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APracticalGuidetoClinicalMedicine
A comprehensive physical examination and clinical education site for medical
students and other health care professionals
Web Site Design by Jan Thompson, Program Representative, UCSD School of Medicine.
Content and Photographs by Charlie Goldberg, M.D., UCSD School of Medicine and VA
Medical Center, San Diego, California 920930611.
Send Comments to: Charlie Goldberg, M.D.
Introduction
HistoryofPresentIllness
TheRestoftheHistory
ReviewofSystems
VitalSigns
TheEyeExam
HeadandNeckExam
TheLungExam
CardiovascularExam
ExamoftheAbdomen

BreastExam
MaleGenital/RectalExam
TheUpperExtremities
TheLowerExtremities
MusculoSkeletalExam
TheMentalStatusExam
TheNeurologicalExam
PhysicalExamCheckLists
MedicalLinks

WriteUps
TheOralPresentation
OutpatientClinics
InpatientMedicine
ClinicalDecisionMaking
PhysicalExamLectureSeries
AFewThoughts
CommonlyUsedAbbreviations
References

The"daVinciAnatomyIcon"denotesalinktorelatedgrossanatomypictures.

TheNeurologicalExamination
Cranial
Nerves

SensoryandMotor
Examinations

Reflex
Testing

Coordination

Gait
Testing

MakingSenseof
Neurological
Findings

Introduction
Thegoalsoftheneurologicalexaminationareseveral:
1.Forpatientspresentingwithsymptomssuggestiveofaneurologicalproblem,theexaminationshould:
a.Determine,onthebasisofanorganizedandthoroughexamination,whetherinfactneurological
dysfunctionexists.
b.Identifywhichcomponent(s)oftheneurologicalsystemareaffected(e.g.motor,sensory,cranial
nerves,orpossiblyseveralsystemssimultaneously).
c.Ifpossible,determinethepreciselocationoftheproblem(e.g.peripheralvcentralnervoussystem
regionandsideofthebrainaffectedetc.).
d.Onthebasisofthesefindings,generatealistofpossibleetiologies.Unlikelydiagnosescanbe
excludedandappropriatetesting(e.g.brainandspinalcordimaging)thenappliedinanorderlyand
logicalfashion.
2.Screeningforthepresenceofdiscreteabnormalitiesinpatientsatriskforthedevelopmentofneurological
disorders.Thisisappropriateforindividualswhohavenoparticularsubjectivesymptomssuggestiveofa
neurologicalproblem,yethavesystemicillnessesthatmightputthematriskforsubtledysfunction.
Diabeticpatients,forexample(particularlythosewithlongstandingpoorcontrol),maydevelop
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peripheralnervedysfunction.Thismayonlybedetectedthroughcarefulsensorytesting(seebelowunder
SensoryTesting),whichwouldhaveimportantclinicalimplications.
3.Cursoryscreening/documentationofbaselinefunctionforthosewhoareotherwisehealthy.Inpatients
withneithersignsnorriskfactorsforneurologicaldisease,it'sunlikelythatthedetailedexamwould
uncoveroccultproblems.SimplyobservingthepatientduringthecourseoftheusualH&P(i.e.watching
themwalk,getupanddownfromtheexamtable,etc.)maywellsuffice.Manyexaminersincorporate
someaspectsoftheneuroexamintotheirstandardevaluations.CranialNervetesting,forexample,canbe
easilyblendedintotheHeadandNeckevaluation.Decidingwhatotheraspectstoroutinelyincludeis
basedonjudgmentandexperience.
Themajorareasoftheexam,coveringthemosttestablecomponentsoftheneurologicalsystem,include:
1.Mentalstatustesting(coveredinaseparatesectionofthiswebsite)
2.CranialNerves
3.Musclestrength,toneandbulk
4.Reflexes
5.Coordination
6.SensoryFunction
7.Gait
Realandimaginedproblemswiththeneurologicalexamination:
Theneurologicalexaminationisoneoftheleastpopularand(perhaps)mostpoorlyperformedaspectsofthe
completephysical.Isuspectthatthissituationexistsforseveralreasons:
1.Thisexamisperceivedasbeingtimeandlaborintensive.
2.Studentsandhousestaffneverdevelopanadequatelevelofconfidenceintheirabilitytoperformthe
exam,norintheaccuracyoftheirfindings.This,inturn,probablytranslatesintopoorperformancelater
intheircareers.
3.Examfindingsareoftenquitesubjective.Thus,particularlywhentheexaminerdoesnothaveconfidence
intheirabilities(seeabove),interpretationoftheresultscanbeproblematic.
4.Understanding/Interpretationofsomeneurologicalfindingsrequiresanindepthunderstandingof
neuroanatomyandpathophysiology.Asmanycliniciansdonotseealargenumberofpatientswith
neurologicaldisorders,theylikelymaintainalimitedworkingunderstandingofthisinformation.
5.Thereisanoverrelianceontheutilityofneuroimaging(e.g.CT,MRI).Thesestudiesprovidean
evaluationofanatomybutnotfunction.Thus,whileextremelyhelpful,theymustbeinterpretedwithinthe
contextofexamfindings.Carefulexaminationmaymakeimagingunnecessary.Also,examfindingscan
makeastrongcaseforthepresenceofapathologicprocess,evenifitisnotseenonaparticular
radiologicalstudy(i.e.therearelimitstowhatcanbeseenoneventhemosthightechimaging).
Theabovearenotmeanttolowerexpectationswithregardstohowwellaphysicianshouldbeexpectedtolearn
andperformtheneurologicalexamination.Rather,Imentionthesepointstohighlightsomeoftherealand
imaginedobstaclestoclinicalperformance.Likeallotheraspectsofthephysicalexam,thereisawealthof
informationthatcanbeobtainedfromtheneurologicalexamination,providedthatitisdonecarefullyand
accurately.Thisis,ofcourse,predicatedonlearninghowtodoitcorrectly.Afewpractical
considerations/suggestions:
1.Ingeneral,theneurologicalexaminationisnotappliedinitsentiretytoasymptomatic,otherwisehealthy
peopleastheyield(i.e.likelihoodofidentifyingoccultdisease)wouldbequitelow.Itis,however,agood
ideatopracticetheexamearlyinyourcareers,evenwhenworkingwithnormalpatients.Thiswill
improvethefacilitywithwhichyouperformtheexam,provideyouwithabettersenseoftherangeof
normal,increasetheaccuracyoftheresultsgenerated,andgiveyouconfidenceinthemeaningoffindings
identifiedwhenevaluatingotherpatients.
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2.Itissometimesappropriatetoperformonlycertainpartsoftheneurologicalexamination(e.g.justcranial
nervesoronlymotortesting)Thesesituationswillbecomeapparentwithexperience.
3.Thetestingdescribedbelowisstillratherbasic.Therearemanyadditionalaspectsoftheexamthatshould
beappliedinspecificsettings.Theyarebeyondthescopeofthistext,butcanbefoundinother
references.
4.Takeadvantageofthoseopportunitieswhenamoreexperiencedclinicianexaminesoneofyourpatients.
Whenpossible,watchthemperformtheirexam.Thengobackaloneandverifythefindings.
Likeanyotheraspectoftheexam,theneurologicalassessmenthaslimits.Testingofonesystemisoften
predicatedonthenormalfunctionofotherorgansystems.If,forexample,apatientisvisuallyimpaired,they
maynotbeabletoperformfingertonosetesting,apartoftheassessmentofcerebellarfunction(seebelow).Or,
apatient'sseveredegenerativehipdiseasewillpreventthemfromwalking,makingthataspectoftheexam
impossibletoassess.Theinterpretationof"findings"mustthereforetakethesethingsintoaccount.Onlyinthis
waycanyougenerateanaccuratepicture.Doingthis,ofcourse,takespracticeandexperience.
CranialNerve(CN)Testing
CN2

CN3,4,6

CN5

CN7

CN8

CN9,10

CN11

CN12

Manypractitionersincorporatecranialnervetestingwiththeircompleteexaminationoftheheadandneck(see
theHeadandNecksectionofthiswebsitefordetails).AdetaileddescriptionoftheCNassessmentisprovided
below.Aseachhalfofthebodyhasitsowncranialnerve,bothrightandleftsidesmustbechecked
independently.
CranialNerve1(Olfactory):Formalassessmentofabilitytosmellisgenerallyomitted,unlessthereisaspecific
complaint.Ifitistobetested:
1.1.Checktomakesurethatthepatientisabletoinhaleandexhalethroughtheopennostril.
2.Havethepatientclosetheireyes.
3.Presentasmalltesttubefilledwithsomethingthathasadistinct,commonodor(e.g.groundcoffee)tothe
opennostrils.Thepatientshouldbeabletocorrectlyidentifytheodoratapproximately10cm.
FormoreinformationaboutCN1,seethefollowinglinks:
YaleUniversityCranialNerveReviewSite
UniformServicesSchoolofMedicineCranialNerveReviewSite
CranialNerve2(Optic):Thisnervecarriesvisualimpulsesfromtheeyetotheopticalcortexofthebrainby
meansoftheoptictracts.Testinginvolves3phases(alsocoveredinthesectionofthissitededicatedtotheEye
Exam):
1.Acuity:
a.Eacheyeistestedseparately.Ifthepatientusesglassestoviewdistantobjects,theyshouldbe
permittedtowearthem(referredtoasbestcorrectedvision).
b.ASnellenChartisthestandard,wallmounteddeviceusedforthisassessment.Patientsareaskedto
readthelettersornumbersonsuccessivelylowerlines(eachwithsmallerimages)untilyouidentify
thelastlinewhichcanbereadwith100%accuracy.Eachlinehasafractionwrittennexttoit.20/20
indicatesnormalvision.20/400meansthatthepatient'svision20feetfromanobjectisequivalent
tothatofanormalpersonviewingthesameobjectfrom400feet.Inotherwords,thelargerthe
denominator,theworsethevision.

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Snellenchartformeasuringvisualacuity
c.TherearehandheldcardsthatlooklikeSnellenChartsbutarepositioned14inchesfromthe
patient.Theseareusedsimplyforconvenience.Testingandinterpretationareasdescribedforthe
Snellen.

