Lower Limb Flashcards
Features of UMN lesions?
No fascicultations or wasting, pronator drift may be present, increase tone (spasticity or rigidity), Pyramidal pattern of weakness e.g. extensors weaker than flexors in arms and opposite in legs) and exaggerated/brisk reflex (hyperreflexia). Plantar reflexes are upgoing/extensor (babinski +ve)
Features of LMN lesions?
Wasting and fascicultations of muscles. May be some drift/movement of the arms if weakened or deafferented but not pronator drift, different patterns of weakness depending on cause e.g. proximal in muscle disease and distal in peripheral neuropathy, reduce or absnt (hyporeflexia or areflexia). Plantar reflexes are normal (downgoing/flexor) or mute
What equipment will you need?
Tendon hammer, neurotip, cotton wool, Tuning fork 128Hz
What signs are you looking for on clinical inspection?
Scars, wasting of muscles (LMN lesions or disuse atrophy), tremor, fasciculations (LMN e.g. amyotrophic lateral sclerosis), pseudoathetosis, chorea, myoclonus e.g. normal = falling asleep, epilepsy = juvenile myoclonic epilepsy, tardive dyskinesia (secondary to neuroleptics e.g. antipsychotics or antiemetics), hypomimia,tosis and frontal balding (myotonic dystrophy) and ophthalmoplegia (MS or myasthenia gravis)
What are you looking for in the patients gait?
Stance: broard based ataxic gait associated with midline cerebellar pathology e.g. lesion in MS or cerebellar vermis degeneration from alcohol.
STABILITY: slow, unsteady. Unilateral cerebellar lesion, patients veer to that side
ARM SWING: often absent reduced in Parkinsons
STEPS: small, shuffling steps in Parkinsons. High stepping may indicate foot drop
TURNING: patients with cerebellar disease will find turning manoeuvres difficult
What are you looking for in Tandem gait?
Heel-to-toe to identify cerebellar vermis degeneration from alcohol. May indicate weakness of flexor muscles of the leg or sensory ataxia
Describe ataxic gait?
Broad-based, unsteady and associated with cerebellar pathology or sensory ataxia (vestibular or proprioceptive dysfunction)
Describe Parkinsonian gait?
Small, shuffling stepps, stooped posture and reduced arm swing (initially unilateral). gait appears fushed (festinating) and may get stuck (freeze). Hand tremor may also be noticeable
Describe high-stepping gait?
Can be unilateral or bilateral and is typically caused by foot drop (weakness of ankle dorsiflecion). Patient wont be able to walk on their heels
Describe waddling gait?
Shoulders sway from side to side, legs lifted off ground with teh aid of tilting the trunk. Commonly caused by proximal lower limb weakness e.g. myopathy
Describe hemiparetic gait?
One leg held stiffly and swings round in an arc with each stride. Associated with stroke patients
Describe spastic paraparesis?
Similar to hemiparetic but bilateral with both legs stiff and circumductiong. Patients feet may be inverted and scissor. Associated with hereditary spastic paraplegia
What is Rombergs test?
Used to assess loss of proprioceptive or vestibular function (sensory ataxia). Does not assess cerebellar function. Patient close eyes with feet together and hands by side (should not fall)
What are causes of positive rombergs?
Proprioceptive dysfunction e.g. joint hypermobility (ED Sydnrome), B12 deficiency, Parkinsons and ageing.
Vestibular = vestibular neuronitis and Menieres
What would Rombergs swaying show?
Not positive but occurs in cerebellar disease e.g. truncal ataxia
What is ankle clonus?
Series of involuntary rhythmic muscular contractions and relaxations associated with UMN lesions in the descending motor pathways e.g. stroke, MS and cerebral palsy
What features of tone are you looking for?
Spsticity, rigidity, cogwheeling and hypotonia.
Spasticity is associated with pyramidal tract lesions e.g. stroke and rigidity is associated with extrapyramidally e.g. Parkinsons
Spasticity is velocity dependent and rigidity is velocity independent.
Rigidity subtypes: cogwheel and lead pipe.
Cogwheel = tremor superimposed on hypertonia e.g. parkinsons.
Lead pipe = unifrom increased tone e.g. neuroleptic malignant syndrome
Hip Flexion myotome and muscles?
L12 iliofemoral and iliopsoas
Hip extension myotome and muscles?
L5 S1 scatic and gluteus maximus
Knee flexion myotome and muscles?`
S1 sciatic and hamstrings
Knee extension myotome and muscles?
L34 femoral and quadriceps
Ankle dorsiflexion myotome and muscles?
L45 deep peroneal nerve and tibialis anterior
Ankle plantarflexion myotome and muscles?
S12 tibial nerve and gastrocnemius and soleus
Bit toe extension myotome and muscles?
L5 deep peroneal and extensor hallucis longus
What scale is used to assess the power of these movements?
MCR power scale
What reflexes are tested?
Knee jerk reflex (L34)
Ankle jerk reflex (S1)
Plantar reflex (l5 s1)
What are the dermatomal areas?
L1: inguinal region and top of medial thigh
L2: middle and lateral aspect of interior thigh
L3: mdeial aspect of knee
L4: medial aspect of the lower leg and ankle
L5: dorsum and medial aspect of big toe
S1: dorsum and lateral aspect of little toe
WHat sensory tests do you do and what tracts?
Light touch = spinothalamic and dorsal
Neurotip = spiothalamic
Tuning fork = dorsal column
Proprioception = dorsal columns
What co-ordination tests do you do?
Heel to skin test: dysmetria shows ipsilateral cerebellar pathology
Proprioception
What further assessments would you do?
Cranial nerve, upper limbs and cerebellar assessment. Neuroimaging e.g. MRI spine and head
