A neurological examination is the assessment of sensory neuron and motor responses, especially reflexes, to determine whether the nervous system is impaired. This typically includes a physical examination and a review of the patient’s medical history, but not a deeper investigation such as neuroimaging.
An upper limb neurological examination is part of the neurological examination and is used to assess the motor and sensory neurons which supply the upper limbs. This assessment helps to detect any impairment of the nervous system, being used both as a screening and an investigative tool. The examination findings when combined with a detailed history of a patient, can help a doctor reach a specific or differential diagnosis. This would enable the doctor to commence treatment if a specific diagnosis has been made, or order further investigations if there are differential diagnoses.
Structure of examination
The examination is performed in sequence:[rx]
- General inspection
- Muscle tone
The upper body is exposed and a general observation is made from the end of the bed. Signs of a neurological disease include:[rx]
- Wasting – May suggest motor neuron disease or a lower motor neuron lesion. It could also indicate local infiltration of nerves such as the brachial plexus, in apical lung tumors, causing wasting of the small muscles of the hand.
- Fasciculation – These are small contractions of muscles seen as movements under the skin. They occur in lower motor neuron lesions.
- Involuntary movements – Different types exist, all of which are distressing to the patient and cause embarrassment in public. They are classified into tremor, chorea, athetosis, hemiballismus, dystonia, myoclonus, and tics.
The hand is grasped like a handshake and the arm is moved in various directions to determine the tone.[rx] The tone is the baseline contractions of the muscles at rest. The tone may be normal or abnormal which would indicate underlying pathology. The tone could be lower than normal (floppy) or it could be higher (stiff or rigid).
The strength of the muscles is tested in different positions against resistance.[rx]
There are 3 reflexes in the upper arm that are tested.[rx][rx] These are the biceps, triceps and supinator reflex. The reflexes may be abnormally brisk or absent. In the latter, the reflex could be elicited through reinforcement by asking the patient to clench their jaw.[rx]
Three separate aspects of coordination are tested:[rx]
This maneuver tests for dysmetria.
Examiner holds his hand in front of the patient, who is then asked to repeatedly touch their index finger to their nose and examiner’s finger. The distance between the examiner’s hand and the patient’s nose should be larger than the forearm length of patient so that the patient needs to move both his shoulder joint and elbow joint during the test instead of just moving the elbow joint.
A healthy individual could touch accurately on the nose and examiner’s hand with ease, while a dysmetria patient will constantly miss the nose and the hand.
This maneuver tests for dysdiadochokinesia.
The patient is asked to tap the palm of one hand with the fingers of the other, then rapidly turn over the fingers and tap the palm with the back of them, repeatedly. The patient is asked to perform the clapping as quickly as he could.
Dydiadochokinesia patients will be impaired in the rate of alternation, the completeness of the sequence, and in the variation in amplitude involving both motor coordination and sequencing.[rx][rx]
The arms are outstretched and the patient is instructed to close their eyes. If the hands do not move, it is normal.
The five aspects of sensation are tested:
- Light touch – tested using cotton wool
- Pain – tested with a neurological pin
- Proprioception (sense of joint position) – tested by moving the thumb while the patient’s eyes are closed. The patient is then asked whether the thumb is moved up or down.
- Vibration – tested with a 128 Hz tuning fork placed at the first joint of the thumb
- Temperature – tested with hot and cold test tubes. Alternatively, the cold tuning fork used for vibration sense, could be used.
- Palpation of sternoclavicular joint, clavicle, acromioclavicular joint, subacromial bursa, bicipital tendon.
- Evaluation of passive and active range of motion: Neck range of motion should be assessed that may reveal a neck source of shoulder pain. The Apley scratch test specifically tests range of motion and in a normal exam, an individual should be able to reach C7 on external rotation, and T7 on internal rotation.
- Evaluation of distal pulses
- Strength testing: wrist extension tests the radial nerve, finger abduction tests the ulnar nerve, and thumb opposition tests the median nerve.
- Sensation testing
- Reflex testing: Triceps reflex tests C6-C8, biceps reflex tests C5 and C6, and brachioradialis reflex tests C5-C7.
