The Transverse Ligament Stress Test is used to assess possible upper cervical instability involving the transverse ligament and C1–C2 region. It is a high-caution test and should not be used routinely or aggressively. If upper cervical instability is suspected from history, symptoms or risk factors, referral and appropriate imaging may be more suitable than repeated manual testing. A 2020 systematic review of the related Sharp-Purser Test reported concerns around diagnostic accuracy, reliability and safety, supporting a cautious approach to upper cervical instability testing.
A client presents with concerning upper cervical symptoms, such as instability sensations, neurological symptoms, dizziness, unusual upper neck pain or symptoms after trauma. In this situation, the priority is not to provoke symptoms. The priority is to identify whether testing is safe and whether referral is needed.
The Transverse Ligament Stress Test has historically been described as a way to assess transverse ligament integrity. However, upper cervical instability cannot be safely cleared by one manual test. When suspicion is high, the safest decision may be to defer the test and recommend further medical assessment.
Test name: Transverse Ligament Stress Test
Also known as: Anterior Shear Test, Anterior Shear Transverse Ligament Test
Body region: Upper cervical spine, C1–C2 region
Purpose: Screen for possible transverse ligament compromise or atlantoaxial instability
Positive finding: Concerning symptom response, abnormal translation sensation, neurological symptom change or instability feeling
Negative finding: No symptom change or abnormal movement response
Best used with: Red flag screening, neurological screen, cervical instability history, Sharp-Purser Test reasoning, referral and imaging where indicated
Key limitation: A negative test does not clear upper cervical instability
The Transverse Ligament Stress Test is an upper cervical stability screen. The test is generally described with the client supine and the head supported. A gentle anteriorly directed force may be applied to assess whether the atlas appears to translate relative to the axis.
Because of the safety implications, this test should only be performed by appropriately trained professionals and only when clinically justified.
The test may be considered when transverse ligament compromise or atlantoaxial instability is part of the clinical reasoning.
It may be relevant in clients with risk factors such as inflammatory arthropathy, connective tissue disorder, Down syndrome, trauma history, 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 the ligament and does not confirm or exclude instability.
Manual upper cervical instability tests are not a replacement for imaging or medical review when red flags are present.
This test is only relevant in carefully selected cases where instability screening is clinically appropriate and safe. In many high-suspicion cases, the better decision is to avoid manual testing and refer.
Use only when clinically justified, after red flag screening and when the client can tolerate the position safely.
Do not perform the test if there is acute trauma, suspected fracture, suspected instability, progressive neurological symptoms, dizziness, drop attacks, visual disturbance, vascular symptoms, severe inflammatory flare, severe pain, unexplained neurological signs or inability to tolerate positioning.
If instability is suspected, do not use the test to clear the client. Consider referral.
Treatment table
Pain and symptom scale
Measurz recording workflow
Referral notes if indicated
Optional neurological and vascular screen notes
Position the client supine with the head and neck supported.
The neck remains neutral or in the selected test position according to the professional’s training and protocol.
Stand or sit at the head of the client.
Support the head and contact the upper cervical region according to the selected protocol.
Maintain gentle control of the head and neck. Avoid excessive movement.
Apply only minimal, controlled force. Do not force translation or provoke symptoms.
Ask the client to immediately report dizziness, nausea, neurological symptoms, instability sensation, visual changes, pain or unusual symptoms.
A positive or concerning finding may include abnormal movement sensation, symptom reproduction, neurological symptom change, instability feeling or poor tolerance.
A negative finding is no abnormal movement or symptom response, but this does not clear instability.
Stop immediately if symptoms appear, dizziness occurs, neurological symptoms change, pain increases, instability sensation occurs or the client feels unsafe.
Do not repeat unnecessarily. Do not use this test as a clearance test when history is concerning.
A positive or concerning Transverse Ligament Stress Test should be treated seriously and may indicate the need for referral or imaging rather than further provocative testing.
A negative test does not rule out upper cervical instability. If the history, symptoms or risk factors remain concerning, further medical assessment may still be needed.
Interpretation must be based on red flags, neurological findings, vascular symptoms, risk factors, trauma history and the broader cervical assessment.
High-quality 2020+ diagnostic accuracy evidence for the exact Transverse Ligament Stress Test is limited. Older diagnostic values are sometimes cited for this test, but they are older than the requested reference window, so they are not included here.
A 2020 systematic review of the related Sharp-Purser Test reported concerns about diagnostic accuracy, reliability and safety in atlantoaxial instability screening, reinforcing that upper cervical instability tests should not be used as stand-alone clearance tools.
Reliability is likely affected by examiner skill, force direction, client guarding, symptom criteria and the risk profile of the client being tested. A 2023 case-based paper on vertebrobasilar pathology and upper cervical instability screening recorded use of manual ligamentous instability tests, including the transverse ligament stress test and Sharp-Purser Test, but this type of evidence supports clinical caution rather than strong stand-alone validity.
Common errors include performing the test routinely without risk screening, applying too much force, using it to clear instability, ignoring neurological or vascular red flags, repeating the test unnecessarily and documenting only positive or negative without safety context.
Limitations include safety concerns, limited current diagnostic accuracy evidence, reliance on examiner interpretation, poor suitability in high-risk presentations and inability to replace imaging.
Use the Transverse Ligament Stress Test only as part of cautious upper cervical instability reasoning. If the risk profile is concerning, the test may be deferred and referral documented.
Record whether the test was 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 upper cervical instability concerns” and document the reason.
Sharp-Purser 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 related to the transverse ligament.
No. A negative result does not rule out instability.
Avoid it when trauma, instability, neurological symptoms, vascular symptoms or other red flags are present.
A concerning finding may include abnormal movement, neurological symptom change, instability sensation or symptom reproduction.
Record whether it was performed or deferred, symptoms, risk factors, result, stopping reason and referral notes.
The Transverse Ligament Stress 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, symptoms 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.
Rushton, A., et al. (2023). Screening for vertebrobasilar pathology and upper cervical instability by physical therapists treating neck pain: A case report. Journal details need verification.
