Athletic Training and Sports Health Care

Pearls of Practice 

Performing a Neurological Examination on Patients With Musculoskeletal Extremity Symptoms: Part I. Clinical Reasoning and Statistical Utility

Dhinu J. Jayaseelan, DPT, OCS, FAAOMPT; Erik B. Lineberry, DPT; Scott E. Resetar, DPT; Eric M. Magrum, DPT, OCS, FAAOMPT

Abstract

Clinical examination of the neurological system can determine the integrity of an individual's central and peripheral nervous system. For clinicians in the orthopedic and/or sports settings, use of a neurological examination can be integral in differential diagnosis, treatment planning, and determination of what, if any, referrals need to be made to enhance patient outcomes. When pain is in the extremities, it is essential to understand whether symptoms are primarily arising from a peripheral or central tissue at fault. The purpose of this clinical pearl is to describe the clinical reasoning behind using neurological examinations in the treatment of individuals with extremity pain.

Prior to performing a neurological examination, clinicians should perform a subjective examination to determine a patient's cognition and report of symptom location, nature, behavior, and severity. If a patient reports extremity pain or paresthesia, neurologic involvement should be considered, even if symptoms do not follow a typical dermatomal or peripheral nerve pattern. In particular, if patients complain of shooting, burning, or electric shock-like symptoms, a thorough neurological assessment should be performed. When suspecting neural involvement, clinicians should perform spinal screening because nerve roots exit the neural foramen of the associated spinal segment(s). Active range of motion with overpressure assessment, with or without passive joint accessory mobility, can be performed to detect possible spinal involvement.

When evaluating a patient with upper extremity pain or paresthesia, examination findings of dizziness, changes in speech or swallowing, global weakness, tinnitus, and nausea or vomiting may warrant further examination and possible referral to another specialist. If a clinician determines that a neural insult may be present, additional tests should be performed to determine the presence of upper motor neuron pathologies. These tests include cranial nerve assessment, Hoffman's reflex (sign), inverted Supinator Sign, and clonus in the upper extremity. Common neurological findings of segmental dysfunction of the cervical spine can be seen in Table 1.1

Clinical examination of the neurological system can determine the integrity of an individual's central and peripheral nervous system. For clinicians in the orthopedic and/or sports settings, use of a neurological examination can be integral in differential diagnosis, treatment planning, and determination of what, if any, referrals need to be made to enhance patient outcomes. When pain is in the extremities, it is essential to understand whether symptoms are primarily arising from a peripheral or central tissue at fault. The purpose of this clinical pearl is to describe the clinical reasoning behind using neurological examinations in the treatment of individuals with extremity pain.

Prior to performing a neurological examination, clinicians should perform a subjective examination to determine a patient's cognition and report of symptom location, nature, behavior, and severity. If a patient reports extremity pain or paresthesia, neurologic involvement should be considered, even if symptoms do not follow a typical dermatomal or peripheral nerve pattern. In particular, if patients complain of shooting, burning, or electric shock-like symptoms, a thorough neurological assessment should be performed. When suspecting neural involvement, clinicians should perform spinal screening because nerve roots exit the neural foramen of the associated spinal segment(s). Active range of motion with overpressure assessment, with or without passive joint accessory mobility, can be performed to detect possible spinal involvement.

When evaluating a patient with upper extremity pain or paresthesia, examination findings of dizziness, changes in speech or swallowing, global weakness, tinnitus, and nausea or vomiting may warrant further examination and possible referral to another specialist. If a clinician determines that a neural insult may be present, additional tests should be performed to determine the presence of upper motor neuron pathologies. These tests include cranial nerve assessment, Hoffman's reflex (sign), inverted Supinator Sign, and clonus in the upper extremity. Common neurological findings of segmental dysfunction of the cervical spine can be seen in Table 1.1

Common Neurological Findings for Cervicothoracic Segmental Dysfunctiona

Table 1:

Common Neurological Findings for Cervicothoracic Segmental Dysfunction

When evaluating a patient with lower extremity pain or paresthesia, subjective findings of changes in bowel and bladder function, decreased balance, saddle paresthesia, sexual dysfunction, and gait ataxia may be indications for further evaluation and diagnostic testing. Based on screening results, the clinician may want to add tests such as the Babinski reflex and clonus to rule out the possibility of an upper motor neuron injury. Common neurological testing for the lumbosacral segments can be found in Table 2.2

