Manual Therapy (1996) 1, 154-161

1996 Pearson Professional Ltd

Case Study

POSITIVE UPPER LIMB TENSION TEST IN A

CASE OF SURGICALLY PROVEN
NEUROPATHY: ANALYSIS AND VALIDITY

Whether the ULTT is a valuable diagnostic tool

depends on its clinical sensitivity and specificity. A sensitive and specific test is one which is positive in the
presence of pathology and negative in the absence of
pathology. The clinical validity of the ULTT has not yet
been established scientifically.
Some researchers have shown that symptom
responses with the ULTT can be abnormal in patients in
whom neuropathlc disorders could justifiably be suspected. Several studies in which this was the case are as
follows. Colles' fracture was an example in which carpal
tunnel dysfunction secondary to fracture may have been
present (Young & Bell 1991). Lateral elbow pare was a
syndrome an which the ULTT 2 radial nerve bias (Butler
1991) evoked patients" clinical pain (Yaxley & Jull
1993). Post-cardiac surgery was also a presentation in
which neuropathy may have been a source of symptoms
in a study of the ULTT 1 by Selvaratnam et al (1994).
This was because the symptoms evoked by the ULTT
were abnormal and neural disorders sometimes develop
after this procedure (Lederman et al 1982; Hanson et al
1983) In that study, the test distinguished between control, shoulder injury and cardiac surgery groups, demonstratlng a degree of discriminative vahdity
Qulntner (1989) described abnormal responses to
Elvey's version of the ULTT (Elvey 1980) in patients
with neck injury caused by vehicle accident. Also,
Grant et al (1995) found a reduction in range of motion
of the glenohumeral abduction component of the ULTT 2
radial nerve bias (Butler 1991, pp 154-155) in keyboard
operators. The imphcatlon that key board operation may
alter extensibility of the nerves was based on the notion
that the test reflected the mechanical function of the
nerves. Finally, based on their chnacal findings with the
ULTT, Elvey et al (1986) proposed the role of the nervous system in production of symptoms an patients with
occupational overuse disorders.
Based on known anatomy, blomechanics and clinical
usage, the ULTT will at times have face vahdity
However. the problem with research into the clinical
validity of the ULTT is that surgical verification that
neural abnormahty is the cause of symptoms frequently
cannot be obtained The above mentioned studies suffer
from this dilemma and it means that validity becomes an
extrapolation rather than a certainty. Although the necessary surgical verification has been provided in the case
of the straight leg raise test (Edgar & Park 1974), the
author is unaware of any reports of a correlation between
a positive ULTT and surgical proof of neuropathy.
The following IS an analysis of the ULTT in a case of
surgically proven ulnar nerve entrapment. Preoperatively,

Although there is theoretical and clinical support for the

upper limb tension test (ULTT) in diagnosis of neurogenic disorders in the upper limb and neck, its clinical
vahdxty is still unproven. Also there is confusion about
what constitutes a positive test and what this actually
means. This paper is an analysis of the ULTT in a case
of surgically proven neuropathy and seeks to clarify the
nature and meaning of a positive test. In the case presented, the ULTT showed distinct diagnostic and prognostic attributes, supporting its role in this context.
However, a positive test raises many issues, including
causes of true positives, false positives and false negatives. Factors which may account for these aspects are
discussed.

INTRODUCTION
Neural tension tests have been used clinically In the
assessment and treatment of neurogenic pain syndromes. Chaveny (1934), Elvey (1980, 1986) as well as
Butler & Gifford (1989) have described these tests for
the neural structures of the upper limb. Further developments in this field have been provided by Butler (1991,
pp 149-159) and Shacklock (1995a, 1995b).
The hmb tension test (ULTT) is used In the diagnosis
of neurogenlc upper limb and neck pain. The test exerts
mechanical stresses in the cervical nerve roots and
upper limb nerves so that mechanical hypersensitivity
of these structures can be detected via the patient's
report of the evoked symptoms. There are several versions of the ULTT. The base ULTT (ULTT~) has been
described by Butler (1991, p 149) in which mechanical
stresses exerted in the neural structures are generalised,
although specific variations in stress and strain in the
nerves have been shown to occur (Selvaratnam et al
1994; KleInrenslnk et al 1995). The ULTT 2 radial nerve
bias (Butler 1991, pp 154-155) is a variation which is
likely to bias stresses to the radial nerve. This is
because, in addition to other movements, the ULTT2
makes use of glenohumeral internal rotation and forearm pronation to apply stress to the radial nerve as it spirals distally around the humerus to the forearm Another
variation is the ULTT 3 (Butler 1991, pp 158-159) which
stresses the ulnar nerve by utilaslng elbow flexion to
stress the ulnar nerve at the elbow More specific discussIon of the relevant tests is presented later
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