Upper Limb Neurological Examination

Prepare patient

General inspection (patient sitting to begin with)

  • Scars
  • Skin (e.g. neurofibromata, café-au-lait)
  • Abnormal movements

Shake hands

Motor system inspection

  • Posture
  • Muscle bulk/wasting/tenderness Abnormal movements
    • Wasting
    • Fasciculations (LMN lesion, MND, root compression, peripheral neuropathy, primary myopathy, thyrotoxicosis)
    • Tremor
  • Drift (with arms extended, palms up & eyes closedwith arms extended, palms up & eyes closed)
    • downward/pronation
      • (UMN pyramidal/muscle weakness),
    • upwards/pronation
      • (cerebellar),
    • searching/random
      • (loss of proprioception)


  • Wrist & elbow
    • Note hypertonia /rigidity incl lead pipe,
    • cog-wheeling (Parkinson’s) or
    • hypotonia (LMN lesion).


  • Muscle bulk
  • Muscle tenderness


  • Shoulder

    • Abduction (C5/6): upper arms abducted to 90o (elbows fully bent) & press down proximally

    • Adduction (C6/7/8): upper arms adducted and examiner tries to abduct them.

  • Elbow
    • Flexion (C5/6) & extension (C7/8) at 90o – examiner holding elbow & wrist
  • Wrist
    • Cocked down & up for flexion (C6/7) & extension (C7/8) testing. Examiner uses his same wrist to test.
  • Fingers
    • Extension (C7/8) – Examiner pushes down just distal to MCPJs on extended fingers
    • Flexion (C7/8) – Squeeze 2 of examiners fingers
    • Abduction (dorsal interossei, C8/T1)– examiner tries to close patient’s spread fingers by
      pressing proximally with his two index fingers
    • Adduction (palmar interossei, C8/T1) – examiner tries to pull apart closed fingers
    • Ulnar, median nerve function

Biceps C5/6

Triceps C7/8

Supinator C5/6

Finger C8

Finger–nose test—

  • intention tremor,
  • past-pointing



Pain (pinprick)

Light touch (cottonwool)

Vibration (128 Hz tuning fork)

Proprioception—distal interphalangeal joint (each hand)

Thickened nerves (wrist, elbow)



Lower limbs

Cranial nerves

Urine analysis etc