Procedure
- Ask the patient to expose the reference points of the pelvis (anterior superior iliac spine and poster superior iliac spine).
- Ask the patient to stand up straight and, from a distance of about 2 to 3 metres, inspect the ventral side, dorsal side and both lateral sides.
- Preferably, inspect in a cranial to caudal sequence.
- Palpate when necessary, to localise the position of a certain structure with greater accuracy.
- Assess the spontaneous posture (‘individual baseline position’) and ask the patient to stretch the knees and place the feet together.
- Assess the bony structures for shape and position (position and relative position of the separate bone structures and joints), comparing left and right during this process.
- The specific inspection follows when the patient is lying down.
Ventral Side
Stand in front of the patient and inspect the shape and position of the following structures [Figure 50].
Figure 50
Bones and Joints
- Pelvis (asymmetry): Determine by palpating reference points on both sides; iliac crest, anterior superior iliac spine [Figure 51].
- Legs: Tibias are normally exorotated, with respect to the femurs (rotation abnormalities of upper and lower leg based on the position of the patella).
- Q-angle [Figure 50].
- Knees: Genu valgum, genu varum; position of the patellas: patella alta = abnormally high patella.
- Feet: Pes planovalgus, pes cavus.
Figure 51
Soft Tissues
- Skin.
- Muscle contours of the quadriceps femoris muscle + adductors.
Dorsal Side
Ask the patient to make a 180° turn, or stand behind the patient and inspect the shape and position of the following structures on the posterior side [Figure 52].
Figure 52
Bones and Joints
- Pelvis: Palpate reference points on both sides; iliac crest, posterior superior iliac spine; palpate the latter at the height of the ‘dimples’ [Figure 53].
- Knees: Genu valgum, genu varum; knee fold height.
- Feet: Calcaneus: valgus/varus position.
Figure 53
Soft Tissue
- Skin: In particular, in the back of the knee (Baker’s cyst).
- Muscle contours of the hamstrings + triceps surae muscle.
Lateral Side
Ask the patient to make a 90° turn followed by a 180° turn, and assess the shape and position of the following structures [Figure 54].
Figure 54
Bones and Joints
- Lumbar vertebrae: Increased lordosis.
- Pelvis (forwards and backwards tilt): Palpate the anterior superior iliac spine and the posterior superior iliac spine on the side concerned. Normally, the pelvis may tilt forwards by about 10° in men and about 25° in women [Figures 55a, 55b].
- Lower extremities (genu recurvatum, flexion contracture in knee and hip joint): Greater trochanter, fibular head and lateral malleolus should lie along a single imaginary vertical line [Figures 55a, 55b].
Figure 55a
Figure 55b
Soft Tissue
- Skin (fluid accumulation, Baker’s cyst).
- Muscle contours of the tensor fascia latae muscle & iliotibial band.
Gait Pattern
Next, ask the patient to walk and note:
- Symmetry (torso rotation).
- Stride length.
- Load left and right leg.
- Flexion contractures of the knee.
Specific Inspection In Lying Position
Ask the patient to lie flat on the examination table in the supine position with extended knees and hips [Figure 56]. Assess if this is possible (Bonnet’s position, flexion contracture), and then assess the shape of the following structures:
Bones
- Contours of femoral condyles and epicondyles.
- Patella.
- Contours of tibial condyles.
- Tibial tuberosities.
- Head of the fibula.
Soft Tissue
- Skin (especially in the knee region).
- Muscle contours of the:
- Quadriceps femoris muscle (especially vastus medialis and vastus lateralis muscles as these atrophies first).
- Patellar ligament.
- Hoffa’s fat pad.
Figure 56