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Upper Limb Tension Tests (ULTTs)

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Original Editor - Jennifer Self

Top Contributors - Kim Jackson, Admin, Purnima Raikwar, Adrianna Simmons, Jennifer Self, Hetvi Gala, Evan Thomas, Vidya Acharya, Aminat Abolade, Cindy John-Chu, Jeannine Escobar, Johnathan Fahrner, WikiSysop, Claire Knott and Lucinda hampton  

Edited April 2022 - by Adrianna Simmons and Jeannine Escobar as part of the Arkansas Colleges of Health Education School of Physical Therapy Musculoskeletal 1 Project

Introduction

Upper Limb Tension Tests (ULTTs), also called upper limb neurodynamic tests (ULNTs), brachial plexus tension tests, are clinical tests that move the upper limb through specific joint positions to load the nervous system and reproduce an individual's arm or neck symptoms.[1] Each test combines joint positions that increase tension in a particular nerve (the "nerve bias"), and further movements, most often cervical side flexion, can be added to increase the load ("sensitiser").

The tests were first described by Elvey and later developed by Butler and Shacklock.[2] They are the upper limb equivalent of the straight leg raise used for the lumbar spine. They are one part of a wider Neurodynamic Assessment and should be interpreted together with the history, neurological examination and other findings. They should not be used on their own to confirm or exclude a diagnosis.[3][4]

Clinically Relevant Anatomy

The brachial plexus is a network of nerves formed from the anterior rami of spinal nerves C5 to T1. It supplies the whole upper limb. Nerves are tested with ULTTs by lengthening them across the neck, shoulder, elbow, wrist and hand. They can be loaded or compressed where they pass through tight or mobile spaces.

Structure of the brachial plexus:[5]

Level What it is Spinal levels
Roots Four nerve roots leaving the cervical spine and T1 spine C5, C6, C7, C8, T1
Trunks Upper, middle and lower, passing between the scalene muscles Upper: C5-C6, Middle: C7, Lower: C8-T1
Divisions Each trunk splits into anterior and posterior divisions behind the clavicle --
Cords Lateral, posterior and medial, named by their position around the axillary artery Lateral: C5-C7, Posterior: C5-T1, Medial: C8-T1
Branches Terminal nerves of the arm, including median, radial and ulnar --

Nerves tested by ULTTs[3]

Nerve Origin Course (key points) Muscles supplied Sensation Common entrapment sites Test that biases it
Median Lateral and medial cords (C5-T1) Medial arm, cubital fossa, between the two heads of pronator teres, then through the carpal tunnel Most forearm flexors, thenar muscles, lateral two lumbricals Palmar thumb, index, middle and radial half of ring finger Pronator teres, carpal tunnel ULTT1, ULTT2A
Radial Posterior cord (C5-T1) Spiral groove of humerus, then lateral elbow, where it divides into superficial radial and posterior interosseous nerves Triceps, wrist and finger extensors Dorsum of the hand and radial three and a half digits Spiral groove, radial tunnel (supinator) ULTT2B
Ulnar Medial cord (C8-T1) Behind the medial epicondyle (cubital tunnel), then between the heads of flexor carpi ulnaris, then Guyon’s canal at the wrist Flexor carpi ulnaris, medial half of flexor digitorum profundus, most hand intrinsics Little finger and medial half of ring finger Cubital tunnel, Guyon’s canal ULTT3

Relevance to ULTTs:

Point Clinical meaning
Each test lengthens one nerve bed Shoulder, elbow, forearm, wrist and neck positions are chosen to bias the median, radial or ulnar nerve
Changing one joint changes the load This is why structural differentiation (for example neck side flexion) is used to check whether symptoms are neural
Nerves pass through narrow or mobile spaces Symptoms may come from the neck, thoracic outlet, elbow or wrist, so look at the whole limb[5]
Test choice follows the history Match the test to the area and nerve distribution of the patient’s symptoms[6]

Purpose

ULTTs are used to assess neural mechanosensitivity and the mobility of the nervous system in individuals with arm, neck or upper thoracic symptoms. They help the clinician judge whether neural tissue is contributing to the presentation and guide further assessment and management or as a part of neurodynamic assessment.[7]

The ULTT1 is one of four items in the Wainner clinical prediction rule for cervical radiculopathy, together with a positive Spurling’s A test, a positive distraction test and cervical rotation of less than 60° to the involved side. When three of the four are positive, the likelihood of cervical radiculopathy increases (positive likelihood ratio 6.1), and with all four it increases further (30.3), although the confidence intervals are wide.[8] Combinations of neurodynamic tests have also been studied, with three of four positive tests able to rule in cervical radiculopathy.[9] A single test is not diagnostic, and the evidence for physical tests in cervical radiculopathy is limited.[10]

Indications

  • Arm, neck, shoulder or upper thoracic symptoms where a neural contribution is suspected, for example suspected cervical radiculopathy or peripheral nerve entrapment[3]
  • Symptoms that are stable, not severe and not easily provoked.

