Assessing the Lower Extremities in the Geriatric Patient

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).

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