The resisted levator scapulae test: a clinical test for C4 radiculopathy

Key Points

1. C4 radiculopathy is uncommon but may present as shoulder pain.
2. The resisted levator scapulae test was found to be sensitive and specific for C4 radiculopathy.

BACKGROUND AND OBJECTIVE

Cervical radiculopathy is typically identified due to the presence of arm pain, paraesthesia, or weakness with apparent dermatomal and myotomal symptoms for C2-3 and C5-8. While there are some clinical tests to identify cervical radiculopathy, there are currently no tests to identify cervical radiculopathy at C4.

This study aimed to assess the clinical utility of using the resisted levator scapulae (RLS) test in identifying patients with C4 radiculopathy on physical examination.

Cervical radiculopathy is typically identified due to the presence of arm pain, paraesthesia, or weakness with apparent dermatomal and myotomal symptoms for C2-3 and C5-8.

The resisted levator scapulae test offers clinicians a tool to screen for the presence of C4 radiculopathy without potentially provoking pain by performing a provocative test.

METHODS

• A convenience sample of patients presenting with cervical pain with a suspicion of C4 radiculopathy was recruited from a private spine clinic.

• All participants with evidence of C3/4 stenosis on MRI or CT images were assigned to the test group and underwent the reference standard test of receiving a CT-guided injection.

• A positive reference standard test showed a decrease in symptoms following a CT-guided nerve root block using local anesthetic performed by a radiologist.

• If there was no evidence of stenosis at C3/4, participants were assigned to the pragmatic control group.

• In supine, the patient shrugs one shoulder towards the ear, and the examiner’s hand is supinated and placed mid-clavicle (see Video 1).

• The patient then laterally flexes the cervical spine to the examiner’s hand.

• The patient resists pressure from the examiner on the mandible.

• The test is repeated on the other side.

• A noticeable asymmetry in strength is considered a positive result.

VIDEO 1 – RESISTED LEVATOR SCAPULA TEST

RESULTS

• In the test group, there were 21 positive results and four negative results, while all participants in the control group tested negative.

• Analysis revealed sensitivity of 90% for patients who had isolated C4 stenosis.

• When the control group was added to the analysis, the specificity improved from 20% to 93%.

• Overall, the RLS was found to be reliable at identifying patients with C4 radiculopathy.

LIMITATIONS

• The convenience sample from a single clinic makes it challenging to generalize the results.

• A single examiner may increase the intra-rater reliability. Still, there was no comparison or confirmation with any other examiners, so the reproducibility of these results is unknown at this time.

• Isolated C4 radiculopathy is very rare, and very often patients will also have other issues such as facet arthropathy. Relief from an injection in that area does not necessarily indicate stenosis at C4.

CLINICAL IMPLICATIONS

Neck pain, with and without radiculopathy, is a very common presentation in clinical practice. Determining the exact incidence of cervical radiculopathy is challenging, but is estimated to be 85 per 100,000, impacting males more than females (1), with an incidence of approximately 50% in software engineers (2). Radicular patterns for C5-8 are well known, often traveling down the upper extremity in a predictable pattern. C4 radiculopathy can be challenging because symptoms do not travel into the arm and are localized to the neck and shoulder.

Patient’s presenting with shoulder and/or neck pain may benefit from being screened for C4 radiculopathy to inform the clinical picture. Narrowing down the source of a patient’s shoulder pain can help clinicians choose more effective interventions by narrowing down the contributing factors. Spurling’s test can be utilized to identify the presence of radiculopathy; however, this test is provocative and has relatively low sensitivity (3).

The RLS test offers clinicians a tool to screen for the presence of C4 radiculopathy without potentially provoking pain by performing a provocative test. Once C4 radiculopathy is suspected due to a positive RLS, clinicians can be more confident moving forward with the recommended conservative care, such as exercise and manual therapy for the neck. (4).

+STUDY REFERENCE

Peters W, Smith, J and Zotti M (2025) The resisted levator scapulae test: A clinical test for C4 radiculopathy, European Spine Journal, Springer Science and Business Media LLC. Online ahead of print.

SUPPORTING REFERENCE

1. Woods, BI & Hilibrand, AS 2015, ‘Cervical Radiculopathy’, Journal of Spinal Disorders and Techniques, vol. 28, no. 5, pp. E251–E259.
2. Joseph, R & Roy, F 2023, ‘Prevalence of Cervical Radiculopathy among Information Technology Professionals with Neck Pain’, Indian Journal of Pain, vol. 37, no. 3, p. 169, viewed 22 January 2024.
3. Jones, SJ & Miller, J-MM 2023, Spurling Test, PubMed, StatPearls Publishing, Treasure Island (FL).
4. Kjaer, P, Kongsted, A, Hartvigsen, J, Isenberg-Jørgensen, A, Schiøttz-Christensen, B, Søborg, B, Krog, C, Møller, CM, Halling, CMB, Lauridsen, HH, Hansen, IR, Nørregaard, J, Jørgensen, KJ, Hansen, LV, Jakobsen, M, Jensen, MB, Melbye, M, Duel, P, Christensen, SW & Povlsen, TM 2017, ‘National clinical guidelines for non-surgical treatment of patients with recent onset neck pain or cervical radiculopathy’, European Spine Journal, vol. 26, no. 9, pp. 2242–2257.