Tendon Stretch Reflexes

Tendon stretch reflexes (TSRs), such as the patellar, biceps, triceps, and Achilles reflexes, can be valuable diagnostic tools in hospital settings. They help clinicians localize neurologic lesions along the corticospinal tract, spinal nerve roots, or peripheral nerves. In cases such as spinal cord injuries, stroke subtypes, or cauda equina syndrome, abnormal reflexes can contribute to diagnosis and management decisions.

However, in the prehospital environment, the relevance and utility of reflex testing are significantly limited. While focal hyporeflexia or hyperreflexia may offer diagnostic clues in theory, TSRs require controlled conditions, patient relaxation, and specific technique (often using a reflex hammer); none of which are consistently feasible in the field.

More importantly, TSRs do not influence prehospital triage, treatment, or destination decisions in a way that improves outcomes.

For paramedics in Ontario, tendon reflex testing is not within the current scope of practice as outlined in the ALS Patient Care Standards (ALS PCS). Instead, prehospital neurological assessments emphasize elements that are more actionable and relevant to urgent care decisions, such as:

• Level of consciousness (GCS/AVPU)
• Pupillary responses
• Motor strength and limb movement
• Stroke assessments (e.g., FAST, LAMS)
• Sensory and motor deficits following trauma

These findings support critical interventions in the field, such as stroke bypass protocols, trauma triage decisions, and early notification of receiving facilities, whereas TSRs do not.

Ultimately, the prehospital focus should be ABC management, rapid recognition of gross neurological deficits, and timely transport to definitive care

That said, looking ahead, futuristically, as paramedics grow in their comprehensive healthcare provision, as alternate models of care evolve, and as advanced assessment skills become more relevant, there may be a role for more advanced physical exam skills - testing ankle or patellar reflexes to check for signs of cauda equina syndrome in a patient with low back pain requesting to stay at home, for example. But currently these tests have minimal impact on prehospital decision-making