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Grading Deep Tendon Reflexes Explained

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Reflexes are involuntary contractions of muscles in response to a stimulus and are classified as deep tendon, superficial, or pathologic. The most common reflexes tested are the deep tendon reflexes which include the biceps, triceps, brachioradialis, quadriceps (patellar), and Achilles (ankle). 

When testing deep tendon reflexes, it is important to ensure your patient is completely relaxed, as these reflexes can be challenging to elicit when the muscles are tense.

Strike the tendons in the following areas:

Scale for Grading Deep Tendon Reflexes

Note the reflex response's speed, force, and amplitude and grade the response using the following 0 to 4 scale. Always compare the response of one side with the other.








No reflex response

Diminished reflex response

Normal reflex response

Increased reflex response

Very brisk reflex response


If a reflex is reduced or absent, try using reinforcement to increase reflex activity. Reinforcement involves isometric contraction of other muscles for up to 10 seconds, which can increase reflex activity. 

For example, ask the patient to clench the teeth or squeeze both knees together to reinforce the arm reflexes. If the leg reflexes are decreased or absent, have the patient lock their fingers together and pull one hand against the other. Ask the patient to pull just before you strike the patella or Achilles tendon.

Interpreting Deep Tendon Reflexes

As you perform your assessment, test the reflexes on one side immediately after testing the corresponding reflex on the other instead of testing all reflexes in one limb and then testing the other. 

If reflexes are brisk, it may be challenging to detect asymmetry. Try to lighten the stimulus until it just barely elicits a response. Check for and document the following:

Key points to remember:

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