Cervical Radiculopathy

Spine

Overview

Cervical radiculopathy is a condition characterized by nerve root compression in the cervical spine, resulting in pain, weakness, and sensory disturbances radiating into the upper limb. The condition commonly arises from disc herniation, osteophyte formation, or foraminal stenosis and typically affects one nerve root. Clinical presentation varies depending on the affected nerve root level, with C5-C7 being most commonly involved.

Pathophysiology

Cervical radiculopathy develops when mechanical compression or inflammatory irritation of a cervical nerve root occurs within the intervertebral foramen or along its course. Common causes include posterolateral disc herniation causing direct compression, spondylotic osteophytes narrowing the foramen, facet joint hypertrophy, or ligamentous thickening. Inflammatory mediators from the intervertebral disc (phospholipase A2, TNF-alpha) contribute to nerve root irritation. The compressed nerve root experiences demyelination, impaired axonal transport, and local ischemia, leading to characteristic radicular pain that follows dermatomal and myotomal distributions. Secondary muscle guarding and postural dysfunction often perpetuate the condition.

Typical Presentation

Site

Unilateral upper limb pain following dermatomal distribution (commonly C5, C6, C7, or C8); pain may originate from the neck and shoulder region; less commonly bilateral

Quality

Sharp, burning, or lancinating pain with possible associated numbness, tingling, or 'pins and needles' sensation; may describe as electric or shooting quality

Intensity

Highly variable, ranging from mild to severe (VAS 2-9/10); often fluctuates throughout the day

Aggravating

Neck extension, ipsilateral rotation toward affected side, Spurling's maneuver, overhead activities, prolonged sitting with poor posture, coughing or straining, neck compression

Relieving

Neck flexion or contralateral rotation, arm elevation or support (hand behind head), rest, anti-inflammatory medications, ice or heat application

Associated

Neck stiffness and reduced cervical range of motion, weakness in myotomal distribution (C5: shoulder abduction/external rotation; C6: wrist extension/elbow flexion; C7: wrist flexion/elbow extension; C8: intrinsic hand muscles), reduced or absent reflexes corresponding to nerve root level, possible headache, scapular dysfunction, postural abnormalities including forward head posture

Orthopaedic Tests

Test descriptions are written with AI assistance from standard clinical texts. Where a test lists Sources, its description has been checked against them; those sources are independent and do not endorse OsteoKit. Accuracy figures and grades (A–D) appear only when checked against the published study; tests without one are marked “No accuracy study”.

Further reading: full test procedures are described in standard clinical examination texts, e.g. Magee & Manske, Orthopedic Physical Assessment (7th ed.), and Cook & Hegedus, Orthopedic Physical Examination Tests: An Evidence-Based Approach (2nd ed.).

Grade A+
A+ABCDNear-definitive: a result is close to conclusive on its own (likelihood ratio ≥20 or ≤0.05)
best for ruling IN (confirmation).
Cluster

Wainner Cluster (Cervical Radiculopathy)

Procedure

Perform four items: Spurling's test, the cervical distraction test, the median-nerve upper limb tension test, and active neck rotation towards the symptomatic side (measured).

Positive Finding

Three or four of the four items positive (rotation counts as positive when it is under 60° towards the symptomatic side).

Sensitivity / Specificity

24% (4/4 positive)/99% (4/4 positive)

Reference: Wainner RS et al., Spine 2003; PMID 12544957

Interpretation

Several positive items together make cervical radiculopathy much more likely than any one test. With few positive items the cluster cannot rule radiculopathy out. Signs of spinal cord compression (clumsy hands, unsteady gait, bladder or bowel change, brisk reflexes, positive Hoffmann's sign) or rapidly worsening weakness need urgent medical referral. Wainner's clinical prediction rule combines four tests: Spurling's, cervical distraction, ULTT (median bias), and ipsilateral cervical rotation <60°. 3/4 positive gives +LR 6.1 (post-test probability ~65%); 4/4 positive gives +LR 30.3 (specificity 99%, sensitivity 24%). High rule-in value; low sensitivity means it cannot rule radiculopathy out.

Sources

Grade B
A+ABCDGood clinical value: meaningfully changes the diagnosis in one direction (LR 5–10 or 0.1–0.2)
best for ruling OUT (screening).

Upper Limb Tension Test A (Median Nerve Bias)

Procedure

Patient lying on their back. In order: depress the shoulder girdle, abduct the shoulder, supinate the forearm, extend the wrist and fingers, externally rotate the shoulder, then extend the elbow. Then side-bend the neck away from and towards the test side.

Positive Finding

The patient's arm symptoms are reproduced, elbow extension is clearly less than on the other side, or symptoms increase with neck side-bending away and ease with side-bending towards the test side.

Sensitivity / Specificity

97%/22%

Reference: Wainner RS et al., Spine 2003; PMID 12544957

Interpretation

A negative test makes cervical radiculopathy much less likely, so it is useful for ruling it out; a positive test alone is common and does not confirm it. Stop if symptoms build rapidly.

