Cervical Radiculopathy
“Client presents with neck pain that radiates into the arm, sometimes with numbness, tingling, or weakness.”
Before applying any manual techniques, ensure there are no red flags and no progressive neurological deficit. If in doubt, do not treat — refer first.
Immediate referral without treatment: bilateral arm symptoms, any leg involvement (weakness, numbness, coordination), gait disturbance, bladder or bowel changes, rapidly progressive weakness, or severe intractable pain.
Radiculopathy refers to symptoms that develop when a spinal nerve root is compressed or irritated. Cervical radiculopathy involves compression of a nerve root in the cervical spine, typically from disc herniation, foraminal stenosis, or degenerative changes.
The intervertebral foramen is a small bony tunnel through which each nerve root exits the spinal canal on its way to the arm. When this opening narrows, the nerve root can become compressed, producing pain, sensory changes, and sometimes motor deficits following the distribution of that nerve root.
Disc herniation does not only result from acute trauma. Sustained poor posture — particularly forward head position and prolonged sitting in flexion — increases intradiscal pressure and progressively weakens the annular fibres over time. Disc herniation is often the endpoint of years of accumulated postural and mechanical load.
Symptoms:
Symptoms in isolation do not automatically indicate radiculopathy — always interpret alongside the full clinical picture.
- Neck pain — often unilateral, deep and aching
- Radiating arm pain following a dermatomal pattern
- Numbness or tingling in the arm or hand
- Weakness in muscles innervated by the affected nerve root
- Pain aggravated by cervical extension, rotation, or lateral flexion toward the affected side
- Pain relieved by placing the hand on top of the head (reduces nerve root tension — a reassuring sign)
- Symptoms often worse at night or on waking
Bilateral arm symptoms, any leg involvement, gait disturbance, bladder or bowel changes, or rapidly progressive weakness. These presentations suggest spinal cord compression (myelopathy) rather than single nerve root involvement. This is a medical emergency.
Subjective — case history:
- Where is the pain? Neck only, or does it radiate into the arm? Where exactly — shoulder, upper arm, forearm, hand, which fingers?
- Describe the quality — pain, numbness, tingling, or weakness?
- How did it start? Gradual or sudden? Any trauma?
- What aggravates it? Neck movement? Coughing or sneezing?
- What relieves it? Rest? Arm position? Hand on head?
- Any weakness — difficulty gripping, dropping objects, fine motor tasks?
- Any changes in bladder or bowel function? (Red flag — refer immediately)
- Any bilateral arm symptoms, or symptoms into the legs? (Red flag — refer immediately)
- Any previous episodes, imaging, or diagnosis?
Observation:
- Head and neck posture — protective posture or head tilt?
- Arm position — does the client hold the arm in a guarded position?
- Muscle wasting — visible atrophy in the shoulder, arm, or hand suggests significant or chronic nerve involvement
- Asymmetry — compare both sides
Range of motion:
| Cervical extension | Often limited and painful; tends to reproduce arm symptoms. |
| Rotation and lateral flexion toward affected side | Often reproduces radicular symptoms. |
| Shoulder flexion, abduction, external rotation | Screen for shoulder pathology, which can closely mimic C5 radiculopathy. Passive shoulder movements in a capsular pattern suggest shoulder pathology rather than radiculopathy. |
If cervical movements reproduce arm symptoms (not just neck pain), this supports radicular involvement.
Neurological screening:
For remedial massage therapists, neurological screening informs recognition and referral — not diagnosis. For physiotherapists, it is within diagnostic scope.
Myotomes (motor) — test against resistance, compare sides:
| C5 | Shoulder abduction — deltoid |
| C6 | Elbow flexion — biceps; wrist extension |
| C7 | Elbow extension — triceps; wrist flexion |
| C8 | Finger flexion — grip strength |
| T1 | Finger abduction — hand intrinsics |
Dermatomes (sensory) — light touch, compare sides:
Ask: “Does this feel the same on both sides?” Note any asymmetry.
| C5 | Lateral upper arm |
| C6 | Thumb and index finger |
| C7 | Middle finger |
| C8 | Ring and little finger |
| T1 | Medial forearm |
Reflexes: Formal deep tendon reflex testing (biceps, triceps, brachioradialis) requires a tendon hammer and is within physiotherapy and medical scope. Understanding what diminished reflexes indicate — lower motor neuron compression at a specific level — is clinically relevant when interpreting findings from co-treating practitioners.
