Examination of Nerves of Lower Limb (ICARS lecture notes)
Understand the concepts & associated principles, functional & clinical anatomy underlying the
physical examination of the peripheral nerves of the lower limbs.
Neurological examination of the lower limb
1. Demonstrate an understanding of the general principles of the neurological examination.
2. Demonstrate the systematic neurological examination of the lower limb.
Peripheral Nerves of the Lower Limb History
(Points 1-7 represent items of specific importance to this history)
INTRODUCTION
 Introduces self and shakes hands
 Explain that you would like to take a history and gain consent
 Do you mind if I write a few things down?
 Full name and Age
 Open questions. ‘So what brings you here today?’
‘Do you have more than one symptom?’
1. SYMPTOMS – get patient to describe symptoms as they occurred. (may suggest a
pattern of symptoms, a cause or a location)
 Weakness
 Difficulty walking
 Altered sensation (parasthesiae)
 Abnormal movements (shaking, tremor)
HISTORY OF PRESENTING SYMPTOM
 2. Onset and Duration
o Sudden – epilepsy or stroke
o Steadily worsening – tumour or neurodegenerative process
o Relapsing and remitting – multiple sclerosis or migraine
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3. Negative and Positive symptoms
o Negative – loss of neurological function
o Positive – A new neurological phenomena
 Flashing lights in migraine
 Olfactory hallucination in epilepsy
 Twitching of fingers in focal motor seizures
 Pill rolling tremor in Parkinson’s disease
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4. Anatomical Localisation
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5. Previous Neurological Hx – important in progressive relapsing conditions
such as MS where the initial event may have occurred decades ago.
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Precipitating factors
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Associated symptoms
PAST AND CURRENT HISTORY
 6. Coexisting Medical Disorders
o Progressive neurological symptoms in cancer patients may suggest
metastatic disease
o Cerebrovascular disease – explore associated symptoms of stroke
(headaches, blurred vision)
o Diabetes (Endocrine diseases)
o Immunocompromised patients – opportunistic infections
o Medications
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Past medical and surgical history
Allergies
Immunisations
7. FAMILY HISTORY
 Inherited neurological disorders (rare)
o Charcot Marie tooth disease
o Huntington’s chorea
SOCIAL HISTORY
 Smoking
 Alcohol
 Occupation
 Overseas Travel
Peripheral Nerves of the Lower Limb Examination
AS YOU BEGIN
 Introduce yourself to the patient, shake hands
 Explains, in simple terms, what they are going to do (informed consent)
 Ask if there are any tender areas and if I cause you any discomfort please let me
know.
 Expose Both lower limbs to above the knee
 Position the patient on the bed so both legs are flat with feet facing up (examine
gait at the end if the patient can walk. If they are not bed ridden, have made their
own way to the consultation examine gait first)
 Washes Hands
 Wipes Stethoscope
GENERAL
 What is going on around the bed? Are there any aids or orthotics/prosthetics?
 What is going in to the patient?
 What is coming out of the patient?
 Look for vital signs/ have vital signs been taken?
GAIT
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Assess normal walking (note any abnormalities)
Heel-toe (cerebellar function)
Stand on toes and walk (S1)
Stand on heels and walk (L4, L5)
Squat and then stand (proximal myopathy)
Rombergs Test (proprioception)
o a. “stand with your feet together”
o b. “now close your eyes, I wont let you fall”
GENERAL INSPECTION & PALPATION
 How sick/distressed does the patient look? Does this patient need resuscitation?
 How alert are they? Can they talk back to you?
 Symmetry
o Muscle atrophy
o Posture (any external/internal rotation)
 Abnormal Involuntary movements
o One limb constantly moving
o Fasiculations (twitching). A sign of dying muscles. You may have to tap
the belly of the muscle to initiate fasiculations
 Skin Lesions
o Scars from past trauma
MOTOR SYSTEM
MUSCLE TONE: “Degree of resistance to stretch on a muscle group”
 Assess degree of resistance (difference between tone on Right and Left)
o Test external rotation of hip (do this by twisting the ankle)
o Test quadriceps and hamstrings (do this by extending and flexing the
knee) Start slowly and then speed up.
o Test ankle dorsi/plantar flexion (standing at the base of the bed: push
and pull foot towards and away from you) Start slowly and then speed up.
 Test for Clonus (KNEE & ANKLE): “sustained rhythmical contractions of
muscles when put under sudden stretch”
o KNEE – Pull down on the knee from above the patellar (stretch the
patellar tendon)
o ANKLE - Standing at base of bed: push foot forwards and hold (foot will
beat/vibrate against the force of your hand) This is from hypertonia:
increased muscle tone. It is indicative of spinal cord damage.
