Examination of lower limb in neurology-medicine short case approach. This document was prepared based on the teachings of Dr.Kahathuduwa. Fonts in blue indicate sample way of presenting the case.

1. Examination of lower limb in neurology-Short case approach
Possible cases
1. Hemiplegia: flaccid or spastic
2. Paraplegia/ paraparesis: flaccid or spastic
3. Myopathy
4. Ataxia
5. Foot drop
6. Myasthenia/ NM
In each & every step always think which category this pt best fits.
Possible instructions at the exam
1. Examine the lower limbs of this pt
2. Inspect the gait & procede: pt may be wearing a diaper & catheter, then you must know that pt
can’t walk
3. Inspect the lower limbs of this pt & procede
Procedure
“Time is money”. Cutdown all unnecessary steps/words
Introduce briefly: I am a final year medical student & going to examine you.
Arrange the setting
 Cover the curtain
 Lit the area if pt is placed in dark/ or atleast lit your torch to show the examiner that you want
adequate light
Commentry can be made at the end or it may be a running commentry
Inspect the pt from the distance
Is he
1. ill looking/
2. in pain/
3. comfortable/
4. looks bed bound/
5. features of urinary or fecal incontinence- Pt with pampers & catheter is likely to have both.
Better not to say “smelly”) /
6. obvious bed sores/
7. posture (if having decorticate, decerebrate)?
“I am going to examine this young/old looking gentleman/lady who is lying comfotably on the bed. He
looks well & not in pain. He is not having any bed sores or features of urinary or fecal incontinence. I
would like to examine his LL.”
 Age is particularly important (atleast a rough estimation) in CVS cases.
 Use ONLY the terms “gentleman or lady” ( avoid other terms as examiners may unnecessarily
cross ques you how do you know girl etc & waste your time)
Yapa Wijeratne

2. Go near the LL
Inspection of LL
1. Wasting/
2. Fasciculations /
3. Contractures/
4. Deformities/
5. Trophic Ulcers/
6. Rashes (Dermatomyositis)/
7. Localized Inflammation (Myositis)/
8. Muscle Biopsy Scars/tendon release scar in an infant
On inspection there is no wasting /fasciculations/ contractures/deformities/ trophic ulcers
Before you touch the pt ask whether there is any pain in the lower limb? (myositis) : without asking this
you may touch the pt & he may scream in pain & this gives the impression of a good professional.
Thre is no tenderness to touch
Better approach would be asking pt to elevate LLs separately as high as they can
This will elicit obvious
 Proximal weakness
 Hypotonia: dragging the foot in the bed
 Foot drop
 Disc prolapse: SLRT+. So you can easily observe as he would not raise above pain.
Added advantages here are you are able to elevate limb upto the point of pain in disc prolapse & you
need not to worry about the tone checking.
But better not to comment about SLRT at that moment & you can perform with lesser force( you may
use just 2 fingers to lift as at any moment pt can put his leg back easily). Focus pt’s face while noting the
angle.
In this pt’s SLRT was 90 degrees B/L
Tone > Power > Then you can do clonus as it takes even a little time if done with tone >Reflexes
You may roll one limb & suddenly lift & release the other limb. This will divert pt’s attention & reveal the
signs well.
Spasticity: initially there is a resistance to both sides. at one point resistance is gives away. clasp knifeLead pipe: Rigidity persisits throughout.
Cog-wheel
Checking for power should be done with one command word.
It is always to better to comment as muscle power is reduced/ normal than comment with grading as
incase of cross questioning, you don’t have an answer how you checked so.
Power was reduced (flexors or the extensors at knee joint on R/S)/ normal (bilaterally)
Reflexes
Then you can do clonus depending on your findings.
Plantar
By this time you have already diagnosed common peroneal nerve palsy/ foot drop or root lesion
Yapa Wijeratne

3. Then go by dermatomal pattern in sensory
If find dermatomal pattern you go above till you find a sensory level. Once you find, check the back also.
You must check the other limb also.
Sir I would like to examine the posterior side as well.
Periperal neuropathy, paralysis will be found.
Superficial abdominal reflexes also can be done at this time.
Superficial abdominal reflexes is a LMN sign.
Umbilicus move to the side to the innervated/ intact group & opposing group is weak.
Accurately localize the level
You may use other side of the tooth pick.
You must check the other limb also. As there can be a crossed hemiplegia (Brown Sequard).
Once you get a sensory level,
I would like to check for other sensory modalities also. (if time permits)
Vibration is better than proprioception to check dorsal column.
B/L Foot drop, only the weakness in plantar & dorsiflexion → sciatic nerve
So check the sensory, check common peroneal & posterior tibial are affected. But the sural is intact
(lateral border of foot).
Foot drop+ affected eversion but big toe extension is preserved. → common peroneal
So check deep & superficial branches of common peroneal. Prick the space between big toe & 2nd toe &
check some other place also
Lateral border
Sole
Either sides: lateral cutaneous/ obturator
If time permits, check the back S2, S3 also.
Foot drop+ affected big toe extension, but able to evert the foot→ L5 root
If pt is in standing position, this can be done by asking the pt to stand with toes(L4,L5) & heel (S1,S2). If
found root pattern, check the sensory in root pattern.
Then do the heel knee shin test.
I would like to check the gait of this pt.
B/L Paraplegia/ paraparesis: flaccid
1. GBS: commonest
2. Spinal shock
3. Transverse myelitis: initially
4. Severe ant horn cell disease
5. Full blown cauda equina lesion
Then how to progress
Spincter control: also has told by now
Yapa Wijeratne