Contraindications and Precautions

Contraindications. Neurodynamic testing should be avoided when:[3]

  • Pain is severe, unstable, irritable or easily provoked
  • Symptoms are rapidly worsening or there is progressive neurological deficit
  • Red flags are suspected (for example spinal cord compression, infection, malignancy or fracture) and need investigation first
  • Physical or psychosocial factors make provocative testing inappropriate

Precautions. Precautions apply when testing is appropriate, but symptoms could be aggravated, so the test is adapted to the individual’s irritability and taken only as far as needed to reproduce their symptoms [4]

  • Symptoms may be provoked more easily in the upper limb than in the lower limb as the tests involve multiple joints and the complex anatomical course of the nerves.
  • Unintended aggravation is unlikely after a thorough subjective examination and good clinical reasoning.
  • Proper history and assessment of irritability should be completed before testing. Testing should stop at the first reproduction of symptoms.
  • Do not hold the final position for a prolonged period.

Technique

General Technique

ULTTs aim to reproduce the patient’s symptoms by placing the upper limb in a series of joint positions that progressively load a specific nerve. They should be performed in a slow, controlled and standardised way, so that the response can be compared between sides and between assessments.[3]

  1. Therapist should briefly explain the patient the procedure they are going to perform in layman terms. This decreases the feeling of anticipation among the patient and they are more calm and relaxed. Inform the patient that it may or may not evoke the symptoms and to communicate verbally when patient feels any kind of discomfort.
  2. Care should be taken to just evoke the symptoms and not further aggravate the symptoms.
  3. Each test is done on the normal/asymptomatic side first.
  4. The precision of the test is attributed to performance with an appropriate stabilizing hand and a slow, steady mobilizing hand.
  5. The final movement should not be held for more than 10 secs.
  6. Watch for unwanted movements which might alter the results. Traditionally for the upper limb, the order of joint positioning is shoulder followed by forearm, wrist, fingers, and lastly elbow. Each joint positioning component is added until the pain is provoked or symptoms are reproduced. To further sensitize the upper limb tests, side flexion of cervical spine can be added[11]. If pain is provoked in the very initial position, then there is no need to add further sensitizers.

Positive Test

Definitions of a positive test vary widely between studies. A widely used definition is:[7][12]

  • Reproduction of some symptoms
  • A change in those symptoms with structural differentiation, that is, movement of a joint away from the symptom site that alters neural load without changing the local tissue load.

Structural differentiation.

  • For distal symptoms (for example in the hand), move proximally: add contralateral cervical side flexion to increase the symptoms, or ipsilateral side flexion to decrease them.
  • For proximal symptoms (for example in the neck or shoulder), move distally: release wrist and finger position to ease the symptoms.

A change in symptoms with structural differentiation supports a neural contribution. No change suggests another source.

A side-to-side difference (usually more than about 10° of elbow extension).[4]

The Tests

Naming varies between sources. The table below shows how the numbering used by Butler, Shacklock and Elvey relates to the numbering in Magee. Always state the nerve bias alongside the test number.[1][13]

Common name Nerve bias Magee (7th ed.)
ULTT1 (ULNT1) Median ULTT1
ULTT2A (ULNT2a) Median ULTT2
ULTT2B (ULNT2b) Radial ULTT3
ULTT3 (ULNT3) Ulnar ULTT4

Upper Limb Tension Test 1 (Median nerve bias)

Indications-
  1. Radiating pain in the upper limb[3]
  2. Tingling sensations in first 3 fingers

Position- supine, close to the edge of the bed.

Movements performed
  1. Shoulder Girdle depression
  2. Shoulder abduction 110°
  3. Shoulder external rotation with elbow at 90°
  4. Forearm supination
  5. Wrist and finger extension
  6. Elbow extension
Structural differentiation
  • Proximal symptoms- Relieve wrist and finger extension
  • Distal symptoms (provocation)- Contralateral neck flexion

[14]

Upper Limb Tension Test 2A (ULTT2A, Median nerve bias)

Indications
  1. Radiating pain in the upper limb
  2. Recent shoulder arthroplasty surgery[3] (precautions must follow)
  3. Recent Dislocation of shoulder and Instability

Position - supine, close to the edge of the bed.

