The Sharp-Purser Test is an upper cervical screening manoeuvre historically used to assess possible atlantoaxial instability, particularly in relation to transverse ligament insufficiency. It is most often discussed in populations with risk factors such as rheumatoid arthritis, inflammatory disease, Down syndrome, trauma or suspected upper cervical instability. Current evidence questions the test’s reliability, validity and safety as a stand-alone screening tool, so it should be used only by appropriately trained professionals and within clear scope. A positive or concerning finding should prompt caution, stopping of provocative cervical testing and appropriate referral rather than being treated as diagnostic confirmation.

Introduction

The Sharp-Purser Test is one of the most safety-sensitive tests in cervical spine assessment. It is traditionally described as a test for atlantoaxial instability, where excessive anterior translation of the atlas on the axis may place the spinal cord at risk. Because of the structures involved, the test should never be treated like a routine neck mobility test.

The test has historically been used in people with conditions that may affect upper cervical ligament integrity, including rheumatoid arthritis and other inflammatory conditions. However, more recent systematic review evidence has raised concerns about diagnostic accuracy, reliability and safety. This means the Sharp-Purser Test should not be used casually, and a negative finding should not be treated as proof that the upper cervical spine is stable.

For health and fitness professionals, the most important educational message is risk recognition. If upper cervical instability is suspected, the professional should avoid provocative cervical testing, document findings carefully and refer for appropriate medical assessment according to scope and local pathways.

Quick Summary

Test name: Sharp-Purser Test
Body region: Upper cervical spine, atlantoaxial joint, transverse ligament region
Purpose: Historically used to screen for possible atlantoaxial instability
Commonly associated with: Transverse ligament insufficiency and upper cervical instability screening
Positive finding: Symptom change, clunk, excessive movement, apprehension or reduction-type response during carefully controlled testing
Negative finding: No symptom change or abnormal movement under test conditions
Best used with: Red-flag screening, neurological screening, medical history, imaging referral consideration and professional scope-based decision-making
Key limitation: A negative test does not exclude upper cervical instability, and the test has questioned reliability, validity and safety.

What Is the Sharp-Purser Test?

The Sharp-Purser Test is a manual upper cervical screening manoeuvre. In a commonly described version, the client sits with the neck slightly flexed while the professional stabilises the axis and applies a gentle posteriorly directed pressure through the forehead. The test is intended to observe whether symptoms or abnormal translation change when the atlas is guided posteriorly relative to the axis.

Historically, a positive test has been described as a clunk, reduction of symptoms, excessive translation, apprehension or neurological symptom change. However, these findings are not simple to interpret, and the test should not be used as a diagnostic confirmation tool.

Why It Is Used

The test has traditionally been used when upper cervical instability is suspected, particularly in people with risk factors for transverse ligament compromise. These may include inflammatory arthropathies, rheumatoid arthritis, Down syndrome, trauma, congenital conditions, history of cervical instability or symptoms suggestive of upper cervical cord compromise.

In modern assessment education, the test is best discussed as part of upper cervical safety reasoning. Its main value is not that it confidently confirms or excludes instability, but that it reminds professionals to identify risk factors and avoid inappropriate cervical loading when instability is possible.

What It Assesses

The Sharp-Purser Test is intended to assess possible signs associated with atlantoaxial instability or transverse ligament insufficiency. It may involve observing:

• Upper cervical symptom response
• Neurological symptom change
• Apprehension or guarding
• Possible clunk or abnormal movement
• Symptom reduction during posterior pressure
• Response to slight cervical flexion
• Safety concerns requiring referral

It does not directly visualise the transverse ligament and does not confirm or exclude atlantoaxial instability.

Who It Is Useful For

This test is relevant only in carefully selected contexts and should be performed only by appropriately trained professionals. It may be discussed when a client has risk factors such as rheumatoid arthritis, inflammatory disease, Down syndrome, trauma history, suspected cervical instability or concerning upper cervical symptoms.

For many health and fitness professionals, the practical role is not to perform the test, but to recognise when upper cervical instability risk is possible and when referral is more appropriate than further physical testing.

When to Use This Test

Use of the Sharp-Purser Test should be limited and cautious. It may only be considered when:

• The professional is appropriately trained and within scope
• Upper cervical instability screening is clinically relevant
• Serious pathology and red flags have been considered
• The client can provide informed consent
• The test result will change safety decisions or referral reasoning
• There is a clear plan to stop immediately if symptoms occur

When Not to Use or When to Be Cautious

Avoid the test or refer instead when there is acute trauma, suspected fracture, severe neck pain, neurological symptoms, myelopathic signs, dizziness, drop attacks, visual disturbance, unexplained severe headache, known instability, recent cervical surgery, inflammatory flare, suspected vascular compromise, or any situation where the professional is not trained or not within scope.

