Routine for examination of lower limbs:
Inspect (walking aids, wasting, fasciculations, pes cavus, calluses, ulcers, charcot joint)
Tone
Power
Reflexes
Sensation: light touch, joint position sense, vibration and pin prick if time allows. Be sure to test both proximally and distally and to determine the level at which sensation returns to normal (start distally and work proximally) and test the back of the leg too!
Coordination
Gait and Rhombergs
If time allows:
Hands: sensation (NB: hands usually only affected if sensory loss in lower limbs is beyond the knees)
General exam for clue to cause: hands (dupuytrens contracture, diabetic fingerprick marks, clubbing, vasculitic changes, wasting), arms (fistula), eyes (conjunctival pallor), abdo (renal, insulin injection sites), thyroid
Present to the examiner:
This patient has a predominantly sensory peripheral polyneuropathy as evidenced by:
Distal (a)symmetrical loss of sensation to light touch (and pinprick +/- vibration) in stocking distribution to knees
Loss of joint position sense at toes (+/-ankle etc)
Comment on whether there was a stomping broad based gait and whether Rhombergs was positive
Comment on whether the motor system was intact
Comment on whether the ankle jerk was present/absent
Comment on whether there was any ankle deformity, calluses, ulcers, pes cavus etc.
There was (no) sensory loss in the upper limbs
With regards to a cause, I looked for …….
I would complete my examination by examining motor and sensory systems in the upper limbs, cranial nerves and performing fundoscopy.
Investigations:
Level 1: FBC, U+E, LFT, TFT, ESR, CRP, B12, folate, glucose/hba1c, bone profile
Urine dipstick
Level 2: ANA, ANCA, Immunoglobulins, RF, complement, serum electrophoresis, urine bence jones proteins, serum ACE, paraneoplastic antibodies (eg. anti-mag, anti-hu, anti-yo), HIV, syphilis, lyme, coeliac serology
CXR
EMG (denervation)
Nerve conduction studies (sensory vs. motor, low amplitude = axonal, low velocity = demyelinating)
Level 3: Lumbar puncture for CSF examination
MRI spine
Nerve/muscle biopsy
Screen for cancer: mammogram, CT, skeletal survey if possible myeloma
Genetic testing
Causes of predominantly sensory peripheral neuropathy:
*ABCDEFGHI*
A Alcohol (and liver dysfunction) LFTs
B B12, B1 deficiency FBC, B12
C Cancer, chemo, CKD, coeliac, connective tissue disease U+E, multiple myeloma
screen, paraneoplastic screen, CXR, mammogram, coeliac, ESR, ANA, ANCA, RF, Igs,
complement, etc.
D Diabetes, Drugs (and toxins) Hba1c
E Endocrine TFTs
F Folate deficiency Folate
G Granulomatous disease eg. sarcoid Calcium, serum ACE
H Hereditary eg. HSMN
I Infection eg. leprosy, idiopathic HIV, syphilis, lyme etc.
Drug causes:
Isoniazid, ethambutol
Vincristine, vinblastine
Cisplatin, oxaliplatin
Phenytoin
Metronidazole, nitrofurantoin
Gold, ciclosporin
Amiodarone, hydralazine
Antiretroviral drugs
Management:
Conservative: physio, OT, orthotics, social worker, DVLA considerations, stop drinking alcohol if this is the cause/contributing, diabetic specialist nurse and doctor if diabetes is the cause/contributing
Medical: analgesia, treat the underlying cause
Written by Dr Sarah Kennedy
Resources used to write this document are listed in the references section of this webpage