Science News: The Resisted Levator Scapulae Test: A Clinical Test for C4 Radiculopathy

Submitted by: Elena Shanina, MD
Edited by: Rebecca O'Bryan, MD

Citation: Peters WR, Smith JTE, Zotti MG. The resisted levator scapulae test: a clinical test for C4 radiculopathy. Eur Spine J. 2025;34(8):3205-3213. doi:10.1007/s00586-025-08903-z

Summary: 
This study examined a novel clinical examination maneuver, the resisted levator scapular (RLS) test, as a potentially useful bedside tool for identifying isolated C4 radiculopathy. Because C4 radiculopathy lacks well-established physical examination findings, diagnosis can be challenging. Patients with clinical suspicion for C4 radiculopathy were enrolled in this study and were categorized either as a test group, who received CT-guided C4 nerve root injection as a diagnostic gold standard, or as a pragmatic control group based on imaging evidence of C3-4 foraminal stenosis. The performance of the RLS test was evaluated by comparing bedside clinical findings with diagnostic nerve block outcomes.

Twenty-five participants (12 male, 13 female) with a median age of 69 completed the study in the test group and 298 participants (192 male, 106 female) completed the study in the pragmatic control group. Among the patients in the test group, nine had isolated C4 radiculopathy confirmed by nerve block and 15 had multilevel involvement including C4. Primary analysis showed that the RLS test had a high sensitivity (90%) but low specificity (20%), suggesting it is good at detecting possible cases, but not strong at ruling out  mimics. Expanded analysis, which included the larger control group, considerably improved specificity (93%) and negative predictive value (99.6%).

The RLS test utilizes shoulder elevation and lateral flexion of the cervical spine, isolating the distal attachment of the levator scapulae at the medial border of the scapula. By doing so, trapezius and sternocleidomastoid activity is minimized, therefore removing or reducing contribution from cranial nerve XI.

Overall, the authors conclude that the RLS test is a novel, practical bedside maneuver that can help raise suspicion for C4 radiculopathy and complement the neurological examination, although confirmatory imaging or diagnostic blocks remain necessary.

Comments: The findings from this study highlight the clinical application of the RLS test as a new bedside diagnostic tool for patients with C4 radiculopathy.

Why is this interesting/relevant to the AANEM audience? Cervical radiculopathies are common in clinical practice, and isolated C4 radiculopathy is difficult to diagnose clinically. Presentation may masquerade as musculoskeletal shoulder pathology. Additional clinical diagnostic tools can help in selecting patients for further diagnostic testing.