Assessing the Lower Extremities in the Geriatric Patient

Mark E. Williams, MD

Disclosures

November 08, 2010

In This Article

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).

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