Living Anatomy, Lower Limb

Palpate bony landmarks of the pelvis
a. Pubic symphysis
b. Pubic crest – attachment for rectus
abdominis
c. Pubic tubercle – attachment for inguinal ligament
d. ASIS
e. PSIS – dimples
f. Ischial tuberosity
g. Crest of ilium
h. Tubercle of iliac crest – widest part of pelvis

Describe Chiene’s and Nelaton’s lines.
a. Chiene’s lines – parallel joining ASIS and greater trochanters. Not parallel if hip is dislocated.
b. Nelaton’s lines – line joining ASIS and ischial tuberosity should pass through tip of greater trochanter.

Demonstrate where you would give a gluteal injection.
Exit of sciatic nerve from greater sciatic foramen is halfway between PSIS and ischial tuberosity. When it crosses quadratus femoris it is halfway between ischial tuberosity and greater trochanter. Inject in upper outer quadrant into gluteus medius.

Palpate bony landmarks of the leg
a. Tibial condyles
b. Tibial tuberosity
c. Fibula – knee flexed to feel head
d. Anterior surface of tibia – subcutaneous
e. Medial surface of tibia
f. Medial malleolus
g. Lateral malleolus – extends more distally than medial malleolus

Three Tests for Stability Testing of the Knee
Lachman’s Test
Drawer Sign
Collateral Testing

Perform Lachman’s Test
Tests ACL and PCL
Put knee in 30 deg flexion
Stabilize femur with one hand, pull forward on tibial condyles with other
Movement forward = ACL tear
Sagging backward = PCL tear

Perform Drawer Sign
ACL/PCL Test
Not too accurate (25%)
Knee flexed to 90 deg
Sit on foot
Pull forward or push back on tibial condyles

Perform Collateral Ligament Testing
Support foot of extended leg in arm pit
Put lateral or medial pressure on joint with finger in joint line

Palpate bony landmarks on the medial border of the foot
-Sustentaculum tali- just below medial malleolus
-Head of talus- evert foot to accentuate
-Tubercle of the navicular- most prominent; anterior to sust tali
-Medial cuneiform bone- anterior to tubercle
-Base, shaft, and head of 1st metatarsal

Demonstrate and describe 3 reflexes in the lower limb
a. Knee jerk- L2-L4, tap patellar tendon with subject sitting
b. Ankle jerk- L5-S2, hit tendo calcaneus while supporting leg and holding foot in dorsiflexion. Clonus elicited.
c. Plantar- L4-S2, called Babinski reflex. Toes should flex when sole is scraped

Demonstrate movements of the ankle
-Dorsiflexion: 15-20
-Plantar flexion: 45
-Abduction: in plantar flexion = 5-10
in dorsiflexion = 0
-Adduction: in plantar flexion = 5-10
in dorsiflexion = 0

Palpate bony landmarks of the femur
-Greater trochanter: flex thigh and palpate medially from behind
-Head of femur: hyperextend thigh and laterally rotate (lean way back)
-femoral condyles: by knee
-adductor tubercle: on superior surface of medial condyle

Test the femoral nerve in as many ways as possible
a. Sartorius: resist lateral rotation of thigh and flexion of leg
b. Rectus femoris: resist hip flexion with leg extended and hip extended
c. Vastus L/M/I: resist leg extension. Flex hip and knee to eliminate rectus femoris
d. Iliopsoas: subject seated with leg flexed. Resist thigh flexion
e. Sensory: Anteromedial thigh, medial aspect of leg and foot

Test the obturator nerve in as many ways as possible
a. Adductor longus – clamp knees together with fist between, follow tendon to pubic tubercle.
b. Adductor magnus – adduction
c. Gracilis – adduction
d. Pectineus – ?
e. Sensory – Medial thigh, right above the knee

Test the superior gluteal nerve in as many ways as possible
a. Tensor fasciae latae – stand on one foot and palpate posterior to ASIS on stance limb.
b. Gluteus medius – stand on one foot and palpate behind tensor.

Test the lateral femoral cutaneous nerve in as many ways as possible
a. Sensory – anterolateral aspect of the thigh

Test the inferior gluteal nerve in as many ways as possible
a. Gluteus maximus – subject prone. Extend thigh against resistance.

