Abdal-Bari Al-Chanati

Upper + Lower Limb Neurological Examination

Introduction
-

SANITIZE
CONSENT: Hello my name is Abdal-Bari Al-Chanati, Im a 4th year medical student. Is it
alright if I examine your arms and legs? Are you comfortable?
EXPOSE: Ideally top off, and wearing only shorts
POSITION: Seated on bed
UPPER LIMB

General Appearance
-

Structural abnormalities
Muscle wasting (feel for this)
Fasciculations
Abnormal movements
Posture
Scars
Adjuncts/aids

Tone
Hold patients hand and support their elbow.
Ask patient to relax fully.
Test slow passive movements for rigidity and fast passive movements for spasticity.
Tone is either normal or increased
If increased: Spastic [UMN disease] vs. Rigid [Basal ganglia disease] Cogwheel vs. Lead pipe rigidity.
Look for clonus in spastic muscle
TEST IN BOTH LIMBS
1. Wrist:
o Flexion/Extension
o Pronation/Supination
2. Elbow:
o Flexion/Extension
Power
Put muscle in action then try to resist it.
Grading power:
0 No contraction
1 Slight contraction, no movement
2 Full range of motion without gravity
3 Full range of motion against gravity but not against resistance
4 Full range of motion, some resistance
5 Full range of motion, full resistance

Abdal-Bari Al-Chanati

Power Test in both limbs simultaneously comparing them. Give a grade for each movement.
a. Shoulder abduction/adduction
b. Elbow flexion/extension
c. Wrist flexion/extension
d. Thumb abduction
e. Finger flexion/extension/abduction
f. Power grip (their handlebar grip vs. your 2 fingers)
g. Pincer grip (their thumb and forefinger vs. yours)

Shoulder Abduction: C5
Shoulder Adduction: C6, C7, C8
Elbow Flexion: C5, C6
Elbow Extension: C6, C7
Wrist Flexion/Extension: C6+C7
Digital Flexion/Extension: C7+C8
Finger Abduction/Adduction: T1

Reflexes
To reinforce reflexes, ask the patient to hold their hands together tightly or clench their teeth JUST
before you hit the tendon.
TEST BOTH ARMS, alternating between each reflex in order to compare.
Grading Reflexes:
0 = Absent
1+ (or +) = Diminished
2+ (or ++) = Normal
3+ (or +++) = Hyperactive without clonus
4+ (or ++++) = Hyperactive with clonus
1.
a.
b.
c.
d.

Biceps reflex C5/C6

Rest patients arm on their lap with forearm supinated
Feel for the biceps tendon with your forefinger
Hit your finger and look for contraction of the biceps
Grade the reflex and test the other arm

2.
a.
b.
c.
d.

Brachioradialis (supinator) reflex C5/C6

Wouldnt need to check if biceps worked
Rest patients arm on their lap with arm halfway between pronation and supination
Place your 2 fingers on the distal end of the radius and strike on your fingers
Grade the reflex and test the other arm

3.
a.
b.
c.

Triceps reflex C7
Dangle patients arm outwards and downwards resting fully on your arm
Hit the point of the reflex tendon
Grade the reflex and test the other arm

Abdal-Bari Al-Chanati
4.
a.
b.
c.

Finger reflex C8 (Extra)

Clasp the patients relaxed fingers which are slightly flexed
Hit your own fingers
Grade reflex and test the other arm

Co-ordination
1. Finger-nose test
a. Ask patient to touch their nose with their finger, then to touch your finger which is in front
of them. Do this repetitively as fast as they can
b. REPEAT FOR THE OTHER HAND
(look for intention tremor and past pointing [cerebellar disease])
2. Rapid alternating movements
a. Ask patient to slap their hand repetitively, alternating with the dorsum and palmar aspects
of their other hand
b. REPEAT FOR THE OTHER HAND
3. Upper limb Pronator drift
a. Ask patient to hold their arms outstretched in front of them, with their palms up and
their eyes closed
b. Look for pronation of palms [UMN disease]

Sensation
General Notes:
- Ask the patient to close their eyes
- Test their sensation first over the cheek to establish a baseline
- Test ALL the dermatomes (at irregular intervals)
- Ask if it feels the same on both sides

Abdal-Bari Al-Chanati

1.
a.
b.
c.

