Assessing the Lower Extremities in the Geriatric Patient

Mark E. Williams, MD
Posted: 11/08/2010

Overview

This presentation is primarily concerned with the orthopaedic and vascular aspects of the lower extremity examination, with a focus on the legs. For more detailed information on assessing the feet, see Evaluating Foot Pain in Elderly Patients . The assessment of balance and gait and the neurologic evaluation of the lower extremities are beyond the scope of this presentation.

Assessment of the Hip in the Geriatric Patient

General Evaluation of the Hip

Observations of standing posture. The hip cannot be inspected or palpated directly; therefore, most inferences derive from changes in movement. Observe the patient's standing posture because hip problems will tend to cause the affected foot to advance slightly and rotate slightly inward. Also check Trendelenburg's sign; have the patient lift the right leg and observe whether the left hip elevates, which is normal, or does not (a positive test). Repeat on the other side. A positive test suggests degenerative joint disease, weakness of the gluteus, or hip dislocation. Seeing a compensatory lordosis when the hip is extended suggests a fixed flexion deformity of the hip. You can confirm your impression with Thomas' Test below.

Thomas' Test for Fixed Flexion Deformity of the Hip First check for lumbar lordosis. With the patient lying supine, try to place your left hand, palm up, between the patient's low back and the table. If your hand is able to be inserted between the back and the table then the patient has a lumbar lordosis. If not, then the deformity is not present Next, ask the patient to flex the normal leg and pull it to the chest. If there is no fixed flexion deformity, the opposite outstretched leg will remain on the table. If the deformity is present, pelvic rotation as the normal leg is flexed will cause the opposite leg to rise off the examination table.

Hip range of motion. Next, perform the hip isolation test to observe the range of motion. With the patient prone, flex the knee to about 90° and move the foot medially and laterally so that the knee also swings medially and laterally. Limited range of motion implies degenerative joint disease of the hip. This test isolates the hip so that extra-articular causes of discomfort are minimized.

Hip Pain After a Fall

First, inspect the leg. Consider the following:

• If it is foreshortened and externally rotated, consider fracture below the femoral neck (intertrochanteric fracture);
• If the leg is externally rotated but not foreshortened, consider fracture of the femoral shaft;
• If the thigh is externally rotated, flexed, and abducted, consider anterior dislocation; and
• If the thigh is internally rotated and adducted with a very prominent greater trochanter, consider posterior dislocation.

Now check for fracture with the use of osteophony (Hueter's sign). This test is extremely helpful in evaluating patients during home visits or in the nursing home. Place the diaphragm of your stethoscope on the pubic symphysis. Gently percuss each kneecap with your forefinger. An intact bone will produce a clear, bright tapping sound. A hip fracture will give a muffled, distant sound. Other approaches use a tuning fork on the patella or listening over each iliac crest as opposed to the pubic symphysis.

Chronic Hip Pain or Decreased Range of Motion

As you perform this assessment, keep in mind the possibility of referred pain from the knee (see below).

Patrick's test. To perform Patrick's test, place the patient's ankle on the contralateral knee and then gently press down on the flexed knee. Pain in the hip suggests osteoarthritis of the hip; pain radiating from the back down the leg suggests radiculopathy; and pain in the lower spine suggests compression fracture.

Laguerre's test. With the patient supine, grasp the heel on the symptomatic side and passively flex the knee and hip and rotate the patient's hip. Pain over the greater trochanter suggests bursitis, whereas pain in the hip and groin suggests degenerative joint disease.

Trendelenburg's sign. Have the patient stand and transfer the weight to the nonpainful leg. If the painful buttock drops and becomes flaccid, suspect severe degenerative joint disease, weakness of the gluteus, or hip dislocation.

Palpate the anterior iliac spine. Palpate along the anterior iliac spine and inguinal ligament. Increasing dysesthesia along the anterior thigh indicates meralgia paresthetica.

Additional Hip Assessment Pearls

• Feeling a crepitant sensation when palpating over a bone in the absence of infection suggests sarcoma (Dupuytren's sign); and
• Flattening of the thigh when a patient lies supine suggests upper motor neuron disease (Heilbronner's sign).

