Lower Limb Neurological Examination

MRCS Part B OSCE Revision

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Lower Limb Neurological Examination

Stacks Image 139366

Lower Limb

Motor

Inspect
Look at skin, muscles and look for wasting and fasciculations.

Tone
‘I’d like you to relax your legs.’ Shake/roll leg. Let leg go floppy and drop from the knee.
Test clonus by revolving ankle and then rapidly dorsiflex to elicit beats. (Gastronemius muscle, >5 beats pathological)

Power
Hip (L1,2) – ‘I’d like you to raise your left leg off he bed. And stop me from moving it.’ Compare sides.
Knee (L3,4,5) – ‘I’d like you to bend your knees. And stop me from moving them.
Ankle (L4,S1,2) – ‘I’d like you to flex your ankle up towards you. And stop me from moving it.’
Toe (L5) – ‘I’d like you to move your big toes towards you. And stop me from moving it.’

Reflexes
Knee (L3, L4)– Place hand underneath knees to take some of the weight. Use tendon hammer to elicit reflex.
Ankle (L5, S1) – relax by slightly flexing knee and slightly dorsiflexing ankle. Reinforce if necessary by asking patient to grasp and pull hands.
Plantar reflex (L5, S1) – Run finger along the lateral border of the sole of the foot from the heel to the toe. Normally produces plantar flexion of toes. In UMN lesion causes dorsiflexion – Babinski’s sign.

Sensory

Pain
(Spinothalamic)
Use neurotip. . ‘I’m going to press this onto your leg. I’d like you to close your eyes and say ‘Yes’ when you can feel it.’
Compare legs. ‘Was it the same on both sides?’

Proprioception (Dorsal Column)
With patient’s eyes closed move big toe up and down. ‘Tell me whether I’m moving your toe up or down.’ Hold sides of toe between finger and immobilise foot.

Vibration (Dorsal Column)
Use tuning fork on medial maleolus. ‘Say ‘Yes’ when you can feel the tuning fork. Now tell me when it stops.’

Light touch (Spinothalamic)
Use cotton wool. ‘I’m going to press this onto your leg. I’d like you to say ‘Yes’ when you can feel it.’
Test dermatomes moving up from big toe and then little toe sides. ‘Was it the same feeling on both sides?’]

Coordination

‘I’d like you to touch your left knee with your right heel. Now run your heel down your leg to your foot and do this as quickly as you can.’ Then other leg.
Gait - Ask the patient to walk if appropriate.

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