Motor, sensory and reflex examination of the limbs

In one minute:

• The limb neurological examination is a set of directed tests of strength, tone, reflexes, sensation and coordination that locates disease in the cortex, brainstem, spinal cord, root, plexus, peripheral nerve, neuromuscular junction or muscle.
• It distinguishes upper motor neuron (spastic, brisk reflexes, extensor plantar) from lower motor neuron (wasted, flaccid, absent reflexes) disease, and a central level from a peripheral pattern.
• Each test answers one anatomical question; the pattern of abnormalities, not any single finding, makes the diagnosis.
• Recording is part of the examination: grade power with the MRC scale, name the reflexes tested, and map sensory levels exactly.
• Presentation comes last and is a one-sentence localisation supported by the findings, with the important negatives stated.

The aim of the examination is to place the disease at a level of the nervous system and to answer the question of whether it behaves like a central or a peripheral process. In practice that means testing voluntary movement against gravity and resistance, feeling how a muscle resists being moved, tapping the tendons, mapping touch and pain, testing position sense and vibration, and watching the limbs do fine, guided tasks. The reader of the notes, and the examiner's own later memory, depend on the order and detail of the record. A "normal neuro exam" written without the tests is not an examination, it is a conclusion.

By the end of this page you should be able to:

1. Prepare and position a patient for a limb neurological examination, with proper consent and safety.
2. Carry out the examination in the accepted order, without missing either side or any major movement.
3. Grade power with the Medical Research Council 0 to 5 scale and tone as flaccid, spastic or rigid.
4. Test and grade the deep tendon reflexes, elicit and interpret clonus and the plantar response, and use reinforcement when reflexes are hard to find.
5. Test primary sensation and map it to a dermatome, single nerve, level or peripheral neuropathy. ^[7]
6. Test coordination in the upper and lower limbs.
7. Turn a list of findings into a one-sentence spoken and written presentation with a differential.

The examination is of most value when it is part of a complete neurological examination, but a focused limb examination is justified for a discrete complaint once the whole sequence is known well enough to be extended at any point. Equipment is a tendon hammer, a pin or sterile safety pin, cotton wool, a cold object, two tuning forks (for vibration sense), a tape measure, a pen and paper, and a ruler for sensory levels. Keep the room warm and quiet, with the patient able to lie and sit, both arms and legs exposed to the same degree, and both sides within easy reach so that one side is not re-examined out of order.

A comprehensive neurologic examination should include evaluation of the sensorium, cognition, cranial nerves, motor function, sensory function and gait. ^[1]

Introduce yourself, explain what the examination involves, how long it will take, and why it is needed. Obtain consent, including consent to expose the limbs and to use a sharp object, and offer a chaperone. Hand hygiene is performed before and after contact with the patient and before and after the examination. Position the patient sitting on the edge of the couch with the legs dangling for the reflexes, then with the arms resting on the lap and the legs supported when tone and strength are tested, and lying supine when tone and sensation in the lower limbs are tested. Ask the person to remain in underwear, kept covered between tests, and warn before anything sharp, cold or uncomfortable.

Ask about pain before starting and re-check throughout. Take a brief focused history of the weakness or sensory change: which limb, where it started, whether it is spreading, what makes it worse, and whether there are associated back or neck pain, sphincter change, visual symptoms, speech change or headache. Sudden-onset limb weakness suggests a stroke or transient ischaemic attack and needs assessment against the NICE guidance on stroke and TIA in adults. ^[6] Rapidly progressive gait unsteadiness over days to weeks warrants urgent neurological assessment. ^[6]

Safety: do not extend the neck or rotate the head if a cervical spine injury is suspected. Do not force the examination on an agitated or distressed person. If a stable vascular event in the neck arteries is a possibility, gentle examination comes first and imaging before completeness. Do not ask a person with unsteadiness to stand without support, and stay close and use a wall or a second person. Adolescents and adults who have difficulty with the history can write or point instead; where consent or chaperone use is standard for your setting, follow local policy.

The order protects you from being misled. Test both sides in the same movement before moving to the next movement. Use a short script so no step is forgotten: INSPECT, TONE, POWER, REFLEXES, SENSATION, COORDINATION, then, for the legs, STATION AND GAIT. Write findings as you go, not at the end.

