Managing Lower Limb Numbness In Primary Care
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Show notes:
What could be causing your patient’s lower limb numbness? There are so many questions – could it be a chronic condition? Was there an acute trauma? Did they get new shoes? And the most important question – how do you figure it out?
This week, we’ll talk about some strategies to help narrow down the cause of your patient’s symptoms, share some clinical pearls, some assessment techniques that can point you in the right direction (FAST), and more:
The most essential history questions to ask
Special questions just for lower limb numbness
A quick assessment that will rule in or rule out a variety of causes
Where to focus your physical exam for best results
Common causes of lower limb numbness, and what you definitely want on your differential
Like so many other things in the clinical setting, assessing and managing lower limb numbness does get easier with practice. Having some pointers will also help to speed that process up and boost your confidence as a provider.
Resources mentioned in this episode:
An example of a dermatome map can be found here: Up-To-Date Dermatome Map
If you liked this post, also check out:
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WEBVTT
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Hey there, welcome to the Real World NP podcast.
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I'm Liz Rohr, family nurse practitioner, educator, and founder of Real World NP, an educational
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company for nurse practitioners in primary care.
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I'm on a mission to equip and guide new nurse practitioners so that they can feel
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confident, capable, and take the best care of their patients.
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If you're looking for clinical pearls and practice tips without the fluff, you're in
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the right place.
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Make sure you subscribe and leave a review so you won't miss an episode.
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Plus, you'll find links to all the episodes with extra goodies over at realworldnp.com
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slash podcast.
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This week's episode, I'm going to be talking about lower extremity numbness.
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This is a really common chief complaint and it can be really stressful.
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There's a broad differential behind it, and it also can feel just really unnerving
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for patients.
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It's just something about it that just, it tends to, I don't know, I just anecdotally
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speaking, patients tend to feel a little bit unnerved about it.
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So in this episode, I'm going to be talking about the general approach to history, specific
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history questions not to miss for this chief complaint, physical exam, differentials,
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as well as approach to testing and referral when it comes to lower extremity numbness.
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So jumping in, whenever I approach a chief complaint, a symptom based chief complaint,
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I always use a systematic approach.
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If you've been with me for a while, you know that I use the old cart acronym to
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help guide my histories so that I am not missing anything.
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So again, on onset, location, duration, characteristics, associated factors, relieving
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factors, time and treatment.
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I always ask those questions to make sure that I'm gathering the information that I
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need.
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However, when it comes to specific chief complaints, you may have extra history
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questions not really captured with those questions.
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So I'm going to jump into those actually real quick before I do another one that
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I add on to old cart is, is it getting better, worse or the same every single
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time?
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Absolutely.
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Every single time.
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Right.
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It'll help you with so much information as well as have you had this before,
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right?
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Don't forget that question because it will give you a lot of information.
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But the specific questions for history when it comes to lower extremity.
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One really important place to start is when you're eliciting the characteristics
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of the numbness.
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So there's kind of two different kinds that I typically see or that's really
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seen in medicine.
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One is like a stripe.
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It's some sort of like stripe, like dermatomal pattern of like it's on the
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side of my left foot.
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It's on the outside of my right leg, or it's on the top of my foot on the
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right side.
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That kind of thing.
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If pro tip is if you don't already have that printed out at your workspace,
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definitely just do a quick Google and print that out because it will help
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you in that memorization process that feels at first really overwhelming.
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But then once you start doing it like a thousand million times, you're
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like, oh, okay, this is the dermatome for L5, S1, L4, et cetera.
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Right.
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And then the next option is more of that stocking pattern.
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So you probably heard of that stocking glove pattern, but basically instead of
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it being like a stripe or a side or just a toe or something like that, it's
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going to be the whole thing, like the whole foot as if they have a
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stocking on that is numb.
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Those two differentiators are really helpful when it comes to what path
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you go down for your differential diagnosis.
