Neck — Fast Exam

Tap a diagnosis. Tests first, interpretation underneath.

30-second screen

Run this before any special testMyelopathy first → red flags → then the root

Screen for myelopathy before anything else. Clumsy hands, unsteady gait, urinary change, bilateral symptoms. Test Hoffman, look for hyperreflexia and clonus, and watch them walk. A missed myelopathy is the one error in this region with permanent consequences.
Red flags: trauma, cancer history, fever, night pain, weight loss, progressive weakness — listed at the bottom.
Is there arm pain below the elbow, or pins and needles? Then it is a root until proven otherwise, and the level matters.
Neuro screen by level — C5 deltoid and biceps reflex, C6 wrist extension and brachioradialis, C7 triceps and elbow extension, C8 grip, T1 finger abduction. Compare both sides.
Spurling and the distraction test. One compresses, one distracts — a positive pair is convincing.
Ask what relieves it. Arm overhead or hand on head relieving the pain is highly suggestive of a root.
Always examine the shoulder too. Pain from C4–C6 and rotator cuff pathology coexist constantly, and each can cause the other's symptoms.

The honest caveat: cervical tests are low sensitivity and high specificity — a positive means something, a negative means little. And the whole region is outshone by the neurology: the myotomes, dermatomes and reflexes carry more information than any provocative manoeuvre.

Nerve root

Cervical radiculopathyArm pain below the elbow with a dermatomal pattern and a matching reflex change

Hallmark

Unilateral arm pain, often with numbness or paraesthesia in a dermatomal pattern, usually with neck pain. Pain may be relieved by putting the arm overhead. Upper trapezius and interscapular pain and occipital headache are common. Deep tendon reflex changes and myotomal weakness confirm the level.

Tests

Spurling — extend and rotate the neck toward the affected side, then apply gentle axial compression. Positive: reproduction of the familiar radicular arm pain. Sn 30–60% / Sp 85–98% · Wainner: Sn 0.50 / Sp 0.86good for ruling in, useless for ruling out
Cervical distraction — gentle axial traction on the head. Positive: relief of the arm pain. Sn 40–43% / Sp 80–100%
Shoulder abduction (relief) sign — rest the hand on top of the head. Positive: arm pain eases. Sn 43–50% / Sp 80–100%
Upper limb tension test A — a neurodynamic test, part of the Wainner cluster. Positive: reproduction of arm symptoms with sensitising manoeuvres.
Neuro screen by level — Positive: reflex loss, myotomal weakness or dermatomal sensory change. This is what actually localises the level.

Next: no single test is adequate. The Wainner cluster — positive Spurling, positive distraction, positive upper limb tension test, and cervical rotation under 60° toward the involved side — substantially raises the probability when all four are present. Most radiculopathy settles with conservative care over 6–12 weeks; image early if there is progressive weakness.

Myelopathy

Cervical myelopathyClumsy hands, unsteady gait — the diagnosis that must not be missed

Hallmark — this is the one to catch

Insidious onset. Difficulty with fine motor tasks — buttons, writing, opening jars. Unsteady gait and a sense of walking on uneven ground. Neck stiffness. Later: urinary urgency or incontinence. Symptoms are usually bilateral, unlike a radiculopathy. Often painless, which is exactly why it is missed.

Tests

Hoffman sign — flick the distal phalanx of the middle finger into extension. Positive: reflexive flexion of the thumb and index finger. can be present in normal people — a positive supports the diagnosis, it does not make it
Deep tendon reflexes — Positive: hyperreflexia, including inverted or spread reflexes, and clonus at the ankle. Hyporeflexia points the other way, to a root.
Babinski and a general upper motor neuron screen — Positive: extensor plantar response.
Lhermitte sign — neck flexion. Positive: an electric shock sensation down the spine or limbs → cord involvement.
Hand dexterity and gait — watch them walk on their heels and toes, and ask them to do up a button. Positive: clumsy, slow, or unstable. The most sensitive "test" is watching them walk and use their hands.
Finger escape sign — hold all fingers extended and adducted; the little finger drifts. Positive: ulnar drift within seconds.