MUSCLE POWER
Must know
Act.) Performing/testing action
Mus.) muscle involved
Ner.) nerve involved
Spi.) spinal cord segment involved
Medical Research Council Classification of Muscle Power
0. No movement (paralysis)
1. Flicker of contraction
2. Movement with gravity eliminated
3. Movement against gravity
4. Movement against resistance but incomplete
5. Normal power
Hip Flexion
 Act. (With leg straight) Doctor pushes down on quadriceps and patient raises leg.
 Mus. Ilio-psoas muscle
 Ner. Femoral nerve
 Spi. L2, L3
Hip Extension
 Act. (With leg straight) Doctor places hand under heel and raises foot slightly.
Patient tries to push against hand/attempts to push heel through bed.
 Mus. Gluteus Maximus
 Ner. Inferior gluteal nerve
 Spi. L5, S1, S2
Hip Abduction
 Act. (With leg straight) Doctor applies force against lateral surface of lower limb.
Patient tries to push against it.
 Mus. Gluteus medius and gluteus minimus
 Ner. Superior gluteal nerve
 Spi. L4, L5,S1
Hip Adduction
 Act. (with leg straight) Doctor applies for against medial side of lower limb.
Patient tries to push against it.
 Mus. Adductor muscles
 Ner. Obturator nerve
 Spi. L2, L3, L4
Knee Extension
 Act. (with knee at 135˚) Doctor places hands on knee and ankle and pushes ankle
down in the direction of knee flexion. Patient pushes against this force.
 Mus. Quadriceps femoris
 Ner. Femoral nerve
 Spi. L3, L4
Knee Flexion
 Act. (with knee at 135˚) Doctor places hands on knee and ankle and pulls ankle
up in the direction of knee extension. Patient pushes against this force.
 Mus. Hamstrings, semimembranosus, semitendinosus
 Ner. Sciatic nerve
 Spi. L5, S1
Ankle Dorsiflexion
 Act. From the base of the bed the doctor pulls the foot away from patient and the
patient resists this force.
(Dr says “pull against my hand)
 Mus. Tibialis anterior, EDL (extensor digitorum longus), EHL (extensor hallucis
longus)
 Ner. Deep peroneal nerve
 Spi. L4, L5
Ankle Plantar Flexion
 Act. From the base of the bed the doctor pushes the foot towards the patient and
the patient resists this force.
(Dr says “push against my hand”)
 Mus. Gastrocnemius, plantaris soleus
 Ner. Tibial nerve
 Spi. S1, S2
Eversion – tarsal joints
 Act. Doctor inverts foot (twists plantar surface medially) patient resists this force.
 Mus. PL (peroneus longus), PB (peroneus brevis) and EDL
 Spi. L5, S1
Inversion – tarsal joints
 Act. Doctor everts foot (twists plantar surface laterally) patient resists this force.
 Mus. TP (tibialis posterior), Gastrocnemius and HL
 Spi. L5, S1
Great Toe Extension
 Act. Similar to ‘ankle dorsi flexion’ with pressure applied solely to the dorsal
surface of the big toe. Patient resists.
 Mus. Extensor hallucis longus
 Ner. Deep peroneal nerve
 Spi. L5
REFLEXES – use weight of hammer with gravity so you are using the same force each
time.
Classification of Muscle Stretch Reflexes
0
Absent
+
Present but reduced
++
Normal
+++ Increased (possibly normal)
++++ Greatly increased, often associated with Clonus
Knee Jerk
 Hammer hits the patellar tendon (below the patellar)
 Spi. L3, L4
Ankle Jerk
 Hammer hits the calcaneal tendon (Achilles tendon)
 S1, S2
Plantar response (Babinski test)
 Negative plantar response (normal) – Toe flexes down
 Positive plantar response – Toe flexes up
 Spi. L5, S1, S2
COORDINATION
 Patient’s big toe touch doctor’s finger
 Tap Doctor’s hand with Patient’s foot
 Heel – Knee – Shin Test
SENSORY SYSTEM – ‘Must learn DERMATOMES for this examination’
VIBRATION – (Don’t do one leg then the other) using a long tuning fork (128Hz)
 Start distal and work proximally
 Place base of tuning fork on bony prominences
 Ask the patient if they can feel the vibrations. Then ask the patient to tell you
when the vibrations stop. Then Doctor stop the vibrating tuning fork with your
hands.
SOFT TOUCH – (Don’t do one leg then the other) using cotton wool
 Checking dermatomes, not peripheral nerves (2nd year)
 With patient’s eyes closed ask if they can feel it.
 “Does it feel the same on both sides?”
PAIN (Don’t do one leg then the other)
 Go through the dermatomes
 Hold sharp object close to tip so you can be steady
PROPRIOCEPTION (Don’t do one leg then the other)
 Lift toe up and down and ask patient to tell you whether it is up or down.
 Note: hold toe by the lateral and medial surface (on the sides) sot that the patient
isn’t using the pressure of your hands against their skin to tell them where their
toe is.