Hoffmann’s Sign

Hoffmann’s sign is a neurological test used to assess the presence of an upper motor neuron lesion (UMNL), particularly within the cervical spine¹.

The sign was named after German neurologist Dr. Johann Hoffmann, who first described the reflex². His assistant, Dr. Hans Curschmann, helped spread awareness of the test, which contributed to its widespread use in neurological examinations³.

Test Procedure

The following steps should be followed for correct performance of Hoffmann’s test⁴ ⁵:

• The patient’s hand is placed in a relaxed position with slight dorsiflexion at the wrist and partially flexed fingers.

• The examiner holds the patient’s middle finger between their own index and middle fingers, stabilizing the proximal interphalangeal joint (PIP).

• A quick downward flick is applied to the nail of the middle finger using the examiner’s thumb.

A positive response is defined as:

• Flexion and adduction of the thumb

• Flexion of the index finger

Clinical Significance

A positive Hoffmann’s sign is often associated with corticospinal tract dysfunction, particularly within the cervical spinal cord⁴. It is comparable to the Babinski reflex, which also evaluates upper motor neuron involvement.

Conditions associated with a positive Hoffmann’s sign:

• Cervical myelopathy

• Multiple sclerosis

• Hyperthyroidism

• Anxiety disorders⁵

Systemic vs. structural causes:

• Systemic disorders (e.g., hyperthyroidism) often produce bilateral responses.

• Structural lesions (e.g., cervical stenosis, tumor) often produce unilateral responses⁵.

👉 Important: Up to 3% of healthy individuals may show a positive Hoffmann’s sign without any neurological disease¹.

Scientific Evidence

• Hoffmann’s sign alone is not sufficient to diagnose cervical myelopathy⁷.

• Unilateral positive responses are more specific for pathology⁸.

• Bilateral positive responses have higher sensitivity for cervical myelopathy⁹.

• The test is included in Cook’s cluster for diagnosing cervical myelopathy, but MRI remains the gold standard⁷ ¹⁰.

• A systematic review concluded that Hoffmann’s sign alone does not provide adequate diagnostic certainty for degenerative cervical myelopathy, and should be combined with other findings¹¹.

Conclusion

Hoffmann’s sign is a quick and simple clinical tool for assessing potential upper motor neuron involvement. However, it should never be used in isolation to diagnose cervical myelopathy. It must be interpreted in combination with other clinical tests and imaging modalities (such as MRI) to ensure diagnostic accuracy.

References

1. Whitney E, Munakomi S. Hoffmann Sign. 2024 Sep 10. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan

2. P Hoffmann. Über eine Methode, den Erfolg einer Nervennaht zu beurteilen. Medizinische Klinik, March 28, 1915b, 11 (13): 359-360.

3. Bendheim, OL. "ON THE HISTORY OF HOFFMANN'S SIGN." Bulletin of the Institute of the History of Medicine 1937; 5(7): 684-86.

4. DeJong’s The Neurologic Examination: Sixth edition; Lippincott Williams and Wilkins 2005, pp 495-496.

5. Barman B. Clinical Sign Revisited: Hoffman’s sign. Indian J Med Spec 2010; 1(1):44-45

6. CRTechnologies. Hoffmann's Sign Test (CR). Available from: https://www.youtube.com/watch?v=q_4gpNizwPg (accessed 19 August 2020)

7. Fogarty A, Lenza E, Gupta G, Jarzem P, Dasgupta K, Radhakrishna M. A Systematic Review of the Utility of the Hoffmann Sign for the Diagnosis of Degenerative Cervical Myelopathy. Spine (Phila Pa 1976). 2018 Dec 1;43(23):1664-1669. doi: 10.1097/BRS.0000000000002697. PMID: 29668564.

8. Bradley WG, Daroff RB, Fenichel GM, Jankovic J. Neurology in clinical practice, 5th edition, Elsevier, 2008, pp 362,427.

9. Houten JK, Noce LA. Clinical correlation of cervical myelopathy and the Hoffman sign. J Neurosurg Spine 2008;9:237-42.

10. Cook C, Brown C, Isaacs R, Roman M, Davis S, Richardson W. Clustered clinical findings for diagnosis of cervical spine myelopathy. Journal of Manual & Manipulative Therapy. 2010 Dec 1;18(4):175-80.

11. Fogarty A, Lenza E, Gupta G, Jarzem P, Dasgupta K, Radhakrishna M. A systematic review of the utility of the Hoffmann sign for the diagnosis of degenerative cervical myelopathy. Spine. 2018 Dec 1;43(23):1664-9.