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Special Tests: Lower Body Neurodynamic Tests Audio

Special nerve tests for the lower body. Straight Leg Raise Test (SLR), Well Leg Raise Test, Slump Test, and Femoral Nerve Neurodynamic Tests. The reliability, specificity, sensitivity, validity, safety, and screening for lumbar radiculopathy, lumbar pathology, irritation of the sciatic nerve, sciatic pain, irritation of the femoral nerve, leg pain, leg pathology, and femoral nerve tension (FNTT). 

Special Tests: Lower Body Neurodynamic Tests

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Straight Leg Raise Test (SLR) and Well Leg Raise Test

Neurodynamic tests aid in ruling-out whether the sciatic nerve, femoral nerve, or dorsal nerve structures are involved in patient's complaints. Generally, these complaints are related to low back pain, and correlated with a diagnosis of a herniated disk, nerve root irritation, or lumbar radiculopathy. The straight leg raise test (SLR) (a.k.a. Lasègue’s sign) is likely the most often performed test, and is an indicator of sciatic nerve involvement. During the SLR, slump test, or femoral nerve test, hip and ankle joint actions may be used to aid in implicating specific nerves; for example, ankle dorsiflexion during the SLR may bias the test toward tibial nerve involvement. Additionally, pain on the opposite side of the low back or lower extremity during a lower extremity neurodynamic test, may be more indicative of hernatid disk. Note, the SLR also lengthens the hamstring and posterior thigh muscles, and it is common for patients to report SLR symptoms as "hamstring tightness." The most accurate neurodynamic tests have been included in this course, and lesser tests have been excluded. Clinical movement professionals (physical therapists, physical therapy assistants, chiropractors, occupational therapists, athletic trainers, etc.) should be aware of these tests, as their skillset is often the safest and most effective option for treating mild to moderate nerve irritation (e.g. manual therapy, certain modalities, and corrective exercise).

The body of research regarding lower extremity nerve tension tests continues to grow; however, additional research is needed to answer clinically relevant questions. Studies have demonstrated the validity of these tests, but perhaps not the specificity. That is, neurodynamic testing results in the lengthening and gliding of nerves (22-25); however, more research is needed to demonstrate that each test results in the lengthening or gliding of the intended nerve.

Generally, neurodynamic tests have demonstrated higher sensitivity than specificity for related diagnoses (4 - 21, 29 - 31); however, a few studies imply specificity increases when various modifications are added to the Straight Leg Raise Test (SLR) (8-11, 17 - 21). More consideration needs to be given to what diagnoses are associated with a "positive test" (lumbar herniation, radiculopathy, neurogenic symptoms, etc.), as diagnoses vary between studies which contributes to the wide range of reported accuracies. Although a considerable number of studies have been performed on these tests, more research is needed to answer these key questions.

 recommends that all clinical professionals (physical therapists, physical therapy assistants, chiropractors, occupational therapists, athletic trainers, etc.) are aware of these lower extremity neurodynamic tests. Because these tests demonstrate good sensitivity but do not provide information regarding the cause of symptoms, the 

 recommends these tests are used as screens; that is, a negative test "rules-out" a nerve's involvement.

For an introduction to Special Tests including definitions of specific terminology, what special tests measure, accuracy (specificity, sensitivity, reliability, etc.), how we chose the tests in each special test course lessons, and best practice recommendations:

Courses covering Special Tests for the Lumbo Pelvic Hip Complex

Course Details: Special Tests: Lower Body Neurodynamic Tests

For an introduction to Special Tests including definitions of specific terminology, what special tests measure, how we chose the tests in these lessons, and best use, check out:

The body of research regarding lower extremity nerve tension tests continues to grow; however, additional research is needed to answer clinically relevant questions. Studies have demonstrated validity; that is, neurodynamic testing results in lengthening and gliding of nerves (22-25). However, further research is needed to demonstrate the motion of the intended nerve during each of the tests in this course, and the various modifications of each test. Generally, neurodynamic tests have demonstrated higher sensitivity than specificity (4 - 21, 29 - 31); however, a few studies imply specificity increases when various modifications are added to the Straight Leg Raise Test (8-11, 17 - 21). More consideration needs to be given to what diagnoses are associated with a "positive test" (lumbar herniation, radiculopathy, neurogenic symptoms, etc.), as diagnoses vary between studies resulting in a wide range of findings regarding test accuracy. Although a significant amount of research has been published, more research will undoubtedly refine the understanding of these potentially useful tests.

Introduction

The patient assumes a supine position on a firm surface with the head and neck in a neutral position and lower extremities in line with the hips.

The examiner then uses one hand on the heel to gently raise the affected leg into flexion.

Note: Initially this test is performed without hip internal rotation, external rotation, abduction, or adduction. Further, neutral dorsiflexion, terminal knee extension, and a neutral pelvis should be maintained. The examiner may place the other hand above the knee to maintain terminal knee extension, or on the ASIS to maintain a neutral position of the pelvis.

