Lower limb neuro examination

Question 1

What is the first part of any introduction to an examination?

Answer 1

Wash hands
Intro self
Pt details

Question 2

Explain a LLN exam to a patient

Answer 2

I’ve been asked to examine your lower limbs today, it’s going to involve moving your legs about a bit, asking you to walk, testing your reflexes, sensation and coordination, would that be alright?

Question 3

What else would you include in your intro?

Answer 3

Expose ok?
Chaperone?
Pain or discomfort?
Handiness of the pt?

Question 4

When inspecting the bedside what do you look for?

Answer 4

Wheelchair.
Walking stick.

Question 5

When generally inspecting the what do you look for?

Answer 5

Any limb deformity or posturing.

Question 6

What does SWIFT stand for when inspecting in a LLN exam?

Answer 6

S - Scars.
W - Wasting of muscles.
I - Involuntary movements (dystonia, chorea, myoclonus).
F - Fasciculations.
T - Tremor (Parkinson’s disease)

Question 7

What do you look for when assessing gait?

Answer 7

Assess the patient’s gait walking normally + any issues turning –
- Look at balance, posture, stride length + arm swing.

Assess the patient’s gait walking tandem (heel-to-toe) –
- Abnormal may suggest weakness, impaired
proprioception or a cerebellar disorder.

Question 8

How do you perform Romberg’s test?

What instructions would you give to the patient?

What is indicated in the following?
a) Unable to do with eyes open
b) Unable to do with eyes closed

Answer 8

Feet together, arms outstretched in front of them + hands supinated.

Can you just put your feet together + arms out in front of you with your palms facing upwards and I’ll be here to catch you if you feel unsteady… now can you close your eyes?

a) Unable with eyes open = cerebellar lesion.
b) Unable with eyes closed = loss of proprioception.

Question 9

What tests do you do to test tone in the LLN exam?

What should you ask the patient to do before performing them?

Answer 9

Leg roll
Leg lift
Ankle clonus

Ask the patient to let their legs go fully relaxed + floppy.

Question 10

How do you perform a leg roll?

Answer 10

Roll the patient’s leg + watch foot (it should flop independently of the leg)

Question 11

How do you perform a leg lift?

Answer 11

Briskly lift leg off the bed at the knee joint (heel should remain in contact with the bed)

Question 12

How do you perform ankle clonus?

What is considered normal?

Answer 12

Position the patient’s leg so the knee + ankle are slightly flexed, support the leg with your hand under their knee so they can relax.
Rapidly dorsiflex + partially evert foot then leave it dorsiflexed.

Clonus felt as rhythmical beats of dorsi/plantar flexion, >5 abnormal.

Question 13

What is the best way to asses power in a ULN exam?

Answer 13

Assess power one side at a time + compare like for like (finger test toe).
Stabilise + isolate the joint when testing.
MRC muscle power assessment scale for scoring

Question 13

What is the best way to asses power in a ULN exam?

Answer 13

Assess power one side at a time + compare like for like (finger test toe).
Stabilise + isolate the joint when testing.
MRC muscle power assessment scale for scoring

Question 14

Where do you want to assess power in a ULN exam?

Answer 14

Hip

Knee

Ankle

Big toe

Question 15

What hip movements do you want to assess?

What instructions do you give to the patient?

Answer 15

Flexion (L1/2) – “Raise your leg off the bed and stop me pushing it down”.

Extension (L5/S1) – “Stop me from lifting your leg up”.

ABduction (L4/5) – “Push your legs out against me”.

ADduction (L2/3) – “Squeeze your legs in against me”.

Question 16

What knee movements do you want to assess?

What instructions do you give to the patient?

Answer 16

Flexion (S1) – “Bend your knee and stop me from straightening it”.

Extension (L3/4) – “Kick your leg out against me”.

Question 17

What ankle movements do you want to assess?

What instructions do you give to the patient?

