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Goniometry: Cervical Spine Flexion

Original Editor - Angeliki Chorti

Top Contributors - Angeliki Chorti and Alexandra Stead  

Introduction

The cervical spine is the most mobile and flexible region of the spine. Its unique features allow for significant movement of the head and neck in various directions. It has 7 articulating vertebrae (C1 to C7) and is divided into 2 parts forming 1) the cranio-cervical junction (CCJ) together with the occiput (C1-atlas and C2-axis) and 2) subaxial spine (C3-C7). [1]

Cervical spine joints may contribute differently during neck kinematics; for flexion, some segments (C2-C5) may contribute more at the midrange of motion, whereas other (e.g. the C5-C6 and C6-C7 segments) are considered to contribute the most over the start and the end range of motion. [2]

For more information on cervical spine kinematics, go to Kinematics of the Cervical Spine

Flexion of the cervical spine (bending your head forward) is crucial for a number of functions related to daily activities, such as reading a book, looking at a mobile phone, nodding, eating and drinking, looking down to wear your shoes etc.

Cervical spine flexion is limited by anatomical structures:

  • Posterior Longitudinal Ligament (PLL)
  • Ligamentum Flavum
  • Ligamentum Nuchae (Supraspinous)
  • Interspinous Ligaments
  • Accessory Atlantoaxial Ligament
  • Articular Capsules
  • Intervertebral Discs
  • Bone contact

These restrictions have a protective and stabilising role, preventing damage to the spinal cord and nerves from extreme forward bending. Age, previous trauma, or degeneration may also affect cervical spine kinematics. [3]

Anatomical Movement

Cervical Spine Flexion (forward head movement towards the chest) [4]

Axis and Plane for Motion

  • Frontal axis
  • Sagittal plane

Testing Position

Testing position for cervical spine flexion may vary according to the aim of the examination. For general range of movement (ROM), the seated position may be more appropriate.

To test neck flexion in a seated position with a goniometer, the subject sits upright in a chair with feet flat, thoracic and lumbar spine supported.

Other positions may serve additional testing purposes. For example, when testing for deep neck flexors (cranio-cervical flexion test),[5] the supine position (lying) is best.[6] For more information on deep neck flexor testing and lying testing position, click on this page.

Goniometer Placement

Placement 1

AXIS LOCATION STATIONARY ARM MOVEMENT ARM
Over the external auditory meatus Vertical to the floor With base of nares or parallel to longitudinal axis of tongue depressor


You can watch an example of cervical spine flexion goniometric measurement in the following video: [7]

Stabilisation

The chair should be stable and supporting the back. Its height is adjusted for a neutral spine and comfortable access.

Shoulder girdle is stabilised to isolate the movement of the cervical spine and prevent flexion of thoracic & lumbar spine.

Placement 2 (using semi-circular goniometer)

AXIS LOCATION STATIONARY ARM MOVEMENT ARM
C7 spinous process Vertical to the floor or aligned with the thoracic spinous processes Following the dorsal midline of the head (aligning with earlobe or nose at end range)

[6][8]

Stabilisation

Ensure that the trunk is stabilised to isolate the movement to the cervical spine.

Technique

Active Range of Motion: Ask the individual to bring the chin to the chest.

Passive Range of Motion: The examiner gently supports the individual's head and moves the cervical spine towards flexion, until the movement stops.

Precautions

Due to the complexity and sensitivity of the neurovascular structures, caution must be paid when assessing neck movements. For example, extreme caution should be paid (and screening should precede) in assessment of neck flexion in individuals with Down syndrome because of atlantoaxial instability.[9] You can find information on cervical spine range of motion precautions in the Cervical Spine Range of Motion page.

Expected Findings

Expected range of motion in seated position may vary for different reasons; nevertheless, it may start from 45 degrees,[10] leading to 57 degrees[11] or extending to 80-90 degrees for flexion.[3] Various factors may influence cervical spine range of motion (e.g. age, gender, temperature, race)[12] and these factors should be taken into account when considering 'normal' values.

Note: Range of motion (available amount of joint movement) and flexibility (soft tissue length) are sometimes used interchangeably. However, these terms do not have the same meaning.[13]

Resources

Examples of cervical spine goniometry by the University of West Alabama.

Normative values of cervical range of motion for both children and adults: A systematic review.

References

  1. ↑ Kaiser JT, Reddy V, Launico MV, Lugo-Pico JG. Anatomy, Head and Neck: Cervical Vertebrae. [Updated 2023 Oct 24]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-.
  2. ↑ Anderst WJ, Donaldson WF 3rd, Lee JY, Kang JD. Cervical motion segment percent contributions to flexion-extension during continuous functional movement in control subjects and arthrodesis patients. Spine (Phila Pa 1976). 2013 Apr 20;38(9):E533-9.
  3. ↑ 3.0 3.1 Swartz EE, Floyd RT, Cendoma M. Cervical spine functional anatomy and the biomechanics of injury due to compressive loading. J Athl Train. 2005 Jul-Sep;40(3):155-61.
  4. ↑ Jung B, Black AC, Bhutta BS. Anatomy, Head and Neck, Neck Movements. [Updated 2023 Nov 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-.
  5. ↑ Jull GA, O'Leary SP, Falla DL. Clinical assessment of the deep cervical flexor muscles: the craniocervical flexion test. J Manipulative Physiol Ther. 2008 Sep;31(7):525-33.
  6. ↑ 6.0 6.1 Sukari AAA, Singh S, Bohari MH, Idris Z, Ghani ARI, Abdullah JM. Examining the Range of Motion of the Cervical Spine: Utilising Different Bedside Instruments. Malays J Med Sci. 2021 Apr;28(2):100-105.
  7. ↑ Sleeper M. Goniometric Measurement: Cervical Flexion range of motion. Available from: https://www.youtube.com/watch?v=15G960Yl_JQ [accessed 5/12/2025]
  8. ↑ Araujo G, Pontes-Silva A, Leal P, Gomes P, Reis M, Lima S, Fidelis-de-Paula-Gomes C, Dibai-Filho A. Goniometry and fleximetry measurements to assess cervical range of motion in individuals with chronic neck pain: a validity and reliability study. BMC Musculoskelet Disord. 2024; 25: 651.
  9. ↑ Ali FE, Al-Bustan MA, Al-Busairi WA, Al-Mulla FA, Esbaita EY. Cervical spine abnormalities associated with Down syndrome. Int Orthop. 2006 Aug;30(4):284-9.
  10. ↑ Hendriks. Normal ROM values according to AAOS. Available from: https://cdn-links.lww.com/permalink/prsgo/b/prsgo_8_6_2020_04_17_hendriks_gox-d-20-00155r2_sdc1.pdf [accessed 5/12/2025]
  11. ↑ Apti A, Kuru Çolak T, Akçay B. NORMATIVE VALUES FOR CERVICAL AND LUMBAR RANGE OF MOTION IN HEALTHY YOUNG ADULTS. J Turk Spinal Surg. 2023 Jul 27;34(3):113-117.
  12. ↑ Kriviskas L.Training flexibility. In: Frontera WR, Dawson D, Slovik D. (eds.), Exercise in Rehabilitation Medicine. Human Kinetics, Champaign, 1999.
  13. ↑ Strimpakos N. The assessment of the cervical spine. Part 1: Range of motion and proprioception. J Bodyw Mov Ther. 2011; 15: 114-24.
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