A positive test is reproduction of concordant signs, signs of nerve sensitization or asymmetry between sides.

This test is performed as described under the "Straight Leg Raise Test"; however, 

the test is performed on the unaffected side.

A positive test is pain or signs of nerve sensitization in the low back or affected lower extremity.

A positive sign on this test is thought to be indicative of significant herniated nucleus pulposus (HNP)

This test is performed as described under the "Straight Leg Raise Test"; however, the following modifications are made:  

Sciatic Nerve (L4 - S3): Straight Leg Raise (SLR)

Dorsal Nerve Structures (Any segment - can be added to any of the above modifications): SLR with cervical flexion

Tibial Nerve (more) (L4 - S3): SLR with dorsiflexion

Tibial Nerve (most) (L4 - S3): SLR with dorsiflexion and eversion

Sural Nerve (S1 - S2): SLR with dorsiflexion and inversion

Peroneal Nerve (L4 - S2): SLR with plantar flexion and inversion

Illustration of bilateral straight leg raise test. Lumbar stability test.

Straight Leg Raise Test, Well Leg Raise Sign and Sensitization

The patient assumes an upright seated position with arms behind back, thigh supported by the table, and lower legs free to swing.

The patient should be instructed to keep the sacrum vertical (pelvis neutral) as they slump into full cervical, thoracic and lumbar flexion.

The examiner applies firm over-pressure to the back while checking to ensure neutral sacrum/pelvic alignment.

Note: the goal of neutral sacrum/pelvic alignment is to prevent additional lumbar flexion or hip flexion that cannot be reliably reproduced in future assessments.

While maintaining spinal flexion with over-pressure the patient is asked to extend one knee, or the knee is passively extended by the examiner.

The examiner then asks the patient to dorsiflex (foot up) or passively dorsiflex the ankle.

A positive test is reproduction of concordant signs, signs of nerve sensitization, or asymmetry between sides.

Note, tension around T8, T9, tension in the back of the knee, and bilateral restriction of knee extension without concordant symptoms are not positive signs. These feelings may be considered "normal discomfort" associated with the test position.

This test is performed as described above:   

Discogenic issue: Although untested, extension of the unaffected lower extremity increasing symptoms in the low back or affected lower extremity may be similar to the Well Leg Raise Sign or Crossed Femoral Nerve Sign.

Sciatic Nerve (L4 - S3): Slump test with knee extension

Dorsal Nerve Structures: Slump test with cervical flexion

Tibial Nerve (more) (L4 - S3): Slump test with dorsiflexion

Tibial Nerve (most) (L4 - S3): Slump test with dorsiflexion and eversion

Sural Nerve (S1 - S2): Slump test with dorsiflexion and inversion

Peroneal Nerve (L4 - S2): Slump test with plantar flexion and inversion

Slump Test

Slump Sit Test

The patient assumes a prone position on a firm surface with the head and neck in a neutral position and lower extremities in line with the hips.

Note: This test may also be performed in side-lying.

The examiner then uses one hand at the ankle to flex the knee of the affected side, while using the other hand (on posterior ilium) to stabilize the pelvis.

Note: Initially this test is performed without ankle motion or hip motion.

This test is performed as described under "Femoral Nerve Tension Test (FNTT)"; however, 

This test is performed as described under the "Femoral Nerve Tension Test" (FNTT) with the addition of the following modifications. 

Femoral Nerve Roots (L2 - L4): Conventional FNTT - knee flexion, and/or knee flexion with hip extension

Sensitization of all nerves (L2 - L4): FNTT with cervical flexion or thoracic flexion

Lateral Femoral Cutaneous Nerve (L2 - L3): FNTT with hip adduction

Saphenous Nerve (L2 - L4): FNTT position; however, the joint actions are dorsiflexion and eversion, knee extension, and hip abduction (neutral flexion/extension).

Image of the Femoral Nerve

Femoral Nerve Neurodynamic Test

Cook, C., & Hegedus, E. J. (2008). Orthopedic physical examination tests: an evidence-based approach.

Dutton's Orthopaedic examination, evaluation, and intervention

Straight Leg Raise, Well Leg Raise Sign and Sensitization

Albeck, M. J. (1996). A critical assessment of clinical diagnosis of disc herniation in patients with monoradicular sciatica. 

Bertilson, B. C., Bring, J., Sjöblom, A., Sundell, K., & Strender, L. E. (2006). Inter-examiner reliability in the assessment of low back pain (LBP) using the Kirkaldy-Willis classification (KWC). 

Charnley, J. (1951). Orthopaedic signs in the diagnosis of disc protrusion: with special reference to the straight-leg-raising test. 

Gurdjian, E. S., Webster, J. E., Ostrowski, A. Z., Hardy, W. G., Lindner, D. W., & Thomas, L. M. (1961). Herniated lumbar intervertebral discs—an analysis of 1176 operated cases. 

Hakelius, A., & Hindmarsh, J. (1972). The comparative reliability of preoperative diagnostic methods in lumbar disc surgery. 

