1. NEUROLOGICAL EXAMINATION MOTOR & SENSORY FUNCTION
AN ANATOMICAL GUIDE
Kaan Yücel M.D., Ph.D.
22.March.2012 Thursday

2. Basic Components of the Neurologic Examination
History
Cerebral function (mental status)
Cranial nerve function
Motor function
Sensory function
Cerebellar function
Reflex function
Gait and stance
Neurologic Exam
Susan R. Winkler, Pharm.D. BCPS Spring 1998

3. TESTING THE MUSCLES

4. SHOULDER Deltoid Shoulder abduction Axillary nerve
The arm is abducted, starting from approximately 15°, against resistance. If acting normally, the deltoid can easily be seen and palpated.

5. SHOULDER Supraspinatus Infraspinatus Initiates abduction of the arm
Suprascapular nerve
Supraspinatus
Abduction of the arm from
fully adducted position against resistance.
Palpated superior to scapular spine.
Supraspinatus & middle deltoid tested together.
Infraspinatus
Laterally rotates the humerus
Suprascapular nerve
The person flexes the elbow and adducts the arm. The arm then laterally rotated against resistance.
Infraspinatus & teres minor tested together.
Palpated inferior to scapular spine.

6. SHOULDER Degenerative tendonitis of the rotator cuff
The person is asked to lower the fully abducted limb slowly and smoothly.
From approximately 90° abduction, the limb will suddenly drop to the side in an uncontrolled manner if the rotator cuff (especially supraspinatus part) is diseased and/or torn

7. ANTERIOR ARM Biceps brachii Forearm flexor & supinator
Musculocutaneous nerve
Biceps brachii
Elbow joint is flexed against resistance when the forearm is supinated. If acting normally, the muscle forms a prominent bulge on the anterior aspect of the arm that is easily palpated.

8. ANTERIOR ARM Brachialis Main flexor of the forearm
Musculocutaneous nerve
Brachialis
Forearm is semipronated and flexed against resistance.
If acting normally, the contracted muscle can be seen and palpated.

9. POSTERIOR ARM Triceps brachii Forearm extension Radial nerve
The arm is abducted 90° and then the flexed forearm is extended against resistance provided by the examiner.
If acting normally, the triceps can be seen and palpated.

10. Flexor & adductor of the wrist Flexor & abductor of the wrist
ANTERIOR FOREARM
Flexor & adductor of the wrist
Ulnar nerve
Flexor carpi ulnaris
The person puts the posterior aspect of the forearm and hand on a flat table and is then asked to flex the wrist against resistance while the examiner palpates the muscle and its tendon.
Flexor & abductor of the wrist
Radial nerve
Flexor carpi radialis
The person is asked to flex the wrist against resistance. If acting normally, its tendon can be easily seen and palpated.

11. ANTERIOR FOREARM Palmaris longus
Accessory flexor of the wrist, opposes shearing forces on the skin of the palm during gripping
Median nerve
Palmaris longus
The wrist is flexed and the pads of the little finger and thumb are tightly pinched together.
If present and acting normally, the tendon can be easily seen and palpated.

12. ANTERIOR FOREARM Pronator teres
Rotates radius over ulna during pronation
Median nerve
Pronator teres
The person's forearm is flexed at the elbow and pronated from the supine position against resistance provided by the examiner.
If acting normally, the muscle is prominent and can be palpated at the medial margin of the cubital fossa.

13. Flexor digitorum superficialis
ANTERIOR FOREARM
Flexes the metacarpophalangeal joint and proximal interphalangeal joint of each finger; also flexes the wrist joint.
Median nerve
Flexor digitorum superficialis
One finger is flexed at the proximal interphalangeal joint against resistance and the other three fingers are held in an extended position to inactivate the flexor digitorum profundus.

14. Flexor digitorum profundus
ANTERIOR FOREARM
Flexes the distal phalanges of the medial four fingers
Lateral half median nerve
Medial half ulnar nerve
Flexor digitorum profundus
The proximal interphalangeal joint is held in the extended position while the person attempts to flex the distal interphalangeal joint.
The integrity of the median nerve in the proximal forearm can be tested by performing this test using the index finger, and that of the ulnar nerve can be assessed by using the little finger.

15. Flexor pollicis longus
ANTERIOR FOREARM
Flexes the thumb
Median nerve
Flexor pollicis longus
The proximal phalanx of the thumb is held and the distal phalanx is flexed against resistance.