Dermatomal reference — pain and sensory distribution:
| Nerve root | Pain / sensory area | Common motor weakness |
| C5 | Lateral shoulder and upper arm | Deltoid, biceps |
| C6 | Lateral forearm, thumb, index finger | Biceps, wrist extensors |
| C7 | Posterior arm, middle finger | Triceps, wrist flexors |
| C8 | Medial forearm, ring and little finger | Finger flexors, grip |
| T1 | Medial arm | Hand intrinsics, finger abduction |
Clinical variation is common, particularly at C6. Use the dermatomal map as a guide, not a rule — always interpret within the full clinical picture.
Special tests:
Vertebral artery screening
Can this client tolerate upper cervical positioning?
Client supine. Perform as described in Scenario 2: Headaches before treating the upper cervical region. If symptoms appear, do not proceed — consider referral.
Spurling’s test
Is there cervical nerve root involvement?
Client seated. Extend the cervical spine, laterally flex and rotate toward the symptomatic side, then apply gentle axial compression through the top of the head. Reproduction of arm symptoms (pain, numbness, tingling) suggests cervical radiculopathy.
Cervical distraction test
Is nerve root compression a contributing factor?
Client supine. Cradle the head with both hands and apply gentle axial traction, lifting the head to distract the cervical spine. Reduction of radicular symptoms with traction supports nerve root compression as a contributing factor.
ULNT 1 — Median nerve bias
Is there median nerve involvement or altered neural mobility?
Client supine. Depress the shoulder girdle. Abduct the shoulder to 90°, externally rotate, extend the elbow, supinate the forearm, then extend the wrist and fingers. Sensitise by adding cervical lateral flexion away from the tested side. Reproduction of symptoms or marked asymmetry suggests neural tissue involvement.
ULNT 2b — Radial nerve bias
Is there radial nerve involvement or altered neural mobility?
Client supine. Depress the shoulder girdle. Abduct the shoulder to approximately 10°. Internally rotate the shoulder, extend the elbow, pronate the forearm, flex the wrist and fingers. Sensitise with cervical lateral flexion away from the tested side. Reproduction of symptoms or marked asymmetry suggests radial nerve involvement.
ULNT 3 — Ulnar nerve bias
Is there ulnar nerve involvement or altered neural mobility?
Client supine. Depress the shoulder girdle. Abduct the shoulder to approximately 90°, externally rotate. Flex the elbow (key distinguishing feature — elbow flexion rather than extension maximally tensions the ulnar nerve). Supinate the forearm, extend the wrist and fingers. Sensitise with cervical lateral flexion away from the tested side. Reproduction of symptoms (often medial forearm, ring and little finger) or asymmetry suggests ulnar nerve involvement.
ULNTs do not differentiate between radiculopathy, peripheral nerve entrapment, or neural tension — use alongside other clinical findings.
Palpation:
Palpation in cervical radiculopathy is secondary to neurological findings but informs soft tissue involvement.
