Alshafi Medicare

Lower Extremity Weakness

The following interactive cases are designed for you to read and answer the questions in preparation for your coursework in neurology, as well as for your licensure preparation. Please proceed through each of the cases and determine the answers to the questions.

Slide 13: Case 1: Jane Has Lower Extremity Weakness

A 68-year-old female was admitted to the hospital due to an acute chest pain. She underwent cardiac catheterization and angioplasty through the right femoral artery.

She was referred to physical therapy one month later for evaluation of her right lower extremity weakness and numbness in her thigh. She described her pain as moderate in her groin and anterior thigh.

Slide 14: Case 1: Jane’s History

Her Medical History:

• One month ago, the patient underwent femoral catheterization and angioplasty with resulting lower extremity weakness, sensory changes, and groin pain.

• On the third day after her admission, a neurologic examination and a CT scan of her pelvis identified a right retroperitoneal hematoma involving the iliacus muscle extending to the iliac crest with surgical evacuation.

Social History:

• She is employed as an administrative assistant.

• She is divorced; has one daughter and two grandchildren.

• She enjoys entertaining and spending time with her grandchildren.

Medication:

• Her medications include Lovenox, Lipitor, and Metoprolol.

Family History:

• Her family history includes hypertension, cardiac disease, and diabetes.

Please stop and review the following:

1. What are the key findings from the history?

2. What is the anatomy and innervation of the iliacus?

3. Look up the medications involved and what they do in the body.

4. Describe why social history is important to the physical therapist.

Slide 15: Case 1: Jane’s Neurologist Report

Jane’s neurologic examination during her acute stay revealed complete paralysis of the right quadriceps and iliopsoas. Thigh adductors and ankle dorsiflexion were normal. The right knee jerk was absent. There was loss of touch and pain sensation over the anterior thigh and medial leg.

Please review the following before proceeding:

1. What nerves innervate the quadriceps and iliopsoas?

2. What nerves innervate the thigh adductors and ankle dorsiflexors?

3. What spinal cord level is responsible for the knee jerk?

4. What spinal cord levels provide sensation to the anterior thigh and medial leg?

Slide 16: Case 1: Jane’s PT Examination

Jane presents for her physical therapy examination with the following findings:

Vital Signs:

• Her blood pressure was 140/90.

• Heart rate, 80 beats per minute.

• Her skin was dry and had scales bilaterally on the lower extremities.

• Her endurance, she demonstrated shortness of breath with activity.

• Passive range of motion was within normal limits.

• Her mental status, she was alert and oriented and provided good history.

• Her cranial nerves were intact.

• Her tone was normal.

• Strength in the bilateral upper extremities was within normal limits.

• The right lower extremity, quadriceps, and iliopsoas were 3-/5.

• Right adductors and dorsiflexors were 5/5.

• Her reflexes, she was hyperreflexive at the right knee jerk.

• Coordination of the right lower extremity was impaired.

Slide 17: Case 1: Examination, Continued

Further physical therapy examination found:

1. Balance, sitting statically and dynamically within normal limits.

2. Good standing static balance and fair standing dynamic balance.

3. Jane ambulates with some loss of balance noted with self-recovery at community level distances on even surfaces.

4. Sensation was diminished, touch and pain, over the anterior thigh and medial leg.

Slide 18: Case 1: Jane's Goals

Jane’s goals were to return to independent ambulation on all surfaces and return to recreational activities including taking care of her grandchildren.

Slide 19: Case 1: Questions

Please answer the following question.

Which of the following nerves are responsible for this patient’s weakness in the quadriceps musculature?

A. Sciatic

B. Obturator

C. Femoral

D. Tibial

Slide 20: Case 1: Questions

Which of the following key signs in the right lower extremity indicate femoral neuropathy versus L4 radiculopathy?