16. POSTERIOR FOREARM & HAND
Relatively weak flexion of forearm; maximal when forearm is in midpronated position
Radial nerve
Brachioradialis
Elbow joint is flexed against resistance with the forearm in the midprone position.
If the brachioradialis is acting normally, the muscle can be seen and palpated.

17. POSTERIOR FOREARM & HAND
Extend & abduct wrist
Radial nerve
Extensor carpi radialis longus
Wrist is extended & abducted with forearm pronated.
Its tendon can be palpated proximal to the wrist.

18. POSTERIOR FOREARM & HAND
Extends medial four digits metacarpophalangeal joints, interphalangeal joints
Deep branch of radial nerve
Extensor digitorum
Forearm is pronated and the fingers are extended.
The person attempts to keep the digits metacarpophalangeal joints as the examiner exerts pressure on the proximal phalanges by attempting to flex them.
Tendons on the dorsum of the hand

19. POSTERIOR FOREARM & HAND
Extends and adducts wrist
Deep branch of radial nerve
Extensor carpi ulnaris
Forearm pronated & fingers are extended
Extended wrist is then adducted against resistance.
Muscle seen and palpated
proximal part of the forearm & tendon felt proximal to ulnar head

20. POSTERIOR FOREARM & HAND
Extends 5th digit joint, interphalangeal joint
Deep branch of radial nerve
Extensor digiti minimi
Little finger is extended against resistance
while holding digits 2-4 metacarpophalangeal joints

21. POSTERIOR FOREARM & HAND
Abducts thumb and extends carpometacarpal joint
Posterior interosseous nerve
Abductor pollicis longus
Thumb is abducted against resistance at the metacarpophalangeal joint.
Tendon seen and palpated at the lateral side of the anatomical snuff box and on the lateral side of the adjacent extensor pollicis brevis tendon.

22. POSTERIOR FOREARM & HAND
Extends proximal phalanx of metacarpophalangeal joint; extends carpometacarpal joint
Posterior interosseous nerve
Extensor pollicis brevis
Thumb is extended against resistance at the metacarpophalangeal joint.
lateral side of the anatomical snuff box and on the medial side of the adjacent abductor pollicis longus tendon

23. POSTERIOR FOREARM & HAND
Extends distal phalanx of interphalangeal joint; extends metacarpophalangeal & carpometacarpal joints
Posterior interosseous nerve
Extensor pollicis longus
Thumb is extended against resistance at the interphalangeal joint.
Tendon on the medial side of the anatomical snuff box

24. POSTERIOR FOREARM & HAND
Abducts the thumb, metacarpophalangeal joint
Median nerve
Abductor pollicis brevis
Abduct the thumb against resistance
Flexes metacarpophalangeal joint of the thumb
Median nerve
Flexor pollicis brevis
Flex the thumb against resistance

25. POSTERIOR FOREARM & HAND
Participate in flexing metacarpophalangeal joints & extending the interphalangeal joints
Medial 2 ulnar nerve
Lateral 2 median nerve
Lumbricals
With the palm facing superiorly patient is asked to flex the metacarpophalangeal (MP) joints while keeping the interphalangeal joints extended.
The examiner uses one finger to apply resistance along the palmar surface of the proximal phalanx of digits 2-5 individually.

26. POSTERIOR FOREARM & HAND
Major abductors of the index, middle, and ring metacarpophalangeal joints
Ulnar nerve
Dorsal interossei
Examiner holds adjacent extended and adducted fingers between thumb and middle finger,
Providing resistance as the individual attempts to abduct the fingers
(the person is asked to “spread the fingers apart”).

27. POSTERIOR FOREARM & HAND
Addduct thumb, index, ring, and little metacarpophalangeal joints
Ulnar nerve
Palmar interossei
A sheet of paper is placed between adjacent fingers.
The individual is asked to “keep the fingers together” to prevent the paper from being pulled away by the examiner.

28. SUPERFICIAL MUSCLES OF BACK
Superior fibers elevate scapula
Middle fibers retract scapula
Inferior fibers depress scapula and lower the shoulder.
The superior and inferior fibers work together to rotate the lateral aspect of the scapula upward, which needs to occur when raising the upper limb above the head.
Spìnal accessory nerve (CN XI)
Trapezius
The shoulder is shrugged against resistance (the person attempts to raise the shoulders as the examiner presses down on them).
If the muscle is acting normally, the superior border of the muscle can be easily seen and palpated.

