The examination of the lower limbs requires the examiner to ask that the patients shoes and socks are removed and the limbs are exposed. Again, a gown or towel can be draped over the perineum for modesty.
Inspection of the limbs will reveal rashes associated with vasculitis and signs of arterial or venous insufficiency. Arterial insufficiency may be associated with a lack of hair on the limb that also appears to have thin shiny skin and occasionally a coolness to touch. Venous insufficiency is best assessed in the lying and standing positions to note varicosities, as well as the brawny induration associated with inspissated blood cells breaking down in the skin to release hemosiderin. Tendon xanthomata are characteristically present over the Achilles tendon and may be better appreciated by palpation.
The pulses are graded in a semi-quantitative manner (increased, normal, reduced, absent). The femoral pulses lie just below the inguinal ligament and are palpated and then auscultated for bruits. The pedal pulses are the dorsalis pedis (anterior aspect of the foot between the large toe and second toe in the mid foot) and the posterior tibial artery (posterior to the tibia at the malleolus). The popliteal pulse is palpated with the knee gently flexed at 90° with both palms on the anterior shin and the fingers grasping around the leg between the gastrocnemius heads. The popliteal pulse is often difficult to palpate and is often felt more as an expanding sensation in the hands than a pulse at the fingers tips.
Oedema is assessed by gentle but continuous pressure over a bone for several seconds. Pitting oedema is seen in heart failure, although this may become non-pitting with fibrotic changes in the lymphatics over time.
The feet should be inspected for ulcers. Ulcers in patients with diabetes or atherosclerosis affecting the peripheral arteries or due to venous insufficiency constitute an important cause of morbidity.