LL Neuro Exam – “Gait Disturbance” POWER

Stem: “difficulty in walking” or “examine the gait and proceed”  Hip flexion (iliopsoas, L1,2, femoral n, L2-4). Hip extension
INSPECTION (hamstrings + glut max, sciatic + inf gluteal n, L5-S2). Hip
 Strip them down to underwear and stand them up adduction (adductors, obturator n, L2-4). Hip abduction (glut
med/min, sup gluteal n)
 ? Can they stand unassisted (prox myopathy), can then stand
still (ataxia), do they have a resting tremor (PD)  Knee flexion (hamstrings, L3/4, sciatic n), knee extension
(quads, L2,4, femoral n) **DDx peripheral femoral n vs L2-4
 Stand back and if necessary ask nurse to stand by pt
plexus lesion by weakness and wasting of quads + unable to
 GAIT: Walk, turn, come back. Tandem walk, then on heels
adduct (as this is also L2/4 but supplied by obturator n)
(tibialis ant supp by common peroneal (CPN) + L4/5 roots), toes
 Ankle dorsiflexion + eversion (tib ant, L4/5, CPN), plantarflexion
(gastroc/soleus supp by S1/2). Look for high stepping + plantar
(tib post, S1, tibial div of sciatic), inversion (tib post, L4, tibial div
flexion + inversion in common peroneal lesion, lack of arm swing
of sciatic n)
in stroke, resting tremor ++ in PD when walking.
 ** DDx peripheral common peroneal nerve lesion (can’t evert,
 Romberg’s – eyes open (cerebellar ataxia), eyes closed
can’t dorsiflex L5, but can invert b/c tibialis post supp by tibial
(proprioception or dorsal columns – sensory ataxia)
division of sciatic nerve L4) versus an L4/5 root lesion (can’t
 Then lie on couch and fully dorsiflex both feet (again looking for
invert or evert as entire sciatic (tib/peroneal) nerve is bad)**
foot drop), look for scars around head of fibula
REFLEXES
 WASTING: look for wasting of quads, etc then check on tibialis
 Knee jerk (L3/4) both simult + Ankle Jerk (S1/2) – frog position
anterior and wasting of ext dig brevis (CPN lesion)
COORDINATION
 PES CAVUS: long standing – Charcot-Marie-Tooth, Fredreich’s
 Ask them to raise leg in air (look how smoothly and when they
ataxia, spina bifida
stop how steady they are). Then ask them to carefully lower
 FASCICULATIONS
heel down to the their knee (again look for accuracy and tremor/
 LOWER SPINE: spina bifida, deformity, previous surgery
swaying). Tap heel on knee. Then ‘carefully’ run heel down shin.
SENSORY (peripheral nerve v dermatome v glove/stocking v
TONE
sensory level with s/cord injury v Brown Sequard pattern)
 Distract by talking to pt then briskly lift knee off bed (hypertonia
 PROPRIOCEPTION – grab hallux by the side, push others out
= distal leg comes up too but tone normal in peripheral nerve
of way then only slight movements up/down
lesion). Then test for ankle clonus.
 VIBRATION – don’t make noise. Close eyes, ask when stops.
 SENSATION – pin prick, temperature (use tuning fork), light tch
COMMON PATTERNS Other patterns of prox weakness are much less common.
 Weakness of iliopsoas and weakness of quadriceps. KJ reduced  Weakness confined to hip adduction is seen with obturator n
or absent. Power in hip adductors normal (same level but lesions (obstetric injury).
obturator n). (femoral n lesion). May also be sensory impairment  Selective lesions of superior gluteal n (glut med and min + TFL)
over thigh and medial shin. Cause: DM amyotrophy or and of inf glut n (glut max) are rare.
haemorrhage into psoas.  Sciatic nerve lesions are a cause of distal weakness of leg
 Weakness of iliopsoas + quads + hip adductors. KJ reduced or (with/without weakness of hamstrings).
absent. (L2/3/4 plexus lesion – NOT femoral as adductors which
are supp by obturator also involved). Sensory loss in
dermatomes for L2/3/4. If at cauda equina then bilateral. Cause:
tumour, disc prolapse less common at this level.
 Weakness of one leg, most marked in hip flexion, knee flexion,
ankle dorsiflexion and eversion. Tone and reflexes increased.
(corticospinal lesion – look at face/arms for hemiparesis)
 Weakness of both legs, most marked in hip flexion, knee flexion,
ankle dorsiflexion and eversion. Tone and reflexes increased.
(Paraparesis; lesion in s.cord – look for motor/sensory level)
 Diffuse weakness in prox muscles of both legs – check power
and reflexes in UL – if also prox weakness in arms then look at
reflexes:
 Reflexes normal or reduced = myopathy (eg MD, PM) or
myasthenia gravis (check fatiguability)
 Reflexes lost = spinal muscular atrophy, myasthenic
syndrome (Eaton-Lambert Syndrome). Reflexes also lost in
GBS but would expect distal as well as prox weakness
 Reflexes increased = MND (check for fasciculations,
wasting and fasc of tongue), quadriparesis or cervical
myelopathy (normal CN, loss of some reflexes in arm)