21/07/2026
# Cervical Orthopedic Assessment
# # Chiropractic Clinical Assessment Manual
# # Purpose
The purpose of the cervical orthopedic assessment is to differentiate among the following conditions in patients presenting with neck pain:
* Cervical radiculopathy
* Cervical disc herniation
* Cervical facet syndrome
* Cervical sprain or strain
* Cervical myelopathy
* Vertebrobasilar insufficiency
* Thoracic outlet syndrome
* Upper cervical instability
Orthopedic tests should not be interpreted in isolation. The examiner should integrate the patient’s history, symptom behavior, active and passive movement findings, neurological examination, and appropriate clinical test clusters.
---
# Assessment Flow
# # Step 1. Observation
# # # Assess
* Head position
* Forward head posture
* Shoulder height
* Muscular asymmetry
* Scapular position
* Cervical lordosis
* Protective or antalgic posture
* Willingness to move the neck
* Use of the hands to support the head
# # # Assessment
Observation may identify:
* Postural loading of the cervical spine
* Muscle imbalance
* Scapular dyskinesis
* Protective muscle guarding
* Possible upper cervical instability
* Compensation associated with pain or neurological dysfunction
---
# # Step 2. Active Range of Motion
# # # Assess
* Flexion
* Extension
* Right and left rotation
* Right and left lateral flexion
# # # Observe
* Pain
* Stiffness
* Range limitation
* Movement quality
* Compensation
* Directional preference
* Centralization or peripheralization of symptoms
# # # Assessment
* Local neck pain may suggest muscular, ligamentous, facet, or discogenic involvement.
* Radiating arm pain may suggest nerve-root irritation or foraminal compromise.
* Pain during extension and ipsilateral rotation may indicate facet loading or foraminal narrowing.
* Restricted rotation may be clinically relevant in cervical radiculopathy test clusters.
* Symptom reduction in a specific direction may indicate a directional preference.
---
# # Step 3. Passive Range of Motion
# # # Assess
* Passive mobility restriction
* Pain reproduction
* End feel
* Capsular restriction
* Muscle guarding
* Side-to-side asymmetry
# # # Assessment
Passive movement may help distinguish:
* Joint restriction
* Capsular involvement
* Protective muscle spasm
* Facet joint irritation
* Ligamentous injury
* Pain-limited movement
---
# Step 4. Neurological Examination
# # Dermatomes
Assess sensation from C2 to T1.
Common upper-extremity reference areas include:
* C5: Lateral upper arm
* C6: Lateral forearm and thumb
* C7: Middle finger
* C8: Little finger and medial forearm
* T1: Medial forearm
# # Myotomes
* C5: Shoulder abduction
* C6: Elbow flexion and wrist extension
* C7: Elbow extension and wrist flexion
* C8: Finger flexion and thumb extension
* T1: Finger abduction and adduction
# # Deep Tendon Reflexes
* Biceps reflex: C5–C6
* Brachioradialis reflex: C6
* Triceps reflex: C7
# # # Assessment
A consistent pattern of sensory loss, muscle weakness, and reflex change may indicate cervical nerve-root involvement.
Upper motor neuron signs, gait disturbance, hand clumsiness, or bilateral neurological findings raise concern for cervical spinal cord involvement.
---
# Step 5. Orthopedic Tests
# 1. Cervical Compression Test
# # Spurling Compression Test
# # # Purpose
To assess for:
* Cervical radiculopathy
* Foraminal stenosis
* Cervical disc pathology
* Nerve-root compression
# # # Procedure
1. Position the patient in sitting.
2. Extend the cervical spine.
3. Laterally flex and, depending on the test variation, rotate the head toward the symptomatic side.
4. Apply a controlled axial compression force through the top of the head.
5. Stop immediately if severe pain, neurological deterioration, dizziness, or other adverse symptoms occur.
# # # Positive Finding
* Reproduction of radiating arm pain
* Paresthesia
* Numbness
* Symptoms following a cervical nerve-root distribution
# # # Assessment
Radiating arm symptoms may indicate:
* Cervical nerve-root compression
* Foraminal encroachment
* Cervical radiculopathy
Localized neck pain without arm symptoms may indicate:
* Facet joint irritation
* Joint sprain
* Ligamentous strain
* Local cervical dysfunction
A positive test should reproduce the patient’s familiar radicular symptoms rather than nonspecific local discomfort.
