Last edited: 1/12/2022

5. UPPER&LOWER LIMB NEUROLOGICAL EXAMINATION

OUTLINE II) MUSCLE TONE

I) MUSCLE APPEARANCE ● Assess for muscle tone in upper extremities by asking

II) MUSCLE TONE patient to
III) MUSCLE STRENGTH/POWER o relax their arms and then circumduct shoulder
POWER/STRENGTH SCORING SYSTEM → flex & extend elbow
→ supinate & pronate wrist
IV) DEEP TENDON REFLEXES → flex and extend wrist
V) SENSATION
→ feel for floppiness or increased tone in the muscle
(A) LIGHT TOUCH
during passive movement
(B) PAIN o relax their legs and then roll legs side to side
(C) TEMPERATURE → flex & extend knee slowly and the quickly
(D) VIBRATION → dorsiflex & plantarflex ankle
(E) PROPRIOCEPTION → invert and evert ankle
(F) DISCRIMINATIVE SENSATION → feel for decreased or increased tone in the muscle
VI) COORDINATION during passive movement
ASSESS COORDINATION WITH THE FOLLOWING TESTS: (1) Hypotonia
VII) REFERENCES ● Decreased muscle tone “floppiness” of muscles during
movement
● If atrophy, weakness, hyporeflexia is present
I) MUSCLE APPEARANCE → LMN lesion may be present

(1) Assess for asymmetry in muscle bulk ● Cerebellar lesion may also be present if hypotonia,
ataxia, nystagmus is present
● If one side exhibits muscle atrophy in combination with
hyporeflexia, weakness, fasciculations (2) Hypertonia
o indicative of LMN lesion ● Increased muscle tone/stiffness of muscles during movement
(2) Assess for abnormal motor movements ● Divided into two types:

(i) Tremors (i) Spasticity

o Velocity dependent:
● Resting tremors
 resistance can be overcome with quick movement
→ may be indicative of parkinson's disease
when assessing tone
● Postural tremors o Clasp-knife phenomenon:
o may be most evident during movement like raising  resistance encountered during tone assessment
hands up and eventually muscle releases and resistance to
→ may be indicative of essential or physiologic movement decreases
tremor o If present with weakness and hyperreflexia
 may be indicative of an UMN lesion
(ii) Dyskinesia
● Chorea
o involuntary, arrhythmic and non-repetitive motor
movements
o may be indicative of
 Huntington’s disease, Figure 1 Clasp-knife phenomenon [IEEE.org]
 rheumatic fever
 Wilson disease. (ii) Rigidity
● Athetosis o Velocity independent:
o writhing and snakelike movement of the hands/fingers  resistance can NOT be overcome with quick
o may be indicative of movement when assessing tone
 Huntington’s disease o Lead pipe rigidity:
 cerebral palsy  extreme resistance throughout the entire range of motion
 thalamic lesions o Cogwheel rigidity:
(iii) Fasciculations- involuntary twitching of the  extreme resistance alternating with quick
releases/catching and back to extreme resistance
muscles  This is essentially lead pipe rigidity with tremors
● May be indicative of LMN lesion if fasciculations, ● Rigidity may be indicative of Parkinson's disease
weakness, atrophy and hyporeflexia is present
(3) Assess for speed of motor movements
● Bradykinesia
o slowing or decreased speed in initiating motor
movements
o may be indicative of Parkinson’s disease

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 III) MUSCLE STRENGTH/POWER
● Power/strength can be assessed using a power/strength
scoring system

POWER/STRENGTH SCORING SYSTEM

Grade 5 Strength against full resistance

Grade 4 Strength against mild to moderate resistance but

eventually the resistance of the practitioner
overcomes strength of the patient

Grade 3 Strength against gravity without any resistance

applied

Grade 2 Movement occurs without gravity or resistance

present

Grade 1 Flickering of the muscle without any movement

without gravity or resistance present

Grade 0 No movement at all

(1) The Upper Limb

Proximal → Distal strength and power assessment

Axillary
(2) Abduction • Deltoid
nerve C5
• Pectoralis major,
(3) Adduction • latissimus dorsi, C6-C7
• teres major
• Biceps brachii, Musculo-
(4) Flexion at
the elbow
brachialis, cutaneous C5-C6
coracobrachialis nerve

(5) Extension • Triceps brachii, Radial

at the
anconeus nerve
C6-C8
elbow

Median C6-C7
• Flexor carpi radialis, nerve (media
(6) Flexion at
the wrist
• palmaris longus and n)
• flexor carpi ulnaris ulnar C8-T1
nerve
(ulnar)
• Extensor carpi radialis
(7) Extension longus, Radial
at the
• Extensor radialis brevis nerve
C6-C8
wrist
• Extensor carpi ulnaris
Median
• Flexor digitorum
Nerve
(8) Flexion of superficialis
and
fingers • flexor digitorum ulnar
profundus
nerve C7-C8
• Extensor digitorum,
(9) Extension Radial
of the • extensor indicis,
nerve
fingers • extensor digit minimi
(10) Abduction
of index • 1st dorsal interosseous Ulnar
and pinky • abductor digiti minimi nerve
fingers

