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Lower Limb Orthopaedic Examination Workshop

Mr Venu Kavarthapu, Mr Patrick Li
General Tips
Movements:
Hip- passive only. Knee-passive and active. Foot and ankle- passive and active. Spine- active
only.
Always consider examining (screening) the joint above and below as appropriate

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Hip Examination
(Common pathological conditions: Young adults: Sports injuries, Hip Impingement, Hip
Dyspasia. Middle aged: Sports injuries, Hip Impingement, Hip Dyspasia, Osteoarthritis.
Older patients: Osteoarthritis.)
Pitfalls:
Hip pain is generally felt in the groin, trochanter (lateral), anterior thigh, buttock (posterior
trochanter) and knee regions.
It is important to identify conditions such as Hip Dysplasia and Hip Impingement in young
patients before they become severely symptomatic as the treatment is less invasive if
identified early.
Look for other sources of pain such as lower back, sacro-iliac joint, inguinal hernia etc.

Standing
Look from front
Shoulder level
Pelvis level
Leg alignment (knee)
Leg lengths
Look from side
Spine alignment
Gluteal muscle bulk
Attitude of hip and knee joints
Look from behind
Spine alignment
Hindfoot
Gait
Antalgic gait
Trendelenburgs sign
Spine screening

Sitting
Knee screening
Look spine
Supine
Non-weight bearing alignment of legs
Apparent leg length measurement
True leg length measurement

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Tenderness over trochanter, anterior hip region, other tender areas
Movements:
Thomas test (for fixed flexion deformity)
Internal rotation and external rotation in hip flexion
Internal rotation and external rotation in hip extension (look at knee caps)
Abduction
Adduction
Prone position
Hip extension
Sacro-iliac joint tenderness
Special situations
Young Patient: Young patients with hip pain may have Hip Impingement Syndrome. Hip
Impingement sign may be the only positive finding.

Knee examination
(Common pathologies: Young adults: Sports injuries, Chondromalacia Patella. Patellofemoral instability. Middle aged: Sports injuries, Patello-femoral degenerative conditions,
Osteoarthitis. Older patients: Osteoarthritis)
Standing
Look from front
Shoulder level
Pelvis level
Leg alignment (knee)
Leg lengths
Look from side
Spine alignment
Gluteal muscle bulk
Popliteal fossa
Attitude of hip and knee joints
Look from behind
Spine alignment
Hindfoot
Gait
Antalgic gait
Sitting
Hip screening
Patellar tracking
Supine
Non-weight bearing alignment of legs
Effusion tests: Moderate effusion (obliteration of gutters) - patellar tap test
Minimal effusion- swipe test
Patello-femoral examination: tenderness, laxity, apprehension, Clarks test
Feel for tenderness: Systematic. Knee in 60-90 degrees
Move- active first
Special tests
Collateral ligaments
Cruciates- posterior sag test. Anterior and posterior draw tests. Lachmans test
Menisci- Mc Murrays test
Hip and Ankle examination

Foot and Ankle

(Common pathologies (numerus). Young adults: Physiological flat foot. Painful flat foot
(tarsal coalition), Juvenile hallux valgus. Sports ankle injuries. Sports Achillies tendon
pathologies. Middle aged: Painful flat foot (Tibialis posterior tendon deficiency), Hallux
valgus. Metatarsalgia (Mortons neuroma), Sports ankle injuries, Osteoarthitis. Heel pain
(Achilles tendonitis, plantar fasceitis). Older patients: Osteoarthritis, Painful flat foot (Tibialis
posterior tendon deficiency)
Pitfalls:
Painful normal looking foot (with no deformities) need to be examined for possible pathologies
in addition to early arthritis, such as Forefoot: Mortons neuroma, tarsal tunnel syndrome,
stress fracture. Plantar heel: Plantar fascietis, tarsal tunnel syndrome. Posterior heel:
insertional Achillis tendonitis, non-insertional Achillis tendonitis
Patients presenting with high arched feet, always examine spine quite often this is associated
with neurological conditions

Standing
Look from front
Shoulder level
Pelvis level
Leg alignment (knee)
Leg lengths
Forefoot
Midfoot
Look from side
Attitude of hip and knee joints
Foot Arches
Ankle and foot
Look from behind
Spine inspection
Arms
Hindfoot- Normal and Tip toeing
Gait
Shoes
Sitting
Callocities
Corns
Deformities- describe in terms of hindfoot, midfoot and forefoot
Feel
Tenderness- systematic
Degree of passive correction of deformities
Active movements
Passive movements
Power of local muscles
Tibialis and peroneals
Special tests:
Mortons neuroma (Mulder Click), Tight Gastrocnemius (Silverskoild test)
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