This document provides guidance on performing a neurological examination of the lower limbs. The examination involves assessing bulk, tone, reflexes, power, function, and sensation through inspection, palpation, and testing various movements. Sensation is tested for light touch, pinprick, vibration, and proprioception. Coordination, gait, and Romberg's test are also evaluated to localize lesions and determine if they are neurological, central vs. peripheral, sensory vs. motor, and acquired vs. hereditary.

1. Neurological exm of lower limbs
Subject steps
Bulk ,
Tone,
Reflexes,
Power,
function,
Sensation
The key diagnostic questions:
1.where is the lesion :
 is it neurological ?
 if so which part of the nervous system does it localize
-central Vs peripheral
-sensory Vs motor
2.what is the lesion:
Hereditary/congenital/acquired
Examination
WIPE
• Wash your hands
• Introduce yourself to the patient
• Permission - to examine the patient
• Position - start with the patient sitting
• Pain - check that the patient has no pain
• Exposure - both upper limbs from shoulders to fingers
INSPECTIONS Wastings,skin,deformity,fasciculations,joint abnormality
Palpation 1.Bulk of the muscles:
Unilateral wastings-old polio
Generalized wastings-MND,POLYNEUROPATHY,LMNL
ISOLATED ANT. WASTINGS-DM
2.Tone:
Lift the leg and allow to fall
Palpate the muscles then do side to side movements
Lastly passive movement of the limb

2. 3.Reflexes:
 Knee jerk (L3/4)
 Ankle jerk (L5/S1)
 Plantar response (S1):
o Run a blunt objectalong the lateral edge of the sole of the
foot, moving towards the little toe
o Observe the great toe
o Normal result = Flexion of the great toe & flexion of the
other toes
o Abnormal (Babinski sign) = Extensionof the great toe –
UMN lesio
Superficial reflexes-abdominal ,cremasteric
4.Muscle power-grading
Hip
Flexion (L1/2) – “raise your leg off the bed & stop me
from pushingit down”
Extension(L5/S1)– “stop me from lifting yourleg off the
bed”
Abduction (L4/5)– “move yourleg away from the midline”
Adduction (L2/3) – “stop me from moving yourleg away
from the midline”
Knee
Flexion (S1) – “bend yourknee & stop me from straightening
it”
Extension(L3/4)– “kick out yourleg”
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 yourfoot”
Inversion(L4) – “push your foot againstmy hand”
Eversion (L5/S1)– “push yourfoot out againstmy hand”
5.Coordination :
Heel to shin test – “run your heel down the other leg from
the knee & repeat in a smooth motion
(An inability to perform this test may suggest loss
of motor strength, proprioception or a cerebellar disorder)

3. 6.Sensory test:
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
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.

4. 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
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

5. 7.Gait:
 Ask patient to walk to the end of the room & back –
assess speed, symmetry & balance
 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
 Heel walking – assesses dorsiflexion power
8.Romberg’s test:
o Ask patient to stand with their feet together and eyes closed
o Observe the patient (ideally for 1 minute)
o Positive test loss of balance (swaying/falling over)
o This suggests a sensory ataxia (defective proprioceptive or
vestibular system)
o It’s important to stand close by the patient during this test to
stop them falling over!
Finally look at the spine to see any deformity,scar,gibbus,tenderness