Kerr, R. S., Cadoux-Hudson, T. A., & Adams, C. B. (1988). The value of accurate clinical assessment in the surgical management of the lumbar disc protrusion. 

Journal of Neurology, Neurosurgery & Psychiatry

Knutsson, B. (1961). Comparative value of electromyographic, myelographic and clinical-neurological examinations in diagnosis of lumbar root compression syndrome. 

Kosteljanetz, M., Espersen, J. O., Halaburt, H., & Miletic, T. (1984). Predictive value of clinical and surgical findings in patients with lumbago-sciatica. 

Lauder, T. D., Dillingham, T. R., Andary, M., Kumar, S., Pezzin, L. E., Stephens, R. T., & Shannon, S. (2000). Effect of history and exam in predicting electrodiagnostic outcome among patients with suspected lumbosacral radiculopathy. 

American journal of physical medicine & rehabilitation

Lyle, M. A., Manes, S., McGuinness, M., Ziaei, S., & Iversen, M. D. (2005). Relationship of physical examination findings and self-reported symptom severity and physical function in patients with degenerative lumbar conditions. 

Majlesi, J., Togay, H., Ünalan, H., & Toprak, S. (2008). The sensitivity and specificity of the Slump and the Straight Leg Raising tests in patients with lumbar disc herniation. 

Porchet, F., Fankhauser, H., & De Tribolet, N. (1994). Extreme lateral lumbar disc herniation: clinical presentation in 178 patients. 

Rabin, A., Gerszten, P. C., Karausky, P., Bunker, C. H., Potter, D. M., & Welch, W. C. (2007). The sensitivity of the seated straight-leg raise test compared with the supine straight-leg raise test in patients presenting with magnetic resonance imaging evidence of lumbar nerve root compression. 

Archives of physical medicine and rehabilitation

Spangfort, E. V. (1972). The lumbar disc herniation: a computer-aided analysis of 2,504 operations. 

Vroomen, P. C. A. J., De Krom, M. C. T. F. M., Wilmink, J. T., Kester, A. D. M., & Knottnerus, J. A. (2002). Diagnostic value of history and physical examination in patients suspected of lumbosacral nerve root compression. 

Baselgia, L. T., Bennett, D. L., Silbiger, R. M., & Schmid, A. B. (2017). Negative neurodynamic tests do not exclude neural dysfunction in patients with entrapment neuropathies. 

Ekedahl, H., Jönsson, B., Annertz, M., & Frobell, R. B. (2018). Accuracy of Clinical Tests in Detecting Disk Herniation and Nerve Root Compression in Subjects With Lumbar Radicular Symptoms. 

Rezkallah, S. S., & Gharib, N. M. (2017). Crossed Straight Leg Raising versus Straight Leg Raising in Patients with Lumbar Disc Herniation: Effects on Pain, Functional Disability and Balance. 

International Journal of Therapies and Rehabilitation Research

Rade, M., Pesonen, J., Könönen, M., Marttila, J., Shacklock, M., Vanninen, R., … & Airaksinen, O. (2017). Reduced spinal cord movement with the straight leg raise test in patients with lumbar intervertebral disc herniation. 

Rade, M., Shacklock, M., Könönen, M., Marttila, J., Vanninen, R., Kankaanpää, M., & Airaksinen, O. (2017). Normal multiplanar movement of the spinal cord during unilateral and bilateral straight leg raise: Quantification, mechanisms, and overview. 

Rade, M., Könönen, M., Marttila, J., Shacklock, M., Vanninen, R., Kankaanpää, M., & Airaksinen, O. (2016). In vivo MRI measurement of spinal cord displacement in the thoracolumbar region of asymptomatic subjects with unilateral and sham straight leg raise tests. 

Rade, M., Könönen, M., Marttila, J., Vanninen, R., Shacklock, M., Kankaanpää, M., & Airaksinen, O. (2016). Correlation analysis of demographic and anthropometric factors, hip flexion angle and conus medullaris displacement with unilateral and bilateral straight leg raise. 

Ridehalgh, C., Moore, A., & Hough, A. (2015). Sciatic nerve excursion during a modified passive straight leg raise test in asymptomatic participants and participants with spinally referred leg pain. 

Femoral Nerve Neurodynamic Test, Crossed Femoral Nerve Stretch and Sensitization (15, 20-21)

Kreitz, B. G., Côté, P., & Yong-Hing, K. (1996). Crossed femoral stretching test: a case report. 

Anloague, P. A., Chorny, W. S., Childs, K. E., Frankovich, M., & Graham, C. (2015). The Relationship between Femoral Nerve Tension and Hip Flexor Muscle Length. 

Stankovic, R., Johnell, O., Maly, P., & Wilmer, S. (1999). Use of lumbar extension, slump test, physical and neurological examination inthe evaluation of patients with suspected herniated nucleurs pulposus. A prospective clinical study. 

Bibliography

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