LOWER LIMB EXAMINATION Flashcards
How would you start any examination?
WIPER QQ Wash hands Introduce yourself Ask permission Expose the patient Reposition the patient
Ask if they are in any pain or discomfort
How exposed should the patient be for the lower limb neurological examination?
Their lower limbs should be bare however, to preserve patient dignity, their underwear should be left on.
How should the patient be positioned for the lower limb neurological examination?
Lying down at 45 degrees
What are you looking for during your inspection of the upper limb in the neurological examination?
From the end of the bed:
Any pain or discomfort
Any walking aids or signs of chronic discomfort
DWARFS: Deformities Wasting of muscles Asymmetry Rashes Fasciculations Scars
When inspecting the foot as part of the neurological exam of the lower limb, what would a high arch of the foot, lack of muscle and claw toes be signs of?
Charcot-Marie-Tooth disease
Having inspected the patient as part of a lower limb neurological exam, what is the next thing to assess?
Tone
When assessing tone as part of an lower limb neurological exam, what must you ask before starting your assessment?
Whether they are in any pain at all.
How do you assess tone in a neurological exam of the lower limb?
Ask patient to relax/go floppy like a rag-doll.
Passively flex and extend the limb.
Roll the leg to look for a slight lag. No lag indicates rigidity or increased tone.
Passively lift the knee from below and then drop it. Heel should stay on the bed. If not there is increased tone.
Test for clonus in the ankle.
You are looking for increased (rigidity/spasticity) or decreased tone.
When might the tone of the lower limb be increased?
Upper motor neuron lesions
Basal ganglia dysfunction (Parkinson’s disease)
When might the tone of the lower limb be decreased?
Lower motor neuron lesions
How do you test for ankle clonus in the lower limb examination?
Plantar flex the foot a few times then quickly dorsi flex and hold. Looking for more than 5 beats of plantar flexion.
What is ankle clonus indicative of?
Upper motor neurone lesion
Having assessed the patient’s muscle tone as part of an lower limb neurological exam, what is the next thing to assess?
Power
What are the different movements that you assess the power of during an lower limb exam? For each movement say which muscle group or spinal nerve is being tested.
Hip flexion - L1, L2 Hip extension - L5, S1 Hip adduction - L2, L3 Hip abduction - L4, L5 Knee flexion - S1 Knee extension - L3, L4 Ankle dorsiflexion - L4 Ankle plantarflexion - S1, S2 Extension of big toe - L5 Ankle inversion - L5 Ankle eversion - L5, S1
What scale is power measured on when assessing the neurological status of the lower limb?
MRC scale for power
What are the different levels on the MRC power scale used during a neurological exam of the lower limb?
0 - No muscle contraction is visible.
1 - Muscle contraction is visible but there is no movement of the joint.
2 - Active joint movement is possible with gravity eliminated.
3 - Movement can overcome gravity but not resistance from the examiner.
4 - The muscle group can overcome gravity and move against some resistance from the examiner.
5 - Full and normal power against resistance.
Does reduced power of any muscle group indicate upper or lower motor neuron lesions?
Either
During a neurological examination of the lower limb, what do you test having assessed the patient’s power?
Reflexes
What are the three reflexes to test in the lower limb? State which nerve(s) is/are being tested for each one.
Knee jerk - L3, L4
Ankle - L5, S1
Plantar reflex - L5, S1, S2
When testing the plantar reflex in the lower limb exam, what is the normal reflex?
Plantar flexion of the foot
What do we call it when the patient’s foot dorsiflex’s when testing the plantar reflex in the lower limb exam?
A positive Babinski sign
What is the Babinski sign indicative of?
An upper motor neuron lesion
What might a hyperreflexia in the lower limb be indicative of?
An upper motor neuron lesion
What might a diminished or absent reflex in the lower limb be indicative of?
A lower motor neuron lesion
If you having trouble eliciting a reflex during an lower limb examination, what can you ask the patient to do?
‘Reinforcement’ (the Jendrassik manoeuvre) - Ask the patient to clench their teeth together while you try to elicit the reflexes again.
Having assessed the tone, power and reflexes in the lower limb, what might you next assess before moving on to sensation?
Coordination
How would you assess coordination as part of a neurological examination of the lower limb?
Heel-shin test
What are you testing when you assess coordination as part of a neurological examination of the lower limb?
The cerebellum. Dysdiadochokinesia (impaired ability to perform rapid, alternating movements) is a sign of cerebellar damage.
Also looking for intention tremors - indicative of multiple sclerosis.
When assessing the sensitivity of the lower limb to light touch, what must you first do?
Ask the patient to close their eyes and touch the sternal angle with the cotton wool to show them what it should feel like.
During a neurological examination of the lower limb, where should you touch to test the L1 dermatome?
Skin overlying the inguinal ligament
During a neurological examination of the lower limb, where should you touch to test the L2 dermatome?
The lateral side of the thigh
During a neurological examination of the lower limb, where should you touch to test the L3 dermatome?
The lower medial side of the thigh
During a neurological examination of the lower limb, where should you touch to test the L4 dermatome?
The medial side of the calf
During a neurological examination of the lower limb, where should you touch to test the L5 dermatome?
The third toe
During a neurological examination of the lower limb, where should you touch to test the S1 dermatome?
The little toe or lateral side of the ankle
During a neurological examination of the lower limb, where should you touch to test the S2 dermatome?
The back of the thigh
When assessing sensitivity to light touch in an lower limb examination, what order must you test the dermatomes?
Compare right with left and ask the patient whether each side feels the same.
Having assessed the sensitivity to light touch in the lower limb, what do you then test? What tract is this testing?
Pin prick test to assess sensitivity to pain. Ask patient to tell you if it feels sharp or dull. Testing the spinothalamic tract.
What do you use to perform the pin prick test in a neurological examination of the lower limb?
A neurological pin
Neurotip
Having performed the pin prick test as part of the lower limb examination, what would you then test? What tract is this testing?
Vibration
Dorsal column
What frequency tuning fork must you use to assess vibration sensitivity in the lower limb?
128 Hz
Where would you test the sensitivity to vibration in the lower limb?
At the most distal bony prominence (eg DIP)
What should you ask the patient to tell you when assessing sensitivity to vibration in the lower limb?
Whether they can feel the vibration and then when the vibration stops (you stop it with your fingers, whilst they have their eyes closed)
Having assessed vibration as part of the neurological examination of the lower limb, what would you then test and how?
Proprioception
Hold the patients finger just proximal to the DIP, then move the distal phalanx with your other hand whilst they close their eyes. Ask them to tell you whether their finger is pointing up or down.
Having tested motor and sensory function of the lower limb, what might you then want to look at?
The patient’s gait
How do you assess a patient’s gait as part of the lower limb exam?
Get them to walk away from you and then turn towards you. Then ask them to walk back to you placing one foot right in front of the other, then on their toes, then on their heels. Then perform Romberg’s test.
What are you looking for when assessing someone’s gait as they walk?
Arm swing Symmetry Speed of turn Stride length Smoothness
What is Romberg’s test?
Testing balance of a patient with their eyes closed. Make sure you put your arms in such a way as to catch them if they begin to fall.
Having assessed sensation in the lower limb, how would you say you would conclude your examination if you had more time?
Upper limb exam
Cranial nerve exam