Common Neurological Findings for Lumbosacral Segmental Dysfunctiona

Table 2:

Common Neurological Findings for Lumbosacral Segmental Dysfunction

Specific components of the neurological examination should include: myotomal strength, dermatomal sensory assessment, and deep tendon reflexes. Basic neurological screening can help the clinician determine whether further examination for possible upper or lower motor neuron involvement is necessary. Although numerous factors may create variability in testing sequence, a consistent and systematic approach can enhance the reliability and validity of testing.

One challenge with screening for neural involvement in the presence of extremity pain is the wide array of symptom presentations associated with the musculoskeletal system. Symptoms related to neural irritation can be mistaken for another condition. For example, lateral shoulder pain is often associated with subacromial or rotator cuff impingement, but may also be related to axillary nerve irritation, C4 nerve root or cervical facet joint involvement, vascular dysfunction, or visceral contributions. Conversely, descriptions of radiating symptoms can be associated with local conditions such as carpal tunnel or pronator teres syndrome. Differentiation through spinal and neurological examination is important because results will guide patient treatment and prognosis.

Another challenge associated with the neurological examination is the lack of standardized testing. As inter-tester variability of testing increases, the ability to provide statistical metrics on utility decreases. Although available metrics for common neurological examination tests are provided in Table 3,3–5 test results should be clustered to strengthen the presence or absence of dysfunction because individual test results offer minimal guidance for clinical decisions. Interpretation of key statistical tools such as sensitivity and specificity (Table 4), which help to make the presence or absence of a condition more or less likely, and likelihood ratios (Table 5), which help to determine the posttest probability, are also presented.6 Until further research establishes more diagnostic information related to neurological examination testing, clinicians should use clinical reasoning to differentiate a condition's upper or lower motor neuron involvement. It is the authors' hope that this “pearl of practice” facilitates this process.

Statistical Use of Neurological Tests

Table 3:

Statistical Use of Neurological Tests

Interpretation of Sensitivity and Specificitya

Table 4:

Interpretation of Sensitivity and Specificity

Interpretation of Likelihood Ratios

Table 5:

Interpretation of Likelihood Ratios

References

  1. Abbed KM, Coumans JV. Cervical radiculopathy: pathophysiology, presentation, and clinical evaluation. Neurosurgery. 2007;60:S28–S34. doi:10.1227/01.NEU.0000249223.51871.C2 [CrossRef]
  2. Suri P, Rainville J, Katz JN, et al. The accuracy of the physical examination for the diagnosis of midlumbar and low lumbar nerve root impingement. Spine (Phila Pa 1976). 2011;36:63–73. doi:10.1097/BRS.0b013e3181c953cc [CrossRef]
  3. Sullivan SJ, Hammond-Tooke GD, Schneiders AG, Gray AR, McCrory P. The diagnostic accuracy of selected neurological tests. J Clin Neurosci. 2012;19:423–427. doi:10.1016/j.jocn.2011.09.011 [CrossRef]
  4. Cook CE, Wilhelm M, Cook AE, Petrosino C, Isaacs R. Clinical tests for screening and diagnosis of cervical spine myelopathy: a systematic review. J Manipulative Physiol Ther. 2011;34:539–546. doi:10.1016/j.jmpt.2011.08.008 [CrossRef]
  5. Cook C, Roman M, Stewart KM, Leithe LG, Isaacs R. Reliability and diagnostic accuracy of clinical special tests for myelopathy in patients seen for cervical dysfunction. J Orthop Sports Phys Ther. 2009;39:172–178. doi:10.2519/jospt.2009.2938 [CrossRef]
  6. Portney LG, Watkins MP. Foundations of Clinical Research: Applications to Practice, 3rd ed. Upper Saddle River, NJ: Prentice Hall; 2009.

