Lower Limb Examination

Lower Limb 

Examination

Introduction

• Introduction, correct patient, wash hands (WINDEC);

• Consent- Hi __, would i able to able to examine your legs, looking at their motor functions, co-ordination sensation & gait; check pain

• Adequate exposure

Inspection: 

• End of the bed- muscle wasting, fasciculations, weakness, scars

Motor

Tone

• Roll legs

• Lift legs- slow & quick

• Clonus- > 5 beats

Power

• Hip 

  • • Flexion L2, femoral nerve

    • Extension, L5-S2, gluteal nerve

• Knee

  • • Flexion, S2, sciatic

    • Extension L3, femoral nerve, quadriceps

• Ankle

  • • Dorsi-flexion, L4 peroneal

    • Plantar flexion, S1 tibial

• Toe 1st 

  • • Flexion, L5 peroneal 

    • Extension S1, tibial

Reflexes

• Reinforcement & distraction, grip hands together

  • Knee L3/4 (lift knee + patellar tendon)

  • Achilles S1 (ankle extended, hit at MTP)

  • Plantar reflex S1 - warn feel ticklish, (scratch outside of foot up foot, first toe flexes)

Co-ordination- both proprioception, motor and cerebellar integration

• Heel shin

Sensory

Fine touch (cotton wool) 

• Touch onto sternum to know touch

  • Lateral mid thigh L2

  • Medial thigh above knee L3

  • Medial calf L4

  • Lateral calf L5

  • Anterior first toe L5

  • Anterior 5th toe S1, lateral 

• Ascending neuropathy- heel to thigh

 Sharp touch (pin prick)

• Same as fine touch

Vibration (tendon hammer)

• Buzzing not metal 

• Start on toe- tell when stopped buzzing

  • If can't tell, move up boney prominence landmarks- 1st to MTP, then, ankle, tibial prominence, patellar, ASIS 

Proprioception

• Toe up or down

• If nil sensation continue to ankle, knee, hip 

Gait

• Normal gait- walk & turn

• Heel-toe gait

• Romberg's test (balance) +- small push

Conclusion

Consider looking for a spinal scar. 

Thank the patient, help getting dressed and wash hands. 

Signs

Inspection

• Fasciculations

Tone

• Spasticity- increased tone with increased speed

• Rigidity- increased tone regardless of speed

• Clonus

Power

Localising the lesion

Reduced power

• UMN Lesion: central nervous system- brain & spinal cord

  • Reduced power, increased tone & reflexes

• LMN Lesion: peripheral nervous system

  • Reduced power, tone and reflexes, fasciculations; muscle wasting

• Causes

  • UMN: MS, stroke

  • LMN: peripheral neuropathy

  • Mixed: B12- subacute DGN of spinal cord, diabetes/ hypertensive neuropathy

Gait

Examination

Introduction

• Hand gel, introduction, consent, ask about pain/ mobility- fall risk

• Walking aid

• Fasciculation, wasting, scars; Parkinsoniasm rigidity + reduced facial expression; unilateral weakness 

Sit to stand

• Can add in standing with arms crossed to look for sarcopenia

Gait

• Simple walk: unaided- leg swing, arm swing & turn

• Heel-toe: ?ataxia

• Walk on tip-toes: S1 (plantar flexion)

• Walk on heels: L5- foot drop, bilateral could be CMT disease

Rhombergs

• Balance requires- sensory, vestibular and proprioception inputs

• Rhomberg's: eyes closed blocks sensory, if falls: issue with vestibular or proprioception

• Proprioception issues is called sensory ataxia

Signs

• Lesions are ipsilateral

• Nystagmus- fast beat towards lesion, slow beat away

• Rhomberg's positive causes

  • Sensory ataxia- B12 deficiency, syphillis

  • Peripheral neuropathy

  • Vestibular disorders- meniere's disease

  • Alcohol and drug consumption

Conditions

• Demyelination - younger (MS)

• Vascular- older (stroke)

• Alcohol Excess