A. Sparing of the right foot dorsiflexion

B. Sparing of right thigh adduction

C. Sparing of right foot plantar flexion

D. Sparing of right knee flexion

Slide 21: Case 1: Questions

Which nerve is responsible for the following pattern of weakness and sensory impairment?

1. 0/5 left tibialis anterior and extensor hallucis longus, 3/5 left foot evertors

2. Decreased pinprick sensation on the dorsum of the right foot especially pronounced in the web space between the second toes

When looking at this pattern of weakness and sensory impairment, is it:

A. Common peroneal nerve

B. Obturator nerve

C. Femoral nerve

D. Tibial nerve

Slide 22: Case 1: Questions

Which nerve is responsible for the following pattern of weakness and sensory impairment?

1. Diminished tone and S1 DTR, the right foot

2. 0/5 right tibialis anterior and extensor hallucis longus, right foot evertors, invertors and gastrocnemius, 3/5 power right hamstrings

3. Decreased light touch, pinprick, vibration, and joint proprioception in the right lateral calf and entire foot

Is it:

A. Tibial nerve

B. Obturator nerve

C. Femoral nerve

D. Sciatic nerve

Slide 23: Case 2: Sally Has Numbness and Pain with Pregnancy

Slide 24: Case 2: Sally’s Case Presentation

Sally is a 25-year-old female, who, one day after giving birth, developed a burning pain and numbness in her left lateral thigh, which increased when ambulating.

She was referred to physical therapy for evaluation of her left lower extremity pain and numbness in her thigh.

Slide 25: Case 2: Sally’s History

Sally’s medical history includes that she is a healthy 25-year-old female, who, one day after giving birth, developed a burning pain and numbness in her left lateral thigh, which increased when ambulating.

Her social history includes the fact that she’s married, and she plans to stay at home and care for her newborn.

The only medication she is currently taking is ibuprofen, and she has a family history of diabetes.

Please stop and review the following:

1. What are the key findings from the history?

2. Please look up the medications involved and what they do in the body.

3. What types of activities do you think will be required to care for a newborn?

Slide 26: Case 2: Sally’s PT Examination

Sally’s physical therapy examination findings are as follows:

Her vitals:

• Blood pressure 115/75.

• Heart rate, 65 beats per minute.

• Her skin was unremarkable.

• No endurance or fatigue was noted during the evaluation.

• Range of motion was within normal limits.

• She is alert and oriented with intact cranial nerves, normal muscle tone.

• Her strength, reflexes, and coordination were all within normal limits.

Slide 27: Case 2: Examination, Continued

Additional examination findings include normal balance, gait, but diminished sensation to light touch and pinprick, and cold on the right lateral thigh. Pain was initially described as burning, rated 3/10 at rest and 6/10 with ambulation.

Slide 28: Case 2: Patient Goals

Sally’s physical therapy goal is to have her leg feel normal and have no pain in her right thigh in order to care for her child.

Slide 29: Case 2: Questions

Please answer the following question:

Which of the following nerve roots should be considered in the differential diagnosis as a source of the patient’s key signs and symptoms?

A. L1 myotome

B. L2 myotome

C. L3 myotome

D. L4 myotome

E. Both B and C myotomes

Slide 30: References

• Kandel ER, Schwartz JH, Jessell TM. Principles of Neural Science. 4th ed. New York: McGraw-Hill; 2000.

• Schuenke M, Schulte E, Shumaker U. Thieme Atlas of Anatomy. New York, NY: Thieme; 2006: 470-471.

• Seigal A, Sapru HN. Essential Neuroscience. New York: Lippincott Williams & Wilkins; 2006.

• Blumenfeld, H. Neuroanatomy through Clinical Cases. Sunderland, MA: Sinauer Associates; 2002.

• Goodman C, Fuller K, et al. Pathology Implications for the Physical Therapist. 3rd ed. St. Louis, MO: Saunders; 2008.

• Hoppenfeld S. Physical Examination of the Spine and Extremities. New Jersey: Prentice-Hall; 197