Lower Limb Flashcards
Inspection UMN vs LMN signs
UMN= No fasciculation or significant wasting (there may however be some disuse atrophy or contractures)
LMN = Wasting and fasciculation of muscles
Tone UMN vs LMN signs
UMN = Increased (spasticity or rigidity) +/- ankle clonus
LMN = Decreased (hypotonia) or normal
Power UMN vs LMN signs
UMN = Classically a “pyramidal” pattern of weakness (extensors weaker than flexors in arms, and vice versa in legs)
LMN = Different patterns of weakness, depending on the cause (e.g. classically a proximal weakness in muscle disease, a distal weakness in peripheral neuropathy)
Reflexes UMN vs LMN signs
UMN= Exaggerated or brisk (hyperreflexia)
LMN = Reduced or absent (hyporeflexia or areflexia)
Plantar reflexes UMN vs LMN signs
UMN = Upgoing/extensor (Babinski positive)
LMN = Normal (downgoing/flexor) or mute (i.e. no movement)
Equipment required
Tendon hammer
Neurotip
Cotton wool
Tuning fork (128Hz)
General inspection
5 key signs
SWIFT s = scars w = wasting of muscles i = involuntary movements f = fasciculation t = tremor
MRC grading of motor power
• 5/5 = movement against gravity with full power against resistance
• 4/5 = movement against gravity with reduced power against resistance. Grades 4-, 4 and
4+ indicate reduced power but the presence of movement against slight, moderate and
strong resistance respectively.
• 3/5 = movement against gravity only without applied resistance
• 2/5 = muscle contraction with active movement only when gravity is eliminated
• 1/5 = flicker of muscle contraction seen, no movement
• 0/5 =no muscle contraction
Romberg’s Test
The patient stands with feet together, arms outstretched in front of them and hands supinated.
If they cannot do this with the eyes open, it suggests a cerebellar lesion.
If the patient can maintain the position with the eyes open but loses balance when the eyes
are closed, this suggests loss of proprioception.
What to test?
Tone Power (against resistance) Reflexes Co-ordination Sensation
Tone
Passively move each joint Is there normal, even resistance? Hypertonia (spasticity or rigidity?) Hypotonia Check for ankle clonus (UMN lesion)
Power
Against resistance. Use MRC grading system. Hip: abduction, adduction, flexion and extension Knee: flexion and extension Ankle: dorsiflexion, plantarflexion, Big toe: plantarflexion and dorsiflexion
Reflexes
Knee Ankle Use reinforcement if needed (clench fingers) Plantar reflex (Babinski response) Ankle Clonus
Co-ordination
Heel-shin test
Sensation
Soft touch Pain / pinprick (OSCE: describe only) Temperature (OSCE: describe only) Proprioception Vibration (128Hz tuning fork) Check the trunk for the sensory level if indicated.
