Neurological Examination of Lower Limbs

Dr Lim Shih-Hui, January 2014

The following is the recommended sequence of neurological examination of lower limbs for the Year-1
Practice Course:
Step 1:
Step 2:
Step 3:
Step 4:
Step 5:
Step 6:
Step 7:

Inspecting
Assessing Muscle Tone
Eliciting Muscle Stretch Reflexes
Assessing Power
Testing Coordination
Testing Sensation
Assessing Standing, Balancing and Gait

Step 1:

Inspecting and Screening

Tasks
(What To
Examine?)

Technique
(How To Examine?)

Observation
(What To Look Out For?)

Expose the lower limbs as

much as possible: e.g.
fold the pants as high as
possible. Inspect
systematically from distal
to proximal (or promixal
to distal) part of the
lower limbs.

Inspect for
Muscle Wasting

Inspect for
Fasciculation &
Involuntary
Movements

Normal Response

Remarks

Look for presence of muscle

wasting in both feet (sole of
feet, extensor digitorum
brevis), legs (tibialis anterior,
gastrocnemius-soleus) and
thighs (vasti). Check for
symmetry (left vs right) as
well as proximal vs distal.

Normal muscle
bulks with no
asymmetry in
both lower limbs.

Wasting indicates disuse

atrophy, lower motor neuron
lesion or others.

Ask the patient not to

move his lower limbs and
continue to relax.

Look out for presence of

fasciculation (muscle
twitches) and any abnormal
movement at this stage as
well as throughout the whole
period of neurological
examination.

No obvious
muscle twitches
throughout the
period of
examination.

Fasciculation indicates active

denervation if associated
with wasting and weakness.

Ask the patient to

dorsiflex both ankles.

Assess the degree of

dorsiflexion of ankles and
compare both sides.

Both ankles fully

& symmetrically
dorsiflexed.

Foot drops indicate possible

neurological disorder (e.g.
common or deep peroneal
nerve palsy, peripheral
neuropathy, sciatic
neuropathy, lumbosacral
plexopathy, lumbar
radiculopathy, and others),
muscular and/or anatomic
dysfunction

Screen for Foot

Drop

Neurological Examination of Lower Limbs

Dr Lim Shih-Hui, January 2014

Step 2:

Tasks
(What To Examine?)

Assessing Muscle Tone

Technique
(How To Examine?)

Observe & Feel

(What To Look Out
For and Feel?)

Normal Response

Remarks

Feel for resistance

to passive flexion
and extension of
right hip and knee.

Minimal or no
resistance.

Detect Rigidity in
the Right Hip and
Right Knee

Ask patient whether there is pain in

the right knee and right hip. If
there is pain, do not proceed with
this step.
If there is no pain, proceed with
passive flexion and extension of
right hip and right knee to confirm
that there is no problem in both
joints.

If resistance is felt in both

flexion and extension of
right hip and right knee,
rigidity is present.
If you could flex and extend
both joints very fast with
no resistance, hypotonia
could be present
(experience is needed).

Detect Spasticity in
the Right Knee

If there is no resistance to passive

flexion and extension of right hip
and knee, place both of your hands
on the side of right knee. Lift
patients right knee up slightly so
o
that the knee is flexed at 10-15 .
Then swiftly lift the right knee
upward.

Look for sudden

extension of right
knee or kicking of
right leg. If absent,
determine how
rapid the right
leg/foot drops back
to the bed/couch.

No extension of
right knee; right
leg/foot drop
back to
bed/couch in a
second

If there is extension of right

knee or kicking of right leg,
spasticity is present.
If the right leg falls towards
the couch/bed very rapidly
or the right heel drags the
couch/bed, hypotonia is
present.

Detect Rigidity in
the Left Hip and Left
Knee

Repeat the above.

As above.

As above.

As above.

Detect Spasticity in
the Left Knee

Repeat the above.

As above.

As above.

As above.

Externally rotate the right hip and

o
flex the right knee at about 90 .
Use your left hand to hold the
patients right thigh just above the
right patella and hold patients
right foot with your right hand.
While holding, swiftly dorsiflex the
right ankle and sustain this
dorsiflexion; do not prevent plantar
flexion if this occurs.

Look for presence

and duration of
repetitive plantar
flexion of the right
ankle.

