Lower limb

Question 1

Explanation of examination

Preexam checks

Answer 1

WIPER QQ
-wash hands
-introduce yourself
-patient ID
-explanation
I'd like to examine your legs, this will involve an assessment of your muscles, sensation and reflexes
-repositioning - standing and lying
-questions - do you have any questions? are you happy for me to start my examination? do you have any pain or stiffness in your legs?

Question 2

General inspection

• bedside
• patient

Answer 2

Bedside - mobility aids, orthotics, prescriptions

Skin

• scars
• pale/cyanosed/red, shiny, dry skin => autonomic loss?
• injuries, ulceration, rashes?

Joints
-deformities => proprioception loss? (Charcot’s joints of feet?)

Muscles

• wasting => motor loss?
• fasciculations => LMN sign?
• tremor, tics, chorea, clonus?

Question 3

Walking

• gait
• stance, stability, arm swing, step, turning
• heel toe walking, stand on heels, toes
• Romberg

Answer 3

Gait
Hemiplegic - leg circumduction (extension) + elbow and wrist flexion => post stroke (due to ULF, LLE being stronger)
High steppage (foot slapping) - foot drop
Myopathic - waddling gait, promixal muscle weakness

Stance - wide base => cerebellar?
Stability - unsteady => something is wrong
Arm swing - loss => early PD sign
Step - shuffling, festination => PD
Turning - difficulty => PD

Heel toe walking - cerebellar ataxia
Stand on heels, toes - cerebellar, neuropathy, myopathic weakness

Romberg - eyes closed, exaggerated sway
-hold your arms infront and behind patient to steady them if they fall

Question 4

Tone

• how would you assess this
• what are you looking for

Answer 4

Leg roll - foot loosely rotates

• too floppy - LMN
• too rigid - UMN

Leg raise from knee - foot stays on bed
-foot leaves bed => UMN

Support bended knee
-rapid dorsiflexion, foot eversion and hold => 5 rhythmic clonic mv

Compare each side

Question 5

Power

Answer 5

Legs flat on bed, stabilise joint above

L1-2, L5-S1
Hip flexion, extension
-straight leg - push down/up on thigh

L3-4, L5-S1
Knee flexion, extension
-bent knee - push and pull leg

L4-5, S1
Ankle flexion, extension
-push against plantar, dorsal foot

Big toe extension - L5
-push down on big toe

Question 6

How would you grade power

Answer 6

5 - normal
4 - active movement against gravity and resistance
3 - active movement against gravity
2 - active movement without gravity
1 - flicker/trace contraction
0 - no contraction

Question 7

Reflexes

Answer 7

Knees L3-4

• bend knee, support their weight
• tap patellar tendon
• normal reflex causes quadricep contraction

Ankle L5-S1

• bend knee, dorsiflexed ankle resting on other shin
• tap Achilles tendon
• normal reflex causes gastrocnemius contraction and foot jerk in plantar direction

Plantar (Babinski)
-abnormal => fanning of toes, +ve

Question 8

Coordination

Answer 8

Heel shin test
-lifting leg up from ankle => knee
-fast as possible
Repeat with opposite leg

Question 9

Sensation

• light touch - dorsal
• pain - spinothalamic

Answer 9

Close eyes
Light touch - dorsal
-touch chest with cotton - central sensation
-dermatomal, alternate between legs

Pain - spinothalamic

• warn patient that you will use neurotip
• if suspecting peripheral neuropathy, test distally first and move proximally

Question 10

Vibration - dorsal

Answer 10

Close eyes
128Hz on sternum - central sensation

Big toe ICP
-confirm if they feel the vibration and when it stops

If vibration sense impaired, test more proximal joints

Question 11

Proprioception - dorsal

Answer 11

Close eyes
Hold sides of big toe
Familiarise with up and down
Ask them to identify up and down positioning

If proprioceptive sense impaired, test more proximal joints

Question 12

Further examinations

Answer 12

Exam
-Upper motor, cranial, cerebellar

Testing
-Blood for diabetes