A10. Examination of the pyramidal signs

• Babinski sign
  • Most important pyramidal sign
  • Procedure:
    • Ask patient to lie on their back
    • Scratch the lateral half of the sole of the foot from bottom to top
    • Response is usually not seen at the beginning of the movement but rather after some centimetres
  • Negative:
    • Plantarflexion, flexion of all toes
  • Positive:
    • Dorsiflexion of the big toe
    • The other toes spread out
• Triple flexion response/triflexion response
  • Same procedure as for Babinski sign
  • Can be felt more easily with one hand on the quadriceps muscle
  • Negative:
    • Plantarflexion of all toes
  • Positive:
    • Dorsiflexion of foot + flexion of knee + flexion of hip
• Achilles clonus
  • Procedure:
    • Ask patient to lie on their back
    • Dorsiflex the foot quickly
  • Negative:
    • No clonus in the gastrocnemius
  • Positive:
    • Clonus in the gastrocnemius
• Patellar clonus
  • Procedure:
    • Ask patient to lie on their back
    • Quickly thrust the patella downwards
  • Negative:
    • No clonus in the quadriceps
  • Positive:
    • Clonus in the quadriceps
• Hoffman sign
  • Procedure:
    • Hold the PIP joint of the middle finger, stabilizing it
    • Repeatedly flick down the distal phalanx of the middle finger
  • Negative:
    • No flexion of the distal phalanx of the thumb or the index finger
    • Bilateral response may be normal
  • Positive
    • Flexion of the distal phalanx of the thumb or the index finger
• Trömner sign
  • Procedure:
    • Hold the PIP joint of the middle finger, stabilizing it
    • Suddenly flick the volar aspect of the distal phalanx of the middle finger
  • Negative:
    • No flexion of the distal phalanx of the thumb or the index finger
    • Bilateral response may be normal
  • Positive
    • Flexion of the distal phalanx of the thumb or the index finger