Median C8-T1
(11) Thumb • Abductor pollicis brevis
abduction nerve
Median
(12) Opposition • Opponens pollicis
Nerve

Assess pronator drift

● Ask patient to supinate arms and hold their arms straight
out in front of them and close their eyes for 30 seconds
● If the patient's arm starts to pronate and drop downwards
within 30 seconds this may be indicative of a
corticospinal tract lesion
Figure 2 the upper limb dermatomes [The Cervical Spine: An atlas of normal
o Example: if a patient has a left MCA stroke, they may
anatomy and the morbid anatomy of ageing and injuries]
have a pronator drift of the right arm

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 (13) The Lower Limb
Proximal → Distal strength and power assessment

• Iliacus,
Femoral
(1) Hip flexion • Psoas major
nerve
L2 L3 L4
• Pectineus

Inferior gluteal
(2) Hip extension • Hamstrings
nerve
L5 - S2

• Obturator externus

• Adductor
Obturator
(3) Hip adduction longus/brevis/magnus nerve L2 L3 L4

• Gracilis

• Gluteus medius and Superior

(4) Hip abduction L5 - S1
minimus gluteal nerve

(5) Knee flexion • Hamstrings Sciatic nerve L4 - S3

Femoral
(6) Knee
extension
• Quadriceps
nerve L2 L3 L4

Deep fibular
(7) Ankle • Tibialis anterior
nerve
L4 - L5
dorsiflexion

• Gastrocnemius,
(8) Ankle
plantarflexion
• Soleus Tibial nerve S1 - S2
• Tibialis posterior

• Tibialis anterior and

(9) Ankle
inversion posterior
Tibial nerve L4 - L5

• Fibularis brevis and Superficial

(10) Thumb
abduction longus fibular nerve L5 - S1

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 IV) DEEP TENDON REFLEXES

● Deep tendon reflexes can be assessed based on a scoring or scaling system

Hyperreflexia with clonus • Clonus of wrist: hyperextend wrist
4+ reflex present → causes beating of wrist after hyperextension

• If combined with weakness and hypertonia

→ may be indicative of an UMN lesion

Hyperreflexia without clonus • If combined with weakness and hypertonia

3+ reflex present → may be indicative of an UMN lesion

Hyperreflexia without clonus

2+ reflex present

Hyporeflexia that can be
1+ reflex increased or accentuated with
Reinforcement maneuver
• Reinforcement (Jendrassik) maneuvers: clench teeth, pull hands apart
→ may accentuate decreased reflex
• If combined with weakness, atrophy, hypotonia and fasciculations may be
indicative of LMN lesion

areflexia • If combined with weakness, atrophy, hypotonia and fasciculations may be

0 reflex indicative of LMN lesion
• If ataxia and ophthalmoplegia is present it may be indicative of miller fisher
variant of GBS

(1) Upper Limb (2) Lower Limb

● Proximal → Distal DTR assessment ● Proximal → Distal DTR assessment
Biceps • First, the examiner
reflex places his/her Adductor • Tapping the tendon on the
thumb on the reflex medial epicondyle of femur
patient's biceps o elicits the adductor reflex.
tendon
→ then the examiner
strikes his/her
L2–L4

thumb with a
reflex hammer
and observes the Knee • Striking the tendon just below the
C5–C6

patient's forearm reflex patella (leg is slightly bent)

movement. o induces knee extension.

Brachio- • Striking the lower

radialis end of the radius
reflex with a reflex
hammer
o elicits movement
Posterior • The tibialis posterior muscle is
of the forearm.
tibial tapped with a reflex hammer,
reflex either just above or below the
L5

medial malleolus.
o The reflex is positive when
an inversion of the foot
Triceps • The examiner occurs.
reflex holds the patient's
arm (forearm
hanging loosely at Ankle • Striking the Achilles tendon with
C7–C8

90° position) and

reflex a reflex hammer
taps the triceps
o elicits a jerking of the foot
S1–S2

tendon with a reflex

hammer towards its plantar
o induce an surface.
extension in the ● Alternatively, the reflex is
elbow joint. triggered by tapping the ball of
a foot from the plantar side.

● stimulation of the lateral

Babinski plantar aspect of the foot
reflex o Abnormal if big toe
dorsiflexes and toes fan
apart
o May be indicative of an
UMN lesion if also
accompanied by
weakness and
hyperreflexia

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 V) SENSATION (D) VIBRATION
● Spinal cord pathway:
● Assess light touch, pain, temperature, vibration,
o Posterior column and sensory cortex
proprioception and discriminative sensations
● Procedure:
o Use tuning fork and assess each dermatome on one limb
and compare to other side to assess for asymmetry
o Use a distal bony prominence like the DIP of a digit or toe
and compare to the other limb
o Use a proximal bony prominence like the acromion process
and compare to the other limb
● Findings
o Pallhypesthesia:
 decreased sensitivity to vibration sensations
 May be due to neuropathy or myelopathy

