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

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