Test the tibial nerve in as many ways as possible
a. Semitendinosus – prominent tendon on medial side
b. Semimembranosus – deep to semitendinosus
c. Long head of biceps femoris – prominent tendon on lateral side
d. Adductor magnus – adduction
e. Gastrocnemius – plantarflexion
f. Soleus – plantarflexion
g. Flexor digitorum longus – behind tibialis posterior tendon. Crosses sustentaculum tali.
h. Tibialis posterior – plantarflexes and inverts foot, tendon just behind medial malleolus.
i. Flexor hallucis longus – flex big toe
j. Sensory – Plantar Aspect of the foot

Test the common peroneal nerve in as many ways as possible
a. Short head of biceps femoris – flex knee
b.Sensory – Lateral leg and dorsum of foot

Test the medial plantar nerve in as many ways as possible
a. Abductor hallucis – mainly flexes big toe
b. Flexor digitorum brevis – flexes 2-5th digits
c. Flexor hallucis brevis – flexes big toe
d. Sensory – Sole of the foot

Test the superficial peroneal nerve in as many ways as possible
a. Peroneus longus – everts and plantarflexes foot, tendon behind lateral malleolus, tendon posterior to peroneus brevis tendon on foot
b. Peroneus brevis – everts and plantarflexes foot, tendon behind lateral malleolus, tendon anterior to peroneus longus tendon on foot
c. Sensory – Dorsum of the foot except first web-space; lateral lower leg

Test the deep peroneal nerve in as many ways as possible
a. Tibialis anterior – dorsiflexion, most medial tendon on dorsum.
b. Extensor hallucis longus – extends big toe, dorsiflexes and inverts, tendon just lateral to tibialis anterior.
c. Extensor digitorum longus – everts and dorsiflexes foot, extends toes, tendon just lateral to extensor hallucis longus
d. Peroneus tertius – extends 5th toe
e. Extensor hallucis brevis – extends big toe
f. Extensor digitorum brevis – contracted belly creates “tumor” on dorsum of foot
g. Sensory – Dorsal web-space between 1st and 2nd toes

Test the lateral plantar nerve in as many ways as possible
a. Plantar interossei – adduct toes 3-5, flex toes 3-5 at MTP
b. Dorsal interossei – abduct toes 2-4, flex toes 2-4 at MTP
c. Abductor digiti minimi – abduct 5th toe
d. Quadratus plantae – flex distal phalanx of 2-5th toes
e. 2nd-4th lumbricals – flex MTP, extend middle and distal phalanges at IP
f. Adductor hallucis – adduct and flex big toe
g. Flexor digiti minimi brevis – flex 5th toe
h. Sensory – Sole of the foot

Perform tests for valvular competence
a. Trendelenburg’s test – empty veins in limb, tourniquet around thigh, stand up. Release tourniquet. If great saphenous fills from above, its valves are incompetent.
b. Test for valvular competence of the perforating veins – empty veins in limb, tourniquet on thigh, stand up. If great saphenous fills from below with tourniquet on, perforating valves are incompetent.

Palpate bony landmarks of the ilium
a. ASIS
b. Iliac tubercle – widest part at L5
c. Iliac crest – at L4

Palpate bony landmarks of the gluteal region, posterior thigh, and hip
a. ASIS
b. Iliac tubercle – widest part at L5
c. Iliac crest – at L4
d. Spinous process of L4
e. PSIS – S2 dimple is landmark
f. Sacrum
g. Ischial tuberosity – reach anterior to inferior border of gluteus maximus.
h. Greater trochanter – flex thigh and palpate medially from behind

Perform Trendelenburg’s test for abductors
a. Stand on one foot. ASIS of limb off ground should remain level or ascend. If it sags, abductors are weak. Tape across the ASIS’s.

Describe the course of the sciatic nerve in the gluteal region
Exit of sciatic nerve from greater sciatic foramen is halfway between PSIS and ischial tuberosity. When it crosses quadratus femoris it is halfway between ischial tuberosity and greater trochanter.