Common Neurological Findings for Cervicothoracic Segmental Dysfunctiona

LevelDermatomal PatternAssociated Myotomal MusclesDeep Tendon ReflexPotential Differential List
C3Supraclavicular, suboccipital, and posterior auricular regionTrapezius, levator scapulae, sternocleido-mastoid, diaphragm, strap musclesSpinal accessory nerve dysfunction
C4Infraclavicular and posterior cervical region, posterior shoulderTrapezius, rhomboids, levator scapulae, diaphragmSpinal accessory nerve dysfunction
C5Superolateral aspect of the armPectoralis major (clavicular head), supraspinatus, infraspinatus, deltoid, biceps, brachialis, brachioradialis, diaphragmBiceps, pectoralisRotator cuff tear, suprascapular nerve entrapment, axillary nerve dysfunction, musculocutaneous nerve
C6Lateral arm and forearm, thumb and index fingerBiceps, brachialis, brachioradialis, extensor carpi radialis longus, supinator, pronator teres, flexor carpi radialis, tricepsBiceps, brachioradialisCarpal tunnel syndrome, musculocutaneous nerve, radial nerve
C7Posterolateral arm and forearm, middle fingerTriceps, latissimus dorsi, pronator teres, flexor carpi radialis, extensor carpi ulnaris, extensor digitorum, abductor pollicis longus, extensor pollicis brevis and longus, extensor indicesTricepsCarpal tunnel syndrome, posterior interosseus nerve compression, radial nerve dysfunction, median nerve dysfunction
C8Medial arm and forearm, 4th and 5th digitsFlexor digitorum superficialis, pronator quadratus, flexor digitorum profundus, flexor pollicus longus, flexor carpi ulnaris, lumbricals 3 and 4Anterior interosseus nerve compression, ulnar entrapment at the elbow, posterior interosseus nerve, median nerve
T1Axillary and pectoral region, medial arm, and proximal medial forearmAdductor pollicis, abductor pollicis brevis, opponens pollicis, flexor pollicis brevis, interossei, lumbricals 1 and 2Ulnar nerve dysfunction

Common Neurological Findings for Lumbosacral Segmental Dysfunctiona

LevelDermatomal PatternAssociated Myotomal MusclesDeep Tendon ReflexPotential Differential List
L2Groin, anterior thighIliopsoas, pectineus, gracilisIntra-articular hip pathology, ilioinguinal nerve pathology, femoral nerve pathology, TFL strain, adductor strain, psoas pathology, PVD
L3Groin, anterior thigh, lateral thigh, anterior knee, anterior calfQuadriceps, adductor longus, brevis and magnusPatellaInguinal nerve pathology, femoral nerve pathology, lateral femoral cutaneous nerve, PVD
L4Anterior thigh, lateral thigh, anterior knee, anterior calf, medial calf, lateral calf, medial footQuadriceps, tibialis anterior, extensor hallucis longus, extensor digitorum longus, gluteus mediusPatellaIliotibial band syndrome, quadriceps pathology, gastrocnemius strain, meralgia paraesthetica, plantar fasciopathy, tarsal tunnel syndrome, femoral nerve entrapment, medial tibial stress syndrome, Achilles pathology, posterior tibialis tendinopathy, PVD
L5Lateral thigh, posterior thigh, anterior knee, posterior knee, anterior calf, posterior calf, lateral calf, dorsum foot, plantar footSemimembranosis, semitendinosis, gluteus medius, peroneals, TFLMedial hamstringMeralgia paraesthetica, iliotibial band syndrome, gluteus medius/maximus tendinopathy, piriformis syndrome plantar fasciopathy, medial or lateral plantar nerve entrapment, deep peroneal nerve injury, medial tibial stress syndrome, 1st ray dysfunction, PVD
S1Lateral thigh, posterior thigh, posterior knee, posterior calf, lateral calf, dorsum foot, plantar footGastrocnemius, soleus, biceps femoris, gluteus maximus, piriformisAchillesMeralgia paraesthetica, gluteus maximus dysfunction, piriformis syndrome, plantar fasciopathy, medial or lateral plantar nerve entrapment, superfical peroneal nerve injury, peroneus longus/brevis injury, gastrocnemius strain, 5th metatarsal stress fracture, PVD
S2Posterior thigh, popliteal fossa, medial ankle and footFlexor hallucis longus, flexor digitorum longusHamstring injury, gastrocnemius strain, posterior tibial nerve entrapment, medial plantar nerve entrapment, PVD