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And we'll talk about that in a second.
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A couple of other things you want to elicit in the history is about motor
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deficits.
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And we'll talk about that with the differentials, but you want to see, are
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they having actual motor deficits that you can assess and evaluate versus
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is it like a perceived like, oh, I actually can't move it because it's
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painful.
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Right.
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So spoiler alert, one of the top differentials is sciatica related to a
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lower back disc problem.
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So those patients can have just numbness, they can have pain or they
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can actually have motor deficits.
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And so you want to elicit on a scale from one to five, your actual
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assessment of their strength level.
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Another pearl is that when you're touching somebody's body, we always ask
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permission first and we explain what we're going to do.
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The other thing that I recommend everyone's cultural experience is so
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different, but one potential option to be polite and respectful of
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people's bodies is to use the back of our hands.
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So if we're assessing their dorsiflexion, their plantar flexion, their, um,
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their quadricep muscle, their hamstrings, we have to, we have to press on
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their body a number of times and using the back of our hand, especially
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on the thigh, um, can be very respectful for patients cause it's
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slightly more intimate to have your palm facing down.
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And again, there's different cultural interpretations that everybody has, but
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that's one potential option, um, that I typically follow with my
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patients.
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And I've said this before, if you're not sure how to approach a
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differential, you just don't have it in the front of your mind with the
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history.
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You can always ask about any other associated factors, just generally
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speaking, like ROS, review of systems, ask all the questions, right?
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But a couple of specific review of systems questions that you want to
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ask specifically with numbness are things like fatigue, other
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neurological deficits that they might have, do they have any vision
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problem, um, any like speech related problems, do they have
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numbness anywhere else on their body?
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Um, do they have, um, other systemic symptoms like a, like a rash,
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polyphasia, polyuria, polydipsia.
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We'll talk about differentials in a second.
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Um, and then again, I, I think I mentioned this already in case I
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didn't say it is the, is the numbness spreading?
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I sort of said already, is it getting better?
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Worse of the same, but specifically with numbness, we want to say, is
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this a spreading thing?
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How is it spreading?
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What does it look like?
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So actually I want to segue into the differentials before we get to the
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physical exam, cause hopefully that will cement all of the questions
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that I've presented so far for the history.
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So the top three most common causes of lower extremity numbness in the
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United States are, um, sciatica related to a disc problem in the lower back.
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Right.
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And I've already kind of said that.
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So that will help you when you're talking about the
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distribution of the numbness.
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Um, if they have motor deficits, if they have other things associated,
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I haven't, I do have a video, um, episode, I don't think I have a podcast,
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but I have a video episode about back pain I can link to down below.
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Um, but that's one of the most common causes, right?
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And so that really ties into all those history questions, right?
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The next one is diabetes related neuropathy, right?
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And that's more of that stocking pattern, less so than the
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dermatomal pattern, very common, right?
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And then you can also ask those diabetes specific questions,
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polyuria, polydipsia, polyphasia, blurred vision, et cetera.
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The third most common cause is nerve injury or damage.
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Um, there isn't necessarily one overarching thing that can, can lead
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you to that, um, pathway of differential pursuit, but, um, typically those
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patients will have some sort of, um, uh, like an injury or some sort of
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trigger that, that may be associated at the onset of it.
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I actually had a, um, someone in my life who was, uh, saying that
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they had toe numbness and I was like, Ooh, you have toe numbness.
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Do you tell?
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And we were talking about it and we did some digging and I was asking
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all these different questions and it turns out that, uh, she had a
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pair of boots that is likely the, um, the culprit that she had been
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wearing, um, hadn't continues to wear, and it may be pressing on some
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sort of like local nerve versus like a sciatica related back thing, right?
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So that's where all these history questions kind of get you, but, um,
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but yeah, let's talk about some of the other broad categories of
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I don't think it's going to be serving for you to go through the
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laundry list of all of the options.