No or presence of
up to 3 repetitive
plantar flexion of
the right ankle.

If there is repetitive plantar

flexion of right ankle more
than 3 times, clonus
(spasticity) is present.

Repeat the above.

As above.

As above.

As above.

Detect Clonus in the

Right Ankle

Detect Clonus in the

Left Ankle

Neurological Examination of Lower Limbs

Dr Lim Shih-Hui, January 2014

Step 3:

Eliciting Reflexes

After eliciting any of the Muscle Stretch Reflexes (MSRs) in one limb, immediately compare with the contralateral side.

If there is no or reduced DTR after 2 attempts, ask the patient to flex both sets of fingers into a hook-like form and interlocks
those sets of fingers together. Instruct the patient to close both eyes and pull the flexed fingers. While the patient is
following your instruction, hit the tendon with the tendon hammer.

Tasks
(What To Examine?)

Elicit Knee Jerk

Patellar Reflex (L2,
L3, L4)

Elicit Ankle (Achilles)

Reflex (S1)

Elicit Plantar
Response / Babinski
Reflex

Technique
(How To Examine?)

Observe & Feel

(What To Look
Out For?)

Normal Response

Remarks

If the patient is lying supine, flex

one knee at a time; support the
flexed knee with your left hand.
Locate the quadriceps tendon
just below the patella and hit the
tendon with the hammer.
If the patient is sitting, have
his/her legs dangle at the edge of
the couch/bed or cross the leg to
be tested.

Observe for
contraction of
quadriceps +/extension of
knee.

Quadriceps contract
with extension of knee.

Quadriceps contract with

no extension of knee
hyporeflexia (1+);
No contraction of
quadriceps Areflexia
(0);
Marked contraction of
quadriceps and brisk
extension of knee
hyper-reflexia (3+)

Have the patient lie supine or sit

with the legs dangling. If lying
supine, hold the patients foot
with left hand, gently flex and
abduct the hip, flex the knee, and
dorsiflex the ankle. Hit the
Achilles tendon just above the
heel.

Observe for
contraction of
calf muscle +/plantar flexion
of ankle.

Calf muscle contracts

with plantar flexion of
ankle.

Calf muscle contracts

with no plantar flexion of
ankle hyporeflexia
(1+);
No contraction of calf
muscle Areflexia (0);
Marked contraction of
calf muscle and brisk /
repetitive plantar flexion
of ankle hyper-reflexia
(3+)

Use the tip of the shaft of a

tendon hammer or an orange
stick; stroke the lateral aspect of
the sole from the heel to the ball
of the foot, curving medially
across the ball. Begin with the
lightest stimulation that provokes
a response. Stop stroking when
there is movement of any toe.

Observe for
movement of
any or all of the
toes.

Flexor plantar response

or negative Babinski
sign: flexion of big toe
or no movement of any
toe.
If the stimulation is
excessive, there might
be extension of all toes
+/- ipsilateral ankle
dorsiflexion +/ipsilateral flexion
knee/hip

If there is extension of 1
toe and/or fanning of the
other 4 toes extensor
plantar response or
positive Babinski sign
cortico-spinal track
dysfunction.

The following reflex is not commonly performed but is useful in suspected thoracic cord lesion.
Task
Elicit Superficial Abdominal Reflex
(above the umbilicus T8, T9, & T10; below the
umbilicus T10, T11, & T12)

Techniques
Use a blunt object (e.g. tongue blade twisted & split
longitudinally, tip of a Queen Square Hammer) to stroke lightly
over each of the upper and lower quadrants of the abdomen
towards the umbilicus. Note the contraction of the abdominal
muscles and deviation of the umbilicus towards the stimulus.

st

Neurological Examination of Lower Limbs

Dr Lim Shih-Hui, January 2014

Step 4:

Assessing Power
Test the muscle power / strength by having the patient activates relevant muscle(s), initially against gravity, followed by
against your resistance.
Always compare one side with the other.
Determine the pattern of weakness, if present: e.g. proximal vs distal weakness, upper vs lower motor neuron pattern of
weakness, left vs right hemiplegia / hemiparesis

Muscle Groups Must Be Tested

Observe & Feel
(What To Look
Out For and
Feel?)

Tasks
(What To Examine?)

Technique
(How To Examine?)

