What is the Stinchfield test and what does it assess?

The Stinchfield test involves passively flexing the hip and applying downward pressure, or having the patient resist hip flexion. It aims to irritate the femoroacetabular joint to pinpoint pain related to intra-articular issues versus muscle strains.

How can hip pain manifest as knee pain?

Hip pain can be referred to the knee due to shared nerve pathways, such as branches of the obturator nerve that innervate both joints. This can lead to misdiagnosis if only the knee is examined.

What is the Lachman exam for?

The Lachman exam is a sensitive test for assessing ACL integrity. It involves stabilizing the femur and applying anterior translation to the tibia, feeling for a firm endpoint which indicates an intact ACL.

What's the difference between shin splints and stress fractures?

Shin splints (medial tibial stress syndrome) typically cause diffuse tenderness over a larger area of the shin, while stress fractures present with very point tenderness over a specific spot on the bone.

How are ankle sprains assessed for lasting instability?

After an ankle sprain, ligaments can heal, but may become looser causing chronic instability and recurrent sprains. Strengthening the dynamic stabilizers (peroneal tendons) through physical therapy and balance training is crucial.

What is the Thompson squeeze test?

The Thompson squeeze test is used to evaluate the integrity of the Achilles tendon. Squeezing the calf muscle should normally cause the foot to plantarflex; a lack of this motion suggests a rupture.

Key Moments

Lower limb exams | Peter Attia & Adam Cohen

Peter Attia MD

Science & Technology4 min read54 min video

Jul 31, 2023|6,821 views|141|11

peter attia adam cohen lower limb exam exams longevity the drive

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Key Moments

TL;DR

A comprehensive guide to lower limb physical examinations, covering gait, standing, and specific joint assessments.

Key Insights

Lower limb examination begins with observing gait for symmetry, alignment, and dynamic abnormalities.

Standing assessments evaluate spinal alignment, balance, and hip abductor strength through single-leg stance.

Hip examination involves palpation, range of motion tests, and specific maneuvers to assess joint integrity and impingement.

Knee examination includes inspection, palpation, ligamentous stability tests (ACL, PCL, MCL, LCL), and meniscus assessment.

Foot and ankle evaluation covers arch assessment, tendon integrity (posterior tibialis, Achilles), ligamentous stability, and range of motion.

Referred pain, particularly from the hip to the knee, is a crucial diagnostic consideration.

INITIAL GAIT ANALYSIS

The initial phase of a lower limb examination involves observing the patient's gait as they walk. This allows for an assessment of symmetry in the coronal and sagittal planes, evaluating arm swing, trunk lean, and weight shift. Specific attention is paid to any lurching, which can indicate hip abductor weakness, and knee alignment for varus or valgus deformities. Foot progression angle and pronation/supination are also noted. Functional gait modifications, like walking on heels or toes, and altered stride length or toe-out/in, can elicit pain and provide neurological insights.

DYNAMIC FUNCTIONAL AND STATIC ASSESSMENTS

Following gait observation, dynamic functional tests are performed, including two-legged and single-legged squats, which reveal compensatory movements and muscle engagement. Standing assessments focus on spinal alignment, checking shoulder height and iliac crest symmetry, and evaluating spinal mobility through flexion, extension, and rotation. Calcaneal alignment and arch formation are assessed when rising onto toes. Single-leg stance tests evaluate balance and hip abductor strength, with pelvic tilt indicating potential weakness or injury to the gluteus medius.

HIP JOINT EVALUATION

The hip examination begins with inspection for asymmetry and atrophy, followed by a log roll to assess range of motion and compare sides. Flexibility of the hamstrings is checked, and the Stinchfield test is performed to evaluate for acetabular or hip flexor irritation. Palpation of the anterior groin assesses for muscle strains. Hip adduction and abduction strength are tested, with palpation of the greater trochanter and gluteal muscles to identify point tenderness, which can indicate bursitis or tendon tears. Range of motion, including circumduction, internal, and external rotation, is assessed gently.

SPECIFIC HIP TESTS AND FLEXIBILITY ASSESSMENT

More specific hip tests include the FABER (flexion, abduction, external rotation) and scour tests, which assess for impingement, labral tears, and intra-articular pathology by rotating the femoral head within the acetabulum. The FADIR (flexion, adduction, internal rotation) test specifically checks for femoroacetabular impingement. Flexibility is further assessed using the modified Thomas test to evaluate hip flexor tightness (iliopsoas) and the iliotibial band. These dynamic movements and flexibility tests help pinpoint potential sources of pain and dysfunction in the hip region.