29. SUPERFICIAL MUSCLES OF BACK
Adductor of the humerus
Extension, adduction, and medial rotation of the upper limb.
Depresses the shoulder, preventing its upward movement.
Thoracodorsal nerve
Latissimus dorsi
The arm is abducted 90° and then adducted against resistance provided by the examiner.
If the muscle is normal, the anterior border of the muscle can be seen and easily palpated in the posterior axillary fold.

30. SUPERFICIAL MUSCLES OF BACK
Retract and rotate the scapula, depressing its glenoid cavity. Assist the serratus anterior in holding the scapula against the thoracic wall.
Dorsal scapular nerve
Rhomboids
The arm is abducted 90° and then adducted against resistance provided by the examiner.
If the muscle is normal, the anterior border of the muscle can be seen and easily palpated in the posterior axillary fold.

31. PECTORAL REGION Pectoralis major
Adduction and medial rotation of the arm
Clavicular head flexes humerus
Sternocostal head extends it back
Lateral and medial pectoral nerves
clavicular head (C5, C6), sternocostal head (C7, C8, T1)
Pectoralis major
Clavicular head
The arm is abducted 90°; the individual then moves the arm anteriorly against resistance.
If acting normally, the clavicular head can be seen and palpated.
Sternocostal head
The arm is abducted 60° and then adducted against resistance. If acting normally, the sternocostal head can be seen and palpated.

32. PECTORAL REGION Serratus anterior
Protracts scapula and holds it against thoracic wall; rotates scapula
Long thoracic nerve
Serratus anterior
The hand of the outstretched limb is pushed against a wall.
If the muscle is acting normally, several digitations of the muscle can be seen and palpated.

33. THIGH & POPLITEAL FOSSA
Great extensor of the leg
Femoral nerve
Quadriceps femoris
Performed with the person in the supine position with the knee partly flexed.
Person extends knee against resistance.

34. THIGH & POPLITEAL FOSSA
hip joint
knee joint
Tibial nerve
Hamstring muscles
Person flexes his leg against resistance.
Normally, these muscles—especially their tendons on each side of the popliteal fossa—should be prominent as they bend the knee.

35. LEG Tibialis anterior Dorsiflexes ankle & inverts foot
Deep fibular nerve
Tibialis anterior
The person is asked to stand on the heels or dorsiflex the foot against resistance.
If normal, its tendon can be seen and palpated.

36. Extensor hallucis longus
LEG
Extends great toe & dorsiflexes ankle
Deep fibular nerve
Extensor hallucis longus
Great toe dorsiflexed against resistance.
If acting normally, its entire tendon can be seen and palpated.
Extensor digitorum longus
Extends the toes & dorsiflexes foot at the ankle joint
Deep fibular nerve
Lateral four toes dorsiflexed against resistance.
If acting normally, the tendons can be seen and palpated.

37. Fibularis longus and brevis
LEG
Everts foot and weakly plantarflexes ankle
Superficial fibular nerve
Fibularis longus and brevis
The foot is everted strongly against resistance.
If acting normally, the muscle tendons can be seen and palpated inferior to the lateral malleolus.
Initial Position Patient plantar flexes and everts foot
Final Position Examiner forces the foot into inversion

38. LEG
Plantarflexes ankle; raises heel during walking; flexes leg at knee joint (soleus; steadies leg on foot)
Tibial nerve
Triceps surae
The foot is plantarflexed against resistance (e.g., by “standing on the toes,” in which case body weight [gravity] provides resistance).
If normal, the calcaneal tendon and triceps surae can be seen and palpated.

39. Flexor hallucis longus
LEG
Flexes great toe at all joints; weakly plantarflexes ankle; supports medial longitudinal arch
Tibial nerve
Flexor hallucis longus
The distal phalanx of the great toe is flexed against resistance.
If normal, the tendon can be seen and palpated on the plantar aspect of the great toe as it crosses the joints of the toe.

40. Flexor digitorum longus
LEG
Flexes lateral four digits; plantarflexes ankle; supports longitudinal arches of foot
Tibial nerve
Flexor digitorum longus
The distal phalanges of the lateral four toes are flexed against resistance.
If they are acting normally, the tendons of the toes can be seen and palpated.