Handheldvisualacuitycard
d.Ifneitherchartisavailableandthepatienthasvisualcomplaints,someattemptshouldbemadeto
objectivelymeasurevisualacuity.Thisisacriticallyimportantreferencepoint,particularlywhen
tryingtocommunicatethemagnitudeofavisualdisturbancetoaconsultingphysician.Canthe
patientreadnewsprint?Theheadlineofanewspaper?Distinguishfingersorhandmovementin
frontoftheirface?Detectlight?Failureateachlevelcorrelateswithamoresevereproblem.
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2.VisualFieldTesting:Specificareasoftheretinareceiveinputfrompreciseareasofthevisualfield.This
informationiscarriedtothebrainalongwelldefinedanatomicpathways.Holesinvision(referredtoas
visualfieldcuts)arecausedbyadisruptionalonganypointinthepathfromtheeyeballtothevisual
cortexofthebrain.Visualfieldscanbecrudelyassessedasfollows:
a.Theexaminershouldbenosetonosewiththepatient,separatedbyapproximately8to12inches.
b.Eacheyeischeckedseparately.Theexaminerclosesoneeyeandthepatientclosestheone
opposite.Theopeneyesshouldthenbestaringdirectlyatoneanother.
c.Theexaminershouldmovetheirhandouttowardstheperipheryofhis/hervisualfieldontheside
wheretheeyesareopen.Thefingershouldbeequidistantfrombothpersons.
d.Theexaminershouldthenmovethewigglingfingerintowardsthem,alonganimaginaryline
drawnbetweenthetwopersons.Thepatientandexaminershoulddetectthefingeratmoreorless
thesametime.
e.Thefingeristhenmovedouttothediagonalcornersofthefieldandmovedinwardsfromeachof
thesedirections.Testingisthendonestartingatapointinfrontoftheclosedeyes.Thewiggling
fingerismovedtowardstheopeneyes.
f.Theothereyeisthentested.
Meaningfulinterpretationispredicatedupontheexaminerhavingnormalfields,astheyareusing
themselvesforcomparison.
Iftheexaminercannotseemtomovetheirfingertoapointthatisoutsidethepatient'sfielddon't
worry,asitsimplymeansthattheirfieldsarenormal.
Interpretation:Thistestisrathercrude,anditisquitepossibletohavesmallvisualfielddefectsthat
wouldnotbeapparentonthistypeoftesting.Priortointerpretingabnormalfindings,theexaminer
mustunderstandthenormalpathwaysbywhichvisualimpulsestravelfromtheeyetothebrain.
Formoreinformationaboutvisualfieldtesting,seethefollowinglinks:
WashingtonUniversity,reviewofvisualfieldoftestingandpathology
UniversityofArkansas,grossanatomyofvisualpathway
3.Pupils:Thepupilhasafferent(sensory)nervesthattravelwithCN2.Thesenervescarrytheimpulse
generatedbythelightbacktowardsthebrain.Theyfunctioninconcertwithefferent(motor)nervesthat
travelwithCN3andcausepupillaryconstriction.SeenunderCN3forspecificsoftesting.
FormoreinformationaboutCN2,seethefollowinglinks:
YaleUniversityCranialNerveReviewSite
UniformServicesSchoolofMedicineCranialNerveReviewSite
Cranialnerves3,4and6&extraocularmovements:
Normally,theeyesmoveinconcert(iewhenlefteyemovesleft,righteyemovesinsamedirectiontoasimilar
degree).Thebraintakestheinputfromeacheyeandputsittogethertoformasingleimage.Thiscoordinated
movementdependson6extraocularmusclesthatinsertaroundtheeyeballsandallowthemtomoveinall
directions.Eachmuscleisinnervatedbyoneof3CranialNerves(CNs):CNs3,4and6.Movementsare
describedas:elevation(pupildirectedupwards),depression(pupildirecteddownwards),adbduction(pupil
directedlaterally),adduction(pupildirectedmedially),extorsion(topofeyerotatingawayfromthenose),and
intorsion(topofeyerotatingtowardsthenose).

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The3CNsresponsibleforeyemovementandthemusclesthattheycontrolareasfollows:
CN4(Trochlear):ControlstheSuperiorObliquemuscle.
CN6(Abducens):ControlstheLateralRectusmuscle.
CN3(Oculomotor):Controlstheremaining4muscles(inferioroblique,inferiorrectus,superiorrectus,and
medialrectus).CN3alsoraisestheeyelidandmediatesconstrictionofthepupil(discussedbelow).
Themnemonic"SO4,LR6,AllTheRest3"mayhelpremindyouwhichCNdoeswhat(SuperiorObliqueCN
4,LateralRectusCN6,AllTheRestofthemusclesinnervatedbyCN3).
EOMsandtheirfunction:
Themedialandlateralrectusmusclesaredescribedfirst,astheirfunctionsareverystraightforward:
Lateralrectus:Abduction(ielateralmovementalongthehorizontalplane)
Medialrectus:Adduction(ie.Medialmovementalongthehorizontalplane)
Theremainingmuscleseachcausesmovementinmorethanonedirection(e.g.somecombinationof
elevation/depression,abduction/adduction,intorsion/extorsion).Thisisduetothefactthattheyinsertonthe
eyeballatvariousangles,andinthecaseofthesuperioroblique,thruapulley.Reviewoftheoriginand
insertionofeachmuscleshedslightonitsactions(seelinks@theendofthissection).Thenetimpactofany
oneEOMistheresultofthepositionoftheeyeandthesumofforcesfromallothercontributingmuscles.
SpecificactionsoftheremainingEOMsaredescribedbelow.Theactionwhichthemuscleprimarilyperformsis
listedfirst,followedbysecondaryandthentertiaryactions.
Inferiorrectus:depression,extorsionandadduction.
Superiorrectus:elevation,intorsionandadduction
Superioroblique:intorsion,depressionandabduction
Inferioroblique:extorsion,elevationandabduction

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Practicallyspeaking,cranialnervetestingisdonesuchthattheexaminercanobserveeyemovementsinall
directions.Themovementsshouldbesmoothandcoordinated.Toassess,proceedasfollows:
1.Standinfrontofthepatient.
2.Askthemtofollowyourfingerwiththeireyeswhilekeepingtheirheadinoneposition
3.Usingyourfinger,traceanimaginary"H"orrectangularshapeinfrontofthem,makingsurethatyour
fingermovesfarenoughoutandupsothatyou'reabletoseeallappropriateeyemovements(ielateraland
up,lateraldown,medialdown,medialup).
4.Attheend,bringyourfingerdirectlyintowardsthepatient'snose.Thiswillcausethepatienttolook
crosseyedandthepupilsshouldconstrict,aresponsereferredtoasaccommodation.

TestingExtraocularMovements
Pathology:Isolatedlesionsofacranialnerveorthemuscleitselfcanadverselyaffectextraocularmovement.
Patientswillreportdiplopia(doublevision)whentheylookinadirectionthat'saffected.Thisisbecausethe
braincan'tputtogetherthediscordantimagesinawaythatformsasinglepicture.Inresponse,theywilleither
assumeaheadtiltthatattemptstocorrectfortheabnormaleyepositioningorclosetheabnormaleye.Asan
example,thepatientshownbelowhasaleftcranialnerve6lesion,whichmeansthathisleftlateralrectusno
longerfunctions.Whenhelooksright,hisvisionisnormal.However,whenhelooksleft,heexperiencesdouble
visionasthelefteyecan'tmovelaterally.Thisisreferredtoashorizontaldiplopia.
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LeftCN6Palsy
Patientwasaskedtolookleft.Notethatlefteyewillnotabduct.
It'sworthmentioningthatdisordersoftheextraocularmusclesthemselves(andnottheCNwhichinnervate
them)canalsoleadtoimpairedeyemovement.Forexample,picturedbelowisapatientwhohassuffereda
traumaticleftorbitalinjury.Theinferiorrectusmusclehasbecomeentrappedwithintheresultingfracture,
preventingthelefteyefrombeingabletolookdownward.Thescleralbloodandperiorbitalechymosisare
secondarytothetraumaaswell.

*FormoreonEOMsgoto:EyesEOMshttp://meded.ucsd.edu/clinicalmed/eyes.htm#Extra
Asmentionedabove,CN3alsoinnervatesthemusclewhichraisestheuppereyelid(LevatorPalpebrae
Superiorismuscle).Thiscanbeassessedbysimplylookingatthepatient.IfthereisCN3dysfunction,the
eyelidonthatsidewillcovermoreoftheiriscomparedwiththeothereye.Thisisreferredtoasptosis.

RighteyeptosisfromCN3Palsy.Inaddition,therighteyeisdirectedlaterally,whichisduetounopposed
effectsofCNs4&6.Thedilatedrightpupilisexplainedbelow.
Theresponseofpupilstolightiscontrolledbyafferent(sensory)nervesthattravelwithCN2andefferent
(motor)nervesthattravelwithCN3.Theseinnervatetheciliarymuscle,whichcontrolsthesizeofthepupil.
Testingisperformedasfollows:
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1.Ithelpsiftheroomisabitdim,asthiswillcausethepupiltobecomemoredilated.
2.Usinganylightsource(flashlight,otoophtahlmoscope,etc),shinethelightintooneeye.Thiswillcause
thatpupiltoconstrict,referredtoasthedirectresponse.
3.Removethelightandthenreexposeittothesameeye,thoughthistimeobservetheotherpupil.Itshould
alsoconstrict,referredtoastheconsensualresponse.Thisoccursbecauseafferentimpulsesfromoneeye
generateanefferentresponse(i.e.signaltoconstrict)thatissenttobothpupils.
4.Ifthepatient'spupilsaresmallatbaselineoryouareotherwisehavingdifficultyseeingthechanges,take
yourfreehandandplaceitabovetheeyessoastoprovidesomeshade.Thisshouldcausethepupilsto
dilateadditionally,makingthechangewhentheyareexposedtolightmoredramatic.Ifyouarestill
unabletoappreciatearesponse,askthepatienttoclosetheireye,generatingmaximumdarknessandthus
dilatation.Thenaskthepatienttoopentheeyeandimmediatelyexposeittothelight.Thiswill
(hopefully)makethechangefromdilatedtoconstrictedveryapparent.
Interpretation:
1.Undernormalconditions,bothpupilswillappearsymmetric.Directandconsensualresponseshouldbe
equalforboth.
2.Asymmetryofthepupilsisreferredtoasaniosocoria.Somepeoplewithanisocoriahavenounderlying
neuropathology.Inthissetting,theasymmetrywillhavebeenpresentforalongtimewithoutchangeand
thepatientwillhavenootherneurologicalsignsorsymptoms.Thedirectandconsensualresponsesshould
bepreserved.
3.Anumberofconditionscanalsoaffectthesizeofthepupils.Medications/intoxicationswhichcause
generalizedsympatheticactivationwillresultindilatationofbothpupils.Otherdrugs(e.g.narcotics)
causesymmetricconstrictionofthepupils.Thesefindingscanprovideimportantclueswhendealingwith
anagitatedorcomatosepatientsufferingfrommedicationoverdose.Eyedropsknownasmydriaticagents
areusedtoparalyzethemuscles,resultingmarkeddilatationofthepupils.Theyareusedduringadetailed
eyeexamination,allowingaclearviewoftheretina.Addiitonally,anyprocesswhichcausesincreased
intracranialpressurecanresultinadilatedpupilthatdoesnotrespondtolight.
4.Iftheafferentnerveisnotworking,neitherpupilwillrespondwhenlightisshinedintheaffectedeye.
Lightshinedinthenormaleye,however,willcausetheaffectedpupiltoconstrict.That'sbecausethe
efferent(signaltoconstrict)responseinthiscaseisgeneratedbytheafferentimpulsereceivedbythe
normallyfunctioningeye.Thisisreferredtoasanafferentpupildefect.
5.Iftheefferentnerveisnotworking,thepupilwillappeardilatedatbaselineandwillhaveneitherdirect
norconsensualpupillaryresponses.

