Upper Limb and Lower Limb Examination

Question 1

What is muscle wasting a sign of?

Answer 1

Lower motor neuron lesions or disuse atrophy.

Question 2

What is the difference between intention and resting tremor?

Answer 2

Resting tremor occurs when the muscle is relaxed, such as when the hands are resting on the lap.

The most common cause of resting tremor is idiopathic Parkinson’s disease (PD).

Intention tremor: a broad, coarse, low-frequency tremor that develops as a limb reaches the endpoint of a deliberate movement. Clinically this results in a tremor that becomes apparent as the patient’s finger approaches yours. Be careful not to mistake an action tremor (which occurs throughout the movement) for an intention tremor.

The presence of dysmetria and intention tremor is suggestive of ipsilateral cerebellar pathology.

Question 3

” You notice small local, involuntary muscle contraction and relaxation which may be visible under the skin. “

Name what is being described and what it is associated with?

Answer 3

Fasciculations: small, local, involuntary muscle contraction and relaxation which may be visible under the skin. Associated with lower motor neuron pathology (e.g. amyotrophic lateral sclerosis).

Question 4

” You notice abnormal writhing movements (typically affecting the fingers)”

Name the sign being described and what it is caused by

Answer 4

Pseudoathetosis: abnormal writhing movements (typically affecting the fingers) caused by a failure of proprioception.

Question 5

“Brief, semi-directed, irregular movements that are not repetitive or rhythmic but appear to flow from one muscle to the next.”

Name the sign being described and its cause?

Answer 5

Chorea: brief, semi-directed, irregular movements that are not repetitive or rhythmic but appear to flow from one muscle to the next. Patients with Huntington’s disease typically present with chorea.

Question 6

” brief, involuntary, irregular twitching of a muscle or group of muscles.”

Name the sign being described and state when it occurs

Answer 6

Myoclonus: brief, involuntary, irregular twitching of a muscle or group of muscles. All individuals experience benign myoclonus on occasion (e.g. whilst falling asleep) however persistent widespread myoclonus is associated with several specific forms of epilepsy (e.g. juvenile myoclonic epilepsy).

Question 7

“involuntary, repetitive body movements which can include protrusion of the tongue, lip-smacking and grimacing.”

Name the sign being described and its cause

Answer 7

Tardive dyskinesia: involuntary, repetitive body movements which can include protrusion of the tongue, lip-smacking and grimacing. This condition can develop secondary to treatment with neuroleptic medications including antipsychotics and antiemetics.

Question 8

What is hypomania?

Answer 8

Hypomimia: a reduced degree of facial expression associated with Parkinson’s disease.

Question 9

What is the following sign and what may it indicate?

Answer 9

Ptosis and frontal balding: typically associated with myotonic dystrophy.

Question 10

What is the following sign and what does it suggest?

Answer 10

Ophthalmoplegia: weakness or paralysis of one or more extraocular muscles responsible for eye movements. Ophthalmoplegia can be caused by a wide range of neurological disorders including multiple sclerosis and myasthenia gravis.

Question 11

What does pronator drift indicate?

Answer 11

Checking for pronator drift is a useful way of assessing for mild upper limb weakness and spasticity:

Interpretation

If the forearm pronates, with or without downward movement, the patient is considered to have pronator drift on that side. The presence of pronator drift indicates a contralateral pyramidal tract lesion. Pronation occurs because, in the context of an UMN lesion, the supinator muscles of the forearm are typically weaker than the pronator muscles.

Question 12

What is the difference between spacticity and rigidity?

Answer 12

Spasticity is “velocity-dependent”, meaning the faster you move the limb, the worse it is. There is typically increased tone in the initial part of the movement which then suddenly reduces past a certain point (known as “clasp knife spasticity”). Spasticity is also typically accompanied by weakness.

Rigidity is “velocity independent” meaning it feels the same if you move the limb rapidly or slowly. There are two main sub-types of rigidity:

Question 13

What can cause spasticity?

Answer 13

Spasticity is associated with pyramidal tract lesions (e.g. stroke)

Question 14

What can cause rigidity?

Answer 14

Rigidity is associated with extrapyramidal tract lesions (e.g. Parkinson’s disease).

Question 15

What is cogwheel rigidity and how is it caused?

Answer 15

Cogwheel rigidity involves a tremor superimposed on the hypertonia, resulting in intermittent increases in tone during movement of the limb. This subtype of rigidity is associated with Parkinson’s disease.

Question 16

What is Lead pipe rigidity and how is it caused?

Answer 16

Lead pipe rigidity involves uniformly increased tone throughout the movement of the muscle. This subtype of rigidity is typically associated with neuroleptic malignant syndrome.

Question 17

Shoulder ABduction test what nerve/muscles?

Answer 17

Myotome assessed: C5 (axillary nerve)

Muscles assessed: deltoid (primary) and other shoulder abductors

Question 18

Shoulder ADduction test what nerve/muscles?

Answer 18

Myotomes assessed: C6/7 (thoracodorsal nerve)

Muscles assessed: teres major, latissimus dorsi and pectoralis major

Question 19

Elbow flexion tests what nerve/muscles?

