3 neck pain diagnostic tests

Annibale Carracci, Sleeping Venus Surrounded by Putti, oil on canvas. Chantilly, Musée Condé.

Here are three clinical tests that have some evidence – with regard to validity and reliability to support their use:

  • a test for nerve root pathology – Spurling’s Test
  • a test for cervical facet related symptoms – Extension Rotation Test
  • a test for upper cervical motion – Flexion Rotation Test


In the presence of symptoms suspected of arising from the nerve root: Spurling’s neck compression test is performed by extending, laterally flexing and rotating the neck to the same side and then applying downward axial pressure through the head.

Spurling’s Test

The test is considered positive if radicular symptoms radiate into the limb ipsilateral to the side to which the head is laterally flexed and rotated (Malanga et al. 2003). The test appears to have high specificity and sensitivity (95% and 92% respectively) and good to fair interrater reliability (Shah & Rajshekhar 2004; Malanga et al. 2003).

The shoulder abduction test (see the above image of Carracci’s Sleeping Venus – NOTE: clothes are NOT optional with this test) can be used in addition to Spurling’s test and is probably worth mentioning here. This test is performed by actively or passively abducting the symptomatic arm and placing the patient’s arm on top of their head. The test is considered positive with reduction or relief of ipsilateral cervical radicular symptoms (Malanga et al. 2003).

Facet joint

In the presence of symptoms suspected of arising from the facet joint: the extension rotation test is performed by extending and rotating the cervical spine to the same side with reproduction of symptoms representing a positive test (Schneider et al 2014).

Extension Rotation Test

Utilising this test in a battery of tests – that includes palpating for segmental tenderness – appears to improve the diagnostic power of these tests:

The Extension Rotation Test

Upper cervical spine motion

In the presence of symptoms or restricted range of motion suspected as arising from the upper cervical spine: the cervical flexion-rotation test (FRT) is an objective method of determining upper cervical joint motion. Everyone can keep their clothes on for this test as well (just making sure).

Hall et al (2008) describe the test as ‘a simplified form of manual examination, in this test the cervical spine is fully flexed and rotated right and left – as movement at other cervical segments would be constrained by this end-range position – movement is isolated to the C1/2 segment.’

Flexion Rotation Test

Range of rotation in end-range flexion is normally at least 45˚ to each side. In contrast, subjects with C1/2 dysfunction have significantly less rotation. Hall et al (2008) report that when administered by highly trained manual therapists, the FRT has high sensitivity (91%) and specificity (90%) in differentiating subjects with cervicogenic headache from asymptomatic controls or subjects with migraine with aura.


Hall, T., Briffa, K., & Hopper, D. 2008 Clinical Evaluation of Cervicogenic Headache: A Clinical Perspective. The Journal of Manual & Manipulative Therapy, 16(2), 73–80.

Malanga, G.A., Landes, P. & Nadler, S.F., 2003. Provocative tests in cervical spine examination: historical basis and scientific analyses. Pain Physician, 6(2), pp.199–205.

Shah, K.C. & Rajshekhar, V., 2004. Reliability of diagnosis of soft cervical disc prolapse using Spurling’s test. British Journal of Neurosurgery, 18(5), pp.480–483.

Schneider, G.M. et al., 2014. Derivation of a clinical decision guide in the diagnosis of cervical facet joint pain. Archives of Physical Medicine and Rehabilitation, 95(9), pp.1695–1701.

Takasaki H et al 2011 Normal kinematics of the upper cervical spine during the Flexion-Rotation Test – In vivo measurements using magnetic resonance imaging. Manual Therapy Apr; 16(2): 167–171.