Next: urgent MRI of the cervical spine and a surgical opinion. This is not a physiotherapy problem, and manipulation should be avoided entirely. Progressive functional decline is the rule without decompression.

Cervical stenosisA narrow canal — from asymptomatic to neurogenic claudication

Hallmark

Congenital or degenerative narrowing. Many people are asymptomatic; in others it produces a radiculopathy, a myelopathy, or a neurogenic claudication picture. Note that a minor injury in a narrow canal can produce a disproportionate cord injury.

Next: if the canal is known to be narrow, treat any new neurological symptom as significant and image. A patient with known stenosis and a stiff neck after a minor trauma deserves a proper assessment, not reassurance.

Axial & referred

Axial neck pain (mechanical / facet)Pain in the neck itself, no arm symptoms, normal neurology

Hallmark

Neck pain and stiffness without radicular features — no arm pain past the elbow, no numbness, no reflex change. Worse on movement and prolonged postures, better with change of position. This is the most common cause and the most benign.

Tests

Range of motion, all six directions — Positive: a painful or restricted direction. The restriction pattern and the pain on movement are the main findings, and the range is a useful outcome measure.
Neurological screen that is normal — Positive: normal power, sensation and reflexes. Reassuring, and it is what separates this from a root.
Cervical rotation to the point of pain, and the neck tornado or equivalent — Positive: reproduction of familiar neck pain, not arm pain.

Next: no imaging for uncomplicated neck pain without red flags or neurology. The evidence for passive treatment is weak; exercise and time are what work. The skill here is knowing that you do not need to investigate.

Referred pain to the shoulder and scapulaShoulder or interscapular pain with a normal shoulder examination

Hallmark

The neck refers to the trapezius, the periscapular region, the shoulder cap and the arm — and it can do so before any arm pain appears, sometimes by several weeks. If the shoulder does not examine badly and the pain is in the trapezius or between the blades, think about the neck.

Next: the shoulder page has the full root-by-root map. The short version: C4 is the shoulder cap and does not descend the arm; C5 is the deltoid and the classic shoulder mimic; C6 and C7 cross the elbow; and C7 carries the highest proportion of scapular pain of any root. The discriminator is what makes it worse — overhead loading helps a root and hurts a shoulder.

Whiplash-associated disorderNeck pain, headache and dizziness after a collision

Hallmark

Neck pain and stiffness, headache, and sometimes dizziness or cognitive symptoms after an acceleration–deceleration injury. Graded I–III by whether there are signs; grade III means neurological signs and needs a different pathway.

Tests

Full neurological examination — mandatory. Positive: any neurological sign puts the patient in grade III and changes management — image and refer.
Range of motion and pain on movement — Positive: restricted and painful; the main clinical measure and the best prognostic marker.
Myelopathy screen — Hoffman, reflexes, gait. Positive: cord involvement after trauma, urgent.

Next: most whiplash recovers. The things that predict a worse outcome are high initial pain and high disability, not the imaging findings. Stay active, avoid collars beyond a day or two, and be careful with the words you use — catastrophising predictions worsen outcomes.

Acute wry neck / torticollisSudden painful tilt that will not straighten

Hallmark

Sudden onset of neck pain with the head held tilted and rotated, severe enough that the patient cannot straighten it against the pain. Often on waking. Self-limiting in most cases.

Next: gentle mobilisation, reassurance and time for the common presentation. Escalate if there is fever, neurological signs, or a history of trauma or of a spinal condition — in a child, consider a retropharyngeal or atlantoaxial problem, which is not a wry neck.

Other

Thoracic outlet syndromeArm symptoms with a normal neck and a normal shoulder

Hallmark

Symptoms across the whole arm rather than a dermatome, often with a positional trigger — carrying heavy bags, or overhead work. Neurogenic TOS is the commonest type and is a clinical diagnosis of exclusion; vascular TOS is rare but is the one that matters.