General Evaluation of the Knee

It is normal for both the ankles and the knees to touch. Being knock-kneed (knees touch but ankles do not) involves a valgus deformity of the knee. Bow-leggedness (ankles touch but knees do not) is a varus deformity of the knee. If the knees curve backward in the lateral dimension, there is a genu recurvatum deformity. Osteoarthritis will produce bony enlargement, which is sometimes magnified by coincident quadricep muscle atrophy. Look for scars that indicate previous knee surgery.
Check knee range of motion. Observe passive knee range of motion by gently flexing and extending the knee with the patient sitting or supine. Decreased range of motion suggests degenerative joint disease. Increased lateral movement suggests damaged ligaments.
Check for crepitus. Check for crepitus in the knee joint by listening for the crunching, popping sound (or feeling) on joint movement. Finding no crepitus is normal. If crepitus is present, it suggests degenerative joint disease. The location defines the affected compartment, so that anterior, lateral, or medial crepitus suggests knee degenerative joint disease in those respective locations. Crepitus on extension suggests patellofemoral syndrome.
Check for effusion. Now search for knee effusion. Feel for a spongy movement of the patella and look for a bulge between the patella and the condyles. If there is any spongy downward movement of the patella when the leg is fully extended, then an effusion is present. In addition, you can milk the fluid from the medial side with your forefingers and middle fingers and then push with your thumbs from the lateral side just below the patella. Seeing a medial bulge (bulge sign) suggests effusion.
Check the tibial and femoral condyles positions. Tibial condyles displaced posteriorly to the femoral condyles suggest a prior posterior cruciate ligament tear. Tibial condyles displaced anteriorly to the femoral condyles suggest a prior anterior cruciate ligament tear.

Anterior Knee Pain

Check for bony deformity.
Check for effusion (vide supra). If present, patellar effusion will present as spongy ballottement, bulging of the joint, or a fluid wave. Check for tenderness and swelling over the quadriceps muscles. The presence of pain suggests quadriceps rupture or strain.
Check for patellar tenderness. Doughy swelling above the patella suggests suprapatellar bursitis (housemaid's knee). Swelling and tenderness on the patella suggest prepatellar bursitis (roofer's knee), usually brought on by constant kneeling. Marked tenderness and swelling over the patella suggest patellar fracture. Tenderness below the patella without swelling suggests tendonitis (jumper's knee). Swelling and tenderness below the patella suggest infrapatellar bursitis (pastor's knee).
Patellofemoral syndrome. Look for quadriceps atrophy, especially the vastus obliquus medialis. Also feel for tenderness behind the patella with palpation. Perform the patellar inhibition test. Stabilize the patella with your thumb and forefinger, and then gently try to push it toward the feet. Have the patient contract the quadriceps to move the patella upward. Pain and relaxation of the quadriceps is a positive test. Now move the patella medially and laterally with knee flexed to 30 degrees. Increased lateral mobility is a positive apprehension test. Voluntary contraction of the quadriceps when moving the patella laterally is also a positive test. Check for lateral patellar displacement with extension that resolves with flexion.

Pain Behind the Knee

Search for a popliteal mass. A nontender area of bogginess suggests a Baker's cyst. Feeling a pulsatile mass suggests popliteal artery aneurysm. Feeling a tender mass in the popliteal fossa suggests bursitis.
Look for focal or diffuse tenderness in the popliteal fossa. Focal tenderness in the medial popliteal fossa without a mass suggests a hamstring muscle strain. Diffuse tenderness and swelling suggest a ruptured Baker's cyst or deep venous thrombosis.

Medial Knee Pain

Palpate for tenderness. Check for an anatomic deformity and palpate the site of tenderness. Pain behind the knee suggests a hamstring tear. Exquisite tenderness medial and inferior to the tibial plateau suggests anserine bursitis. Tenderness midway between the femur and the tibia suggests medial collateral ligament damage. Tenderness anterior to the condyles suggests a medial meniscus tear.
Check for joint laxity. Now test for joint laxity with lateral movement. The degree of laxity defines the extent of medial collateral ligament tear. Pain in the lateral knee with this movement suggests lateral meniscus tear (Bohler's sign).
Check for meniscus tear. Employ McMurray's maneuver; with the patient supine, passively flex the knee until the heel hits the buttock. Rotate foot laterally and then extend the knee. A loud click over the lateral knee suggests a medial meniscus tear. Also check Apley's compression test. With the patient prone and the knee flexed to 90° (perpendicular to the examining table), push down and gently twist the foot. Pain or crepitus is a positive test. Payr's test is also useful. With the patient sitting cross-legged, push on the painful knee. Medial knee pain is a positive test.

