Lower Limb Flashcards
What should you look for on inspection of the lower limb?
Scars Wasting Involuntary movements Fasciculations Tremor
List 4 types of involuntary movement that may be seen on inspection of the lower limb
Pseudoathetosis: writing movements due to failure of proprioception
Chorea: semi-directed, irregular movements (Huntington’s)
Myoclonus: brief, irregular twitching of muscle/ group
Tardive dyskinesia: repetitive e.g. protrusion of tongue, lip-smacking
List 3 facial signs that may be seen on inspection of the lower limb
Hypomimia: reduced facial exp. (Huntington’s)
Ptosis + frontal balding (Myotonic dystrophy)
Opthamoplegia: weakness of >,1 extra ocular muscle (MS)
List 5 features of gait that should be assessed
Stance Stability Arm swing Steps Turning
What is ataxic gait? Give 2 underlying pathologies causing ataxic gait
Broad-based + unsteady Cerebellar pathology (e.g. Lesion in MS, Degeneration of cerebellar vermis secondary to chronic alcohol excess) Sensory ataxia (e.g. vestibular or proprioceptive dysfunction)
Who may find turning difficult?
Patients with cerebellar disease
What does heel to toe walking exacerbate?
Underlying unsteadiness
Makes it easier to identify more subtle ataxia.
Give 3 causes of difficulty in heel to toe walking
Dysfunction of thecerebellarvermis(e.g. alcohol-induced cerebellar degeneration).
Weakness of the flexors muscles of the leg
Sensory ataxia.
How does proprioceptive sensory ataxia differ to cerebellar ataxia?
Proprioceptive: Pts watch their feet intently to compensate for proprioceptive loss.
Cerebellar: pt may veer to the side of the lesion.
List 6 features of a parkinsonian gait
Small, shuffling steps
Stooped posture
Reduced arm swing (initially unilateral).
Requires several small steps to turn around.
Gait appears rushed (festinating) + may get stuck (freeze).
Hand tremor may also be noticeable.
List 3 features of High stepping gait
Unilateral or bilateral
Typically caused by foot drop (weakness of ankle dorsiflexion).
Patient also won’t be able to walk on their heel(s).
What is Waddling gait? What is it commonly caused by?
Shoulders sway from side to side, legs lifted off ground with the aid of tilting the trunk.
Proximal lower limb weakness (e.g. myopathy).
What is Hemiparetic gait? What is it associated with?
one leg held stiffly + swings round in an arc with each stride (circumduction).
Individuals who have had a stroke.
What is spastic parapesis? What is it associated with?
similar to hemiparetic gait but bilateral, with both legs stiff + circumducting.
Patient’s feet may be inverted+ “scissor”.
Hereditary spastic paraplegia.
What does Rombergs test assess?
Loss of proprioceptiveorvestibularfunction (sensory ataxia).
i.e. non cerebellar causes of balance issues
How do you perform Romberg’s test?
- Stand within arms reach of pt to allow in case they begin to fall.
- Ask pt to put their feet together + keep their arms by their sides
- Ask pt to close their eyes.
What is a positive Romberg’s sign? What does this indicate?
Falling without correction(abnormal)
Indicates unsteadiness is due to sensory ataxia (i.e. a deficit of proprioceptive or vestibular function, rather than cerebellar function).
List 4 causes of proprioceptive dysfunction
Joint hyper mobility: Ehlers-Danlos syndrome
B12 deficiency
Parkinson’s disease
Ageing (presbypropria)
List causes of vestibular dysfunction
Vestibular neuronitis
Ménière’s disease.
What does swaying with correction in a Romberg’s test indicate?
Nota +ve result + often occurs incerebellardiseasedue to truncal ataxia.
How is tone of the lower limb assessed?
- Roll each leg to assess tone in muscles responsible for rotation of the hip.
- Lift each knee briskly off the bed + observe movement of the leg. In normal tone, the knee should rise whilst the heel remains in contact with the bed (heel will lift off the bed if there is increased tone).
In which conditions may you see ankle clonus?
UMN lesions of the descending motor pathways:
Stroke
Multiple sclerosis
Cerebral palsy
How do you test for ankle clonus?
