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Home› Physical Therapy› Free Self-Checks› Special Tests› Cervical Spine

Cervical Spine Special Tests

Radiculopathy, upper cervical instability and cervicogenic headache tests, including the Wainner cluster.

Reviewed by Dr. Richard Holsman, PT, DPT, NCS · Last reviewed November 13, 2026 · For clinician education

⚠️ For clinicians

For clinician education; special tests support but do not replace a full examination. This page is a reference for physical therapists, occupational therapists, athletic trainers, students and other clinicians. Patients with joint or spine pain should be examined by a licensed clinician.

For cervical radiculopathy, the upper limb tension test A is the best single test to rule it out, and the four-item Wainner cluster is far better than any single test to rule it in. Screen for red flags before any provocation test.

On this page

Accuracy at a glance

TestTarget conditionSnSp+LR−LRSource
Spurling’s test (Spurling A)Cervical radiculopathy (EMG/NCS reference)50%86%3.50.58[1]
Neck distraction testCervical radiculopathy (EMG/NCS reference)44%90%4.40.62[1]
Upper limb tension test A (median nerve bias)Cervical radiculopathy (EMG/NCS reference)97%22%1.30.12[1]
Cervical rotation less than 60° to the involved sideCervical radiculopathy (EMG/NCS reference)89%49%1.80.23[1]
Sharp-Purser testAtlantoaxial subluxation in rheumatoid arthritis88% (subluxation >4 mm)96%——[2]
Cervical flexion-rotation testCervicogenic headache with C1–C2 as the main level (experienced examiners)90%88%——[3]

Sn = sensitivity, Sp = specificity, LR = likelihood ratio. A dash means the source we checked did not report that value.

How to read the accuracy numbers

  • Sensitivity: of people who have the condition, the share with a positive test. A highly sensitive test that is negative helps rule the condition out.
  • Specificity: of people without the condition, the share with a negative test. A highly specific test that is positive helps rule it in.
  • Positive likelihood ratio (+LR): how much a positive result raises the odds. About 5–10 is a moderate shift; above 10 is large.
  • Negative likelihood ratio (−LR): how much a negative result lowers the odds. About 0.1–0.2 is a moderate-to-large shift; near 1 means little change.
  • Values depend on the study’s patients, examiners and reference standard. Many studies are small, so treat single-study numbers with caution.

Cervical Spine special tests, step by step

Each test is described in our own words. Compare with the uninvolved side and stop if the test provokes severe pain.

Spurling’s test (Spurling A)

Also called: Foraminal compression test

Purpose
Narrows the intervertebral foramen to reproduce radicular arm symptoms.
Patient position
Sitting upright.
How to perform[4]
  1. Side-bend the head toward the symptomatic side.
  2. Apply gentle, controlled downward pressure through the top of the head.
Positive finding
The patient’s familiar arm or shoulder-blade symptoms, not just local neck pain.

Diagnostic accuracy

Target condition (source)SensitivitySpecificity+LR−LR
Cervical radiculopathy (EMG/NCS reference)[1]50%86%3.50.58

Neck distraction test

Purpose
Opens the foramen to see if radicular symptoms ease.
Patient position
Supine, head supported.
How to perform[4]
  1. Cradle the occiput and chin.
  2. Gently flex the neck to comfort and apply a gradual upward pull.
Positive finding
Arm symptoms decrease or go away.

Diagnostic accuracy

Target condition (source)SensitivitySpecificity+LR−LR
Cervical radiculopathy (EMG/NCS reference)[1]44%90%4.40.62

Upper limb tension test A (median nerve bias)

Also called: ULTT A, ULNT1

Purpose
Tensions the median nerve and cervical nerve roots.
Patient position
Supine, close to the edge of the table.
How to perform[4]
  1. Depress the shoulder girdle.
  2. Abduct the shoulder to about 90–110°.
  3. Supinate the forearm and extend the wrist and fingers.
  4. Rotate the shoulder outward.
  5. Slowly straighten the elbow.
  6. Side-bend the neck away, then toward the tested side, and note any change.
Positive finding
Familiar symptoms are reproduced; or there is a side-to-side difference of more than 10° of elbow extension; or neck side-bending away makes symptoms worse (or toward eases them).

Diagnostic accuracy

Target condition (source)SensitivitySpecificity+LR−LR
Cervical radiculopathy (EMG/NCS reference)[1]97%22%1.30.12
Best single test to rule out radiculopathy when negative.

Cervical rotation less than 60° to the involved side

Purpose
A range-of-motion finding that is one item of the Wainner cluster.
Patient position
Sitting upright.
How to perform[4]
  1. Measure active rotation toward the symptomatic side with a goniometer (see our cervical ROM page).
Positive finding
Rotation toward the symptomatic side under 60°.

Diagnostic accuracy

Target condition (source)SensitivitySpecificity+LR−LR
Cervical radiculopathy (EMG/NCS reference)[1]89%49%1.80.23

Sharp-Purser test

Purpose
Screens for anterior atlantoaxial (C1–C2) instability, especially in rheumatoid arthritis.
Patient position
Sitting, neck relaxed in slight flexion.
How to perform[4]
  1. Stabilize the C2 spinous process between thumb and finger.
  2. With the palm on the forehead, gently push the head backward.
Positive finding
A sliding motion or clunk of the head backward relative to C2, often with relief of symptoms. Stop if symptoms provoke; do not force.

