Lower Limb Exam

Question 1

General inspection from end of bed of pt

Answer 1

• any limb deformity of posturing
• SWIFT: scars, wasting of muscles, involuntary movements (dystonia, chorea, myoclonus, fasciculations (LMN lesions), tremor (Parkinson’s)

Question 2

How do you assess for tone?

Answer 2

• ask pt to make their leg as floppy as possible
• Roll leg watching movement of foot
• briskly lift leg off bed at knee joint, heel should remain in contact with bed
• ask pt to relax their ankle: move ankle in circles then rapidly dorsiflex the foot. Look for clonus (>5 beats is abnormal)

Question 3

How do you assess power of the hip?

Answer 3

• isolate hip joint
• raise leg off bed and “stop me from pushing it down” (hip flexion L5)
• put hand underneath the leg “push down against my hand” (hip extension L5/S1)
• move leg away from lifeline and “stop me pushing it in” (hip abduction L4/5)
• move leg towards the midline and “stop me pushing it out” (hip adduction L2/3)

Question 4

How do you assess knee power?

Answer 4

• isolate knee joint
• ask pt to bend their knees and “push out against my hand” (kick legs out = flexion S1)
• pt bends knees and “pull your legs in towards you and push against my hand (extension L3/4)

Question 5

How do you assess ankle power?

Answer 5

• stabilise ankle joint
• point foot up and don’t let me push it down (dorsiflexion L4)
• press against my hand with the sole of your foot (plantarflexion S1/2)

Question 6

How do you assess power of big toe?

Answer 6

Don’t let me push your big toe down

Extension L5

Question 7

Which reflexes do you need to do?

Answer 7

• knee jerk (L3/4)
• ankle jerk (L5/S1)
• Babinski (S1): normal is flexion of great toe, abnormal is extension of great toe (UMN lesion)

Question 8

How do you test sensation?

Answer 8

Same as before but on dermatomes of legs

• light tough
• pin prick
• temperature offer it
• vibration starting on DIP of great toe
• proprioception (holds distal phalanx of toe by its sides, move it up and down)

Question 9

How do you test coordination?

Answer 9

• heel to shin test: run heel down other leg from knee to ankle, being foot up to touch my hand, then move foot back to your knee
• inability to do this: loss of motor strength, proprioception, acerebellar disorder
• hit foot against your hand as fast as possible = dysdiadochokinesia

Question 10

How do you assess gait?

Answer 10

• ask pt to walk to end of room and back
• assess speed, symmetry and balance
• Tandem (heel to toe) gait: abnormal may suggest weakness, impaired proprioception or cerebellar disorder
• heel walking (assesses dorsiflexion power)
• Romberg’s test (ask pt to stand with feet together and eyes closed. Positive test if loss of balance = sensory ataxia)

Question 11

How to complete exam?

Answer 11

• full history
• cranial never and upper limb neurological exam
• GALS screen
• further imaging if indicated