NEUROLOGICAL EXAMINATION MOTOR & SENSORY FUNCTION LOWER LIMB AN ANATOMICAL GUIDE Kaan Yücel M.D., Ph.D. 21.May.2014. Wednesday

TESTING THE MUSCLES

THIGH & POPLITEAL FOSSA Great extensor of the leg Femoral nerve Quadriceps femoris Performed with the person in the supine position with the knee partly flexed. Person extends knee against resistance.

THIGH & POPLITEAL FOSSA Extension @ hip joint Flexion @ knee joint Tibial nerve Hamstring muscles Person flexes his leg against resistance. Normally, these muscles—especially their tendons on each side of the popliteal fossa—should be prominent as they bend the knee.

LEG Tibialis anterior Dorsiflexes ankle & inverts foot Deep fibular nerve Tibialis anterior The person is asked to stand on the heels or dorsiflex the foot against resistance. If normal, its tendon can be seen and palpated.

Extensor hallucis longus LEG Extends great toe & dorsiflexes ankle Deep fibular nerve Extensor hallucis longus Great toe dorsiflexed against resistance. If acting normally, its entire tendon can be seen and palpated. Extensor digitorum longus Extends the toes & dorsiflexes foot at the ankle joint Deep fibular nerve Lateral four toes dorsiflexed against resistance. If acting normally, the tendons can be seen and palpated.

Fibularis longus and brevis LEG Everts foot and weakly plantarflexes ankle Superficial fibular nerve Fibularis longus and brevis The foot is everted strongly against resistance. If acting normally, the muscle tendons can be seen and palpated inferior to the lateral malleolus. Initial Position Patient plantar flexes and everts foot Final Position Examiner forces the foot into inversion

LEG Plantarflexes ankle; raises heel during walking; flexes leg at knee joint (soleus; steadies leg on foot) Tibial nerve Triceps surae The foot is plantarflexed against resistance (e.g., by “standing on the toes,” in which case body weight [gravity] provides resistance). If normal, the calcaneal tendon and triceps surae can be seen and palpated.

Flexor hallucis longus LEG Flexes great toe at all joints; weakly plantarflexes ankle; supports medial longitudinal arch Tibial nerve Flexor hallucis longus The distal phalanx of the great toe is flexed against resistance. If normal, the tendon can be seen and palpated on the plantar aspect of the great toe as it crosses the joints of the toe.

Flexor digitorum longus LEG Flexes lateral four digits; plantarflexes ankle; supports longitudinal arches of foot Tibial nerve Flexor digitorum longus The distal phalanges of the lateral four toes are flexed against resistance. If they are acting normally, the tendons of the toes can be seen and palpated.

LEG Tibialis posterior Plantarflexes ankle; inverts foot Tibial nerve The foot is inverted against resistance with foot in slight plantarflexion. If normal, the tendon can be seen and palpated posterior to the medial malleolus .

regIONS & SENSORy INNERVATION

Upper lateral quadrant Superior clunial nerves L1-L3 posterior rami Skin overlying superior and central parts of buttock Medial clunial nerves S1-S3 posterior rami Skin of medial buttock and intergluteal cleft Inferior clunial nerves Posterior cutaneous nerve of thigh (S2-S3) Skin of inferior buttock (overlying gluteal fold Upper lateral quadrant lateral branches of the iliohypogastric (L1) and 12th thoracic nerves (anterior rami)

Obturator nerve Superior medial thigh Genitofemoral nerve Middle anterior thigh Posterior cutaneous nerve of the thigh Posterior aspect of the thigh Intermediate cutaneous nerve of the thigh (femoral nerve) Variable area on the medial aspect of the thigh Medial cutaneous nerve of the thigh (femoral nerve) Medial aspect of the thigh

Saphenous nerve (femoral nerve) Medial aspect of leg Posterior cutaneous nerve of the thigh Upper part of the leg Superficial fibular nerve Anterolateral leg Sural nerve Posterolateral leg

Medially saphenous nerve, which extends distally to the head of 1st metatarsal Superiorly (dorsum of foot) superficial (primarily) and deep fibular nerves Inferiorly (sole of foot) medial and lateral plantar nerves; Common border of their distribution along the 4th metacarpal toe or digit Laterally sural nerve, including part of the heel. Posteriorly (heel) medial and lateral calcaneal branches of the tibial and sural nerves, respectively

reflexes

Calcaneal Tendon Reflex S1 & 2 Patellar Reflex L3 & 4 A tap with a tendon hammer on the patellar ligament Calcaneal Tendon Reflex S1 & 2 Person's legs are dangling over the side of the examining table. The calcaneal tendon is struck briskly with a reflex hammer just proximal to the calcaneus. The normal result is plantarflexion of the ankle joint.

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