- Provocative maneuvers
Tests for rotator cuff pathology
- Neer impingement sign: a positive test indicates shoulder impingement
- Hawkins-Kennedy test: a positive test indicates shoulder impingement
- An empty beer can test: a positive test indicates rotator cuff tear, specifically, supraspinatus muscle tear
- Drop arm test: a positive test indicates a supraspinatus tear
- External Rotation test: a positive test indicates an infraspinatus or teres minor tear
- Lift-off test: a positive test indicates subscapularis pathology
Tests for bicipital tenosynovitis and labral pathology
- Ferguson’s test
- Speed’s test
- Biceps load test
- O’Brien’s test: positive test indicates a SLAP (or superior labral tear from anterior to posterior) tear
Tests for shoulder instability
- Apprehension test or Jobe’s test: positive test indicates anterior glenohumeral instability
- Relocation test
- Cross-arm test: positive test indicates acromioclavicular joint degeneration/arthritis
- Adson’s sign tests for thoracic outlet syndrome
- Lhermitte’s sign may indicate cervical radiculopathy or spinal cord disease
- Spurling’s test tests for cervical spine disease[rx][rx]
A meta-analysis in 2008 concluded that the diagnostic accuracy of individual tests in the shoulder examination was limited, specifically that the Hawkins-Kennedy test and the Speed test have no discriminatory ability to diagnose specific shoulder pathology, and that results of studies evaluating other tests were too statistically heterogeneous to make meaningful conclusions about their diagnostic accuracy.[rx]
Examination of the shoulder can be complex because the shoulder can present with more than one pathology at a time.
The hip examination, like all examinations of the joints, is typically divided into the following sections:
- Special maneuvers
The middle three steps are often remembered with the saying look, feel, move.
Position – for most of the exam the patient should be supine and the bed or examination table should be flat. The patient’s hands should remain at their sides with the head resting on a pillow. The knees and hips should be in the anatomical position (knee extended, hip neither flexed nor extended).
Lighting – adjusted so that it is ideal.
Draping – both of the patient’s hips should be exposed so that the quadriceps muscles and greater trochanter can be assessed.
Inspection is done while the patient is standing
Front and back of pelvis/hips and legs and comment on
- Ischaemic or trophic changes·
- Level of ASIS (anterior superior iliac spine)
- Swelling (soft tissue, bony swellings)
- Scars (old injuries, previous surgery)
- Sinuses (infection, neuropathic ulcers)
- Wasting (old polio, Charcot-Marie-Tooth) or hypertrophy (e.g. calf pseudo-hypertrophy in muscular dystrophy)
- Deformity (leg length discrepancy, pes cavus, scoliosis, lordosis, kyphosis)
- Any swellings·Anteriorly in Scarpa’s triangle, Trochanteric region, or gluteal region
- Pelvic tilt by palpating level of ASIS (anterior superior iliac spine)
- Smooth and progression of phases of the gait cycle
- Comment on stance, toe-off, swing heel strike, stride, and step length
- Sufficient flexion/extension at hip/knee ankle and foot:
- Any fixed contractures?
- Arm-swing and balance on turning around·
Abnormal Gait Patterns
- Trendelenburg (pelvic sway/tilt, aka waddling gait if bilateral)
- Broad-based (ataxia)
- High-stepping (loss of proprioception/drop foot)
- Antalgic (mention “with reduced stance phase on left/right side”)
- In-toeing (persistent femoral anteversion)
Inspection is done while supine
The hip should be examined for:
- Signs of trauma/previous surgery
- Bony alignment (rotation, leg length)
- Muscle bulk and symmetry at the hip and knee
- True leg length – Greater Trochanter of the femur or Anterior Superior Iliac Spine of pelvis to medial malleolus of ipsilateral leg.
- Apparent leg length – umbilicus or xiphisternum (noting which is used) to the medial malleolus of ipsilateral leg.
In hip fractures, the affected leg is often shortened and externally rotated.
The hip joint lies deep inside the body and cannot normally be directly palpated.
To assess for pelvic fracture one should palpate the:
- Iliac spines
- Superior and inferior pubic rami
- Internal rotation – with knee and hip both flexed at 90 degrees the ankle is abducted.