Sources

Grade C
A+ABCDModest value: a small but usable shift in probability (LR 2–5 or 0.2–0.5)
modest, supportive value.

Spurling Test (Cervical Compression Test)

Procedure

Patient seated. Side-bend the neck towards the symptomatic side and apply gentle downward pressure through the top of the head. Do not use after recent trauma, with suspected instability or rheumatoid arthritis, or with symptoms of cervical arterial dysfunction.

Positive Finding

Reproduction of the patient's arm pain, tingling or numbness. Neck pain alone is not a positive result.

Sensitivity / Specificity

50%/86%

Reference: Wainner RS et al., Spine 2003; PMID 12544957

Interpretation

A positive test makes cervical radiculopathy more likely; a negative test does not rule it out. Combine with the neurological examination (dermatomes, myotomes, reflexes). Signs of spinal cord compression (clumsy hands, unsteady gait, bladder or bowel change, brisk reflexes, positive Hoffmann's sign) or rapidly worsening weakness need urgent medical referral.

Further reading

Grade C
A+ABCDModest value: a small but usable shift in probability (LR 2–5 or 0.2–0.5)
modest, supportive value.

Cervical Distraction Test

Procedure

Patient lying on their back. Cup the chin and the back of the head, flex the neck slightly and apply a gentle, gradually increasing upward pull.

Positive Finding

Arm symptoms ease or disappear during distraction.

Sensitivity / Specificity

44%/90%

Reference: Wainner RS et al., Spine 2003; PMID 12544957

Interpretation

Relief with distraction supports a nerve root cause and suggests traction or unloading positions may help. A negative test does not rule radiculopathy out.

Sources

No accuracy study

Upper Limb Neurodynamic Tests (Radial and Ulnar Bias)

Procedure

Radial bias: depress the shoulder girdle, extend the elbow, internally rotate the arm, then flex the wrist and fingers with ulnar deviation. Ulnar bias: depress the shoulder girdle, extend the wrist and fingers, flex the elbow, then abduct and externally rotate the shoulder. Add neck side-bending to differentiate.

Positive Finding

Reproduction of the patient's symptoms that changes with neck movement.

Interpretation

Shows which nerve is irritated by movement and guides neural mobilisation. These variations are less well studied than the median-nerve test. The figure previously stored (attributed to a 2015 Cochrane review that could not be found) is not shown. The checked figures for the median-nerve-bias upper limb tension test (Wainner 2003) are on the ULTT entry above.

Further reading

No accuracy study

Cervical Foraminal and Brachial Plexus Palpation

Procedure

Palpate the side of the neck over the articular pillars and the brachial plexus in the supraclavicular area, comparing sides.

Positive Finding

Tenderness or reproduction of arm symptoms.

Interpretation

Mechanosensitivity of the nerve to palpation can support a neural source, but tenderness here is common and evidence is limited. Use with the neurological examination and neurodynamic tests.

Sources

⚠ Red Flags

  • •Bilateral upper limb symptoms or progressive bilateral weakness suggesting myelopathy
  • •Progressive neurological deficit or rapidly worsening weakness
  • •Bowel or bladder dysfunction indicating cauda equina or conus medullaris compression
  • •Significant unintentional weight loss or constitutional symptoms suggesting malignancy
  • •Fever accompanying severe neck pain suggesting infection
  • •History of cancer with new neurological symptoms
  • •Severe trauma or high-velocity mechanism with neurological signs
  • •Signs of myelopathy including hyperreflexia, positive Babinski sign, or gait disturbance
  • •Acute onset with severe neurological deficit requiring urgent imaging and specialist assessment

⚡ Yellow Flags

  • •High pain catastrophizing or kinesiophobia affecting treatment engagement
  • •Significant psychological distress or comorbid depression/anxiety
  • •Belief that pain indicates serious structural damage despite reassurance
  • •Passive coping strategies or over-reliance on medication without rehabilitation
  • •Work-related stress or job dissatisfaction as a contributing factor
  • •Pending litigation or workers' compensation claims affecting symptom reporting
  • •Social isolation or poor support systems limiting engagement in physical activity
  • •History of chronic pain conditions suggesting central sensitization risk

Osteopathic Techniques

Most cervical radiculopathy settles within 8–12 weeks. Mobilisation added to usual care helps short-term pain.

Safety: Before any neck technique, screen for blood-vessel problems in the neck. Progressive weakness, spreading numbness or signs of cord compression: refer, do not treat.

Region

Cervical nerve roots and the nerves of the arm

Technique

Neural mobilisation, upper limb
Grade B
Moderate evidence: supported by at least one good study
A review of 50 trials: neural mobilisation added to usual care improved disability. Certainty moderate to very low.

Rationale

Gentle sliding of the nerve along its path through the neck, arm, forearm and hand.

How it's done & evidence

How it's done

A movement-based treatment aimed at the nerve and the tissues around it. Gentle, rhythmic neck and arm movements either slide the nerve along its path (sliders) or lightly tension it (tensioners), with a median, radial or ulnar bias. One review found sliders helped more in acute pain and tensioners in chronic pain.