Assess Power of Proximal

Lower Limbs:
Flexion of Hip
(Psoas and Iliacus
[iliopsoas], L2, L3 & L1,
femoral nerve)

With patient lying down on a couch, bring the right

o
hip into a flexed position at ~90 with the knee
o
bent at ~90 . If the patient is sitting, ask him/her
to elevate the thigh/knee against gravity.
Then, ask the patient to resist while you press the
distal portion of thigh for a few seconds.

Feel the strength

of his/her
resistance to your
pressing.

You are not

able to
overcome
his/her hip
flexion.

Assess Power of Distal

Lower Limbs:
Ankle Dorsiflexion
(Tibialis Anterior, L4 & L5,
Deep Peroneal Nerve)

With the patient lying on a couch or sitting, ask

him/her to move his/her foot and toes towards
him/her, i.e. dorsiflex the ankle. Ask the patient to
resist while trying to plantar flex the ankle.

Feel the strength

of his/her
resistance to your
plantar flexion.

You are not

able to
overcome
his/her ankle
dorsiflexion.

Normal
Response

Remarks

Other Commonly Tested Muscle Groups

Extension at the hips (Gluteus Maximus, Inferior Gleuteal N, L5, S1 & S2)
Extension at the knee (Quadriceps, Femoral Nerve, L2, L3 & L4)
Flexion at the knee (Semimembranosus, Semitendinosus, Biceps Femoris, Tibial N, L5 & S1)
Plantar flexion (Soleus, Gastrocnemius, Tibial N, S1 & S2)

Less Commonly Tested Muscle Groups

If weakness is detected only in one limb, proceed to test the following muscles to confirm or rule out mono-neuropathy,
multiple mononeuropathies (mononeuritis multiplex), plexopathy or motor radiculopathy(ies).

Inversion of foot (L4, Tibialis Posterior, Tibial Nerve, L5 & S1, Tibialis Anterior, Deep Peroneal Nerve, L4, L5 & S1)
Eversion of foot (Peroneal Longus and Brevis, Superficial Peroneal, L4, L5 & S1)
Extension of big toe (Extensor Hallucis Longus and Brevis, Deep Peroneal, L5)
Flexion of big toe (Flexor Hallucis Longus, Tibial N, L5, S1 & S2)
Extension of 4 toes (Extensor digitorum brevis, Deep Peroneal, L5 & S1)
Flexion of toes (Flexor Digitorum Longus Tibial N, Flexor Digitorum Brevis, Medial Plantar, L5 & S1)

Neurological Examination of Lower Limbs

Dr Lim Shih-Hui, January 2014

Step 5:

Testing Coordination

Tasks
(What To Examine?)

Conduct Heel-Knee-Shin
Test

Technique
(How To Examine?)

Observe & Feel

(What To Look Out
For and Feel?)

Normal
Response

Remarks

Ask the patient to place one

heel on the opposite knee and
then run it down the shin
towards the ankle. Repeat the
same movements 3-4 times.

Observe for
smoothness or
fragmentation of
these movements

Patient can
perform these
movements
very smoothly

In the presence of
cerebellar
dysfunction, these
movements are
fragmented.

Repeat the same for his left

lower limb

As above

As above

As above

Neurological Examination of Lower Limbs

Dr Lim Shih-Hui, January 2014

Step 6:

Testing Sensation

Tasks
(What To
Examine?)

Technique
(How To Examine?)

Normal Response

Remarks

Explain to the patient you will be using a sharp object to touch

his/her skin. Reassure the patient that he/she will not be hurt and
his/her skin will not be punctured by the examiners sharp object.

Test Pain
Sensation

Test Vibration
Sense

Use a toothpick (if unavailable, use a pin). First use the blunt, then
the sharp end of the toothpick to touch the mid-forehead and ask
the patient to describe the difference between the two. Patients
eyes remained opened.

Patient can
differentiate sharp and
blunt sensations.

Repeat the above with patients eyes closed and ask him/her to
report the perceived sensation.

As above.

Begin testing over the middle of the sole of the foot (S1) and
compare with the contralateral side. This is followed by medial half
of the dorsum of foot near the base of the big toe (L5), lateral aspect
of leg (L5), medial aspect of the leg (L4), patella (L3), and middle
third of anterior thigh (L2).
After testing the corresponding skin area on the both sides, ask the
patient whether the sharp sensation (should not be painful) is
equally felt on both sides or otherwise.