- Position pt’s leg so knee + ankle are slightly flexed, supporting the leg with your hand under their knee, so they can relax.
- Rapidly dorsiflex + partially evert the foot to stretch the gastrocnemius muscle.
- Keep the foot in this position + observe for clonus. Clonus is felt as rhythmic beats of dorsiflexion + plantarflexion. If >5 beats of clonus are present= an abnormal finding.
Which myotome(s) and muscle(s) are assessed in flexion of the hip?
L1/2 (iliofemoral nerve)
iliopsoas
Lift your leg off the bed + don’t let me push down
Which myotome(s) and muscle(s) are assessed in extension of the hip?
L5/S1 (sciatic nerve)
Gluteus maximus
“Don’t let me lift your leg off the bed.”
Which myotome(s) and muscle(s) are assessed in flexion of the knee?
S1 (sciatic nerve)
Hamstrings
Bend your knee so your foot is on the bed + don’t let me pull your leg towards me
Which myotome(s) and muscle(s) are assessed in extension of the knee?
L3/4 (femoral nerve)
Quadriceps
Bend your knee so your foot is on the bed + try to straighten your leg while I resist
Which myotome(s) and muscle(s) are assessed in adduction of the hip?
L4/5 Medial thigh (adductor magnus, brevis, longus...)
Which myotome(s) and muscle(s) are assessed in abduction of the hip?
L2/3
Gluteus minimus + medius
Which myotome(s) and muscle(s) are assessed in dorsiflexion of the foot?
L4/5 (deep peroneal nerve)
Tibialis anterior
Put your legs flat on the bed, cock your foot back + don’t let me push your foot down
Which myotome(s) and muscle(s) are assessed in plantarflexion of the foot?
S1/2 (tibial nerve)
Gastrocnemius, soleus
“Point your foot down like you’re pushing a car pedal + don’t let me pull it up.”
Which myotome(s) and muscle(s) are assessed in extension of the big toe?
L5 (deep peroneal nerve)
Extensor hallucis longus
“Point your big toe up towards your head + don’t let me push it down.”
Which nerves are involved in the knee jerk reflex?
L3
L4
How do you elicit the knee jerk reflex?
- Remove weight from the pt’s lower limb by either supporting it or asking the patient to hang their legs over side of bed. Ensure completely relaxed
- Tap the patellar tendon with the tendon hammer
- If a reflex appears absent make sure the patient is fully relaxed + then perform a reinforcement manoeuvre.
How do you elicit the ankle jerk reflex?
With patient on the examination couch support their leg so that their hip is slightly abducted, knee is flexed and ankle is dorsiflexed.
2.Tap the Achille’s tendon with tendon hammer + observe for a contraction in the gastrocnemius muscle with associated plantarflexion of the foot.
Which nerves are involved in the ankle jerk reflex?
S1
Which nerves are involved in the plantar reflex?
L5
S1
How do you elicit the plantar reflex?
- Hold ankle (if left foot is being assessed, use left hand to hold the ankle + vice versa).
- Run the blunt object along the lateral edge of the sole of the foot, moving towards the base of the little toe + then turn medially to run across the transverse arch of the foot under the toes.
- Observe the big toe
Describe the normal and abnormal findings of a plantar reflex
Normal: flexion of the big toe + flexion of the other toes.
Abnormal (Babinski sign): extension of big toe + spread of other toes (suggestive of a UMN lesion).
What test is used to assess coordination in the lower limb?
Heel-to-shin test
What is the Heel-to-shin test?
- Ask pt to place their left heel on their right knee + then run it down their shin in a straight line.
- Ask them to return their left heel to the starting position over the right knee.
- Now ask them to repeat this sequence of movements in a smooth motion until you tell them to stop.
- Repeat the assessment with the right heel on the left leg.
What does dysmetria (incoordination) suggest?
Dysmetria(i.e. incoordination) suggests ipsilateral cerebellar pathology.
What may produce an apparent incoorindation of movement?
Weakness (e.g. from UMN lesion) can also produce apparent incoordination of this movement.
