Legs, Feet, and Related Joints

Assessment of the legs and feet progresses from the upper leg to the toes; related joints include the hips, knees, ankles, and toes. This assessment involves inspection, palpation, range of motion, and muscle testing. Most of it is completed with the client in a supine position with their head on the pillow and their arms relaxed at their side.

Use a trauma-informed approach: tell the client you need to inspect their legs, including their hips, and provide them with a drape. Only expose the areas that you are assessing, particularly the hips, because clients may feel a sense of discomfort exposing this area.

Inspection

Steps for inspecting the legs and feet:

1. Inspect for colour, swelling, masses, and deformities with a focus on the muscles, bones, and joints. This involves inspecting from the hips/upper leg to the toes on the anterior, lateral, and posterior sides of the legs. To inspect the posterior side, you can either ask the client to lift their leg into the air or to reposition on their lateral side. Then, you should expose the full area of the hip ensuring the client is draped. Inspect all of the joints (hip, knee, ankles, and toes). 
   • Normally, there will be no discolouration, swelling, masses, or deformities.
   • Describe the appearance and location of any discolouration, swelling, masses, and deformities.
2. Inspect for symmetry in terms of leg size and length. This can be done by just looking at the legs: compare the thigh size and the calf size from one limb to the other and from the hips to the feet. You can evaluate with a tape measure for accuracy if upon inspection you notice a potential discrepancy, or the client has indicated a concern. For circumference, measure at the largest point around the thigh and the calf. For leg length, place the tape measure at the anterior-superior point of the iliac crest to the inferior point of the bony prominence of the medial malleolus and repeat again. Some begin at the umbilicus as opposed to the iliac crest. Because many factors can affect accuracy, it is best to measure twice and take an average of the two measurements (Applebaum et al., 2021). 
   • The legs are usually of equal length and circumference. 
   • Describe any asymmetry that is greater than 10 mm (1 cm).
3. Note the findings:
   • Normal findings might be documented as: “Thigh and calf circumference and leg length are equal bilaterally. No discolouration, swelling, masses, and deformities noted on hips, legs, knees, ankles, or toes.”
   • Abnormal findings might be documented as: “Swelling and purple-blue discolouration over lateral side of left knee. No deformities noted. Client reported they were ‘side tackled’ during rugby.”

Palpation

Steps for palpating the legs and feet:

1. Palpate for temperature from the hips/upper legs to the toes bilaterally. Palpate around each of the joints as you move down the client’s legs.
   • Temperature is normally warm to touch and equal bilaterally. Temperature may get slightly cooler toward the feet.
   • Abnormal findings include increased temperature over a joint and sometimes a muscle. Describe the characteristics and the location.
2. Palpate for pain, masses, swelling, deformities, and palpable fluid from hips to toes. Palpate the whole leg and foot including the full joint. If the client reports pain prior to assessment, assess that area last.
   • Normally, there will be no pain, masses, swelling deformities or palpable fluid.
   • If present, describe the characteristics and the location.
3. Note the findings:
   • Normal findings might be documented as: “Client’s hips, legs, knees, ankles, and toes are warm to touch and cooler at toes, equal bilaterally with no swelling, masses, deformities, pain, or palpable fluid noted.”
   • Abnormal findings might be documented as: “Client’s left ankle to toes are cool to touch in comparison to right ankle. Swelling around the base of the ankle. Client reported discomfort as a 4/10 upon palpation. Client reported ‘twisting ankle’ stepping off a ladder.”

Range of Motion

ROM of the legs and feet is focused on the hips, knees, ankles, and toes (see Table 7 for normal ranges). While performing this assessment, observe the ROM and also listen for crepitus and ask the client about the presence of pain. Start with the unaffected leg first, and then move to the affected leg for comparisons.

The assessment begins with the client in a supine position with the legs straight – this is considered: neutral position. All assessments are completed in supine position except hip extension.