Diagnostic accuracy

Target condition (source)SensitivitySpecificity+LR−LR
Atlantoaxial subluxation in rheumatoid arthritis[2]88% (subluxation >4 mm)96%——
Reported predictive value 85%.

Cervical flexion-rotation test

Also called: FRT

Purpose
Looks for restricted C1–C2 rotation in cervicogenic headache.
Patient position
Supine.
How to perform[4]
  1. Fully flex the neck passively.
  2. Holding full flexion, rotate the head to each side to end range or pain.
  3. Estimate or measure the range each way.
Positive finding
Clearly less rotation to one side than the other, with a firm stop, often reproducing the headache.

Diagnostic accuracy

Target condition (source)SensitivitySpecificity+LR−LR
Cervicogenic headache with C1–C2 as the main level (experienced examiners)[3]90%88%——
Small sample.

Test clusters and prediction rules

Combinations of findings usually shift probability more than any single test.

Wainner cluster for cervical radiculopathy

Items: Spurling A, distraction, ULTT A and cervical rotation less than 60° to the involved side.

Accuracy: 3 of 4 positive: sensitivity 39%, specificity 94%, +LR 6.1. All 4 positive: sensitivity 24%, specificity 99%, +LR 30.3 (95% CI 1.7–538.2). The confidence intervals are very wide.[1]

What we left out

Vertebral artery and cervical arterial dysfunction screening, Valsalva, shoulder abduction (Bakody) sign and alar ligament tests are not covered here. We only show accuracy numbers we could check against the original study or review.

Sources, review and disclosures

Graded citations

How we grade sources. A = systematic review or meta-analysis. B = single prospective diagnostic accuracy study. C = small, retrospective or case-control study, or a clinical prediction rule that has only been derived (not yet validated). D = expert clinical opinion (our test descriptions). Every accuracy number on this page was checked against the cited abstract or full text on November 13, 2026. If we could not check a number, we left it out and say “accuracy data not verified.”

  1. Grade B Wainner RS, Fritz JM, Irrgang JJ, Boninger ML, Delitto A, Allison S. Reliability and diagnostic accuracy of the clinical examination and patient self-report measures for cervical radiculopathy. Spine. 2003;28(1):52-62. doi:10.1097/00007632-200301010-00014 (Tables 4 and 5; reference standard EMG/nerve conduction; 82 patients). PubMed 12544957
  2. Grade B Uitvlugt G, Indenbaum S. Clinical assessment of atlantoaxial instability using the Sharp-Purser test. Arthritis Rheum. 1988;31(7):918-922. doi:10.1002/art.1780310715 (abstract; 123 outpatients with rheumatoid arthritis). PubMed 3395385
  3. Grade C Hall TM, Robinson KW, Fujinawa O, Akasaka K, Pyne EA. Intertester reliability and diagnostic validity of the cervical flexion-rotation test. J Manipulative Physiol Ther. 2008;31(4):293-300. doi:10.1016/j.jmpt.2008.03.012 (abstract; small sample). PubMed 18486750
  4. Grade D Holsman Physical Therapy clinical guidance. Patient position, test steps and positive findings written in our own words by Holsman physical therapists and reviewed by Dr. Richard Holsman, PT, DPT, NCS. Expert opinion, not a research source.

Reviewer

Reviewed by Dr. Richard Holsman, PT, DPT, NCS (Board-Certified Clinical Specialist in Neurologic Physical Therapy), founder of Holsman Physical Therapy. Last reviewed: November 13, 2026.

Change log

  • November 13, 2026: Page published. Test descriptions written in our own words; accuracy values checked against the cited sources.

Review policy

We re-check every number on this page against its source at least once a year, and sooner if a source is updated, a better study is published or a reader reports a problem. Changes are listed in the change log with the date. To report an error, contact us.

Licensing

Test descriptions, steps and the accuracy summaries are original text by Holsman Physical Therapy. Accuracy values are individual numbers cited with credit to the original studies; no tables, figures or text from journals, textbooks or other websites are reproduced. Linking to a source does not imply its endorsement. Demonstration videos, when added, will be filmed by Holsman physical therapists with consenting adult models.

Conflict of interest and advertising

This page is published by Holsman Physical Therapy and Wellness, P.C., which runs outpatient and in-home therapy practices; that is our only commercial interest. The page carries no advertising, no sponsorship and no affiliate links, and we received no payment from any source for it. Holsman Physical Therapy is not affiliated with the authors or publishers cited, and they do not endorse this website.

For clinician education; special tests support but do not replace a full examination. A positive or negative test changes the probability of a condition; it does not make a diagnosis. Interpret every result with the history, the rest of the examination, imaging when indicated, and clinical judgment. Stop any test that provokes severe pain or neurological symptoms.

Common Questions

What is the Wainner cluster?

Four findings for cervical radiculopathy: Spurling A, neck distraction, upper limb tension test A, and cervical rotation under 60 degrees toward the involved side. In Wainner 2003, all four positive gave a positive likelihood ratio of 30.3 and three of four gave 6.1.

Which test rules out cervical radiculopathy?

A negative upper limb tension test A. In Wainner 2003 it was 97% sensitive with a negative likelihood ratio of 0.12.

Referring a Patient?

Holsman physical therapists see patients at clinics across North Jersey, the Bronx and Brooklyn, plus in-home visits.

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