Lateral Knee Pain

Check for anatomic deformity.
Palpate for tenderness. Palpate the site of tenderness with the knee straight and then flexed to 90°. Tenderness over the fibular head suggests fibular fracture. Tenderness between the femur and fibular head suggests lateral collateral ligament sprain. Tenderness just anterior to the femoral condyles suggests lateral meniscus tear. Tenderness over the lateral tibial condyle radiating over the lateral thigh suggests iliotibial band syndrome.
Check for joint laxity. Check for joint laxity by holding the knee and moving the foot medially. The amount of pain and the degree of laxity define the extent of lateral collateral ligament tear. Pain in the medial knee suggests medial meniscus tear.
Check for Ober's sign. With the patient supine, passively flex and abduct the leg, and then gently let go and have the patient maintain the leg position. Pain in the anterior thigh (positive Ober's sign) suggests tensor fascia lata syndrome. Pain in the lateral knee suggests iliotibial band syndrome.
Look for a meniscus tear. See "Check for Meniscus Tear" under "Medial Knee Pain," above.

A Knee That Gives Way

Check the basic landmarks for anatomic deformity.
Examine the anterior cruciate ligament. Perform the drawer test by pulling out on the tibia to see how far the tibia slides anteriorly over the femur. Sensing a sharp stopping point of movement is normal. Noting greater than 2 mm of movement and/or a boggy stopping point suggests a tear. Rotational movement (where only 1 condyle moves) suggests tear of the corresponding collateral ligament.
Now check the drawer test with the patient prone. Lachman sign is basically a drawer sign with the posterior knee supported to relax the hamstrings.
Check the Galway-MacIntosh test. With the patient supine, passively flex the hip with the knee extended. Anterior movement of the tibia more than 2 mm suggests a tear. Confirm by applying valgus force to the leg while passively flexing the knee. A sharp reduction of the subluxation at 20°-40° flexion is a positive test.
Check the posterior cruciate ligament. Perform the drawer test to see how far the tibia slides posteriorly over the femur. A sharp stopping point of movement is normal. Greater than 2 mm of movement and/or a boggy stopping point suggests a tear. Rotational movement, where only 1 condyle moves, suggests a tear of the corresponding collateral ligament.
Check for posterior sag by supporting the distal femur with pillows and see whether the tibia is posteriorly displaced. With the patient supine and knee flexed at 90°, push posteriorly on the tibial plateau. Posterior movement suggests a tear.
Check for Godfrey's sign. With the patient supine, passively flex at the hip with the knee in full extension. Pull up on the distal foot to 90° with varus and external rotation. Posterior movement of the tibia suggests a tear.
Check the collateral ligaments. Check for joint laxity with lateral movement. The degree of laxity defines the extent of medial collateral ligament tear. Hold the knee and move the foot medially. The amount of pain and the degree of laxity define the extent of lateral collateral ligament tear.
Check for meniscal tear. See "Check for Meniscus Tear" under "Medial Knee Pain," above
Palpate the lateral knee. Tenderness suggests proximal fibular fracture.

Additional Knee Assessment Pearls

• A decrease in knee pain by forward flexion and lateral rotation of the foot suggests medial meniscus injury (Bragard's sign).
• Increased anterior-posterior movement of the tibia over the femur with a click or pain suggests damage to the anterior or posterior cruciate ligaments (drawer or Rocher's sign).
• With the patient sitting cross-legged, exert downward pressure along the medial aspect of the knee. Medial knee pain indicates a posterior horn lesion of the medial meniscus.
• Anesthesia in the popliteal fossa suggests neurosyphilis (Bekhterev's sign).

General Evaluation of Lower Extremity Circulation

Inspect the legs from the groin to the feet noting any asymmetry, skin changes, hair distribution, varicosities, or edema. Signs of vascular insufficiency include pallor, coolness, cyanosis, atrophy, loss of hair, pigmentation along the shin or ankles, or ulcers. Check the capillary refill by pinching the great toes and noting the time that it takes for the color of the nail beds to return to normal (should be less than 3 seconds).

Arteries in the Legs

Assessing the femoral artery. Palpate the right femoral artery pulse by placing the index and middle fingers of your left hand over the patient's right inguinal ligament about midway between the right anterior superior iliac spine and the right symphysis pubis. Feel the opposite side with your right hand at the left inguinal ligament appreciating both pulses. Inequality of the pulse suggests vascular disease.

