Lower Limb Neurological Examination

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1. As with all examinations, the best method is your own – one with which you are comfortable and familiar. The one explained here takes the following format:

   • Tone
   • Power
   • Reflexes
   • Function
   • Sensation

2. The patient should have their lower body exposed, although in an exam situation the patient will be in shorts. Initially, observe the patient’s legs, look for any muscle wasting, fasciculations or asymmetry.

3. Start by examining the tone of the muscles. Roll the leg on the bed to see if it moves easily and pull up on the knee to check its tone. Also check for ankle clonus by placing the patients leg turned outwards on the bed, moving the ankle joint a few times to relax it and then sharply dorsiflexing it. Any further movement of the joint may suggest clonus.

4. You should next assess the power of each of the muscle groups. Again, start at the hip asking the patient to abduct, adduct and flex against your hand so you can assess how much force they can overcome. Do the same for flexion and extension at the knee and ankle as well as the toes.

   1. 

      Leg tone
   2. 

      Knee tone
   3. 

      Check for clonus

5. You should test the patient’s reflexes. There are three reflexes in the lower limb – the patellar reflex, the ankle jerk and the plantar reflex – elicited by stroking up the lateral aspect of the plantar surface.

   1. 

      Hip flexion
   2. 

      Hip extension
   3. 

      Knee flexion
   4. 

      Knee extension
   5. 

      Dorsiflexion
   6. 

      Plantarflexion
   7. 

      Toe dorsiflexion
   8. 

      Toe plantarflexion

6. The patellar reflex is tested by placing the patient’s leg flexed at roughly 60º, taking the entire weight of their leg with your arm and hitting the patellar tendon with the tendon hammer. It is vital to get your patient to relax as much as possible and for you to take the entire weight of their leg.

   1. 

      The patellar reflex test

7. The ankle jerk is elicited by resting the patient’s leg on the bed with their hip laterally rotated. Pull the foot into dorsiflexion and hit the calcaneal tendon.

   1. 

      The ankle jerk test

8. Finally, with their leg out straight and resting on the bed, run the end of the handle of the tendon hammer along the outside of the foot. This gives the plantar reflex. An abnormal reflex would see the great toe extending. If you struggle with any of these reflexes, asking the patient to clench their teeth should exaggerate the reflex.

9. Function is a very important part of any neurological examination as this is the area which will affect people’s day to day lives the most. For the lower limb you should assess the patient’s walking. Observe their gait and check for any abnormalities. Whilst they are standing you should perform Romberg’s test. Ask the patient to stand with their feet apart and then close their eyes. Any swaying may be suggestive of a posterior column pathology.

   1. 

      Assess walk
   2. 

      Romberg's test

10. The final test is sensation. However, this is tested in a number of ways. You should test light touch, pin prick, vibration and joint position sense, or proprioception.

11. Ask the patient to place their legs out straight on the bed. Lightly touch the patient’s sternum with a piece of cotton wool so that they know how it feels. Then, with the patient’s eyes shut, lightly touch their leg with the cotton wool. The places to touch them should test each of the dermatomes – make sure you know these! Tell the patient to say yes every time they feel the cotton wool as it felt before. Then repeat this using a light pin prick.

    1. 

       Sensation test 1
    2. 

       Sensation test 2

12. To assess vibration you should use a sounding tuning fork. Place the fork on the patient’s sternum to show them how it should feel. Then place it on their medial malleolus and ask them if it feels the same. If it does, there is no need to check any higher. If it feels different you should move to the tibial epicondyle and then to the greater trochanter until it feels normal.

    1. 

       Vibration test

13. Finally, proprioception. Hold the distal phalanx of the great toe on either side so that you can flex the interphalangeal joint. Show the patient that when you hold the joint extended, that represents ‘Up’ whereas when you hold it flexed that represents ‘Down’. Ask the patient to close their eyes and, having moved the joint a few times hold it in one position – up or down. Ask the patient which position the joint is in.

    1. 

       Flex the interphalangeal joint up
    2. 

       Flex the interphalangeal joint down