Lower Limb Flashcards
Observation
- Scars –
Represent previous trauma or Lower limb surgery
Any Redness, colour change or any swelling or lumps and bumps that could interrupt the nervous system. - Symmetry of the Limbs
*Fasciculations - Twitching of the muscles, When the LMN is compromised this can take place
- Wasting of muscles –
Atrophy of the upper and lower aspects of the limb as well as the intrinsic muscles of the foot - LMNL
*Combination of atrophy and fasciculations could indicate denervation at the perioheral nerve or nerve root or something more significant like a motor neuron disease
- Involuntary movements / Fasciculations
Commonly seen in LMNL, Or a combination of atrophy and fasciculation’s which can indicate denervation of peripheral nerve, nerve root or could indicate a motor neurone disease. - Tremors
Such as resting tremors often first motor symptom of Parkinson’s
Hyperkinetic movements - These are excessive or involuntary movements that are often rapid and uncoordinated
Hypokinetic movements - These are reduced or slowed movements (parkinsons)
Gait
Gait – Normal walk, Tip toe walk S 1, Heel walk L5, Tandem walk (heel to toe)
Gait: Ask patient to walk to the end of room and walk back
Observing for any
* Discordination
* Assess stride length
* Slapping of the foot – May take place in a L5 radiculopathy
* Hyperkinetic disorders – such as abnormal involuntary movements
* Broad Based Gait – Where the person stands and walks with their feet spaced
widely apart often a sign of cerebellar ataxia
* Drop foot – Compression of peroneal nerve - L4/5 radiculopathy
* Bradykinesia – Slowness of movement and speed (Parkinsons)
* Sensory ataxia – Postural instability and lack of coordination
* Postural instability – Associated with Parkinson’s due to problem with
reticulopsinal tract
Palpation
Palpating entire limb from Hip to Toes
Assessing the muscles groups,
Assessing the Tone, any obvious signs of atrophy and increase in tone
Also feeling for any swelling, heat or pain could be signs of Inflammation
AROM/PROM
Passively checking for any resistance to passive movements Hip, Knee, Ankle
Through various speeds to check for any spasticity or rigidity
-Spasticity – Can indicate a pathology in the pyramidal system or contralateral cerebral hemisphere
-Rigidity- Can indicate extra pyramidal conditions such as basal ganglia involvement often seen in Parkinson’s
Coordination
Looking coordination of the lower leg and that requires cerebellar function and spinal cerebellar pathways
Heel to Shin:
o Ask the patient “I want you to put this ankle on the other knee”
o “Run it down your leg” & “Lift it off and go back to your knee and run it down your leg again a few times”
o Now do this with your eyes closed
o Observe for abnormality and asymmetry
o Indicative of cerebellar pathology e.g. Ipsilateral cerebellar function
o Check bilaterally
Toe to Finger
o Hold your finger above the patients toes.
o Ask the patient to hit your finger with their toe. do it at different speeds and angles
o Observing for discordinated movements and intention tremor.
Sensory testing
Gross touch - (Dermatome, Cutaneous pattern)
Soft and Sharp - Bony promininces
Soft touch – Assesses Dorsa column
Pinpprick – Asses Lateral spinothalamic tract
* Touch the patient´s sternum with the sharp and the soft “this is sharp, this is soft,
can you feel the difference?”
* Ask them to close their eyes and tell you when they feel sharp and when they feel
soft
* Test in a dermatome pattern
* If there is abnormality – Check cutaneous nerve pattern and compare with myotomes to see where the lesion is located.
-Temperature - Spinothalamic
-Vibration - 128Hz - Dorsal Column-Medial Lemniscus (DCML)
-Joint Position Sense - DCML
-Two Point Discrimination - DCML
-Graphesthesia/Steregnosis - DCML & Association Cortex
-Sensory Neglect Phenomenon - Parietal Lobe
Myotomes
Myotome testing
Myotomes; - Check “Tomes”
* L1/L2 – Hip flexion
* L3/L4 – Knee extension
* L5/S1 - Knee Flexion
* L4 – Dorsiflexion of the ankle
* L5 – Big toe extension
* S1/S2 – Plantar flexion of the ankle
Deep tendon reflex
L4
L5
S1
Hypoflexia or absent deep tendon reflexes are seen in lower motor neuron lesions
May be seen in disease states such as hypothyroidism, hypothermia, cerebellar dysfunction, or beta-blockade
Hyperflexia: Seen in UMNL, usually indicate an interruption of corticospinal and other descending pathwaysIt can happen due to certain neurological conditions, like amyotrophic lateral sclerosis (ALS) and multiple sclerosis (MS)
Pathological reflex
Primitive reflex should be present at birth and then become absent. I am not expecting a response in these tests
Babinskis (Most sensitive and concerning relfex, which could indicate pathology in the
corticospinal system) Big toe extends upwards and toes flare
Chaddocks - Big toe extension and digit flaring
Oppenheim’s
Gordons
Clonus