RightCN3PalsyNotethattherightpupilisdilatedrelativetotheleft,duetolossofefferent
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input.Theptosisandabnormaleyepositioningarediscussedabove.
FormoreinformationaboutpupillaryresponseandCN3,seethefollowinglinks:
MoreonExtraocularmovements:http://www.tedmontgomery.com/the_eye/eom.html#top
DartmouthNeurosciencesExtraocularmovements
http://www.dartmouth.edu/~dons/part_1/chapter_4.html
YaleUniversityExtraocularMuscleshttp://info.med.yale.edu/caim/cnerves/cn3/cn3_3.html
YaleUniversityCranialNerveReviewSite
UCDavisExtraOccularMovementandPupilaryResponseSimulator
CN4(Trochlear):SeenunderCN3.
CN5(Trigeminal):Thisnervehasbothmotorandsensorycomponents.
AssessmentofCN5SensoryFunction:Thesensorylimbhas3majorbranches,eachcoveringroughly1/3ofthe
face.Theyare:theOphthlamic,Maxillary,andMandibular.Assessmentisperformedasfollows:
1.Useasharpimplement(e.g.brokenwoodenhandleofacottontippedapplicator).
2.Askthepatienttoclosetheireyessothattheyreceivenovisualcues.
3.Touchthesharptipofthesticktotherightandleftsideoftheforehead,assessingtheOphthalmicbranch.
4.Touchthetiptotherightandleftsideofthecheekarea,assessingtheMaxillarybranch.
5.Touchthetiptotherightandleftsideofthejawarea,assessingtheMandibularbranch.
Thepatientshouldbeabletoclearlyidentifywhenthesharpendtouchestheirface.Ofcourse,makesurethat
youdonotpushtoohardasthefaceisnormallyquitesensitive.TheOphthalmicbranchofCN5alsoreceives
sensoryinputfromthesurfaceoftheeye.Toassessthiscomponent:

1.Pulloutawispofcotton.
2.Whilethepatientislookingstraightahead,gentlybrushthewispagainstthelateralaspectofthesclera
(outerwhiteareaoftheeyeball).
3.Thisshouldcausethepatienttoblink.BlinkingalsorequiresthatCN7functionnormally,asitcontrols
eyelidclosure.
AssessmentofCN5MotorFunction:ThemotorlimbofCN5innervatestheTemporalisandMassetermuscles,
bothimportantforclosingthejaw.Assessmentisperformedasfollows:
1.PlaceyourhandonbothTemporalismuscles,locatedonthelateralaspectsoftheforehead.
2.Askthepatienttotightlyclosetheirjaw,causingthemusclesbeneathyourfingerstobecometaught.
3.ThenplaceyourhandsonbothMassetermuscles,locatedjustinfromoftheTemperoMandibularjoints
(pointwherelowerjawarticulateswithskull).
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4.Askthepatienttotightlyclosetheirjaw,whichshouldagaincausethemusclesbeneathyourfingersto
becometaught.Thenaskthemtomovetheirjawfromsidetoside,anotherfunctionoftheMassester.

FormoreinformationaboutCN5motorfunction,seethefollowinglinks:
YaleUniversityCranialNerveReviewSite
UniformServicesSchoolofMedicineCranialNerveReviewSite
CN6(Abducens):SeeunderCN3.
CN7(Facial):Thisnerveinnervatesmanyofthemusclesoffacialexpression.Assessmentisperformedas
follows:
1.Firstlookatthepatient'sface.Itshouldappearsymmetric.Thatis:
a.Thereshouldbethesameamountofwrinklesapparentoneithersideoftheforehead...barring
asymmetricBoToxinjection!
b.Thenasolabialfolds(linescomingdownfromeithersideofthenosetowardsthecornersofthe
mouth)shouldbeequal
c.Thecornersofthemouthshouldbeatthesameheight
Ifthereisanyquestionastowhetheranapparentasymmetryifneworold,askthepatientforapicture
(oftenfoundonadriver'slicense)forcomparison.
2.Askthepatienttowrinkletheireyebrowsandthenclosetheireyestightly.CN7controlsthemusclesthat
closetheeyelids(asopposedtoCN3,whichcontrolsthemuscleswhichopenthelid).Youshouldnotbe
abletoopenthepatient'seyelidswiththeapplicationofgentleupwardspressure.
3.Askthepatienttosmile.Thecornersofthemouthshouldrisetothesameheightandequalamountsof
teethshouldbevisibleoneitherside.
4.Askthepatienttopuffouttheircheeks.Bothsidesshouldpuffequallyandairshouldnotleakfromthe
mouth.
Interpretation:CN7hasaprecisepatternofinervation,whichhasimportantclinicalimplications.Therightand
leftuppermotorneurons(UMNs)eachinnervateboththerightandleftlowermotorneurons(LMNs)thatallow
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theforeheadtomoveupanddown.However,theLMNsthatcontrolthemusclesofthelowerfaceareonly
innervatedbytheUMNfromtheoppositesideoftheface.
CN7FacialNerve
PrecisePatternofInnervation

Thus,inthesettingofCN7dysfunction,thepatternofweaknessorparalysisobservedwilldifferdependingon
whethertheUMNorLMNisaffected.Specifically:
1.UMNdysfunction:Thismightoccurwithacentralnervoussystemevent,suchasastroke.Inthesetting
ofRUMNCN7dysfunction,thepatientwouldbeabletowrinkletheirforeheadonbothsidesoftheir
face,astheleftCN7UMNcrossinnervatestheRCN7LMNthatcontrolsthismovement.However,the
patientwouldbeunabletoeffectivelyclosetheirlefteyeorraisetheleftcorneroftheirmouth.

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RightcentralCN7dysfunction:Notepreservedabiltiytowrinkleforehead.Leftcornerofmouth,
however,isslightlylowerthanright.Leftnasolabialfoldisslightlylesspronouncedcomparedwithright.
2.LMNdysfunction:ThisoccursmostcommonlyinthesettingofBell'sPalsy,anidiopathic,acuteCN7
peripheralnervepalsy.InthesettingofRCN7peripheral(i.e.LMN)dysfunction,thepatientwouldnot
beabletowrinkletheirforehead,closetheireyeorraisethecorneroftheirmouthontherightside.Left
sidedfunctionwouldbenormal.

LeftperipheralCN7dysfunction:Notelossofforeheadwrinkle,abilitytocloseeye,abilitytoraisecornerof
mouth,anddecreasednasolabialfoldprominenceonleft.
Thisclinicaldistinctionisveryimportant,ascentralvsperipheraldysfunctioncarrydifferentprognosticand
treatmentimplications.Bell'sPalsy(peripheralCN7dysfunction)tendstohappeninpatient'sover50andoften
respondstotreatmentwithAcyclovir(anantiviralagent)andPrednisone(acorticosteroid).Overthecourseof
weeksormonthsthereisusuallyimprovementandoftencompleteresolutionofsymptoms.Assessmentofacute
central(UMN)CN7dysfunctionwouldrequirequiteadifferentapproach(e.g.neuroimagingtodetermine
etiology).
CN7isalsoresponsibleforcarryingtastesensationsfromtheanterior2/3ofthetongue.Howeverasthisis
rarelyofclinicalimport,furtherdiscussionisnotincluded.
FormoreinformationaboutCN7,seethefollowinglinks:
YaleUniversityCranialNerveReviewSite
UniformServicesSchoolofMedicineCranialNerveReviewSite
CN8(Acoustic):CN8carriessoundimpulsesfromthecochleatothebrain.Priortoreachingthecochlea,the
soundmustfirsttraversetheexternalcanalandmiddleear.Auditoryacuitycanbeassessedverycrudelyon
physicalexamasfollows:
1.Standbehindthepatientandaskthemtoclosetheireyes.
2.Whisperafewwordsfromjustbehindoneear.Thepatientshouldbeabletorepeatthesebackaccurately.
Thenperformthesametestfortheotherear.
3.Alternatively,placeyourfingersapproximately5cmfromoneearandrubthemtogether.Thepatient
shouldbeabletohearthesoundgenerated.Repeatfortheotherear.
Formoreinformationaboutearanatomy,seethefollowinglink:
WashingtonUniversityInnerEarAnatomy
Thesetestsarerathercrude.Precisequantification,generallynecessarywheneverthereisasubjectivedeclinein
acuity,requiresspecialequipmentandtraining.
Thecauseofsubjectivehearinglosscanbeassessedwithbedsidetesting.Hearingisbrokeninto2phases:
conductiveandsensorineural.Theconductivephasereferstothepassageofsoundfromtheoutsidetothelevel
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ofCN8.Thisincludesthetransmissionofsoundthroughtheexternalcanalandmiddleear.Sensorineuralrefers
tothetransmissionofsoundviaCN8tothebrain.Identificationofconductive(amuchmorecommonproblem
inthegeneralpopulation)defectsisdeterminedasfollows:
WeberTest:
1.Graspthe512Hztuningforkbythestemandstrikeitagainstthebonyedgeofyourpalm,generatinga
continuoustone.Alternativelyyoucangettheforktovibrateby"snapping"theendsbetweenyourthumb
andindexfinger.
512HzTuningFork

2.Holdthestemagainstthepatient'sskull,alonganimaginarylinethatisequidistantfromeitherear.
3.ThebonesoftheskullwillcarrythesoundequallytoboththerightandleftCN8.BothCN8s,inturn,
willtransmittheimpulsetothebrain.
4.Thepatientshouldreportwhetherthesoundwasheardequallyinbothearsorbetterononesidethenthe
other(referredtoaslateralizingtoaside).

