Lower Limb Neurological Examination: A Step-by-Step Guide

1️⃣ Introduction & Inspection

• Introduce yourself, confirm patient identity, and explain the procedure.
• Ask about weakness, numbness, tingling, or pain.
• Observe gait for abnormalities (e.g., foot drop, spasticity).
• Inspect for muscle wasting, fasciculations, tremors, or contractures.

2️⃣ Muscle Tone

• Passively move the hip, knee, and ankle to check for resistance.
• Spasticity → UMN lesion (e.g., stroke, MS).
• Rigidity → Extrapyramidal disorder (e.g., Parkinson’s).
• Clonus → Sustained beats at the ankle suggest UMN pathology.

3️⃣ Muscle Strength (Power)

Use the MRC scale (0-5) to test key muscle groups:

• Hip flexion (L2, L3) → Lift thigh against resistance.
• Hip extension (L5, S1) → Push thigh backward.
• Knee extension (L3, L4) → Straighten leg against resistance.
• Knee flexion (L5, S1) → Bend knee against resistance.
• Ankle dorsiflexion (L4, L5) → Lift foot up.
• Ankle plantarflexion (S1, S2) → Point foot down.
• Big toe extension (L5) → Lift big toe against resistance.

4️⃣ Reflexes

Test deep tendon reflexes with a reflex hammer:

• Knee (L3, L4) → Leg extension.
• Ankle (S1, S2) → Foot plantarflexion.
• Plantar (Babinski) reflex → Toes should curl down; upward movement suggests UMN lesion.

5️⃣ Coordination (Cerebellar Function)

• Heel-to-shin test → Drag heel along opposite shin (tests ataxia).
• Gait assessment → Look for wide-based or unsteady gait.
• Romberg’s test → Loss of balance with eyes closed suggests sensory ataxia.

6️⃣ Sensory Testing

Check different modalities:

• Light touch → Cotton wool.
• Pain → Pinprick.
• Temperature → Warm/cold object.
• Vibration → 128 Hz tuning fork.
• Proprioception → Move toe up/down with eyes closed.

7️⃣ Special Tests

• Straight Leg Raise (SLR) → Tests for lumbar nerve root compression (sciatica).
• Femoral Stretch Test → Identifies L2-L4 nerve root irritation.
• Trendelenburg Test → Assesses hip abductor weakness.

8️⃣ Identifying the Lesion

• UMN lesion? → Hypertonia, hyperreflexia, positive Babinski sign.
• LMN lesion? → Hypotonia, hyporeflexia, muscle wasting.
• Cerebellar dysfunction? → Ataxia, intention tremor.
• Peripheral neuropathy? → Stocking-glove sensory loss.

This structured approach helps in localizing the lesion and guiding further investigation.

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