The steps in the exact order used at the bedside:

1. Gait and station (legs first, if safe). Ask the person to walk a few metres, turn, and walk back. Watch arm swing, base, step length, symmetry, foot slap, scuffing or dragging. Test heel-to-toe walking, walking on toes, walking on heels and standing on one leg. Station is tested by standing feet together, then closing the eyes (Romberg); increasing sway or a fall with the eyes closed points to loss of proprioception rather than cerebellar disease.
2. Inspection. Look at posture and spontaneous movement. Inspect muscle bulk in shoulders, upper arms, forearms, thighs, calves and intrinsic hand muscles, comparing sides. Look for wasting, fasciculation (fine, irregular twitches of small patches of muscle), hypertrophy and trophic changes of the skin, nails and joints. Measure with a tape if the two sides look different.
3. Tone (upper limbs). Test each movement slowly then quickly: shoulder flexion and extension, elbow flexion and extension, wrist flexion and extension. Feel for the point of "catch" and for clonus.
4. Tone (lower limbs). Test hip rotation and extension, knee flexion and extension and ankle dorsiflexion and plantarflexion, both slowly and quickly. ^[5]
5. Power (upper limbs). Test shoulder abduction and adduction, elbow flexion and extension, wrist flexion and extension, finger flexion and extension, grip, and fine finger movements. Grade each with the Medical Research Council scale.
6. Power (lower limbs). Test hip flexion and extension, abduction and adduction, knee flexion and extension, ankle dorsiflexion and plantarflexion, and toe flexion and extension. Grade each.
7. Coordination (upper limbs). Test finger-to-nose, rapid alternating pronation and supination (dysdiadochokinesia), and finger tapping. Use heel-to-shin in the lower limbs and test tandem gait again if not already done.
8. Deep tendon reflexes (upper limbs). Test biceps (C5 and C6), triceps (C7) and supinator (C5 and C6), with the tendon slightly stretched and the muscle relaxed.
9. Deep tendon reflexes (lower limbs). Test quadriceps (L3 and L4) and Achilles (S1). Use reinforcement immediately when a reflex is absent or appears absent; do not conclude it is absent without trying.
10. Plantar response. Test both feet last, because it can make the legs stiff.
11. Sensation (upper limbs). Test light touch, pinprick, temperature, vibration and joint position sense in a systematic grid, compare sides, and map any loss to a peripheral nerve or dermatome.
12. Sensation (lower limbs). Test the same five modalities from the toes proximally, looking for a level on the leg and trunk as well as a distal pattern.
13. Cortical sensation (if indicated). Two-point discrimination, graphesthesia, stereognosis and sensory extinction with simultaneous touch on both sides.
14. Recheck and record. Go back to any earlier step that was abnormal, compare sides one final time, and write findings with the level, the side, the test performed and the result.

If the problem is focal, the sequence can be shortened, but full bilateral comparison of the tested movements must still be performed. If both arms or both legs are involved, compare proximal with distal as well as left with right.

The table lists the principal limb signs, how to elicit them, and what they mean. Numbers that define a scale are cited.

Deep tendon reflexes are named by nerve root so that findings lead naturally to a level: biceps C5 to C6, triceps C7, supinator C5 to C6, quadriceps L3 to L4, Achilles S1. ^[1]

The following dermatome key sensory points, from standard surface-anatomy mapping, are commonly used and should be tested as boundaries: C5 the lateral (radial) side of the antecubital fossa just proximal to the elbow crease; C6 the dorsal proximal phalanx of the thumb; C7 the dorsal proximal phalanx of the middle finger; C8 the dorsal proximal phalanx of the little finger; T1 the medial (ulnar) side of the antecubital fossa; T4 the nipple line; T10 the umbilicus; L4 the medial malleolus; L5 the dorsum of the foot at the third metatarsophalangeal joint; and S1 the lateral aspect of the calcaneus. ^[7]

In the upper limb, typical root patterns described in surgically verified cervical radiculopathy are C5 (deltoid area and lateral arm, deltoid, biceps reflex), C6 (radial forearm to thumb and index finger, wrist extensor, biceps and brachioradialis reflex), C7 (mid radial forearm to index and middle finger, wrist flexor, triceps reflex) and C8 (ulnar forearm and hand, hand intrinsics and finger flexors, no reflex change). ^[4]

