11/13/24, 7\:06 PM Guide | Lower limb neurological exam

Lower limb neurological exam

Table of contents
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Gather equipment

Gather the appropriate equipment\:
Tendon hammer
Neurotip
Cotton wool
Tuning fork (128Hz)

Introduction

Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Con
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Gain consent to proceed with the examination.
Adequately expose the patient’s legs (typically this involves the patient wearing only their underwear) and provide a blanket to
cover the patient when not being examined.
Position the patient appropriately on an examination couch (typically with the headrest elevated to 30-45°).
Ask the patient if they have any pain before proceeding with the clinical examination.
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General inspection

Clinical signs

Perform a brief general inspection of the patient, looking for clinical signs suggestive of underlying pathology\:
Scars\: may provide clues regarding previous spinal or lower limb surgery.
Wasting of muscles\: suggestive of lower motor neuron lesions or disuse atrophy.
Tremor\: there are several subtypes including resting tremor and intention tremor.
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).
Pseudoathetosis\: abnormal writhing movements (typically a
Chorea\: brief, semi-directed, irregular movements that are not repetitive or rhythmic but appear to
the next. Patients with Huntington's disease typically present with chorea.
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
speci
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.
Hypomimia\: a reduced degree of facial expression associated with Parkinson's disease.
Ptosis and frontal balding\: typically associated with myotonic dystrophy.
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.

Objects or equipment

Look for objects or equipment on or around the patient that may provide useful insights into their medical history and current
clinical status\:
Walking aids\: the ability to walk can be impacted by a wide range of neurological pathology.
Prescriptions\: prescribing charts or personal prescriptions can provide useful information about the patient’s recent
medications.
General inspection
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Gait

Patients with neurological disease are often at an increased risk of falls so make sure to remain close to the patient during the
assessment so that you are able to intervene if required.
Ask the patient to walk to the end of the examination room and then turn and walk back whilst you observe their gait paying
attention to\:
Stance\: observe the patient's posture for asymmetries which may indicate weakness, abnormalities of proprioception or
cerebellar pathology.
Base\: a broad-based ataxic gait is typically associated with midline cerebellar pathology (e.g. a lesion in multiple sclerosis or
degeneration of the cerebellar vermis secondary to chronic alcohol excess).
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.
Arm swing\: often absent or reduced in Parkinson's disease (typically unilateral initially).
Stride length and step height\: small, shu
the presence of foot drop.
Turning\: patients with cerebellar disease will

Tandem ('heel-to-toe') gait

Ask the patient to walk to the end of the examination room and back with their heels to their toes (known as 'tandem gait').
Heel-to-toe walking exacerbates underlying unsteadiness making it easier to identify more subtle ataxia.
Tandem gait is particularly sensitive at identifying dysfunction of the cerebellar vermis (e.g. alcohol-induced cerebellar
degeneration). Di
ataxia.
Assess gait
Gait abnormalities
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.
Parkinsonian gait\: small, shu
require several small steps to turn around. The gait appears rushed (festinating) and may get stuck (freeze). Hand
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tremor may also be noticeable.
High-stepping gait\: can be unilateral or bilateral and is typically caused by foot drop (weakness of ankle dorsi
The patient also won’t be able to walk on their heel(s).
Waddling gait\: shoulders sway from side to side, legs lifted o
commonly caused by proximal lower limb weakness (e.g. myopathy).
Hemiparetic gait\: one leg held sti
commonly associated with individuals who have had a stroke.
Spastic paraparesis\: similar to hemiparetic gait but bilateral, with both legs sti
may be inverted and “scissor”
. This type of gait is typically associated with hereditary spastic paraplegia.

Romberg's test

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
de

Assessment

1. Position yourself within arms reach of the patient to allow you to intervene should they begin to fall.
2. Ask the patient to put their feet together and keep their arms by their sides (be aware that patients with truncal ataxia may
struggle to do this, however, this type of unsteadiness is not the same as a positive Romberg's sign).
3. Ask the patient to close their eyes.

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 de
dysfunction include joint hypermobility (e.g. Ehlers-Danlos syndrome), B12 de
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.
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Romberg's test

Tone

Leg roll and leg lift

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patient to keep their legs fully relaxed throughout the assessment.
1. With the patient lying on the examination couch, roll each leg to assess tone in the muscles responsible for the rotation of
the hip.
2. Lift each knee briskly o
tone, the knee should rise whilst the heel remains in contact with the bed (the heel will typically lift o
increased tone).