WeberTest
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RinneTest:
1.Graspthe512Hztuningforkbythestemandstrikeitagainstthebonyedgeofyourpalm,generatinga
continuoustone.
2.Placethestemofthetuningforkonthemastoidbone,thebonyprominencelocatedimmediatelybehind
thelowerpartoftheear.
3.ThevibrationstravelviathebonesoftheskulltoCN8,allowingthepatienttohearthesound.
4.Askthepatienttoinformyouwhentheycannolongerappreciatethesound.Whenthisoccurs,movethe
tuningforksuchthatthetinesareplacedrightnextto(butnottouching)theopeningoftheear.Atthis
point,thepatientshouldbeabletoagainhearthesound.Thisisbecauseairisabetterconductingmedium
thenbone.

RinneTest
Interpretation:
1.Theabovetestingisreservedforthoseinstanceswhenapatientcomplainsofadeficitinhearing.Thus,on
thebasisofhistory,thereshouldbeacomplaintofhearingdeclineinoneorbothears.
2.Inthesettingofaconductivehearingloss(e.g.waxintheexternalcanal),theWebbertestwilllateralize
(i.e.soundwillbeheardbetter)intheearthathasthesubjectivedeclineinhearing.Thisisbecausewhen
thereisaproblemwithconduction,competingsoundsfromtheoutsidecannotreachCN8viatheexternal
canal.Thus,soundgeneratedbythevibratingtuningforkandtravelingtoCN8bymeansofbony
conductionisbetterheardasithasnooutside"competition."Youcantransientlycreateaconductive
hearinglossbyputtingthetipofyourindexfingerintheexternalcanalofoneear.Ifyoudothiswhile
performingtheWebbertest,thesoundwillbeheardonthatside.
3.Inthesettingofasensorineuralhearingloss(e.g.atumorofCN8),theWebbertestwilllateralizetothe
earwhichdoesnothavethesubjectivedeclineinhearing.ThisisbecauseCN8isthefinalpathway
throughwhichsoundiscarriedtothebrain.Thus,eventhoughthebonesoftheskullwillsuccessfully
transmitthesoundtoCN8,itcannotthenbecarriedtothebrainduetotheunderlyingnervedysfunction.
4.Inthesettingofconductivehearingloss,boneconduction(BC)willbebetterthenairconduction(AC)
whenassessedbytheRinneTest.Ifthereisablockageinthepassageway(e.g.wax)thatcarriessound
fromtheoutsidetoCN8,thensoundwillbebetterheardwhenittravelsviathebonesoftheskull.Thus,
thepatientwillnoteBCtobebetterthenorequaltoACintheearwiththesubjectivedeclineinhearing.
5.Inthesettingofasensorineuralhearingloss,airconductionwillstillbebetterthenboneconduction(i.e.
thenormalpatternwillberetained).ThisisbecausetheproblemisatthelevelofCN8.Thus,regardless
ofthemeans(boneorair)bywhichtheimpulsegetstoCN8,therewillstillbeamarkedhearing
decrementintheaffectedear.AsACisnormallybetterthenBC,thiswillstillbethecase.
Summary:
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Identifyingconductivevsensorineuralhearingdeficitsrequireshistoricalinformationaswellastheresultsof
WebberandRinnetesting.Insummary,thisdataisinterpretedasfollows:
1.Firstdeterminebyhistoryandcrudeacuitytestingwhichearhasthehearingproblem.
2.PerformtheWebbertest.Ifthereisaconductivehearingdeficit,theWebberwilllateralizetotheaffected
ear.Ifthereisasensorineuraldeficit,theWebberwilllateralizetothenormalear.
3.PerformtheRinnetest.Ifthereisaconductivehearingdeficit,BCwillbegreaterthenorequaltoACin
theaffectedear.Ifthereisasensorineuralhearingdeficit,ACwillbegreaterthenBCintheaffectedear.
FormoreinformationaboutCN8,seethefollowinglinks:
YaleUniversityCranialNerveReviewSite
UniformServicesSchoolofMedicineCranialNerveReviewSite
CN9(Glosopharyngeal)andCN10(Vagus):Thesenervesareresponsibleforraisingthesoftpalateofthe
mouthandthegagreflex,aprotectivemechanismwhichpreventsfoodorliquidfromtravelingintothelungsAs
bothCNscontributetothesefunctions,theyaretestedtogether.
TestingElevationofthesoftpalate:
1.Askthepatienttoopentheirmouthandsay,"ahhhh,"causingthesoftpalatetoriseupward.
2.Lookattheuvula,amidlinestructurehangingdownfromthepalate.Ifthetongueobscuresyourview,
takeatonguedepressorandgentlypushitdownandoutoftheway.
3.TheUvulashouldriseupstraightandinthemidline.

NormalOropharynx
Interpretation:
IfCN9ontherightisnotfunctioning(e.g.inthesettingofastroke),theuvulawillbepulledtotheleft.The
oppositeoccursinthesettingofleftCN9dysfunction.

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LeftCN9Dysfunction:PatientstatuspoststrokeaffectingleftCN9.Uvulathereforepulledovertowardsright.
Beawarethatotherprocessescancausedeviationoftheuvula.Aperitonsilarabscess,forexample,willpushthe
uvulatowardstheopposite(i.e.normal)tonsil.

Leftperitonsillarabscess:infectionwithinlefttonsilhaspusheduvulatowardstheright.
TestingtheGagReflex:
1.Askthepatienttowidelyopentheirmouth.Ifyouareunabletoseetheposteriorpharynx(i.e.thebackof
theirthroat),gentlypushdownwithatonguedepressor.
2.Insomepatients,thetonguedepressoralonewillelicitagag.Inmostothers,additionalstimulationis
required.Takeacottontippedapplicatorandgentlybrushitagainsttheposteriorpharynxoruvula.This
shouldgenerateagaginmostpatients.
3.Asmallbutmeasurablepercentofthenormalpopulationhaseitheraminimalornonexistentgagreflex.
Presumably,theymakeuseofothermechanismstopreventaspiration.
Gagtestingisrathernoxious.Somepeopleareparticularlysensitivetoevenminimalstimulation.Assuch,I
wouldsuggestthatyouonlyperformthistestwhenthereisreasonablesuspicionthatpathologyexists.This
wouldincludetwomajorclinicalsituations:
1.Ifyoususpectthatthepatienthassufferedacutedysfunction,mostcommonlyinthesettingofastroke.
Thesepatientsmaycomplainof/benotedtocoughwhentheyswallow.Or,theymaysufferfromrecurrent
pneumonia.Bothoftheseeventsaresignsofaspirationoffoodcontentsintothepassagewaysofthe
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lungs.ThesepatientsmayalsohaveothercranialnerveabnormalitiesaslesionsaffectingCN9and10
oftenaffectCNs11and12,whichareanatomicallynearby.
2.Patient'ssufferingfromsuddendecreasedlevelofconsciousness.Inthissetting,theabsenceofagag
mightindicatethatthepatientisnolongerabletoreflexivelyprotecttheirairwayfromaspiration.Strong
considerationshouldbegiventointubatingthepatient,providingthemwithasecuremechanicalairway
untiltheirgeneralconditionimproves.
CN9isalsoresponsiblefortasteoriginatingontheposterior1/3ofthetongue.Asthisisrarelyaclinically
importantproblem,furtherdiscussionisnotincluded.
CN10alsoprovidesparasympatheticinnervationtotheheart,thoughthiscannotbeeasilytestedonphysical
examination.
FormoreinformationaboutCN9and10,seethefollowinglinks:
YaleUniversityCranialNerveReviewSite
UniformServicesSchoolofMedicineCranialNerveReviewSite
CN11(SpinalAccessory):CN11innervatesthemuscleswhichpermitshruggingoftheshoulders(Trapezius)
andturningtheheadlaterally(Sternocleidomastoid).
1.Placeyourhandsontopofeithershoulderandaskthepatienttoshrugwhileyouprovideresistance.
Dysfunctionwillcauseweakness/absenceofmovementontheaffectedside.

2.Placeyouropenlefthandagainstthepatient'srightcheekandaskthemtoturnintoyourhandwhileyou
provideresistance.Thenrepeatontheotherside.TherightSternocleidomasoidmuscle(andthusrightCN
11)causestheheadtoturntotheleft,andviceversa.

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CN12(Hypoglossal):CN12isresponsiblefortonguemovement.EachCN12innervatesonehalfofthetongue.
Testing:
1.Askthepatienttosticktheirtonguestraightoutoftheirmouth.
2.Ifthereisanysuggestionofdeviationtooneside/weakness,directthemtopushthetipoftheirtongue
intoeithercheekwhileyouprovidecounterpressurefromtheoutside.

Interpretation:
IftherightCN12isdysfunctional,thetonguewilldeviatetotheright.Thisisbecausethenormallyfunctioning
lefthalfwilldominateasitnolongerhasoppositionfromtheright.Similarly,thetonguewouldhavelimitedor
absentabilitytoresistagainstpressureappliedfromoutsidetheleftcheek.

