Physical Exam of the Lower Extremity: What Works and

Physical Exam of the Lower

Extremity: What Works and

What’s Worthless

Ken Mautner, MD

Emory Sports Medicine Center

Atlanta, GA

Objectives

• To discuss relevant literature as it pertains to the

lower extremity examination in our patients

• Summarize original description of tests

• Evaluate sensitivity/ specificity of tests

• Only have 20 minutes--- so much to cover!!!!!

History

• Acute vs Insidious Onset

• Mechanism of injury

• Risk factors for overuse injury

• Swelling

• Pain

• Location helps

• Instability

• Describe

• Past orthopedic history

Physical Exam

• Inspection

• ROM

• Palpation

• Strength

• Special Tests

• Neurovascular

Statistics

• Sensitivity: • If a person has a disease, how often will the test be positive (true

positive rate)?

• If the test is highly sensitive and the test result is negative you can be nearly certain that they don’t have disease.

• A Sensitive test helps rule out disease (when the result is negative). Sensitivity rule out or "Snout"

• Specificity: • If a person does not have the disease how often will the test be

negative (true negative rate)?

• If the test result for a highly specific test is positive you can be nearly certain that they actually have the disease.

• A very specific test rules in disease with a high degree of confidence Specificity rule in or "Spin"

Hip Exam

Is primary problem coming

from Inside the Hip Joint?

• For time sake will only look at exam for IA hip

pain:

• Among athletes a reported 60% of IA problems were

originally diagnosed as extra-articular problems

• Treatments averaged 7 mo for original Dx

• Avg of 4.2 Doctors to get to accurate diagnosis of

hip impingement (Clohisy, 2009)

• H&P Most Accurate Predictor (98%) of Intra-articular

Problem

Log Roll

• Passive Supine Rotation Test

• The examiner passively rotates the hip internally and

externally, and notes any pain or restricted motion in the

involved hip compared to the other side.

• Clohisy et al.- 2009

• 51 patient with symptomatic hip FAI and labral pathology

• Sensitivity: 30%

Resisted Straight Leg Raise

(Stinchfields’ Test)

• The test is performed with the patient supine and knee extended. The patient actively flexes the hip to 20 to 30 degrees, and the examiner then provides a downward force resisting the hip flexion.

• The test is thought to increase pressure on the labrum as the iliopsoas contracts, and is considered a positive test if it reproduces the patients groin pain.

• This test also assess the strength of the iliopsoas and rectus femoris muscles, and caution should be used in interpreting a positive test.

Impingement Testing

• Abnormal contact between the femoral head and acetabular rim in terminal hip motion can result in femoroacetabular impingement or FAI. Since the acetabular labrum provides joint stability at the extremes of motion, the labrum and adjacent cartilage can be impinged between the bony structures. Aberrant bony morphology of the proximal femur and/or acetabulum can lead to continued abutment of the bony structures of the hip, early chondral and/or labral lesions.

CAM PINCER

Hip Scour Test/Quadrant Test

• Maitland – 1973

• The test is performed with the patient lying in a supine position

and the examiner flexes and adducts the hip to end range where

resistance is felt. The examiner then moves the hip into

abduction while maintaining the flexed position in circular arc

and applying a posterior compressive force in the direction of

the femoral shaft.

• The four quadrants tested can be divided

into the following arc of motion: • 1. Flexion/abduction/external rotation

to extension/abduction/external rotation

• 2. Flexion/adduction/external rotation

to extension/adduction/external rotation

• 3. Flexion/abduction/internal rotation

to extension/abduction/internal rotation

• 4. Flexion/adduction/internal rotation

to extension/adduction/internal rotation

Hip Scour Test

• Maslowski et al.- 2010


• Specificity: 29%

• Scour was not useful in predicting positive response to intra-

articular injection

• Sutlive et al.- 2003



• Hip OA

Trendelenburg Sign

• Friedrich Trendelenburg- 1895

• The pelvis hangs down on the swinging side, and the upper part of the body leans far over to the standing side to restore balance. From what has been said, the cause of the pelvis hanging down can only be that the abductors of the standing leg cannot keep the pelvis horizontal.

• Suggests glut medius or minimus weakness

• Bird et al. – 2001



• Woodley et al.- 2008



• Lequesne et al.- 2008



Knee Exam

Knee Injury

• ACL TESTS

• Anterior Drawer

• Lachman Test

• Pivot Shift Test

Anterior Drawer

• Noulis 1875 French Thesis

• Paul Segond, 1879

• Described abnormal “anterior-posterior mobility” of knee with ACL ruptures

• Flex patients leg, the thigh can be grasped with one hand at the lower leg with the other hand keeping the thumbs to the front and fingers to the back. If the lower leg is held in this grip and then moved backwards and forwards, it will be seen that the tibia can be moved directly backwards and forwards.

Lachman

• Described by Torg, 1976 (worked under Dr. Lachman)

• Knee held between full extension and 15° flexion

• The femur is stabilized with one hand while firm pressure is applied to the posterior aspect of the proximal tibia

Pivot Shift

• Galway and MacIntosh, 1972

• Leg is picked up at the ankle with one of the examiner’s hands, and if the patient is holding the leg in extension, the knee is flexed by placing the heel of the other hand behind the fibula over the lateral head of the gastrocnemius.

• As the knee is extended, the tibia is supported on the lateral side with a slight valgus strain applied to it.