| Cervical paraspinals | Semispinalis cervicis, multifidus, splenius cervicis. Note tone, tenderness, and guarding. Protective muscle spasm is common. |
| Scalenes | Often tight and tender in radicular presentations; can contribute via neural tension or compression. |
| Upper Trapezius & Levator Scapulae | Often hypertonic as compensatory guarding. |
| Brachial plexus (posterior triangle) | Palpate between the SCM and upper trapezius. Tenderness or reproduction of arm symptoms on palpation suggests neural involvement. |
Conservative approach:
- Avoid positions that reproduce arm symptoms — cervical extension, rotation, and lateral flexion toward the affected side typically worsen symptoms
- Gentle soft tissue work to reduce muscle guarding — FMT, TPT, and MET applied with care to scalenes, upper trapezius, and cervical paraspinals
- Avoid aggressive mobilisation or manipulation of the cervical spine in acute radiculopathy
- Gentle neural sliders (not tensioners) to reduce neural tension without overstressing the nerve root — see Scenario 3: Postural / Tension Pattern for full neurodynamic technique description
- Thoracic spine soft tissue work is a useful adjunct and avoids direct cervical stress
When to refer:
- Red flags are present
- Neurological deficit is significant or progressive
- Symptoms are not responding after 6–8 weeks of structured conservative care
- You are uncertain about the safety of treatment
Monitor neurological status during and between sessions. If symptoms worsen or new deficits appear, stop and refer.
Cautions:
- Red flags for immediate referral: bilateral arm symptoms, any leg symptoms, rapidly progressive weakness, severe intractable pain, history of cancer with new neck or arm pain, unexplained weight loss or fever.
- Progressive neurological deficit: motor weakness or sensory loss that is getting worse over time warrants prompt referral for imaging and specialist review, even without other red flags.
- Central canal stenosis: bilateral symptoms, leg involvement, or balance and bladder changes suggest spinal cord compression (myelopathy) rather than single nerve root involvement. Medical emergency — refer immediately.
- Scope of practice: Remedial massage therapists do not diagnose cervical radiculopathy — the role is to recognise the presentation, gauge severity, and treat conservatively where appropriate. Physiotherapists may diagnose and manage radiculopathy within their scope, including referral for imaging when indicated. When in doubt, refer.
Evidence: Manual therapy and exercise are recommended as first-line conservative treatment for cervical radiculopathy in the absence of red flags or progressive neurological deficit (Blanpied et al., 2017 — APTA Clinical Practice Guidelines). Neural mobilisation techniques have been shown to reduce pain and improve function in patients with nerve-related neck and arm pain (Nee & Butler, 2006). Thoracic manipulation reduces neck pain and improves cervical range of motion even in patients with radicular symptoms (Cleland et al., 2005). Most cases improve without surgery.
Activity modification:
- Avoid positions and activities that aggravate arm symptoms — particularly sustained cervical extension, rotation toward the affected side, and overhead work
- Regular breaks from static sitting postures
Sleep position:
- Avoid stomach sleeping
- Side sleepers: adequate pillow height to fill the gap between shoulder and head
- Back sleepers: support that maintains the natural cervical curve without pushing the head forward
Pain-relief positions:
- Hand resting on top of the head often reduces nerve root tension and provides temporary relief
- Lying supine with a small rolled towel under the neck may be comfortable
Gentle movement (within pain-free range):
Cervical retraction (chin tucks): May help centralise symptoms — arm pain moves closer to the neck and reduces distally, which is a positive sign. Stop if arm symptoms worsen or spread further.
Slow cervical rotation away from the affected side: To maintain mobility.
Neural gliding (if tolerated):
Gentle median nerve sliders — alternating wrist extension and flexion with coordinated elbow movement — may help reduce neural tension. Introduce gradually and stop if symptoms are provoked.
Strengthening (once acute symptoms settle):
Deep neck flexor activation and scapular stabilisation, including serratus anterior reactivation as described in Scenario 3: Postural / Tension Pattern. Note: in some cases of C7 radiculopathy, the long thoracic nerve (which innervates the serratus anterior) is involved — making this exercise particularly relevant once acute symptoms settle.
| Postural dysfunction | Forward head position and sustained cervical loading contribute to the disc and foraminal changes that predispose to radiculopathy. Addressing posture is part of long-term management. See Scenario 3. |
| Headaches | At higher cervical levels (C2–C3), radiculopathy can contribute to cervicogenic headache. If the client reports headaches alongside radicular symptoms, both may require attention. See Scenario 2. |
| TMD | Cervical dysfunction and TMD often coexist. Clients with radiculopathy may also present with jaw tension from guarding and stress. See Scenario 1. |