AMC Clinical Physical examination Class 1.pptx

WELCOME TO MY
PHYSICAL EXAMINATION
CLASS
Today’s topic: Lower Limb
Shahriar’s Medical Academy
Tutor :Dr.Tasfeen Arnab
AMC clinical online course
+8801670636131

ONLINE PE TYPES AND CRITERIA
• Explain physical examination to Medical student with anatomical landmarks
• Explain Physical examination to Examiner with landmarks
• Explain Briefly to examiner/then to patient briefly.
• Explain to patient what you will look for and briefly the procedure.
• Name the instruments you will use.
What will be assessed
• Approach to examiner/patient/student.
• Choice, technique and sequence of examination
• Familiarity of instruments.

You must be having a lot stress
because of AMC clinical exam Online Via Zoom
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GENERAL APPROACH TO PE
• W - Wash your hands
• I - Introduce yourself to the patient stating your name and role
• P - Permission/consent
• E - Exposure, Explanation of procedure briefly.
• Chaperone where necessary.
Hello, My name is Dr. T, nice to meet you. Can I please confirm your name please. Today I will be examining your knee,
for that I will need to have you walk a few steps for me, have a look at your knee, feel different parts of your knee and do
some special tests. For that I ideally need exposure upto your mid thighs. Before we start do you have any pain
anywhere in your legs? Do have any concerns? Are you happy to proceed?

IN CASE OF MED STUDENTS.
• Hi, my name is Dr. T and how may I address you. Ok so today I am asked to show you
the examination… system. Then explain the wipe approach and also state the fact that is
the patient ok with the student being there. Explain briefly the process and request
proper exposure and start off with the examination.
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KNEE EXAMINATION.
• WIPE
• Gait
• Look, Feel Move.
• Special tests

CONT…
Case: 24 year old Jason came with knee pain since 12 hours.
Tasks
• Explain knee examination to Med student.
High, I’m Dr. T, how may I address you.
Student: Hi Dr, im Alex, and I want to learn about knee examination.
Me: Of course Alex. Im glad that you are keen to learn. So, today we have Jason, a 24 year old male
came with knee pain since 12 hours. Now before we start we gotta wash our hands while we introduce
ourselves to the patient stating our name and role. Now, since youre a student I need to ask my patient
whether he is ok with you being here. Now briefly explain what we’re gonna do, LOOK FEEL MOVE etc.
and request for proper exposure up to the mid thigh. Before we start always make sure there is no pain
and proceed. Always examine the other knee along with the adffected one

INSPECTION
• First ask our patient to take a few steps towards the end of the room and come back. Watch for any
limping, or pain in weight bearing.
• Then inspect from the front and back. Inspect for Scar, swelling, redness , rash, Bone and muscle
deformity (SSRRBMD).
• Inspect for Varus deformity ( Outward splaying of the leg) and Varus deformity(Inward splaying of the
leg)
• Inspect the back for any popliteal cyst/ Baker’s cyst which is outpouching of the synovial membrane out
of the joint capsule.
• No hyper extension( Cruciate ligament injury)
• Flexion deformity.
• Do the same on the opposite side.

PALPATION- SHOULD BE IN SUPINE POSITION.
• Temperature- With the back of your hand and compare with normal side.
• Tenderness- (Suggests trauma.eg fracture)
Palpate the patella, the patellar ligament, the tibial tuberosity, suprapatellar bursa, quadriceps
muscle, joint line( Medial and lateral) and back of the patella with the leg semi-flexed to feel for
baker’s cyst as well as the popliteal artery.
Movement:
The knee joint has two movements.
Flexion- Bending the knee.
Extension- Extending the knee
Do active first: Look for any hyper extension or flexion deformity,
Do passive to feel for crepitus- Chondromalacia Patellae, Osteoartghritis.

