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Lower Extremity Assessment

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Lab Guy, Jan 21, 2015.

  1. Lab Guy

    Lab Guy Well-Known Member

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    I decided to post this as I recently saw a very well known and respected Podiatrist for possible surgery for my hallux limitus. He literally never touched me, just told me what procedure he would do based on my radiographs. I think many Podiatrists should not only physically examine the anatomical region that brought the patient in but do a complete lower extremity assessment bilateral to ascertain if other tissues are being stressed from compensation.

    One of the valuable lessons I picked up early in my career was the lower extremity assessment. It involves palpating specific areas of the lower extremity on every new patient no matter what the chief complaint is. I found this very valuable so I
    would not overlook anything. In turn, the patient was always surprised when I discovered areas of tenderness that they did not even know existed. I would always mobilize the joints and strap their feet if I found tender areas and patients could not believe how much better they felt then when they arrived. I usually followed this up with orthotics and other forms of therapy.

    Additional tests are performed that are deemed appropriate to the practitioner. After a treatment program is initiated, the specific areas of the lower extremity that were tender to palpation can be reassessed during and at the conclusion of treatment to see if the areas have improved in terms of tenderness and if not, to determine the underlying cause.

    Tissue Stress Theory is gaining popularity and this assessment of the lower extremity in my opinion is a valuable way to identify as well as gauge the progess of the patient.

    Below is more detailed information on my lower extremity assessment that is updated by information I have learned in Kevin Kirby’s books and elsewhere. Let me know if you think this is a good idea, if your already doing something just like this, or if you think any changes should be made.



    The purpose of performing the lower extremity assessment (LEA) is to systematically and qualitatively identify areas of tenderness that may be indicative of tissues under greater than normal stress. Performing the LEA prevents the practitioner from missing a potential problem.

    For example, a patient may present with a chief complaint of a
    wart or ingrown nail but also have pes plano valgus but deny any symptoms. Yet, when the LEA is performed, other areas of the lower extremity may be found to be tender on direct palpation by the patient even though the patient was previously unaware of that.

    During weight bearing activities, compressive, tensile and bending forces can overload tissues beyond their zone of
    optimal stress due to mechanical imbalances causing excessive pronation or supination moments.
    By the time the patient experiences pain, the injured tissue has progressed and may require
    more extensive treatment. Performing the LEA, especially on new patients, helps to identify high stresses being exerted on tissues so appropriate treatment can be initiated earlier rather than later.


    Using the pulp of the fingertips, deep palpation is performed. You do not want to press so deep that the
    you will always cause pain and not so lightly that you never elicit a response. It does take practice
    to obtain the feel for tissue palpation. Palpate systematically along the following areas:

    Tensor fascia lata and iliotibial band

    Palpate along the course of the Iliotibial band.

    Iliotibial band problems can stem from excess pronation, rearfoot varus, lateral pelvic tilt (assisting weak hip abductors), genu varum, leg length discrepancy and overuse from stabilizing the knee.

    Medial knee

    Palpate over the pes anserius, the insertion of the conjoined tendon of the sartorius, gracilis and semitendionosis onto the anteromedial surface of the proximal tibia. Overuse can cause pes anserinus bursitis. Condition can coexist with other knee disorders.

    Medial tibial border

    Palpate along the course of the medial border of the tibia. If very painful, must consider stress fracture of the tibia.

    Increased tensile force and traction from the medial tibial muscles and fascia may contribute to the pain of medial tibial stress syndrome. PT, FDL and the soleus are the muscles that may contribute to traction of the tibia. Another possible etiology is excessive valgus bending of the tibia that cause excessive stresses in the area of the tibia with the narrowest cross-section. The greater the force is away from the midline axis of the tibia, the greater the bending and stress within the tibia.

    Sinus tarsi

    Palpate deep within the sinus tarsi.

    Sinus tarsi syndrome is common when the foot is maximally pronated and the STJ is at its end range of motion in the direction of pronation. Interosseous compression becomes greatly increased as the lateral process of the talus presses against the floor of the calcaneus. These increased forces can result in synovitis with infiltration of fibrotic tissue within the sinus tarsi. Excessive motion of the subtalar joint from ankle sprains can also result in subtalar joint synovitis and infiltration of fibrotic tissue into the sinus tarsi space.

    Plantar talo-navicular joint

    Palpate the plantar aspect of the talo-navicular joint to assess tenderness of the spring ligament and insertion of the Posterior Tibial tendon.

    Plantar calcaneal-cuboid joint

    Palpate plantar aspect of calcaneal cuboid joint and plantar cuboid.

    Pain on palpation can be from a number of causes including high lateral loads from favoring the foot as well as partially compensated and uncompensated rearfoot Varus. Injury and surgical plantar release of the plantar fascia is also known to
    cause subluxation of the cuboid.

    Dorsal calcaneal cuboid joint and 4th and 5th metatarsal cuboid joints and metatarsal cuneiform joints of the medial column

    Plantarflex the forefoot to increase tension on the dorsal ligaments and palpate the dorsal cuboid 4th and 5th metatarsal joints of the lateral column. Repeat the procedure for the metatarsal cuneiform joints of the medial column to test for excessive compressive forces.

    Dorsal midfoot interosseous compression syndrome is the result of excessive compression forces within the dorsal aspects of the joints of the midfoot due to decreased dorsiflexion stiffness of the forefoot on the rearfoot. In time, this can cause osteochondral lesions at the dorsal margins of the joints.

    Dorsal interspaces and dorsal neck/shafts of metatatarsals

    Palpate dorsal interspaces one through four. Rarely tender dorsal 1-2 and 4-5 interspace.

    If tender, rule out metatarsalgia, stress fracture and overuse of intrinsics.

    Plantar interspaces and plantar metatarsal phalangeal joints

    Palpate plantar interspaces 1 through 4.

    Rule out neuritis/neuroma, plantar plate pathology and lesser metatarsalgia.

    Note: Palpation of other anatomical areas should be performed based on the patient’s chief complaint (plantar heel, fasica, posterior heel, tarsal tunnel region, base of 5th met, patellar tendon, et).

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