The Evaluation of Patients With Neck Pain

Donald R. Gore, MD


Medscape Orthopaedics & Sports Medicine eJourn. 2001;5(4) 

In This Article

Physical Examination

A neuroskeletal-muscular examination is done to evaluate neck pain. As with all physical examinations, it begins with inspection and palpation. A cursory examination is performed to identify abnormalities of cranial nerves. Then the examiner determines range of motion (ROM) of the neck and extremities and perform a sensory evaluation, manual muscle testing, and elicitation of normal and abnormal reflexes. Necessary tools include a reflex hammer, a safety pin, and a marking pen. The best reflex hammer is heavy at the end and long enough so that a brisk tap can be delivered to the tendon. Pin-prick sensory testing and mapping of any sensory deficit can be done with a simple safety pin, which is usually sharp enough for adequate testing but dull enough so that breaking the skin can be avoided. A safety pin also has a blunt end, which allows alternate sharp and dull evaluation.

The examiner first observes the patient's gait. This can be done when the patient enters the room. If an abnormal gait pattern is noted, then additional observation after the patient disrobes is required. Any abnormalities are noted and fully described. The next step in observation is to look for skin lesions and describe their characteristics and distribution. The examiner should note any muscle atrophy and fasciculations and, if either or both are present, describe their exact location and specific muscles involved. Finally, the patient is inspected for unusual facial characteristics, head position, involuntary movements, and deformities of the neck or rest of the body. The patient's eyes are inspected and special note taken of any eyelid drooping, abnormal pupillary contractions, or asymmetric facial characteristics.

Palpation may elicit tenderness. If so, its exact location and the amount of pressure needed to produce pain is noted. In addition, the patient's nonverbal response to palpation, such as withdrawal or facial grimaces, should be observed.

The purpose of the initial sensory examination is to determine if sensation is altered in any way. The examiner determines the patient's ability to distinguish between dull and sharp sensations and changes in temperature.

Practical ROM testing can be done rapidly and simply; the examiner should note if the motion is smooth and painless. Obvious limitation and/or pain in any direction of motion should be noted. The examiner also needs to be aware of passive motion limitation of the extremities because that may affect the patient's ability to comply and respond to further testing.

Strength Evaluation

Muscle strength evaluation is performed using manual resistance applied by the examiner (Figure 2). The examiner applies resistance and determines whether there is unilateral or bilateral involvement and compare with the opposite side. The numerical muscle grading that is proposed in most general textbooks has limited value in current clinical settings ( Table 1 ) because the classification was developed for use in poliomyelitis patients where profound weakness may be present. Occasionally, there is obvious weakness and this can be easily identified and graded, but frequently, only mild weakness is present. If the numerical grading system is used, most of the upper extremity weakness caused by cervical disc disease would be graded as 4. This is a broad category, therefore further description is necessary.

Figure 2.

Manual muscle testing of muscles that flex the elbow.

In addition to the presence or absence of weakness, the characteristics of the weakness should be noted.


  1. Is the weakness present throughout the entire arc of motion?

  2. Is there a point where the patient's response abruptly gives way?

  3. Is there resistance to passive motion and, if so, what pattern does it follow?

  4. Is the motion jerky and intermittent or smooth?


Initially, all major upper-extremity muscle groups need to be tested, including muscles that are responsible for shoulder elevation, abduction, flexion, extension, and rotation; elbow flexion, extension, supination, and pronation; wrist flexion, extension, and radial and ulnar deviation; and, finally, all finger motions. If weakness is detected, individual muscle testing should be performed to localize as precisely as possible the location and extent of the deficit.


If there is any suggestion of lower extremity involvement, these tests are also applicable to the lower extremities.


Reflex testing involves deep-tendon and abnormal reflexes. The deep-tendon reflexes are elicited by placing the muscle and its tendon under slight tension and then briskly tapping the tendon with a reflex hammer (Figure 3). This gives a slight but quick stretch to the tendon, resulting in a reflex muscle contraction. Deep-tendon reflexes to be examined are at the elbow (biceps and triceps), wrist (brachioradialis), knee (quadriceps), and ankle (gastrocnemius), and the presence or absence of clonus is noted.

Figure 3.

Triceps reflex that is tested by flexing the elbow, putting the triceps muscles on a slight stretch, and then briskly tapping the triceps tendon just proximal to its attachment to the olecranon.

The abnormal reflexes that are of specific interest are Babinski's sign, Hoffmann's sign, and inverted radial reflex ( Table 2 ). Babinski's sign is the presence of dorsiflexion of the great toe when the bottom of the foot is stroked (Figure 4). Hoffmann's sign is positive when there is a quick movement of the thumb into flexion and adduction elicited by flicking the nail of the patient's long finger (Figure 5). The inverted radial reflex is flexion of the wrist when eliciting the brachioradialis reflex (Figure 6). The additional signs and tests that are of interest in evaluating patients with neck pain are the arm abduction sign, Spurling's test, response to axial compression, the finger escape sign, and Lhermitte's sign. These are summarized in Table 3 .

Figure 4.

Babinski's sign, which is tested by stroking the lateral side of the foot on the plantar surface. A negative response is flexion of the toes. A positive response, as shown here, is extension of the great toe and spreading of the lesser toes.

Figure 5.

