Deep Tendon Reflexes
- Queen Square hammer preferred to shorter tomahawk
- the patient should be relaxed.
- explain to the patient the examination technique.
- before concluding that reflexes are absent, have
the patient re-enforce by performing an isometric
contraction of other muscles (e.g. clench teeth or
opposite limb for upper extremity reflexes or pull
hooked fingers apart for lower extremity reflexes).
- before concluding that ankle reflexes are absent,
position the patient in a chair by having them kneel
where one would normally sit, squeeze the back of
the chair for reinforcement, on your count of three,
just as you deliver the strike to the Achilles
tendon which should be gently stretched by passive
dorsiflexion of the ankle.
Deep tendon reflexes tested:
- Upper extremities: biceps (C5, C6), brachioradialis
(C5, C6), triceps (C6, C7), finger flexors (C6-T1)
- Lower extremities: knee or patellar (L2, 3, 4),
ankle (S1, S2)
- Superficial reflexes: Abdominal - above umbilicus
(T8, T9, T10) and below umbilicus (T10, T11, T12).
Reflexes are graded using a 0 to 4+ scale:
||hyperactive without clonus
||hyperactive with clonus
- explain the examination technique to the patient
and ask them to relax.
- stroke the lateral aspect of the sole of each foot
and then come across the ball of the foot medially
with a sharp object.
If reflexes are hyperactive, test for ankle clonus.
- ask the patient to relax.
- support the knee in a partly flexed position.
- quickly dorsiflex the foot and observe for rhythmic
- explain the examination technique.
- the patient should be lying down and relaxed with
their arms by their side.
- a blunt object such as a key or tongue blade may
be used (A safety pin may also be used as long as
the stimulus is delivered lightly).
- stroke the abdomen lightly on each side in an inward
direction above and below the umbilicus.
- note the contraction of the abdominal muscles and
deviation of the umbilicus towards the stimulus.
- Some studies indicate that up to 10% of people with
no nervous system disease may have absence of one
or more of the deep tendon reflexes. In general however,
deep tendon reflexes are rarely absent in normal persons
if the technique of eliciting them is adequate. Note
that the reflex response depends on the force of the
stimulus. Reflexes should be symmetrical.
- some individuals especially young anxious people
may have brisk reflexes which are not necessarily
pathological. There should be no asymmetry.
- usually clonus is abnormal although a few beats
of non-sustained transient clonus may occasionally
- abdominal reflexes are usually obtainable in healthy
non-obese individuals. They may be absent in obese
individuals or those with lax abdominal musculature.
Local diminishment or absence, suggests a disturbance
in the continuity of the reflex arc (afferent nerve,
motor center, efferent nerve). Loss, when associated
with exaggeration of deep tendon reflexes implies
a pyramidal tract lesion.