KNEE JOINT EXAMINATION AND STABILITY TESTING

The knee exam starts with inspection for swelling, warmth, scars, or muscle atrophy, particularly the quadriceps and VMO. Palpation covers the patellar tendon, tibial tuberosity, and the medial and lateral joint lines, checking for tenderness indicative of meniscal tears or arthritis. Ligamentous integrity is crucial; the ACL is assessed via anterior drawer and Lachman tests, feeling for the endpoint. PCL integrity is evaluated with the posterior sag sign. Collateral ligaments (MCL and LCL) are tested with valgus and varus stress, respectively, in extension and slight flexion.

MENISCUS, PATELLA, AND REFERRED PAIN CONSIDERATIONS

Meniscal tears are often suspected with joint line tenderness and provocative tests like the McMurray maneuver, which aims to elicit a click or pain. Patellar stability and apprehension are assessed by attempting to translate the kneecap. An important consideration is referred pain, particularly from the hip to the knee, which can mimic knee pathology and lead to misdiagnosis or unnecessary surgery if not identified through thorough hip and knee evaluations. The concept of the "unhappy triad" (ACL, MCL, medial meniscus) is also discussed, though variations exist in common injuries.

FOOT AND ANKLE ASSESSMENT

The foot and ankle examination includes assessing the posterior aspect for tenderness around the toe flexor tendons and palpating the deltoid ligament medially. The posterior tibialis tendon is evaluated for pain and swelling, crucial for foot inversion and arch support. The top of the foot is examined for arthritis of the first metatarsophalangeal joint, bunions, and stress fractures of the navicular or metatarsals. Examination of the lesser toes checks for neuromas. The tibialis anterior tendon is palpated for tenderness and crepitus, which can indicate significant inflammation.

ANKLE STABILITY AND CALF EVALUATION

Ankle ligamentous stability is assessed, particularly the lateral ligaments (ATFL, CFL, PTFL) which are commonly injured in sprains, leading to potential chronic instability. The integrity of the distal tibiofibular syndesmosis is also checked. Calf tightness is evaluated by assessing dorsiflexion with the knee flexed (soleus) and extended (gastrocnemius). The Achilles tendon is examined for rupture, using the Thompson squeeze test, and its contour is inspected. Tenderness at the musculotendinous junction ("tennis leg") is also noted.

DEVELOPMENTAL AND BIOMECHANICAL FACTORS

The examination considers developmental factors, such as high arches possibly correlating with laxity and an increased risk of ankle sprains. Conditions like tarsal coalition and Sharsman's disease are mentioned in relation to foot mechanics. The "windlass mechanism" of the foot, important for propulsion during gait, is discussed in context of arch functionality. Ankle sprains can lead to lasting laxity and instability, emphasizing the importance of strengthening dynamic stabilizers like the peroneal tendons through physical therapy and balance training.

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Lower Limb Examination Cheat Sheet

Practical takeaways from this episode

Do This

Observe gait for symmetry, arm swing, trunk lean, and weight shift.

Assess for genu varus/valgus (bow-legged/knock-kneed) deformities.

Check foot pronation/supination and foot progression angle.

Evaluate single-leg stance for pelvic tilt and balance.

Perform dynamic squats, observing body mechanics and compensatory movements.

Assess range of motion and palpate for tenderness in hip, knee, and ankle joints.

Test ligamentous integrity (ACL, PCL, MCL, LCL) and meniscal function.

Differentiate between shin splints and stress fractures through point tenderness.

Examine foot structures, including arches, metatarsals, and toes.

Assess calf muscle tightness and Achilles tendon integrity.

Avoid This

Do not assume knee pain originates solely from the knee; consider referred hip pain.

Do not rely on a single test; use a combination of exams to confirm diagnoses.

Do not ignore point tenderness in the shin, as it could indicate a stress fracture.

Do not focus solely on acute injuries; consider chronic issues and prior surgeries.

Do not underestimate the importance of palpating specific anatomical landmarks.

Do not skip a thorough examination of the hip when evaluating knee pain.

ACL Translation Measurement

Data extracted from this episode

Condition	Translation (mm)	Notes
Normal Range	5-7	Measured with KT-1000 arthrometer
Partial ACL Tear	0-3	Can also indicate other supporting structures
Complete ACL Rupture	3+	Can be >10-15mm in acute ruptures

Common Questions

During a gait analysis, patients are asked to walk normally, on their heels, and on their toes to assess alignment, arm swing, trunk stability, and neurological function. Pain response to altered strides or speed is also noted.