General Lower Extremity Exam

Inspection/Palpation

Inspect for open wounds, ulcers, skin rashes, gross deformity, gross motion, ligamentous instability. Remember skin issues can affect surgical eligibility or incision site.

Evaluate for skin compromise or tenting over fractures. This is particularly important for ankle and tongue-type calcaneal fractures.

Plantar ecchymosis: pathognomonic for Lisfranc injury

Neurovascular Exam

Motor: Knee flexion (sciatic)
Knee extension (femoral)
Plantarflexion (tibial)
Dorsiflexion (deep peroneal)
Foot eversion (superficial peroneal)

Sensory: Medial thigh (obturator)
Anterior thigh (femoral)
Posterolateral leg (sciatic)
Dorsal foot (peroneal)
Plantar foot (tibial)
Lower Extremity Sensory Innervation

Pulses: Popliteal, dorsalis pedis (DP), and posterior tibial (PT)

Provocative maneuvers or special tests

Hip: Axial loading and log roll (internal/external rotation) may be indicative of hip pathology

Knee: Lachman’s test (most sensitive for ACL rupture): attempt to translate tibia anteriorly with knee flexed to 20-30° Grade 1: <5mm translation Grade 2: 5-10mm translation Grade 3: >10 mm translation A or B qualifiers: A = firm endpoint, B = no endpoint

Anterior drawer: attempt to translate tibia anteriorly with knee flexed to 90°

Posterior drawer: apply posteriorly directed force to tibia with knee flexed to 90°

Pivot shift: place patient supine on the bed with knee fully extended. While flexing the knee, apply an internal rotation and valgus force at the knee/proximal tibia. If there is a palpable clunk (signifying reduction of a subluxated tibia due to pull from the ITB), the ACL is deficient. Note, this is easiest to perform with adequate sedation (i.e. in the OR).

Dial test: patient prone, knees flexed to 90, ER both legs
- Greater than 10° ER asymmetry at 30° & 90° consistent with PLC and PCL injury
- Greater than 10° ER asymmetry at 30° only consistent with isolated PLC injury

Valgus stress: apply a medially directed force to the knee at 0° and 30°. Laxity at 30° = MCL injury. Laxity at 0° and 30° = MCL and cruciate injury.

Varus stress: apply laterally directed force to knee at 0° and 30°. Laxity at 30° = LCL injury. Laxity at 0° and 30° = LCL and cruciate injury.

Joint line tenderness = meniscal tear

McMurray’s test: start with the knee in flexion, varus and internal rotation, then gradually extend the knee. Pain or popping = lateral meniscus injury Start with the knee in flexion, valgus and external rotation, then gradually extend the knee. Pain or popping = medial meniscus injury.

Straight leg raise: with patient supine and leg extended, have them raise their leg off the bed and hold it there. Inability to perform = extensor mechanism injury. Many patients will have quadriceps inhibition due to pain and will be unable to perform this test even with an intact extensor mechanism.

Stinchfield sign: With patient supine, patient flexes the hip with the knee extended (e.g. straight leg raise) with examiner placing resistive downward force on the leg. Pain at the groin/hip suggests intraarticular hip pathology.

Ankle: Syndesmosis evaluation Syndesmotic tenderness Squeeze test: pain with compression of tib/fib at mid-calf External rotation stress test (imaging included)