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

Name	Spinal level	Peripheral nerve	Location struck to elicit	Response
Upper extremity
Biceps	C5-C6	Musculocutaneous	Examiner’s fingers over biceps tendon	Biceps contraction with slight elbow flexion
Brachioradialis or Radial periosteal or Supinator	C6	Radial	Examiner’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
Triceps	C7-C8	Radial	Triceps tendon just above the olecranon insertion	Triceps contraction with elbow extension – Inverted/paradoxical reflex: elbow flexion instead of extension
Finger flexor or Warternberg’s sign	C8-T1	Median and ulnar	Examiner’s fingers on the palmar surface of the patient’s fingers	Flexion of patient’s fingers and distal phalanx of thumb
Scapulohumeral	C4-C5	Dorsal scapular	Tip of scapula at vertebral body	Retraction of scapula with adduction of humerus
Deltoid	C5-C6	Axillary	Examiner’s finger over deltoid insertion on humerus	Slight abduction of upper arm
Pectoralis	C5-T1	Medial and lateral pectoral	Examiner’s finger on deltopectoral groove	– Normal: Contraction of pectoralis major felt but not seen – Hyperactive: Adduction and slight internal rotation of arm at shoulder
Clavicle			Lateral aspect of clavicle	Hyperreflexia: Contraction of various muscle groups – Watch for symmetry
Latissimus dorsi	C6-C8	Thoracodorsal	Examiner’s finger over latissimus dorsi tendon at intertubercular groove of humerus	Abduction and slight shoulder internal rotation
Pronator teres	C6-C7	Median	Volar surface of distal radius or dorsal aspect of styloid process of ulna	Brief supination followed by pronation of forearm
Trunk				Minimal/absent in normal
Deep abdominal	T5-T12	Intercostal nerves, Ilioinguinal and Iliohypogastric nerves	Anterior rectus abdominal muscle sheath	Contraction of abdominal muscles and deviation of umbilicus towards site of stimuli (weak or absent normally)
Iliac	T10-T12	Lower intercostal nerves	Over iliac crest	Contraction of lower abdominal muscles
Symphysis pubis	T11-T12 and upper lumbar	Lower intercostal, ilioinguinal, iliohypogastric	Over symphysis pubis, 1.5-2 cm from midline	Normal ‘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 periosteal	T5-T9	Upper intercostal	Xiphoid process, lower rib margins	Contraction of upper abdominal muscles and slight movement of umbilicus towards side of stimulation
Lower extremity
Knee or Patellar or Quadriceps	L3-L4	Femoral	Patellar tendon just below patella	Palpated/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 surae	S1-S2	Tibial	Achilles tendon just above its insertion on calcaneus	Hamstring 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
Adductor	L2-L4	Obturator	Medial epicondyle femur	Contraction of adductors with inward movement of thigh – Exaggerated: Crossed or bilateral adduction of thigs
Medial hamstring	L5	Tibial portion of sciatic nerve	Examiner’s finger over semimembranosus or semitendinosus at insertion of tibia	Hip extension and knee flexion with internal rotation
Lateral hamstring	S1	Tibial portion of sciatic nerve	Examiner’s finger over biceps femoris tendon insertion or fibular head	Knee flexion
Peroneal or Tibialis anterior	L4-S1	Deep and superficial peroneal	Examiner’s finger over distal 1st and 2nd metatarsal of inverted and plantar-flexed foot	Eversion and dorsiflexion of foot
Tibialis posterior	L5-S1	Tibial nerve	Tibialis posterior just above and behind medial malleolus	Foot inversion
Tensor lata	L4-S1	Superior gluteal	Origin of tensor fascia lata near ASIS	Slight thigh abduction
Gluteal	L5-S1	Inferior gluteal	Lower portion of sacrum or posterior aspect of ilium near gluteus maximus insertion	Contraction of gluteus maximus and extension of thigh
Head
Jaw or Chin	Pons	V3 division of trigeminal nerve	Examiner’s finger on jaw tip	Upward 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