Clinical Neurology · Neurological Examination
Deep Tendon Reflexes
Deep tendon reflexes (DTRs) tested on neurological examination, organized by limb. For each reflex the table lists the eliciting maneuver, the expected response (including notable exaggerated, inverted, or pathological variants), and the segmental nerve supply.
Upper Limb Reflexes
| Reflex | Mechanism | Response | Nerve supply |
|---|---|---|---|
| Biceps | Tapping over a finger placed on the biceps tendon while arm semi-flexed. Exaggerated reflex: | Elbow flexion. Increased reflexogenic zone (tapping the clavicle); reflex spread (finger flexion). | C5–6 |
| Brachioradialis | Tapping just above the styloid process of the radius with the forearm in semiflexion. Inverted supinator reflex: cervical myelopathy (cord compression) with C5–6 radiculopathy (absent biceps contraction). | Elbow flexion ± supination. Inverted: flexion of fingers without elbow flexion ± elbow extension. | C5–6 |
| Triceps | Tapping the triceps tendon just above its insertion on the olecranon process. Inverted triceps reflex: in combined cord lesion above C5 and radiculopathy of C7–8. | Elbow extension. Inverted: elbow flexion. | C7–8 |
| Finger flexor “Wartenberg sign” | Patient’s hand is supine, resting on a table or a solid surface. Place your fingers against the patient’s fingers, and tap the backs of his own fingers. | Flexion of fingers and the distal phalanx of thumb. | C8–T1 |
| Hoffmann / Tromner | Hold the middle finger with your index and thumb then nip or snap the nail of the middle finger (down). Tromner: snap the belly of the distal phalanx instead (up). | Adduction of the thumb and flexion of the index finger. | C8–T1 |
| Scapulohumeral | Tapping over the vertebral border of the scapula. | Retraction of the scapula; contraction of rhomboids. | C4–5 (Dorsal scapular) |
| Deltoid | Tapping over the insertion of the deltoid muscle at the lateral aspect of the humerus. | Slight arm abduction. | C5–6 (Axillary) |
| Pectoralis | Tapping over a finger placed on the insertion of pectoralis at the greater tuberosity of humerus. | Slight adduction & internal rotation. | C5–T1 (Pectoral Ns) |
| Latissimus Dorsi | Tapping over a finger placed on the insertion of latissimus at intertubercular groove of the humerus. | Slight abduction & internal rotation. | C6–8 (Thoracodorsal) |
| Clavicular | Tapping over the lateral border of the clavicle. A non-specific reflex that indicates increased reflexogenic zone; used to compare reflexes in both upper limbs. | Contraction of various muscle groups in the upper limb. | — |
| Wrist Extension | Tapping the extensor tendons of the wrist with wrist hanging down. | Wrist extension. | — |
Lower Limb Reflexes
| Reflex | Mechanism | Response | Nerve supply |
|---|---|---|---|
| Patellar | Place one hand over the muscle, and with the other hand tap the patellar tendon just below the patella. Exaggerated reflex. Inverted patellar reflex: knee flexion instead of extension due to femoral or L2–4 root lesions. | Knee extension. Exaggerated: increased reflexogenic zone (tapping suprapatellar); reflex spread (hip adduction). Inverted: knee flexion. | L2–4 (Femoral) |
| Achilles | Place the patient’s legs in a figure four position, with mild dorsiflexion exerted on the ankle, tap over the Achilles tendon. | Plantar flexion of the ankle. | S1 (Tibial nerve) |
| Adductor | With the thigh in slight abduction, tap over the adductor tubercle (above medial epicondyle). Crossed adductor: slight adduction is not abnormal but strong adduction is pathological. Spinal adductor reflex: tapping the spinous process of lumbar vertebra causes adductor response. | Ipsilateral thigh adduction. Crossed: adduction of opposite thigh. | L2–4 (Obturator) |
| Internal Hamstrings | Tapping on examiner’s fingers placed on the medial part of posterior aspect of the knee while leg is abducted and laterally rotated. | Knee flexion. | L5 (Tibial portion of sciatic) |
| External Hamstrings | Tapping on examiner’s fingers placed on the lateral part of posterior aspect of the knee while leg is flexed. Another S1 reflex (besides ankle jerk) which helps with sorting out absent ankle reflex due to neuropathy (present) from S1 radiculopathy (present). | Knee flexion. | S1 (Tibial portion of sciatic) |
| Tensor Fascia Lata | Tapping near the ASIS. | Slight hip abduction. | L4–S1 (Sup gluteal) |
| Gluteal | Tapping over the posterior aspect of the ilium bone. | Hip extension & gluteal contraction. | L5–S2 (Inf gluteal) |
Ahmed Koriesh, MD