SPECIAL TESTS
• Patellar tap test
• Bulge test
• Clarke test
• Patellar tilt test
• Patellar apprehension test
• Anterior/posterior drawer test
• Valgus/ varus stress test for collateral ligaments
• McMurray’s Test

CLARKE’S TEST FOR PATELLOFEMORAL PAIN
SYNDROME.
• Have the patient Supine with the knee extended.
• Grasp the superior pole of patella and apply patella femoral compression.
• Ask the patient to contract the quadriceps muscle(tighten your legs)
• Ellicits pain in the patellofemoral pain syndrome.
• Postitive in chondromalacia Patellae.

PATELLAR TAP TEST POSITIVE FOR LARGE JOINT
EFFUSION
• Have your patient lying in supine position with knee extended
• Run your hands down from the mid thigh upto the upper pole of patella to empty the supra
patellar pouch and keep your hand in that position.
• Using your index/middle finger of the other hand tap on the patella to feel a tap or
downward movement of patella.
Bulge test – For small effusion
• Same position, empty the supra patellar pouch as described above
• Swipe your hand through the medial aspect of the knee to move the fluid to the lateral
aspect of the knee.
• Then swipe your hand through the lateral aspect of the knee to move the excess fluid to
the lateral knee and look for a bulge.

PATELLAR APPREHENSION TEST- PATELLAR
SUBLAXATION.

PATELLAR TILT TEST- FOR PATELLAR TENDONITIS.
• Patient in supine and knee extended, tilt the patella by exerting pressure over its
superior pole. This lifts its inferior pole.
• Now palpate the under surface of patella
• Very sharp pain elicited in case of patellar tendinopathy.
• With the knee mid flexed to 90 degrees and the foot flat on the examination
table, fix the foot with your thighs by somewhat sitting on the foot of the patient.
• Grab the tibia with your fingers anchored on the back of the leg and thumb fixed
on the tibial tuborisity.

ANTERIOR/POSTERIOR DRAWER TEST- ACL/PCL
TEAR RESPECTIVELY
• With the knee mid flexed to 90 degrees and the foot flat on the examination table, fix the
foot with your thighs by somewhat sitting on the foot of the patient.
• Grab the tibia with your fingers anchored on the back of the leg and thumb fixed on the
tibial tuborisity.
• Give a brisk traction towards yourself and if there is excessive anterior displacement of
the leg then its positive for ACL tear.
• A brisk push forward will displace the tibia posteriorly and it will be positive for PCL tear.

MCMURRAY’S TEST- MENISCUS INJURY

VALGUS/ VARUS STRESS TEST
• Valgus stress test: For Medial collateral Ligament.
With the leg supported with your hand, and the knee flexed at 30 degrees apply
valgus compression( compression on the lateral aspect of the knee). If there is
excessive splaying of the knee then there is tear of the medial collateral ligament.
Cause – Direct blow on the lateral knee when the leg is fixed to the ground.
• Varus stress test: Lateral collateral ligament (Rare)
With the leg supported with your hand, and the knee flexed at 30 degrees apply
varus compression( compression on the medial aspect of the knee). If there is
excessive splaying of the knee then there is tear of the lateral collateral ligament

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GENERAL APPROACH
• WIPE approach.
• Gait- Limping
• Inspect: (Ideally lying position) Look for asymmetry,
• Look for SSRRBMD, Color change, Hair distribution, Missing toes/nails and check the
wedge spaces for any ulcer.
• Always compare with the other side.

PALPATION
• Temperature: Look for temperature changes on both foot with the dorsum of your hand
and compare with the normal region of the leg.
• CRT: Squeeze the pulp of the big toe for five seconds and let go. The pink color should
ideally return within 3 seconds.
• Dorsalis Pedis pulse: Feel the artery pulse just lateral to the Extensor Hallucis Longus
tendon just over the navicular bone with your three fingers.
• Posterior Tibial Artery: Feel just behind and below the medial malleolus.

PALPATION CONTINUED…
• Palpate for tenderness: Toes, MTP joints, interdigital clefts(Morton’s Neuroma),
Metatarsal bones, Navicular bone, Heel, sole, Medial and lateral malleolus and the
Achille’s tendon.
• Ottawa Rule for fracture:
1. Tenderness at the medial malleolus to 6cm distally
2. Tenderness at the navicular bone and base of 5th metatarsal.
3. Unable to take 4 consecutive steps.
• If all these are negative then no chance of fracture.

