CLIN SKILLS: PNS Lower Limb Exam

Question 1

general process for PNS lower limb exam

Answer 1

• introduction
• inspection
• motor
• sensory
• HAND HYGIENE

Question 2

inspection for lower limb PNS

Answer 2

• general appearance: posture
• gait
• muscle bulk/wasting of quads, hamstrings, calves
• abnormal movements
• skin
• rise from squat or chair to test proximal muscle strength
• trendelenburg test
• pull (beam test)
• romberg’s test

Question 3

how to check gait in lower limb PNS inspection

Answer 3

• walk a few metres, heel to toe
• alk on tiptoes (S1 nerve root) and on heels (L4/L5 nerve root)
• see if it’s stiff or floppy, regular or irregular, broad or narrow
• check if there is proximal muscle weakness (trendelenburg gait)

Question 4

abnormal movements to check for in lower limb PNS inspection

Answer 4

• fasciculation - random quick muscle twitches (flick quads/calf muscles)
• tremor
• dystonia - slow twisting movements
• chorea - slow dancing movements
• hemiballismus - limb jerks rapidly

Question 5

Pull (beam) test

Answer 5

• stand behind Pt, put hands on shoulders and pull back sharply
• Warn Pt first and be prepared to catch them (Parkinson’s)

Question 6

Romberg’s test

Answer 6

• Stand w/ feet together, eyes open then eyes closed.
• Watch to see if they sway = proprioceptive defect

Question 7

motor examination for PNS lower limb

Answer 7

• tone
• clonus
• power
• reflexes
• coordination

Question 8

how to check for tone in PNS lower limb

Answer 8

• checked @ knee and ankles, similar to handshake position in hands
• flex and extend knee and ankle quickly (to test for spasticity) and slowly (to test for basal ganglia abnormalities)

Question 9

what is clonus and how do we check for it?

Answer 9

• sustained rhythmical contraction of muscles while stretched (UMNL)
• ankle: bend knee, externally rotate hip, sharply dorsiflex foot.
• knee: extend knee, hold patella b/n thumb and index finger, move patella sharply downward

Question 10

how to check for power - lower limb PNS

Answer 10

• resisted movements (rate from 0-5, 5 is normal)
• Hip: flexion, extension, abduction, adduction
• Knee: Flexion, extension
• Ankle: dorsiflexion, plantar flexion, inversion, eversion

Question 11

which reflexes to check for - lower limb PNS

Answer 11

• knee: Pt sitting w/ legs freely dangling > hit patellar tendon
• ankle: Pt lying supine, knee extended, dorsiflex foot. Place fingers on plantar side of foot and strike w/ tendon hammer > plantar flexion
• plantar (babinski): hold ankle, stroke lateral plantar surface from heel to toe using the tip of tendon hammer (normal = plantar flexion of all toes)

Question 12

how to test for coordination (PNS lower limb)

Answer 12

• heel-shin test (cerebellar lesions): run heel down opposite shin as accurately as possible (+ve test = heel moves in a zig-zag fashion w/ tremor)
• toe-finger test (cerebellar lesions): get Pt to lift foot and touch your finger w/ big toe (tremor = +ve)
• foot tapping test (dysdiadochokinesia - Parkinson’s): ask Pt to dorsiflex foot to touch your hand repeatedly as quickly as possible

Question 13

coordination for PNS lower limb

Answer 13

• light touch: let them feel wisp of cotton wool on sternum first, then they tell u when they feel it on each dermatome - ask if it feels the same on both sides
• temperature: let them feel cold tuning fork on sternum first, then they tell u when they feel it on each dermatome - ask if it feels the same on both sides
• vibration: let them feel vibrating and still tuning fork on sternum first, then they tell u when they feel it vibrating and stopped on distal phalanx - if they can’t feel it move proximally (ankles, knees, ASIS)
• proprioception - they tell u whether u moved their distal phalanx of big toe up/down - hold toe from sides (if abnormal, move proximal)
• pain
• two-point discrimination

Question 14

dermatome for patella

Answer 14

L3/4

Question 15

what is tandem walking and what does it assess?

Answer 15

• one foot directly in front of the other like a tightrope
• cerebellar function

Question 16

what does avoiding heel strikes indicate?

Answer 16

• pes cavus (high medial arch)

Question 17

Sx for UMNL vs LMNL

Answer 17

• upper: hypertonia - spasticity (pyramidal), rigidity (extrapyramidal), hyperreflexia (inc. positive babinski reflex), clonus
• lower: hypotonia, hyporeflexia, muscle atrophy

Question 18

2 point discrimination for plantar surface

Answer 18

3 cm