1. Peter Farrell Sameer Sinha Andrew Palmisano Mark Upton
Lower Limb Case #2
Peter Farrell
Sameer Sinha
Andrew Palmisano
Mark Upton

2. Chief Compaint 28 year-old African American male
Walks in examination room with an abnormal gait in which he:
Leans his body toward the right side during the single stance interval of the right lower limb’s stance period
Shortens the stride to minimize the duration of the right lower limb’s stance period
Feels uncomfortable when he sits down

3. Physical Exam Vital Signs: Normal Musculoskeletal Examination:
Inspection, movement, and palpation of the lower back and the upper and lower limbs are normal except for the following findings:
Inspection of the lower back shows a flattening of the normal lumbar lordosis and a listing of the lumbar spine to the right.
Pain restricts active flexion of the lumbosacral spine. Extension of the lumbosacral spine is relatively painless.
The straight leg raising test exacerbates right lower limb pain; lowering the leg to the highest level at which pain is relieved and then dorsiflexing the foot reintensifies the pain.
Palpation of the lower back reveals bilateral paraspinal muscle spasm in the lumbar region.

4. Neurologic Exam
The patient reports diminished pin and cotton touch sensation on the medial aspect of the dorsum of the right foot and the contiguous areas of the big and second toes.
Extension of the big toe in the right foot has a strength of grade 1.
Pertinent normal findings include bilaterally symmetrical knee jerk and Achilles tendon reflex tests

5. Differential Diagnosis
What could be causing this patient’s symptoms?
Nerve Cyst
Cancer of the spinal cord
Sciatica
Herniated Disc

6. Paraspinal Muscle Spasms
Paraspinal Muscles are muscles which are adjacent to the vertebral column (i.e. Multifidus, Rotatores, etc.)
Spasms (contractions that can’t be controlled) of these muscles can occur when a part of the spine around the area near them has been injured
Injuries can include a problem with:
Intervertebral Discs, ligaments, or the muscles themselves

8. Straight Leg Raising Test
Test used to identify compression of the Sciatic Nerve
Most commonly due to a herniated intervertebral disc
The patient lays in the supine position while the examiner raises his/her leg while it is fully extended
The level at which pain is experienced is noted
Dorsiflexing the ankle may increase the strain on the Sciatic nerve – further increasing the pain
The area of pain can be indicative of the type of spinal cord injury
Back pain  Central Disc Protrusion
Leg pain  Lateral Disc Protrusion

9. Reflex Tests
These tests can help clinicians determine where a potential herniation has occurred
In our case two reflex tests were conducted:
1.) Knee Jerk Reflex –
What muscle(s) does this reflex involve?
Quadriceps Femoris
What is the innervation of the Quadriceps?
Femoral nerve
Spinal Cord Segments?
L2-L4

10. Achilles Tendon Reflex Test
Reflex Tests
Achilles Tendon Reflex Test
What muscles does this test involve?
Gastrocnemius
Soleus
What nerve innervates these muscles?
Tibial Nerve
This test specifically tests the S1 spinal nerve

11. Herniated Discs
Herniated discs most commonly occur at either the L4-L5 IV disc or the L5-S1 IV disc
Based on the reflex test results where do you think the herniation has occurred in our patient?
Most likely in the L4-L5 IV disc
There is no definitive reflex test for this level

12. What is a Herniated Disc?
What are the two parts of an intervertebral disc?
Annulus Fibrosis and Nucleus Pulposis
What happens when a disc is herniated?
Nucleus Pulposis protrudes out and impinges a spinal nerve
Which nerve root tends to be impinged in an IV disc?
The lower nerve root
i.e. L5 in an L4-L5 herniation

13. Symptoms

14. Symptoms
Why did our patient experience pain during active flexion of the lumbosacral spine and no pain when the back was extended?

16. Nerves of the Leg and Foot
What are the Major Nerves of the Leg and Foot?
Sciatic Nerve (L4-S3)
Tibial Nerve (L4-S3)
Common Fibular (L4,L5,S1)
Superficial Fibular
Deep Fibular

21. Dermatome Pattern of the Lower Limb

22. Extensor Hallicus Longus
Origin
Insertion
Action
Innervation

23. Abnormal Gait
L5 nerve  superior gluteal nerve  gluteus medius?

26. Treatment Many times herniated discs will heal on their own over time
To help decrease the recovery time
Bed rest is advised to reduce pain and the load on the spinal cord
Pain medication is given if needed
In severe cases surgery may be necessary