Lower limb examination

Question 1

Observations?

Answer 1

BBRSS, Muscle wastage & Asymmetry, Tone, Gait, Discolouration

Question 2

OBSERVATION?
Gait?

Answer 2

• May be wide, unsteady & dragging feet with cervical myelopathy (UMN)
• Bradykinesia, changes in stride length or turning on bloc can indicate basal ganglia/extrapyramidal e.g. parkinsons (UMN)
• Walk tandem to test proprioception & cerebellar pathology
• Slapping of foot or foot drop (dragging) in L4-5 radiculopathy
• Tiptoe (inability to tiptoe suggests weakness of ankle plantarflexion) e.g. myopathy S1/2 neuropathy

Question 3

OBSERVATION
Atrophy? (LMN sign)

Answer 3

Check for symmetry appearance of muscle bulk especially intrinsic foot muscles (tibial nerve e.g. tarsal tunnel)

Can be a sign of normal ageing

Question 4

OBSERVATION
Fasciculations (LMN sign)

Answer 4

twitches of muscles which can range from mild to severe

Excessive caffeine

Nerve root compression/Peripheral nerve compressions

Question 5

OBSERVATIONS
Discolouration?

Answer 5

Vascular problems such as peripheral vascular disease can mimic neurological issues

Question 6

OBSERVATIONS
Tremor?

Answer 6

Resting - Parkinsons with basal ganglia issues

Intentional - MS, cerebellar problems

Question 7

What test can be done to indicate impairment of proprioception or vestibular function?

Answer 7

Romberg Test

Feet together - close eyes

test that measures a person’s sense of balance. Specifically, the test assesses the function of the dorsal column of the spinal cord

Question 8

OBSERVATIONS
Asymmetry?

Answer 8

Posture changes e.g. bearing weight on one leg d/t injury on the other

Question 9

PALPATION
What are we feeling for?

Answer 9

Bone and soft tissues for outline, tone, texture, temperature, lumps and bumps

Question 10

PALPATION
What test can be done during to assess nerve pain?

Answer 10

Tinels Test

Can be tested in both
- Anterior Tibial Branch of the deep peroneal nerve (Tap above the anterior to the medial malleolus)

• Posterior tibial nerve (tapping behind the medial malleolus)

POS - if felt distally with tingling

Question 11

PALPATION
What test can we do to assess Tone within the lower limb?
Include reasons for increased/Decrease tone

Answer 11

Leg roll/ Leg lift

“im going to put my hand on your leg and roll while having a look at the tone, the resting muscles”

Leg should swing with the momentum

Causes of increased tone:
- Stroke (spasticity)
- Parkinson’s (cogwheel rigidity)

Decrease in tone:
- LMN lesion
- Cerebellar disease

Question 12

What does spasticity and rigidity mean?

Answer 12

Indicates pathology in the pyramidal system or contralateral cerebral hemisphere

Rigidity can indicate extra pyramidal conditions such as basal ganglia involvement which we may see in parkinson’s disease

Question 13

AROM
What aspects of the Active ROM are you going through in the lower limb?

Answer 13

Hip - Flexion, Extension, Lateral Rotation, Medial Rotation, ABduction, ADduction

Knee Flexion - Flexion, Extension, Lateral Rotation, Medial Rotation

Foot - Dorsi flexion, Plantarflexion, eversion, inversion

Question 14

PASSIVE ROM
What are you doing during Passive ROM?

Answer 14

Checking for full, end feel (check at different rates)

Question 15

COORDINATION
What Tests can be done?

Answer 15

Heel to shin
- Tests coordination & potential cerebellar pathology

Rapid alternating movement (wiggling toes)
- slower performance with cerebellar pathology

Toe to finger
- Any intention tremor
- Checking for any over/undershooting with cerebellar damage e.g. MS, Stroke

Question 16

SENSORY TESTING
What tests can be done?

Answer 16

Soft Sharp - (lateral spinothalamic & DMCL for touch): Using cocktail & wool & start distally - start on sternum

Vibration (128Hz) (DCML): Tuning fork at bony prominences
- Start distally and work proximally

Two point discrimination (DCML):
- 2 cocktail stick together & see when can identify 1 or 2
Should be close together at feet

Graphesthesia (DCML pathway/ Parietal centre)
- With numbers/letter on foot

Question 17

REFLEXES
What reflexes can be done during this exam?

Answer 17

L4 Patella - inducing the stretch of the quadricep
L5/S1 Tibialis Posterior (behind heel/Achillies) - bring toes back

Question 18

REFLEXES
How would you grade, what are you looking for?

Answer 18

Grade 0 +3
0 = no response; Abnormal response
1 = SLight but present response
2 = Brisk normal response
3 = Very brisk response

Looking for hypo e.g. nerve root,

Question 19

PATHOLOGICAL REFLEXES
What tests can you do for Lower limb? What is this testing?

Answer 19

Babinski reflex - indicates pathology of cortical spinal system
- Hold the ankle, to stabilise leg
- Using end of reflex hammer, swipe from heel to lateral foot

NORMAL Response - No response
ABNORMAL Response - Toes Extend and small digit flares

Oppenheimers -
Run your thumb nail down medial aspect of tibia quickly with force looking for big toe extension or toe flaring

Gordons Test -
Place calf over your hand while supine & squeeze calf muscle and look for big toe extension & toes flaring

Chaddock’s
Test on lateral aspect of foot from post lateral malleoli onto lateral foot – observe for any big toe extension or toe flaring

Question 20

MYOTOME TESTING

Answer 20

• Hip flexion - resisted L1/2
• Quadriceps - (pushing up on knee) L3/4
• Hamstring - (pushing foot into buttock) L5/S1
• Extensor Tibial anterior - (toes dorsiflexed and resisted) L4/5
• Big Toe towards you - L5 sensitive for nerve root compression
  -Pushing down on plantar flexion - S1 myotome