Evidence in Cervical Radiculopathy

In the same network meta-analysis, neural mobilisation added to usual care improved pain-related disability more than usual care alone and more than sham. Trials had risk of bias and varied a lot.

Region

Cervical spine (symptomatic levels)

Technique

Articulation, cervical
Grade B
Moderate evidence: supported by at least one good study
A review of 50 trials: mobilisation added to usual care reduced short-term arm and neck pain. Certainty moderate to very low.

Rationale

Gentle mobilisation of the neck segments that supply the arm.

How it's done & evidence

How it's done

Rhythmic, low-velocity movement of a restricted cervical segment within its passive range, with no thrust. Usually done with the patient supine and the head supported; the amplitude can vary.

Evidence in Cervical Radiculopathy

In a network meta-analysis of 50 trials, joint plus neural mobilisation added to usual care reduced short-term pain more than wait-and-see or sham, and more than usual care alone. An umbrella review also supports mobilisation in radiculopathy with moderate confidence.

Region

Upper cervical, cervicothoracic junction and shoulder girdle

Technique

Soft tissue, neck and shoulder girdle
Grade C
Limited evidence: indirect or low-quality support only
An umbrella review supports soft tissue work in radiculopathy. Confidence moderate; few direct trials.

Rationale

Soft tissue to the neck, cervicothoracic junction and shoulder girdle muscles.

How it's done & evidence

How it's done

Hands-on soft-tissue work (kneading, stretching and sustained pressure) across or along the cervical paraspinals, upper trapezius and levator scapulae, usually with the patient supine.

Evidence in Cervical Radiculopathy

An umbrella review of 35 systematic reviews found soft tissue treatment supported in cervical radiculopathy, with moderate confidence in the reviews' results. Individual trials were of mixed quality.

Region

Cervical spine (symptomatic levels)

Technique

Muscle energy, cervical (C2–C7)
Grade D
Low evidence: expert consensus or could not be verified against literature
No trial comparing MET with usual care or sham in radiculopathy was found.

Rationale

Muscle energy technique to ease restricted neck segments.

How it's done, cautions & evidence

How it's done

The neck is positioned against the restricted barrier. The patient gently pushes back toward neutral for 3–5 seconds against equal resistance, relaxes, and the neck is taken to the new barrier. Repeat 3–5 times, then re-check.

Cautions

Do not use with fracture, dislocation, infection or muscle tear. Take care with cervical instability (check for it in rheumatoid arthritis and Down syndrome), other rheumatological disease, and recent heart attack or surgery. Use the least force needed, especially in older patients.

Evidence in Cervical Radiculopathy

Searched 12 Oct 2026: no trial compared MET with usual care, sham or no treatment in cervical radiculopathy.

Rehabilitation Exercises

Cervical Flexion and Extension Mobility

Range of MotionBeginner

Cervical Rotation with Neural Mobilization

Range of MotionBeginner

Lateral Cervical Flexion (Side Bending) Stretch

Range of MotionBeginner

Upper Trapezius and Levator Scapulae Stretch

StretchingBeginner

Scalene Muscle Stretch

StretchingBeginner

Deep Cervical Flexor Activation (Chin Tucks)

StrengtheningBeginner

Isometric Cervical Stabilization (Four Directions)

StrengtheningIntermediate

Scapular Stabilization - Prone Shoulder Blade Squeezes

StrengtheningIntermediate

Forward Head Posture Correction with Mirror Feedback

PosturalBeginner

Thoracic Extension with Foam Roller

PosturalIntermediate

Upper Limb Neurodynamic Mobilization Sequence

BalanceIntermediate

Prone Y-T-W Shoulder Blade Strengthening Series

StrengtheningAdvanced

Referral Criteria

  • •Persistent neurological deficit or progressive weakness despite 4-6 weeks of conservative management warranting specialist neurological assessment
  • •Suspected myelopathy (hyperreflexia, positive Babinski, gait disturbance) requiring urgent MRI and neurosurgical consultation
  • •Severe unrelenting pain unresponsive to manual therapy and exercise within 2-3 weeks suggesting need for medical imaging and pain management consultation
  • •Any red flag presentation (cauda equina signs, cancer history, infection signs, severe trauma) requiring immediate medical evaluation
  • •Imaging-confirmed severe nerve root compression or canal stenosis with significant neurological deficit considering surgical intervention
  • •Suspected thoracic outlet syndrome or complex regional pain syndrome developing secondary to cervical radiculopathy
  • •Comorbid psychiatric presentation with high pain catastrophizing or treatment-resistant symptoms suggesting psychological intervention
  • •Failure to improve after 8-12 weeks of appropriate osteopathic and rehabilitative management warranting reassessment and alternative diagnostic consideration
  • •Functional limitations exceeding scope of manual therapy practice (e.g., severe disability affecting work capacity) requiring multidisciplinary pain management program