The neurological examination is relative to the pathology you are investigating. This should not be used in a cut and paste fashion but rather for reference.



Hip flexion “pull your knee to your chest” (L2/3) 5/5

Hip adduction “pull your knees into each other” (L2/3) 5/5

Hip abduction “pull your knees apart” (L4/5/S1) 5/5

Hip extension “pull your thigh back” (L4/5) 5/5

Knee extension “hold your knee straight” (L3/4) 5/5

Knee flexion “pull your heel to your bottom” (L5/S1) 5/5

Ankle dorsiflexion “pull your foot up” (L4/5) 5/5

Ankle plantarflexion “step on the gas” (S1/S2) 5/5

Great toe dorsiflexion “pull your big toe up” (L5) 5/5

Great toe plantarflexion “squeeze your big tow down” (S1,S2) 5/5

Anal tone – (S2/3/4) 5/5



Light touch (pinprick vs ice vs proprioception vs vibration if evidence of pathology found)

L1 – inguinal ligament

L2 – medial thigh

L3 – distal thigh

L4 – medial leg and dorsal foot

L5 – 1st web space, lateral foot

S1 – plantar foot

S2 – popliteal fossa, posterior thigh

S3/4/5 – perianal area




Patellar – L3/4

Medial hamstring reflex L5

Ankle – S1


A 2 year old presents with leg pain and a limp after slipping on a “slip and slide” water toy slide. X-rays are negative. The child will step when asked but will not walk on his own. Is this an occult fracture?

This is a situation where the reference standard, radiography, has limitations in sensitivity. Studies show that using alternative tests reveal evidence of fracture, such as hematoma elevation on ultrasound (Lewis J Clin Ultrasound 2006) or MRI or delayed radiographs.

You go back and examine the leg, placing “bowing” stress on the leg. Sometimes it elicits pain and sometimes it does not. You press on different parts of the leg and it is difficult to localize but there does seem to be the most pain on the distal tibia.

You then twist the leg and foot spirally and the child shouts in pain. You make a clinical diagnosis of Toddler’s fracture. On follow-up, the mother reports that the child reverted to crawling for about 4 weeks before gingerly walking and then returning to normal use of the leg in about 6 weeks. Repeat xrays in the primary physician’s office remained negative. This was an occult tibial fracture.

Take Home Points

Negative x-rays do not rule out fracture

Twisting a long-bone can elicit pain from an occult fracture, especially one in a spiral pattern