4. Sir I would like to examine the Upper limbs also. So I would know upto which level this process has
ascends.
Wrist tone (T1,C8): if flaccid > power biceps C5,C6 > if weak > check diapragm: single breath count
Get a one breath & count for the maximum 1,2,3,…
I would like to do single breath count
Then check neck flexors by
 Flexing the neck
 Keeping the hand to resist on the forehead & flex again.
Can check the other side of the neck/ trapezius & check upto accessory nerve level.
If transverse myelitis you have found the sensory level.
Spinal shock, transverse myelitis→pt would be in pain.
Spinal shock: examine the back for spinal tenderness. Or atleast ask
Spastic
Tone is more.
power biceps
BJ/ TJ reflexes
Ask the pt to open the mouth & look at the tongue: hypoglossal
Look at the face: facial nerve
Ask for jaw jerk. But better not to do as due to your mental stress you might hit the mouth
Spastic, but UL normal tone→ look for spinal tenderness
Spastic, sensory in upper abdomen, but UL flaccid
 ALS- grossly wasted hands
 Lesion at that level: I am suspecting a lesion at C7-8 nerve roots, so I would like to check for the
sensory at that level.
Hemiplegia: flaccid or spastic
Both UL
Spastic hemiplegia. Normal tone in UL→ pyramidal drift
Tone can get compensated later by innervating myotomes. But pyramidal drift persists for some time.
This can be performed, even in the lying position with closed eyes.
Localize stroke. (swallowing in long case. If in short case, pulse, auscultate heart, carotids)
Look at the face/ eyes: if normal, this can be at the internal capsule level. Chronic cases, CN VII palsy get
corrected & treat also.
Eyes: gaze palsy
Hemiplegia: flaccid→polio
Know stool collection etc
AFP/ vaccination schedule
Common peroneal
inspect ULs: hypopigmented areas:
palpate neck of fibula/ ulnar nerves
Ataxia
Yapa Wijeratne

5. head to toe CL features
proximal weakenss is clearly seen in gait. If any waddle, get the pt squat & stand.
Proximal weakenss
Rashes (Dermatomyositis/
Myositis) UL tenderness may be there.
Thyroid: pulse/ tremor
If Stroke: at least tell the examiner that you want to examine the CVS for possible cause
Myasthenia in unexplained weakness. If does not fit for any check for this.
Ask the pt to look up for 20s for myesthenia
Occular myes 50%. In other conditions also having occular involvement in ~80%
Flacccid paralysis
Pt is having B/L flaccid paralysis of LLs & Uls. Tone is reduced at the wrists. C5-6 power is normal. Single
breath count is normal. Neck flexors & extensors have normal power. There is no spinal lesion & no
sensory level.
Pt is having acute flacccid paralysis involving B/L LLs & the weakness is extending upto C8-T1 level. But
there is no sensory loss.
So my DD are
1. Acute inflammmatory demyelinating polyneuropathy which is most likely to be GBS.
2. Chronic inflammmatory demyelinating polyneuropathy
3. Predominantly peripheral motor neuropathy
So to confirm my diagnosis, NCS, LP
& to support my diagnosis FBC
If having diarrhea or other infective features…..
Rx:
1. Ig
2. Plasmaparesis if IG not available
Mx
1. Monitoring & chart
a. Single breath count tds
b. Motor level tds
2. If rapid, send the pt to ICU
3. Check ETT & ambu
4. Cannulate: resp arrest
5. Notify
If you are to ask a single question from the pt what are you going to ask?
Temporal nature of disease & onset
Spastic paraparesis
1. Transverse myelitis→ MS
2. Trauma→ brown sequard
Ix:
Thoracic lumbar xray
Yapa Wijeratne

6. MRI-dorsal/ lumbar spine/ cauda equina
Stroke > CT
[Brain > CT, brainstem > MRI]
Foot drop
Ix:
Xray : neck of fibula #
Uss nerve
Peripheral nerve > nerve biopsy- sural
Muscle biopsy-gastrocnemius soleus (in a infant-vastus medius/lateralis)
Any radiculopathy
Xray AP/ lateral
EMG: denervation features
MRI of the area
NCS: NO USE. Usually normal.
Yapa Wijeratne

7. Yapa Wijeratne