Medically Fit For Exams
Medically Fit For Exams

Lower limb peripheral nerve examination

  • Wash hands and introduce yourself
  • Check the patient’s name and DOB
  • Explain the examination and gain consent

 

Inspection

  • Ask the patient to undress sufficiently to see the full lower limb
  • Look for walking aids
  • Look at the patient’s shoes
  • Look for muscle wastage, especially of quadriceps and hip girdle
  • Posture
  • Tremor or fasciculation

 

Walk

  • Ask the patient to walk away from you, turn briskly and walk back
  • Observe for abnormal gaits including:
    • Antalgic – pain, resulting in minimal weight bearing through painful side
    • Scissoring – eg cerebral palsy
    • Ataxic – wide based, irregular, unstable (cerebellar dysfunction)
    • Foot-slapping – sensory polyneuropathy

 

Tone

  • Ask the patient to lie on the couch, and relax their legs
  • Roll the patient’s legs from side to side, look at the feet for resistance
  • Without warning, lift the knee abruptly
  • Observe for the leg lifting off the table – in hypertonia it will do, even if the patient is relaxed
  • Passively extend and flex the knee joint

 

Power

  • Tell the patient you are going to ask them to perform some movements with their legs
  • Ask the patient to do the following, all against resistance:

Scale of muscle power

0

No movement

1

Flicker of movement

2

Movement only with gravity

3

Movement against gravity, but not resistance

4

Some movement against resistance

5

Full power against resistance

  • Without bending your knee, lift your leg off the couch, don’t let me push it down
  • From here, push your thigh back down, push against me
  • (With straight legs) Push your knees together against me
  • Push your knees apart against my hands
  • Bend your knees with your feet on the couch, and pull your heel into your bottom against me

 

Reflexes

  • Ask the patient to fully relax
  • Can be reinforced by Jendrassik manoeuvre (locking fingers and pulling apart from each other in front of chest)
  • Knee/quadriceps tendon
    • Support the knee with your left hand, with it flexed to about 90 degrees and relaxed
    • Alternatively you can position the patient with their knees hanging off the bed
    • Strike directly on the skin below the inferior pole of the patella
    • Observe for quadriceps contraction/foot kick
  • Ankle/achilles tendon
    • Place the foot on top of the other ankle, while laying on the couch
    • Ask the patient to fully relax
    • Dorsiflex the foot
    • Strike the achilles tendon directly
    • Observe for movement of the foot
  • Plantar/babinski reflex
    • Use a blunt object to run up the lateral edge of the foot towards the toes
    • Observe for either no toe movement, or flexion
    • Extension (upwards) is a sign of an upper motor neuron lesion
  • Ankle clonus
    • Unexpectedly dorsiflex the foot and observe for clonus (additional beats of the foot)
    • More than three is abnormal, is a sign of hypertonicity/upper motor neuron lesion

 

Coordination

  • With the patient lying down, ask to run their heel up their shin, lift off and the knee, place on the ankle and repeat
  • Repeat with the other leg

 

Sensation

  • Using a cotton wool tip, touch the sternum as a reference
  • Ask the patient to close their eyes and tell you when they feel the cotton wool
  • Alternate between legs to compare the two
  • Ensure that you touch each dermatome:
    • Upper outer thigh (lateral cutaneous nerve of thigh, L2)
    • Inner thigh (femoral nerve, L3)
    • Medial lower leg (saphenous nerve, L4)
    • Upper outer lower leg (common peroneal nerve, L5)
    • Dorsal surface of foot, medial aspect of big toe (superficial peroneal nerve, L5)
    • Heel of foot (tibial nerve, S1)
    • Posterior aspect of knee (sciatic nerve, S2)
  • Repeat for pain, using a neurotip, asking the patient to identify ‘blunt’ or ‘dull’
  • Proprioception:
    • With the patient’s eyes open move the big toe up and down, grip at the sides, and hold other toes away
    • Tell the patient which is up and which is down as a reference
    • Ask the patient to close their eyes and tell you if the toe is moving up or down
  • Vibration sense on bony protuberances can be assessed if there are any abnormalities (or if there is a tuning fork present!)

Get social with us.

Print Print | Sitemap
© medicallyfitforexams.co.uk