Range-of-Motion Testing

ROM testing is essentially "muscle-length" testing (although fascia, tendons, and ligaments can also come into play). The following examples reveal muscle shortening or hypermobility that underlie much pain and dysfunction. Their impact is commonly disregarded in favor of diagnoses based on nerves and organs. Yet our 600-some muscles make up the largest "organ" of the body.

Considering muscles does not dismiss neurological issues. The two are intimately related. Muscles commonly entrap the nerves passing through them. Nerves, in turn, may produce painful or frightening symptoms (including slowed or altered responses to neurological tests) without being the origin of the problem. Check muscles! If you cannot rotate or tilt your head by at least 45 degrees, if you cannot point the tip of your closed jaw at the ceiling or touch it to your chest, you may have found the a myofascial origin of many severe headaches, including and frightening neurological symptoms including nausea, dizziness, and more.

Material below is excerpted with commentary from our Range-of-Motion (ROM) Testing charts. See also tests for shoulder problems.

Cervical and Masticatory Tests

Head pain of muscular origin (including that commonly diagnosed as "sinus" and "migraine") comes primarily from the neck. Muscles shown in bold type are the ones most likely to inhibit a specific motion.

    Cervical Rotation Test

    Levator Scapula
    Splenius Cervicis
    Splenius Capitis

    Cervical Rotation Test

    With patient sitting on hands or holding seat of chair,

    1. Patient rotates head to one side then the other.
    2. Note degree of rotation.

      Substitution: Shifting shoulder forward, tilting head forward or back.

      No restriction: Nose should align with acromion (90o).

      Restriction: Nose at lesser angle to shoulder
    • Restriction most commonly due to levator scapula and splenius cervicis. These muscles restrict on same side.
    • Sternocleidomastoid may restrict last 10o of rotation to the opposite (contralateral) side.
    • Trapezius slightly restricts rotation to the opposite side, often causing pain at nearly full rotation. Upper trapezius involvement most strongly indicated by Cervical Lateral Flexion Test, below.
    • Scalenes restrict at end of motion. See Scalene Cramp Test.

    Note: Levator scapula, especially in combination with trapezius, is the leading cause of a "stiff" or "crick" neck. Even where pain is not present, inability to turn your head fully to the side to check for oncoming cars is a potentially life-threatening condition.

    Cervical Lateral Flexion Test


    Cervical Lateral Flexion

    1. Patient attempts to press ear to shoulder.
    2. Observe bottom of ear lobe. Measure distance from shoulder.

    Substitution: Tilting to side, raising shoulder to meet ear rather than lowering ear to shoulder. Have patient hold chair seat or sit on hands to stabilize shoulders.

    No restriction: Ear to shoulder.

    Restriction: Unable to reach shoulder with ear.

      • Upper trapezius: may limit movement to an angle of 45o or less.
      • Scalenes: may restrict final 30o of motion. See Scalene Cramp Test.
      • Sternocleidomastoid: occasionally restricts about 10o to opposite side.
      • Referral zones of trapezius and sternocleidomastoid perpetuate trigger points in the masticatory muscles. See Masticatory Tests, below.

        Note: Some patients have virtually no lateral movement and are quite surprised that an ear should be able to come anywhere near a shoulder. This restriction is common, but it is not "normal." Those who have it are likely to suffer tension or migraine headaches with a typical "fishhook" pain pattern.

      Cervical Flexion Test

      Splenius Capitis
      Splenius Cervicis
      Semispinalis Capitus
      Semispinalis Cervicis

      Cervical Flexion

      1. Patient clenches jaw and curls neck forward touching chin to chest.
      2. Observe base of chin; measure distance from chest.

      Substitution: Dropping open jaw to chest. Dropping neck straight forward from C7, then flexing neck.

      No restriction:
      Chin touches chest.

      Cannot reach chest with chin. For deep cervical paraspinals, do Flat Back Test.

      Note: The muscles that restrict this motion are commonly involved in brutal head and neck pain commonly diagnosed as "occipital neuralgia," "tension and cervicogenic headache," and "chronic intractable benign headache." They may be fired off by such everyday actions as watching TV with head proppred on elbows and wrists or by bi- or trifocals that require holding the head in a set position to focus.

      Cervical Extension Test

      Cervical Extension

      With mouth firmly closed (teeth touching),

      1. Patient extends neck to back and looks directly up at the ceiling. Caution: Patient should emphasize lifting chin to ceiling rather than scrunching the back of the head down onto the upper back.
      2. Observe distance between occiput and back of neck. Ear and eye should be vertically aligned.

      Substitution: Patient allows mouth to open.

      No restriction: Able to look straight up without pain.

      Restriction: Unable to extend fully or without pain.

      Note: These muscles are commonly injured in whiplash and vehicle accidents. Pain may refer to eye, ear, neck and cause difficulty opening the mouth or swallowing.

      Scalene Relief Test

      Scalene Relief

      To relieve current scalene pain or to counteract any pain created by the Scalene Cramp Test (below),

      1. Bring forearm up against forehead on symptomatic side.
      2. Rotate shoulder forward. This movement opens up space for the brachial plexus.

        No restriction: No change.

        Restriction: Decreased scalene pressure on brachial plexus results in decreased pain.
        Scalene Cramp


        Scalene Cramp

        This test is essentially the same as playing the violin. It is used to reproduce suspected scalene pain or dysfunction. Use with caution: it may also distress a bulging disc or compromised facet joint on the side being tested. Discontinue test if cervical pain increases. Do not test through pain. Use with caution when patient has tender spinous processes in the cervical spine.

        1. Patient turns head to side and pulls chin firmly into clavicle area.
        2. Hold for 60 seconds.

          No restriction: No change.

          Restriction: Pain or tingling may appear in scalene pain reference areas: chest, back, fingers. Follow immediately with Scalene Relief Test, above.

        Opening and Closing Test

        Digastric (posterior)

        TMJ Test

        1. Stand behind head as patient slowly opens and closes mouth. Watch for deviation of mandible to one or both sides. If:
          • Most marked away from affected side as opening reaches full ROM: medial pterygoid.
          • Contralateral deviation: lateral pterygoid.
          • “Zig-zag” motion on opening: temporalis.
        2. Listen for and ask about popping and clicking. One side or both? Grating sounds require a dental/TMJ evaluation.
        3. Repeat this test supine to eliminate postural muscles.

          No restriction: Jaw opens widely, closes smoothly and evenly, with no sound.

          Restriction: Jaw deviates to side or produces a narrow opening.

          Note: Muscular dysfunction is a far more common cause of TMJ dysfunction than the joint itself. Surgery is RARELY the best initial treatment. After all, it is the muscles that move the joint in a balanced, even manner -- or not. Check muscles and correct dysfunction before damage to the joint capsule does occur.

        2-Knuckle Test


        2-knuckle Test

        1. Patient inserts 1-2 fingers or knuckles between teeth.
          1. Gently adding one finger or knuckle at a time, see how many can fit inside mouth. Do not force.
          2. Repeat this test supine to eliminate postural muscles.

            No restriction: Minimum of 2 fingers or knuckles.

            Restriction: Tight masseter and temporalis restrict or deviate jaw opening. See Opening and Closing Test.

            Hypermobility : Suggested by three or more fingers.

              Referral zones of the sternocleidomastoid and trapezius perpetuate TrPs in masticatory muscles. See Cervical Lateral Flexion Test and Cervical Rotation Test.

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