Lower Limb

Question 1

What should you look for on inspection of the lower limb?

Answer 1

Scars
Wasting 
Involuntary movements 
Fasciculations 
Tremor

Question 2

List 4 types of involuntary movement that may be seen on inspection of the lower limb

Answer 2

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

Question 3

List 3 facial signs that may be seen on inspection of the lower limb

Answer 3

Hypomimia: reduced facial exp. (Huntington’s)
Ptosis + frontal balding (Myotonic dystrophy)
Opthamoplegia: weakness of >,1 extra ocular muscle (MS)

Question 4

List 5 features of gait that should be assessed

Answer 4

Stance 
Stability
Arm swing
Steps
Turning

Question 5

What is ataxic gait? Give 2 underlying pathologies causing ataxic gait

Answer 5

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)

Question 6

Who may find turning difficult?

Answer 6

Patients with cerebellar disease

Question 7

What does heel to toe walking exacerbate?

Answer 7

Underlying unsteadiness

Makes it easier to identify more subtle ataxia.

Question 8

Give 3 causes of difficulty in heel to toe walking

Answer 8

Dysfunction of thecerebellarvermis(e.g. alcohol-induced cerebellar degeneration).
Weakness of the flexors muscles of the leg
Sensory ataxia.

Question 9

How does proprioceptive sensory ataxia differ to cerebellar ataxia?

Answer 9

Proprioceptive: Pts watch their feet intently to compensate for proprioceptive loss.
Cerebellar: pt may veer to the side of the lesion.

Question 10

List 6 features of a parkinsonian gait

Answer 10

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.

Question 11

List 3 features of High stepping gait

Answer 11

Unilateral or bilateral
Typically caused by foot drop (weakness of ankle dorsiflexion).
Patient also won’t be able to walk on their heel(s).

Question 12

What is Waddling gait? What is it commonly caused by?

Answer 12

Shoulders sway from side to side, legs lifted off ground with the aid of tilting the trunk.
Proximal lower limb weakness (e.g. myopathy).

Question 13

What is Hemiparetic gait? What is it associated with?

Answer 13

one leg held stiffly + swings round in an arc with each stride (circumduction).
Individuals who have had a stroke.

Question 14

What is spastic parapesis? What is it associated with?

Answer 14

similar to hemiparetic gait but bilateral, with both legs stiff + circumducting.
Patient’s feet may be inverted+ “scissor”.
Hereditary spastic paraplegia.

Question 15

What does Rombergs test assess?

Answer 15

Loss of proprioceptiveorvestibularfunction (sensory ataxia).
i.e. non cerebellar causes of balance issues

Question 16

How do you perform Romberg’s test?

Answer 16

1. Stand within arms reach of pt to allow in case they begin to fall.
2. Ask pt to put their feet together + keep their arms by their sides
3. Ask pt to close their eyes.

Question 17

What is a positive Romberg’s sign? What does this indicate?

Answer 17

Falling without correction(abnormal)
Indicates unsteadiness is due to sensory ataxia (i.e. a deficit of proprioceptive or vestibular function, rather than cerebellar function).

Question 18

List 4 causes of proprioceptive dysfunction

Answer 18

Joint hyper mobility: Ehlers-Danlos syndrome
B12 deficiency
Parkinson’s disease
Ageing (presbypropria)

Question 19

List causes of vestibular dysfunction

Answer 19

Vestibular neuronitis

Ménière’s disease.

Question 20

What does swaying with correction in a Romberg’s test indicate?

Answer 20

Nota +ve result + often occurs incerebellardiseasedue to truncal ataxia.

Question 21

How is tone of the lower limb assessed?

Answer 21

1. Roll each leg to assess tone in muscles responsible for rotation of the hip.
2. 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).

Question 22

In which conditions may you see ankle clonus?

Answer 22

UMN lesions of the descending motor pathways:
Stroke
Multiple sclerosis
Cerebral palsy

Question 23

How do you test for ankle clonus?

Answer 23

1. Position pt’s leg so knee + ankle are slightly flexed, supporting the leg with your hand under their knee, so they can relax.
2. Rapidly dorsiflex + partially evert the foot to stretch the gastrocnemius muscle.
3. 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.

Question 24

Which myotome(s) and muscle(s) are assessed in flexion of the hip?

Answer 24

L1/2 (iliofemoral nerve)
iliopsoas
Lift your leg off the bed + don’t let me push down

Question 25

Which myotome(s) and muscle(s) are assessed in extension of the hip?

Answer 25

L5/S1 (sciatic nerve) Gluteus maximus “Don’t let me lift your leg off the bed.”

Question 26

Which myotome(s) and muscle(s) are assessed in flexion of the knee?

Answer 26

S1 (sciatic nerve) Hamstrings Bend your knee so your foot is on the bed + don't let me pull your leg towards me

Question 27

Which myotome(s) and muscle(s) are assessed in extension of the knee?

Answer 27

L3/4 (femoral nerve) Quadriceps Bend your knee so your foot is on the bed + try to straighten your leg while I resist

Question 28

Which myotome(s) and muscle(s) are assessed in adduction of the hip?

Answer 28

``` L4/5 Medial thigh (adductor magnus, brevis, longus...) ```

Question 29

Which myotome(s) and muscle(s) are assessed in abduction of the hip?

Answer 29

L2/3 | Gluteus minimus + medius

Question 30

Which myotome(s) and muscle(s) are assessed in dorsiflexion of the foot?

Answer 30

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

Question 31

Which myotome(s) and muscle(s) are assessed in plantarflexion of the foot?

Answer 31

S1/2 (tibial nerve) Gastrocnemius, soleus “Point your foot down like you’re pushing a car pedal + don’t let me pull it up.”

Question 32

Which myotome(s) and muscle(s) are assessed in extension of the big toe?

Answer 32

L5 (deep peroneal nerve) Extensor hallucis longus “Point your big toe up towards your head + don’t let me push it down.”

Question 33

Which nerves are involved in the knee jerk reflex?

Answer 33

L3 | L4

Question 34

How do you elicit the knee jerk reflex?

Answer 34

1.  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 2.  Tap the patellar tendon with the tendon hammer 3.  If a reflex appears absent make sure the patient is fully relaxed + then perform a reinforcement manoeuvre.

Question 35

How do you elicit the ankle jerk reflex?

Answer 35

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.

Question 36

Which nerves are involved in the ankle jerk reflex?

Answer 36

S1

Question 37

Which nerves are involved in the plantar reflex?

Answer 37

L5 | S1

Question 38

How do you elicit the plantar reflex?

Answer 38

1.  Hold ankle (if left foot is being assessed, use left hand to hold the ankle + vice versa). 2.  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. 3.  Observe the big toe

Question 39

Describe the normal and abnormal findings of a plantar reflex

Answer 39

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).

Question 40

What test is used to assess coordination in the lower limb?

Answer 40

Heel-to-shin test

Question 41

What is the Heel-to-shin test?

Answer 41

1.  Ask pt to place their left heel on their right knee + then run it down their shin in a straight line. 2.  Ask them to return their left heel to the starting position over the right knee. 3.  Now ask them to repeat this sequence of movements in a smooth motion until you tell them to stop. 4.  Repeat the assessment with the right heel on the left leg.

Question 42

What does dysmetria (incoordination) suggest?

Answer 42

Dysmetria (i.e. incoordination) suggests ipsilateral cerebellar pathology.

Question 43

What may produce an apparent incoorindation of movement?

Answer 43

Weakness (e.g. from UMN lesion) can also produce apparent incoordination of this movement.