- External rotation – with knee and hip both flexed at 90 degrees the ankle is adducted. (also done with Patrick’s test / FABER test)
- Flexion (also known as the Gaenslen’s test)
- Extension – done with the patient on their side. Alignment should be assessed by palpation of the ASIS, PSIS, and greater trochanter.
- Abduction – assessed whilst palpating the contralateral ASIS.
- Adduction – assessed whilst palpating the ipsilateral ASIS.
- Assessment for hidden flexion contracture of the hip – hip flexion contractures may be occult, due to compensation by the back. They are assessed by:
- Placing a hand behind the lumbar region of the back
- Getting the patient to fully flex the contralateral hip.
- The hand in the lumbar region is used to confirm the back is straightened (flexed relative to the anatomic position). If there is a flexion contracture in the ipsilateral hip it should be evident, as the hip will appear flexed.
Normal range of motion
- Internal rotation – 40°
- External rotation – 45°
- Flexion – 125°
- Extension – 10-40°
- Abduction – 45°
- Adduction – 30°
- Trendelenburg test/sign:
- Make sure the pelvis is horizontal by palpating ASIS.
- Ask the patient to stand on one leg and then on the other.
- Assess any pelvic tilt by keeping an index finger on each ASIS.
- Normal (Trendelenburg negative): In the one-legged stance, the unsupported side of the pelvis remains at the same level as the side the patient is standing or even rises a little, because of the powerful contraction of hip abductors on the stance leg.
- Abnormal (Trendelenburg positive): In the one-legged stance, the unsupported side of the pelvis drops below the level as the side the patient is standing on. This is because of the (abnormal) weakness of hip abductors on the stance leg. The latter hip joint may therefore be abnormal.
- Assisted Trendelenburg test – If the balance is a problem, face the patient and ask them to place their hands on yours to support him/her as he/she does alternate one-legged stance. Increased asymmetrical pressure, on one hand, indicates a positive Trendelenburg test, on the side of the abnormal hip
- A ‘delayed’ Trendelenburg – has also been described, where the pelvic tilt appears after a minute or so: this indicates abnormal fatiguability of the hip abductors.
Romberg’s test This assesses proprioception/balance (dorsal columns of spinal cord/spinocerebellar pathways).
- Ask the patient to stand with heels together and hands by the side. Ask the patient to close his/her eyes and observe for swaying for about 10seconds.
- Most people sway a bit but then quickly decrease the amplitude of swaying. If however, the swaying is not corrected, or the patient opens the eyes or takes a step to regain balance, Romberg’s test is positive.
- When doing this test, stand facing the patient with your arms outstretched and hands are at the level of the patient’s shoulders to catch or stabilize him/her in case of a positive Romberg test.
- Ober’s test for tight ITB (Iliotibial Band, also called IlioTibial Tract) performed with the patient side-lying on the unaffected side and the provider extending the affected hip. Stabilize the pelvis and let the affected leg drop. A positive test is indicated if the leg does not adduct to the table.[rx]
- Thomas test for tight hip flexors both performed by the provider holding the unaffected leg to the chest and leaving the affected leg on the table. If the affected leg cannot lie flat on the table it is a positive test.[rx]
- the Kendall test is similar, but the patient holds the unaffected leg to their chest.[rx]
- Rectus Femoris Contracture test for tight rectus femoris performed like Thomas test, but with the affected leg bent off the end of a table. a positive test is indicated if the thigh is not parallel with the table.[rx]
Kaltenborn test or Hip Lag Sign for hip abductor function. To perform the Kaltenborn test, the patient has to lie in a lateral, neutral position with the affected leg being on top. The examiner then positions one arm under this leg to have good hold and control over the relaxed extremity, whereas the other hand stabilizes the pelvis. The next step is to passively extend to 10° in the hip, abduct to 20° and rotate internally as far as possible, while the knee remains in a flexed position of 45°. After the patient is asked to hold the leg actively in this position, the examiner releases the leg. The Hip Lag Sign is considered positive if the patient is not able to keep the leg in the aforementioned abducted, internally rotated position and the foot drops more than 10 cm. To ensure an accurate result, the test should be repeated three times.[rx]