If instability is suspected, do not attempt to “clear” the client with this test. A negative test should not be used to justify cervical manipulation, high-load manual testing or aggressive ROM testing.

Equipment Required

The Sharp-Purser Test requires no equipment, but safe assessment requires:

• Clear clinical reasoning
• Informed consent
• Knowledge of red flags
• Ability to perform neurological screening
• Referral pathway awareness
• Measurz app for structured documentation
• Optional medical history and symptom notes

Within Measurz, the Sharp-Purser Test should be recorded cautiously as a safety screening observation. It can be documented alongside cervical red-flag notes, neurological screening, symptom behaviour, referral decisions, cervical ROM limitations and “unable to test” notes when testing is not appropriate.

Step-by-Step Protocol / Practice

Setup

Before any test is considered, screen for risk factors and red flags. Explain the reason for the test, its safety-sensitive nature and that it will be stopped immediately if symptoms occur. Gain informed consent.

Client position

The client is typically seated upright. The cervical spine may be placed in slight flexion, depending on the protocol used.

Examiner/professional position

Stand beside or slightly in front of the client so the head and upper cervical region can be supported and controlled.

Hand placement

One hand may stabilise the spinous process of C2. The other hand may contact the forehead.

Stabilisation

The axis is stabilised while the head and atlas region are controlled. Movement should be minimal, gentle and carefully monitored.

Movement or force direction

A gentle posteriorly directed pressure may be applied through the forehead while C2 is stabilised. The test should not be forceful. The professional monitors for symptom change, neurological symptoms, apprehension or abnormal movement.

Instructions

Ask:

“Tell me immediately if you feel dizziness, numbness, tingling, weakness, visual symptoms, headache change or anything unusual.”
“Tell me if this feels unsafe or uncomfortable.”
“We will stop immediately if symptoms change.”

Positive finding

A positive or concerning finding may include a clunk, abnormal movement, symptom reduction, neurological symptom change, apprehension, dizziness, paraesthesia, weakness, visual symptoms, nausea or other concerning response.

Negative finding

A negative finding means no concerning response was observed during the test. It does not exclude upper cervical instability.

Stopping criteria

Stop immediately if dizziness, neurological symptoms, visual symptoms, nausea, severe pain, headache change, apprehension, clunk, abnormal movement, client distress or any unusual symptom occurs.

Safety notes

The Sharp-Purser Test should not be performed as a routine screen. If risk factors are present, referral may be more appropriate than provocative testing.

Positive and Negative Test Interpretation

A positive Sharp-Purser Test should be treated as a safety concern. It may increase suspicion of upper cervical instability or ligament compromise, but it does not confirm the condition on its own. The appropriate response is to stop provocative cervical testing, document the finding clearly and refer according to scope and clinical context.

A negative Sharp-Purser Test does not exclude upper cervical instability. This is critical. Because reliability and sensitivity are limited, a negative result should not be used as clearance for cervical manipulation, aggressive manual therapy, high-load exercise or end-range cervical testing when risk factors remain.

Interpretation is strongest when combined with medical history, red-flag screening, neurological signs, symptom behaviour and appropriate imaging or medical review where indicated.

Sensitivity, Specificity and Diagnostic Accuracy

Diagnostic accuracy evidence for the Sharp-Purser Test is limited and concerning. A systematic review by Mansfield and colleagues reported that available studies had limitations and that the test lacked sufficient support as a reliable and valid clinical screening tool for atlantoaxial instability. Reported sensitivity values vary and may be too low for a safety screening test, while specificity is generally higher but still not enough to confirm instability in isolation.

Some secondary summaries report sensitivity ranges from approximately 0.19 to 0.69 and specificity ranges from approximately 0.71 to 0.98 across available studies. These ranges should be interpreted cautiously because populations, reference standards and test methods vary.

In plain language, the test may miss some people with instability, and a negative test should not be considered reassuring when risk factors or red flags remain.

Reliability and Validity

Reliability evidence for the Sharp-Purser Test is variable and generally not strong enough to support confident interpretation between examiners. Some reports describe low reliability across studies, with wide kappa ranges depending on population and examiner method.

Validity is limited because the test does not directly visualise ligament integrity or quantify atlantoaxial movement. It relies on examiner perception, symptom response and sometimes a subjective sense of movement or clunk. For safety-sensitive decisions, this is not enough to replace appropriate medical investigation when instability is suspected.

