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The following is the recommended sequence of neurological examination of lower limbs for the Year-1
Practice Course:
Step 1:
Step 2:
Step 3:
Step 4:
Step 5:
Step 6:
Step 7:
Inspecting
Assessing Muscle Tone
Eliciting Muscle Stretch Reflexes
Assessing Power
Testing Coordination
Testing Sensation
Assessing Standing, Balancing and Gait
Step 1:
Tasks
(What To
Examine?)
Technique
(How To Examine?)
Observation
(What To Look Out For?)
Inspect for
Muscle Wasting
Inspect for
Fasciculation &
Involuntary
Movements
Normal Response
Remarks
Normal muscle
bulks with no
asymmetry in
both lower limbs.
No obvious
muscle twitches
throughout the
period of
examination.
Step 2:
Tasks
(What To Examine?)
Technique
(How To Examine?)
Normal Response
Remarks
Minimal or no
resistance.
Detect Rigidity in
the Right Hip and
Right Knee
Detect Spasticity in
the Right Knee
No extension of
right knee; right
leg/foot drop
back to
bed/couch in a
second
Detect Rigidity in
the Left Hip and Left
Knee
As above.
As above.
As above.
Detect Spasticity in
the Left Knee
As above.
As above.
As above.
No or presence of
up to 3 repetitive
plantar flexion of
the right ankle.
As above.
As above.
As above.
Step 3:
Eliciting Reflexes
After eliciting any of the Muscle Stretch Reflexes (MSRs) in one limb, immediately compare with the contralateral side.
If there is no or reduced DTR after 2 attempts, ask the patient to flex both sets of fingers into a hook-like form and interlocks
those sets of fingers together. Instruct the patient to close both eyes and pull the flexed fingers. While the patient is
following your instruction, hit the tendon with the tendon hammer.
Tasks
(What To Examine?)
Elicit Plantar
Response / Babinski
Reflex
Technique
(How To Examine?)
Normal Response
Remarks
Observe for
contraction of
quadriceps +/extension of
knee.
Quadriceps contract
with extension of knee.
Observe for
contraction of
calf muscle +/plantar flexion
of ankle.
Observe for
movement of
any or all of the
toes.
If there is extension of 1
toe and/or fanning of the
other 4 toes extensor
plantar response or
positive Babinski sign
cortico-spinal track
dysfunction.
The following reflex is not commonly performed but is useful in suspected thoracic cord lesion.
Task
Elicit Superficial Abdominal Reflex
(above the umbilicus T8, T9, & T10; below the
umbilicus T10, T11, & T12)
Techniques
Use a blunt object (e.g. tongue blade twisted & split
longitudinally, tip of a Queen Square Hammer) to stroke lightly
over each of the upper and lower quadrants of the abdomen
towards the umbilicus. Note the contraction of the abdominal
muscles and deviation of the umbilicus towards the stimulus.
st
Step 4:
Assessing Power
Test the muscle power / strength by having the patient activates relevant muscle(s), initially against gravity, followed by
against your resistance.
Always compare one side with the other.
Determine the pattern of weakness, if present: e.g. proximal vs distal weakness, upper vs lower motor neuron pattern of
weakness, left vs right hemiplegia / hemiparesis
Tasks
(What To Examine?)
Technique
(How To Examine?)
Normal
Response
Remarks
If weakness is detected only in one limb, proceed to test the following muscles to confirm or rule out mono-neuropathy,
multiple mononeuropathies (mononeuritis multiplex), plexopathy or motor radiculopathy(ies).
Inversion of foot (L4, Tibialis Posterior, Tibial Nerve, L5 & S1, Tibialis Anterior, Deep Peroneal Nerve, L4, L5 & S1)
Eversion of foot (Peroneal Longus and Brevis, Superficial Peroneal, L4, L5 & S1)
Extension of big toe (Extensor Hallucis Longus and Brevis, Deep Peroneal, L5)
Flexion of big toe (Flexor Hallucis Longus, Tibial N, L5, S1 & S2)
Extension of 4 toes (Extensor digitorum brevis, Deep Peroneal, L5 & S1)
Flexion of toes (Flexor Digitorum Longus Tibial N, Flexor Digitorum Brevis, Medial Plantar, L5 & S1)
Step 5:
Testing Coordination
Tasks
(What To Examine?)
Conduct Heel-Knee-Shin
Test
Technique
(How To Examine?)
Normal
Response
Remarks
Observe for
smoothness or
fragmentation of
these movements
Patient can
perform these
movements
very smoothly
In the presence of
cerebellar
dysfunction, these
movements are
fragmented.
As above
As above
As above
Step 6:
Testing Sensation
Tasks
(What To
Examine?)
Technique
(How To Examine?)
Normal Response
Remarks
Test Pain
Sensation
Test Vibration
Sense
Use a toothpick (if unavailable, use a pin). First use the blunt, then
the sharp end of the toothpick to touch the mid-forehead and ask
the patient to describe the difference between the two. Patients
eyes remained opened.
Patient can
differentiate sharp and
blunt sensations.
Repeat the above with patients eyes closed and ask him/her to
report the perceived sensation.
As above.
Begin testing over the middle of the sole of the foot (S1) and
compare with the contralateral side. This is followed by medial half
of the dorsum of foot near the base of the big toe (L5), lateral aspect
of leg (L5), medial aspect of the leg (L4), patella (L3), and middle
third of anterior thigh (L2).
After testing the corresponding skin area on the both sides, ask the
patient whether the sharp sensation (should not be painful) is
equally felt on both sides or otherwise.
Use a 128Hz tuning fork, set it vibrating and place it firmly over the
mid-forehead and ask the patient how he/she feels. If he/she could
sense the vibration, stop the vibration and ask whether he/she
could still feel the vibration.
Ask patient to close his/her eyes. Place the vibrating fork firmly over
anybody prominence of right foot/ankle (e.g. medial aspect of right
st
1 MTP joint or medial malleolus) and ask the patient how he/she
feels. If he/she could sense the vibration, stop the vibration and ask
whether he/she could still feel the vibration.
If vibration sense is not perceived, hit the tuning fork harder, and
recheck. If patient still could not sense the vibration, move to more
proximal bony prominences, e.g. patella and anterior superior iliac
spine.
Repeat on the left side and compare.
Use your right thumb and index finger to hold the patients right big
nd
toe by the side and use your left thumb to push away his right 2
toe (patient could sense the movement if the two toes are not
separated).
Move the right big toe up or down a few times, stop moving it when
it is in up or down position, and ask the patient to look and report
the toe position.
Instruct patient to keep his/her eyes closed, repeat the above and
ask patient to report the big toe positions.
Repeat on the left side.
Move more proximally if joint position is impaired, e.g. passively
dorsiflex and plantar-flex the ankle.
Able to perceive
positions of big toe
correctly
Alternatively
the sensation
could be
assessed from
L2 to S1.
Step 7:
Tasks
(What To
Examine?)
Technique
(How To Examine?)
Normal Response
Remarks
Patient is able to
stand with no
difficulty
Patient remains
steady with both
feet together
Elicit Cerebellar
Truncal Ataxia
Perform
Rombergs Test
Patient remains
steady when both
eyes are closed.
Ask the patient to walk across the room, then turn and
walk back. Observe for posture, balance, arm swing
and leg movements.
Steady walking
with good arm
swing and
turning.
Patient remains
steady.
Walk on toes
Able to walk on
toes.
Able to walk on
heels.
Assessing Gait