How to ellicit babinski in a patient with amputation of limb
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Babinski sign amputation elicitation alternatives
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Eliciting the Babinski Sign in Patients with Limb Amputation
The Babinski sign (extensor plantar response) is a marker of upper motor neuron (corticospinal tract) dysfunction. When the foot/toes are absent due to amputation, the standard plantar stroking technique is impossible — but several well-validated alternatives exist that tap into the same underlying reflex arc.
Why Alternatives Work
The Babinski sign is not strictly a foot reflex — it is part of a flexor reflex synergy of the entire lower limb (as described by Sherrington). With UMN lesions, the receptive field from which this reflex can be elicited expands progressively to include the leg and even the thigh. This is the physiological basis for all the surrogate tests. — Adams and Victor's Principles of Neurology, 12th Ed.
Alternatives to Use in Amputation
These are the key maneuvers, organized by the level of amputation:
1. Oppenheim Sign
- Technique: Apply firm, sliding pressure with the knuckle or thumb down the medial aspect of the tibia (shin), from knee toward ankle.
- Positive response: Dorsiflexion of the great toe (or upward movement of the stump).
- Usable when: Leg is present up to at least the mid-tibia; works even with foot/forefoot amputation.
2. Gordon Sign
- Technique: Firmly squeeze the calf muscle.
- Positive response: Extensor toe response or stump movement.
- Usable when: Calf is present (below-knee amputation or any level where the calf is intact).
3. Chaddock Sign
- Technique: Stroke laterally below and around the lateral malleolus of the ankle.
- Positive response: Toe extension.
- Usable when: The ankle is intact (e.g., trans-metatarsal amputation or toe amputation only).
4. Schäffer Sign
- Technique: Squeeze the Achilles tendon.
- Positive response: Toe extension.
5. Moniz Sign
- Technique: Forceful passive plantar flexion of the ankle — a kinaesthetic (proprioceptive) stimulus rather than a cutaneous one.
- Useful concept: In advanced pyramidal dysfunction, the receptive field may extend beyond cutaneous modalities to integrate kinaesthetic stimulation, such as joint movement. — PMC3200044
6. Bing Sign
- Technique: Apply multiple pinpricks to the dorsum of the foot/stump.
- Positive response: Extensor response.
7. Straight Leg Raising (SLR) maneuver variant
- Technique: Passively lift the extended leg — the proprioceptive input can trigger the flexor reflex synergy in patients with severe UMN lesions. — Adams and Victor's Principles of Neurology
Practical Approach by Amputation Level
| Amputation Level | Preferred Alternatives |
|---|---|
| Toe/forefoot only | Chaddock, Oppenheim, Gordon, Schäffer |
| Below-knee (trans-tibial) | Oppenheim, Gordon, Schäffer, Moniz |
| Above-knee (trans-femoral) | Oppenheim (on thigh), Gordon (thigh squeezing), kinaesthetic/SLR |
| Hip disarticulation | Look for reflex stump withdrawal/flexion pattern; triple flexion of residual limb suggests UMN lesion |
Additional Point: Triple Flexion
Even without a foot, a pathological spinal flexor reflex ("triple flexion") — simultaneous flexion at the hip, knee, and dorsiflexion of the stump — carries similar significance to the Babinski sign and confirms UMN involvement. — Adams and Victor's Principles of Neurology, 12th Ed.
Summary
In amputation, the Babinski cannot be elicited in the classical way, but Oppenheim and Gordon signs are the most practical alternatives since they require only an intact calf/tibia, not the foot. In high-level amputations, observe for triple flexion of the residual limb and use kinaesthetic maneuvers. The expanding receptive field of the pyramidal flexor reflex makes all these alternatives physiologically valid.
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