Lower Limb Exam

Ask The patients .....

• 1. pain /stiffness of joint ,muscle or bone .
• 2. History of arthritis 
• 3. Dress himself / herself without difficulty 
• 4. can walk up and downstairs 

Look : 

• 1. Any swelling of joint .
• 2. Skin color .
• 3. Active movement : movement of joint by the patient himself or herself .
• 4. Any Deformities .
• 5. Visible muscle wasting 
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  Feel : 

  
  
  • 1. Local Temperature
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  • 2. Tenderness: 
  • Grading of tenderness: 
  • Grade-1:- patient says the joint is tender .
  • Grade-2 : the patient winces/grimace 
  • Grade-3:- the patient winces & withdraw the affected part .
  • Grade-4;- the patient will not allow touching the affected part .
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  • 3. Measuring the muscle wasting .
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  • 4. Joint effusion 
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  • 5.Passive movement of joint ( by eximaner’s hand)
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  • 6. Stability of joint 
  
  
  
  

  • Move :

    
    
    • 1. Examine the range of movement of all joint 
    • 2. Passive movement 
    • 3. Active movement – to see the power of joint 
  
  
  
  

Neurological part : 

1. Bulk of the muscles (measure with tape from a particular point):

•  Unilateral wasting (in old poliomyelitis).
•  Generalized wasting (in MND, polyneuropathy, lower motor neuron lesion).
•  Isolated anterior wasting in thigh (in diabetic amyotrophy).
• Wasting in the leg that stops suddenly at a certain level (in Charcot–Marie–Tooth disease).

2. Muscle tone: Tell the patient, ‘Keep your limbs relaxed’. Now the examinee should do the

following—

•  Lift the leg and allow it to fall.
•  Palpate the muscle and perform side to side movement of the limbs.
•  Lastly, passive movement of the limb (in irregular fashion—flexion and extension).

3. Test for clonus (ankle and patella).

4. Muscle power (against resistance): If any weakness, mention grading of weakness. To test, ask

the patient to follow your instructions as follows:

• Hip flexion: ‘Raise your leg straight, do not let me push it down’. (Prime mover: iliopsoas—L1

& L2).

• Hip extension: ‘Push your leg down, do not let me pull it up’. (Prime mover: glutei muscles—

L4 & L5).

• Hip adduction: ‘Push your thighs inwards, do not let me move them apart’. (Prime movers:

adductors of thigh, such as adductor longus, brevis and magnus—L2, L3 & L4).

• Hip abduction: ‘Push your thigh outwards. Do not let me push them inward’. (Prime movers:

gluteus medius and minimus, sartorius and tensor fasciae latae—L4, L5 & S1).

• Knee flexion: ‘Bend your knees, do not let me straighten them’. (Prime mover: hamstrings such

as biceps femoris, semimembranosus and semitendinosus—L5, S1 & S2).

• Knee extension: ‘Straighten your knees, do not let me stop doing’. (Prime mover: quadriceps

femoris—L3 & L4).

• Plantar flexion of ankle: ‘Push your foot downwards against my hand’. (Prime movers:

gastrocnemius, plantaris and soleus—S1 & S2).

• Dorsiflexion of ankle: ‘Push your foot upwards against my hand’. (Prime movers: tibialis

anterior, extensor digitorum longus and extensor hallucis longus—L4 & L5).

• Inversion of foot: ‘Push your foot inward against my hand’. (Prime movers: tibialis anterior and

posterior—L5 & S1).

• Eversion of foot: ‘Push your foot outward against my hand’. (Prime movers: peroneus longus

and brevis—L5 & S1).

• Extension of great toe: ‘Push your great toe

5. Reflexes:

•  Knee (L3 and L4).
•  Ankle (S1 and S2).
•  Plantar (L5, S1 and S2): Tell the patient, ‘I am going to tickle the bottom of your foot, with an orange stick at the outer portion of the sole’. Mention your finding, ‘Plantar is extensor or flexor or equivocal or cannot be elicited’.