Movements performed
  1. Shoulder girdle depression
  2. Shoulder abduction 10°
  3. Lateral (external) rotation of the whole arm
  4. Forearm supination
  5. Wrist and finger extension
  6. Elbow extension
Structural differentiation
  • Proximal symptoms- Relieve wrist and finger extension
  • Distal symptoms (provocation)- Contralateral neck flexion

[15]

Upper Limb Tension Test 2B (ULTT2B, Radial nerve bias)

Indications-
  1. Radiating pain in the upper limb
  2. Supinator tunnel syndrome[3]
  3. De Quervain`s disease

Position: supine, with the shoulder at the edge of the bed.

Movements performed
  1. Shoulder girdle depression
  2. Shoulder abduction 20-30°
  3. Shoulder internal rotation
  4. Forearm pronation
  5. Wrist, finger and thumb flexion
  6. Elbow extension
Structural differentiation
  • Proximal symptoms- Relieve wrist and finger flexion
  • Distal symptoms (provocation)- Contralateral neck flexion

[16]

Upper Limb Tension Test 3 (ULTT3, Ulnar nerve bias)

Indications
  1. Pain radiating to 4th and 5th digits[3]
  2. Thoracic outlet syndrome

Position - supine, close to the edge of the bed.

Movements performed
  1. Shoulder girdle depression
  2. Shoulder abduction 110°
  3. Shoulder external rotation
  4. Forearm pronation
  5. Wrist and Finger extension
  6. Elbow flexion
Structural Differentiation
  • Proximal symptoms- Relieve wrist and finger extension
  • Distal symptoms (provocation)- Contralateral neck flexion

[17]

Normal Responses

In asymptomatic people the following responses are common during ULTT1 and ULTT2A:[13]

  • Deep ache or stretch in the cubital fossa (reported in about 99%)
  • Deep ache or stretch into the anterior and radial forearm and the radial side of the hand (about 80%)
  • Tingling in the fingers supplied by the nerve being tested
  • Stretch over the anterior shoulder
  • Response increased by contralateral cervical side flexion (about 90%) and decreased by ipsilateral side flexion (about 70%)


Evidence

Reliability

  • Inter-examiner reliability: In the Wainner et al. study, the ULTT had a kappa of 0.76, which is substantial agreement.
  • Upper limb nerve tests in general: A reliability study of clinical tests of nerve function and mechanosensitivity of the upper limb reported moderate to substantial reliability for neurodynamic tests.
  • Definition of a positive test: Reliability depends on how a positive test is defined. When a positive test is defined as reproduction of the patient’s symptoms with a change on structural differentiation, the evidence suggests it can be applied reliably in clinical practice.[18]

Validity

Plausibility. Biomechanical and experimental pain data support the idea that the tests load neural tissue. In a cadaver study, adding cervical contralateral side flexion during ULNT1 changed the position of the median nerve at the wrist differently from the surrounding fascia, which supports the logic of structural differentiation.

Diagnostic accuracy (criterion validity). The figures below come from Wainner et al., using cervical radiculopathy as the condition.

Test Sensitivity Specificity Interpretation
ULTT1 (ULTT A) 0.97 0.22 Good at ruling out when negative, poor at ruling in
Spurling’s A 0.50 0.86 Better at ruling in than ruling out
Cervical rotation < 60° 0.89 0.49 Better at ruling out
Distraction test 0.44 0.90 Better at ruling in

[8]

Combinations of neurodynamic tests. In 85 people with suspected cervical radiculopathy, single ULNTs were better at ruling in than ruling out the condition. Three of four positive tests could rule in cervical radiculopathy, and four negative tests could help rule it out.[9][7]

Systematic reviews. Reviews of cervical radiculopathy and peripheral neuropathic pain describe limited and variable evidence for the diagnostic accuracy of neurodynamic tests, partly because studies define a positive test differently.[12]

A negative test does not exclude neural involvement. In patients with electro-diagnostically confirmed carpal tunnel syndrome, only 46% had positive neurodynamic tests.[19]

Clinical Bottom Line

  • ULTTs assess neural mechanosensitivity. They are not stand-alone diagnostic tests.
  • A positive test needs reproduction of the patient's symptoms and a change in symptoms with structural differentiation.
  • ULTT1 is most useful for helping to rule out cervical radiculopathy when negative. Combinations of tests perform better than single tests.
  • A negative test does not rule out neural involvement. Interpret the result with the history and the rest of the examination.

