Royal Australasian College of Physicians Examinations/Resources/Clinical Exam/Short Cases/Neurology/The Lower Limb Examination

Work in progress!

This card is a suggested method for the neurological examination of the lower limb.

Example Stem: "This patient has noticed difficulty walking. Please examine him."

Initial Inspection

• Wash your hands
• Introduce yourself to the patient and shake their hand
• Ask the patient to undress to their underwear
• With the patient standing upright in front of the examination couch, perform a general inspection
  • Look for wasting or asymmetry
  • Look for unsteadiness of their posture at rest
• Ask them if they usually require a walking aid
• Get them to walk a few steps away from you, assessing their gait
• Ask them to turn and walk back towards you
• Test their Rhomberg's sign by asking them to stand with their feet together, then close their eyes
  • Make sure they are standing away from the couch / wall so they cannot lean against it
  • Be seen to be ready to catch them if they are Rhomberg's positive
• If their gait was normal and there was no obvious weakness, test proximal strength by asking them to squat, then rise from squatting
  • If this is normal, then ask them to repeat, looking for fatiguability suggesting myaesthenia
    • If the patient is able to do this, the abnormality is probably not in the motor system
• While they are standing, examine their lower back for scars or tender areas
• Ask them to lie supine on the couch
• At rest, examine proximally for fasiculations in the thigh muscles

Assess Tone

• Ask the patient to try and relax completely. Explain you will move their leg, but you do not want them to help at all
• Dorsiflex and plantarflex one ankle a few times to assess their relaxation. Once happy they are relaxed, forcefully dorsiflex (not too hard!) to look for clonus