Lower Limb Neurological Examination – OSCE Guide

geekymedics.com/lower-limb-neurological-examination/

Dr David Bargiela

Lower limb neurological examination frequently appears in OSCEs. You’ll be

expected to pick up the relevant clinical signs using your examination skills. This guide
provides a clear step by step approach to performing a neurological examination of the
lower limb, with an included video demonstration. Check out the lower limb neurological
examination mark scheme here.

The main point of a neurological examination is to localise where in the nervous system
the problem is. This can seem daunting, but with practice it is relatively straightforward.
The most basic localisation question you have to think about during the upper and lower
limb examination is:

Is there an upper motor neuron (UMN) lesion? – i.e. in the brain or spine

Or is there a lower motor neuron lesion (LMN)? – i.e. in the nerve roots, peripheral
nerve, neuromuscular junction or muscle

The following is a summary of some basic UMN and LMN signs that you should be
looking out for during the upper and lower limb examinations:

UMN signs LMN signs

Inspection No fasciculation or significant Wasting and fasciculation of muscles

wasting (may be some disuse
atrophy or contractures)

Pronator May be present May be some drift/movement of arm(s) if weak or

drift de-afferented, but not pronator

Tone Increased (spasticity) +/- ankle Decreased (hypotonia) or normal

clonus

Power Classically a “pyramidal” pattern of Different patterns of weakness, depending on

weakness (extensors weaker than cause e.g. classically a proximal weakness in
flexors in arms, and vice versa in muscle disease, a distal weakness in peripheral
legs) neuropathy

Reflexes Exaggerated or brisk (hyper- Reduced or absent (hyporeflexia or areflexia)

reflexia)

Plantar Upgoing/extensor (Babinski Normal (downgoing/flexor) or mute (i.e. no

reflexes positive) movement)

Equipment
Inspection
Gait
Tone
Power
Reflexes
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Sensation
Co-ordination
Completing the examination
Interactive mark scheme
Mark Scheme (PDF)

Introduction
Wash hands

Introduce yourself

Confirm patient details – name / DOB

Explain the examination

Gain consent

Expose patient’s legs – underpants or shorts

Ask if the patient currently has any pain

Gather equipment
Tendon hammer
Neurotip
Cotton wool
Tuning fork (128Hz)

Inspection
Observe for clues around the bed – walking stick / wheelchair

General appearance – any limb deformity or posturing?

Scars
Wasting of muscles
Involuntary movements – dystonia/chorea/myoclonus
Fasciculation – lower motor neurone lesions
Tremor – Parkinson’s

Gait
1. Ask the patient to walk to the end of the room and back– assess posture, arm
swing, stride length, base, speed, symmetry, balance and for abnormal movements.
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Some common types of gait abnormality to observe for:

Ataxic: broad-based and unsteady. As if drunk. From cerebellar pathology or a

sensory ataxia. Often won’t be able to tandem gait either. With a sensory ataxia,
the patients watch their feet intently to compensate for proprioceptive loss. In a
cerebellar lesion, may veer to one side.
Parkinsonian: small, shuffling steps, stooped posture and reduced arm swing
(initially unilateral). Several steps taken to turn. Appears rushed (festinating) and
may get stuck (freeze). Hand tremor may be noticeable.
High-stepping: (either unilateral or bilateral) caused by foot drop (weakness of
ankle dorsiflexion). Also won’t be able to walk on their heel(s).
Waddling gait: shoulders sway from side to side, legs lifted off ground with the aid
of tilting the trunk. Caused by proximal lower limb weakness, e.g. myopathy.
Hemiparetic: one leg held stiffly and swings round in an arc with each stride
(circumduction).
Spastic paraparesis: similar to above but bilateral – both are stiff and
circumducting. Feet may be inverted and “scissor”.

2. Tandem (heel-to-toe) gait – ask to walk in a straight line heel-to-toe –an abnormal
heel-to-toe test may suggest weakness, impaired proprioception or a cerebellar disorder

3. Heel walking – assesses dorsiflexion power

Romberg’s test
Ask the patient to stand with their feet together and eyes closed
Observe the patient (ideally for 1 minute)
Positive test – loss of balance (swaying without correction/falling over) – this
suggests a sensory ataxia (proprioceptive deficit)
It’s important to stand close by the patient during this test to stop them falling over!

Tone
Ask the patient to keep their legs fully relaxed and “floppy” throughout your assessment.

