Dr Subhransu M Jr1 ID: 1039511
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1. Lower Deep Tendon Reflex Dr. Subhransu M. Jr1
2. A reflex is an involuntary response to a sensory stimulus.When a normal muscle is passively stretched, its fibers resist by contracting.Reflexes elicited by application of stretch stimulus to either tendons or periosteum or occasionally to bones , joints and fascia or aponeurotic structures are usually referred to as a muscle stretch or deep tendon reflexes.
3. Interpretation of DTRThe activity of a DTR is judged by the threshold,latencySpeedVigor Duration of contractionRange of movementSpread or irradiation of the reflex.
4. GradingReflexes may be graded as :0 – absent1+ – present but diminished2+ – normal3+ – increased but not necessarily to a pathological degree4+ – markedly hyperactive , pathologic, accompanying extra beats or clonus
5. Lower Extremities DTRThe Patellar Reflex (Quadriceps Reflex, Knee Jerk)The Achilles Reflex (Ankle Jerk, Triceps Surae Reflex)The Adductor Reflex The Internal Hamstring (Posterior Tibiofemoral) ReflexThe External Hamstring (Posterior Peroneofemoral) Reflex
6. The Tensor Fascia Lata ReflexThe Gluteal ReflexesThe Extensor Hallucis Longus ReflexThe Tibialis Posterior Reflex The Peroneal (Tibialis Anterior) ReflexThe Plantar Muscle Reflexes
7. The Patellar Reflex (Quadriceps Reflex, Knee Jerk)Mediated by the femoral nerve (L2-L4).A firm tap on the tendon draws the patella downStretching the quadriceps and provoking reflex contractionPalpation helps in judging the latency between the time of the stimulus and the resulting response.
8. Sitting in a chair with the knees slightly extended and the heels resting on the floor
9. Partially flex the knee by placing one handbeneath it and then tap the tendon
10. Patient sit with one leg crossed over the other and tapping the patellar tendon of the uppermost leg
11. If the reflex is exaggerated, the responsemay be obtained by tapping the tendon also just above the patella (suprapatellar or epipatellar reflex)
12. Marked exaggeration of the patellar reflex may be accompanied by patellar clonus Absence of the patellar reflex is known as Westphal’s sign. Inverted patellar reflexlesions of the femoral nerve or nerve roots (L2 – L4) supplying the quadricepsresults in contraction of the hamstrings and flexion of the knee.
13. Pendular patellar reflexIn diseases of the cerebellum, Eliciting the patellar reflex while the foot is hanging free may elicit a series of to-and-fro pendular movements of the foot and leg Hypotonia of the extensor and flexor muscles and a lack of the restraining influence on each otherMay also be observed in chorea
14. The Achilles Reflex (Ankle Jerk, Triceps Surae Reflex)Mediated by the tibial nerve (S1/S2).Striking the Achilles tendon just above its insertion on the calcaneus. Causing contraction of the posterior crural muscles, the gastrocnemius, soleus, and plantaris, Resulting in plantar flexion of the foot at the ankle
15. The thigh should be held in moderate abduction and external rotation keeping the knee flexedplace one hand under the foot and pull upward slightly to passively dorsiflex
16. Frog leg position
17. Babinski method - patient kneel on a chair with the feet projecting at right angles
18. Paradoxical ankle reflex - If the ankle jerk is hyperactive, it may be elicited by tapping other areas of the sole of the foot, themedioplantar reflex, or by tapping the anterior aspectof the ankleWhen there is reflex spread, striking the Achilles tendon may cause flexion of the knee. Tends to diminish with age
19. Woltman’s sign – A prolonged relaxation phase causing a “hung-up” reflex classical finding of HypothyroidismBut most patients with seemingly hung-up ankle jerks are euthyroidThe reflexes return to normal with treatment
20. The Adductor ReflexMediated by the Obturator Nerve (L2-L4)Thigh in slight abductiontapping over either the medial epicondyle of the femur or tibia results in contraction of the adductor muscles of the thigh Causing inward movement of the extremity.Hannington-Kiff signAbsent adductor reflex with a normal patellar reflex sign of strangulated obturator hernia .
21. Striking the medial epicondyle of the femur
22. The Internal Hamstring ReflexMediated by tibial portion of the sciatic nerve (L5)Patient seated or recumbent, with the leg abducted and slightly rotated externally and the knee flexed.The examiner’s fingers are placed over the tendons on the medial posterior aspect of the knee Firm tap on finger causes knee flexion with internal rotation.Only DTR useful in suspecting L5 radiculopathy
23. Striking the semimembranous or semitendinous tendons
24. The External Hamstring ( Biceps Femoris or Posterior Peroneofemoral) ReflexMediated by tibial portion of sciatic nerve (S1)Patient sitting, recumbent, or lying on the opposite sidethe knee moderately flexed, the examiner’s fingers are placed over the tendon on the lateral posterior aspect of the knee or head of fibula and tappedThe response is knee flexion.
25. Striking the biceps femoris tendon
26. This reflex helps to determine if an absence of ankle jerk is due to peripheral neuropathy (preserved external hamstring reflex)or due to radiculopathy (absent lateral hamstring reflex).
27. The Tensor Fascia Lata ReflexMediated by Superior Gluteal Nerve, L4-S1In a recumbent patient, tap the origin on the TFL near the anterior superior iliac spineObserve for slight abduction of the thigh
28. The Gluteal ReflexesMediated by the inferior gluteal nerve (L5-S2)In a recumbent patient, position the patient by shifting the weight to the opposite side with moderate flexion of the ipsilateral thigh. Alternatively, the patient can be in a prone positionTap the lower portion of the sacrum or the posterior aspect of the ilium near the insertion of the gluteus maximusObserve for a contraction of the gluteus maximus and extension of the thigh
29. Tibialis Posterior ReflexMediated by tibial nerve (L5-S1)Tapping the tendon of the tibialis posterior just above and behind the medial malleolus is followed by inversion of the footMay be absent in L5 or S1 radiculopathy
30. The Peroneal (Tibialis Anterior) ReflexMediated by deep and superficial peroneal nerves (L4-S1)Patient’s foot in a plantarflexed and inverted positionExaminer’s fingers placed firmly on the distal first and second metatarsal bones, fingers are tappedResults in eversion and dorsiflexion of the foot
31. Thank You