Resources

For more information visit this Physiopedia page Neurodynamic Assessment

References

  1. ↑ 1.0 1.1 Magee DJ.Orthopaedic physical assessment.5th ed. St Louis: Elsevier; 2020 publication.
  2. ↑ Elvey RL: The investigation of arm pain. In Boyling JD, Palastanga N (eds): Grieve’s modern manual therapy: the vertebral column, 2nd ed. Edinburgh, 1994, Churchill Livingstone.
  3. ↑ 3.0 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 Shacklock M. Clinical neurodynamics: a new system of neuromusculoskeletal treatment. Elsevier Health Sciences; 2005 May 6.
  4. ↑ 4.0 4.1 4.2 Butler DS. Mobilisation of the nervous system. Melbourne: Churchill Livingstone; 1991.
  5. ↑ 5.0 5.1 Stephens A, Langley C. Anatomy of the brachial plexus and upper limb peripheral neuropathies. Surgery (Oxford). 2024 Dec 18. doi:10.1016/j.mpsur.2024.11.007.
  6. ↑ Baselgia LT, Bennett DL, Silbiger RM, Schmid AB. Negative neurodynamic tests do not exclude neural dysfunction in patients with entrapment neuropathies. Arch Phys Med Rehabil. 2017.
  7. ↑ 7.0 7.1 7.2 Nee RJ, Jull GA, Vicenzino B, Coppieters MW. The validity of upper-limb neurodynamic tests for detecting peripheral neuropathic pain. J Orthop Sports Phys Ther. 2012;42(5):413-24. doi:10.2519/jospt.2012.3988.
  8. ↑ 8.0 8.1 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 (Phila Pa 1976). 2003;28(1):52-62. PMID: 12544957.
  9. ↑ 9.0 9.1 Grondin F, Cook C, Hall T, Maillard O, Perdrix Y, Freppel S. Diagnostic accuracy of upper limb neurodynamic tests in the diagnosis of cervical radiculopathy. Musculoskelet Sci Pract. 2021;55:102427.
  10. ↑ Thoomes EJ, van Geest S, van der Windt DA, Falla D, Verhagen AP, Koes BW, et al. Value of physical tests in diagnosing cervical radiculopathy: a systematic review. Spine J. 2018;18(1):179-89. doi:10.1016/j.spinee.2017.08.241.
  11. ↑ Wells P. Cervical dysfunction and shoulder problems. Physiotherapy, 1982; 68: 66-73.
  12. ↑ 12.0 12.1 Koulidis K, Veremis Y, Anderson C, Heneghan NR. Diagnostic accuracy of upper limb neurodynamic tests for the assessment of peripheral neuropathic pain: a systematic review. Musculoskelet Sci Pract. 2019;40:21-33. PMID: 30665045.
  13. ↑ 13.0 13.1 Magee DJ, Manske RC. Orthopedic physical assessment. 7th ed. Philadelphia, PA: Saunders; 2021.
  14. ↑ Adrianna Simmons. Upper Limb Tension Test 1. Available from: https://www.youtube.com/watch?v=Cy6kqiLLDII [last accessed 14/4/2022]
  15. ↑ Adrianna Simmons. Upper Limb Tension Test 2A. Available from: https://www.youtube.com/watch?v=kcTN1Tmp-Zg [last accessed 14/4/2022]
  16. ↑ Adrianna Simmons. Upper Limb Tension Test 2B. Available from: https://www.youtube.com/watch?v=b5VkzZ06vW4 [last accessed 14/4/2022]
  17. ↑ Adrianna Simmons. Upper Limb Tension Test 3. Available from: https://www.youtube.com/watch?v=dogBcKQ1y88 [last accessed 14/4/2022]
  18. ↑ Schmid AB, Brunner F, Luomajoki H, Held U, Bachmann LM, Kunzer S, et al. Reliability of clinical tests to evaluate nerve function and mechanosensitivity of the upper limb peripheral nervous system. BMC Musculoskelet Disord. 2009;10:11.
  19. ↑ Baselgia LT, Bennett DL, Silbiger RM, Schmid AB. Negative neurodynamic tests do not exclude neural dysfunction in patients with entrapment neuropathies. Arch Phys Med Rehabil. 2017.
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