One of our jobs as physical therapist’s include identifying red flags and ruling out more serious disorders that warrant referring out.

Considering I treat a great deal of spinal patients (especially ones of increasing age), one disorder that comes to mind is identifying cervical spine myelopathy (CSM).  The main concern with this condition is the compression placed on the actual spinal cord, not nerve roots.  If neurological status is worsening, this would mean immediate referral.  There are many sites to read about the pathophysiology further, but here is one you can go to.

In 2010, Cook et al published a paper entitled, “Clustered Clinical Findings for Diagnosis of Cervical Spine Myelopathy”.  The findings provided a clinical decision making tool that had high sensitivity (to rule-out CSM) and even high specificity (to rule-in CSM).  The picture blow shows these values:

Physical Therapy
Physical Therapy

Out of the five tests, the two that students have the most trouble with (and never see a positive sign) are the Hoffman’s Test and Inverted Supinator Sign.  I find both of these to have high specificity values in my practice (which means if the test is positive, a high probability of an upper motor neuron disorder is present).  So, here they are:


Hoffmans’ Test:

How to perform: Grasp the patient’s middle phalanx of 3rd digit at distal end with your 2nd and 3rd distal phalanges.  Flick the patient’s distal phalanx into flexion using your thumb.

Positive test: Adduction of thumb and/or flexion of fingers

A negative test or normal response (as provided by Clinically Relevant’s YouTube Page).

A positive test or abnormal response provided by my YouTube Page:

Angle 1:

Angle 2:


Inverted Supinator Sign

How to perform: Using reflex hammer, strike the brachioradialis tendon near radial styloid process at distal end of radius (C6 DTR).

Positive test: Finger flexion

A negative test or normal response (as provided by Clinically Relevant’s YouTube Page).

A positive test or abnormal response provided by my YouTube Page:




  1. HV,

    Great post and thanks for the reference for the CSM test cluster. I have seen only one + Hoffmans test in practice thus far, that patient did ultimately get confirmation via imaging that he had cervical stenosis.

    1. No problem Tommy. Yeh its quite interesting to see it the first time. I’ve picked it up before (and even in this case) after a person has had a fusion for c/s myelopathy but still exhibiting UMN signs.
      See ya next week man!

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