Now check the radial and femoral pulses on the right side. The femoral pulse should be felt before the radial pulse; if it is not, suspect aortoiliac disease. Listen for a vascular bruit. If one is present, observe whether it increases when the patient flexes and extends the ankle rapidly. Then, compress the femoral artery high in the femoral triangle near the inguinal ligament in the anterior and medial thigh. If the bruit increases, consider occlusion of the profunda artery. If the bruit decreases, consider occlusion of the common femoral artery or the proximal femoral artery. If the patient has a femoral popliteal bypass graft, hearing the bruit decrease with compression suggests that occlusion of the graft is eminent.

Popliteal artery. With the patient supine, place both hands around the knee and feel in the popliteal space. Slowly lift the knee until it is about 90°. If you cannot detect a pulse, then stop at that point. Feel the skin temperature over the shin. Normally, you would detect a point of warmth at the upper portion of the anterior thigh. Coolness in this area suggests acute vascular insufficiency. Note, however, that in chronic popliteal disease, vascular collaterals may cause the involved knee to feel warmer rather than cooler.

Dorsalis pedis and posterior tibial arteries. The dorsalis pedis pulse is usually felt along the dorsum of the foot just lateral to the extensor tendon of the great toe. The posterior tibial pulse is usually just behind and slightly below the medial malleolus.

Deep Venous Obstruction

With the patient supine, check the veins over the tibial plateau. Dilated veins that do not collapse with leg elevation suggest deep venous obstruction (Pratt's sign). If the skin on 1 leg is warm and stiff to a pinch (secondary to edema), then deep venous thrombosis is also indicated (Rose's sign). Measure the difference in circumference between the normal and distended leg -- both thighs and calves. Greater than 2.5 cm difference between the calves and greater than 2 cm between the thighs suggest deep venous thrombosis. Deep venous thrombosis is also suggested by the following:

• Tenderness to percussion of the medial surface of the tibia (Lisker's sign);
• Cough-induced pain that disappears when the proximal vein is compressed (Louvel's sign); and
• Asymmetric tenderness to blood pressure cuff inflation at less than half the pressure of the opposite side (Löwenberg's sign).

Varicose Veins

Varicose veins with pulsations suggest tricuspid insufficiency. Hearing a murmur over the veins suggests tricuspid insufficiency. Dark purple discoloration of the skin with varicose veins suggests arteriovenous fistula.

Inspect the saphenous system for varicosities that will appear as large wormlike, tortuous vessels. Perform the manual compression test by having the patient stand and placing your right hand over the distal lower part of the varicose vein and your left hand over the proximal vein. Your hands will be about 15-20 cm apart. Compress the proximal portion of the varicose vein. If you feel a palpable pulsation in your distal hand, the test is positive.

Now perform Trendelenburg's test. Have the supine patient elevate the leg to 90° until the venous blood has drained from the great saphenous vein. Now place a tourniquet around the upper thigh of the patient's leg tightly enough to occlude the great saphenous vein but not the arterial pressure. Help the patient stand and look for venous filling. Slow filling (over 30 seconds) below the superficial veins while the tourniquet is applied is normal. Rapid filling of the superficial veins while the tourniquet is applied is abnormal, as is sudden additional filling of the superficial veins after the tourniquet has been released.

Additional Lower Extremity Circulation Pearls

• Aneurysms of the abdominal aorta are associated with distal peripheral aneurysm.
• Atherosclerosis, although a generalized metabolic disorder, tends to build up at bifurcations of major vessels. In the lower extremity, the superficial femoral artery becomes occluded at the adductor hiatus.
• Patients with diabetes tend to have femoral-tibial occlusions, whereas nondiabetic patients tend to have ileal-femoral occlusions.

Assessment of Other Lower Extremity Conditions in the Geriatric Patient

Leg Fracture

Palpate over the greater trochanter. Pain suggests fracture if other signs are present. (Otherwise consider trochanteric bursitis or possible referred pain from the knee.) Laxity on palpation of the fascia lata, which connects the greater trochanter to the iliac crest, suggests femoral neck fracture (Allis' sign). Swelling along the inguinal ligament in a femoral neck fracture is called Laugier's sign. A transverse crease superior to the patella suggests a femoral fracture (Cleemann's sign). Ecchymosis and swelling along the inguinal ligament and inability to raise the thigh when the patient is sitting suggest fracture of the greater trochanter (Ludloff's sign). Limitation in the normal range of motion in the circular arc of the hip suggests proximal femoral fracture (Desault's sign). Relaxation of the extensor muscles of the thigh with intrascapular femoral fracture is called Langoria's sign. Increased diameter of the leg at the level of the malleoli suggests fibular fracture (Keen's sign of Pott's fracture).

