Examination of the Lower Limbs	37

of the adductor muscles. The anal reflex is tested by stimulating the perianal skin, e. g., with a pointed wooden stick. This induces reflex contraction of the anal sphincter. The anal reflex is sometimes easier to appreciate on rectal examination with a gloved finger (with which the examiner can also assess sphincter tone); it is abolished by lesions of the cauda equina and conus medullaris (p. 143 ff.).

Sensation. Sensation on the trunk is tested to localize a possible sensory level due to a spinal cord lesion. A

sensory level is a segmentally delimited sensory deficit. If caused by a bilateral lesion of one or more spinal nerve roots, it is limited to one or a few dermatomes; if caused by spinal cord transection, it covers the entire body from the toes up to the rostral border of the injured spinal segment. The segmental height of a sensory level should be located as precisely as possible by testing both from above and from below.

Examination of the Lower Limbs

The procedure here is essentially the same as in the upper limbs (cf. Examination of the Upper Limbs, pp. 27 ff.). Particular attention should be paid to the examination of the peripheral pulses, because pathological processes frequently affect the circulation of the lower limbs. The pedal and popliteal pulses should be palpated; the pulses in the abdominal vessels should be examined by auscultation, as should those of the femoral a., both in the groin and in the proximal adductor canal. The Ratschow test is a provocative test of the blood supply to the leg: the examiner holds up both legs of the supine patient and the patient rotates the feet back and forth. A normal individual can do this for several minutes without difficulty, but, if arterial insufficiency is present, pain soon develops in the feet. In addition, when the legs are brought back to the horizontal position, the skin takes a longer time than normal to regain its usual pink color (in patients of light complexion) and venous refilling is likewise delayed.

		Fig. 3.28	The heel−knee−shin test. With eyes closed, the patient
Coordination and Strength		brings one heel to the opposite knee, then slides it down the shin.
The following motor tests should be performed: in the
heel−knee−shin (HKS) test, the patient closes the eyes,
brings the heel of one leg through the air in a wide arc to
place it on the opposite knee, then slides the heel down
the shin to the front of the ankle, and finally back up to
the knee (Fig. 3.28). Unsteadiness indicates ataxia. In the
postural test, the patient lies supine, raises the lower
limbs so that the hips and knees are at right angles, and
holds them in this position (Fig. 3.29). The examiner
looks for possible sinking of a leg, indicating (mild)
paresis. Strength, too, should be tested in the supine
patient. Additional special tests are used for individual
muscle groups. For example, a patient with quadriceps
weakness has trouble stepping up onto a stool or chair,
or standing up from a sitting position (if the weakness is
bilateral). The dorsiflexors of the feet and toes should
always be tested, because these distal muscles are
frequently weakened early in the course of many differ-		Fig. 3.29	Postural test of the legs in the supine position.
ent neurological disorders. Great toe dorsiflexion, for
example, is weak in L5 radiculopathy. In suspected
polyneuropathy, it may be useful to palpate the con-
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3

The Neurological Examination

38 3 The Neurological Examination

	tractions of the muscles of the dorsum of the foot and					flex or the knee flexor reflexes. The latter are elicited by
	to compare the patient’s ability to spread the toes on					tapping the biceps femoris tendon (lateral border of the
	the two sides.					popliteal fossa) and the semimembranosus and semiten-
						dinosus tendons (medial border of the popliteal fossa).
	Reflexes					The inconstantly present tibialis posterior reflex is elicited
						by a tap on the tendon of this muscle behind the medial
	Intrinsic muscle reflexes. The quadriceps reflex (patel-					malleolus, while the foot is held in mild pronation. The
						response consists of supination.
	lar tendon reflex) and Achilles’ reflex are the most impor-					Pathological reflexes. There are a number of important
	tant intrinsic muscle reflexes of the lower limb. They
	should be tested in every patient (Fig. 3.30). In some sit-					pathological reflexes in the lower limb whose presence
	uations, it may also be advisable to test the adductor re-					implies a lesion of the pyramidal pathway. Chief among
						these is the Babinski reflex or “Babinski sign” (Fig. 3.31a).
						To elicit it, the examiner forcefully strokes the lateral
						plantar surface of the patient’s foot, proceeding from the
						heel toward the toes. The pathological response is a slow,
						tonic dorsiflexion of the great toe, usually accompanied
						by fanning of the other toes. (Babinski himself called
						these phenomena “signe de l’orteil”—the great toe sign—
						and “signe de l’éventail”—the fan sign.) The same re-
						sponse can sometimes be elicited by stroking other parts
						of the foot, particularly the anterior ball of the foot from
						lateral to medial. The Oppenheim sign is the Babinski phe-
						nomenon evoked by a painfully intense stroke along the
						edge of the tibia, from the knee downward (Fig. 3.31b);
						the Gordon sign is the same phenomenon evoked by
	Quadriceps reflex			Achilles’ reflex		pressing or forcefully squeezing the calf muscles
						(Fig. 3.31c). The Rossolimo sign (toe flexor reflex) consists
	Fig. 3.30 Testing of the quadriceps and Achilles’ reflexes.					of flexion of the second through fifth toes in response to a
						tap, from the plantar side, on their distal phalanges; it is a
						somewhat unreliable indicator of a pyramidal tract le-
						sion. These additional pathological reflexes need not be
	a					sought if the “classic” Babinski reflex is present, but only
						when it is absent or equivocal despite other clinical evi-
						dence of a pyramidal tract lesion. “Mute soles,” i. e., the
						lack of any toe movement at all when the Babinski reflex
						is tested, is a preliminary stage of the Babinski reflex in
						some patients and clinically meaningless in others. Mute
						soles in deeply comatose patients are associated with a
						poorer prognosis.
						All of the important reflexes of the lower limbs are
						summarized in Tables 3.5−3.7, including the normal in-
						trinsic and extrinsic muscle reflexes and the pathologi-
	b					cal reflexes.
						Sensation
						The earliest and most sensitive evidence of a mainly dis-
						tal sensory deficit in the lower limbs, e. g., in poly-
						neuropathy, is an impairment of vibration sense. Nor-
	c					mal persons can feel vibration in all joints down to the
						distal interphalangeal joints of the toes. They can also
						recognize numbers drawn on the skin of the lower leg
						and usually on the pad of the great toe as well (stereog-
						nosis). Position sense in the great toe is tested by hold-
						ing it on both sides and alternately dorsiflexing and
						plantar-flexing it; the patient should be able to state in
						which direction the toe was moved. Position sense is
						impaired, for example, by posterior column lesions.

Fig. 3.31 Pyramidal tract signs in the lower limbs. a Babinski sign. b Oppenheim reflex. c Gordon reflex.

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