The document outlines a detailed guide for conducting a lower limb neurological examination, discussing the anatomy of the lumbar and sacral plexuses, their associated nerves, and their motor and sensory functions. It provides step-by-step instructions on conducting various assessments, including gait, tone, power, reflexes, sensation, and coordination. The examination aims to evaluate neurological health in patients by identifying signs of upper or lower motor neuron lesions and sensory abnormalities.

1. LOWER LIMB NEUROLOGICAL
EXAMINATION
Prepared by:
Dr. Abdulla Kamal Ghafour
3rd year IBFMS trainee

2. Anatomy
• Lumber plexus:
formed by the anterior rami (divisions) of the
lumbar spinal nerves L1, L2, L3 and L4. It also
receives contributions from thoracic spinal nerve
12. These roots divide into several cords. These
cords then combine together to form the six major
peripheral nerves:
1. Iliohypogastric Nerve [(L1 (with contributions
from T12)]
Motor: Innervates the internal oblique and
transversus abdominis.
Sensory: Innervates the posterolateral gluteal skin in
the pubic region.

3. Anatomy
2. Ilioinguinal Nerve [L1]
Motor: Innervates the internal oblique and
transversus abdominis.
Sensory: skin on the upper middle thigh In males,
it also supplies the skin over the root of the penis
and anterior scrotum. In females, it supplies the
skin over mons pubis and labia majora.
3. Genitofemoral Nerve [L1, L2]
Motor: cremasteric muscle.
Sensory: The genital branch innervates the skin of
the anterior scrotum (in males) or the skin over
mons pubis and labia majora (in females). The
femoral branch innervates the skin on the upper
anterior thigh.

4. Anatomy
4. Lateral Cutaneous Nerve of the Thigh
[L2,L3]
Motor: None
Sensory: anterior and lateral thigh down to
the level of the knee.
5. Obturator Nerve [L2, L3,L4]
Motor: obturator externus, pectineus, adductor
longus, adductor brevis, adductor magnus,
gracilis.
Sensory: Innervates the skin over the medial
thigh.

5. Anatomy
6. Femoral Nerve [L2,L3,L4]
Motor: Illiacus, pectineus, sartorius, all the
muscles of quadriceps femoris.
Sensory: skin on the anterior thigh and the medial
leg as a saphenous nerve.

6. Anatomy
• Sacral plexus:
formed by the anterior rami (divisions) of the sacral
spinal nerves S1, S2, S3 and S4. It also receives
contributions from the lumbar spinal nerves L4 and L5.
these spinal roots (and the lumbosacral trunk) divide into
several cords. These cords then combine together to form
the five major peripheral nerves:
1. superior gluteal nerve [L4, L5, S1]
Motor: gluteus minimus, gluteus medius and tensor
fascia lata
Sensory: None

7. Anatomy
2. Inferior gluteal nerve[ L5, S1, S2]
Motor: Innervates gluteus maximus
Sensory: none.
3. Sciatic Nerve [L4, L5, S1, S2, S3]
derived from the lumbosacral plexus.
When the sciatic nerve reaches the apex of
he popliteal fossa, it terminates by
bifurcating into the tibial and common
fibular nerves.

8. Anatomy
• Motor:
Tibial Portion – Innervates all of the muscles in the
posterior compartment of the thigh, including the
hamstring portion of adductor magnus, apart from
the short head of the biceps femoris.
When it become the tibial nerve innervates all the
muscles in the posterior compartment of the leg (
superficial and deep). All muscles in the sole of the
foot as medial plantar nerve or the lateral plantar
nerve

9. Anatomy
• Motor:
Common Fibular Portion–
innervates the short head of the biceps
femoris then via its terminal branches
provide innervation to:
o Superficial fibular nerve: Innervates
the muscles of the lateral
compartment of the leg
o Deep fibular nerve: Innervates the
muscles of the anterior compartment
of the leg and extensor digitorum
brevis.

10. Anatomy
• Sensory Functions of sciatic nerve:
Tibial Portion: Innervates the skin on the posterolateral and medial surfaces
of the foot as well as the sole of the foot.
Common Fibular Portion: Innervates the skin on the anterolateral surface of
the leg and the dorsal aspect of the foot

11. Anatomy
4. Posterior Femoral Cutaneous: [S1, S2, S3}
Motor : none
Sensory : skin on the posterior surface of the thigh
and leg and skin of the perineum.
5. Pudendal Nerve: [S2, S3, S4]
Motor: skeletal muscles in the perineum, the external
urethral sphincter, the external anal sphincter, levator
ani.
Sensory: penis and the clitoris and most of the skin
of the perineum.

12. Anatomy

13. Introduction
• Wash hands
Introduce yourself
Confirm patient details – name / DOB
Explain the examination
Gain consent
Expose patient’s legs – shorts are most appropriate
Ask if the patient currently has any pain

14. Inspection
• Observe for clues around the bed – walking stick / wheelchair
General appearance – any limb deformity or posturing?
• Scars
• Wasting of muscles
• Involuntary movements – dystonia/chorea/myoclonus
• Fasciculations – lower motor neurone lesions
• Tremor – Parkinson’s

15. Gait
1. Ask patient to walk to the end of the
room & back – assess speed, symmetry
,balance and arm swing
2. Tandem (heel-to-toe) gait – ask to walk
in a straight line heel-to-toe – an
abnormal heel-to-toe test may suggest
weakness, impaired proprioception or a
cerebellar disorder
3. stand on heel then on toes walking:
testing distal power. toes (L4/5) & heels
(S1)

16. Gait
• Abnormal gaits:
· Hemiplegia: the foot is plantar flexed and the leg is swung in a lateral arc
· Spastic paraparesis: scissors gait
· Parkinson's: starting hesitation, shuffling, freezing, festination
pro/retropulsion
· Cerebellar: drunken wide-based or reeling on a narrow base gait; staggers
towards side of cerebellar lesion
· Posterior column lesion: clumsy slapping down of the feet on a broad base
· Footdrop: high stepping gait
· Proximal myopathy: waddling gait
· Prefrontal lobe (apraxic): feet appear glued to floor when erect, but move
more easily when the patient is supine
· Hysterical: characterised by a bizarre, inconsistent gait

17. Gait
Romberg’s test
• Ask patient to stand with their feet
together and eyes closed
• Observe the patient (ideally for 1 minute)
• Positive test loss of balance
(swaying/falling over)
• This suggests a sensory ataxia (defective
proprioceptive or vestibular system)
• It’s important to stand close by the patient
during this test to stop them falling over!