6. Superficial reflexes:

•  Abdominal reflex (T6 to T11): Elicited by lightly stroking the abdominal wall diagonally towards umbilicus in each of the four quadrants of abdomen. If positive, reflex contraction of abdominal wall occurs. It is absent in upper motor neuron lesion (early loss is found in multiple sclerosis).
• Cremasteric reflex (L1 & L2): Stroke the inner part of thigh in downward direction. Normally, contraction of cremasteric muscles pulls up the scrotum and testis on the side stroked.

7. Co-ordination (Explain and show it to the patient.):

•  Heel–shin test: ‘Please raise your leg, put your heel upon the knee of other leg and run it along the shin’. (Repeat the same for other leg).
•  Foot taping test: Keep your hand at a little distance from ball

8. Sensory test: Explain to the patient with light touch by cotton-wool in normal area such as forehead. Ask the patient ‘Can you feel it’? Now touch the leg or foot. Ask the patient, ‘Can you feel it’? If no, continue to touch above, until the patient can feel to find out the level of

sensory loss.

•  Light touch (cotton-wool).
•  Pin prick.

Perform the test according to the nerve distribution:

•  Outer thigh L2 (upper thigh).
•  Inner thigh L3 (also around knee).
•  Outer leg L5 (up to medial foot).
•  Inner leg L4.
• Medial foot L5.
•  Lateral foot S1.
•  Vibration sense (with 128 Hz tuning fork): Always explain the patient first by plucking a tuning fork and placing it over sternum. Then repeat it without vibration. Now, test is done placing the vibrating fork on bony prominence such as side of great toe, medial malleolus. If impaired, it may also be tested in knee and anterior superior iliac spine.
•  Position sense (in great toe, always explain this to the patient.)

9. Test for proximal myopathy: ask the patient to stand up from sitting without support. Unable to

do in proximal myopathy.

10. Test for Rombergism: Ask the patient to stand with feet together and close the eyes. In positive

case, the patient tends to sway or fall. Be careful to protect the patient from falling. If positive,

indicates sensory ataxia, dorsal column lesion (e.g., subacute combined degeneration, tabes

dorsalis). In cerebellar lesion, positive in both closed and open eyes.

11. Gait:

• Ask the patient to walk, look any abnormality such as hemiplegic gait, foot drop, scissor gait.
• Look for festinant gait. Also ask to turn quickly (in Parkinsonism, unable to turn quickly).
•  Ask the patient to walk heel-to-toe (to exclude midline cerebellar lesion, in which ataxia may be present).
•  Ask the patient to walk on toes (S1 lesion will make it impossible).
•  Ask the patient to walk on heel (L4 and L5 lesion will make it impossible).

12. Finally, look at the spine to see any deformity, scar, gibbus and local tenderness.

Pateller /knee clonus : 

1. the examiner holds the patient's patella between thumb and index finger - rest other hand - left - on top of patient's quadriceps.

2. sharply pull down patella - if clonus is present then there is sustained rhythmical contraction of quadriceps as long as the examiner maintains downward pressure on the patella.

Planter reflex : 

Root value : L5 & S1 

To test the plantar reflex, the examiner uses the sharp end of the reflex hammer to stroke the sole of the patient's foot, starting at the lateral aspect of the heel and moving along the lateral border of the foot to the base of the fifth metatarsal bone and then onwards to the base of the big toe at the medial aspect .

Ankle reflex: 

Root vale: S1, S2

Slightly externally rotate at the hip, and gently dorsiflex the foot, tapping the Achilles tendon with a reflex hammer. There should be a reflex contraction of the gastrocnemius muscle (plantar flexion).

Knee Jerk:

Root value : L3,4 

Let the knees swing free by the side of the bed, and place one hand on the quadriceps so you can feel its contraction. If the patient is in bed, slightly flex the knee by placing your forearm under both knees by contraction of the quadriceps with extension of the lower leg.