Demonstrate movements of the hip joint
a.Flexion – subject supine
i. Flexed knee – 120-130
ii. Extended knees – 90
b. Extension – subject prone, push
down on back to keep ASIS on table- get
15 deg
-30 deg if includes lumbar spine
c. Abduction – subject supine, mark
ASIS to ensure pelvic movement
doesnt contribute
i. In knee flexion – 75-90
ii. In knee extension – 45
d. Adduction – subject supine
Elevate and cross midline -30 deg
e. Rotation – subject supine
i. In flexion – use leg and foot as lever
1. Medial – 45
2. Lateral -45
ii. In extension – use foot as lever
1. Medial – 30
2. Lateral – 30

Palpate bony landmarks of the knee
a. Femoral condyles
b. Patella
c. Tibial condyles

Palpate 7 structures in the knee
a. Patella – push back on patella during flexion and extension.
b. Medial meniscus – flex leg to find
c. Lateral meniscus- flex leg to find
d. Tibial condyles
e. Adductor tubercle- continuation of
adductor magnus

Tests for Meniscal Assessment
McMurray Sign
Apley Sign
Thessaly Test

Perform McMurray’s Sign
-subject supine, knee flexed
-rotate leg laterally and extend leg
-popping/clicking= medial meniscus damage
-opposite for lateral meniscus

Perform Apley’s Sign
-subject prone, knee flexed
-push down on foot and rotate leg
-grinding sound = meniscal tear
-medial rotation for lateral meniscus/and v/v

Perform Thessaly’s Test
most accurate
-Subject stands on one foot
-knee flexed 5, then 20 deg
-Subject rotates thigh and body medially and laterally
-will experience joint line discomfort and locking or catching if meniscal tear

Palpate bony landmarks of the lateral border of the foot
a. Peroneal trochlea – projection on calcaneus.
b. Calcaneus
c. Base, shaft, and head of 5th metatarsal

Palpabe bony landmarks of the dorsum of the foot
a. Talus
b. Cuneiforms
c. Metatarsals

Palpate bony landmarks of the sole of the foot
a. Calcaneus
b. Sesamoid bones – against head of first metatarsal

Palpate tendons in the foot and ankle
a. Tibialis anterior – most medial on dorsum
b. Extensor hallucis longus – just lateral to tibialis anterior
c. Extensor digitorum longus – just lateral to extensor hallucis longus
d. Peroneus tertius – extends 5th toe
e. Tibialis posterior – right behind tibialis posterior tendon. Also crosses sustentaculum tali.
f. Peroneus longus – right behind lateral malleolus. Posterior to peroneus brevis tendon on foot.
g. Peroneus brevis – right behind lateral malleolus. Anterior to peroneus longus tendon on foot

Demonstrate movements of the knee
Flexion = 130
Extension = 0
Abduction w/ knee flexed = 5-10
Abduction w/ knee extended = 0
Adduction w/ knee flexed = 5-10
Adduction w/ knee extended = 0
Rotation w/ knee flexed = 5-10
Rotation w/ knee extended = 0

Describe the anterior drawer test in the ankle
Stabilize tibia and pull forward on calcaneus. Anterior talofibular ligament prevents forward movement

Demonstrate movement at the talonavicular joint
Hold calcaneus and ask subject to invert and evert foot

Demonstrate plantarflexors of the foot
a. Gastrocnemius – plantarflexion
b. Soleus – plantarflexion
c. Flexor digitorum longus – behind tibialis posterior tendon. Crosses sustentaculum tali.
d. Tibialis posterior – plantarflexes and inverts foot, tendon just behind medial malleolus.
e. Flexor hallucis longus – flex big toe
f. Peroneus longus – everts and plantarflexes foot, tendon behind lateral malleolus, tendon posterior to peroneus brevis tendon on foot
g. Peroneus brevis – everts and plantarflexes foot, tendon behind lateral malleolus, tendon anterior to peroneus longus tendon on foot

Demonstrate dorsiflexors of the foot
a. Tibialis anterior – dorsiflexion, most medial tendon on dorsum.
b. Extensor hallucis longus – extends big toe, dorsiflexes and inverts, tendon just lateral to tibialis anterior.
c. Extensor digitorum longus – everts and dorsiflexes foot, extends toes, tendon just lateral to extensor hallucis longus
d. Peroneus tertius – extends 5th toe

Demonstrate inverters of the foot
a. Flexor digitorum longus – behind tibialis posterior tendon. Crosses sustentaculum tali.
b. Tibialis posterior – plantarflexes and inverts foot, tendon just behind medial malleolus.
c. Flexor hallucis longus – flex big toe
d. Tibialis anterior – dorsiflexion, most medial tendon on dorsum.
e. Extensor hallucis longus – extends big toe, dorsiflexes and inverts, tendon just lateral to tibialis anterior

Demonstrate everters of the foot
a. Peroneus longus – everts and plantarflexes foot, tendon behind lateral malleolus, tendon posterior to peroneus brevis tendon on foot
b. Peroneus brevis – everts and plantarflexes foot, tendon behind lateral malleolus, tendon anterior to peroneus longus tendon on foot
c. Extensor digitorum longus – everts and dorsiflexes foot, extends toes, tendon just lateral to extensor hallucis longus