LeftCN12Dysfunction:StrokehasresultedinLCN12Palsy.
Tonguethereforedeviatestotheleft.
FormoreinformationaboutCN12,seethefollowinglinks:
YaleUniversityCranialNerveReviewSite
UniformServicesSchoolofMedicineCranialNerveReviewSite
SensoryandMotorExaminationsABriefReviewofAnatomyandPhysiology:
SensoryTesting
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MotorTesting
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Testingofmotorandsensoryfunctionrequiresabasicunderstandingofnormalanatomyandphysiology.In
brief:
1.Voluntarymovementbeginswithanimpulsegeneratedbycellbodieslocatedinthebrain.
2.Signalstravelfromthesecellsdowntheirrespectiveaxons,formingtheCortiospinal(a.k.a.Pyramidal)
tract.Atthelevelofthebrainstem,thismotorpathwaycrossesovertotheoppositesideofthebodyand
continuedownwardonthatsideofthespinalcord.Thenerveswhichcomprisethismotorpathwayare
collectivelyreferredtoasUpperMotorNeurons(UMNs).It'simportanttonotethatthereareothermotor
pathwaysthatcarryimpulsesfromthebraintotheperipheryandhelpmodulatemovement.Adiscussion
ofthesetractscanbefoundinotherNeurologyreferencetexts.
Formoreinformationaboutmotorpathways,seethefollowinglink:
UniversityofWashingtonReviewofMotorPathways
3.Ataspecificpointinthespinalcordtheaxonsynapseswitha2ndnerve,referredtoasaLowerMotor
Neuron(LMN).Thepreciselocationofthesynapsedependsuponwherethelowermotorneuronis
destinedtotravel.If,forexample,theLMNterminatesinthehand,thesynapseoccursinthecervical
spine(i.e.neckarea).However,ifit'sheadedforthefoot,thesynapseoccursinthelumbarspine(i.e.
lowerback).
4.TheUMNsarepartoftheCentralNervousSystem(CNS),whichiscomposedofneuronswhosecell
bodiesarelocatedinthebrainorspinalcord.TheLMNsarepartofthePeripheralNervousSystem
(PNS),madeupofmotorandsensoryneuronswithcellbodieslocatedoutsideofthebrainandspinal
cord.TheaxonsofthePNStraveltoandfromtheperiphery,connectingtheorgansofaction(e.g.
muscles,sensoryreceptors)withtheCNS.
5.NerveswhichcarryimpulsesawayfromtheCNSarereferredtoEfferents(i.e.motor)whilethosethat
bringsignalsbackarecalledAfferents(i.e.sensory).
6.Axonsthatexitandenterthespineatanygivenlevelgenerallyconnecttothesamedistalanatomicarea.
Thesebundlesofaxons,referredtoasspinalnerveroots,containbothafferentandefferentnerves.The
rootsexit/enterthespinalcordthroughneruoforaminainthespine,pairedopeningsthatallowfortheir
passageoutofthebonyprotectionprovidedbythevertebralcolumn.
Formoreinformationaboutspinalcordanatomy,seethefollowinglink:
ReviewofSpinalAnatomy
7.Astheefferentneuronstravelsperipherally,componentsfromdifferentrootscommingleandbranch,
followingahighlyprogrammedpattern.Ultimately,contributionsfromseveralrootsmaycombinetoform
anamedperipheralnerve,whichthenfollowsapreciseanatomicrouteonitswaytoinnervatingaspecific
muscle.TheRadialNerve,forexample,travelsaroundtheHumerus(boneoftheupperarm),contains
contributionsfromCervicalNerveRoots6,7and8andinnervatesmusclesthatextendthewristand
supinatetheforearm.
Itmayhelptothinkofanerverootasanelectricalcablecomposedofmanydifferentcoloredwires,each
wirerepresentinganaxon.Asthecablemovesawayfromthespinalcord,wiressplitoffandheadto
differentdestinations.Priortoreachingtheirtargets,theycombinewithwiresoriginatingfromother
cables.Thegroupofwiresthatultimatelyendsatatargetmusclegroupmaythereforehavecontributions
fromseveraldifferentroots.
Formoreinformationaboutradialnerveanatomyandfunction,seebelow.
8.Afferentscarryimpulsesintheoppositedirectionofthemotornerves.Thatis,theybringinformation
fromtheperipherytothespinalcordandbrain.
9.Sensorynervesbeginintheperiphery,receivinginputfromspecializedreceptororgans.Theaxonsthen
moveproximally,joininginaprecisefashionwithotheraxonstoformtheafferentcomponentofanamed
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peripheralnerve.TheRadialNerve,forexample,notonlyhasamotorfunction(describedpreviously)but
alsocarriessensoryinformationfromdiscretepartsofthehandandforearm.
10.Asthesensoryneuronsapproachthespinalcord,theyjoinspecificspinalnerveroots.Eachrootcarries
sensoryinformationfromadiscreteareaofthebody.Theareaofskininnervatedbyaparticularnerve
rootisreferredtoasadermatome.Dermatomemapsdescribethepreciseareasofthebodyinnervatedby
eachnerveroot.Thesedistributionsaremoreorlessthesameforallpeople,whichisclinicallyimportant.
Inthesettingofnerverootdysfunction,thespecificareasuppliedbythatrootwillbeaffected.Thiscanbe
mappedoutduringacarefulexam(seebelow),identifyingwhichroot(s)isdysfunctional.
Toviewadermatomalmap,seethefollowinglink:
DermatomeMapUniversityofScranton
11.Sensoryinputtravelsupthroughthespinalcordalongspecificpaths,withthepreciseroutedefinedbythe
typeofsensationbeingtransmitted.Nervescarryingpainimpulses,forexample,crosstotheoppositeside
ofthespinalcordsoonafterentering,andtraveluptothebrainonthatsideofthecord.Vibratory
sensations,ontheotherhand,enterthecordandtravelupthesameside,crossingoveronlywhenthey
reachthebrainstem(seefollowingsectionsfordetaileddescriptions).
Formoreinformationaboutsensorypathways,seethefollowinglink:
UniversityofWashingtonReviewofSensoryPathways
12.Ultimately,thesensorynervesterminateinthebrain,wheretheimpulsesareintegratedandperception
occurs.
Understandingtheaboveneruoanatomicrelationshipsandpatternsofinnervationhasimportantclinical
implicationswhentryingtodeterminetheprecisesiteofneurologicaldysfunction.Injuryatthespinalnerveroot
level,forexample,willproduceacharacteristiclossofsensoryandmotorfunction.Thiswilldifferfromthat
causedbyaproblemattheleveloftheperipheralnerve.Anapproachtolocalizinglesionsonthebasisofmotor
andsensoryfindingsisdescribedinthesectionswhichfollow.Realizethatthereisafairamountofinter
individualvariationwithregardstothespecificsofinnervation.Also,recognizethatoftenonlypartsofnerves
maybecomedysfunctional,leadingtopartialmotororsensorydeficits.Assuch,thepatternsoflossarerarelyas
"pure"asmightbesuggestedbytheprecisedescriptionsofnervesandtheirinnervations.
SensoryTesting
SensorytestingofthefaceisdiscussedinthesectiononCranialNerves.Testingoftheextremitiesfocuseson
thetwomainafferentpathways:SpinothalamicsandDorsalColumns.
1.Spinothalamics:Thesenervesdetectpain,temperatureandcrudetouch.Theytravelfromtheperiphery,
enterthespinalcordandthencrosstotheothersideofthecordwithinoneortwovertebrallevelsoftheir
entrypointTheythencontinueupthatsidetothebrain,terminatinginthecerebralhemisphereonthe
oppositesideofthebodyfromwheretheybegan.
2.DorsalColumns:Thesenervesdetectposition(a.k.a.proprioception),vibratorysensationandlighttouch.
Theytravelfromtheperiphery,enteringthespinalcordandthenmovinguptothebaseofthebrainonthe
samesideofthecordaswheretheystarted.Uponreachingthebrainstemtheycrosstotheoppositeside,
terminatinginthecerebralhemisphereontheoppositesideofthebodyfromwheretheybegan.
Ascreeningevaluationofthesepathwayscanbeperformedasfollows:
Spinothalamics

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1.Thepatient'sabilitytoperceivethetouchofasharpobjectisusedtoassessthepainpathwayofthe
Spinothalamics.Todothis,breakaQtiportonguedepressorinhalf,suchthatyoucreateasharp,pointy
end.Alternatively,youcanuseadisposableneedleorthesharpandbluntendsofasafetypin.Iwould
discouragetheuseofthepointy,metalspikesthataccompanysomereflexhammers.If,forexample,you
usedthisandcausedbleeding,it'spossible(ifthetipwerenotwellcleaned)totransmitbloodborne
infectionsfromonepatienttoanother.Bettertouseadisposableimplement.
2.Askthepatienttoclosetheireyessothattheyarenotabletogetvisualclues.
3.Startatthetopofthefoot.Orientthepatientbyinformingthemthatyouaregoingtofirsttouchthemwith
thesharpimplement.Thendothesamewithanonsharpobject(e.g.thesoftendofaqtip).Thisclarifies
forthepatientwhatyouaredefiningassharpanddull.

4.Now,touchthelateralaspectofthefootwitheitherthesharpordulltool,askingthemtoreporttheir
response.Movemediallyacrossthetopofthefootcrossingmultipledermatomes,notingthepatient's
responsetoeachtouch.
5.Iftheygiveaccurateresponses,dothesameontheotherfoot.Thesametestcanberepeatedfortheupper
extremities(i.e.onthehand),thoughthiswouldonlybeofutilityifthepatientcomplainedof
numbness/impairedsensationinthatarea.
6.Spinothalamictractfunctioncanalsobeassessedbycheckingthepatient'sabilitytodetectdifferencesin
temperature.Coldandwarmcanbereproducedbyrunningatuningforkunderwaterofthattemperature,
touchingitagainsttheaffectedlimb,andaskingthepatienttocomment(patient'seyesshouldbeclosed).
DorsalColumns
Proprioception:Thisreferstothebody'sabilitytoknowwhereitisinspace.Assuch,itcontributestobalance.
SimilartotheSpinothalamictracts,disorderswhichaffectthissystemtendtofirstoccuratthemostdistal
aspectsofthebody.Thus,proprioceptionischeckedfirstinthefeetandthen,ifabnormal,moreproximally(e.g.
thehands).
Technique:
1.Askthepatienttoclosetheireyessothattheydonotreceiveanyvisualcues.
2.Withonehand,graspeithersideofgreattoeattheinterphalangeal(IP)joint.Placeyourotherhandonthe
lateralandmedialaspectsofthegreattoedistaltotheIP.
3.Orientpatienttoupanddownasfollows:
Flexthetoe(pullitupwards)whiletellingpatientwhatyou'redoing.
Extendtoe(pullitdownwards)whileinformingthemofwhichdirectionyou'removingit.

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TestingProprioception
4.Alternatelydeflectthetoeupordownwithouttellingthepatientinwhichdirectionyouaremovingit.
Theyshouldbeabletocorrectlyidentifythemovementanddirection.
5.Bothgreattoesshouldbecheckedinthesamefashion.Ifnormal,nofurthertestingneedbedoneinthe
screeningexam.
6.Ifthepatientisunabletocorrectlyidentifythemovement/direction,movemoreproximally(e.g.tothe
anklejoint)andrepeat(e.g.testwhethertheycandeterminewhetherthefootismovedupordownatthe
ankle).
Similartestingcanbedoneonthefingers.Thisisusuallyreservedforthosesettingswhenpatientshavedistal
findingsand/orsymptomsintheupperextremities.
VibratorySensation:Vibratorysensationtravelstothebrainviathedorsalcolumns.Thus,thefindingsgenerated
fromtestingthissystemshouldcorroboratethoseofproprioception(seeabove).
Technique:
1.Startatthetoeswiththepatientseated.Youwillneeda128hztuningfork.

128Hztuningfork
2.Askthepatienttoclosetheireyessothattheydonotreceiveanyvisualcues.
3.Graspthetuningforkbythestemandstriketheforkedendsagainstthefloor,causingittovibrate.
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4.Placethestemontopoftheinterphalangealjointofthegreattoe.Putafewfingersofyourotherhandon
thebottomsideofthisjoint.

