Examinations
CPSA · Clinical examination · Neurological
Lower limb neurological examination
The same inspect → tone → power → reflexes → sensation → coordination → gait sequence for the legs. Gait and Romberg add localising value.
Practise it out loudPosition: Patient on the couch, legs exposed; space to assess gait.
The routine
Inspection
- 1Wasting, fasciculations, scars, deformity, walking aids
Tone
- 1Roll the leg, lift the knee (spasticity), test for clonus at the ankle
Power
- 1Hip flexion (L1/2), knee ext (L3/4)/flexion (L5/S1), ankle dorsiflexion (L4/5)/plantarflexion (S1/2), MRC 0–5
Reflexes
- 1Knee (L3/4), ankle (S1/2), plantar — up-going (Babinski) = UMN
Sensation
- 1Light touch, pinprick, vibration, proprioception by dermatome
Coordination & gait
- 1Heel-to-shin; observe gait (spastic, ataxic, high-stepping, waddling); Romberg’s test (sensory ataxia)
Signs & what they mean
Increased tone, clonus, brisk reflexes, up-going plantarsUpper motor neurone lesion (e.g. cord compression)
Reduced tone/reflexes, wasting, down-going plantarsLower motor neurone lesion
Positive Romberg (falls with eyes closed)Sensory ataxia (dorsal column/proprioceptive loss)
Broad-based, unsteady gait, worse with eyes openCerebellar ataxia
Bilateral spastic weakness with a sensory levelSpinal cord compression — a surgical emergency
To complete, I would…
- Examine the upper limbs, cranial nerves and cerebellum
- Examine the back and consider urgent MRI if cord compression is suspected
OSCE tips
- An up-going plantar (Babinski) is a hard UMN sign — check it.
- A sensory level with bilateral leg weakness = cord compression until proven otherwise.
- Romberg tests proprioception (dorsal columns), not the cerebellum.