41. LEG Tibialis posterior Plantarflexes ankle; inverts foot Tibial nerve
The foot is inverted against resistance with foot in slight plantarflexion.
If normal, the tendon can be seen and palpated posterior to the medial malleolus .

42. regIONS
&
SENSORy INNERVATION

43. Inferior lateral cutaneous nerve of arm
Lateral & anterior aspects of the lower part of the arm
Medial cutaneous nerve of forearm
Medial surface of the forearm down to the wrist
Posterior cutaneous nerve of forearm
Posterior aspect of the arm and forearm
Medial cutaneous nerve of arm
Medial side of the distal third of the arm
Lateral cutaneous nerve of forearm
Lateral half of the anterior aspect forearm
supraclavicular nerves (medial,intermediate,lateral) the skin as far as the middle line, the skin over the pectoralis major and deltoideus, the skin of the upper and posterior parts of the shoulder,
inferior part of the deltoid muscle

44. Superficial branch of the radial nerve Dorsolateral aspect of the palm
Dorsal aspects of the lateral 3 ½ digits
distally to approximately the terminal interphalangeal joints  
Ulnar nerve
Medial side of the palm
Medial half of the dorsum of the hand
5th finger & medial half of the 4th finger
Anterior surfaces of the medial 1 ½ digits
Median nerve
Thumb,index,middle fingers
Lateral side of the ring [distal parts on the dorsum of the hand]
Palmar surface of the lateral 3 ½ digits
Lateral side of the palm & middle of the wrist

45. Upper lateral quadrant
Superior clunial nerves
L1-L3 posterior rami
Skin overlying superior and central parts of buttock
Medial clunial nerves
S1-S3 posterior rami
Skin of medial buttock and intergluteal cleft
Inferior clunial nerves
Posterior cutaneous nerve of thigh (S2-S3)
Skin of inferior buttock (overlying gluteal fold
Upper lateral quadrant
lateral branches of the iliohypogastric (L1) and 12th thoracic nerves (anterior rami)

46. Obturator nerve
Superior medial thigh
Genitofemoral nerve
Middle anterior thigh
Posterior cutaneous nerve of the thigh
Posterior aspect of the thigh
Intermediate cutaneous nerve of the thigh (femoral nerve)
Variable area on the medial aspect of the thigh
Medial cutaneous nerve of the thigh
(femoral nerve)
Medial aspect of the thigh

47. Saphenous nerve (femoral nerve)
Medial aspect of leg
Posterior cutaneous nerve of the thigh
Upper part of the leg
Superficial fibular nerve Anterolateral leg
Sural nerve Posterolateral leg

48. Medially saphenous nerve, which extends distally to the head of 1st metatarsal
Superiorly (dorsum of foot) superficial (primarily) and deep fibular nerves
Inferiorly (sole of foot) medial and lateral plantar nerves; Common border of their distribution along the 4th metacarpal toe or digit
Laterally sural nerve, including part of the heel.
Posteriorly (heel) medial and lateral calcaneal branches of the tibial and sural nerves, respectively

49. DERMATOMES

50. The dermatomes for the upper cervical segments C3 to 6 are located along the lateral margin of the upper limb
C7 dermatome is situated on the middle finger
C8, T1, and T2 along the medial margin of the limb

51. reflexes

52. Biceps brachii tendon reflex C5 & 6
flexion of the elbow joint by tapping the biceps tendon
Triceps tendon reflex C6, 7, and 8
extension of the elbow joint by tapping the triceps tendon
Brachioradialis tendon reflex: C5, 6, and 7 supination of the radioulnar joints by tapping the insertion of the brachioradialis tendon
Patellar Reflex L3 & 4
A tap with a tendon hammer on the patellar ligament
Calcaneal Tendon Reflex S1 & 2
Person's legs are dangling over the side of the examining table. The calcaneal tendon is struck briskly with a reflex hammer just proximal to the calcaneus. The normal result is plantarflexion of the ankle joint.

54. NEUROLOGICAL EXAM Online resources
NeuroLogic Examination Videos and Descriptions...an Anatomical Approach
The Precise Neurological Exam
Neuroexam
Neurologic Examination
The Neurological Examination
What is a Neurological Exam?
Neurologic Exam