The Sharp-Purser Test is used to assess possible atlantoaxial instability, particularly where transverse ligament compromise is a concern. It is usually described as a symptom-reduction or clunk test rather than a pain provocation test. A 2020 systematic review examined diagnostic accuracy, reliability and safety and reported ongoing concerns about reliability, validity and clinical use, meaning the test should be used cautiously and should not replace imaging or medical assessment when instability is suspected.
A client with risk factors for upper cervical instability reports neurological symptoms, instability sensations, severe upper neck symptoms or concerning signs during cervical movement. In this context, the priority is safety, not forceful testing.
The Sharp-Purser Test has historically been used to assess possible transverse ligament compromise, but evidence and safety concerns mean it should be handled cautiously. If instability is suspected, referral and imaging may be more appropriate than provocative manual testing.
Test name: Sharp-Purser Test
Body region: Upper cervical spine, C1–C2 region
Purpose: Screen for possible atlantoaxial instability or transverse ligament compromise
Positive finding: Reduction of symptoms, posterior translation sensation, clunk or abnormal movement response
Negative finding: No symptom change or abnormal movement response
Best used with: Red flag screening, neurological screen, cervical instability history, medical referral and imaging where indicated
Key limitation: Evidence does not support using it as a stand-alone clearance test
The Sharp-Purser Test is an upper cervical stability test. The client is usually seated, the neck is gently flexed, and the professional applies a posteriorly directed force through the forehead while stabilising the spinous process of C2.
The test is intended to assess whether the atlas translates posteriorly relative to the axis, potentially reducing symptoms associated with atlantoaxial instability. It should never be performed aggressively.
The test may be considered when upper cervical instability is part of the clinical reasoning.
It may be relevant in clients with risk factors such as inflammatory arthropathy, connective tissue disorder, trauma history, Down syndrome, known cervical instability or concerning neurological symptoms.
The test attempts to assess upper cervical stability and possible transverse ligament compromise. It does not directly visualise ligament integrity or confirm instability.
This test may be relevant only in carefully selected clients where instability screening is clinically appropriate and safe. In many cases, referral is more appropriate than manual testing.
Use only when clinically justified, after red flag screening and when the professional is trained and confident.
Do not perform if there are signs of serious instability, progressive neurological symptoms, recent trauma, suspected fracture, severe inflammatory flare, vascular symptoms, dizziness, drop attacks, visual disturbance, unexplained neurological signs or inability to tolerate the position.
If instability is suspected, do not use the test as clearance. Consider referral.
Chair
Pain and symptom scale
Measurz recording workflow
Referral notes if indicated
Optional neurological screen notes
Position the client sitting upright.
The client’s head and neck are placed in slight flexion only if tolerated.
Stand beside or in front of the client.
One hand stabilises the C2 spinous process. The other hand contacts the forehead.
Stabilise C2 carefully. Avoid excessive cervical flexion.
Apply a gentle posterior force through the forehead while maintaining C2 stabilisation.
Ask the client to report symptom change, neurological symptoms, dizziness, nausea, instability sensation or discomfort.
A positive finding may include symptom reduction, clunk, abnormal translation sensation or meaningful neurological symptom change.
A negative finding is no symptom change or abnormal movement response.
Stop immediately if symptoms worsen, dizziness occurs, neurological symptoms appear, pain increases, clunk occurs or the client feels unsafe.
Use minimal force. Do not repeat unnecessarily. Do not use the test to clear suspected instability.
A positive Sharp-Purser Test is concerning and should be interpreted as a potential indication for further medical assessment rather than as a treatment target.
A negative test does not rule out atlantoaxial instability. If history or symptoms remain concerning, further assessment or referral may still be required.
Interpretation must be based on risk factors, red flags, neurological findings, symptom behaviour and imaging where appropriate.
A 2020 systematic review evaluated diagnostic accuracy, reliability and safety of the Sharp-Purser Test and reported that the test is debated due to concerns about reliability, validity and safety.
Because diagnostic accuracy depends heavily on population and reference standard, and because safety concerns are central, this article does not list the test as a stand-alone rule-in or rule-out tool.
The 2020 systematic review specifically examined reliability and safety concerns. The available evidence does not support using the Sharp-Purser Test as a stand-alone clearance test for cervical instability.
Reliability may be affected by examiner skill, force direction, client guarding, symptom criteria and whether the target population actually has instability risk.
Common errors include using the test as routine screening in low-risk clients, applying excessive force, using it to clear instability, ignoring red flags, repeating the test unnecessarily and failing to refer when suspicion remains.
Limitations include safety concerns, limited applicability outside specific risk groups, poor stand-alone certainty and reliance on examiner interpretation.
Use the Sharp-Purser Test only as part of a cautious cervical instability reasoning process. When suspicion is high, prioritise referral and appropriate imaging rather than repeated manual testing.
Record test name, whether performed or deferred, reason for testing, risk factors, result, symptom response, neurological symptoms, dizziness or vascular symptoms, force direction, client position, confidence in result, reason for stopping and referral recommendation.
If the test is not performed due to safety concerns, record “deferred due to safety/instability concerns” and document the referral reasoning.
Transverse Ligament Stress Test
Cervical ROM Tests
Cervical Distraction Test
Spurling’s Test
Neurological Screen
Vascular Screen
Upper Cervical Assessment
Red Flag Screening
It attempts to assess possible upper cervical instability or transverse ligament compromise.
It requires caution. Do not perform it when instability, trauma or neurological red flags are suspected.
No. A negative result does not rule out instability.
Symptom reduction, clunk, abnormal translation or concerning neurological symptom change may be considered positive.
Record whether it was performed or deferred, risk factors, symptoms, result, stopping reason and referral notes.
The Sharp-Purser Test is a high-caution upper cervical test.
It should not be used routinely or aggressively.
A negative result does not clear instability.
Referral may be more appropriate when suspicion is high.
Measurz should capture safety reasoning and whether the test was deferred.
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.
Landel, R. (2021). Letter to the editor Re: Mansfield et al. Systematic review of the diagnostic accuracy, reliability, and safety of the Sharp-Purser Test. Journal of Manual & Manipulative Therapy, 29(6), 337–338.
