MOTOR EXAMINATION OF THE LOWER LIMB
• Inspection - Ask the child to lie down on the bed and expose to the underpants with the legs and thighs entirely exposed. Place a towel over the groin and inspect the lower limb.
o Posture – Note the resting posture. Look for abnormal flexion or extension, unusual rotation, clawing of the foot or limb shortening. Always compare with the other side for symmetry.
o Muscle Bulk - Look for muscle wasting of the quadriceps and anterior tibials and hypertrophy of the calf muscles. Compare one side with the other and proximal with distal (asymmetry).
o Involuntary Movements - Inspect for abnormal involuntary motor activity like fasciculations, tremor, etc.
o Paucity of voluntary movements
o Scars particularly on the posterior aspect of the lower limb
o Equipment - Urinary catheter
• Gait Examination
Function assessment of the lower limbs is a very important part of the neurological examination. In some instances, this area alone is given as an individual case in the exam. It is important to remember that normal stance and gait depends on intact visual, proprioceptive, corticospinal, extrapyramidal, cerebellar pathways and motor systems. There are two phases to the normal walking cycle: stance phase, when the foot is on the ground; and swing phase, when it is moving forward. While assessing gait, one should evaluate both the stance and walking (with various manoeuvres). Prior to the assessment, ask the child to remove the socks and shoes and examine the shoe.
o Stance: Make sure the legs and the thighs are clearly visible.
Look for limb shortening
Foot and knee position – valgus/ varus
Width of stance
Romberg sign (refer cerebellar examination)
Ask the child to walk normally, with walking aid if needed for a few metres and then turn around quickly and walk back. Look for age appropriate walking, symmetry and smoothness of the gait and ability to turn quickly. Watch the width of gait, the arm swing and position, movement of pelvis and knee, the heel lift and toe push off. Toddlers walk with wide jerky steps. By age 7, children should have a smooth, mature gait with heel strike, stance phase (whole foot on the ground), push off phase and arm swing.
Next, ask the child to ‘walk heel to toe’ in a straight line (tandem gait) to exclude a midline cerebellar lesion.
Ask the chid to ‘Walk on tiptoes’ (to identify foot dorsiflexion weakness and S1 lesion)
Ask to ‘Walk on your heels’ (child with L4-5 lesion, footdrop and achilles tendon contracture cannot do this maneuver)
‘Hop on each leg’ (tests balance, coordination and quadriceps function)
Fog’s test: ‘Walk on the outside (everted) of the feet’. Useful in identifying mild hemiplegia and athetoid posturing of hands.
Finally ask to the child to run. (identifies subtle hemiplegia which may be missed otherwise)
o Other maneuvers
Gowers’ sign: Ask the child to squat and then stand up. This...