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Lower Limb Neurological Examination

NeurologyYear 3

Lower limb neurology starts with gait — the finding that most often gives the diagnosis away. This checklist runs gait first, then the full tone, power, reflex, coordination and sensation sequence with the levels to quote.

Marking points
37
Run-through
~9m
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1

Introduction

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2

Inspection

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  • Ask patient to walk heel-to-toe. Observe for ataxic, parkinsonian, high-stepping, waddling, hemiparetic, or spastic paraparesis gait patterns.

  • Patient stands with feet together, arms by sides, eyes closed. Positive if falling without correction, indicating sensory ataxia. Swaying with correction is not positive.

    • Foot should flop side to side

    • Relaxed limb should keep ankle on couch

    • Present with Upper Motor Neurone (UMN) lesions

  • Use MRC scale: 0 (no contraction) to 5 (normal power).

    • Patient places heel on opposite knee, slides down tibia to ankle, lifts and repeats. Test both sides.

    • Patient taps sole of foot quickly on examiner's hand. Test both sides.

    • Use pin. Demonstrate on sternum first. Start distally, work proximally, test each dermatome, compare sides.

    • For vibration, use tuning fork on MTPJ of great toes. For proprioception, move DIPJ of great toe, patient reports direction with eyes closed.

    • Use cotton wool with dabbing motion. Start distally, work proximally, test each dermatome, compare sides.

  • Classification: absent, + (reduced), ++ (normal), +++ (increased). Use reinforcement (e.g., hand gripping) if needed.

    • L3/4

    • S1/2

    • L5/S1/2. Look for first movement of first MTP, should be down-going. Extensor response indicates UMN lesion.

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