Deep tendon reflex exam

Key takeaways

The deep tendon reflex exam checks the reflex arc, testing sensory nerves, the spinal cord synapse, and motor fibers in seconds.

The 0-4+ grading scale runs from absent reflexes (0) to clonus (4+), with grade 2+ recorded as normal.

Five reflexes map to set nerve roots: biceps and brachioradialis (C5-C6), triceps (C7-C8), patellar (L3-L4), and Achilles (S1-S2).

The downloadable template is a two-page recording form, so use the grading scale and nerve root tables on this page as your reference.

Pabau’s digital intake forms capture every reflex grade in the patient record, so you can compare findings visit to visit.

The deep tendon reflex exam is the most common neurological test in clinical practice. A single tap with a reflex hammer produces an involuntary muscle contraction. That contraction tells you whether the sensory nerve, the spinal cord synapse, and the motor nerve are all working.

The appeal is speed. You need a reflex hammer, a quiet room, and a patient who can relax. In under two minutes you can check several nerve root levels at once. What you find ranges from mild peripheral neuropathy to early signs of spinal cord compression.

This guide covers patient positioning, the five reflexes and their nerve roots, the 0-4+ grading scale, and what abnormal results point to. The downloadable form above gives you somewhere to write the findings down while you work.

What is inside the printable form

The template is a recording form rather than a reference chart. Across two pages it gives you blank fields to complete during the exam, and nothing else.

• Patient information: full name, date of birth, gender, height, weight, blood pressure, heart rate, and respiratory rate.
• Actual response lines: separate left and right entries for the biceps, triceps, brachioradialis, patellar, and ankle reflexes.
• A plantar response line on each side, which records the Babinski response rather than a deep tendon reflex.
• Description of responses: a free-text box under each reflex for the detail a single grade cannot carry.

The form does not print the 0-4+ scale, the nerve root map, a technique checklist, or reinforcement maneuver prompts. Those references sit in this article instead. Keep the page open beside you while the scale is still new, or add your own header to the form before printing it.

The form labels the ankle jerk as Ankle, while most textbooks call it the Achilles reflex. Both names describe the same S1-S2 response.

What is a deep tendon reflex exam?

A deep tendon reflex exam tests a three-link chain. Sensory neurons carry a signal from the stretched tendon to the spinal cord. The spinal cord synapse bridges the gap. Motor neurons then fire back and contract the muscle.

This reflex arc bypasses the brain entirely. Tapping the patellar tendon makes the quadriceps contract before the patient has thought about it. Testing the arc at five sites maps the spinal cord and peripheral nerves from the neck down to the ankles.

The exam is non-invasive and gives you an answer immediately. It needs no equipment beyond a reflex hammer, and it fits inside a wider neurological exam checklist.

The 0-4+ DTR grading scale

The 0-4+ scale is the clinical standard for grading deep tendon reflexes. It works the way the numeric pain rating scale does, with every clinician using the same five categories. A grade 2+ recorded today reads the same way in five years, or when another practitioner opens the note.

Grade 2+ is the reference point for normal. Grades 0 and 1+ suggest a problem inside the reflex arc itself. Grades 3+ and 4+ point the other way, toward lost inhibition from above. Grading all five reflexes the same way is what lets you localize the level involved.

Upper extremity reflexes: biceps, brachioradialis, and triceps

The upper extremity reflexes test the cervical spine, from C5 through C8. Each one has its own tendon, technique, and nerve root.

Diminished biceps and brachioradialis reflexes both point to C5-C6. That pattern suggests cervical radiculopathy or nerve root compression, a frequent finding in sports medicine caseloads. An absent triceps reflex localizes the problem lower, at C7-C8.

Lower extremity reflexes: patellar and Achilles

The lower extremity reflexes test the lumbar and sacral spine, from L3 through S2. These two are the most commonly examined DTRs, because they are easy to elicit and quick to interpret.

Absent patellar reflexes (L3-L4) are common in older patients and in peripheral neuropathy. Absent Achilles reflexes (S1-S2) often signal lower lumbar or sacral involvement. Disc herniation is a frequent cause, and a familiar pattern in physical therapy practices.

The plantar response and reflexes beyond the standard five

The plantar response is not a deep tendon reflex, even though the template records it alongside them. Stroking the sole of the foot tests a superficial cutaneous pathway rather than a muscle stretch reflex. It is graded by direction, not on the 0-4+ scale.

A normal adult response is downward flexion of the big toe. Upward extension of the big toe with fanning of the others is the Babinski sign, which indicates upper motor neuron dysfunction. Record it as flexor or extensor, never as a number.

The Hoffmann sign is the upper limb equivalent. Flicking the middle fingernail produces thumb and index finger flexion when corticospinal pathways are affected. Abdominal and cremasteric reflexes are superficial too, and they are documented less often but still worth knowing.

Step-by-step DTR examination technique

Technique decides whether a borderline finding shows up at all. Small changes in positioning separate a detected abnormality from a missed one.