1. Leg roll – roll the patient’s leg and watch the foot – it should flop independently of the
leg

2. Leg lift – briskly lift leg off the bed at the knee joint – the heel should remain in contact
with the bed

3. Ankle clonus:

Position the patient’s leg so that the knee and ankle are slightly flexed, supporting
the leg with your hand under their knee, so they can relax.

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 Rapidly dorsiflex and partially evert the foot
Keep the foot in this position
Clonus is felt as rhythmical beats of dorsiflexion/plantarflexion (>5 is abnormal)

Power
Assess one side at a time and compare like for like.

Remember to stabilise the joint whilst testing power.

Hip
Flexion (L1/2) – “raise your leg off the bed and stop me from pushing it down”

Extension (L5/S1) – “stop me from lifting your leg off the bed”

ABduction (L4/5) – “push your legs out”

ADduction (L2/3) – “squeeze your legs in”

Knee
Flexion (S1) – “bend your knee and stop me from straightening it”

Extension (L3/4) – “kick out your leg”

Ankle
Dorsiflexion (L4) – “keep your legs flat on the bed…cock your foot up towards your
face…don’t let me push it down “

Plantarflexion (S1/2) – “push down like on a pedal”

Inversion (L4) – “push your foot in against my hand”

Eversion (L5/S1) – “push your foot out against my hand”

Big toe
Extension (L5) – “don’t let me push your big toe down”

Deep tendon reflexes

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Ensure the patient’s lower limb is completely relaxed.

Hold at the end of the tendon hammer handle and allow gravity to aid a good swing.

If a reflex appears absent: make sure the patient is fully relaxed and then perform a
reinforcement manoeuvre – ask the patient to hook their hands together in a monkey grip
and try to pull them apart, whilst you hit the tendon.

1. Knee jerk (L3/4)

2. Ankle jerk (L5/S1)

3. Plantar reflex (S1):

Run a blunt object along the lateral edge of the sole of the foot, moving towards
the little toe, then medially under the toes
Observe the great toe
Normal result = Flexion of the great toe and flexion of the other toes
Abnormal (Babinski sign) = Extension of the great toe and spread of the other
toes – upper motor neuron lesion

Sensation

Light touch sensation

Assesses dorsal/posterior columns and spinothalamic tracts.

1. The patient’s eyes should be closed for this assessment

2. Touch the patient’s sternum with the cotton wool wisp to confirm they can feel it

3. Ask the patient to say “yes” when they are touched

4. Using a wisp of cotton wool, gently touch the skin (don’t stroke)

5. Assess each of the dermatomes of the lower limbs

6. Compare left to right, by asking the patient if it feels the same on both sides

Pin-prick sensation
Assesses spinothalamic tracts.

Repeat the previous assessment steps, but this time using the sharp end of a
neurotip.

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If sensation is reduced peripherally, assess from a distal point and move proximally to
identify ‘stocking’ sensory loss (peripheral neuropathy). If necessary, keep going all the
way up the leg and truck until normal sensation is felt. This may reveal a “sensory level”,
which is suggestive of a spinal lesion (e.g. if there is abnormal sensation up to the level
of the umbilicus, this suggests a spinal lesion at around T10).

Vibration sensation
Assesses dorsal / posterior columns

1. Ask patient to close their eyes

2. Tap a 128 Hz tuning fork

3. Place onto patient’s sternum and confirm patient can feel it buzzing

4. Ask patient to tell you when they can feel it on their foot and to tell you when it stops
buzzing

5. Place onto the distal phalanx of the great toe

6. If sensation is impaired, continue to assess more proximally – e.g. proximal phalanx

Proprioception
Dorsal / posterior columns

1. Hold the distal phalanx of the great toe by its sides

2. Demonstrate movement of the toe “upwards” and “downwards” to the patient (whilst
they watch)

3. Then ask patient to close their eyes and tell you if you are moving the toe up or down

4. If the patient is unable to correctly identify direction of movement, move to a more

proximal joint (big toe > ankle > knee > hip)

Co-ordination
Heel to shin test –“put your heel on your knee, run it down your shin, lift it up and
repeat”

An inability to perform this test may suggest loss of motor strength, proprioception or a
cerebellar disorder.

To complete the examination…

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Thank patient

Wash hands

Summarise findings

Suggest further assessments and investigations

Cranial nerve examination
Upper limb neurological examination
Further imaging if indicated – e.g. Lumbar spine MRI

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