Answer 19

Myotomes assessed: C5/6 (musculocutaneous and radial nerve)

Muscles assessed: biceps brachii, coracobrachialis and brachialis

Question 20

Elbow extension tests what nerve/muscles?

Answer 20

Myotome assessed: C7 (radial nerve)

Muscles assessed: triceps brachii

Question 21

Wrist extension tests what nerve/muscles?

Answer 21

Myotome assessed: C6 (radial nerve)

Muscles assessed: extensors of the wrist

Question 22

Wrist flexion tests what nerve/muscles?

Answer 22

Myotomes assessed: C6/7 (median nerve)

Muscles assessed: flexors of the wrist

Question 23

Finger extension tests what nerve/muscles?

Answer 23

Myotome assessed: C7 (radial nerve)

Muscles assessed: extensor digitorum

Question 24

Finger ABduction tests what nerve/muscles?

Answer 24

Myotome assessed: T1 (ulnar nerve)

Muscles assessed:

First dorsal interosseous (FDI)

Abductor digiti minimi (ADM)

Question 25

Thumb ABduction tests what nerve/muscles?

Answer 25

Myotomes assessed: T1 (median nerve)

Muscle assessed: abductor pollicis brevis

Question 26

What is the difference between UMN and LMN lesions?

Answer 26

Patterns of muscle weakness

Upper motor neuron lesions cause a ‘pyramidal’ pattern of weakness that disproportionately affects upper limb extensors and lower limb flexors (i.e. upper limb extensors are weaker than flexors in an upper limb neurological assessment).

Lower motor neuron lesions cause a focal pattern of weakness, with only the muscles directly innervated by the damaged neurones affected.

Question 27

Explain the MRC power scale

Answer 27

MRC muscle power assessment scale

The MRC scale of muscle strength uses a score of 0 to 5 to grade the power of a particular muscle group in relation to the movement of a single joint.

0No contraction

1Flicker or trace of contraction

2Active movement, with gravity eliminated

3Active movement against gravity

4Active movement against gravity and resistance

5Normal power

Question 28

What reflexes should you test in an upper lim exam and what nerves do they test?

Answer 28

Biceps reflex (C5/6)

Supinator (brachioradialis) reflex (C5/6)

Triceps reflex (C7)

Question 29

Explain the causes of hyper/hyporeflexia ?

What are pendular reflexes?

Answer 29

Hyperreflexia is typically associated with upper motor neuron lesions (e.g. stroke, spinal cord injury) due to the loss of inhibition from higher brain centres which normally exert a degree of suppression over the lower motor neuron reflex arc.

Hyporeflexia is typically associated with lower motor neuron lesions (e.g. brachial plexus pathology or other peripheral nerve injuries) due to loss of the efferent and afferent branches of the normal reflex arc.

In cerebellar disease, reflexes are described as ‘pendular’, which means less brisk and slower in their rise and fall. This sign is, however, very subjective and often reflexes appear to be ‘normal’ in cerebellar disease.

Question 30

Describe the dermatomes of the upper limb

Answer 30

Question 31

Define the following conditions:

Patterns of sensory loss

Mononeuropathies

Peripheral neuropathy

Radiculopathy

Spinal cord damage

Thalamic lesions

Myopathies

Answer 31

Patterns of sensory loss

Mononeuropathies result in a localised sensory disturbance in the area supplied by the damaged nerve.

Peripheral neuropathy typically causes symmetrical sensory deficits in a ‘glove and stocking’ distribution in the peripheral limbs. The most common causes of peripheral neuropathy are diabetes mellitus and chronic alcohol excess.

Radiculopathy occurs due to nerve root damage (e.g. compression by a herniated intervertebral disc), resulting in sensory disturbances in the associated dermatomes.

Spinal cord damage results in sensory loss both at and below the level of involvement in a dermatomal pattern due to its impact on the sensory tracts running through the cord.

Thalamic lesions (e.g. stroke) result in contralateral sensory loss.

Myopathies often involve symmetrical proximal muscle weakness.

Question 32

What is the following clinical sign and its cause?

“the inability to perform rapid, alternating movements,”

Answer 32

Dysdiadochokinesia is a term that describes the inability to perform rapid, alternating movements, which is a feature of ipsilateral cerebellar pathology.

Question 33

What further assessments and investigations would you request after completing an upper limb exam?

Answer 33

Further assessments and investigations

Full neurological examination including the cranial nerves, lower limbs and cerebellar assessment.

Neuroimaging (e.g. MRI spine and head).

Question 35

What does a broad-based ataxic gait suggest?

Answer 35

Ataxic gait: broad-based, unsteady and associated with either cerebellar pathology or sensory ataxia (e.g. vestibular or proprioceptive dysfunction). In the context of proprioceptive sensory ataxia, patients typically watch their feet intently to compensate for the proprioceptive loss. If a cerebellar lesion is present the patient may veer to the side of the lesion.

Question 36

What does a staggering, slow and unsteady gait suggest?

Answer 36

Stability: a staggering, slow and unsteady gait is typical of cerebellar pathology. In unilateral cerebellar disease, patients will veer towards the side of the lesion.

