Lower Limbs Examination

Prepare patient

  • Introduction
  • Position lying in bed with lower limbs exposed Cover groin

Patient lying

  • Room inspection
  • Patient inspection
    • Scars, skin
    • Urinary catheter

Motor system

  • Posture
  • Inspect
    • Wasting
    • Fasciculation
      • (LMN lesion, MND, root compression, peripheral neuropathy, primary myopathy, thyrotoxicosis)
    • Tremor
  • Palpate
    • Muscle bulk
    • Muscle tenderness
  • Tone
    • Ankle—and test for clonus
    • Knee—and test for clonus
      • dorsiflex ankle with knee bent and also move patella sharply down on extended knee
  • Power
    • Hip
      • Flexion (L2/3)
      • Extension (L5, S1/2)
      • Abduction (L4/5, S1)
      • Adduction (L2/3/4)
    • Knee
      • Flexion (L5, S1)
      • Extension (L3/4)
    • Ankle
      • Plantar flexion (S1/2)
      • Dorsiflexion (L4/5)
      • Eversion (L5,S1)
      • Inversion (L5,S1)

Reflexes

  • Knee (L3/4)
  • Ankle (S1/2)
  • Plantar (L5, S1/2) up lateral side or sole and curve inwards behind toes
  • Anal S3-5

Coordination

  • Heelshin test
  • Toefinger test
  • Foot tapping test

Sensory system

  • Pain & Temp
  • Dorsal columns
    • Vibration
    • Proprioception
    • Light touch
  • Saddle region sensation

Back

  • Deformity
  • Scars
  • Tenderness

Standing

  • Romberg

Gait

  • If able to walk Types:
    • Hemiplegia: the foot is plantar flexed and the leg is swung in a lateral arc
    • Spastic paraparesis: scissors gait
    • Parkinson’s: starting hesitation, shuffling, freezing, festination, pro/retropulsion
    • Cerebellar: drunken wide-based or reeling on a narrow base gait; staggers towards side of cerebellar lesion
    • Posterior column lesion: clumsy slapping down of the feet on a broad base
    • Footdrop: high stepping gait
    • Proximal myopathy: waddling gait
    • Prefrontal lobe (apraxic): feet appear glued to floor when erect, but move more easily when the patient is supine
    • Hysterical: characterised by a bizarre, inconsistent gait
  • Test heel to toe walking unable to with a midline cerebellar lesion
  • Test walking on toes (L4/5) & heels (S1)
  • Squatting to standing test
    • (L/4, proximal myopathy)
  • Romberg test (stand feet together eyes open, when steady close eyes & if becomes markedly unsteady loss of proprioception)
    • Unsteadiness with eyes open
      • (cerebellar)

Ask for

  • Urinalysis
  • Residual volume

Wash hands

Summary & Interpretation

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