Neurological exm of lower limbs

Subject stepsBulk ,Tone,Reflexes,Power,function,SensationThe key diagnostic questions:1.where is the lesion :

is it neurological ? if so which part of the nervous system does it localize

-central Vs peripheral-sensory Vs motor

2.what is the lesion:Hereditary/congenital/acquired

Examination

WIPE

• Wash your hands• Introduce yourself to the patient• Permission - to examine the patient• Position - start with the patient sitting• Pain - check that the patient has no pain• Exposure - both upper limbs from shoulders to fingers

INSPECTIONS

Wastings,skin,deformity,fasciculations,joint abnormality

Palpation

1.Bulk of the muscles:Unilateral wastings-old polioGeneralized wastings-MND,POLYNEUROPATHY,LMNLISOLATED ANT. WASTINGS-DM2.Tone:Lift the leg and allow to fall

Palpate the muscles then do side to side movementsLastly passive movement of the limb

3.Reflexes: Knee jerk (L3/4) Ankle jerk (L5/S1) Plantar response (S1):

o Run a blunt object along the lateral edge of the sole of the foot, moving towards the little toe

o Observe the great toeo Normal result = Flexion of the great toe & flexion of the

other toeso Abnormal (Babinski sign) = Extension of the great toe

– UMN lesioSuperficial reflexes-abdominal ,cremasteric4.Muscle power-gradingHipFlexion (L1/2) – “raise your leg off the bed & stop me from pushing it down”Extension (L5/S1) – “stop me from lifting your leg off the bed”Abduction (L4/5) – “move your leg away from the midline”Adduction (L2/3)  – “stop me from moving your leg away from the midline”KneeFlexion (S1) – “bend your knee & stop me from straightening it”Extension (L3/4) – “kick out your leg”AnkleDorsiflexion (L4) – “point your foot towards your head & don’t let me push it down”Plantarflexion (S1/2) – “press against my hand with the sole of your foot”Inversion (L4) – “push your foot against my hand”Eversion (L5/S1) – “push your foot out against my hand”

5.Coordination :Heel to shin test – “run your heel down the other leg from the knee & repeat in a smooth motion

(An inability to perform this test may suggest loss of motor strength, proprioception or a cerebellar disorder)

6.Sensory test:Light   touch sensation Assesses dorsal/posterior columns and spinothalamic tracts.1. The patient’s eyes should be closed for this assessment2. Touch the patient’s sternum with the cotton wool wisp to confirm they can feel it3. Ask the patient to say “yes” when they are touched4. Using a wisp of cotton wool, gently touch the skin (don’t stroke)5. Assess each of the dermatomes of the lower limbs6. Compare left to right, by asking the patient if it feels the same on both sides

Pin-prick   sensation  

Assesses spinothalamic tracts.Repeat the previous assessment steps, but this time using the sharp end of a neurotip.If sensation is reduced peripherally, assess from a distal point and move proximally to identify ‘stocking’ sensory loss.

Vibration sensationAssesses dorsal/posterior columns/1, Ask patient to close their eyes2. Tap a 128 Hz tuning fork3. Place onto patient’s sternum & confirm patient can feel it buzzing4. Ask patient to tell you when they can feel it on their foot & to tell you when it stops buzzing5. Place onto the distal phalanx of the great toe6. If sensation is impaired, continue to assess more proximally – e.g. proximal phalanx

ProprioceptionDorsal / posterior columns.1. Hold the distal phalanx of the great toe by its sides2. Demonstrate movement of the toe “upwards” & “downwards” to the patient ( whilst

7.Gait: Ask patient to walk to the end of the room & back

– assess speed, symmetry & balance Tandem (heel-to-toe) gait – ask to walk in a straight

line heel-to-toe – an abnormal heel-to-toe test may suggest weakness, impaired proprioception or a cerebellar disorder

Heel walking – assesses dorsiflexion power8.Romberg’s test:o Ask patient to stand with their feet together and eyes

closedo Observe the patient (ideally for 1 minute)o Positive test  loss of balance (swaying/falling over)o This suggests a sensory ataxia (defective proprioceptive or

vestibular system)o It’s important to stand close by the patient during this test

to stop them falling over!

Finally look at the spine to see any deformity,scar,gibbus,tenderness