---
# 2. Cervical Distraction Test
# # # Purpose
To assess whether unloading the cervical spine reduces nerve-root symptoms.
# # # Procedure
1. Position the patient in sitting or supine.
2. Support the occiput and mandible without compressing the throat.
3. Apply a gentle superior traction force to the head.
4. Monitor changes in neck and upper-extremity symptoms.
# # # Positive Finding
* Reduction of radiating arm pain
* Reduction of numbness or paresthesia
* Decreased peripheral symptoms
# # # Assessment
Relief of peripheral symptoms may indicate:
* Cervical nerve-root compression
* Foraminal narrowing
* Cervical disc lesion
* Cervical radiculopathy
An increase in localized neck pain may suggest:
* Capsular injury
* Ligamentous sprain
* Irritation of local cervical structures
---
# 3. Bakody Sign
# # Shoulder Abduction Relief Test
# # # Purpose
To assess cervical radiculopathy, particularly involving the lower cervical nerve roots.
# # # Procedure
1. Ask the patient to place the hand of the symptomatic arm on top of the head.
2. The shoulder is abducted and the elbow is flexed.
3. Observe whether upper-extremity symptoms change.
# # # Positive Finding
* Reduction of arm pain
* Reduction of paresthesia or numbness
# # # Assessment
Symptom relief may indicate:
* Cervical radiculopathy
* Reduced tension on the involved cervical nerve root
* Reduced tension on the brachial plexus
The maneuver may temporarily reduce mechanical loading on the affected neural tissues.
---
# 4. Shoulder Depression Test
# # # Purpose
To assess:
* Cervical nerve-root tension
* Brachial plexus tension
* Lower cervical radiculopathy
* Cervical soft-tissue or ligamentous injury
# # # Procedure
1. Position the patient in sitting.
2. Stabilize and depress one shoulder.
3. Passively laterally flex the head away from the depressed shoulder.
4. Apply the movement gradually and monitor symptom location.
# # # Positive Finding
* Radiating arm pain
* Paresthesia
* Numbness
* Localized neck or shoulder pain
# # # Assessment
Radiating arm symptoms may indicate:
* Cervical nerve-root tension
* Brachial plexus tension
* Cervical radiculopathy
Localized pain may indicate:
* Cervical muscle strain
* Ligamentous sprain
* Local cervical pathology
---
# 5. Doorbell Sign
# # # Purpose
To assess localized nerve-root irritation.
# # # Procedure
1. Position the patient in sitting.
2. Identify the suspected cervical intervertebral foramen or nerve-root region.
3. Apply controlled digital pressure over the area.
4. Ask whether symptoms are reproduced locally or distally.
# # # Positive Finding
* Reproduction of radiating arm pain
* Paresthesia in a nerve-root distribution
# # # Assessment
Radiating symptoms may suggest:
* Cervical nerve-root irritation
* Cervical radiculopathy
* Foraminal pathology
Localized tenderness without radiating symptoms is less specific and may reflect local joint or muscular irritation.
---
# 6. Soto-Hall Test
# # # Purpose
To assess cervical pain associated with:
* Disc pathology
* Ligamentous injury
* Posterior cervical structures
* Nerve-root irritation
# # # Procedure
1. Position the patient in supine.
2. Stabilize the sternum.
3. Passively flex the patient’s head and Cột sống cổ toward the chest.
4. Observe the location and character of the reproduced symptoms.
# # # Positive Finding
* Local cervical pain
* Radicular pain
* Marked restriction or guarding
# # # Assessment
Localized pain may indicate:
* Cervical sprain or strain
* Ligamentous injury
* Facet or posterior-element irritation
Radiating pain may indicate:
* Nerve-root tension
* Cervical radiculopathy
* Neural tissue irritation
The test should be performed cautiously when instability, fracture, severe trauma, or spinal cord pathology is suspected.
---
# 7. DeKleyn Test
# # # Purpose
Historically used to assess possible vertebrobasilar circulatory compromise associated with cervical positioning.
