Trick of the trade: Improve your ability to detect a cerebellar lesion

The finger-to-nose exam is typically used to detect a cerebellar lesion. In subtle cases though, this can be be difficult to detect.

How can you improve your sensitivity of this exam?

Trick of the trade: Elbows up!

I used to do the exam with the patient’s elbow down at his/her side. An abnormal finger-to-nose test can be masked because you are mainly testing only biceps and triceps strength. Also the arm motion momentum can easily compensate for a subtle deficit. Instead have the patient raise the elbows (a chicken-wing position) for the exam. It is a little more difficult to compensate now. I recently picked up a subtle cerebellar stroke with this maneuver.

Also, it is important to have the patient fully extend his/her arm so that it is stretching to reach your finger. A subtle deficit becomes more obvious.

Thanks to Dr. Farzan for demonstrating!

Author information

Michelle Lin, MD

ALiEM Founder and CEO
Professor and Digital Innovation Lab Director
Department of Emergency Medicine
University of California, San Francisco

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