In the lower limb, typical myotomes are L2 hip flexion (iliopsoas), L3 knee extension, L4 ankle dorsiflexion (tibialis anterior), L5 great toe extension and ankle eversion (extensor hallucis longus and peronei), and S1 plantar flexion (gastrocnemius and soleus). ^[5]

Tone is classified by feel and speed. Spasticity is velocity-dependent, increases at speed, and is classically felt as a catch with sudden release, the clasp-knife phenomenon; it is caused by upper motor neuron damage of the pyramidal system. ^[3] Rigidity is present at all speeds of passive movement and is felt as constant resistance, like bending lead pipe, with a superimposed cogwheel feel when tremor is present; it is extrapyramidal. ^[3] Clonus at the ankle or patella is always abnormal. ^[1]

Power should be read with the pattern as well as the number. Grade 4 spans the widest band of strength on the scale, so a single grade 4 says little; record whether it was weak against slight, moderate or strong resistance, and whether pain or fatigue limited performance. ^[2] The MRC scale grades of 4 and 5 are subjective, relying on the examiner's resistance and the patient's willingness, whereas grades 0 to 3 have clear cut-offs, such as a visible contraction for grade 1. ^[2]

Present findings as one short, ordered, spoken paragraph. Lead with the most important fact; if a single finding determines the urgency, say it first. State the level and side before the list, then give the motor, reflex and sensory findings in that order, then state the important negatives, then give a one-line summary of the most likely level, then a short differential if more than one is realistic. End with the effect on the patient (walking, self-care) where relevant.

A useful fixed order:

1. Identify yourself and the patient situation in one phrase.
2. State the main finding and its side and level.
3. Motor: tone, bulk, power by movement and MRC grade, coordination.
4. Reflexes: deep tendon, plantar, any clonus.
5. Sensation: modalities, pattern and dermatome boundary.
6. Important negatives.
7. One-sentence localisation.
8. Differential, if needed.
9. Effect on function and the next step.

Written notes should follow a layout that another clinician can repeat: appearance and behaviour; arms (bulk, tone, power, coordination, reflexes, sensation); legs (same); gait and Romberg; plantar responses; summary and plan. For every abnormality write the objective finding rather than the interpretation ("grade 3 power at left ankle dorsiflexion" instead of "weak"). Use the same wording for reflexes throughout your notes, such as absent, diminished, normal, brisk and clonic.

In the written summary the localisation should be a full sentence with the evidence named: "Left cerebral hemisphere is most likely, on the basis of sudden right hemiparesis with upper motor neuron signs and dysphasia, with no level suggesting spinal cord or peripheral nerve." Sensory level, degree and modality should be written as a measurement, for example "reduced pinprick to T8 on the right."

These examples are illustrative; all patient details are invented.

Normal report, spoken. "Patrick is a 22-year-old medical student. Neurological examination of the limbs is normal. In both upper limbs there is normal bulk and tone, full power in all tested movements with grade 5, coordination is accurate, biceps, triceps and supinator reflexes are normal and symmetric, plantar response is flexor, and light touch, pinprick, vibration and position sense are intact to the fingertips. In both lower limbs power is full, tone normal, knee and ankle reflexes normal and symmetric, coordination on heel-to-shin is accurate, gait and tandem gait are normal, Romberg is negative, and sensation is intact to the toes. In summary, no upper or lower motor neuron, root or peripheral nerve abnormality is found."

Abnormal report 1, spoken. "Marta, 58, has a one-day history of sudden right arm and leg weakness. Power is grade 3 at right shoulder abduction, grade 2 at right elbow extension, grade 3 at right knee flexion and grade 2 at right ankle dorsiflexion; tone is increased on the right with a clasp-knife catch at the elbow and knee; the right biceps, triceps and knee jerks are brisk and the right plantar response is extensor with clonus at the ankle. All modalities of sensation are reduced to pinprick and light touch on the whole right side from the face down, without a clear spinal level. Coordination is impaired on the right. Cranial nerve testing shows a mild right facial weakness. The most important finding is an acute upper motor neuron hemiparesis with a hemisensory loss; I think a left cerebral hemisphere lesion, most likely vascular, is the level, and I would arrange urgent brain imaging without further waiting."

