Dr. Kaan Yücel
http://yeditepeanatomy1.org
Neurological Examination:Lower Limb
NEUROLOGICAL EXAMINATION
MOTOR & SENSORY FUNCTION
LOWER LIMB
AN ANATOMICAL GUIDE
THIGH & POPLITEAL FOSSA
20.March.2013 Wednesday
Testing the quadriceps is performed with the person in the supine position with the knee partly flexed. The
person extends the knee against resistance. During the test, contraction of the rectus femoris should be observable
and palpable if the muscle is acting normally, indicating that its nerve supply is intact.
To test the hamstrings, the person flexes his leg against resistance. Normally, these muscles—especially
their tendons on each side of the popliteal fossa—should be prominent as they bend the knee.
LEG
To test the the tibialis anterior, the person is asked to stand on the heels or dorsiflex the foot against
resistance; if normal, its tendon can be seen and palpated.
To test the extensor hallucis longus, the great toe is dorsiflexed against resistance; if acting normally, its
entire tendon can be seen and palpated.
To test the extensor digitorum longus, the lateral four toes are dorsiflexed against resistance; if acting
normally, the tendons can be seen and palpated. The extensor digitorum longus extends the toes and dorsiflexes
the foot at the ankle joint.
To test the fibularis longus and brevis, the foot is everted strongly against resistance; if acting normally,
the muscle tendons can be seen and palpated inferior to the lateral malleolus.
To test the triceps surae, the foot is plantarflexed against resistance (e.g., by “standing on the toes,” in
which case body weight [gravity] provides resistance). If normal, the calcaneal tendon and triceps surae can be
seen and palpated.
To test the flexor hallucis longus, the distal phalanx of the great toe is flexed against resistance; if normal,
the tendon can be seen and palpated on the plantar aspect of the great toe as it crosses the joints of the toe.
To test the flexor digitorum longus, the distal phalanges of the lateral four toes are flexed against
resistance; if they are acting normally, the tendons of the toes can be seen and palpated.
To test the tibilalis posterior, the foot is inverted against resistance with the foot in slight plantarflexion;
if normal, the tendon can be seen and palpated posterior to the medial malleolus.
http://www.youtube.com/yeditepeanatomy
1
Dr. Kaan Yücel
http://yeditepeanatomy1.org
Neurological Examination:Lower Limb
RegIons & MUSCLES
Gluteal region superficial: Gluteus maximus Gluteus medius & minimus
Tensor fasciae latae
Function
extends the flexed thigh
Abduct and medially rotate thigh
Gluteal region deep: Piriformis Obturator internus Gemellus superior Gemellus inferior Quadratus femoris
Function
abduct flexed thigh (excp q.f.) laterally rotate extended thigh& steady femoral head in acetabulum
Anterior thigh: Ilıopsoas
Quadriceps femoris
Sartorius
Function
chief flexor of the thigh, hip flexor
Extends leg at knee joint
Flexes, abducts, and laterally rotates thigh at
hip joint; flexes leg at knee joint
Medial thigh: Adductor longus Adductor brevis Adductor magnus
Gracilis
Function
Adducts thigh
Adducts thigh; flexes leg; helps rotate leg medially
Pectineus
Obturator externus
Function Adducts and flexes thigh; assists with medial rotation of thigh Laterally rotates thigh; steadies head of femur in
acetabulum
Posterior thigh: Semitendinosus
Semimembranosus
Function Extend thigh; flex leg & rotate it medially when knee is flexed; when thigh and leg are flexed, these muscles can
extend trunk
Biceps femoris
Function Flexes leg and rotates it laterally when knee is flexed; extends thigh (e.g., accelerating mass during first step of gait)
Anterior leg: Tibialis anterior
Extensor hallucis longus
Function Dorsiflexes ankle and inverts foot
Extends great toe and dorsiflexes ankle
Extensor digitorum longus
Fibularis tertius
Function Extends lateral four digits and dorsiflexes ankle
Dorsiflexes ankle and aids in eversion of foot
Lateral leg: Fibularis longus
Fibularis brevis
Function Everts foot and weakly plantarflexes ankle
Posterior leg superficial: Gastrocnemius
Function
Plantarflexes ankle when knee is extended; raises heel during walking; flexes leg at knee joint
Soleus
Plantaris
Function Plantarflexes ankle independent of position of knee; steadies leg on foot Weakly assists gastrocnemius in
plantarflexing ankle
Posterior leg deep: Popliteus