Testingvibratorysensation
5.Askthepatientiftheycanfeelthevibration.Youshouldbeabletofeelthesamesensationwithyour
fingersonthebottomsideofthejoint.
6.Thepatientshouldbeabletodeterminewhenthevibrationstops,whichwillcorrelatewithwhenyouare
nolongerabletofeelittransmittedthroughthejoint.Itsometimestakesawhilebeforetheforkstops
vibrating.Ifyouwanttomovethingsalong,rubtheindexfingerofthehandholdingtheforkalongthe
tines,rapidlydampeningthevibration.
Repeattestingontheotherfoot.
Additional/SpecialTestingforDorsalColumnDysfunction
TestingTwoPointDiscrimination:Patientsshouldnormallybeabletodistinguishsimultaneoustouchwith2
objectswhichareseparatedbyatleast5mm.ThesestimuliarecarriedviatheDorsalColumns.Whilenot
checkedroutinely,itisusefultestifadiscreteperipheralneruropathyissuspected(e.g.injurytotheradial
nerve).
Technique:
1.Testingcanbedonewithapaperclip,openedsuchthattheendsare5mmapart.
2.Thepatientshouldbeabletocorrectlyidentifywhetheryouaretouchingthemwithoneorbothends
simultaneously,alongtheentiredistributionofthespecificnervewhichisbeingassessed.
SpecialTestingforEarlyDiabeticNeuropathy:Acarefulfootexaminationshouldbeperformedonall
patientswithsymptomssuggestiveofsensoryneuropathyoratparticularriskforthisdisorder(e.g.anyonewith
Diabetes).Lossofsensationinthisareacanbeparticularlyproblematicasthefeetareadifficultareaforthe
patienttoevaluateontheirown.Smallwoundscanbecomelargeandinfected,unbeknownsttotheinsensate
patient.Sensorytestingasdescribedabovecandetectthistypeofproblem.Disposablemonofilaments(known
astheSemmesWeinsteinAethesiometer)arespeciallydesignedforascreeningevaluation.Thesesmallnylon
fibersaredesignedsuchthatthenormalpatientshouldbeabletofeeltheendswhentheyaregentlypressed
againstthesolesoftheirfeet.
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Monofiliment
Technique:
1.Havethepatientclosetheireyessothattheydonotreceiveanyvisualcues.
2.Touchthemonofilamentto57areasonthebottomofthepatient'sfoot.Picklocationssothatallofthe
majorareasofthesoleareassessed.Avoidcalluses,whicharerelativelyinsensate.
3.Thepatientshouldbeabletodetectthefilamentwhenthetipislightlyappliedtotheskin.

Monofilimenttesting:Patientswithnormalsensationshouldbeabletodetectthemonofilimentwhenit
islightlyapplied(pictureonleft).Iftheforcerequiredtoprovokeasensoryresponseisstrongenoughto
bendthemonofiliment
(pictureonright),thensensationisimpaired.
Interpretation:Iftheexaminerhastosupplyenoughpressuresuchthatthefilamentbendspriortothepatient
beingabletodetectit,theylikelysufferfromsensoryneuropathy.Testingshouldbedoneinmultiplespotsto
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verifytheresults.Patient'swithdistalsensoryneuropathyshouldcarefullyexaminetheirfeetandweargood
fittingshoestoassurethatskinbreakdownandinfectionsdon'tdevelop.Effortsshouldalsobemadetoclosely
controltheirdiabetessothattheneuropathydoesnotprogress.

NeuropathicUlcer:Largeulcerhasdevelopedinthispatientwithseverediabeticneuropathy.
InterpretingResultsofSensoryTesting
PatternsofImpairmentfortheSpinothalamicTracts:
1.Patientsshouldbeabletocorrectlydistinguishsharpsensation,indicatingnormalfunctionofthe
spinothalamicpathway.
2.Mappingoutregionsofimpairedsensation:Theexaminationdescribedaboveisascreeningevaluation
forevidenceofsensoryloss.Thisisperfectlyadequateinmostclinicalsettings.Occasionally,thehistory
orscreeningexaminationwillsuggestadiscreteanatomicregionthathassensoryimpairment.Whenthis
occurs,itisimportanttotryandmapouttheterritoryinvolved,usingcarefulpintestingtodefinethe
medial/lateralandproximal/distalboundariesoftheaffectedregion.Youmayevenmakepenmarkson
theskintoclearlyidentifywherethechangesoccur.Asmostclinicianshavenotmemorizedthe
distributionsofallperipheralnervesorspinalnerveroots,youcansimultaneouslyconsultareference
booktoseeifthemappedterritorymatchesaspecificnervedistribution.Thistypeofmappingis
somewhattediousandshouldonlybedoneinappropriatesituations.
3.DiffuseDistalSensoryLoss:Anumberofchronicsystemicdiseasesaffectnervefunction.Themost
commonlyoccurringofthese,atleastinWesterncountries,isDiabetes.Whencontrolhasbeenpoorover
manyyears,thesensorynervesbecomedysfunctional.Thisfirstaffectsthemostdistalaspectsofthe
nervesandthenmovesproximally.Thus,thefeetarethefirstareatobeaffected.Asitisasystemic
disease,itoccurssimultaneouslyinbothlimbs.Examrevealslossofabilitytodetectthesharpstimulus
acrosstheentirefoot.Thus,thesensorylossdoesnotfollowadermatomal(i.e.spinalnerveroot)or
peripheralnervedistribution.Astheexaminertestsmoreproximally,he/shewillultimatelyreachapoint
wheresensationisagainnormal.Themoreadvancedthedisease,thehigherupthelegthiswilloccur.
Handscanbeaffected,thoughmuchlesscommonlythenfeetasthenervestravelingtothelegsarelonger
andthusatmuchgreaterrisk.ThispatternoflossisreferredtoasaStockingorGlovedistribution
impairment,astheareainvolvedcoversanentiredistalregion,muchasasockorglovewouldcovera
footorhand.Suchdeficitsmaybeassociatedwithneuropathicpain,acontinuousburningsensation
affectingthedistalextremity.
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4.PeripheralNerveDistribution:Aspecificperipheralnervecanbecomedysfunctional.Thismight,for
example,occurastheresultoftraumaorinfarction(anothercomplicationofdiabetes).Inthissetting,
therewillbeapatternofsensoryimpairmentthatfollowsthedistributionofthenerve.Radialnervepalsy,
forexample,canoccurifanintoxicatedpersonfallsasleepinapositionthatputspressureonthenerveas
ittravelsaroundtheHumerus(boneoftheupperarm).Intoxicationinducedlossofconsciousnessthen
preventsthepatientfromreflexivelychangingposition,thenormalmeansbywhichwepreventnerves
frombeingexposedtoconstantdirectpressure.Theresultantsensorylosswouldinvolvethebackofthe
handandforearm.Motorfunctionwouldalsobeaffected(seeundermotorexam).Pinningdownthe
culpritnerverequiresknowledgeofnerveanatomyandinnervation.Onapracticallevel,mostclinicians
don'tcommitthistomemory.Rather,theygatherahistorysuggestiveofadiscretenervedeficit,verifythe
territoryoflossonexam,andthenlookitupinareferencebook.
Formoreinformationaboutperipheralnerveinjuries,seethefollowinglink:
Peripheralnervesandtheirterritoriesofinnervation
5.NerveRootImpairment:Anerveroot(orroots)canbedamagedasitleavesthecord.Thiswillresultina
sensorydeficitalongitsspecificdistribution,whichcaninturnbeidentifiedonexamination.TheS1
nerveroot,forexample,canbecompressedbyherniateddiscmaterialinthelumbarspine.Thiswould
causesensorylossalongthelateralaspectofthelowerlegandthebottomofthefoot.Onlythelegonthe
affectedsidewouldhavethisdeficit.Asmentionedunderperipheralnervedysfunction,mostcliniciansdo
notmemorizethedermatomesrelatedtoeachnerveroot.Rather,theygatherahistorysuggestiveofa
discretenervedeficit,verifyadermatomaldistributionoflossonexam,andthenlookitupinareference
book.
Formoreinformationaboutnerverootcompression,seethefollowinglinks:
UniversityofWisconsin,Anatomyandpathophysiologyofnerverootcompression
ImageofHerniatedDisk
6.TheSpinothalamicsarealsoresponsiblefortemperaturediscrimination.Forpracticalreasons(i.e.it's
oftenhardtofindtesttubes,fillthemwiththerequisitetemperaturewater,etc)thisisomittedinthe
screeningexam.Theinformationfromsharpstimulustestingasdescribedaboveshouldsuffice.
Temperaturediscriminationcouldbeassessedasameansofverifyinganyabnormalitydetectedon
sharp/dulltesting.
7.Testingofthesacralnerveroots,servingtheanusandrectum,isimportantifpatientscomplainof
incontinence,inabilitytodefecate/urinate,orthereisotherwisereasontosuspectthattheserootsmaybe
compromised.InthesettingofCaudaEquinasyndrome,forexample,multiplesacralandlumbarroots
becomecompressedbilaterally(e.g.byposteriorlyherniateddiscmaterialoratumor).Whenthisoccurs,
thepatientisunabletourinate,asthelowermotorneuronscarriedinthesesacralnerverootsnolonger
function.Thusthereisnowaytosendanimpulsetothebladderinstructingittocontract.Norwilltheybe
awarethattherebladdersarefull.Therewillalsobelossofanalspinctertone,whichcanbeappreciated
onrectalexam.Abilitytodetectpinpricksintheperinealarea(a.k.a.saddledistribution)isalso
diminished.
Formoreinformationaboutperipheralnervesandtheirterritoriesofinnervation,seethefollowinglink:
Peripheralnervesandtheirterritoriesofinnervation
PatternsofImpairmentforDorsalColumnDysfunction:
Proprioception:

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Patientsshouldbeabletocorrectlyidentifythemotionanddirectionofthetoe.InthesettingofDorsalColumn
dysfunction(acommoncomplicationofdiabetes,forexample),distaltestingwillbeabnormal.Thisissimilarto
thepatternofinjurywhichaffectstheSpinothalamictractsdescribedabove.
VibratorySensation:
1.Patientsshouldbeabletodetecttheinitialvibrationandaccuratelydeterminewhenithasstopped.
2.Asdescribedundertestingofproprioception,dorsalcolumndysfunctiontendstofirstaffectthemost
distalaspectsofthesystem.Whenthisoccurs,thepatientiseitherunabletodetectthevibrationorthey
perceivethatthesensationextinguishestooearly(i.e.theystopfeelingiteventhoughyoucanstill
appreciatethesensationwithyourfingersontheundersideofthejoint).
3.Thefindingsonvibratorytestingshouldparallelthoseobtainedwhenassessingproprioception,asboth
sensationstravelviathesamepathway.
MotorTesting
Themuscleistheunitofactionthatcausesmovement.Normalmotorfunctiondependsonintactupperand
lowermotorneurons,sensorypathwaysandinputfromanumberofotherneurologicalsystems.Disordersof
movementcanbecausedbyproblemsatanypointwithinthisinterconnectedsystem.
MuscleBulkandAppearance:
Thisassessmentissomewhatsubjectiveandquitedependentontheage,sexandtheactivity/fitnesslevelofthe
individual.Afrailelderlyperson,forexample,willhavelessmusclebulkthena25yearoldbodybuilder.With
experience,youwillgetasenseofthenormalrangeforgivenagegroups,factoringintheirparticularactivity
levelsandoverallstatesofhealth.
Thingstolookfor:
1.Usingyoureyesandhands,carefullyexaminethemajormusclegroupsoftheupperandlower
extremities.Firstyouneedtofullyexposethemusclesofbothextremities(forcomparison)thatyou're
examining.Palpationofthemuscleswillgiveyouasenseofunderlyingmass.Thelargestandmost
powerfulgroupsarethoseofthequadricepsandhamstringsoftheupperleg(i.e.frontandbackofthe
thighs).
2.Musclegroupsshouldappearsymmetricallydevelopedwhencomparedwiththeircounterpartsonthe
othersideofthebody.Theyshouldalsobeappropriatelydeveloped,aftermakingallowancesforthe
patient'sage,sex,andactivitylevel.