Pin Prick
Use a safety pin and discard at the end
Alternate between sharp and blunt, and ask whether the sensation feels sharp or blunt
Test ALL dermatomes with the sharp side

2. Light Touch
a. Use a wisp of cotton wool
3.
a.
b.
c.
d.
4.
a.
b.
c.

Proprioception
Test in most distal part first, and if abnormal move proximally
Steady distal phalangeal joint of the finger and hold distal part of finger from the sides
Demonstrate first what is up and down with their eyes open
Test with eyes closed

Vibration
Use a 128 Hz tuning fork
Demonstrate a typical vibration on the sternum
Place the vibrating tuning fork on the dorsal aspect of the DIP joint. Ask patient to tell you
when they feel it.
d. Ask patient to tell you when they feel it stopping. Stop the vibration by dampening the
tuning fork.

Abdal-Bari Al-Chanati
LOWER LIMB
General Appearance
-

Structural abnormalities
Muscle wasting (feel for this and look from front and back)
Fasciculations
Abnormal movements
Posture
Scars
Adjuncts/aids

GAIT
Ask patient to walk to a point and back, then on their heels, then on their toes.
Observe: Posture, stride length, broadness of base, arm swing, smoothness, turning ability
Do Rhombergs test: Ask patient to stand with feet together and arms by side, to close their eyes
and stay there for ideally 1 minute. Negative is normal. Positive is if there is any excess swaying.
[sensory ataxia NON-cerebellar]
STANCE PHASE: Heel strike Mid-stance Toe off SWING PHASE
Abnormalities of gait:
1) Wide-based: Balance problem
2) Parkinsonian: Hesitancy, shuffling, no arm swing, festinating, many steps to turn around
3) Spastic Hemiplegic: The leg on the affected side is extended and internally rotated and is
swung in a wide, lateral arc rather than lifted in order to move it forward
4) Foot-drop: Tibialis anterior malfunction (deep peroneal nerve)
5) Stiff-knee: Rocking motion
6) Stiff-hip: Swinging hip forward on one side
7) Short-leg: Shoulders tilt during gait
8) Trendelenburg gait: Hip abductor malfunction (sup. Gluteal nerve), pelvis drop on opp. side
9) Antalgic: (unequal time on each foot due to pain)
10) Varus thrust: Disruption to posterolateral aspect of knee, buckles laterally
Tone
Ask patient to relax fully.
Test slow passive movements for rigidity and fast passive movements for spasticity.
Tone is either normal or increased
If increased: Spastic [UMN disease] vs. Rigid [Basal ganglia disease] Cogwheel vs. Lead pipe rigidity.
Look for clonus in spastic muscle
TEST IN BOTH LIMBS
1. Knee:
o Roll the whole extended limb slowly
o Flexion/Extension: Do this slowly first. Then lift the middle of the extended limb
from the bottom of the knee upwards quickly (heel should drag along bed)

Abdal-Bari Al-Chanati
2. Ankle:
o Flexion/Extension: Do this slowly. Then flex the knee to 90o and externally rotate the
hip. Quickly dorsiflex the ankle and hold it there. >3 beats is abnormal.