Answer 17

“Keep your legs flat on the bed and…”

Dorsiflexion (L4) – “Don’t let me push your foot down”.

Plantarflexion (S1/2) – “Don’t let me push your foot up”.

Inversion (L4) – “Push your foot in against my hand”.

Eversion (L5/S1) – “Push your foot out against my hand”.

Question 18

What big toe movements do you want to assess?

What instructions do you give to the patient?

Answer 18

Extension (L5) – “Don’t let me push your big toe down”.

Flexion (?) – “Don’t let me push your big toe up”.

Question 19

What reflexes do you want to check in a ULN exam?

Answer 19

Knee jerk (L3/4)

Ankle jerk (L5/S1)

Plantar reflex (S1)

Question 20

What reinforcement manoeuvre can do you to accentuate a reflex?

Answer 20

Clench teeth

Question 21

How to do test the knee jerk reflex?

Answer 21

Hold under the knee joint + strike tendon hammer at the patellar tendon

Question 22

How to do test the ankle jerk reflex?

Answer 22

Bend leg + let it flop out to the side, relax your ankle then dorsiflex it.

Question 23

How to do test the plantar reflex?

What is a normal response?

What is babinski sign?

Answer 23

Run a blunt object along the lateral edge of the sole of the foot, moving towards the little toe then medially under toes, observing big toe, warn might be a bit ticklish.

Normal = flexion of the big toe + other toes.

Abnormal (Babinski sign) = extension of big toe + spread of other toes 🡪 UMN lesion.

Question 24

How do you assess coordination in the LLN exam?

What instructions do you give to the patient?

What does an inability indicate?

Answer 24

Heel to shin test

“Put your heel on your knee, run it down your shin, lift it up and repeat as fast as you can”.

Loss of motor strength, proprioception or a cerebellar disorder.

Question 25

How do you assess the sensation in the LLN exam?

Answer 25

Assess dermatomes L2–S1.

Provide a comparison point (sternum/forehead) and then ask patient to close eyes.

Ask patient to say yes when they are touched.

Compare left to right + ask if it feels the same on both sides.

Question 26

What does light touch sensation test?

What do you use?

Answer 26

Assesses dorsal/posterior columns + spinothalamic tracts.

Use cotton wool.

Question 27

What does vibration sensation test?

Answer 27

Assesses dorsal/posterior columns.

Question 28

How do you assess vibration sense?

Answer 28

Place on distal phalanx joint of big toe + ask if they can feel it buzzing + if they feel it stop.

If vibration sensation is impaired, continue to assess the bony prominence of more proximal joints –
- Proximal phalanx
- Ankle
- Knee
- Hip

Question 29

What does proprioception sensation test?

Answer 29

Assesses dorsal/posterior columns.

Question 30

How do you asses proprioception in the LLN exam?

Answer 30

Hold the distal phalanx of their big toe by its sides.

Demonstrate the movement of the toes upwards + downwards to the patient whilst they watch.

Ask patient to close their eyes + state if you are moving toes up/down.

If patient is unable to correctly identify the direction then move to a more proximal joint –
- Big toe.
- Ankle.
- Knee.
- Hip.

Question 31

Upon completing the exam what do you do first?

Answer 31

Thank patient
Wash hands

Question 32

To complete my exam…

Answer 32

To complete my examination, I’d like to do an upper limb neurological examination and a full cranial nerve examination

Question 33

Summarise a normal LLN exam

Answer 33

Today I performed a LLN exam on ___ a ___ y/o __

On general inspection ___ appeared comfy at rest

There were no abnormalities in posture, deformities, muscle wasting or fasciculations detected

Gait was normal and Romberg’s -ve

Tone was normal throughout

Power was 5/5 in all muscle groups bilaterally

Reflexes were normal + present at knee + ankles bilaterally

Plantars were down going bilaterally

Coordination was intact

Sensation was normal in all modalities tested

In summary, this was consistent w/ a normal ULN exam