Demonstrate muscles of the 5th toe
a. Peroneus tertius – extends 5th toe
b. Extensor hallucis brevis – extends big toe
c. Flexor digiti minimi – flex 5th toe
d. Abductor digiti minimi – abducts 5th toe

Demonstrate muscles of the MTP joint
a. Lumbricals – flex MTP, extend middle and distal phalanges at IP
b. Plantar interossei (3-5) – adduct toes 3-5, flex toes 3-5 at MTP
c. Dorsal interossei (2-4) – abduct toes 2-4, flex toes 2-4 at MTP

Demonstrate flexors of the knee
a. Semitendinosus – prominent tendon on medial side
b. Semimembranosus – deep to semitendinosus
c. Short head of the biceps
d. Gracilis
e. Sartorius – resist lateral rotation of thigh and flexioin of leg
f. Gastrocnemius

Demonstrate extensors of the knee
a. Rectus femoris – resist hip flexion with leg extended and hip extended.
b. Vastus lateralis – resist leg extension. Flex hip and knee to eliminate rectus femoris.
c. Vastus medialis – resist leg extension. Flex hip and knee to eliminate rectus femoris.
d. Vastus intermedius – resist leg extension. Flex hip and knee to eliminate rectus femoris

Demonstrate medial rotators of the knee
a. Semitendinosus – prominent tendon on medial side
b. Semimembranosus – deep to semitendinosus
c. Gracilis –
d. Popliteus – origin fixed

Demonstrate muscles of the toes
a. Flexor digitorum longus – behind tibialis posterior tendon. Crosses sustentaculum tali.
b. Flexor digitorum brevis – flexion
c. Plantar interossei – adduct toes 3-5, flex toes 3-5 at MTP
d. Extensor digitorum brevis – contracted belly creates “tumor” on dorsum of foot
e. Extensor digitorum longus – everts and dorsiflexes foot, extends toes, tendon just lateral to extensor hallucis longus

Demonstrate muscles of the big toe
a. Flexor hallucis longus – flex big toe
b. Abductor hallucis – mostly flexion
c. Flexor hallucis brevis – flexion
d. Adductor hallucis – adduction and flexion
e. Extensor hallucis longus – extends big toe, dorsiflexes and inverts, tendon just lateral to tibialis anterior.

Demonstrate flexors of the hip
a. Tensor fasciae latae – stand on one foot and palpate posterior to ASIS on stance limb.
b. Rectus femoris – resist hip flexion with leg extended and hip extended.
c. Sartorius – resist lateral rotation of thigh and flexioin of leg
d. Iliopsoas – subject seated with leg flexed. Resist thigh flexion.
e. Adductor longus – clamp knees together with fist between, follow tendon to pubic tubercle.

Demonstrate extensors of the hip
a. Gluteus maximus – subject prone. Extend thigh against resistance.
b. Semitendinosus – prominent tendon on medial side
c. Semimembranosus – deep to semitendinosus
d. Long head of the biceps femoris – prominent tendon on lateral side
e. Adductor magnus –

Demonstrate lateral rotators of the hip
a. Gluteus maximus – subject prone. Extend thigh against resistance.
b. Piriformus – thigh extended
c. Obturator internus
d. Biceps femoris – knee flexed
e. Adductor magnus
f. Sartorius – hip flexed, resist lateral rotation of thigh and flexioin of leg
g. Iliopsoas – subject seated with leg flexed. Resist thigh flexion.
h. Popliteus – insertion fixed,

Demonstrate medial rotators of the hip
a. Tensor fasciae latae – thigh flexed, stand on one foot and palpate posterior to ASIS on stance limb.
b. Gluteus medius – stand on one foot and palpate behind tensor.
c. Pectineus – ?

Demonstrate adductors of the hip
a. Adductor longus – clamp knees together with fist between, follow tendon to pubic tubercle.
b. Adductor magnus
c. Gracilis
d. Pectineus – ?

Demonstrate abductors of the hip
a. Tensor fasciae latae – thigh flexed, stand on one foot and palpate posterior to ASIS on stance limb.
b. Gluteus maximus – subject prone. Extend thigh against resistance.
c. Gluteus medius – stand on one foot and palpate behind tensor.
d. Obturator internus – thigh flexed

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