LOWER LIMB NEUROLOGICAL EXAMINATION

OSCE GUIDE
David Bargiela
Neurology

Lower limb neurological examination frequently appears in OSCEs. Youll be expected

to pick up the relevant clinical signs using your examination skills. This lower limb
neurological examination OSCE guide provides a clear, concise, step-by-step approach
to performing a neurological examination of the lower limb, with an included video
demonstration.

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

Gather equipment
o

Tendon hammer

o
o
o

Neurotip
Cotton wool
Tuning fork (128hz)

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 Parkinsons

General inspection
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Gait
1. Ask patient to walk to the end of the room & back assess speed, symmetry &
balance
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. Heel walking assesses dorsiflexion power
Rombergs test
o

Ask patient to stand with their feet together and eyes closed

o
o
o
o

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)
Its important to stand close by the patient during this test to stop them falling over!

Gait

Tandem (Heel to toe) walking

Heel walking

Tip-toe walking

Romberg's test

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2.
3.
4.
5.

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5

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Tone
Ask the patient to keep their legs fully relaxed and floppy throughout your assessment.
1. Leg roll roll the patients 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 patients leg so that the knee & ankle are 90 flexed

o
o
o

Rapidly dorsiflex & partially evert the foot

Keep the foot in this position
Clonus is felt as rhythmical beats of dorsiflexion/plantarflexion (>5 is abnormal)

Leg roll

Leg lift

Ankle clonus

1.
2.
3.

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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

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 & dont 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) dont let me push your big toe down

Hip flexion

Hip extension

Hip ABduction

Hip ADduction

Knee flexion

Knee extension

Ankle plantarflexion

Ankle dorsiflexion

EHL

Ankle eversion

Ankle inversion

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.

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Reflexes
1. Knee jerk (L3/4)
2. Ankle jerk (L5/S1)
3. Plantar response (S1):
Run a blunt object along the lateral edge of the sole of the foot, moving towards the little

toe
o
o
o

Observe the great toe

Normal result = Flexion of the great toe & flexion of the other toes
Abnormal (Babinski sign) = Extension of the great toe UMN lesion

Knee jerk reflex

Ankle jerk reflex

Plantar reflex

1.
2.
3.

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Sensation
Light touch sensation

1
2
3

Assesses dorsal/posterior columns and spinothalamic tracts.

1. The patients eyes should be closed for this assessment
2. Touch the patients 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 (dont 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.

Vibration sensation
Assesses dorsal/posterior columns/
1, Ask patient to close their eyes
2. Tap a 128 Hz tuning fork
3. Place onto patients 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
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)

Soft touch sensation

Assess dermatomes, comparing right with left

Pin-prick sensation

Assessment for peripheral neuropathy

Vibration sensation

Proprioception

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2.
3.
4.
5.
6.

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Co-ordination

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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
acerebellar disorder.

Heel to shin test

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To complete the examination

Thank patient
Wash hands
Summarise findings
.
Suggest further assessments
o

Cranial nerve examination

Upper limb neurological examination

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