Common Errors and Limitations

Common errors include:

• Performing the test routinely without risk screening
• Using a negative result to “clear” the cervical spine
• Applying excessive force
• Ignoring neurological symptoms
• Testing despite red flags
• Failing to obtain informed consent
• Treating the test as diagnostic confirmation
• Not documenting why the test was or was not performed
• Continuing cervical testing after a concerning response
• Using the test outside professional scope

Limitations include safety concerns, low-to-variable sensitivity, questionable reliability, limited validity evidence, variable protocols and high consequence of false reassurance.

Practical Applications

For many professionals, the Sharp-Purser Test is most useful as an educational reminder of upper cervical risk rather than a test to perform frequently. It highlights the need to screen medical history, recognise red flags and refer when instability is possible.

In Measurz and MAT education, the safest approach is to document risk factors, symptoms, decision-making and referral notes clearly. If the test is not appropriate, recording “unable to test — safety concern/referral indicated” may be more clinically useful than attempting the manoeuvre.

How to Record This in Measurz

In Measurz, record:

• Test name: Sharp-Purser Test
• Whether the test was performed or not performed
• Reason if not performed
• Relevant risk factors
• Informed consent
• Client position
• Neck position
• Force direction
• Result: positive, negative, unclear or unable to test
• Symptoms before testing
• Symptoms during testing
• Neurological symptoms
• Dizziness, nausea, visual symptoms or headache change
• Clunk or abnormal movement if present
• Apprehension or guarding
• Reason for stopping
• Confidence in result
• Related neurological screen findings
• Referral or medical review notes
• Safety precautions and follow-up recommendation

Recording these details improves safety, communication, professional reasoning, team consistency and reporting quality.

Related Tests / Internal Links

• Transverse Ligament Stress Test
• Cervical Flexion Rotation Test
• Cervical Rotation Lateral Flexion Test
• Cervical Distraction Test
• Spurling’s Test
• Cervical ROM Assessment
• Neurological Screen
• Upper Limb Tension Test
• Red Flag Screening in Measurz

FAQs

What is the Sharp-Purser Test used for?

It has historically been used to screen for possible atlantoaxial instability, particularly involving the transverse ligament.

Does the Sharp-Purser Test diagnose upper cervical instability?

No. It does not confirm or exclude instability on its own, and current evidence questions its reliability, validity and safety.

What is a positive Sharp-Purser Test?

A positive or concerning finding may include a clunk, abnormal movement, symptom reduction, neurological symptom change, dizziness, apprehension or other unusual symptoms.

What is a negative Sharp-Purser Test?

A negative result means no concerning response was observed during the test. It does not rule out upper cervical instability.

Should this test be used before cervical manipulation?

A negative Sharp-Purser Test should not be used as the sole basis for clearing someone for cervical manipulation or high-load cervical testing.

When should the test be avoided?

Avoid it when red flags, trauma, known instability, neurological symptoms, vascular symptoms or lack of professional scope/training are present.

What should be recorded in Measurz?

Record whether the test was performed, reason if not performed, risk factors, symptoms, result, stopping reason, neurological findings and referral notes.

Key Takeaways

The Sharp-Purser Test is a high-risk upper cervical screening manoeuvre.
Current evidence questions its reliability, validity and safety as a stand-alone screen.
A positive or concerning finding should prompt stopping and referral-based reasoning.
A negative test does not exclude upper cervical instability.
Measurz should capture risk factors, safety decisions, symptoms, result and referral notes.

References

Mansfield, C. J., Domnisch, C., Iglar, L., Boucher, L., Onate, J., & Briggs, M. (2020). Systematic review of the diagnostic accuracy, reliability, and safety of the Sharp-Purser Test. Journal of Manual & Manipulative Therapy, 28(2), 72–81. https://doi.org/10.1080/10669817.2019.1667045

Mintken, P. E., Metrick, L., Flynn, T. W., & Cleland, J. A. (2008). Upper cervical ligament testing in a patient with os odontoideum presenting with headaches. Journal of Orthopaedic & Sports Physical Therapy, 38(8), 465–475. https://doi.org/10.2519/jospt.2008.2687

Rushton, A., Rivett, D., Carlesso, L., Flynn, T., Hing, W., Kerry, R., & Kelder, J. (2014). International framework for examination of the cervical region for potential of cervical arterial dysfunction prior to orthopaedic manual therapy intervention. Manual Therapy, 19(3), 222–228. https://doi.org/10.1016/j.math.2013.11.005

Wynd, S., Westaway, M., Vohra, S., Kawchuk, G., & Mior, S. (2008). The quality of reports on cervical arterial dissection following cervical spinal manipulation. PLoS ONE, 8(3), e59170. https://doi.org/10.1371/journal.pone.0059170