Deep tendon reflexes

Deep tendon reflexes are monosynaptic reflexes integrated at lamina IX of the spinal cord. Deep tendon reflexes may be interpreted as:

  1. Normal
  2. Diminished or absent (hyporeflexia): Lower motor neuron lesions
  3. Exaggerated or clonus (hyper-reflexia): Upper motor neuron lesions
  4. Inverted or paradoxical: Damaged afferent pathway
deep tendon reflexes
Amiya Sarkar, CC BY-SA 4.0, via Wikimedia Commons
NameSpinal levelPeripheral nerveLocation struck to elicitResponse
Upper extremity
BicepsC5-C6MusculocutaneousExaminer’s fingers over biceps tendonBiceps contraction with slight elbow flexion
Brachioradialis or Radial periosteal or SupinatorC6RadialExaminer’s fingers about 10 cm above the wrist on radial aspect of forearm (musculo-tendinous junction)Elbow flexion with variable supination
– Exaggerated: finger and wrist flexion too
– Inverted reflex: absent elbow flexion/supination with present finger/wrist flexion
TricepsC7-C8RadialTriceps tendon just above the olecranon insertionTriceps contraction with elbow extension
– Inverted/paradoxical reflex: elbow flexion instead of extension
Finger flexor or Warternberg’s signC8-T1Median and ulnarExaminer’s fingers on the palmar surface of the patient’s fingersFlexion of patient’s fingers and distal phalanx of thumb
ScapulohumeralC4-C5Dorsal scapularTip of scapula at vertebral bodyRetraction of scapula with adduction of humerus
DeltoidC5-C6AxillaryExaminer’s finger over deltoid insertion on humerusSlight abduction of upper arm
PectoralisC5-T1Medial and lateral pectoralExaminer’s finger on deltopectoral groove– Normal: Contraction of pectoralis major felt but not seen
– Hyperactive: Adduction and slight internal rotation of arm at shoulder
ClavicleLateral aspect of clavicleHyperreflexia: Contraction of various muscle groups
– Watch for symmetry
Latissimus dorsiC6-C8ThoracodorsalExaminer’s finger over latissimus dorsi tendon at intertubercular groove of humerusAbduction and slight shoulder internal rotation
Pronator teresC6-C7MedianVolar surface of distal radius or dorsal aspect of styloid process of ulnaBrief supination followed by pronation of forearm
TrunkMinimal/absent in normal
Deep abdominalT5-T12Intercostal nerves, Ilioinguinal and Iliohypogastric nervesAnterior rectus abdominal muscle sheathContraction of abdominal muscles and deviation of umbilicus towards site of stimuli (weak or absent normally)
IliacT10-T12Lower intercostal nervesOver iliac crestContraction of lower abdominal muscles
Symphysis pubisT11-T12 and upper lumbarLower intercostal, ilioinguinal, iliohypogastricOver symphysis pubis, 1.5-2 cm from midlineNormal ‘upper response’: Contraction of abdominal muscles and downward movement of umbilicus

Exaggerated ‘lower response’ or puboadductor reflex: Ipsilateral adductor muscle contracts with some hip flexion
Costal periostealT5-T9Upper intercostalXiphoid process, lower rib marginsContraction of upper abdominal muscles and slight movement of umbilicus towards side of stimulation
Lower extremity
Knee or Patellar or QuadricepsL3-L4FemoralPatellar tendon just below patellaPalpated/seen quadriceps contraction with knee extension
– Absent: Westphal’s sign
– Exaggerated: Response obtained by tapping over examiner’s finger superior to patella (supra-patellar reflex) or Clonus seen
– Inverted: Contraction of hamstrings and knee flexion
Achilles or Ankle or Triceps suraeS1-S2TibialAchilles tendon just above its insertion on calcaneusHamstring contraction with plantar flexion
– Hyperactive: Elicited by tapping other areas of sole of foot (medioplantar reflex) or clonus
– Paradoxical: Elicited by tapping anterior aspect of ankle
AdductorL2-L4ObturatorMedial epicondyle femurContraction of adductors with inward movement of thigh
– Exaggerated: Crossed or bilateral adduction of thigs
Medial hamstringL5Tibial portion of sciatic nerveExaminer’s finger over semimembranosus or semitendinosus at insertion of tibiaHip extension and knee flexion with internal rotation
Lateral hamstringS1Tibial portion of sciatic nerveExaminer’s finger over biceps femoris tendon insertion or fibular headKnee flexion
Peroneal or Tibialis anteriorL4-S1Deep and superficial peronealExaminer’s finger over distal 1st and 2nd metatarsal of inverted and plantar-flexed footEversion and dorsiflexion of foot
Tibialis posteriorL5-S1Tibial nerveTibialis posterior just above and behind medial malleolusFoot inversion
Tensor lataL4-S1Superior glutealOrigin of tensor fascia lata near ASISSlight thigh abduction
GlutealL5-S1Inferior glutealLower portion of sacrum or posterior aspect of ilium near gluteus maximus insertionContraction of gluteus maximus and extension of thigh
Head
Jaw or ChinPonsV3 division of trigeminal nerveExaminer’s finger on jaw tipUpward movement of jaw

References:

  1. Lin-Wei O, Xian LLS, Shen VTW, Chuan CY, Halim SA, Ghani ARI, Idris Z, Abdullah JM. Deep Tendon Reflex: The Tools and Techniques. What Surgical Neurology Residents Should Know. Malays J Med Sci. 2021 Apr;28(2):48-62. doi: 10.21315/mjms2021.28.2.5. Epub 2021 Apr 21. PMID: 33958960; PMCID: PMC8075597.
  2. DeJong’s – The Neurologic Examination, 8th Edition


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