Clinical Examination 75
Lower Limb Neurological Examination
1. Steps before beginning examination
• Introduce yourself : “I am Dr._______ , your attending physician and I'll be examining you today. At any point of the examination you feel uncomfortable, please let me know and I’ll stop the examination right there.”
• Wash/Sanitize hands
• Explain to the patient what you are about to do and gain informed consent. • Verbalize the steps of the examination and your findings.
• Make sure patient is adequately exposed, use proper draping techniques 2. Inspection
• Observe the patient's legs, look for any muscle wasting, fasciculations or asymmetry. 3. Tone
• Start by examining the tone of the muscles. Roll the leg on the bed to see if it moves easily and pull up on the knee to check its tone. Also check for ankle clonus by placing the patients leg turned outwards on the bed, moving the ankle joint a few times to relax it and then sharply dorsiflexing it. Any further movement of the joint may suggest clonus.
4. Power
• Next assess the power of each of the muscle groups. - Hip flexion (L1/L2) & Hip extension (L5/S1) - Hip abduction (L2/L3) & Hip adduction (L2/L3) - Knee flexion (L5/S1) & Knee extension (L3/L4)
- Ankle dorsiflexion (L4/L5) & Ankle plantar flexion (S1/S2) - Big toe flexion (S1/S2)
5. Reflexes
• Test the patient's reflexes. There are three reflexes in the lower limb - the knee reflex, the ankle jerk and the plantar reflex - elicited by stroking up the lateral aspect of the plantar surface.
• The knee reflex (L3/L4) is tested by placing the patient's leg flexed at roughly 60°, taking the entire weight of their leg with your arm and hitting the patellar tendon with the tendon hammer. It is vital to get your patient to relax as much as possible and for you to take the entire weight of their leg. • The ankle jerk (S1/S2) is elicited by resting the patient's leg on the bed with their hip laterally rotated.
Pull the foot into dorsiflexion and hit the calcaneal tendon.
• Finally, with their leg out straight and resting on the bed, run the end of the handle of the tendon hammer along the outside of the foot. This gives the plantar reflex (Si). An abnormal reflex would see the great toe extending. If you struggle with any of these reflexes, asking the patient to clench their teeth should exaggerate the reflex.
76 NAC OSCE | A Comprehensive Review 6. Sensation
The final test is sensation. However, this is tested in a number of ways. You should test light touch, pin prick, vibration and joint position sense and proprioception.
Ask the patient to place their legs out straight on the bed. Lightly touch the patient's sternum with a piece of cotton wool so that they know how it feels. Then, with the patient's eyes shut, lightly touch their leg with the cotton wool. The places to touch them should test each of the dermatomes - make sure you know these! Tell the patient to say yes every time they feel the cotton wool as it felt before. Then repeat this using a light pin prick.
To assess vibration you should use a sounding tuning fork. Place the fork on the patient's sternum to show them how it should feel. Then place it on their medial malleolus and ask them if it feels the same. If it does, there is no need to check any higher. If it feels different you should move to the tibial epicondyle and then to the greater trochanter until it feels normal.
Finally, proprioception. Hold the distal phalanx of the great toe on either side so that you can flex the interphalangeal joint.
Show the patient that when you hold the joint extended, that represents 'Up' whereas when you hold it flexed that represents 'Down'. Ask the patient to close their eyes and, having moved the joint a few times hold it in one position - up or down. Ask the patient which position the joint is in.
Anterior
7. Function is a very important part of any neurological examination as this is the area which will affect people’s day to day lives the most. For the lower limb you should assess the patient's walking. Observe their gait and check for any abnormalities. Whilst they are standing you should perform Romberg's test. Ask the patient to stand with their feet apart and then close their eyes. Stand next to the patient in case he falls. Any swaying may be suggestive of a posterior column pathology.
Clinical Examination 77
Musculo-skeletal system : Spine/Back 1. Steps before beginning examination
• Introduce yourself : aI am Dr.________, your attending physician and I'll be examining you today. At any point of the examination you feel uncomfortable, please let me know and I'll stop the examination right there.”
• Wash/Sanitize hands
• Explain to the patient what you are about to do and gain informed consent. • Ensure patient is adequately exposed.
• Look for medical equipment/therapies • Show empathy.
• Verbalize the steps of the examination and your findings. 2. Inspection
• Ask for patient’s vitals
• Observe patient : Is patient sitting comfortably? Gait? Position of comfort. • Observe the patient from behind :
- Pelvic and shoulder symmetry, palpate the pelvic brim to check for symmetry. - Scoliosis
- Gibbus (dorsal spines abnormally prominent) • Observe patient from side :
- Kyphosis
- Increased lumbar lordosis
• Check the spine for SEADS : S: Swelling, E: Erythema, ecchymosis, A: Atrophy/asymmetry (muscle bulk), D: Deformity, S: Skin changes/scars/bruising
3. Range of Motion
• Flexion : In the standing position by asking the patient to touch the toes. Normal - 90° .The normal spine should lengthen more than 5 cm in the thoracic area and more than 7.5 cm in the lumbar area on forward flexion.