Statistical Use of Neurological Tests

TestCondition TestedSnSpLR+LR−
Hoffman'sMyelopathy44751.80.7
BabinskiMyelopathy339240.7
ClonusMyelopathy11962.70.9
L'hermitte's signMyelopathy39711
Gonda-Allen signMyelopathy90
Deep tendon reflexesMyelopathy44711.50.8
Inverted supinator signMyelopathy61782.80.5
Suprapatellar tendon reflexMyelopathy56330.81.3
Hand withdrawal reflexMyelopathy41631.10.9
Biceps or triceps hyperreflexiaMyelopathy44711.50.8
Achilles tendon hyperreflexiaMyelopathy15 to 2681 to 981.3 to 7.80.87 to 0.91
ULTT medianCervical radiculopathy97221.30.12
ULTT radialCervical radiculopathy72331.10.85
Anterior thigh sensation changeL2 radiculopathy5096120.52
Femoral nerve stretch testL3 radiculopathy70885.70.88
Sit to standL3 radiculopathy50772.20.65
Sit to standL4 radiculopathy54812.80.57
Crossed femoral stretch testL4 radiculopathy91000.91
Medial ankle sensation changeL4 radiculopathy311000.69
Patellar tendon reflexL4 radiculopathy39957.70.65
Achilles tendon reflexL5 radiculopathy33913.90.73
Straight leg raiseL5 radiculopathy676720.5
Straight leg raiseS1 radiculopathy736320.43
Heel raise testL5 or S1 radiculopathy4860.291.1
Heel walk testL5 or S1 radiculopathy20861.10.98
Great toe extensor weaknessL5 radiculopathy20620.531.3
Hip abductor weaknessL5 radiculopathy2997110.73
Speech productionCNS lesion11931.470.96
Finger to noseCNS lesion11952.210.94
SLS (eyes closed firm surface)CNS lesion379815.470.65
SLS (eyes open unstable surface)CNS lesion539822.110.49
SLS (eyes closed unstable surface)CNS lesion329813.260.7
Pupil symmetryCNS lesion31003.310.97
Pronator driftCNS lesion61431.060.92
Tandem gaitCNS lesion559511.610.47

Interpretation of Sensitivity and Specificitya

Statistical TermDefinitionClinical Take HomeExample
SensitivityThe test's ability to obtain a positive result when the condition is present (true positive).A negative result for a highly sensitive test suggests the absence of the condition. Tip: ‘SNout rule out’The upper limb tension test is highly sensitive for cervical radiculopathy (0.97). When this test is negative, clinicians can more confidently believe that the condition is not present. Given its lower specificity (0.22), a positive result does not help rule in the condition.
SpecificityThe test's ability to obtain a negative test when the condition is absent (true negative).A positive result for a highly specific test suggests the presence of the condition. Tip: ‘SPin rule in’L'hermitte's sign is highly specific (0.97) for myelopathy. When this test is positive, clinicians can more confidently believe the condition is present. Given its low sensitivity (0.03), a negative result does not help rule the condition out.

Interpretation of Likelihood Ratios

LR+LR−Interpretation
> 10< 0.1Creates large and typically conclusive shift in probability
5 to 100.1 to 0.2Creates moderate shift in probability
2 to 50.2 to 0.5Creates small but possibly important shift in probability
1 to 20.5 to 1Alteration to probability is small, rarely important
Authors

From the Physical Therapy Program, School of Medicine and Health Sciences, George Washington University, Washington, DC (DJJ); and the Virginia Orthopedic Manual Physical Therapy Institute, Charlottesville, Virginia (DJJ, EBL, SER, EMM).

The authors have no financial or proprietary interest in the materials presented herein.

Correspondence: Dhinu J. Jayaseelan, DPT, OCS, FAAOMPT, 2000 Pennsylvania Avenue NW, Suite 2000, Washington, DC 20006. E-mail: dhinuj@gwu.edu

10.3928/19425864-20180614-01

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