Power
Put muscle in action then try to resist it.
Grading power:
0 No contraction
1 Slight contraction, no movement
2 Full range of motion without gravity
3 Full range of motion against gravity but not against resistance
4 Full range of motion , some resistance
5 Full range of motion, full resistance
Power Test in both limbs simultaneously comparing them. Give a grade for each movement.
a. Hip flexion/extension
b. Knee flexion/extension
c. Ankle dorsiflexion/Plantar flexion
d. Great toe dorsiflexion/plantar flexion
Hip Flexion: L2, L3
Hip Extension: L4, L5
Knee Extension: L3, L4
Knee Flexion: L5, S1
Ankle Dorsiflexion: L4, L5
Ankle Plantar-flexion: S1, S2
Big Toe Dorsiflexion: L5, S1
Big Toe Plantar-flexion: S1, S2
Reflexes
To reinforce reflexes, ask the patient to hold their hands together tightly or clench their teeth JUST
before you hit the tendon.
TEST BOTH LEGS, alternating between each reflex in order to compare.
Grading Reflexes:
0 = Absent
1+ (or +) = Diminished
2+ (or ++) = Normal
3+ (or +++) = Hyperactive without clonus
4+ (or ++++) = Hyperactive with clonus
1. Knee Reflex L3/L4
a. Flex the knee to 90o, and rest their thigh on your arm (or have their legs dangling over the
bed)
b. Hit the patellar tendon
c. Grade the reflex and repeat on the other leg

Abdal-Bari Al-Chanati

2. Ankle Reflex S1
a. Kneel the patient with their feet dangling over the edge of the bed
b. Hit the Achilles tendon
c. Grade the reflex and repeat on the other leg
(Alternate method: Externally rotate the hip, flex the knee and dorsi-flex the ankle. Hold the
bottom of their foot and tap on your fingers, OR hold the base of their foot and tap on the
medial aspect of the Achilles tendon)

3.
a.
b.
c.
d.

Plantar Response
Ideally use a key and scrape it over the lateral edge of the sole of the foot
Normal response = Flexion of the big toe (Flexor plantar response)
UMN lesion = Extension of the big toe (Babinski reflex)
May also be no response

Co-ordination
1. Heel-Knee test
a. Ask patient to place their heel of one foot onto the toe of the other foot
b. Then demonstrate that you would like them to move it up to the knee and then back again
repetitively
c. Repeat for the other leg
2. Rapid alternating movements
a. Ask patient to tap their foot repetitively on your hand
b. Repeat for the other foot

Sensation

Abdal-Bari Al-Chanati
General Notes:
- Ask the patient to close their eyes
- Test their sensation first over the sternum to establish a baseline
- Test ALL the dermatomes (at irregular intervals)
- Ask if it feels the same on both sides
1. Pin Prick
a. Use a safety pin and discard at the end
b. Alternate between sharp and blunt, and ask whether the sensation feels sharp or blunt
c. Test ALL dermatomes with the sharp side
2. Light Touch
a. Use a wisp of cotton wool
3. Proprioception
a. Test in most distal part first, and if abnormal move proximally
b. Steady phalangeal joint of the great toe and hold distal phalanx from the sides
c. Demonstrate first what is up and down with their eyes open
d. Test with eyes closed
4. Vibration
a. Use a 128 Hz tuning fork
b. Demonstrate a typical vibration on the sternum
c. Place the vibrating tuning fork on the dorsal aspect of the IP joint. Ask patient to tell you
when they feel it.
d. Ask patient to tell you when they feel it stopping. Stop the vibration by dampening the
tuning fork.

EXTRA
-

Rectal exam
Full Locomotor exam

*Thank patient, re-sanitise and summarise findings*

Summary of Pathologies

Tone
Power
Reflexes
Co-ordination
Special
features

LMN lesion
Decreased/Normal
Decreased
Reduced.
Plantar Babinski
Normal
Wasting
Fasciculations

UMN lesion
Increased (spastic)
Decreased
Brisk
Upwards Babinski
Decreased
Clonus

Extrapyramidal
Increased (rigid)
Normal
Normal

Cerebellar
Decreased
Normal
Normal

Decreased
Resting tremor
Bradykinesia
Postural Instability

Very bad
Intention tremor
Nystagmus
Staccato speech