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How to Assess Reflexes

By George Newman , MD, PhD, Albert Einstein Medical Center

(See also Introduction to the Neurologic Examination)

Deep tendon reflexes

Deep tendon (muscle stretch) reflex testing evaluates afferent nerves, synaptic connections within the spinal cord,
motor nerves, and descending motor pathways. Lower motor neuron lesions (eg, affecting the anterior horn cell, spinal
root, or peripheral nerve) depress reflexes; upper motor neuron lesions (ie, non–basal ganglia disorders anywhere
above the anterior horn cell) increase reflexes.

How to Test Reflexes

VIDEO

Reflexes tested include the following:

Biceps (innervated by C5 and C6)

Radial brachialis (by C6)

Triceps (by C7)

Distal finger flexors (by C8)

Quadriceps knee jerk (by L4)

Ankle jerk (by S1)

Jaw jerk (by the 5th cranial nerve)

Any asymmetric increase or depression is noted. Jendrassik maneuver can be used to augment hypoactive reflexes:
The patient locks the hands together and pulls vigorously apart as a tendon in the lower extremity is tapped.
Alternatively, the patient can push the knees together against each other, while the upper limb tendon is tested.

Pathologic reflexes
Pathologic reflexes (eg, Babinski, Chaddock, Oppenheim, snout, rooting, grasp) are reversions to primitive responses
and indicate loss of cortical inhibition.
Babinski, Chaddock, and Oppenheim reflexes all evaluate the plantar response. The normal reflex response is
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flexion of the great toe. An abnormal response is slower and consists of extension of the great toe with fanning of the
other toes and often knee and hip flexion. This reaction is of spinal reflex origin and indicates spinal disinhibition due
to an upper motor neuron lesion.
For Babinski reflex, the lateral sole of the foot is firmly stroked from the heel to the ball of the foot with a tongue blade
or end of a reflex hammer. The stimulus must be noxious but not injurious; stroking should not veer too medially, or it
may inadvertently induce a primitive grasp reflex. In sensitive patients, the reflex response may be masked by quick
voluntary withdrawal of the foot, which is not a problem in Chaddock or Oppenheim reflex testing.
For Chaddock reflex, the lateral foot, from lateral malleolus to small toe, is stroked with a blunt instrument.
For the Oppenheim reflex, the anterior tibia, from just below the patella to the foot, is firmly stroked with a knuckle.
The Oppenheim test may be used with the Babinski test or the Chaddock test to make withdrawal less likely.
The snout reflex is present if tapping a tongue blade across the lips causes pursing of the lips.
The rooting reflex is present if stroking the lateral upper lip causes movement of the mouth toward the stimulus.
The grasp reflex is present if gently stroking the palm of the patient’s hand causes the fingers to flex and grasp the
examiner’s finger.
The palmomental reflex is present if stroking the palm of the hand causes contraction of the ipsilateral mentalis
muscle of the lower lip.
Hoffmann sign is present if flicking down on the nail on the 3rd or 4th finger elicits involuntary flexion of the distal
phalanx of the thumb and index finger.
Tromner sign is similar to the Hoffman sign, but the finger is flicked upward.
For the glabellar sign, the forehead is tapped to induce blinking; normally, each of the first 5 taps induces a single
blink, then the reflex fatigues. Blinking persists in patients with diffuse cerebral dysfunction.

Other reflexes
Testing for clonus (rhythmic, rapid alternation of muscle contraction and relaxation caused by sudden, passive tendon
stretching) is done by rapid dorsiflexion of the foot at the ankle. Sustained clonus indicates an upper motor neuron
disorder.
The superficial abdominal reflex is elicited by lightly stroking the 4 quadrants of the abdomen near the umbilicus
with a wooden cotton applicator stick or similar tool. The normal response is contraction of the abdominal muscles
causing the umbilicus to move toward the area being stroked. Stroking the skin toward the umbilicus is recommended
to rule out the possibility that movement was caused by the skin being dragged by the stroking. Depression of this
reflex may be due to a central lesion, obesity, or lax skeletal muscles (eg, after pregnancy); its absence may indicate
spinal cord injury.
Sphincteric reflexes may be tested during the rectal examination. To test sphincteric tone (S2 to S4 nerve root levels),
the examiner inserts a gloved finger into the rectum and asks the patient to squeeze it. Alternatively, the perianal
region is touched lightly with a cotton wisp; the normal response is contraction of the external anal sphincter (anal
wink reflex). Rectal tone typically becomes lax in patients with acute spinal cord injury or cauda equine syndrome.
For the bulbospongiosus reflex, which tests S2 to S4 levels, the dorsum of the penis is tapped; normal response is
contraction of the bulbospongiosus muscle.
For the cremasteric reflex, which tests the L2 level, the medial thigh 7.6 cm (3 in) below the inguinal crease is stroked
upward; normal response is elevation of the ipsilateral testis.
Last full review/revision February 2018 by George Newman, MD, PhD

© 2018 Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA)

TES T YOU R KN OWL ED G E

Huntington Disease

Patients with Huntington disease most likely have symptoms that include a puppet-like gait, facial
grimacing, and which of the following?

A.  Motor persistence  

B.  Oculomotor apraxia
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C.  Peripheral neuropathy
AM I CORRECT?

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