1. Position the patient. Seated with the feet clear of the floor works for the lower limb reflexes, and supine positioning works if the patient cannot sit. Every muscle needs to be relaxed, because tension masks the true response.
2. Find the tendon first. Palpate the exact location before you tap. The patellar tendon sits below the kneecap, and the Achilles tendon sits just above the heel.
3. Let the hammer swing. Hold it loosely at the end of the handle and let the weight of the head do the work. Tap briskly rather than hard, since momentum matters more than force.
4. Grade the response as you see it. Watch the muscle, then assign a grade on the 0-4+ scale straight away. Compare left with right, because asymmetry carries more weight than any single grade.
5. Repeat before you call it absent. Test again if a reflex is absent or diminished. Add a reinforcement maneuver before you record a zero.

Reinforcement maneuvers for difficult-to-elicit reflexes

A reinforcement maneuver amplifies a reflex that looks absent or borderline. The Jendrassik maneuver is the standard choice for the lower limbs. Ask the patient to interlace their fingers and pull their hands apart hard while you tap.

For the upper limb reflexes, ask the patient to clench their teeth or press their knees together instead. Either action lifts spinal cord excitability for a moment, which is often enough to bring out a weak response.

Time the tap to land during the effort rather than before or after it. If the reflex is still absent with reinforcement, document it as truly absent. Note that you used reinforcement, so the next clinician knows the zero is real.

What abnormal DTR findings mean

Hyperreflexia (grade 3+ or 4+) suggests an upper motor neuron lesion. Damage to the brain or spinal cord removes the inhibition that normally damps the reflex arc. Stroke, multiple sclerosis, and spinal cord compression all produce this pattern. In acute injury, reflex testing sits in the disability step of the primary trauma survey.

Hyporeflexia or areflexia (grade 0 or 1+) points to the lower motor neuron side. Peripheral nerve damage, radiculopathy, and nerve root compression all reduce the response. Diabetic neuropathy classically blunts the Achilles reflex first, and absent reflexes at all five sites suggest a systemic neuropathy.

Asymmetry matters more than the absolute grade. One side normal and the other abnormal points to localized pathology on the affected side. Compare sides at every site, every time.

When to investigate a reflex finding further

A single absent Achilles reflex in an older patient is often normal aging. Multiple absent reflexes, new asymmetry, or a grade that has shifted since the last visit are not. Any of those three warrants imaging or a specialist referral.

Reflex grades are most useful as a trend. Tracking them in a practice dashboard alongside other neurological findings makes a slow change visible. Treat DTR results as one input into the wider assessment, since they are not diagnostic on their own.

Documenting reflex results in clinical notes

Documentation is what turns a two-minute exam into something you can compare later. Reflex grades belong in the objective section of your progress notes. Standardized workflow templates keep the format identical across everyone on your team.

• Use the 0-4+ scale every time. Spell out the meaning if your record system expects words, as in grade 2+, normal and symmetrical.
• Record left and right side by side: biceps 2+ bilaterally, patellar 2+ right and 1+ left, Achilles 2+ bilaterally. Asymmetry then jumps off the page.
• State whether you used a reinforcement maneuver, and which one.
• Record the plantar response as flexor or extensor rather than as a grade.
• Tie the findings to a plan, such as absent Achilles reflexes bilaterally, consistent with peripheral neuropathy, screen for diabetes.

Where this guidance comes from

This guide follows established clinical references. For technique detail, see Merck Manual’s reflex guidance. For hammers and elicitation methods, see this review of reflex tools. The Cleveland Clinic DTR overview is a useful patient-facing summary.

The American Academy of Neurology and the American Association of Neuromuscular and Electrodiagnostic Medicine both publish examination standards. Check their current guidance for your own setting and patient population.

How Pabau keeps reflex findings in one patient record

A paper form solves the bedside problem and creates a filing one. The sheet gets scanned, emailed, or left in a folder. Six months later nobody can answer whether the left patellar reflex has actually changed.

Practice management software like Pabau removes that step. Build the reflex exam as a digital form once, and it opens inside the patient’s record at every visit. Grades, side comparisons, and your free-text description all save to the same timeline.

Because the findings live in the record rather than in a scan, you can pull up the last three exams during the consultation. Follow-up appointments book from the same screen, and the referral letter carries the notes with it.

Keep every reflex exam in the patient record

Pabau’s digital forms capture DTR grades, side comparisons, and your written description inside the patient’s chart. Findings from every visit sit on one timeline, so change over time is easy to spot.

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Conclusion

The reflex hammer is cheap and the exam is quick. What limits the value of a reflex finding is whether it was graded consistently and written down where somebody can compare it next time.

Print the form, grade against the 0-4+ scale on this page, and keep the plantar response separate from the deep tendon reflexes. Those three habits are what make a reflex grade worth revisiting.

The trade-off with paper is that it only helps once. Book a demo to see how Pabau turns the same form into a record you can compare visit by visit.

Continue your research

Working through the rest of the neuro exam? Cranial nerve examination checklist walks the twelve nerves in the order you test them.

Watching a neurological picture change hour by hour? Neurological vital signs covers what to record between reflex checks.

Need a grading scale for muscle power? MRC muscle strength scale gives you the 0-5 equivalent of the reflex scale.

Assessing joints alongside the reflex exam? Range of motion assessment explains how to measure and record joint movement.

Following up an upper motor neuron finding? Neurological eye exam shows what pupils and eye movements add to the picture.

Frequently asked questions