Upper Limb Neurological Examination

Subject summary

A full neurological examination includes assessment of the motor and sensory systems. You may be asked to examine one or both of these, but this guide will include both (view Lower Limb Neurological Examination).

  1. As with all examinations, the best method is your own – one with which you are comfortable and familiar. The one explained here takes the following format:

    • Tone
    • Power
    • Reflexes
    • Function
    • Sensation

  2. The upper body should be exposed for this examination. Initially, observe the patient’s arms, look for any muscle wasting, fasciculation’s or asymmetry.

    1. Observe the patients arms
      Observe the patients arms

  3. Start by examining the tone of the muscles. Start proximally at the shoulder, feeling how easy the joint is to move passively. Then move down to the elbow, wrist and hand joints again assessing each one’s tone in turn.

    1. Arm tone
      Arm tone
    2. Wrist and hand tone
      Wrist and hand tone

  4. You should next assess the power of each of the muscle groups. Again, start at the shoulder asking the patient to abduct and adduct against your hand so you can assess how much force they can overcome. Do the same for flexion and extension at the elbow and wrist as well as the fingers also checking abduction and adduction of the thumb.

    1. Shoulders
      Shoulders
    2. Arm flexion
      Arm flexion
    3. Arm extension
      Arm extension
    4. Wrist flexion
      Wrist flexion
    5. Wrist extension
      Wrist extension
    6. Finger flexion
      Finger flexion
    7. Finger extension
      Finger extension
    8. Finger abduction
      Finger abduction
    9. Thumb
      Thumb

  5. Next you should test the patient’s reflexes. There are three reflexes in the upper limb – the biceps, triceps and supinator reflexes.

  6. The biceps reflex is tested by supporting the patient’s arm, with it flexed at roughly 60º, placing your thumb over the biceps tendon and hitting your thumb with the tendon hammer. It is vital to get your patient to relax as much as possible and for you to take the entire weight of their arm.

    1. Biceps reflex test
      Biceps reflex test

  7. The triceps reflex is elicited by resting the patient’s arm across their chest and hitting the triceps tendon just proximal to the elbow.

    1. Triceps reflex test
      Triceps reflex test

  8. Finally, with their arm rested on their abdomen, locate the supinator tendon as it crosses the radius, place three fingers on it and hit the fingers. This should give the supinator reflex. If you struggle with any of these reflexes, asking the patient to clench their teeth should exaggerate the reflex.

    1. Supinator reflex test
      Supinator reflex test

  9. Function is a very important part of any neurological examination as this is the area which will affect people’s day to day lives the most. For upper limb you should ask people to touch their head with both hands and then ask them to pick up a small object such as a coin which each hand.

  10. The final test is sensation. However, this is tested in a number of ways. You should test light touch, pin prick, vibration and joint position sense, or proprioception.

  11. Ask the patient to place their arms by their sides with their palms facing forwards. Lightly touch the patient’s sternum with a piece of cotton wool so that they know how it feels. Then, with the patient’s eyes shut, lightly touch their arm with the cotton wool. The places to touch them should test each of the dermatomes – make sure you know these! Tell the patient to say yes every time they feel the cotton wool as it felt before. Then repeat this using a light pin prick.

    1. Touch sensation 1
      Touch sensation 1
    2. Touch sensation 2
      Touch sensation 2

  12. To assess vibration you should use a sounding tuning fork. Place the fork on the patient’s sternum to show them how it should feel. Then place it on the bony prominence at the base of their thumb and ask them if it feels the same. If it does, there is no need to check any higher. If it feels different you should move to the radial stylus and then to the olecranon until it feels normal.

    1. Vibration test
      Vibration test

  13. Finally, proprioception. Hold the distal phalanx of the thumb on either side so that you can flex the interphalangeal joint. Show the patient that when you hold the joint extended, that represents ‘Up’ whereas when you hold it flexed that represents ‘Down’. Ask the patient to close their eyes and, having moved the joint a few times hold it in one position – up or down. Ask the patient which position the joint is in.

    1. Thumb
      Thumb
    2. Thumb
      Thumb