• Extension : Stabilize the patient, ask the patient to bend backwards. Normal - 30°.
• Lateral flexion : ask the patient to slide their hand straight down the thigh, first on the right and then on the left, keeping the hips straight.
• Observe for restricted movement and loss of symmetry.
• Test for facet joint disease : Ask patient to extend their back as far as possible and to rotate (pain suggests facet joint pathology).
4. Palpation
• Examine the back and palpate for areas of muscle spasm and tenderness (paraspinal muscles). • Palpate spinous processes with thumb for tenderness
78 NAC OSCE | A Comprehensive Review 5. Ankylosing spondylitis tests
• Chest expansion : Measure with a tape measure (should be >5cm)
• Schober'sTest : Draw a horizontal line 10cm above and one 5cm below the dimples of Venus (the distance between these lines should increase to >20cm during lumbar flexion - in ankylosing spondylitis the distance will not increase to >20cm)
• Distance of tragus to wall when patient is standing with their back to the wall (useful for monitoring). 6. Cervical and thoracic movements (patient sitting on edge of bed)
• Cervical movements
- Flexion (ask patient to touch chin to chest)
- Extension (ask patient to look to the ceiling as far back as possible)
- Lateral flexion (ask patient to touch their ear to the shoulder keeping the shoulder still)
- Spurling Maneuver : Extend head back & bring ear towards shoulder. Give gentle axial pressure on the head. If patient complains of pain radiating from head to ipsilateral arm - diagnosis of Radiculopathy is made.
- Rotation (ask patient to look over the left and right shoulder)
- Perform these movements passively if active movements are restricted. • Thoracic rotation : ask patient to fold their arms and twist around. 7. Tests with patient lying on their back
• Straight leg raising test : ask the patient to lie with the spine on the table and to relax completely. With the knee fully extended, first one leg and then the other is slowly lifted and flexed at the hip. This produces stretch on the sciatic nerve, at which point sciatic pain is produced. If this maneuver produces pain in the hip or low back with radiation in the sciatic area, the test is considered positive for nerve root irritation. The angle of elevation of the leg from the table at the point where pain is produced should be recorded.
• FABER (Flexion Abduction External Rotation) : Ask the patient to lie supine on the exam table. Place the foot of the affected side on the opposite knee. Pain in the groin area indicates a problem with the hip and not the spine. Press down gently but firmly on the flexed knee and the opposite anterior superior iliac crest. Pain in the sacroiliac area indicates a problem with the sacroiliac joints. • Bowstring test: Once the level of pain has been reached, flex the knee slighdy and apply firm pressure
with the thumb in the popliteal fossa over the stretched tibial nerve. Radiating pain and paraesthesiae suggest nerve root irritation.
8. Tests with patient lying on their abdomen
• Lasegue's sign: With the patient supine and hip flexed, dorsiflexion of the ankle causes pain or muscle spasm in the posterior thigh if there is lumbar root or sciatic nerve irritation.
• Femoral stretch test:With the patient prone and the anterior thigh fixed to the couch, flex each knee in turn. This causes pain in the appropriate distributions by stretching the femoral nerve roots in L2- L4.The pain produced is normally aggravated by extension of the hip. The test is positive if pain is felt in the anterior compartment of thigh.
Clinical Examination 79 Hip Examination
1. Steps before beginning examination
• Introduce yourself : “I am Dr.________, your attending physician and I'll be examining you today. At any point of the examination you feel uncomfortable, please let me know and I'll stop the examination right there.”
• Wash/Sanitize hands
• Explain to the patient what you are about to do and gain informed consent. • Ensure patient is adequately exposed.
• Look for medical equipment/therapies • Ask which hip is painful, show empathy.
• Verbalize the steps of the examination and your findings. 2. Inspection of hip (with patient standing up)
• While the patient is standing, check the hip for SEADS : S: Swelling, E: Erythema, ecchymosis, A: Atrophy/asymmetry (muscle bulk), D: Deformity, S: Skin changes (erythema/scars/abscess/sinuses) • Leg length discrepancy
• Whilst the patient is still standing, perform the Trendelenberg test. This is done by asking the patient to alternately stand on one leg. Stand behind the patient and feel the pelvis. It should remain at level or rise slightly. If the pelvis drops markedly on the side of the raised leg, then it suggests abductor muscle weakness on the leg the patient is standing on.
3. Gait - ask patient to walk across the floor. Look for any abnormalities,