Steps for assessing ROM of the legs and feet:

1. To perform hip flexion with straight leg and hip flexion with knee flexion, ask the client to lie with their hips/pelvis still. Ask the client to lift one leg up (with leg straight) while bending it at the hip and moving it as close to the upper body as they can, then return to a neutral position (this is hip flexion with straight leg). Next, ask the client to lift the leg up as high as they can while bending it at the hip and the knee (hip flexion with knee flexion). Perform on the other leg.
2. To perform hip extension, ask the client to stand and move one straight leg back while keeping their body facing forward and upright. This is normally done at the end of the exam when the client stands up for you to assess their spine. If the client cannot stand, you may assess in the prone position. NOTE: this ROM can be performed toward the end of the assessment when asking the client to stand to assess the spine.
3. To perform hip abduction and adduction, ask the client to lie in a neutral position. For hip abduction, ask the client to move their leg out (keeping leg straight) toward the side (moving off the bed) and back to neutral. Repeat on the opposite leg. Next, for hip adduction, place one hand proximal to the ankle and one proximal to the knee on the underside of the leg and lift the client’s legs up enough so that the client can slide their other leg underneath. Next, ask the client to slide the opposite leg underneath the leg that you are holding up. Return to a neutral position and repeat on the opposite leg.
4. To perform hip internal rotation (also called medial rotation) and external rotation (also called lateral rotation), first ensure the client does not engage the spine with any sort of spinal rotation. For hip internal rotation, ask the client to bend one leg up at the knee, keeping their foot flat on the table with the knee pointing to the ceiling, then tip their knee inward (medially) and keeping their heel fixed to the table and their hips still (flat on table). Then, return the leg so that the knee is pointing to the ceiling. For external rotation, ask the client to tip their knee outward (laterally) while keeping the heel fixed to the surface and keeping their hips still (flat on table). Then, return to the leg to a neutral position with both legs straight. Repeat on the opposite leg. Note, both of these ROM can also be done in sitting position, which is commonly seen in practice.
5. To perform knee flexion and extension, ask the client to bend their leg at the knee by sliding their foot/heel toward their buttocks (knee flexion), and then back to a neutral position (extension). Repeat on the opposite leg.
6. To perform dorsiflexion and plantar flexion, ask the client to point and move their toes on both feet toward their shin or head (dorsiflexion), and then back to a neutral position. Next, ask the client to point and move their toes away from the body with the soles of the feet facing down (plantar flexion), and then return to a neutral position.
7. To perform ankle inversion and eversion, place one hand on the client’s lower leg to stabilize their tibia and ask the client to tilt/move the sole/bottom of the feet inward (medially) facing each other (inversion), and then back to a neutral position. Next, for ankle eversion, ask the client to move the sole/bottom of the feet outward (away from each other), and then return to a neutral position.
8. To perform toe flexion and extension, ask the client to curl their toes toward the bottom of the foot, and then ask the client to uncurl their toes and point the tips of their toes up as much as possible, and then back to a neutral position.
9. Note the findings:

• • Normal findings might be documented as: “Full range of motion, no crepitation, and pain of hip, knees, ankles, and toes bilaterally, smooth and symmetrical movements of joints with no obvious misalignments.”
  • Abnormal findings might be documented as: “Right knee flexion is 110 degrees and extension 10 degrees, no crepitation. Reported muscle tightness on movement.”

NOTE: See Video 15 for ROM of hips, Video 16 for ROM of the knees, Video 17 for ROM of the ankles, and Video 18 for ROM of the toes.

Video 16: ROM of the hips [1:59]

Video 17: ROM of the knees [0:29]

Video 18: ROM of the ankles [0:37]

Video 19: ROM of toes [0:21]

Table 7: Normal ROM of hips, knees, ankles, and toes (adapted from American Academy of Orthopaedic Surgeons, 1965; Luttgens & Hamilton, 1997)

Manual Muscle Testing (MMT)

Perform  MMT after you assess ROM. Explain the procedure before applying force. Perform MMT on each joint bilaterally. Grade the resistance according to the institution’s grading scale (e.g., MRC) or just describe it and note whether it is equal bilaterally.

