Upper limb Neurological Exam


  • Wash hands, Introduce self, Check patient name and DOB/CHI, Explain procedure and Gain consent


  • Look at the patient in general, their posture, their gait (if applicable)
  • Look at the arms, shoulder girdle and their muscle groups at rest for
    • Tremor; muscle wasting/fasciculations; deformity; injury; abnormal movements
    • Cutaneous signs e.g. neurofibromas, cafe au lait spots, scars


  • Ensure the patient is relaxed
  • Taking the patient’s hand in your ipsilateral hand (i.e. right – right) and supporting the patient’s elbow with the opposite hand:
    • Test for rigidity (extrapyramidal) by slowly extending and flexing the wrist(/elbow) and pronating/supinating the arm
      • Cogwheel rigidity may be felt if there is both tremor and rigidity (feels like cogs catching as you supinate the arm)
    • Test for spasticity (pyramidal) by rapidly extending the elbow- spasticity will be felt as a ‘catch’ followed by relaxation
  • If any increased tone is felt (particularly spasticity), ask the patient to clench their teeth and repeat manoeuvre (this can increase the features)


  • NB Always support the proximal joint to the muscle tested; compare sides like with like, but use a lot of strength (i.e. provide as much resistance to both sides equally)
    • Grade response
      • 0- no movement
      • 1- Flicker/muscle contraction
      • 2- Movement but not against gravity
      • 3- Movement against gravity but not resistance
      • 4- Movement against resistance but not full
        • (4+ is sometimes used to help differentiate further)
      • 5- Full strength
  • Movements
    • Shoulder abduction (C5); Elbow flexion (C6); Elbow extension (C7); Wrist extension (C7); Wrist flexion (C7/8); Finger extension (C7- radial); Finger flexion (C8); Finger spread (T1- ulnar); Thumb abduction (T1- median)


  • Biceps (C5/6)- Ask the patient to relax their arm across their lap.  Place your index finger across the biceps tendon and strike finger with the tendon hammer.  Observe the biceps for contraction
  • Supinator (C6)- In the same position, place a finger over the brachioradialis tendon (lateral forearm) and strike.  Look at the brachioradialis (upper lateral forearm) for contraction.
  • Triceps (C7)- Hold the ipsilateral wrist (with your same (right-right) hand) and let their arm go floppy.  Strike the triceps tendon (above the olecranon) and observe for contraction of the triceps.

Coordination (cerebellar)

  • Finger nose test (point at your finger then their nose repeatedly) for intention tremor and past-pointing
  • Alternate palmar/dorsal clapping (dysdiadokinesia)


  • NB For light touch and pain, provide example sensation on the sternum first.
  • Touch the arm in each dermatome with their eyes closed using a cotton wool bud (light touch) and a pin (pain)
    • Ask whether it feels the same as the sternum; also compare side with side and ask about any differences
  • Grant_1962_663
  • Proprioception
    • Hold the proximal phalanx of the thumb with one hand and the distal phalanx with your finger/thumb on either side of the phalanx.  Show patient the up/down movements.  Ask them to close their eyes and tell you which movement is occurring as you move the thumb.  Repeatedly wiggle it up/down before settling on a position each time.
  • Vibration (use 128Hz fork)
    • Start by example on sternum and then work proximally from the thumb DIP, PIP, wrist, elbow (NB if they can feel it distally, unlikely need for testing proximally)
  • Temperature may also be tested
    • Usually rough test using the cold of the tuning fork


  • Thank the patient, Wash hands
  • Record findings in notes/to examiner/supervisor
  • Suggest any further investigations/management
  • (suggest examination of the lower limbs and cranial nerves if appropriate)

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