Can perceive the sharp

end of the toothpick (or
pin), and report no
difference between 2
sides.

Use a 128Hz tuning fork, set it vibrating and place it firmly over the
mid-forehead and ask the patient how he/she feels. If he/she could
sense the vibration, stop the vibration and ask whether he/she
could still feel the vibration.

Can sense the presence

and absence of
vibration.

Ask patient to close his/her eyes. Place the vibrating fork firmly over
anybody prominence of right foot/ankle (e.g. medial aspect of right
st
1 MTP joint or medial malleolus) and ask the patient how he/she
feels. If he/she could sense the vibration, stop the vibration and ask
whether he/she could still feel the vibration.

Can sense the presence

and absence of
vibration.

If vibration sense is not perceived, hit the tuning fork harder, and
recheck. If patient still could not sense the vibration, move to more
proximal bony prominences, e.g. patella and anterior superior iliac
spine.
Repeat on the left side and compare.

Both sides should be

equal.

Use your right thumb and index finger to hold the patients right big
nd
toe by the side and use your left thumb to push away his right 2
toe (patient could sense the movement if the two toes are not
separated).

Test Joint Position

Sense

Move the right big toe up or down a few times, stop moving it when
it is in up or down position, and ask the patient to look and report
the toe position.
Instruct patient to keep his/her eyes closed, repeat the above and
ask patient to report the big toe positions.
Repeat on the left side.
Move more proximally if joint position is impaired, e.g. passively
dorsiflex and plantar-flex the ankle.

Able to perceive
positions of big toe
correctly

Alternatively
the sensation
could be
assessed from
L2 to S1.

Neurological Examination of Lower Limbs

Dr Lim Shih-Hui, January 2014

Step 7:

Assessing Standing, Balancing and Gait

Tasks
(What To
Examine?)

Technique
(How To Examine?)

Normal Response

Remarks

Test for Proximal

Weakness

Ask the patient to stand from a sitting position (from a

chair or bed/couch) with arms folded across the chest.
Specifically instruct him/her not to use his/her hands
to assist in the standing process.

Patient is able to
stand with no
difficulty

Proximal weakness is present if

the patient has difficulty
standing without the help of
his/her upper limbs

Patient remains
steady with both
feet together

Truncal ataxia is present if

unsteadiness is detected with
both feet closed and disappears
when both feet are re-opened.

Elicit Cerebellar
Truncal Ataxia

Instruct patient to stand in the usual manner with

his/her eyes opened, feet apart at shoulder width.
Then instruct him/her to place the feet together.
You should stand close to patient to catch him/her if
he/she loses the balance.
If the patient is unsteady with feet together, ask
him/her to open his/her feet and recheck the balance.
Do not proceed with the next step or proceed with the
next step with extreme caution.

Perform
Rombergs Test

Instruct patient to stand with his/her eyes opened,

feet apart at shoulder width. Then instruct patient to
close his/her eyes for 15-30 seconds and keep still.
You should stand close to patient to catch him/her if
he/she loses his/her balance. If the patient is unsteady
with eye closed, ask him/her to open eyes
immediately.

Patient remains
steady when both
eyes are closed.

Rombergs test is considered

positive, i.e. there is loss of
position sense in both lower
limbs if unsteadiness appears
with eyes closed and
disappears with eye opened.

Ask the patient to walk across the room, then turn and
walk back. Observe for posture, balance, arm swing
and leg movements.

Steady walking
with good arm
swing and
turning.

Tandem Walking (heel-to-toe in a straight line):

instruct patient to place one foot firmly and directly in
front of the other. You should follow the patient to
catch him/her if he/she loses his/her balance. Walk
forwards first. If there is no unsteadiness, then ask
him/her to walk backwards.

Patient remains
steady.

Gait ataxia is present if patient

is unsteady on Tandem
walking;
truncal ataxia will get worse on
tandem walking

Walk on toes

Able to walk on
toes.

Not able to walk on toes

weakness in ankle plantar
flexors.

Walk on heels to detect weakness in ankle

dorsiflexor.

Able to walk on
heels.

Not able to walk on heels

weakness in ankle dorsiflexors.

Assessing Gait