This testing generally begins with the client in a supine position with the legs straight (neutral position).

Steps for MMT:

1. To perform hip flexion with straight leg, place one hand proximal to the ankle and the other proximal to the knee. Ask the client to bend/flex their leg at the hip as if they were going to lift their leg up (keeping leg straight) while you apply force and they resist it. Return to a neutral position and then repeat the procedure on the opposite side.
2. To perform hip extension, ask the client to raise their  straight leg up (hip flexion with leg straight), place one hand proximal to the ankle and the other proximal to the knee (both on the underside of the leg), and then ask the client to move their leg back down to the table while you apply force and they resist it. Return to a neutral position and repeat on the opposite leg.
3. To perform hip abduction and adduction, place one hand proximal to the knee and the other proximal to the ankle on the lateral side of the leg. Ask the client to move their leg out toward the side (moving off the bed) while you apply force and they resist it. Return to a neutral position and repeat on the opposite leg. Next, ask the client to move their leg out/abduct toward the edge of the bed (about 15 degrees). Place one hand proximal to the knee and the other proximal to the ankle on the medial side of leg. Ask the client to move their leg in toward the centre (moving their leg toward the other leg) while you apply force and they resist it.
4. To perform knee extension and flexion, ask the client to bend their leg/knee keeping their foot flat on the table (about 90 degrees) with the other leg remaining straight in neutral position. Place one hand proximal to the knee for support and the other proximal to the ankle so that you can apply force. Ask the client to extend their leg by moving their foot off the bed (like a kicking action) while you apply force and they resist it. Return to the 90-degree position with the foot flat on the table. Next, for flexion, place one hand proximal to the knee for support and the other proximal to the ankle to apply force on the posterior side of the leg. Ask the client to move their foot off the table so that their lower leg is parallel to the table and knee at about 90 degrees, and then bend their knee and bring the heel of their foot back down to the table while you apply force and they resist it. Repeat on the opposite leg.
5. To perform ankle dorsiflexion and plantarflexion, place your hand on the top (dorsal) side of one foot. Ask the client to point and move their toes toward their shin or head while you apply force and they resist it. Repeat on the other foot. For plantar flexion, place your hand on the bottom (plantar) side of the foot. Ask the client to point and move their toes away from the body, with the sole of the foot facing down, while you apply force and they resist it. Repeat on the other foot.
6. Note the findings:

• • Normal findings might be documented as: ““full resistance equal bilaterally on all lower limb ROM with no pain.”
  • Abnormal findings might be documented as: “partial resistance with left hip ROM with mild pain.”

NOTE: see Video 20 for MMT of hips, Video 21 for MMT of knees, Video 22 for MMT of ankles.

Video 20: MMT of hips [3:08] 

Video 21: MMT of knees [1:47]

Video 22: MMT of ankles [1:11]

Activity: Check Your Understanding

References

Applebaum, A., Nessim, A., & Cho, W. (2021). Overview and spinal implications of leg length discrepancy: Narrative review. Clinics in Orthopedic Surgery, 13(2), 127-134. https://doi.org/10.4055/cios20224

American Academy of Orthopaedic Surgeons. Joint Motion: Method of Measuring and Recording. Chicago: AAOS; 1965.

Burton, & Melkumova-Reynolds, J. (2019). “My Leg is a Giant Stiletto Heel”: Fashioning the Prosthetised Body. Fashion Theory, 23(2), 195–218. https://doi.org/10.1080/1362704X.2019.1567061

Franzino, J. (2020). “Harmonies of form and color”: Race and the prosthetic body in civil war America. Literature and Medicine, 38(1), 51–87. https://doi.org/10.1353/lm.2020.0003

Hussain. (2011). Toes That Look Like Toes: Cambodian Children’s Perspectives on Prosthetic Legs. Qualitative Health Research, 21(10), 1427–1440. https://doi.org/10.1177/1049732311411058

Luttgens, K. & Hamilton, N. (1997). Kinesiology: Scientific Basis of Human Motion, 9th Ed., Madison, WI: Brown & Benchmark