ankle and Foot Examination

Inspection Inspection Dermatologic Examination

• Observe the individual walking and standing.
  • Assess the gait Gait Manner or style of walking. Neurological Examination.
  • 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 drop may be noticed as a steppage gait Gait Manner or style of walking. Neurological Examination.
• 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 cavus Pes cavus A foot deformity in which the arch of the foot is high and often the heel adducted. Friedreich’s Ataxia (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: 
    • Bunion (lateral deviation of the 1st metatarsophalangeal joint Metatarsophalangeal Joint Foot: Anatomy)
    • Swelling Swelling Inflammation of the 1st metatarsophalangeal joint Metatarsophalangeal Joint Foot: Anatomy 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 Redness Inflammation/ swelling Swelling Inflammation of the nail bed Nail bed Skin: Structure and Functions(s) may indicate ingrown toenail.
  • 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 joint Distal tibiofibular joint Leg: Anatomy for syndesmotic injury (indicates high ankle sprain)
• Palpate the distal lower-extremity pulses at the:
  • Dorsalis pedis artery Dorsalis pedis artery Foot: Anatomy
  • Posterior tibial artery

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 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 drop).
  • Normal range: 20–30 degrees
• Plantar flexion Plantar Flexion Chronic Apophyseal Injury:
  •  L5 and S1 S1 Heart Sounds nerve roots
  • Assess strength in plantar flexion Plantar Flexion Chronic Apophyseal Injury 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.
  • Normal range: 40–50 degrees
• Inversion: 
  • Resisted inversion: tests the integrity of the posterior tibial tendons
  • Normal range: 0–60 degrees
• Eversion Eversion Chronic Apophyseal Injury: 
  • Resisted eversion Eversion Chronic Apophyseal Injury: tests the integrity of the fibular tendons 
  • Normal range: 0–30 degrees
• 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 Plantar Flexion Chronic Apophyseal Injury 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 Plantar Flexion Chronic Apophyseal Injury.
• 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:
  • Tests the integrity of the ATFL ATFL Ankle Joint: Anatomy
  • Performed by applying a gentle passive inversion motion at the ankle
  • A lack of a hard stop (laxity) suggests a tear to the ATFL ATFL Ankle Joint: Anatomy.

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.

Clinical Relevance