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MuscleAsymmetry
Whilebothlegshavewelldevelopedmusculature,thelefthasgreaterbulk.

Thereshouldbenomusclemovementwhenthelimbisatrest.Raredisorders(e.g.AmyotrophicLateral
Sclerosis)resultindeathofthelowermotorneuronandsubsequentdenervationofthemuscle.This
causestwitchingofthefibersknownasfasciculations,whichcanbeseenongrossinspectionofaffected
muscles.ALSisaccompaniedbyotherfindingsandsymptoms,inparticular,relentlesslyprogressive
weakness.MoreonALShttp://www.ninds.nih.gov/disorders/amyotrophiclateralsclerosis/ALS.htm
Anumberofmorecommon(andrelativelybenign)conditionscanalsocausefasciulations,including:post
exercise,meds,stimulants,andassortedmetabolicprocesses.
Toseeavideodemonstratingfeaturesoffasciculations,clickonthe
movieicon.
3.Tremorsareaspecifictypeofcontinuous,involuntarymuscleactivitythatresultsinlimbmovement.
Parkinson'sDisease(PD),forexample,cancauseaverycharacteristicrestingtremorofthehand(thehead
andotherbodypartscanalsobeaffected)thatdiminisheswhenthepatientvoluntarilymovestheaffected
limb.BenignEssentialTremor,ontheotherhand,persiststhroughoutmovementandisnotassociated
withanyotherneurologicalfindings,easilydistinguishingitfromPD.
Toseeavideodemonstratingfeaturesofbenignessentialtremor,click
onthemovieicon.
ToseeavideodemonstratingfeaturesofParkinson'sDisease,clickon
themovieicon.
FormoreinformationaboutParkinson'sDisease,seethefollowinglink:
NIHSponsoredSiteAboutParkinson'sDisease
4.Themajormusclegroupstobepalpatedinclude:biceps,triceps,deltoids,quadricepsandhamstrings.
Palpationshouldnotelicitpain.Interestingly,myositis(arareconditioncharacterizedbyidiopathic
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muscleinflammation)causesthepatienttoexperienceweaknessbutnotpain.
5.Ifthereisasymmetry,noteifitfollowsaparticularpattern.Rememberthatsomeallowancemustbemade
forhandedness(i.e.rightvlefthanddominance).Doestheasymmetryfollowaparticularnerve
distribution,suggestingaperipheralmotorneuroninjury?Forexample,muscleswhichlosetheirLMN
inervationbecomeveryatrophic.Isthebulkintheupperandlowerextremitiessimilar?Spinalcord
transectionattheThoraciclevelwillcauseupperextremitymusclebulktobenormalorevenincreased
duetoincreaseddependenceonarmsforactivity,mobility,etc.However,themusclesofthelower
extremitywillatrophyduetolossofinnervationandsubsequentdisuse.Isthereanotherprocess
(suggestedbyhistoryorotheraspectsoftheexam)thathasresultedinlimitedmovementofaparticular
limb?Forexample,abrokenlegthathasrecentlybeenliberatedfromacastwillappearmarkedly
atrophic.

DiffuseMuscleWasting:Notelossmusclebulkinlefthandduetoperipheraldenervation.
Inparticular,compareleftandrightthenareminences.
Tone:Whenamusclegroupisrelaxed,theexaminershouldbeabletoeasilymanipulatethejointthroughits
normalrangeofmotion.Thismovementshouldfeelfluid.Anumberofdiseasestatesmayalterthissensation.
Forthescreeningexamination,itisreasonabletolimitthisassessmenttoonlythemajorjoints,including:wrist,
elbow,shoulder,hipsandknees.
Technique:
1.Askthepatienttorelaxthejointthatistobetested.
2.Carefullymovethelimbthroughitsnormalrangeofmotion,beingcarefulnottomaneuveritinanyway
thatisuncomfortableorgeneratespain.
3.Beawarethatmanypatients,particularlytheelderly,oftenhaveothermedicalconditionsthatlimitjoint
movement.Degenerativejointdiseaseoftheknee,forexample,mightcauselimitedrangeofmotion,
thoughtoneshouldstillbenormal.Ifthepatienthasrecentlyinjuredtheareaorareinpain,donot
performthisaspectoftheexam.
Thingstolookfor:
1.Normalmusclegeneratessomeresistancetomovementwhenalimbismovedpassivelybyanexaminer.
Afterperformingthisexamonanumberofpatients,you'lldevelopanappreciationfortherangeof
normaltone.
2.Iftheexaminermovesthejoint(patientrelaxed)andthereisincreasedresistance,thisisreferredtoas
increasedtone,whichcanbefurthercharacterizedasrigidorspastic.
a.Spasticity:Toneincreasesiftheexaminermovesthejointmorequickly(i.e.thehypertonicityis
affectedbytherateofmovementofthejoint).Thisisthetypicalfindingwithanuppermotor
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neuronlesion(e.g.strokeorspinalcordinjury).
b.Rigidity:Toneremainsincreasedregardlessofhowquicklythejointismoved.Oneexampleofthis
isParkinson'sdisease,wherelimbmovementgeneratesaratchetlikesensationknownascog
wheeling.
3.Flaccidnessisthecompleteabsenceoftone.Thisoccurswhenthelowermotorneuroniscutofffromthe
musclesthatitnormallyinnervates.
Strength:Aswithmusclebulk(describedabove),strengthtestingmusttakeintoaccounttheage,sexandfitness
levelofthepatient.Forexample,afrail,elderly,bedboundpatientmayhavemuscleweaknessduetosevere
deconditioningandnottointrinsicneurologicaldisease.Interpretationmustalsoconsidertheexpectedstrength
ofthemusclegroupbeingtested.Thequadricepsgroup,forexample,shouldbemuchmorepowerfulthenthe
Biceps.
Thereisa0to5ratingscaleformusclestrength:
0/5
1/5
2/5
3/5
4/5
5/5

Nomovement
Barestflickerofmovementofthemuscle,thoughnotenoughtomovethe
structuretowhichit'sattached.
Voluntarymovementwhichisnotsufficienttoovercometheforceof
gravity.Forexample,thepatientwouldbeabletoslidetheirhandacrossa
tablebutnotliftitfromthesurface.
Voluntarymovementcapableofovercominggravity,butnotanyapplied
resistance.Forexample,thepatientcouldraisetheirhandoffatable,but
notifanyadditionalresistancewereapplied.
Voluntarymovementcapableofovercoming"some"resistance
Normalstrength

'+'and''canbeaddedtoallowformorenuancedscoringof4/5strength(e.g.,4+or4butnot5,3+or3,etc.)
Thus,apatientwhocanovercome"moderatebutnotfullresistance"mightbegraded4+.Thisisquite
subjective,withafairamountofvariabilityamongstclinicians.Ultimately,it'smostimportantthatyoudevelop
yourownsenseofwhatthesegradationsmean,allowingforinternalconsistencyandinterpretabilityofserial
measurements.
SpecificsofStrengthTestingMajorMuscleGroups:Inthescreeningexamination,itisreasonabletocheck
onlythemajormuscles/musclegroups.Moredetailedtestingcanbeperformedinthesettingof
discrete/unexplainedweakness.Thenamesofthemajormuscles/musclegroupsalongwiththespinalrootsand
peripheralnervesthatprovidetheirinnervationareprovidedbelow.Nerverootsprovidingthegreatest
contributionareprintedinbold.Moreextensivedescriptionsofindividualmusclesandtheirfunctions,along
withtheirpreciseinnervationscanbefoundinaNeurologyreferencetext.
1.Intrinsicmusclesofthehand(C8,T1):Askthepatienttospreadtheirfingersapartagainstresistance
(abduction).Thensqueezethemtogether,withyourfingersplacedinbetweeneachoftheirdigits
(adduction).Testeachhandseparately.Themuscleswhichcontroladductionandabductionofthefingers
arecalledtheInterossei,innervatedbytheUlnarNerve.

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Formoreinformationaboutfingerabductorsandadductors,seethefollowinglinks:
UniversityofWashington,Anatomyoffingerabductorsandadductors
2.Flexorsofthefingers(C7,8,T1):Askthepatienttomakeafist,squeezingtheirhandaroundtwoofyour
fingers.Ifthegripisnormal,youwillnotbeabletopullyourfingersout.Testeachhandseparately.The
FlexorDigitorumProfunduscontrolsfingerflexionandisinnervatedbytheMedian(radial1/2)andUlnar
(medial1/2)Nerves.

Formoreinformationaboutfingerflexors,seethefollowinglinks:
UniversityofWashington,Anatomyoffingerflexors1
UniversityofWashington,Anatomyoffingerflexors2
3.Wristflexion(C7,8,T1):Havethepatienttrytoflextheirwristasyouprovideresistance.Testeach
handseparately.ThemusclegroupswhichcontrolflexionareinnervatedbytheMedianandUlnarNerves.

