Procedure
- Ask the patient to undress, leaving underwear on.
- Ask the patient to stand upright and inspect the ventral side, the dorsal side and then both lateral sides from a distance of about 2 to 3 metres.
- You should inspect in a cranial to caudal sequence.
- If necessary, palpate to accurately locate the position of a certain structure.
- Assess the spontaneous posture first (individual baseline posture) and ask the patient to extend the knees and to place the feet next to each other.
- Assess all bony structures for shape and position (position of the separate bony structures and joints, and their position in relation to each other), comparing left and right.
Ventral Side
Stand in front of the patient and inspect the shape and position of the following structures [Figure 4].
Figure 4
Bones and Joints
- Torso and arms.
- Pelvis (tilt: palpate the reference points on both sides: iliac crest, anterior superior iliac spine) [Figure 5].
- Legs: The femur should normally be endorotated with respect to the tibia (rotation abnormalities of upper and lower leg).
- Knees: Genu valgum (knock knees), genu varum (bow legs); position of the patella.
- Feet: Pes planovalgus (flat feet), pes cavus (high arch foot).
Figure 5
Soft Tissue
- Skin.
- Muscle contours of the:
- Quadriceps femoris muscle.
- Adductors.
Dorsal Side
Ask the patient to turn around 180° or stand behind the patient and inspect the shape and (relative) position of the following structures on the posterior side [Figure 6].
Figure 6
Bones and Joints
- Spinal column (spinous process; if necessary this can be superficially palpated).
- Torso and arms.
- Pelvis (tilt: palpate the reference points on both sides: iliac crest, posterior superior iliac spine; palpate this at the height of the ‘dimples’) [Figure 7].
- Knees (genu valgum, genu varum: knee fold height).
- Feet (calcaneus).
Figure 7
Soft Tissue
- Skin (especially the position of the gluteal fold).
- Muscle contours of the:
- Erector spinae muscle (especially lumbar), multifidus muscle.
- Gluteus maximus muscle (contours of buttocks).
- Hamstrings.
- Triceps surae muscle.
Lateral Side
Have the patient turn around 90° and subsequently 180° and assess the shape and position of the following structures [Figure 8].
Figure 8
Bones and Joints
- Lumbar spine (excessive lordosis).
- Pelvis (forwards and backwards tilt: palpate the anterior superior iliac spine and the posterior superior iliac spine on the side concerned; in a normal situation the pelvis may tilt forwards by about 10° in men and 25° in women) [Figures 9a and 9b].
- Lower extremities (genu recurvatum, flexion contracture in knee and hip joint; greater trochanter, head of fibula and lateral malleolus should effectively lie on a single imaginary vertical line) [Figures 9a and 9b].
Figure 9a
Side View Skeleton
A. Imaginary horizontal line originating from the posterior superior iliac spine.
B. Imaginary connecting line between posterior superior iliac spine and anterior superior iliac spine. The angle formed by these two imaginary lines is the measure for the pelvic tilt.
C. Imaginary vertical line between greater trochanter, head of fibula and lateral malleus.
Figure 9b
Soft Tissues
- Skin.
- Muscle contours of the:
- Tensor fascia latae muscle and iliotibial band.
- Gluteus maximus muscles (contours of buttocks).
Gait Pattern
Ask the patient to walk and carefully observe the following:
- Symmetry/asymmetry (torso rotation, Duchenne sign, Trendelenburg sign).
- Stride length.
- Load on left and right leg.
- Occurrence of a ‘snapping hip.’