Flexor hallucis longus
Function
Weakly flexes knee Flexes great toe at all joints; weakly plantarflexes ankle; supports medial longitudinal arch of
foot
Flexor digitorum longus
Tibialis posterior
Function Flexes lateral four digits; plantarflexes ankle; supports longitudinal arches of foot Plantarflexes ankle; inverts foot
Foot (Dorsum): Extensor digitorum brevis
Extensor hallucis brevis
Function
Extends metatarsophalangeal joint of the great toe, and the three middle toes
Foot (Sole,1st layer): Abductor hallucis
Flexor digitorum brevis
Abductor digiti minimi
Function
Abducts and flexes 1st digit Flexes lateral four digits
Abducts and flexes little toe
Foot (Sole,2nd layer): Quadratus plantae
Function
Assists flexor digitorum longus in flexing lateral four digits
Lumbricals
Flex proximal phalanges, extend middle and
distal phalanges of lateral four digits
Foot (Sole,3rd layer): Flexor hallucis brevis
Adductor hallucis
Function
Flexes proximal phalanx of 1st digit adduct 1st digit; assists in transverse arch of foot by metatarsals medially
Flexor digit minimi brevis
Function Flexes proximal phalanx of 5th digit
Foot (Sole,4th layer): Plantar interossei (three muscles)
Dorsal interossei (four muscles)
Function
Adduct digits (2-4) and flex metatarsophalangeal joints Abduct digits (2-4) and flex metatarsophalangeal
joints
http://www.youtube.com/yeditepeanatomy
2
Dr. Kaan Yücel
http://yeditepeanatomy1.org
Neurological Examination:Lower Limb
REGIONS & Nerves (Motor INNERVATION ONLY)
Shoulder: supraclavicular nerves (medial,intermediate,lateral) the skin as far as the middle line,
the skin over the pectoralis major and deltoideus, the skin of the upper and posterior parts of the shoulder,
inferior part of the deltoid muscle (axillary nerve)
Anterior arm: inferior lateral cutaneous nerve of the arm (radial nerve) lateral and anterior
aspects of the lower part of the arm medial cutaneous nerve of arm back of the lower third of the arm,
extending as far as the elbow superior lateral cutaneous nerve of arm (axillary nerve) the skin
over the lower two-thirds of the posterior part of the deltoid muscle, as well as that covering the long head of
the triceps brachii
Anterior forearm: medial cutaneous nerve of forearm medial surface of the forearm down to the
wrist lateral cutaneous nerve of forearm (continuation of musculocutaneous nerve) lateral
half of the anterior aspect of the forearm
Posterior arm & forearm: radial nerve posterior aspect of the arm and forearm (posterior cutaneous
nerve of forearm), lower lateral surface of the arm, medial cutaneous nerve of arm medial side of the
distal third of the arm
Hand: superficial branch of the radial nerve dorsolateral aspect of the palm and the dorsal aspects of
the lateral three and one-half digits distally to approximately the terminal interphalangeal joints ulnar
nerve medial side of the palm, medial half of the dorsum of the hand, the 5th finger, and the medial half of
the 4th finger, anterior surfaces of the medial one and a half digits
median nerve thumb,index,middle fingers,lateral side of the ring [distal parts on the dorsum of the hand],
palmar surface of the lateral three and one-half digits and over the lateral side of the palm and middle of the
wrist
Gluteal region: Upper lateral quadrant of the gluteal region is supplied by the lateral branches of the
iliohypogastric (L1) and 12th thoracic nerves (anterior rami).
Superior clunial nerves L1-L3 posterior rami
Skin overlying superior and central parts of buttock
Medial clunial nerves S1-S3 posterior rami
Skin of medial buttock and intergluteal cleft
Inferior clunial nerves
Posterior cutaneous nerve of thigh (S2-S3)
Skin of inferior buttock (overlying gluteal fold
Thigh: obturator nerve superior medial thigh, genitofemoral nerve middle anterior thigh,
posterior cutaneous nerve of the thigh posterior aspect of the thigh, intermediate cutaneous
nerve of the thigh (femoral nerve) variable area on the medial aspect of the thigh, the medial
cutaneous nerve of the thigh (femoral nerve) medial aspect of the thigh
Leg: saphenous nerve (femoral nerve) medial aspect of leg, posterior cutaneous nerve of the
thigh upper part of the leg superficial fibular nerve anterolateral leg, sural nerve posterolateral leg
Foot: Medially saphenous nerve, which extends distally to the head of 1st metatarsal.
Superiorly (dorsum of foot) superficial (primarily) and deep fibular nerves.