# # # Procedure
1. Position the patient in supine.
2. Carefully extend the neck.
3. Add rotation and lateral flexion.
4. Hold the position while observing for adverse neurological or vascular symptoms.
5. Stop immediately if symptoms occur.
# # # Positive Finding
* Vertigo
* Nystagmus
* Blurred vision
* Diplopia
* Nausea
* Syncope or presyncope
* Dysarthria
* Dysphagia
* Ataxia
* Unusual neurological symptoms
# # # Assessment
Symptoms may raise concern for:
* Vertebrobasilar insufficiency
* Cervical arterial dysfunction
* Neurological compromise
A positional test cannot safely rule out cervical arterial pathology. Clinical history and vascular symptom screening are more important than relying on this test alone.
---
# 8. Lhermitte Sign
# # # Purpose
To assess possible cervical spinal cord or meningeal involvement.
# # # Procedure
1. Position the patient in sitting.
2. Ask the patient to actively flex the neck, or gently assist cervical flexion when appropriate.
3. Ask whether an electric-shock sensation travels down the spine or into the limbs.
# # # Positive Finding
* Electric-shock-like sensation radiating down the spine
* Symptoms extending into the arms or legs
# # # Assessment
A positive finding may be associated with:
* Cervical myelopathy
* Cervical spinal cord compression
* Multiple sclerosis
* Spinal cord tumor
* Meningeal irritation or adhesion
* Other cervical cord disorders
This finding warrants further neurological investigation and should not be interpreted as a diagnosis by itself.
---
# 9. Hoffman’s Sign
# # # Purpose
To screen for upper motor neuron involvement.
# # # Procedure
1. Support the patient’s hand in a relaxed position.
2. Hold the middle finger.
3. Flick the distal phalanx downward and release it.
4. Observe the thumb and index finger.
# # # Positive Finding
* Reflex flexion or adduction of the thumb
* Flexion of the index finger
# # # Assessment
A positive response may be associated with:
* Cervical myelopathy
* Cervical spinal cord compression
* Upper motor neuron lesion
* Multiple sclerosis
* Generalized hyperreflexia
Hoffman’s sign may also be present in some asymptomatic individuals. It must be correlated with gait, reflexes, strength, sensation, and other upper motor neuron findings.
---
# 10. Adson Test
# # # Purpose
To assess possible neurovascular compression within the thoracic outlet, particularly near the scalene triangle.
# # # Procedure
1. Position the patient in sitting.
2. Palpate the radial pulse.
3. Slightly abduct and extend the arm.
4. Ask the patient to extend and rotate the neck toward the tested side.
5. Ask the patient to take a deep breath and hold it briefly.
6. Monitor symptoms and pulse response.
# # # Positive Finding
* Reproduction of arm numbness or paresthesia
* Upper-extremity pain
* Weakness
* Marked reduction in radial pulse
# # # Assessment
A positive test may suggest:
* Thoracic outlet syndrome
* Anterior scalene-related compression
* Cervical rib-related compression
* Neurovascular compromise
Pulse reduction alone is not sufficiently specific. Reproduction of the patient’s familiar neurological symptoms is more clinically meaningful.
---
# 11. Eden Test
# # Costoclavicular Test
# # # Purpose
To assess neurovascular compression between the clavicle and first rib.
# # # Procedure
1. Position the patient in sitting or standing.
2. Palpate the radial pulse.
3. Draw the shoulders downward and backward.
4. Maintain the position while monitoring symptoms.
# # # Positive Finding
* Numbness
* Tingling
* Pain
* Weakness
* Reduction in radial pulse
# # # Assessment
A positive test may indicate:
* Costoclavicular compression
* Thoracic outlet syndrome
* Brachial plexus or vascular compression
Clinical interpretation should emphasize symptom reproduction rather than pulse change alone.
---
# 12. Wright Test
# # Hyperabduction Test
# # # Purpose
To assess neurovascular compression beneath the pectoralis minor tendon.
# # # Procedure
1. Position the patient in sitting or supine.
2. Palpate the radial pulse.
3. Abduct and externally rotate the shoulder.
4. Progressively elevate the arm into hyperabduction.
5. Monitor neurological and vascular symptoms.
# # # Positive Finding
* Numbness
* Tingling
* Arm pain
* Weakness
* Heaviness
* Marked reduction in radial pulse
# # # Assessment
A positive finding may suggest:
* Pectoralis minor syndrome
* Thoracic outlet syndrome
* Neurovascular compression beneath the pectoralis minor
---
# 13. Roos Test
# # Elevated Arm Stress Test
# # # Purpose
To assess neurogenic or vascular thoracic outlet syndrome.