Ankle clonus

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).
1. Position the patient's leg so that the knee and ankle are slightly
they can relax.
2. Rapidly dorsi
3. Keep the foot in this position and observe for clonus. Clonus is felt as rhythmic beats of dorsi
more than 5 beats of clonus are present, this would be classed as an abnormal
Spasticity vs rigidity
Spasticity is associated with pyramidal tract lesions (e.g. stroke) and rigidity is associated with extrapyramidal tract
lesions (e.g. Parkinson's disease). Spasticity and rigidity both involve increased tone, so it's important to understand how
to di
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.
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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\:
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.
Lead pipe rigidity involves uniformly increased tone throughout the movement of the muscle. This subtype of rigidity is
typically associated with neuroleptic malignant syndrome.
Roll the leg

Power

Assess the power of the patient's lower limbs by working through the sequence of assessments below.
You must stabilise and isolate the relevant joint for each assessment to ensure you can accurately measure and compare
muscle strength. As a result, you should only assess one side at a time.
At each stage in the assessment, you should compare like for like.
Use the MRC muscle power assessment scale for scoring muscle strength (details below).
You need to communicate clear instructions to the patient during each stage of the assessment. Demonstrating each position
you want the patient to assume can aid understanding.

Hip

Hip
Myotome assessed\: L1/2
Muscles assessed\: iliopsoas
Instructions\: Ask the patient to raise their leg o
o
"
" L i f t y o u r l e g
Hip extension
Myotome assessed\: L5/S1/S2 (inferior gluteal nerve)
Muscles assessed\: gluteus maximus
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Instructions\: Place your hand under the patient's thigh and ask them to resist you trying to lift their leg\: " D o n' t l e t m e l i f t y o u r
l e g o
"

Knee

Knee
Myotome assessed\: S1 (sciatic nerve)
Muscles assessed\: hamstrings
Instructions\: Ask the patient to
leg towards you\:
" B e n d y o u r k n e e s o t h a t y o u r f o o t i s
"
Knee extension
Myotome assessed\: L3/4 (femoral nerve)
Muscles assessed\: quadriceps
Instructions\: With the patient's knee still
patient to try and straighten their leg\:
" T r y a n d s t r a i g h t e n y o u r l e g w h i l s t I t r y t o s t o p y o u .
"

Ankle

Ankle dorsi
Myotome assessed\: L4/5 (deep peroneal nerve)
Muscles assessed\: tibialis anterior
Instructions\: Ask the patient to position their legs
downwards\:
" P u t y o u r l e g s
"
Ankle plantar
Myotome assessed\: S1/2 (tibial nerve)
Muscles assessed\: gastrocnemius, soleus
Instructions\: With the patient's legs still
upwards\:
" P o i n t y o u r f o o t d o w n w a r d s l i k e y o u' r e p u s h i n g a c a r p e d a l a n d d o n' t l e t m e p u l l i t u p .
"

Big toe

Big toe extension
Myotome assessed\: L5 (deep peroneal nerve)
Muscles assessed\: extensor hallucis longus
Instructions\: With the patient's legs still
" P o i n t y o u r b i g t o e u p t o w a r d s y o u r h e a d a n d d o n' t l e t m e p u s h i t d o w n .
"
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Hip
Patterns of muscle weakness
Upper motor neuron lesions cause a 'pyramidal' pattern of weakness that disproportionately a
and upper limb extensors (i.e. lower limb
Lower motor neuron lesions cause a focal pattern of weakness, with only the muscles directly innervated by the
damaged neurones a
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.
Score Description
0 No contraction
1 Flicker or trace of contraction
2 Active movement, with gravity eliminated
3 Active movement against gravity
4 Active movement against gravity and resistance
5 Normal power

Re

Explain to the patient that you are now going to assess their re
useful to show the patient the tendon hammer at this stage).
For each of the re
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Make sure to hold the tendon hammer handle at its end to allow gravity to aid a good swing.
If a re
patient to clench their teeth together whilst you simultaneously tap the tendon.

Knee-jerk re

Assess the knee-jerk re
1. Remove the weight from the patient's lower limb by either supporting it or asking the patient to hang their legs over the side
of the bed. Ensure the patient’s lower limb is completely relaxed before assessing the knee-jerk re
2. Tap the patellar tendon with the tendon hammer (making sure to hold the tendon hammer handle at its end to allow gravity
to aid a good swing).
3. If a re

Ankle-jerk re

Assess the ankle-jerk re
There are several methods for eliciting the ankle-jerk re
Method 1
ankle is dorsi
1. With the patient on the examination couch support their leg so that their hip is slightly abducted, the knee is
2. Tap the Achilles tendon with the tendon hammer and observe for a contraction in the gastrocnemius muscle with associated
plantar
Method 2
1. Ask the patient to kneel on a chair and hold the back of it to steady themselves.
2. Tap the Achilles tendon with the tendon hammer and observe for a contraction in the gastrocnemius muscle with associated
plantar