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Um, but if you can think about those broad categories and then start to
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investigate those pieces, when you have a patient in front of you with
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these symptoms, then you can start to cement in that really broad list
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of differentials.
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So the categories that we're talking about with differential
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diagnosis, I've already talked about nervous system, right?
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So we're talking about sciatica related pain.
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We're talking about local nerve.
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Um, we could be talking about some other more rare things like
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Yon Barre, um, uh, or some sort of spinal cord injury or tumor or
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something like that, right?
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But some sort of nerve related thing, right?
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The point is not to memorize all of the little kind of subcategories
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of the actual differentials, but if you can at least have like nerves,
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like what kind of nerve related things are we talking about here?
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Right.
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The next one is, um, is, um, chronic condition related.
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This is kind of a broad category that I lumped together, but these
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are things like, um, alcohol use disorder, um, over the course of
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time can lead to some, um, deficiencies in vitamins, uh, diabetes.
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Like I said, diabetes related neuropathy, multiple sclerosis,
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thyroid dysfunction, autoimmune conditions.
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Those are the type of things that I'm talking about.
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And even if you don't feel super comfortable with rheumatoid
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arthritis or Schorgen syndrome or lupus, you're like, okay,
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is this a stocking glove?
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Is this metabolic?
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Is there something else going on or some sort of chronic
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condition related, right?
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I'm jumping ahead.
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The next one is metabolic and that's the kind of category
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that I, that I lumped together.
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So those are things like iron deficiency, anemia, B12 deficiency,
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um, heavy metal toxicity, a little bit more of a rare one.
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So last two general categories, one is infectious.
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So things like syphilis and, um, shingles potentially, right.
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Um, and then the last one is medications.
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So there's actually a pretty long list of medications that
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can cause, um, uh, numbness.
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And I can link to some of them below, but that's something
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to always think about when you're in your differential
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experience with this person in front of you is like,
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especially like what are the meds that they're taking?
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And is there any risk of numbness associated with those,
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especially with medications that you're not especially
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familiar with, um, to look at those potential side effects
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of an, of a med that you don't see all the time.
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Okay.
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Now that we've talked about some of the differentials, let's
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just recap, um, with the physical exam.
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It kind of pulls in all of those things together.
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So we want to do a full neurologic exam, including deep tendon reflexes.
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I know those are not the easiest, but it's good to practice them.
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We want to look at all the cranial nerves and we want to
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look at the patient's gate, right?
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Even if we're not neurological experts, we just, we do our best.
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We collect the information and then we go from there.
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Right.
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Um, we do want to do an assessment of the extremity itself.
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We want to do capillary refill.
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We want to look at pulses to see the circulation.
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Is there any, some sort of potential vascular related issue causing, uh, the
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numbness less common of a cause, but something to look at.
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Um, and then again, I talked about the physical exam of like using
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the back of your hand, but you want to assess the strength, um, the
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range of motion, as well as the muscle strength, especially of the lower
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extremities related, especially to lower back disc related problems.
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Okay.
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Last things are approach to diagnostics.
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So as you probably gathered so far, there are some physical things we can assess.
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There are some history questions that we can get, and then there are some
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lab and some diagnostic tools that we have to help us with that
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history taking process, right?
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So we can look at, um, the way I approach lower extremity, numbness
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and primary care is asking all those questions, doing the initial blood
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tests, and then just making a decision of like, do they need to be referred
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out, basically the majority of the time we're talking about neurology, right?
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Um, that's usually the person that you're the, the team you're going to refer out
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to, but you can start the workup with all of the potential chronic
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condition and metabolic causes that you're going to hopeful and infectious
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causes too of like, what can you potentially rule out before we get
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the assistance of neurology?
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So the labs that typically I do with lower extremity that's recommended,
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we're looking at blood sugar level, right?
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Is this diabetes related?
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Thyroid TSH, is this thyroid related?