# # # Procedure
1. Position both shoulders in approximately 90° abduction and external rotation.
2. Flex both elbows to approximately 90°.
3. Ask the patient to repeatedly open and close both hands.
4. Continue for up to three minutes as tolerated.
5. Monitor symptom onset, side-to-side differences, and inability to maintain the position.
# # # Positive Finding
* Numbness
* Tingling
* Pain
* Heaviness
* Fatigue
* Weakness
* Inability to maintain the arm position
* Reproduction of the patient’s familiar symptoms
# # # Assessment
A positive test may suggest:
* Neurogenic thoracic outlet syndrome
* Neurovascular compression
* Reduced tolerance of the thoracic outlet under sustained loading
General muscular fatigue alone is not sufficient for a positive finding.
---
# 14. Halstead Maneuver
# # Reverse Adson Test
# # # Purpose
To assess neurovascular compression involving the scalene triangle or adjacent thoracic outlet structures.
# # # Procedure
1. Position the patient in sitting.
2. Palpate the radial pulse.
3. Apply downward traction to the tested arm.
4. Extend the neck and rotate the head away from the tested side.
5. Monitor symptoms and pulse response.
# # # Positive Finding
* Paresthesia
* Numbness
* Pain
* Weakness
* Marked reduction in radial pulse
# # # Assessment
A positive test may suggest:
* Thoracic outlet syndrome
* Anterior scalene-related compression
* Neurovascular compromise
As with other thoracic outlet tests, neurological symptom reproduction is more important than pulse reduction alone.
---
# 15. Swivel Chair Test
# # # Purpose
To help differentiate dizziness associated with cervical movement from dizziness associated with head movement relative to space.
# # # Procedure
1. Seat the patient on a rotating chair.
2. The examiner stabilizes the patient’s head so that it remains facing forward.
3. Rotate the patient’s trunk and chair beneath the stabilized head.
4. Ask whether dizziness or vertigo is reproduced.
# # # Positive Finding
* Reproduction of the patient’s familiar dizziness while the head remains relatively stationary
# # # Assessment
A positive finding may suggest:
* Cervicogenic dizziness
* Cervical proprioceptive dysfunction
* Cervical contribution to dizziness
Cervicogenic dizziness is a diagnosis of exclusion. Vestibular, neurological, cardiovascular, and cervical arterial causes must first be considered.
---
# 16. Rust Sign
# # # Purpose
To identify protective behavior associated with severe upper cervical pain or instability.
# # # Procedure
Observe whether the patient supports the head or neck with both hands during:
* Sitting
* Standing
* Lying down
* Changing position
* Moving the neck
# # # Positive Finding
The patient manually supports the head or neck to reduce pain or create a sense of stability.
# # # Assessment
A positive Rust sign may raise concern for:
* Upper cervical fracture
* Severe cervical sprain
* Upper cervical instability
* Rheumatoid involvement
* Destructive upper cervical pathology
This sign requires immediate caution. Forceful cervical testing or manipulation should not be performed until serious pathology has been excluded.
# Key Clinical Interpretation
# # Cervical Radiculopathy
A commonly used clinical cluster includes:
* Positive Spurling test
* Positive cervical distraction test
* Positive upper-limb tension test
* Cervical rotation toward the symptomatic side of less than 60°
The probability of cervical radiculopathy increases when several findings are present together and correspond with the patient’s history and neurological examination.
---
# # Cervical Myelopathy
Cervical myelopathy should be suspected when several of the following are present:
* Hand clumsiness
* Gait disturbance
* Hyperreflexia
* Hoffman’s sign
* Babinski sign
* Ankle clonus
* Lhermitte sign
* Bilateral neurological symptoms
* Progressive weakness
* Bowel or bladder dysfunction
These findings require further medical investigation.
---
# # Thoracic Outlet Syndrome
Thoracic outlet tests have limited diagnostic value when used individually. Assessment should combine:
* Symptom history
* Postural examination
* Neurological testing
* Vascular testing
* Symptom reproduction during provocation tests
* Differential assessment of the Cột sống cổ, shoulder, peripheral nerves, and vascular system