Question 37

Turning manouvres are difficult in which pathology?

Answer 37

Turning: patients with cerebellar disease will find the turning manoeuvre particularly difficult.

Question 38

What changes in gait may you notice in patients with parkinsons?

Answer 38

Parkinsonian gait: small, shuffling steps, stooped posture and reduced arm swing (initially unilateral). The patient will require several small steps to turn around. The gait appears rushed (festinating) and may get stuck (freeze). Hand tremor may also be noticeable.

Question 39

What does a high stepping gait suggest?

Answer 39

High-stepping gait: can be unilateral or bilateral and is typically caused by foot drop (weakness of ankle dorsiflexion). The patient also won’t be able to walk on their heel(s).

Question 40

What does a waddling gait suggest?

Answer 40

Waddling gait: shoulders sway from side to side, legs lifted off ground with the aid of tilting the trunk. Waddling gait is commonly caused by proximal lower limb weakness (e.g. myopathy).

Question 41

What does a hemiparetic gait suggest?

Answer 41

Hemiparetic gait: one leg held stiffly and swings round in an arc with each stride (circumduction). This type of gait is commonly associated with individuals who have had a stroke.

Question 42

What does spastic paraparesis suggest?

Answer 42

Spastic paraparesis: similar to hemiparetic gait but bilateral, with both legs stiff and circumducting. The patient’s feet may be inverted and “scissor”. This type of gait is typically associated with hereditary spastic paraplegia.

Question 43

What does Rombergs test assess?

Answer 43

Romberg’s test is used to assess for loss of proprioceptive or vestibular function (known as sensory ataxia). The test does not assess cerebellar function and instead is used to quickly screen for evidence of sensory ataxia (i.e. non-cerebellar causes of balance issues).

Romberg’s test is based on the premise that a patient requires at least two of the following three senses to maintain balance whilst standing:

Proprioception: the awareness of one’s body position in space.

Vestibular function: the ability to know one’s head position in space.

Vision: the ability to see one’s position in space.

Romberg’s test involves removing the sense of vision by asking the patient to close their eyes. As a result, if the patient has a deficit in proprioception or vestibular function they will struggle to remain standing without visual input.

Interpretation

Falling without correction is abnormal and referred to as a positive Romberg’s sign. This indicates unsteadiness is due to sensory ataxia (i.e. a deficit of proprioceptive or vestibular function, rather than cerebellar function). Causes of proprioceptive dysfunction include joint hypermobility (e.g. Ehlers-Danlos syndrome), B12 deficiency, Parkinson’s disease and ageing (known as presbypropria). Causes of vestibular dysfunction include vestibular neuronitis and Ménière’s disease.

Swaying with correction is not a positive result and often occurs in cerebellar disease due to truncal ataxia.

Question 44

What is ankle clonus a sign of?

Answer 44

Clonus is a series of involuntary rhythmic muscular contractions and relaxations that is associated with upper motor neuron lesions of the descending motor pathways (e.g. stroke, multiple sclerosis, cerebral palsy).

Question 45

Hip flexion tests what myotome/Muscles?

Answer 45

Hip flexion

Myotome assessed: L1/2

Muscles assessed: iliopsoas

Question 46

Hip extension tests what myotome/Muscles?

Answer 46

Myotome assessed: L5/S1/S2 (inferior gluteal nerve)

Muscles assessed: gluteus maximus

Question 47

Knee flexion tests what myotome/Muscles?

Answer 47

Myotome assessed: S1 (sciatic nerve)

Muscles assessed: hamstrings

Question 48

Knee extension tests what myotome/Muscles?

Answer 48

Myotome assessed: L3/4 (femoral nerve)

Muscles assessed: quadriceps

Question 49

Ankle dorsiflexion tests what myotome/Muscles?

Answer 49

Myotome assessed: L4/5 (deep peroneal nerve)

Muscles assessed: tibialis anterior

Question 50

Ankle plantarflexion tests what myotome/Muscles?

Answer 50

Ankle plantarflexion

Myotome assessed: S1/2 (tibial nerve)

Muscles assessed: gastrocnemius, soleus

Question 51

Big toe extension tests what myotome/Muscles?

Answer 51

Myotome assessed: L5 (deep peroneal nerve)

Muscles assessed: extensor hallucis longus

Question 52

What reflexes are tested in a lower limb examination what nerves are tested?

Answer 52

Knee-jerk reflex (L3, L4)

Ankle-jerk reflex (S1)

Plantar reflex (L5, S1)

Abnormal (Babinski sign): extension of the big toe and spread of the other toes (suggestive of an upper motor neuron lesion).

Question 53

What is babinskis sign?

Answer 53

Abnormal (Babinski sign): extension of the big toe and spread of the other toes (suggestive of an upper motor neuron lesion)

Question 54

Describe the dermatoes supplying the lower limb

Answer 54

Question 55

What Further assessments and investigations would you request after completing a lower limb exam?`

Answer 55

Further assessments and investigations

Full neurological examination including the cranial nerves, upper limbs and cerebellar assessment.

Neuroimaging (e.g. MRI spine and head).