Ammar Alnajjar

Motor Examination
1- Inspection:
A- Posture of the limb: if we have an abnormality, we should mention it which is
1- In the upper or lower limb or both
2- Symmetrical or Asymmetrical
3- If Asymmetrical, in which side more prominent (right or left)

Abnormal Posture

Central Lesion Peripheral Lesion Both

1- Decorticate Posture Claw hand → lesion to ulnar nerve

2- Decerebrate Posture
Wrist drop → lesion to radial nerve
‫هذي األوضاع ميصير نكولها و نشخصها اال نشوف‬
Lower Limbs (Must be hyper-extended) Ape hand → ulnar & median injury (lower
brachial plexus injury)
Decorticate Posture ‫مومياء‬
a- Shoulder = over adduction Foot drop → peroneal nerve injury
b- Elbow = over flexion, supination
c- Wrist = over flexion, external rotation
d- fists crossing across the chest

Cause: Lesion above the superior colliculi

(midbrain)

Decerebrate Posture
a- Shoulder = over adduction
b- Elbow = over extension
c- Wrist = over flexion, internal rotation
d- If severe will be associated with
opisthotonos (Arching of back)

Cause: lesion between the superior &

inferior colliculi (midbrain)
Note: usually bilateral and symmetrical
but maybe unilateral

Note: The cause usually not a local lesion

but rather in diffuse metabolic
encephalopathy (hepatic or renal)

Lower Limb Postures

1- Everted ‫متباعدة‬ 2- Inverted ‫متقاربة‬
Hypotonia Hypertonia
1- Unilateral 1- Spasticity → UMNL in the
a- LMNL chronic phase
b- Disc prolapse
c- Common peroneal compression 2- May be cerebral palsy (scissor
d- Severe root lesion on 1 side gate)
e- (UMNL): In acute phase there
will be acute flaccid paralysis 3- Multiple strokes ( ‫بس مو نفس‬
(hypotonia) then in the chronic )‫الوقت‬
phase, there will be (hypertonia)
Unilateral inversion → UMNL
2- Bilateral (chronic phase)
a- Polyneuropathy Unilateral eversion → UMNL
b- DM (acute phase)
c- Gullian barre syndrome

3- Foot drop (like wrist drop)

Look for Any deformity in the limbs:
Like dupuytren’s contracture, extra finger, etc.

Foot arch (arc):

If absent → flat foot
If increase → pes cavus (usually idiopathic) but could be neurological due to:
a- Charcot marie tooth disease
b- Periphral neuropathy, diabetic neuropathy
c- Syphilis
d- Fired reich ataxia

Importance:
1- Effect on planter reflex → ‫ → يعني اذا شخص عنده‬upgoing planter reflex ‫ → طلع‬UMNL ‫ميصير‬
‫ → نكول‬pyramidal extension, clonus ‫الزم ندور على غير شي‬
2- Effect on movement
3- Shock absorber ‫ → اذا ماكو و الشخص وكع على رجله ممكن يصير عنده‬vertical root avulsion

2- Muscle Bulk (Normal, Atrophy, Hypertrophy)

Hypertrophy: Atrophy:
1- Pseudo → ‫يزيد الحجم بس متزيد القوة‬ 1- LMNL → de-innervation atrophy (not
2- Jeniuen → ‫يزيد الحجم و تزيد القوة‬ acutely)
2- UMNL → Disuse atrophy (advanced)
Causes:
1- Duchenne-muscular dystrophy Upper limb → best site → back of the hand
2- Backer muscular dystrophy (doughy (dorsal interossei muscle)
calf)
Lower limb → best site → Medial aspect of the
thigh

- Thenar and Hypothenar

- Dorsal hand surface
- Symmetry (tape measure to compare)
- Dorsiflexion of big toe
- Leg (lateral side) → convex muscle belly (normal) → Flat or concave (abnormal)
- Thigh → round or oval
3- Involuntary Movement
a- Tics
b- Tremors
c- Chorea ( The lesion on contralateral side)
d- Athetosis
e- Myoclonus
f- Dystonia

Tremors:
1- Resting tremor → ‫يكعد و يخلي ايده على رجله‬
2- Postural tremor → ‫( يمد ايده و يفتح اصابعه‬usually fine tremor)
3- Finger – nose test ( Intention tremor) → ‫ميحتاج يسد عينه و هاي تزيد كل ما يوصل للهدف‬
‫ → لكن اذا ظلت ثابتة على طول الحركة هاي‬postural tremor
4- Flapping tremor

Fasciculation: Involuntary hyper-synochrous contraction (flickering movement) of a group

of muscle fibers that are supplied by a single motor neuron unit.

LMNL: (a) Nuclear type (b) Infra-nuclear

Fasciculation is a sign of LMNL (usually Nuclear)

Fasciculation could be physiological in case of cold or tiredness

Best site to see it:

in upper limb → area between biceps, triceps and deltoid
in lower limb → lateral aspect of thigh
2- Tone: the resistance felt when moving a joint through its range of movement
Active → patient do it. Passive → examiner do it

1- Hypertonia

Spasticity Rigidity
1- UMNL (stroke) 1- Extrapyramidal tract lesion (except
chorea → hypotonia)
2- Large joints (shoulder, elbow) in rapid 2- Small joints (wrist) on slow movement
movement
3- Resistance felt only at the beginning 3- Resistance felt throughout range of
4- EX: Clasp knife movement
4- EX:
a- Cog-wheel in upper limb (parkinson)
b- Lead pipe in lower limb (velocity-
independent)
(cog wheel rigidity = lead pipe rigidity +
tremor)

2- Hypotonia or atonia Hypertonia could be due to psychology:

