Lower limb neuro examination Flashcards
What are the introductory steps of the lower limb neuro examination?
- Wash hands.
- Put on PPE.
- Introduce yourself.
- Ask the patient to confirm their name and DOB.
- Explain examination.
- Gain consent.
Extra steps:
- Ask if the patient has pain anywhere.
- Specifically enquire about back pain.
- If there are any signs of cognitive impairment, GCS + speech assessment.
What comes after introduction in the lower limb neuro exam?
Romberg’s test (modified).
How is Romberg’s test conducted?
Ask the patient to stand with arms outstretched in front, palms supinated and feet together:
- If they cannot do this eyes open this suggests a cerebellar lesion.
- If they cannot do this with eyes closed, this suggests a loss of proprioception.
What comes after Romberg’s test (modified)?
Assessment of gait.
How is the patients gait assessed?
Ask the patient to walk both normally, and then heel-to-toe.
Observe the gait for:
- Foot drop.
- Wide gait.
- Apraxic gait (Parkinson’s).
- Paralysis in one leg.
What comes after gait assessment?
Inspection.
How are the lower limbs inspected, and what is being looked for?
Adequately expose the patients lower limbs (shorts or underwear).
Inspect the legs for:
- Wasting/reduced tone (LMN).
- Fasciculations (LMN).
- Tremor (intention or resting).
- Involuntary movements.
What comes after lower limb inspection?
Assessment of tone.
How is the tone assessed?
- Move legs at hip, knee and ankle joints.
- Do so slowly initially (rigidity) then move them more rapidly (spasticity).
Both are UMN signs.
Lift each knee off the bed briskly. In normal patients, the foot will remain in contact with the bed and slide closer to the patient. If tone is increased, the foot may come off the bed.
Roll the leg at the hip joint.
Check for ankle clonus. Lift their leg off the bed supporting their calf with one hand, and then press on the dorsal aspect of their foot to create dorsiflexion. Hold this position for approximately 5 seconds, and feel for clonus (rapid plantarflexion/dorsiflexion of the ankle). This would be a sign on an UMN lesion.
What comes after assessment of the tone?
Power assessment.
How is power of the lower limbs assessed?
Hip:
Flexion - ask the patient to lift their leg off the bed and not let you push it down.
Extension - Place hand under thigh and ask patient to not let you lift leg off the bed.
Abduction - Ask patient to swing leg out to the side and then not let you push it back to midline.
Adduction - Ask patient to keep leg in position and not let you pull out to the side.
Knee:
Flexion - Ask patient to bend knee so foot is flat on the bed. Then don’t let you straighten their leg.
Extension - Ask the patient to try and straighten their leg against your resistance on their shin.
Ankle:
Dorsiflexion - Ask patient to lie on bed, cock foot backwards and not let you push it down.
Plantarflexion - Ask patient to push foot downwards (“like a car pedal”) and not let you pull their foot back upwards.
Big toe:
Extension - Ask patient to point big toe upwards and not to let you push it down.
Flexion - Ask patient to bend their big toe and then not let you push it upwards.
What comes after power assessment?
Reflex assessment.
How are the lower limb reflexes assessed?
Assess the following reflexes:
- Knee.
- Achilles.
- Plantar reflex. Run a blunt object over the lateral aspect of the sole, and then across the base of the toes whilst holding the ankle in place. A normal response is flexion of the toes. Babinski +ve is extension and splaying of the toes, and suggests an UMN lesion.
What is assessed after reflexes?
Coordination.
How is coordination assessed?
- Heel shin test.
- Ask the patient to rub their heel up their shin. Do this on both sides.