(E) PROPRIOCEPTION
● Spinal cord pathway:
o Posterior column and sensory cortex
● Procedure
o Isolate the first digit by holding the DIP and move finger or
toe up and down and ask patient to identify the position with
their eyes closed
● Findings
Figure 3 Posterior (dorsal) column and the o Inability to identify the position of the digit with eyes closed
Spinothalamic Tract may be indicative of neuropathy or myelopathy
(A) LIGHT TOUCH (F) DISCRIMINATIVE SENSATION
● Spinal cord pathway:
o Posterior column and sensory cortex (i) Stereognosis
● Spinal cord pathway:
● Procedure: o Posterior column and sensory cortex
o Use cotton swab and assess each dermatome ● Procedure
on one limb and compare to other side to o Assess the patient's ability to identify common objects with
assess for asymmetry their eyes closed
● Findings ● Findings
o Paresthesia: o Astereognosis
 numbness and tingling sensation  Inability to identify common objects with eyes closed
o Hypesthesia:  May be caused by sensory cortex lesion when light
 decreased sensitivity to touch touch, proprioception and vibration is intact
o Hyperesthesia:
 increased sensitivity to touch (ii) Graphesthesia
(B) PAIN ● Spinal cord pathway:
o Posterior column and sensory cortex
● Spinal cord pathway:
o Lateral spinothalamic tract and sensory cortex ● Procedure
o Assess the patient's ability to identify a number or letter your
● Procedure: are drawing in the patients palm
o Use sharp tool and assess each dermatome on
one limb and compare to other side to assess ●
for asymmetry ● Findings
o Agraphetheisa:
● Findings
 Inability to identify the letter or number written in their
o Hypoalgesia: palm
 decreased sensitivity to painful stimuli  May be caused by sensory cortex lesion when light
o Hyperalgesia: touch, proprioception and vibration is intact
 Increased sensitivity to painful stimuli
(iii) Extinction
(C) TEMPERATURE
● Function is carried out by the sensory cortex
● Spinal cord pathway:
● Double simultaneous stimulation of upper limbs and ask patient
o Lateral spinothalamic tract and sensory cortex
which arm you are touching
● Procedure: o If the patient has a lesion of the sensory cortex (right MCA
o Use test tube with cold water and another test stroke) on the right parietal lobe they may neglect their
tube with hot water and assess each entire left side and tell you are only touching their left arm
dermatome on one limb and compare to other when you double simultaneously stimulate or tough both
side to assess for asymmetry upper limbs
● Findings
o Hypoalgesia:
 decreased sensitivity to painful stimuli
o Hyperalgesia:
 Increased sensitivity to painful stimuli

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 VI) COORDINATION
● The cerebellum is responsible for coordination
o Lesion of the right cerebellum may cause loss of coordination on the right side
 Associated findings may be
• ataxia,
• nystagmus,
• hypotonia,
• nausea,
• vomiting,
• vertigo
• dysarthria
ASSESS COORDINATION WITH THE FOLLOWING TESTS:
(1) Finger to nose (3) Cerebellar drift
● Procedure ● Procedure
o Ask patient to touch finger to nose and then that same o Ask patient to supinate arms and hold their arms
finger to your finger and compare to the other side straight out in front of them and close their eyes

● Findings
o If patients arm pronates and raises upwards this can
be indicative of cerebellar drift

● Findings
o Dysmetria:
 Patient over shoots bringing their finger to your
finger (4) Rebound phenomenon
o Intention tremor:
 Intensity of tremor worsens as patients finger ● Procedure
approaches your finger o Ask the patient to resist flexion at the elbow and then
quickly let go and assess of patient almost hits
(2) Rapid alternating movement themself in the face (brace your arm near the patients
face to prevent this)
● Procedure
o Ask patient to slap front and back of hand on the
other and as fast as they can

● Findings
● Findings o Inability to prevent their arm from hitting themselves in
o Dysdiadokinesis: the face may indicate loss of muscle agonist and
 slow rate, loss of smooth pursuit and abnormal antagonistic contro
rhythm of the rapid alternating movements
(5) Pendulous leg swing after patellar reflex
o Abnormally increased patellar reflex where the leg
continues to swing continuously after the reflex
hammer initiated the deep tendon reflex

VII) REFERENCES
● Bickley LS, Szilagyi PG, Hoffman RM, Soriano RP, Bates B. Bates' Guide to Physical Examination and History Taking. Philadelphia: Wolters Kluwer; 2021.
● Longmore JM. Mini Oxford Handbook of Clinical Medicine. Oxford: Oxford University Press; 2015.
● Sabatine MS. Pocket Medicine: the Massachusetts General Hospital Handbook of Internal Medicine. Philadelphia: Wolters Kluwer; 2020.
● Williams DA. Pance Prep Pearls. Middletown, DE: Kindle Direct Publishing Platform; 2020.
● Deep Tendon Reflex: The Tools and Techniques. What Surgical Neurology Residents Should Know https://europepmc.org/article/pmc/pmc8075597

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