MOVEMENTS
• Dorsiflexion: Bending the leg towards the patient.
• Planter flexion: Straightening the leg away from the patient.
• Inversion: Pointing the soles inwards
• Eversion: Splaying the foot outwards.
Special Tests:
1. Anterior Drawer test: ATFL tear
2. Windlass test: Planter Fasciitis
3. Taller tilt test
4. Mulder’s squeeze text
5. Thompson’s Test
6. Syndesmosis test

CONT…
• Windlass test- With the patient in supine
position, the foot is positioned beyond the
edge of the bed, dorsiflex the great toe as
to stretch and strain the planter fascia,
and apply pressure on the middle of the
sole. Pain suggests planter fasciitis.

MULDER’S CLICK : MORTON’S NEUROMA.
• Squeeze the foot with one hand and
press the 2nd, 3rd, 4th, interphalangeal
spaces. You should hear a click and it will
illicit pain in case of Morton’s Neuroma.
• Morton’s Neuroma is the thickening and
fibrosis of tissue between the
interphalangeal spaces due to over use
stress, compressing the nerve supplying
the web spaces leading to pain.

ANTERIOR DRAWER TEST- ATFL TEAL
• With the patient supine and foot extending beyond
the edge of the bed, fix the ankle with one hand,
and put the other hand beneath the heal and
provide upward traction. Excessive displacement
suggests ATFL tear.
Talar tilt test. Check for 4 ligaments
1. Anterior Talofibular Ligament
2. Posterior Talofibular ligament
3. Calcaneofibular Ligament
4. Deltoid Ligament

• Dorsiflexion and Inversion- PTFL
• Plantarflexion and Inversion- ATFL
• Neutral and Inversion- Calcaneo Fibular
Ligament.
• Neutral and EVERSION: Deltoid
Ligament.

THOMPSONS TEST- ACHILLE’ TENDON RUPTURE
SYNDESMOSIS SQUEEZE TEST- SYNDESMOSIS
LIGAMENT INJURY

EXAMINATION OF THE
BACK
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EXAMINATION OF THE BACK.
Case: Drake, a 45 year old male comes with back pain since yesterday started suddenly while
lifting heavy weight.
Task: Explain PE to medical student/Examiner/Patient
WIPE: Hello, I’m Dr. T one of the doctors here and today I will be explaining the
examination of the back of Mr. Drake who came to us with back pain since
yesterday. Before we start, we need to introduce ourselves stating our name and
role, wash our hands, and address any concern the patient might have, e.g. pain.
Then we need to explain briefly the procedure like it will involve looking at your
back, touching your back, and doing some special tests.
For the purpose of the examination appropriate exposure is needed and that’s why
I would request you to be in your shorts and take of your gown. After taking
consent, proceed with examination.

INSPECTION
• Patient sitting/standing, comfortably or in pain. Any posture assumed.
• Any walking aids
• Ask your patient to take a few steps, and notice and limping or leaning towards any side.
• Gait: Can you please walk on your toes: S1
Walk on your heals- L5
• From the front: look for both ASIS are in the same level.
• From Back. Look for any unilateral crease on the waist indicating Scoliosis.
Also see is the PSIS(Two dimples are at the same level).
• Side: Lumber Lordosis is maintained or not.
• Look for SSRRBMD.

FEEL:
• Temperature:
• Tenderness: Vertebrae, Paraspinal
Muscles, PSIS, ASIS, Sacroiliac joint.

MOVE:
• Movements:
1. Flexion. Bend forward to touch your
toes
2. Extension. Bend backwards as far as
you can
3. Lateral extension. Bend sideways.
4. Rotation. Rotate sideways.

SPECIAL TESTS
• Straight leg raise test: With the patient in
supine position, raise the leg with knee
extended and see if there is complaint of
any pain.
SLR +ve indicates Sciatica.