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We want to do some preliminary potentially, right?
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Depending on your history and your symptoms, we potentially want to
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consider some rheumatologic labs, uh, perhaps an ANA, rheumatoid factor,
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um, CCP anti-CCP, which is a little bit more specific for rheumatoid arthritis.
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Again, based on your history and what you're looking at with the patient,
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not necessarily like a scatter shot for every patient, um, potentially
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looking at a Lyme or, um, RPR syphilis labs, um, definitely starting
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with a CBC iron studies and B12, right?
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Because the iron deficiency anemia B12 deficiency, those are really
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things that we can handle in primary care.
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So those are some of the labs to consider before you send
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somebody to, um, neurology.
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The next, like kind of last other thing that you may or may
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not do in primary care is, um, uh, an electromyelogram EMG and
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nerve conduction studies, NCS, EMG slash NCS.
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My personal approach, I think my impression is that this is like
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a cultural perspective of your clinic and the culture of
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your supervising provider.
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Most of my providers that I've worked with and myself included,
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I have ordered EMG NCS tests.
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The kicker is that you'd have to know how to interpret them.
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And they are not easy to interpret.
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And there's a reason why neurology neurology providers do all
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the extensive training that they do.
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And that is their bread and butter.
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So my philosophy approach to practice is I would love to know how to very
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confidently interpret EMG NCS tests.
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However, they are not easy to interpret and my physician
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colleagues do not do those either.
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They let, they let neurology do them.
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So I do not.
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So that is, that is where I would stand.
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If you are a newer grad, is that collaborate with your
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collaborator or supervising provider and think very hard before you order
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a test, just because you know to order, it doesn't mean you know how to
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interpret it and even experienced physicians that I work with do not
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order and interpret these.
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So that would be my guidance and my personal perspective, but you get to
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decide your own philosophy of practice and what the rules are in your own clinic.
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The other note about that is that those are not, those are painful tests.
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So, um, uh, they stick a needle basically, and kind of like shock your
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muscles and nerves and see what is responding.
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I've, I've seen it in a, in someone in my life has gotten that done.
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And it looks very painful.
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So I tread very lightly before I do that.
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One other test that you may see, um, is, uh, uh, an ankle brachial
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and ankle brachial index, which is assessing for blood flow, but kind
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of pearl of practice there, if somebody has two plus or more pulses
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in their lower extremities, they probably don't need that test.
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Um, that's really mainly for people who are, are not showing
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full signs of circulation in their lower extremities.
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So, yeah, so that is it.
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So, um, that is the approach to history, physical exam,
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differentials, when to refer, and the tests that you want to consider
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ordering and that triage based approach in primary care.
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So hopefully this is a helpful, uh, place to work on your knowledge
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or cement your knowledge so that you feel more comfortable
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with this chief complaint.
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Definitely check out the other episodes that I have linked below
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and the medication list that I've linked below.
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And if you haven't grabbed the ultimate resource guide for the new NP,
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head over to realworldnp.com slash guide.
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You will get all of my favorite resources.
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These episodes don't break your inbox every week with notes from me,
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patient stories and bonuses.
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I really just don't share anywhere else.
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Thank you so much for watching.
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Hang in there and I'll see you soon.
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That's our episode for today.
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Thank you so much for listening.
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Make sure you subscribe, leave a review and tell all your NP friends.
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So together we can help as many nurse practitioners as possible,
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give the best care to their patients.
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If you haven't gotten your copy of the ultimate resource guide for the new NP,
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00:16:10.590 --> 00:16:13.710
head over to realworldnp.com slash guide.
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00:16:14.130 --> 00:16:17.310
You'll get these episodes sent straight to your inbox every week
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with notes from me, patient stories and extra bonuses.
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00:16:21.030 --> 00:16:22.970
I really just don't share anywhere else.
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Thank you so much again for listening.
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Take care and talk soon.
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