Upper Limb Tension Tests (ULTTs) – Nevrodynamisk testing i overekstremiteter
- Fysiobasen
- Oct 4
- 5 min read
Upper Limb Tension Tests (ULTTs), also known as Brachial Plexus Tension Tests or Elvey Test, are a series of assessments used to evaluate the mobility, sensitivity, and compression of peripheral nerves in the upper extremities. They were first described by Elvey[1] and are considered the upper limb equivalent of the Straight Leg Raise Test (SLR), which is used to evaluate lumbar nerve irritation. ULTTs function both as diagnostic tools for nerve pathology and as therapeutic interventions to mobilize entrapped nerves.
By stretching and provoking neural structures in the upper extremities, ULTTs can help identify neurogenic pain, radiculopathy, or mechanical irritation of peripheral nerves. These tests are particularly useful when cervical radiculopathy, thoracic outlet syndrome, carpal tunnel syndrome, or other conditions involving nerve compression are suspected.
Technique
ULTTs are performed by positioning the shoulder, elbow, forearm, wrist, and fingers in specific ways to place stress on a particular nerve (nerve bias). Additionally, the position of each joint component can be adjusted to “sensitize” the test, which helps differentiate between musculoskeletal and neurological causes of pain.[2]
Key considerations when performing the test[3]:
Patient preparation: Explain the procedure in simple terms to reduce anxiety and promote relaxation. The patient should be informed that the tests may, but will not necessarily, provoke symptoms.
Gentle provocation: The goal is to reproduce the patient’s symptoms without worsening them, so pressure should be increased gradually.
Normal side first: Always test the unaffected side first to establish a reference value.
Stabilization and mobilization technique: Use one hand to stabilize the relevant joint while the other performs controlled, gradual mobilization.
Time limit: The final test position should not be held for more than 10 seconds to avoid unnecessary irritation.
Monitor unwanted movements: Avoid compensatory movements that may affect test validity.
ULTTs are usually performed in a specific sequence: shoulder positioning first, followed by forearm, wrist, fingers, and finally elbow. If pain or symptoms occur early, the test can be terminated without further sensitization.[4]
Positive Test
A ULTT is considered positive if one or more of the following criteria are met:
Symptom reproduction: The test provokes the patient’s familiar pain or paresthesia.
Range of motion asymmetry: A side-to-side difference of more than 10 degrees in elbow extension is observed.
Symptom worsening during sensitization:
Contralateral cervical side-bending increases symptoms.
Ipsilateral cervical side-bending reduces symptoms.
A positive test often indicates mechanical irritation, compression, or reduced nerve gliding in the upper extremities and requires further evaluation for accurate diagnosis.
Upper Limb Tension Test 1 (ULTT1) – Median Nerve Bias
ULTT1 is a neurodynamic test used to assess the mobility and sensitivity of the median nerve in the upper extremity. It is particularly useful for identifying nerve irritation, compression, or dysfunction related to the median nerve, such as:
Radiating pain in the upper extremity[5].
Paresthesia or tingling in the thumb, index finger, and middle finger (median nerve distribution).
Suspected carpal tunnel syndrome, cervical radiculopathy, or thoracic outlet syndrome.
Test procedure
ULTT1 is performed by positioning the patient’s arm in a sequence designed to stretch and provoke the median nerve. The following movements are carried out in order:
Shoulder depression – Creates traction in the brachial plexus by lowering the shoulder.
Shoulder abduction to approximately 110 degrees to increase nerve tension.
Shoulder external rotation with the elbow flexed to 90 degrees.
Forearm supination to maximize median nerve stretch.
Wrist and finger extension to further increase nerve stress.
Elbow extension to complete the nerve bias and provoke symptoms.
Movements should be performed gradually and in a controlled manner, and the patient should be instructed to report any symptoms during the test.
Structural differentiation
Proximal symptoms: If symptoms are relieved by reducing wrist and finger extension, this suggests a neurogenic cause.
Distal symptoms (provocation test): If symptoms worsen with contralateral neck flexion, it indicates nerve involvement, since this increases tension throughout the nervous system.
Interpretation of test results
Positive test: Reproduction of the patient’s familiar symptoms, particularly along the median nerve pathway, may indicate irritation, neuropathy, or compression.
Negative test: No reproduction of symptoms, or only a normal stretching sensation without asymmetry.
Upper Limb Tension Test 2B (ULTT2B) – Radial Nerve Bias
ULTT2B is a neurodynamic test specifically assessing radial nerve mobility and sensitivity. It is indicated when radial nerve entrapment or radiculopathy is suspected and can help identify conditions such as:
Radiating pain in the upper extremity, especially along the radial side.
Supinator tunnel syndrome (radial nerve compressed in supinator muscle)[5].
De Quervain’s disease (tendinitis of thumb extensors and abductors).
Cervical radiculopathy, particularly at C5–C7 levels.