-physiological hypotonia occur during sleep Early stage → ‫شتكوله يسوي عكس‬
-hypothyroidism advance → lead pipe but(velocity dependent)
-cerebral palsy
3- Power: Resistance to active movement
‫ و حتى تعرف‬weakness ‫ و نحدد اذا اكو أي‬power ‫مفصل نحركه فد حركة – المريض حتى تفحص ال‬
‫ مالتها مثل ما مكتوب جوة‬nerve supply ‫العضلة و ال‬
Scale:

0 = no muscle contraction

1 = flicker of contraction

2= Joint moves with gravity

3 = joint moves against gravity with no

added resistance

4 = movement against resistance but

weaker than normal

5 = normal power
4- Reflexes:
Upper Limb Reflexes (3 main + 2 extra)
1- Biceps Reflex (C5 , C6) Patient lying flat, relax the patient’s arm
on his trunk, flex the elbow 90 & localize
the tendon by your thumb. Now strike
your thumb by hammer and try to
identify any muscle contraction or elbow
flexion.

2- Triceps Reflex (C7) Flex the elbow (less than 90, acute angle,),
locate the triceps tendon & strike it with
hammer (no finger needed here)

To identify triceps contraction or elbow

extension

3- Brachioradialis Reflex (C5 , C6) Flex the elbow in an obtuse angle (more
than 90), locate the brachio-radialis
Supinator muscle tendon.

2 finger bridth above the styloid process,

directly strike it (no finger use) with
hammer and see any contraction or elbow
flexion.

Jendrassik ‫ هاي الطريقةاسمها‬.‫ و نعيد الفحص‬reinforcement ‫ الزم نسوي‬areflexia ‫اذا الفحص طلع‬
: maneuver
Ask the patient to clinch his teeth and at that moment strike the tendon.
Do the hand thing (‫) أصابع تجر أصابع‬
4- Hoffmann’s sign (pathological flexion of the thumb) a- Place your right index under the distal
a- Bilateral symmetrical → could be normal interphalangeal joint of the patient middle
finger
b- Unilateral → UMNL
c- Bilateral asymmetrical → spinal cord compression b- By your right thumb, flick the patient’s
& myelopathy middle finger downward

c- Look for any reflex thumb flexion.

5- Finger jerk A- Place your middle & index fingers across

the palmar surface of the patient’s fingers
)‫ → اذا صعدت ايده (ابنورمال‬UMNL
B- Tap your own fingers with hammer

C- Look for any fingers flexion

NORMAL (+,++)

HYPER-REFLEXIA (+++)→ UMNL

HYPO-REFLEXIA (-+) → LMNL

AREFLEXIA → LMNL

Signs of UMNL Signs of LMNL

1- Spasticity or Rigidity 1- Weakness, wasting
2- Hypertonia 2- Fasciculation
3- Hyperreflexia 3- Hypotonia
4- Hoffman sign, finger jerk 4- Areflexia or hyporeflexia
5- Clonus in Lower limb
 Lower limb reflexes -Ask the patient to relax both legs completely.
-Slightly flex the knee joint of the desired leg to be
1- Knee jerk (L3 , L4)
tested.
-Locate the patellar tendon and strike it directly with
hammer
-Look for quadriceps femoris muscles contraction or
knee extension.

(avoid both legs touching each others while doing this

reflex)

- Flex the knee joint, laterally rotate the hip joint

2- Ankle jerk (S1) - support the foot by your other hand

- locate the gastrocnemius tendon then strike it

- Look for any contraction of calf muscles or foot

planter flexion.

Using a blunt object, run it vertically along the lateral

3- Planter reflex (S1 , S2) side of the foot sole toward little finger,

Normally, there will be fingers adduction / foot & big

Note : Just like upper limb, when we toe planter flexion
see areflexia, we must do the
Abnormally, there will be abduction of the toes / foot
jendrassik maneuver.
& big toe dorsiflexion (upward movement → UMNL)

Equivocal planter reflex (foot & toes do not move In any direction) indicates :
1- Severe distal weakness
2- Necrotizing myelopathy
3- Transition period from early LMNL signs to UMNL signs after stroke for example
Absent planter reflex indicates:
1- Cold
2- S1 lesion
3- Paralysis of long flexor or extensor
4- Acute stage of UMNL
4- Knee Clonus Push the patella down and keep pushing
(don’t release your hand)

Look for any upward antagonizing

movement of the patella

5- Ankle Clonus Push the foot upward (dorsiflex it) and sustain your resistance.

Look for any counter acting planter flexion

Normal finding would be 5 times or less planter flexion.

Abnormally, sustained planter flexion → > 5 times

Superficial Reflexes
1- Cremasteric reflex (L1 , L2) only male - Abduct & externally rotate the thigh
- use an object to stroke the upper medial
aspect of the thigh

Normally, ipsilateral testes will rise briskly

2- Abdominal reflex (T8 – T12) - Supine position

- Stroke each of the 4 quadrants of the abdomen from

outward toward the umbilicus

Normally, there would be contraction of the underlying

abdominal muscles + upward or downward lateral
movement of the umbilicus depending upon the
Loss if Superficial abdominal reflexes quadrant being tested
indicate corticospinal lesions
(multiple sclerosis or stroke) or
UMNL (‫)كشمولة‬
Significant difference in power (at least 2 degrees) between
proximal & distal means pyramidal extension

1- Proximal + distal or just distal → UMNL OR LMNL (Look for pyramidal

extension)

Pyramidal extension:
Examine flexion & extension if equal → LMNL
But if there is difference (larger than 1 degree) 2 & more → UMNL
This means that flexor in upper limb markedly stronger than
extensor and extensors in lower limb markedly stronger than
flexors

2- Proximal or proximal & distal (mostly proximal) → proximal

myopathy.