Inferiorly (sole of foot) medial and lateral plantar nerves; the common border of their distribution
extends along the 4th metacarpal and toe or digit. (This is similar to the pattern of
innervation of the palm of the hand.)
Laterally sural nerve, including part of the heel.
Posteriorly (heel) medial and lateral calcaneal branches of the tibial and sural nerves, respectively.
http://www.youtube.com/yeditepeanatomy
3
Dr. Kaan Yücel
http://yeditepeanatomy1.org
Neurological Examination:Lower Limb
Sensory Innervation of the Lower Limb
Iliohypogastric
(L1; occasionally T12)
superolateral quadrant of buttock
Ilioinguinal
(L1; occasionally T12)
Skin over medial femoral triangle
Genitofemoral
Lumbar plexus (L1-L2)
Femoral branch supplies skin over lateral part of femoral
triangle; genital branch supplies anterior scrotum or labia
majora
Lateral cutaneous nerve of thigh
Lumbar plexus (L2-L3)
Skin on anterior and lateral aspects of thigh
Anterior cutaneous branches
Lumbar plexus via femoral nerve (L2-L4)
Skin of anterior and medial aspects of thigh
Cutaneous branch of obturator nerve
Lumbar plexus via obturator nerve, anterior branch (L2L4)
Skin of middle part of medial thigh
Posterior cutaneous nerve of thigh
Sacral plexus (S1-S3)
Skin of posterior thigh and popliteal fossa
Saphenous nerve
Lumbar plexus via femoral nerve (L3-L4)
Skin on medial side of leg and foot
Superficial fibular nerve
Common fibular nerve (L4-S1)
Skin of anterolateral leg and dorsum of foot, excluding
web between great and 2nd toes
Deep fibular nerve
Common fibular nerve (L5)
Skin of web between great and 2nd toes
Sural nerve
Tibial and common fibular nerves (S1-S2)
Skin of posterolateral leg and lateral margin of foot
Medial plantar nerve
Tibial nerve (L4-L5)
Skin of medial side of sole, and plantar aspect, sides, and
nail beds of medial 3½ toes
Lateral plantar nerve
Tibial nerve (S1-S2)
Skin of lateral sole, and plantar aspect, sides, and nail
beds of lateral 1½ toes
Calcaneal nerves
Tibial and sural nerves (S1-S2)
Skin of heel
http://www.youtube.com/yeditepeanatomy
4
Dr. Kaan Yücel
http://yeditepeanatomy1.org
Neurological Examination:Lower Limb
reflexes
Tendon Reflexes and the Segmental Innervation of Muscles of the Lower Limb
Patellar Reflex
The quadriceps femoris is innervated by the femoral nerve. A tap with a tendon hammer on the patellar ligament
therefore tests reflex activity mainly at spinal cord levels L3 and L4.
Calcaneal Tendon Reflex
The ankle jerk reflex, or triceps surae reflex, is a calcaneal tendon reflex. It is a myotatic reflex elicited while the
person's legs are dangling over the side of the examining table. The calcaneal tendon is struck briskly with a reflex
hammer just proximal to the calcaneus. The normal result is plantarflexion of the ankle joint. The calcaneal tendon
reflex tests the S1 and S2 nerve roots. If the S1 nerve root is injured or compressed, the ankle reflex is virtually
absent.
http://www.youtube.com/yeditepeanatomy
5
Dr. Kaan Yücel
http://yeditepeanatomy1.org
Neurological Examination:Lower Limb
NEUROLOGICAL EXAM
Online resources
NeuroLogic Examination Videos and Descriptions...an Anatomical Approach
http://library.med.utah.edu/neurologicexam/html/home_exam.html
The Precise Neurological Exam
http://cloud.med.nyu.edu/modules/pub/neurosurgery/
Neuroexam
http://www.neuroexam.com/neuroexam/
Neurologic Examination
http://medinfo.ufl.edu/year1/bcs/clist/neuro.html
The Neurological Examination
http://www.aan.com/familypractice/pdf/FINAL%20THE%20NEUROLOGIC%20EXAMINATION.pdf
What is a Neurological Exam?
http://peripheralneuropathycenter.uchicago.edu/learnaboutpn/evaluation/neuroexam/index.shtml
The Neurological Examination
http://meded.ucsd.edu/clinicalmed/neuro2.htm
Neurologic Exam
http://www.uic.edu/classes/pmpr/pmpr652/Final/Winkler/NEUROEXM.html
http://www.youtube.com/yeditepeanatomy
6