Lower limb Flashcards
What are you looking for on gait?
Stance Stability Arm swing Steps Turning
What can stance (on gait) indicate?
Broad base - suggests cerebellar pathology e.g. lesion of MS
What can stability (on gait) indicate?
A staggering, slow and unsteady gait = cerebellar pathology
Note : in unilateral cerebellar disease the pt will veer towards the side of the lesion
What can arm swing indicate?
Absent or reduced in Parkinson’s disease
What can the steps (on gait) indicate?
Small, shuffling steps = Parkinson’s disease
High-stepping –> presence of foot drop
What can turning (on gait) indicate?
Turning will be difficult in cerebellar lesions
What is the benefit of asking the patient to tandem gait?
Note: tandem gait is heel-to-toe walking
benefit = detect more subtle ataxia
What are the different types of gait abnormalities? (6)
- Ataxic gait
- Parkinsonian gait
- High-stepping gait
- Waddling gait
- Hemiparetic gait
- Spastic paraparesis
What is an ataxic gait?
Broad based, unsteady gait
What are the differentials of ataxic gait and how can you differentiate?
Cerebellar pathology
OR
Sensory ataxia (e.g. vestibular or proprioceptive dysfunction)
Proprioceptive sensory ataxia - tend to stamp and tend to watch their feet (using vision sense to compensate for proprioceptive loss)
Cerebellar lesion - pt might veer towards the side of the lesion
What is a Parkinsonian gait?
- Small shuffling steps, stooped posture, reduced arm swing
- Many small steps in order to turn around
- Gait appears rushed and may get stuck
- Hand tremor may be noticeable
What causes a high stepping gait?
can be unilateral or bilateral
- typically caused by foot droop (weakness of ankle dorsiflexion)
What is a waddling gait?
Shoulders sway from side to side
Legs lifted off the ground with the aid of the tilting trunk
What is a waddling gait caused by?
proximal lower limb weakness e.g. myopathy
What is a hemiparetic gait?
one leg held stiffly and swings round in an arc with each stride (circumduction)
What is hemiparetic gait associated with?
patients who have had a stroke
What is spastic paraparesis?
Similar to hemiparetic gait but bilateral - both legs stiff and circumducting
the patients feet may beb inverted and ‘scissor’
What is spastic paraparesis associated with
hereditary spastic paraplegia
What does Romberg’s test assess?
loss of proprioceptive or vestibular function (sensory ataxia)
Does not check for cerebellar function, but checks for sensory as opposed to cerebellar causes of ataxia
Romberg’s test assumes the patient requires at least 2 out which 3 things in order to maintain balance whilst standing?
- Proprioception (to know the position of the body)
- Vestibular function (to know the position of the head)
- Vision (to see your position in space)
What does a positive Romberg’s test mean?
They have a deficit in proprioception or vestibular function
Explains what happens on a positive Romberg’s test
The patient will fall without correcting themselves
If a patient sways with correction during a Romberg’s test - what does this mean?
It is not a positive results and often occurs in cerebellar disease
What are some causes of proprioceptive dysfunction? (4)
- Joint hypermobility (ehlers-Danlos syndrome)
- B12 deficiency
- Parkinson’s disease
- Ageing (presbypropria)
What are some causes of vestibular dysfunction? (2)
Vestibular neuronitis
Menieres disease
Where do you assess tone?
hip (rotate the legs), knee (lifting up the knees) and ankle (rotate the ankle)
What happens when you life the knees up during tone assessment in a patient with increased tone?
The heel will lift off the bed if there is increased tone
How do you check for tone/clonus in the ankle?
hold the patients calf and foot and then rotate the ankle and RAPIDLY dorsiflex /slightly evert the foot
How many beats of clonus do you need for an abnormal finding?
> 5
Which tracts are spasticity vs rigidity associated with?
Pyramidal tract lesions = spasticity
Extrapyramidal tract lesions = rigidity
Give an example of what can cause a pyramidal or trapped lesion and an extrapyramidal tract
Pyramidal = stroke Extrapyramidal = Parkinson's disease
How do you differentiate between spasticity and rigidity clinically? (2)
Both have increased tone but spasticity is velocity dependent (the faster you move the limb the worse it is) whilst rigidity is velocity independent (It feels the same if you move the limb fast or slow)
Spasticity is also accompanied by weakness
What is “clasp knife spasticity”? And what condition is it associated with?
There is increased tone in the initial part of the movement which then suddenly reduces past to certain point
Associated with typical UMN pyramidal increased tone
What are the two main subtypes of rigidity? and what condition are they associated with?