Hoffmann's sign, which is elicited by flicking the distal phalanx of the long finger. A negative response, as shown here, is no motion of the thumb. A positive response is flexion of the thumb at the interphalangeal joint.

Figure 6.

Inverted radial reflex is elicited by tapping the brachioradialis tendon just proximal to the radial styloid. A positive response, as shown here, is wrist and finger flexion. A negative response is wrist dorsiflexion.

The arm abduction sign is relief of arm pain when abducting the arm and flexing the elbow, which is done by grasping the top of the head with the hand of the affected extremity (Figure 7). The test is positive if the patient is more comfortable in that position and the upper extremity pain is partially or completely relieved.

Figure 7.

Arm abduction sign is positive if pain is relieved with the upper extremity in this position.

A positive Spurling's test is the creation of upper extremity pain by extending the neck and rotating the chin toward the affected extremity (Figure 8). The axial compression test reproduces pain when pressure is applied to the top of the patient's head; alternatively, relief of symptoms occurs when traction is applied under the chin and occiput (Figure 9 ). The finger escape sign is performed by asking the patient to hold his/her fingers in extension. The test is positive if the ring and small fingers gradually flex and abduct (Figure 10). The patient should further be observed for the ability to rapidly open and close his/her hands.

Figure 8.

Spurling's sign is performed by the patient extending her neck and rotating her head toward the side of their pain. The test is positive if pain is exacerbated by this position.

Figure 9A.

Axial compression test is performed by pressing on the top of the patient's head with her neck in a neutral position. The test is positive if the pain is exacerbated.

Figure 9B.

Traction is applied by the examiner by placing her hands under the chin and occiput. The test is positive if the patient's pain is decreased.

Figure 10.

The finger flexion test is performed by asking the patient to extend her finger. The test is positive, as shown here, if the patient cannot maintain all fingers in extension and the ring finger and small finger flex and abduct.

Lhermitte's sign is positive if the patient complains of shooting electric-like sensations in the lower extremities when his/her neck is maximally flexed (Figure 11).

Figure 11.

Lhermitte's sign is performed by asking the patient to maximally flex her neck. The test is positive if this causes shooting, electric-like pain in the lower extremities.

Pain Distribution

The exact location of the patient's pain and, if present, the paresthesias and feelings of weakness not only help in directing the physical examination, but give the examiner an indication of the anatomic source of the pain. Patterns and physical findings of specific nerve root compression are given in Table 4 . In addition, the characteristics of the pain such as onset, duration, and severity help to define the underlying pathology.

Pain of abrupt onset and not related to severe trauma is frequently caused by disc pathology. Herniation of an intervertebral disc is usually, but not always, associated with radicular pain, which is pain in the distribution of a nerve root. A posterior lateral disc protrusion results in compression of the nerve whose number corresponds to that of the lower vertebral body. For instance, a disc protrusion at the C5-6 interspace involves the 6th nerve root. The most common location for a disc protrusion is C5-6, followed closely by C6-7, and then by C4-5.[4] Protrusions at C2-3 and C7-T1 can occur but are rare. Although disc protrusions at C3-4 are not common, when they occur, the fourth nerve root is compressed, and the pain distribution is to the superior aspect of the shoulder rather than into the arm, forearm, or hand.

Degenerative conditions of the disc without protrusion causing neck pain may also cause radicular pain, but these are usually slow in onset, and the pain pattern is not as easily localized.

Determining the exact location of the nerve root compression may require imaging studies, especially if the pain pattern is unusual. The duration and how constant the pain is distinguish between chronic and acute conditions. Pain of long duration that gradually increases in severity and has become fairly constant is characteristic of a degenerative process. However, pain of abrupt onset that is initially severe and partially subsides over a few weeks is characteristic of a disc protrusion. Pain of gradual but progressive onset that is constant and not relieved by rest and especially worse at night is typical of a neoplastic process, which, in the neck, is usually of metastatic origin. Unrelenting, constant, intolerable pain suggests the possibility of an infectious process.

Patients describe radicular pain as shooting or searing beginning in the neck and into the upper extremity. The pain worsens when the neck is extended, which decreases the size of the neural foramen (Figure 8). Elevation of the affected upper extremity may relieve the pain (Figure 7). This is accomplished by grasping the opposite side of the head with the hand, which decreases the tension on the nerve root.

Numbness, tingling, and a feeling of weakness may accompany the complaint of pain, and, if of cervical origin, it can be expected to be in the distribution of the affected nerve root (Figure 12). Peripheral nerve entrapments of the upper extremity can mimic cervical disease.

Figure 12.

Dermatomal pattern of cervical nerve roots.

Accompanying complaints of lack of coordination, clumsiness in gait or use of the upper extremities, and alterations in bowel and bladder control should alert the examiner to the possibility of cervical cord involvement either from external pressure or from some intrinsic neurologic disease.

Finally, systemic complaints that have serious implications such as cough, shortness of breath, fatigue, weight loss, and pain and dysfunction in other areas must be investigated. The generalized conditions that may mimic primary neck pain are tumors or infection in the apex of the lung, disease processes that involve or irritate the diaphragm, coronary artery obstruction, and inflammatory arthritides such as rheumatoid disease. In most of these conditions, neck pain is only one of many symptoms.


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