special tests for the neck exam

Special Tests for the Neck Examination in Sports Medicine

The physical examination of the neck should include a standardized exam approach as well as a series of special tests to help diagnose the cause of the patient’s neck pain. In general, a thorough physical examination will include inspection, palpation, active and passive range of motion, strength, neurovascular and special tests. The purpose of today’s post is to review some of the special tests for the neck exam that all members of the sports medicine team should be familiar with. We will review some of the more commonly used exam techniques but it is worth mentioning there are dozens of others that are not covered here. It is also worth noting that some of these examination techniques may overlap with more than one disease process.

Lhermitte’s Sign and Test

Lhermitte’s sign is when a patient describes an electric shock that occurs with flexion of the neck. The sensation radiates down the spine into the legs, arms and/or trunk depending on where the lesion is. Lhermitte’s test is when the patient is seated, the examiner passively flexes the patient’s neck. The examiner then passively flexes one hip with the knee in extension. A positive test is sharp pain down the spine or a limb. This test is non specific.

Shoulder Abduction Relief Test

The shoulder abduction relief test, sometimes called Bakody’s sign, is used to evaluate for cervical radiculopathy. The patient can be seated or standing. The affected limb has to be passively or actively raised above the head. The palm is placed on top of the head. A positive test is actually relief of symptoms, suggesting relief of traction forces on the nerve. A negative test is when the symptoms worse, suggesting myofascial tension on the nerve. One study estimated the sensitivity to be 17-78%, the specificity 75-92%[1]Rubinstein SM, Pool JJ, van Tulder MW, et al. A systematic review of the diagnostic accuracy of provocative tests of the neck for diagnosing cervical radiculopathy. Eur Spine J. 2007;16:307–19

Spurlings Test

Spurling’s test is probably the most well known and taught neck exam. It is used to test for cervical radiculopathy. The patient is seated. The examiner is in a position to apply axial load to the top of patients head. The patient then places the neck in extension, lateral rotation in the direction of the patients symptoms. The examiner applies an axial load. Repeat with head rotated to the unaffected side. A positive test is reproduction of pain radiating into upper extremity. A pair of studies estimated the sensitivity to be 30-93% and specificity 74-95%.[2]Tong HC, Haig AJ, Yamakawa K. The Spurling test and cervical radiculopathy. Spine. 2002; 27: 156-159.[3]Shah KC, Rajshekhar V. Reliability of diagnosis of soft cervical disc prolapse using Spurling’s test. Br J Neuro-surg. 2004; 18: 480-483.

Hoffman Sign

Hoffman’s sign is a special test use to evaluate for spinal cord myelopathy or compression. The patient is seated or standing. The examiner repeatedly flips either the volar or dorsal surfaces of the middle finger and observing the thumb and index finger. A positive test is the thumb and index finger reflexively contract. This suggests presence of upper motor neuron lesion. One study estimated this was 58% sensitive and 78% specificity for cervical cord compression.[4]Glaser, John A., et al. “Cervical spinal cord compression and the Hoffman sign.” The Iowa orthopaedic journal 21 (2001): 49.

Cervical Distraction Test

The cervical distraction test can be used to evaluate for cervical radiculopathy and facet symptoms. The patient lays supine on the examination table. The physician stands or sits at the head of the bed with the patients occiput resting in their hands, thumbs along mastoid process. Slightly flex the neck and pull the head towards the examiner providing a distracting force. A positive test is reduction or elimination of symptoms with distraction. One study looking at cervical radiculopathy estimated sensitivity at 44%, specificity 97%[5]Rubinstein SM, Pool JJM, van Tulder MW, Riphagen II, de Vet HCW. A systemic review of the diagnostic accuracy of provocative tests of the neck for diagnosing cervical radiculopathy. Eur Spine … Continue reading

Adson test

Adson’s test is used to help diagnose thoracic outlet syndrome. The patient is seated, examiner behind the patient. The patients arm is abducted to 30 degrees at the shoulder, and then fully extended. The examiner maintains palpation of the radial pulse. The patient then inhales, holds the breath and rotates their head towards the tested extremity. The quality of the radial pulse is then compared to the patient at rest. The test is positive if marked decrease, or disappearance, of the radial pulse. Note: Be sure to check pulses in both arms before and after the test. One study estimated the sensitivity to be 94%, specificity 18% to 87%.[6]Malanga GA, Nadler S. Musculoskeletal Physical Examination: An Evidence-based Approach. Philadelphia: Elsevier Health Sciences, 2006

Wrights Test

Wright’s test or the hyperabduction test is used to assess for thoracic outlet syndrome. The patient is seated. The examiner passively brings affected limb into abduction and external rotation to 90°. Elbow flexed no more than 45°, arm held in this position for 1 minute. The patient can be asked to take a deep breath. Monitor radial pulse and patients symptoms. Now the examiner repeats the same test with the arm in hyperabduction over the patients head. A positive test is a decrease in radial pulse or reproduction of patients symptoms.

Elevated Arm Stress Test

The elevated arm stress test is used to evaluate for thoracic outlet syndrome. The patient is seated with both arms abducted to 90°, elbows flexed to 90° with hands pointed towards the ceiling. The patient must open and close hands repeatedly over 3 minute period. Normal finding is muscle fatigue. Abnormal results is increasing pain progressing down neck and arms; Parasthesias; Pallor which resolves when arms brought to rest (arterial); Cyanosis and swelling (venous); Inability to complete tests; Reproduction of patient symptoms affecting entire extremity. One study estimated the sensitivity of 84%, specificity 30%.[7]Lee J, Laker S, Fredericson M. Thoracic outlet syndrome. PM R. 2010 Jan;2(1):64-70
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