SCHOBER’S TEST- CAN BE POSITIVE IN
ANKYLOSING SPONDYLITIS.
• Identify PSIS which
are two indentations
just above the
buttock
• Mark a point with a
marker 5cm below
the PSIS
• Mark a point 10cm
above the PSIS
• Ask the patient to
bend forward as far
as they can in an
attempt to touch
their toes
• Measure the
distance between
• 15cm distance
should increase to
20cm.

CONTINUE…..
• Finish with Lower limb neurological Examination
SLR +ve indicates SCIATICA which indicates compression of nerve root exiting the lumbar
spine. Rights are reserved to shahriar’s medical AMC clinical
Schober’s test +ve indicates Ankylosing spondylitis or restriction of flexion due to
mechanical back strain or OA
Other DDs of low back pain
OA, RA, Metastatic cancer, Mechanical back pain

HIP EXAMINATION

HIP EXAMINATION
• How the patient may present:
1. Pain around the hip following trauma
2. Pain around groin
3. Limping and difficulty in weight bearing.
Approach:
Wipe approach.
Analgesia
Any other concerns

GOOD LINK FOR HIP PE
https://www.orthobullets.com/recon/5037/hip-physical-exam--
adult

INSPECTION.
• Gait: Walk with bearing full weight.
Look for limping or tilting to one side
FRONT: Compare both ASIS, groin crease, SSRRBMD
Side: Lumbar Lordosis
Back: PSIS, bone muscle atrophy (Gluteal, Hamstring)

CONT…
• Trendelenburg sign: For unilateral hip abductor
weakness usually caused by superior gluteal
nerve lesion or L5 radiculopathy.
• Weakness in Gluteal Medius and Maximus
weakness.
• When the patient stands on one leg, the
contralateral hip is supposed to rise up the level
of the weight bearing hip but due to weakness
in the hip abductors, the contralateral hip will
actually drop down.

CONT…
Trendelenburg Sign:
• Stand behind the patient.
• Ask the patient to stand on one leg and bear the whole weight on that leg.
• Reassure the patient that you will keep your hands by his sides and provide support.
• Notice the drop of the contralateral hip.

PALPATION.
• Temperature
• Tenderness over the ASIS, Iliac crest, Trochanteric area, Over the hip joint line
• Go behind and palpate the PSIS and sacroiliac joint.
Movement: Best to assess in supine position
• Flexion: Bend your hip and bring you knees close to your chest
• Extension: Bend your knees and try to straighten your legs from the bend position.
• Abduction: Move your hips away from each other
• Adduction: Cross your legs over each other
• Internal rotation: Roll your legs inwards
• External Rotation: Roll your legs outwards.

MEASURE LENGTH
• True Length: ASIS to Medial Malleolus
• Apparent length: Umbilicus to Medial Malleolus.
• Usually Apparent length is greater than true length.(Pic)
• Compare lengths of two sides.
• Decreased length suggests fracture of neck of femur
https://boneandspine.com/true-and-apparent-leg-length/ Usually Apparent length is
greater than true length

SPECIAL TESTS
• Thomas test
• Squeeze test
• Faber test
Thomas test ( Fixed Flexion Deformity in OA)
Inability to extend the leg fully.
1. Position the patient in supine position place your hand below the lumbar spine with
your palm facing upward
2. Passively flex the hip of the affected leg as far as possible and observe the
contralateral hip. The test is positive if the affected limb is raised off the bed(Flexion).
This suggests a fixed flexion deformity

SQUEEZE TEST: ADDUCTOR TENDINITIS
• Bend your legs.
• Make a fist and place your fist between
the patient’s knees
• Ask the patient to squeeze your fists
between his knees.
• Positive test means pain on the medial
aspect of the thighs

DX/DD
Osteoarthritis
• Antalgic gait
• Restricted movement in all plains
• Thomas test +ve
• Faber test +ve
• Trendelenburg test +ve
Adductor tendinitis
• Tenderness at medial group of muscles
• Painful adduction
• Squeeze test +ve

THANK YOU
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Prepared by Dr.Tasfeen Arnab
Edited & Slide design- by Dr.shahriar
AMC clinical PE session

AMC Clinical Physical examination Class 1.pptx

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AMC Clinical Physical examination Class 1.pptx