Test procedure
Shoulder depression – Increases brachial plexus traction.
Shoulder abduction between 20 and 30 degrees.
Shoulder internal rotation to elongate the nerve pathway.
Forearm pronation to increase nerve stress.
Wrist, finger, and thumb flexion to maximize distal tension.
Elbow extension to complete the nerve bias.
Structural differentiation
Proximal symptoms: Relief by reducing wrist/finger flexion suggests neurogenic involvement.
Distal symptoms: Worsening with contralateral neck flexion suggests nerve involvement.
Interpretation of test results
Positive test: Reproduction of familiar pain or paresthesia, especially along the radial nerve.
Negative test: No symptoms, or only a normal stretch sensation without asymmetry.
Upper Limb Tension Test 3 (ULTT3) – Ulnar Nerve Bias
ULTT3 evaluates ulnar nerve mobility and sensitivity, used when compression or neuropathy is suspected, such as:
Radiating pain in 4th and 5th fingers, often linked to ulnar entrapment[5].
Thoracic Outlet Syndrome.
Cubital tunnel syndrome (elbow compression).
Guyon’s canal syndrome (wrist compression).
Carpal tunnel syndrome (though primarily median nerve, ulnar may also be involved).
Test procedure
Shoulder depression – Traction on brachial plexus.
Shoulder abduction to ~110°.
Shoulder external rotation.
Forearm pronation.
Wrist and finger extension (esp. 4th & 5th).
Elbow flexion.
Structural differentiation
Proximal symptoms: Relief when wrist/finger extension is reduced → ulnar nerve likely.
Distal symptoms: Worsening with contralateral neck flexion → neurogenic.
Interpretation of test results
Positive test: Reproduction of familiar ulnar pain/paresthesia.
Negative test: Only normal stretching sensation, no asymmetry.
Magee’s Description of ULTTs
Updated classification
In Orthopedic Physical Assessment (7th ed., 2020), David Magee standardized ULTT1–ULTT4. Unlike earlier nomenclature (ULTT2a/b), ULTT2 now also tests musculocutaneous and axillary nerves[10].
Normal (negative) response
Deep stretch in cubital fossa (99%).
Stretch in anterior/radial forearm and hand (80%).
Tingling in fingers of tested nerve.
Stretch in anterior shoulder.
Symptoms ↑ with contralateral neck side-bending (90%).
Symptoms ↓ with ipsilateral neck side-bending (70%).
Diagnostic Accuracy of ULTTs
Sensitivity: 50% → not enough to rule out radiculopathy.
Specificity: 86% → strong indicator if positive.
-LR: 0.58 → reduces but doesn’t rule out.
+LR: 3.5 → increases probability significantly.
Reliability of ULTTs
Intertester Kappa = 0.76 → good agreement.
Most reliable as part of a test battery.
Clinical Implications
Magee’s standardized approach improves diagnostic accuracy and reproducibility. ULTTs should be combined with Spurling’s test, distraction test, and sensory exams for best diagnostic precision.
Sources:
Magee DJ.Orthopaedic physical assessment.5th edition.Elsevier publication.
Elvey RL: The investigation of arm pain. In Boyling JD, Palastanga N (eds): Grieve’s modern manual therapy: the vertebral column, 2nd ed. Edinburgh, 1994, Churchill Livingstone.
Butler DS: Mobilisation of the nervous system, Melbourne, 1991, Churchill Livingstone.
Flynn TW, Cleland JA, Whitman JM. Users' Guide To The Musculoskeletal Examination. Evidence in Motion; 2008.
Shacklock M. Clinical neurodynamics: a new system of neuromusculoskeletal treatment. Elsevier Health Sciences; 2005 May 6.
Adrianna Simmons. Upper Limb Tension Test 1. Available from: https://www.youtube.com/watch?v=Cy6kqiLLDII [last accessed 14/4/2022]
Adrianna Simmons. Upper Limb Tension Test 2A. Available from: https://www.youtube.com/watch?v=kcTN1Tmp-Zg [last accessed 14/4/2022]
Adrianna Simmons. Upper Limb Tension Test 2B. Available from: https://www.youtube.com/watch?v=b5VkzZ06vW4 [last accessed 14/4/2022]
Adrianna Simmons. Upper Limb Tension Test 3. Available from: https://www.youtube.com/watch?v=dogBcKQ1y88 [last accessed 14/4/2022]
Magee DJ, Manske RC. Orthopedic physical assessment. 7th ed. Philadelphia, PA: Saunders; 2021.
Hartley A. Practical Joint Assessment. St Louis: Mosby; 1995.
Schmid AB, Brunner F, Luomajoki H, Held U, Bachmann LM, Künzer S, Coppieters MW. Reliability of clinical tests to evaluate nerve function and mechanosensitivity of the upper limb peripheral nervous system. BMC musculoskeletal disorders. 2009 Dec;10(1):1-9.
