General examination

• Look at whole patient
• Note any aids or orthoses

Standard examination

• Compare both sides

Look - standing

• Positioning
• Undress
• Standing
• Space
• Look from anteriorly (front), laterally (side) and posteriorly (back)
• Skin
• Posture and symmetry
• Bony structures
• Muscle bulk

Look - lying

• Square on bed
• Assess limb length
• Discrepancy?
• Apparent shortening?
• Legs should be parallel
• Measure from fixed point
• True shortening?

Feel

• Hurts?
• Bony landmarks

Move

Active

• Flexion

• Stabilise iliac crest with one hand

• Bend their knees and bring to stomach

• Normal range is 0$\mathrm{°}$-120$\mathrm{°}$

• Extension - don't do if there was fixed flexion deformity

• Position patient prone (laying on stomach)

• Stretch leg out behind them

• Normal 15$\mathrm{°}$-20$\mathrm{°}$

• Abduction

• Immobilise pelvis by putting hand on opposite iliac crest

• Move leg out to the side

• Minimum 45$\mathrm{°}$-60$\mathrm{°}$

• Pelvis with rise from couch when full abduction reached

• Adduction

• Fix pelvis

• Abduct opposite leg

• Move leg that is being tested over the opposite ankle or under the opposite leg

• Normal is 45$\mathrm{°}$

• Rotation

• Knee flexed or extended

 Thomas' test (fixed flexion deformity)

• Patient supine - laying on back

1. Place one hand beneath lumbar spine
2. Flex hips and knees
3. Passive flexion of the normal knee to flatten the lumbar tordosis
4. Lower affected leg towards bed
5. Note where it stops
6. Limb as a pointer to ascertain degrees of flexion

Passive

• When active movement seems reduced
• Same movement but gently assist

Resistance

• Quadriceps (flexors)

• Bring knee up to chest against your hand

• Hip extension (gluteus maximus)

• Leg straight and elevated, push leg back onto couch against resistance

• Adductors

• Leg abducted, move inwards against your hand

• Abductors

• Legs together, move outwards against hand

Gait

• Watch them walk away you
• Then walk towards you

Trendelenburg's Test

• Weakness of hip abductors

1. Patient stands facing you
2. Ask to hold your hands
3. Gently lift one foot from the floor
4. If good leg is lifted they should squeeze your hand on their bad side
5. Pelvis will tilt on weight-bearing leg towards the good side
6. Repeat lifting the bad leg, there will be no squeeze and no tilt

Knee examination

Look

• 3 angles
• Skin
• Posture/symmetry
• Muscle bulk
• Joint swelling
• Bony structures
  

Feel

• Hurts?
• Temperature/tenderness behind knee
• Patella, joint line, condyles, tibial tuberosity, head of fibula
• Effusion (fluid escape) - bulge sign, patella tap

Move

• Crepitus - sounds

• Flexion

• Bring foot up towards bottom

• Normal - calf touching thigh

• Extension

• Place hand behind patient knee and push their knee down onto couch

• Normal - 10$\mathrm{°}$ beyond straight limb

• Hyperextension

• Hold patient's foot and lift leg up

• Look for hyperextensions - wrong bending greater than 15$\mathrm{°}$-20$\mathrm{°}$

• Cruciate ligaments

• Place knee in a flexed position and stabilise foot

• Check hamstrings relaxed

• Test anterior cruciate ligament by grasping tibia and drawing it forward

• Test posterior cruciate ligament by pushing tibia backwards

• Collateral ligaments

• Support relaxed knee in slight flexion

• Stabilise upper leg

• Test lateral collateral by moving lower leg medially

• Test medial collateral by moving lower leg more lateral

Ankle and foot examination

Look

• Skin

• Posture/symmetry

• Bony structures

• Joint swelling

• Muscle bulk/achilles tendon

• Gait

• Hindfoot - valgus or varus

• Arch

• Forefoot - toes
  

• Claw toe involved abnormal position of all three joints in toe

• Extension contracture with dorsal subluxation of the metatarsophalangeal (MTP) joint with flexion deformities of proximal and distal interphalangeal (P/DIP) joints

• Hammer toe - extension of the MTP joints and DIP joints. PIP joints hyperflexed

• Mallet toe - flexed DIP joint

• Lying

• Callus formation

• Footwear

Feel

• Hurts?
• Temperature/pulse/MTP squeeze/tenderness
• Lateral/medial malleolus
• Calcaneus
• 5^th metatarsal base
• Medial longitudinal arch
• Joints

Move

• Fix joints that are not being assessed

• Ankle/hindfoot - stabilise distal tibia and move heel

• Midfoot - stabilise the talus and move the forefoot

• Assess toes

• Move individual toes

• Active movement reduced, test passive movements

• Extension/dorsiflexion

• Bring toes towards self

• 30$\mathrm{°}$ is normal

• Flexion/plantar flexion

• Point toes down

• 60$\mathrm{°}$ is normal

• Inversion

• Roll foot in

• 30$\mathrm{°}$ is normal

• Eversion

• Roll foot out

• Normal is 10$\mathrm{°}$-20$\mathrm{°}$

• Examine

• Achilles tendon

• Rest of limb

• Pulses

• Reflexes

• Knee