• A strong valgus force is placed on the knee by the upper hand

ACL tests

Name Sensitivity Specificity

Anterior Drawer 18-92% 78-98%

Lachman 86% 91%

Pivot Shift 38% 81%

Conclusions:

PCL

• PCL rupture does not have a definitive test

• Most accurate method of physical examination is

still a matter of debate

Posterior Drawer

• Supine with the test hip flexed to 45 degrees, knee flexed to 90 degrees, and foot in neutral position.

• The examiner is sitting on the subject’s foot with both hands behind the subject’s proximal tibia and thumbs on the tibial plateau.

• Apply a posterior force to the proximal tibia.

Posterior Sag Sign

• Mayo Robson,1903

• Patient lies supine with the hip flexed to 45 degrees and the knee flexed to 90 degrees.

• In this position, the tibia ‘rocks back,’ or sags back, on the femur if the posterior cruciate ligament is torn.

PCL Tests


Posterior Sag Sign 79% 100%

Posterior Drawer 90% 99%

Quads Active Test 54% 97%

Conclusions:

Collateral Ligaments

• MCL

• Valgus Stress Testing

• LCL

• Varus Stress Testing

Patellofemoral Pain Exam

• Patellofemoral Grinding Test • 1936, Dr. Owre, Earliest

description of Grind Test

• The subject is lying supine with the knees extended. The examiner stands next to the involved side and places the web space of the thumb on the superior border of the patella. The subject is asked to contract the quadriceps muscle, while the examiner applies downward and inferior pressure on the patella.

Patellofemoral Pain Exam

• Sensitivity/Specificity

McMurray Test

• T.P. McMurray first described the test in his lecture, entitled "The Semilunar Cartilages," which was given to the Royal College of Surgeons of England in 1940.

• Patient lying flat, the knee is first fully flexed until the heel approaches the buttock. The foot is then held by grasping the heel and using the forearm as a lever. The knee being now steadied by the examiner’s other hand, the leg is rotated on the thigh with the knee still in full flexion. During this movement the posterior section of the cartilage is rotated with the head of the tibia, and if the whole cartilage, or any fragment of the posterior section is loose, this movement produces an appreciable snap in the joint.

Apley Grind Test

• AG Apley, 1947, Journal of Bone & Joint Surgery

• Patient lies on his face., examiner grasps one foot in each hand, externally rotates as far as possible, and then flexes both knees together to their limit. When this limit has been reached, grasp is changed, rotates the feet inward, and extends the knees together again. Examiner then applies his left knee to the back of the patient’s thigh. The foot is grasped in both hands, the knee is bent to a right angle, and the powerful external rotation is applied. Next, without changing the position of the hands, the patient’s leg is strongly pulled upward, while the examiners weight prevents the femur from rising off the table. In this position of distraction, the powerful external rotation is repeated.

Bounce Home Test

• Patient supine with the patient’s foot cupped in the examiner’s hand.

• With the patient’s knee completely flexed, the knee is passively allowed to extend.

• The knee should extend completely, or bounce home into extension with a sharp end-point.

Thessaly Test

• Examiner supports the patient by holding their outstretched hands while the patient then rotates their knee and body, internally and externally three times, while keeping their knee flexed at 20 degrees of flexion.

• Pain localized to the joint line (medial or lateral) is a positive test.

Meniscal Tear Tests


Joint Line Palpation 79% 15%

McMurray Test 53% 59%

Apley Grind Test 13% 80%

Bounce Home Test 44% 95%

Thessaly Test 90% 98%

Conclusions:

Ankle Injury

Anterior Drawer Test

• 1968- Landeros et al

• With the patient relaxed, the knee flexed and the ankle at right angles, the ankle is grasped on the tibial side by one hand, whose index finger is placed on the posteromedial part of the talus and whose middle finger lies on the posterior tibial malleolus. The heel of this hand braces the anterior distal leg. On pulling the heel forward with the other hand, relative anteroposterior motion between the 2 fingers (and thus between talus and tibia) is easily palpated and is also visible to both patient and examiner.

• Tohyama added that a lower load (30N) better than higher load (60N) for performing the test

Ankle Stability Testing

• Anterior drawer test

• Lindstrand, 1976


• Specificity: 84.2%

• PPV: 96.25%

• NPV: 80%

• Van Dijk et al., 1996



• PPV: 91%

• NPV: 52%

• Phisitkul and Vaseenon



Syndesmosis Injuries

• The distal tibiofibular syndesmosis

consists of four stabilizing ligaments:

• anterior, posterior, transverse, and interosseous tibiofibular ligaments

• Three well-described exam maneuvers are used to detect syndesmosis injury:

• External rotation test (Kleiger’s Test)

• Syndesmosis ligament palpation

• Squeeze test

External Rotation Test

• Kleiger’s test, 1954

• patient is seated with the knee hanging over the edge of the examination table.

• examiner stabilizes the tibia with one hand and applies a small force on medial border of the foot with the other, rotating it laterally.

• Alonso et al., 1998

• concluded that the external rotation test has the best inter-rater reliability

Syndesmosis Squeeze Test

• Hopkinson WJ et al.,

1990; Teitz CC,

Harrington RM, 1998)

• The squeeze test is

performed by manually

compressing the fibula

to the tibia above the

mid-point of the calf.

• A positive test produces

pain over the area of the

syndesmotic ligaments.

Syndesmosis Injuries

• Two independent studies (Ryan LP et al., 2014; Rae

K et al., 2015) have reported:

• tenderness with palpation over the anterior

syndesmosis to be the most sensitive (83-92%)

• a positive squeeze test to be the most specific (88-89%)

physical exam findings when compared to MRI or

arthroscopy.

• External rotation stressing seems to be neither

sensitive nor specific

THANKS !

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Physical Exam of the Lower Extremity: What Works and

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