Lower Limb Neurology Examination

Question 1

What do you look out for inspection of the patient and environment?

Answer 1

Environment:

• check for any walking aids and medication

Patient:

• check for muscle hypertrophy or atrophy
• check for fasciculations by flicking the leg (warn them first)
• check for any myoclonic jerks (sudden contraction of the muscle)

Question 2

How do you do check for gait?

How do you check for romberg’s?

Answer 2

Gait:

• check for any broad based ataxic gait
• check for shuffling steps or reduced arm swing
• check for restriction of movement
• ask them to walk to the end of the room
• ask them to turn and walk with one foot in front of the other like they’re on a tight rope-tandem gait to check for cerebellar vermis dysfunction (alcohol induced cerebellar degeneration)
• walk on their heels-ankle dorsiflexion
• walk on their tip toes-ankle plantarflexion

Romberg’s

• ask them to put their feet together and arms to their side
• position your arms such that you can intervene when they fall
• assess for 30s
• falling without correction-> positive romberg’s test: suggest proprioception/dorsal column abnormality or vestibular dysfunction

Question 3

How do you assess for tone in the leg?

Answer 3

Check for pain in the leg first

• Roll the leg back and forth; briskly flexing knee
• check for clonus-rhythmic contractions induced by sudden stretch of the muscle by bending the leg until knee is 90 degrees and suddenly dorsiflexing the ankle

Assess for:

• hypotonia
• hypertonia
• spasticity: velocity dependent
• rigidity: velocity independent

Question 4

How do you assess muscle power in the legs? What are the muscles involved

Answer 4

• hip flexion (iliopsoas)
• hip extension (gluteus maximus)
• Knee flexion (hamstrings)
• knee extension (quadriceps femoris)
• Ankle dorsiflexion (tibialis anterior)
• ankle plantarflexion (gastrocnemius; soleus)
• big toe dorsiflexion (extensor hallucis longus)
• ankle eversion (peronei); ankle inversion (tibialis posterior)

Assess MRC grade 5/5

Question 5

What are the reflexes to assess in the leg? (what nerve root)

Answer 5

• knee (L3,L4)
• ankle (S1)
• babinski’s reflex

-dorsiflexion of big toe and fanning of other toes (get in LMN lesions)

Question 6

What is apraxia and constructional apraxia?

Answer 6

Apraxia-inability to do simple motor tasks (like drinking cup of tea-lesion in motor cortex)

constructional apraxia-inability to draw objects like star (lesion in sensory cortex)

Question 7

How do you assess for sensation in lower limb? Describe the dermatomes in the lower limb?

Answer 7

For lower limb: start off with big toe-> medial malleolus-> knee-> ASIS

Sensory examination (always test on sternum first with eyes closed so that they can use the system)

light touch-cotton wool. Ask them if it feels like cotton wool on sternum. Testing for dorsal column

pain-neurotip. Ask them if it feels dull or sharp on sternum. Testing for both dorsal column/spinothalamic tract.

temperature-tip of tuning fork. Ask them if it feels cold. Testing for spinothalamic tract

vibration-with tuning fork. Testing for dorsal column

proprioception. Testing for dorsal column

Map out area of lesion by moving proximally

Question 8

How do you test for stereognosia/graphaesthesia/sensory inattention?

Answer 8

Stereognosia (inability to identify familiar objects)

Place a familiar object like coin.

If unable to identify it-> lesion in dorsal column or alzheimer’s dementia

Graphaesthesia

Draw a figure/number in palm

If unable to identify it-> lesion in dorsal column

Sensory inattention

testing right and left and both