Cogwheel rigidity and lead pipe rigidity
Rigidity is to do with Extra-pyramidal increased tone such as parkinson’s disease
What is cogwheel rigidity?
Tremor superimposed on the hypertonia
What condition is cogwheel rigidity associated?
Parkinson’s disease
What is lead pipe rigidity?
Uniformly increased tone throughout the movement
What condition is lead pipe rigidity associated with?
Neuroleptic malignant syndrome
State the myotome assessed and the muscle assessed on hip flexion
Myotome: L1/2 (ileofemral nerve)
Muscle: Iliopsoas
State the myotome assessed and the muscle assessed on hip extension
Myotome: L5/S1 (sciatic nerve)
Muscle: Gluteus maximus
What are the patient instructions for hip flexion and extension?
Hip flexion: lift your leg of the bed and don’t let me push your leg down
Hip extension: don’t let me lift your leg of the bed
State the myotome assessed and the muscle assessed on knee flexion
Myotome: S1 (sciatic nerve)
Muscle: Hamstrings
State the myotome assessed and the muscle assessed on knee extension
Myotome: L3/4 (femoral nerve)
Muscle: Quadriceps
What are the patient instructions for knee flexion and extension?
Knee flexion: bend your knee so that your foot is flat on the bed and then don’t let me pull your leg towards me
Knee extension: try and straighten your leg whilst I try to stop you
State the myotome assessed and the muscle assessed on ankle dorsiflexion
Myotome: L4/5 (deep peroneal nerve)
Muscle: tibialis anterior
State the myotome assessed and the muscle assessed on ankle plantarflexion
Myotome: S1/2 (tibial nerve)
Muscle: Gastrocnemius, soleus
What are the patient instructions for ankle dorsiflexion and plantarflexion?
Dorsiflexion: Put your legs flat on the bed put your feet backwards and don’t let me push your foot down
Plantarflexion: Point your feet and don’t let me pull them up
State the myotome assessed and the muscle assessed on big toe extension
Myotome: L5 (deep peroneal nerve)
Muscle: Extensor hallucis longus
What are the patient instructions for big toe extension?
Point your big toe up towards your head and don’t let me push it down
Describe the difference in pattern of muscle weakness for UMN and LMN
UMN: pyramidal pattern
LMN: focal pattern of weakness (only the muscles associated with the damaged neurones will be affected)
Describe the MRC scale
0 - no contraction
1 - flicker or trace of contraction
2 - active movement, with gravity eliminated
3 - active movement, against gravity
4 - active movement against gravity and resistance
5 - normal power
What do you say to the patient to assess their reflexes?
I am now going to check your reflexes by tapping gently on you legs with this tendon hammer - for this, i need to you relax your muscles completely
What are the 3 reflexes in the lower limb exam?
Knee-jerk
Ankle-jerk reflex
Plantar reflex
What nerve roots are assessed with knee-jerk reflex? which tendon do you tap?
L3/4
tap the patellar tendon
What nerve roots are assessed with ankle-jerk reflex?
S1
tap the Achille’s tendon
What nerve roots are assessed with plantar reflex?
L5/S1
What is a normal vs abnormal plantar reflex?
Normal = flexion of the big toe and flexion of the other toes Abnormal = extension or the big toe and spread of the other toes (UMN)
Which tracts does light touch sensation involve?
Dorsal columns and spinothalamic tracts
Which tracts does pin-prick (pain) sensation involve?
Spinothalamic tract
If there is a sensory level of pain sensation what does this suggest?
There is a spinal lesion
What tracts does vibration sensation involve?
Dorsal columns
What tracts does proprioception involve?
Dorsal columns
What test checks co-ordination in the lower limb?
Heel-to-shin test
What is it called if the patient struggles with the heel-to-shin test?
Dysmetria
What is dysmetria (incoordination) suggestive of?
Ipsilateral cerebellar lesion
note: weakness from an UMN lesion can also causes apparent incoordination
Present a lower limb examination
“Today I examined Mr Smith, a 32-year-old male. On general inspection, the patient appeared comfortable at rest, with normal speech and no other stigmata of neurological disease. There were no objects or medical equipment around the bed of relevance.”
“Assessment of the lower limbs revealed normal gait, tone, power, reflexes, sensation and coordination.”
“In summary, these findings are consistent with a normal lower limb neurological examination.”
“To complete the neurological examination i would do cranial nerve and upper limb examination”
I would also request neuroimaging such as a MRI spine or head