Abnormal report 2, spoken. "John, 62, reports six months of progressive numbness and weakness in both feet spreading to the knees, with burning pain at night. Bulk is reduced in both intrinsic hand muscles and the anterior compartments of both legs; tone is normal; power is grade 4 at bilateral ankle dorsiflexion and grade 4 at toe extension; knee reflexes are diminished and ankle reflexes are absent bilaterally; light touch, pinprick and temperature are lost in a glove-and-stocking pattern to the mid-forearms and mid-shins; vibration is lost to the knees; joint position sense is impaired at the toes and improved with eyes open during standing. Coordination is impaired by sensory loss rather than true dysmetria. Romberg is positive. My summary is a length-dependent peripheral (sensorimotor) neuropathy with proprioceptive involvement; the important negatives are normal tone and no sphincter disturbance, which argue against a cord level, and I would check glucose, renal function, B12, alcohol and neurophysiology next."

Abnormal report 3, spoken. "Aisha, 44, has neck pain radiating to the left thumb and index finger with weakness. Inspection, bulk and tone are normal; power is grade 4 at left wrist extension and grade 3 at left elbow flexion; the left biceps and brachioradialis reflexes are diminished and the left triceps reflex is normal; the left plantar response is flexor; sensation is reduced over the radial forearm and thumb and index finger on the left in a C6 distribution; coordination is intact and gait is normal. My presentation is a left C6 root or upper trunk plexus lesion on the motor and sensory pattern, most likely a compressive radiculopathy, with the radial forearm and thumb pointing to C6 rather than C5 or C7; imaging of the cervical spine and neurophysiology would be the next step."

• Letting the patient move against you before you have set a standard position, so the resistance feels different on each side.
• Confusing a withdrawal movement with an extensor plantar response and so calling a depressed patient a case of upper motor neuron disease.
• Testing speed-sensitive signs without varying the speed, which is what separates velocity-dependent spasticity from speed-independent rigidity.
• Calling a reflex absent before using reinforcement and before ensuring the patient was relaxed.
• Testing sensation with the person's eyes open, or without explaining "say yes every time you feel something" to avoid guessing.
• Comparing left then right for power, then skipping the same comparison for tone and sensation.
• Ignoring the asymmetry of cranial and truncal findings and testing only the limb that the patient complains about.
• Mistaking weakness from pain for neurological weakness; record it as pain-limited if that is suspected.
• Recording a single MRC grade 4 without saying whether it was against slight, moderate or strong resistance.
• Forgetting that grade 4 is the widest band on the MRC scale, so early change in strength inside grade 4 is not visible as a grade change.
• Mapping sensation to a single point instead of drawing the boundary, or mistaking a nerve territory for a dermatome.
• Ending the examination at the bedside without a one-sentence localisation in the notes.

• The limb examination separates central from peripheral disease by tone, reflexes and the plantar response before it tries to name the diagnosis.
• Always compare the two sides in the same movement, in the same position, and record objective findings.
• Upper motor neuron signs are spasticity, hyperreflexia, clonus and an extensor plantar response; lower motor neuron signs are wasting, fasciculation, hypotonia and lost reflexes.
• Use the full Medical Research Council 0 to 5 muscle strength scale and remember that grades 0 to 3 have objective cut-offs while 4 and 5 are subjective. ^[2]
• The pattern of weakness (which movements are weak, which are spared) localises better than the severity.
• Deep tendon reflexes are graded on a named scale, such as the NINDS 0 to 4 scale or the British 0 to 5+ scale; reinforcement and the presence of clonus are part of the record. ^[1]
• The plantar response is normal when flexor; an extensor up-going toe with fanning is an important upper motor neuron sign and must be distinguished from withdrawal.
• Test light touch, pinprick, temperature, vibration and joint position sense, then map them to dermatomes and peripheral nerve territories.
• Coordination in the limbs is tested after weakness is excluded, and accuracy is compared side to side.
• Sensory level and pattern localise better than a single sensory symptom; draw the boundary.
• Presentation leads with the most important finding, gives the level, lists findings in muscle-reflex-sensation order, states the important negatives, and ends with the localisation and differential.
• Keep the unsafe manoeuvres out of routine testing: no forced neck extension, no unsupported standing for an unsteady person.