Tests

Provocative tests — Roos, Adson, Wright, costoclavicular — Positive: reproduction of symptoms.all of these are frequently positive in normal subjects, and none is reliable. Interpret with the history or not at all
Vascular check — pulses, colour, swelling, and a bruit over the subclavian. Positive: any of these → this is vascular and needs urgent referral.
Screen the neck and shoulder first — Positive: a root lesion or a shoulder problem explains the symptoms better in the great majority of cases.

Next: diagnose by exclusion, and be sceptical. The tests are near-useless on their own. Vascular signs need immediate imaging and referral.

Choosing the imagingMost neck pain needs no imaging

No imaging — uncomplicated mechanical neck pain without red flags or neurological signs. Radiographs in this group change nothing and find incidental degeneration in almost everyone over 40.
MRI — progressive neurological deficit, a suspected myelopathy, radiculopathy that is not settling, or any red flag. MRI is the test for cord and root compression.
CT — bone detail: trauma, fracture, and surgical planning.
Nerve conduction studies and EMG — to separate a radiculopathy from a peripheral entrapment such as carpal tunnel, and to grade axonal loss.

Worth remembering: cervical MRI findings are common in asymptomatic middle-aged adults. A disc bulge on a scan of someone with neck pain is not automatically the cause — correlate with the level that the clinical findings point to.

Red flags — before you test

Re-route before you testSeven findings that take precedence over any special test

Stop and re-route

Clumsy hands, unsteady gait, bilateral symptoms, or urinary change → myelopathy. Urgent MRI and a surgical opinion. Do not manipulate.
Trauma with midline tenderness, or any significant trauma mechanism → fracture or ligamentous instability. Immobilise and image. Consider imaging rules rather than examining by hand.
Fever, rigors, or a hot spine with severe pain → spinal infection. Urgent.
Night pain unrelieved by rest, unexplained weight loss, or a history of cancer → metastasis. Urgent referral.
Neck pain with sudden severe headache, vertigo, visual change, or a neurological deficit, especially after neck manipulation or trauma → vertebral artery dissection. Emergency.
Progressive or bilateral weakness, or a deteriorating neurological picture → cord compression. Emergency imaging.
Rheumatoid arthritis, Down syndrome, or a history of significant spinal surgery with new symptoms → instability or atlantoaxial problem. Image before you examine roughly.

Built for Ruby — PRM & sports medicine cervical spine reference.
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Sources. [1] Spurling test — Wainner et al., Spine 2003: Sn 0.50 / Sp 0.86. Broader literature summarised by APTA and StatPearls: Sn 30–60% / Sp 85–98%. A 2017 comparison study found specificity 98.53% for MRI-confirmed cervical radiculopathy. [2] Shoulder abduction relief sign — Sn 43–50% / Sp 80–100%; neck distraction test — Sn 40–43% / Sp 80–100% (as summarised in the same literature). [3] Wainner clinical prediction cluster — positive Spurling, positive distraction, positive upper limb tension test A, and cervical rotation under 60° toward the involved side. All four together substantially raise the probability of cervical radiculopathy. [4] Cervical root map, dermatomes, myotomes and reflexes — see the shoulder page, sources [11] and [12], including the scoping review (PMC12226383) showing C7 carries the highest proportion of scapular pain descriptions, and that scapular pain may precede arm pain by weeks. [5] Hoffman sign and myelopathy signs — described from standard technique. Hoffman can be present in asymptomatic individuals, so a positive supports rather than confirms the diagnosis. [6] Tests without figures are described from standard technique. Where the literature does not provide robust accuracy data — including Roos, Adson and the other thoracic outlet provocation tests — none is quoted rather than inventing one, and their poor specificity is stated instead.

Diagnostic accuracy figures are pooled from the cited literature and vary widely between studies and populations. Interpret alongside history and pre-test probability. Not a decision-support system, and not a substitute for your own clinical judgement or local protocols.