18. Tone
• Ask the patient to keep their legs fully relaxed and “floppy”
throughout your assessment.
1. Leg roll – roll the patient’s leg & watch the foot – it should
flop independently of the leg
2. Leg lift – briskly lift leg off the bed at the knee joint – the heel
should remain in contact with the bed
3. Ankle clonus
o Position the patient’s leg so that the knee & ankle are 90º flexed
o Rapidly dorsiflex & partially evert the foot
o Keep the foot in this position
o Clonus is felt as rhythmical beats on
dorsiflexion/plantarflexion (>5 is abnormal)

19. Tone
• Hypertonia is found in upper motor
neurone lesions
• hypotonia is found in lower motor
neurone lesions and cerebellar
disorders
• Clonus is a sign of certain
neurological conditions, and is
particularly associated with upper
motor neuron lesions such as in
spastic diplegia, multiple sclerosis,
stroke, spinal cord damage.

20. Power
• Assess one side at a time and compare like for like.
• Remember to stabilise the joint whilst testing power.
Hip
Flexion (L1/2) – “raise your leg off the bed & stop me from pushing it
down”
Extension (L5/S1) – “stop me from lifting your leg off the bed”
Abduction (L4/5) – “move your leg away from the midline”
Adduction (L2/3) – “stop me from moving your leg away from the
midline”

21. Power
Knee
Flexion (S1) – “bend your knee & stop me from straightening it”
Extension (L3/4) – “kick out your leg”
Ankle
Dorsiflexion (L4) – “point your foot towards your head & don’t let me
push it down”
Plantarflexion (S1/2) – “press against my hand with the sole of your
foot”
Inversion (L4) – “push your foot against my hand”
Eversion (L5/S1) – “push your foot out against my hand”
Big Toe
Extension (L5) – “don’t let me push your big toe down”

22. Power
.
MRC scale for muscle power
0 No muscle contraction is visible
1
Muscle contraction is visible but there is no movement of
the joint
2 Active joint movement is possible with gravity eliminated
3
Movement can overcome gravity but not resistance from
the examiner.
4
The muscle group can overcome gravity and move against
some resistance from the examiner.
5 Full and normal power against resistance

23. Reflexes
1. Knee jerk (L3/4)
2. Ankle jerk (L5/S1)
3. Plantar response (S1)

24. Reflexes
• Interpretation:
o Upper motor neurone lesions usually produce hyperreflexia.
o Lower motor neurone lesions usually produce a diminished or
absent response.
o It may be normal to have reduced or absent ankle reflexes in some
elderly people, although the frequency and significance of this is
disputed.
o Isolated loss of a reflex can point to a radiculopathy affecting that
segment - eg, loss of ankle jerk if there is an S1 disc prolapse.
o An extensor plantar response (upgoing big toe) is pathological and
signifies an upper motor neurone lesion.

25. Sensation
Light touch sensation
Assesses dorsal/posterior columns and spinothalamic tracts.
1. The patient’s eyes should be closed for this assessment
2. Touch the patient’s sternum with the cotton wool wisp to confirm
they can feel it
3. Ask the patient to say “yes” when they are touched
4. Using a wisp of cotton wool, gently touch the skin (don’t stroke)
5. Assess each of the dermatomes of the lower limbs
6. Compare left to right, by asking the patient if it feels the same on
both sides

26. Sensation
Pin-prick sensation
Assesses spinothalamic tracts.
Repeat the previous assessment steps, but this time using the sharp
end of a neurotip.
If sensation is reduced peripherally, assess from a distal point and
move proximally to identify ‘stocking’sensory loss.

27. Sensation
Vibration sensation
Assesses dorsal/posterior columns/
1, Ask patient to close their eyes
2. Tap a 128 Hz tuning fork
3. Place onto patient’s sternum & confirm patient can feel it buzzing
4. Ask patient to tell you when they can feel it on their foot & to tell
you when it stops buzzing
5. Place onto the distal phalanx of the great toe
6. If sensation is impaired, continue to assess more proximally –
e.g. proximal phalanx

28. Sensation
Proprioception
Dorsal / posterior columns.
1. Hold the distal phalanx of the great toe by its sides
2. Demonstrate movement of the toe “upwards” & “downwards” to the
patient (whilst they watch)
3. Then ask patient to close their eyes & tell you if you are moving the
toe up or down
4. If the patient is unable to correctly identify direction of movement,
move to a more proximal joint (big toe > ankle > knee > hip)

29. Co-ordination
• Heel to shin test – “run your heel down the other leg from the knee
& repeat in a smooth motion”
• Toe-finger test – lift leg short distance to touch examiner’s finger
with hallux.
• Foot tapping – rapid foot tapping with sole against examiners hand.
• An inability to perform this test may suggest loss of motor
strength, proprioception or a cerebellar disorder.

30. To complete the examination…
• Thank patient
Wash hands
Summarize findings

31. THANKS
• Lower Limb Neurological Examination - OSCE guide