Ankle Injury

Check landmarks for anatomic abnormality.
Ecchymoses and/or swelling. Ecchymosis under both malleoli with a broad-appearing heel suggests a calcaneal fracture. Ecchymosis and focal swelling over the fifth metatarsal suggest fracture of the proximal fifth metatarsal bone (Jones fracture). Swelling and tenderness over the lateral malleolus suggest a lateral sprain if anterior and inferior and a peroneal retinaculum sprain if on the posterior rim. Swelling and tenderness over the medial malleolus suggest a medial sprain, syndesmotic sprain, or tibialis tendonitis if posterior to the medial malleolus.
The talar tilt test. The talar tilt test is used to examine the integrity of the calcaneofibular or the deltoid ligament. Passively invert the foot and compare it with the opposite side. A > 10° difference implies a second- or third-degree lateral ankle sprain. The talus will tilt if both the talofibular and calcaneofibular ligaments are ruptured, but not with only 1 ruptured ligament (talar tilt sign).
Check for anterior movement of the calcaneus over the distal tibia. A firm endpoint and 4 mm of movement or less suggest a first-degree lateral sprain. Sensing a boggy endpoint and > 4 mm movement suggest a second-degree lateral sprain. Greater than 4 mm of movement and no endpoint suggest a third-degree lateral sprain.
Squeeze the malleoli together. Increased pain produced by squeezing the malleoli together suggests a syndesmotic sprain.
Externally rotate foot at the ankle. Increased pain produced by externally rotating the foot at the ankle suggests syndesmotic sprain.

Sciatica

Acute radicular low back pain (sciatica) radiates or shoots down 1 leg. The discomfort is often characterized as sharp, tingling, shooting, or "electrical" and may be exacerbated by coughing, straining, sneezing, or Valsalva maneuvers. It may occur in several ways, depending on the nerve roots affected. The pattern of weakness (if present) in the lower extremity is an important clue to the site of the neurologic dysfunction. Significant unilateral thigh and leg weakness suggests involvement by multiple nerve roots or peripheral nerves, although most peripheral nerve processes are not usually associated with back pain.
To differentiate sciatica from a hamstring injury, have the patient flex the hip with the leg straight until it feels painful and then have the patient dorsiflex the foot. A hamstring pull will not be painful, whereas with sciatica the pain will increase (Bragard's leg sign).
Other signs of sciatica include the following:

• Pain on the contralateral side when the nonpainful side is flexed at the thigh and the leg is held in extension (Fajersztajn's sign);
• Loss of sensation on the lateral portion of the foot (Szabo's sign);
• Pain on straight leg raise that is relieved with leg flexion (Lasegue's sign);
• Pain on adduction of the thigh (Bonnet's sign);
• Pain in the buttocks when the great toe is hyperextended (Turyn's sign); and
• Pain in the lower back or down the leg when the patient is supine (Linder's sign).

Signs of Endocrine or Metabolic Disorders

Symptoms in the legs can often indicate endocrine or metabolic disorders. Check for the following:

• Cramping of the calves can be an early sign of diabetes mellitus (Unschuld's sign).
• Difficulty walking up stairs or rising from a chair secondary to proximal muscle weakness suggests hyperthyroidism (Plummer's sign).
• Leg weakness, pain on gently squeezing the calves, decreased knee-jerk reflexes, and anesthesia over the anterior thigh suggest Beriberi (Vedder's sign).
• Hypocalcemia can be suggested when thigh flexion produces knee spasm and calf spasm (Pool-Schlesinger sign). Eversion of the foot when tapping over the peroneal nerve also suggests hypocalcemia (peroneal sign). Note: This is the author's favorite method to determine hypocalcemia because it seems to be the first to appear and last to disappear.
• Tenderness to percussion over the tibia suggests chlorosis (Golonbov's sign).
• Exquisite pain of the great toe when touching the fifth toe joint suggests gout (Plotz's sign).
• Loss of hair on the posterior surface of the legs suggests gout (Tommasi's sign).

http://www.medscape.com/viewarticle/731813
regards, taniafdi ^_^