Plantar re

Assess the plantar re
1. With the patient positioned laying on the examination couch, explain that you are going to scratch the foot with a blunt stick
(typically an orange stick) and that this will feel brie
2. Fix the foot in position by holding the ankle (if the left foot is being assessed, use your left hand to hold the ankle and vice
versa).
3. Run the blunt object along the lateral edge of the sole of the foot, moving towards the base of the little toe and then turn
medially to run across the transverse arch of the foot under the toes.
4. Observe the big toe\:
Normal result\:
Abnormal (Babinski sign)\: extension of the big toe and spread of the other toes (suggestive of an upper motor neuron lesion).
Hyperre
Hyperre
inhibition from higher brain centres which normally exert a degree of suppression over the lower motor neuron re
Hypore
nerve injuries) due to loss of the e
In cerebellar disease, re
, which means less brisk and slower in their rise and fall. This
sign is, however, very subjective and often re
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Knee-jerk re

Sensation

It’s easy to get bogged down in examining sensation, but the key points are as follows\:
Check at least one modality each from the dorsal columns and spinothalamic tracts.
Ensure the patient has their eyes closed for the assessment.
Demonstrate normal sensation on the patient's sternum.
Assess sensation across each of the lower limb dermatomes (see below), comparing left to right at equivalent regions as
you progress.

Dermatomes

It's important to avoid assessing sensation close to dermatomal boundaries to minimise the risk of misinterpretation. Here are
some locations you can use to assess each of the lower limb dermatomes\:
L1\: inguinal region and the very top of the medial thigh
L2\: middle and lateral aspect of the anterior thigh
L3\: medial aspect of the knee
L4\: medial aspect of the lower leg and ankle
L5\: dorsum and medial aspect of the big toe
S1\: dorsum and lateral aspect of the little toe
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Lower limb dermatomes

Light touch sensation

Light touch sensation involves both the dorsal columns and spinothalamic tracts.
1. Ask the patient to close their eyes and touch their sternum with the wisp of cotton wool to provide an example of light touch
sensation.
2. Ask the patient to say
"
yes"
when they feel the sensation.
3. Using the wisp of cotton wool, begin to assess light touch sensation across each of the lower limb dermatomes, comparing
each side as you go by asking the patient if it feels the same.
L2
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Pin-prick sensation

Pin-prick (pain) sensation involves the spinothalamic tracts.
Repeat the previous assessment steps used for light touch sensation, but this time using the sharp end of a neuro-tip.
If loss of sensation is noted distally, test for "stocking" distribution of sensory loss (associated with peripheral neuropathy) by
moving distal to proximal. If necessary, keep going all the way up the leg and trunk until an area of normal sensation is
identi
, which is suggestive of a spinal lesion (e.g. if there is abnormal sensation up to the
level of the umbilicus, this suggests a spinal lesion at around T10).
L2

Vibration sensation

Vibration sensation involves the dorsal columns.
1. Ask the patient to close their eyes and to let you know both when they can detect vibration and when it stops.
2. Tap a 128 Hz tuning fork and place onto the patient's sternum to check they are able to feel it vibrating. Then grasp the ends
of the tuning fork to cease vibration and see if the patient is able to accurately identify that it has stopped.
3. Tap the tuning fork again and place onto the interphalangeal joint of the patient's big toe. If the patient is able to accurately
identify when the vibration begins and when it stops at this point in both lower limbs, the assessment is complete.
4. If vibration sensation is impaired at the interphalangeal joint of the patient's big toe, continue to sequentially assess more
proximal joints (e.g. metatarsophalangeal joint of the big toe → ankle joint → knee joint) until the patient is able to accurately
identify vibration.
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Assess vibration sensation

Proprioception

Proprioception, also known as joint position sense, involves the dorsal columns.
1. Begin assessment of proprioception at the interphalangeal joint of the big toe by holding the distal phalanx of the big toe by
its sides (avoid holding the nail bed as this can allow the patient to determine direction based on pressure).
2. Demonstrate movement of the big toe "
upwards" and "downwards" to the patient whilst they watch.
3. Ask the patient to close their eyes and state if you are moving their big toe up or down.
4. Move the big toe up or down 3-4 times in a random sequence to see if the patient is able to accurately identify joint position
with their eyes closed.
5. If the patient is unable to correctly identify the direction of movement, continue to sequentially assess more proximal joints
(e.g. metatarsophalangeal joint of the big toe → ankle joint → knee joint).
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Assess proprioception

Co-ordination

Heel-to-shin test

Assessment
The heel-to-shin test is a convenient method of assessing lower limb co-ordination\:
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