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Formoreinformationaboutwristflexors,seethefollowinglinks:
UniversityofWashington,Anatomyofwristflexors1
UniversityofWashington,Anatomyofwristflexors2
4.Wristextension(C6,7,8):Havethepatienttrytoextendtheirwristasyouprovideresistance.Testeach
handseparately.TheExtensorRadialismusclescontrolextensionandareinnervatedbytheRadialNerve.
ClinicalCorrelate:Damagetotheradialnerveresultsinwristdrop(lossofabilitytoextendthehandat
thewrist).Thiscanoccurviaanyoneofanumberofmechanisms.Forexample,thenervecanbe
compressedagainstthehumerusforaprolongedperiodoftimewhenanintoxicatedpersonloses
consciousnesswiththeinsideaspectoftheupperarmrestingagainstasolidobject(knownasa"Saturday
NightPalsy").

Formoreinformationaboutwristextensors,seethefollowinglinks:
UniversityofWashington,Anatomyofwristextensors1
UniversityofWashington,Anatomyofwristextensors2
5.ElbowFlexion(C5,6):Themainflexor(andsupinator)oftheforearmistheBrachialisMuscle(along
withtheBicepsMuscle).Havethepatientbendtheirelbowtoninetydegreeswhilekeepingtheirpalm
directedupwards.Thendirectthemtoflextheirforearmwhileyouprovideresistance.Testeacharm
separately.ThesemusclesareinnervatedbytheMusculocutaneousNerve.

Formoreinformationaboutelbowflexors,seethefollowinglinks:
UniversityofWashington,Anatomyofelbowflexors1
UniversityofWashington,Anatomyofelbowflexors2

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6.ElbowExtension(C7,8):Themainextensoroftheforearmisthetricepsmuscle.Havethepatientextend
theirelbowagainstresistancewhilethearmisheldout(abductedattheshoulder)fromthebodyatninety
degrees.Testeacharmseparately.TheTricepsisinnervatedbytheRadialNerve.

Formoreinformationaboutelbowextensors,seethefollowinglink:
UniversityofWashington,Anatomyofelbowextensors
7.ShoulderAdduction(C5thruT1):ThemainmuscleofadductionisthePectoralisMajor,thoughthe
Latissiumusandotherscontributeaswell.Havethepatientflexattheelbowwhilethearmisheldout
fromthebodyatfortyfivedegrees.Thenprovideresistanceastheytrytofurtheradductattheshoulder.
Testeachshoulderseparately.

Formoreinformationaboutshoulderadductors,seethefollowinglinks:
UniversityofWashington,Anatomyofshoulderadductors1
UniversityofWashington,Anatomyofshoulderadductors2
8.ShoulderAbduction(C5,6):Thedeltoidmuscle,innervatedbytheaxillarynerve,isthemainmuscleof
abduction.Havethepatientflexattheelbowwhilethearmsisheldoutfromthebodyatfortyfive
degress.Thenprovideresistanceastheytrytofurtherabductattheshoulder.Testeachshoulder
separately.

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Formoreinformationaboutshoulderabductors,seethefollowinglink:
UniversityofWashington,Anatomyofshoulderabductors
9.HipFlexion(L2,3,4):Withthepatientseated,placeyourhandontopofonethighandinstructthe
patienttoliftthelegupfromthetable.ThemainhipflexoristheIliopsoasmuscle,innervatedbythe
femoralnerve.

Formoreinformationabouthipflexors,seethefollowinglinks:
UniversityofWashington,Anatomyofhipflexors1
UniversityofWashington,Anatomyofhipflexors2
10.HipExtension(L5,S1):Withthepatientlyingprone,directthepatienttolifttheirlegoffthetableagainst
resistance.Testeachlegseparately.Themainhipextensoristhegluteusmaximus,innervatedbyinferior
glutealnerve.

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Formoreinformationabouthipextensors,seethefollowinglink:
UniversityofWashington,Anatomyofhipextensors
11.HipAbduction(L4,5,S1):Placeyourhandsontheoutsideofeitherthighanddirectthepatientto
separatetheirlegsagainstresistance.Thismovementismediatedbyanumberofmuscles.

Formoreinformationabouthipabductors,seethefollowinglinks:
UniversityofWashington,Anatomyofhipabductors1
UniversityofWashington,Anatomyofhipabductors2
UniversityofWashington,Anatomyofhipabductors3
12.HipAdduction(L2,3,4):Placeyourhandsontheinneraspectsofthethighsandrepeatthemaneuver.A
numberofmusclesareresponsibleforadduction.Theyareinnervatedbytheobturatornerve.

Formoreinformationabouthipadductors,seethefollowinglinks:
UniversityofWashington,Anatomyofhipadductors1
UniversityofWashington,Anatomyofhipadductors2
UniversityofWashington,Anatomyofhipadductors3
UniversityofWashington,Anatomyofhipadductors4
13.KneeExtension(L2,3,4):Havetheseatedpatientsteadilypresstheirlowerextremityintoyourhand
againstresistance.Testeachlegseparately.Extensionismediatedbythequadricepsmusclegroup,which
isinnervatedbythefemoralnerve.
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Formoreinformationaboutkneeextensors,seethefollowinglinks:
UnivervsityofWashington,Anatomyofkneeextensors1
UnivervsityofWashington,Anatomyofkneeextensors2
UniversityofWashington,Anatomyofkneeextensors3
UniversityofWashington,Anatomyofkneeextensors4
14.Kneeflexion(L5S1,2):Havethepatientrestprone.Thenhavethempulltheirheelupandoffthetable
againstresistance.Eachlegistestedseparately.Flexionismediatedbythehamstringmusclegroup,via
branchesofthesciaticnerve.

Formoreinformationaboutkneeflexors,seethefollowinglinks:
UniversityofWashington,Anatomyofkneeflexors1
UniversityofWashington,Anatomyofkneeflexors2
UniversityofWashington,Anatomyofkneeflexors3
UniversityofWashington,Anatomyofkneeflexors4
UniversityofWashington,Anatomyofkneeflexors5
15.AnkleDorsiflexion(L4,5):Directthepatienttopulltheirtoesupwardswhileyouprovideresistancewith
yourhand.Eachfootistestedseparately.Themuscleswhichmediatedorsiflexionareinnervatedbythe
deepperonealnerve.ClinicalCorrelate:Theperonealnerveissusceptibletoinjuryatthepointwhereit
crossestheheadofthefibula(laterally,belowtheknee).Ifinjured,thepatientdevelops"FootDrop,"an
inabilitytodorsiflexthefoot.

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Formoreinformationaboutankledorsiflexors,seethefollowinglink:
UniversityofWashington,Anatomyofankledorsiflexors
16.AnklePlantarFlexion(S1,S2).Havethepatient"steponthegas"whileprovidingresistancewithyour
hand.Testeachfootseparately.Thegastrocnemiusandsoleus,themuscleswhichmediatethismovement,
areinnervatedbyabranchofthesciaticnerve.Plantarflexionanddorsiflexioncanalsobeassessedby
askingthepatienttowalkontheirtoes(plantarflexion)andheels(dorsiflexion).

Formoreinformationaboutankleplantarflexors,seethefollowinglinks:
UniversityofWashington,Anatomyofankleplantarflexors1
UniversityofWashington,Anatomyofankleplantarflexors2
UniversityofWashington,Anatomyofankleplantarflexors3
Itisgenerallyquitehelpfultodirectlycomparerightvleftsidedstrength,astheyshouldmoreorlessbe
equivalent(takingintoaccountthehandednessofthepatient).Ifthereisweakness,trytoidentifyapattern,
whichmightprovideaclueastotheetiologyoftheobserveddecreaseinstrength.Inparticular,makenoteof
differencesbetween:
1.RightvLeft
2.Proximalmusclesvdistal
3.Upperextremitiesvlower
4.Oristheweaknessgeneralized,suggestiveofasystemicneurologicaldisorderorglobaldeconditioning
SpecialTestingforsubtleweakness:Subtleweaknesscanbehardtodetect.Payattentiontohowthepatient
walks,usesandholdstheirarmsandhandsastheyentertheroom,getupanddownfromaseatedposition,
moveontotheexaminationtable,etc.Pronatordriftisatestforslightweaknessoftheupperextremities.The
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patientshouldsitwithbotharmsextended,palmsdirectedupward.Subtleweaknessineitherarmwillcause
slightdownwarddriftandpronationofthatlimb(i.e.thearmwillrotateslightlyinwardanddown).
Commonperipheralnerves,territoriesofinnervation,andclinicalcorrelates.
CommonPeripheralNervesandTheirAnatomy
Peripheral
SensoryInnervation
Nerve

Motor
Innervation

Contributing
SpinalNerve Clinical
Roots
Atriskforcompressionat
humerus,knownas
"SaturdayNightPalsy"

Radial
Nerve

Backofthumb,index,
middle,and1/2ring
fingerbackof
forearm

Wrist
extensionand
abductionof
thumbin
palmerplane

Ulnar
Nerve

Palmaranddorsal
aspectsofpinkyand
1/2ofringfinger

Abductionof
fingers
(intrinsic
musclesof
hand)

Median
Nerve

Palmaraspectofthe
thumb,index,middle
and1/2ringfinger
palmbelowthese
fingers.

Abductionof
thumb
perpendicular C8,T1
topalm(thenar
muscles).

Compressionatcarpal
tunnelcausescarpaltunnel
syndrome

Canbecomecompressedin
obesepatients,causing
numbnessoverits
distribution

Lateral
Cutaneous
Nerveof
Thigh

Peroneal

Lateralaspectthigh

C6,7,8

RadialNervePalsyImage
RadialNervePalsyVideo

C7,8andT1

L1,2

Dorsiflexionof
foot(tibialis
Lateralleg,topoffoot
L4,5S1
anterior
muscle)

Atriskforinjurywith
elbowfracture.Canget
transientsymptomswhen
insideofelbowisstruck
("funnybone"distribution)

Canbeinjuredwith
proximalfibulafracture,
leadingtofootdrop
(inabilitytodorsiflexfoot)
FootDropvideo

Thistableprovidesinformationaboutusualpatternsofinnervations.Thereisoccasionallyinterindividual
variation.Inthesettingofperipheralnervedysfunction,thelevelofthelesionwilldeterminetheextentofthe
deficit.Thatis,proximalinsultswillcausetheentirenervedistributiontobeaffectedwhilemoredistallesions
willonlyimpactfunctionbeyondthesiteoftheinjury.
Moreoncarpaltunnelsyndrome...
Videooffindingsinadvancedcarpaltunnel
syndrome.

CarpalTunnelInducedAtrophy:Chronic,severecompressionofthemediannerve
withinthecarpaltunnelhasledtoatrophyoftheThenarmuscles(handonright).A
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normalappearingThenarEminenceis
demonstratedonleft.

Cranial
Nerves

SensoryandMotor
Examinations

ReflexTesting Coordination

Gait
Testing

MakingSenseof
NeurologicalFindings

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https://meded.ucsd.edu/clinicalmed/neuro2.htm

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