LUMBAR SPINE

The patient is standing.

The examiner is positioned directly in front or in back of the patient so as to instruct the patient and observe motion.

Forward Flexion

The patient is asked to bend forward and to try to touch the toes while keeping the knees straight. The examiner may use a tape measure to measure the increase in the distance between L1 spinous process and S1 on forward flexion. The examiner should note how far forward the patient is able to bend (i.e., to the midthigh, knees, midtibia, or floor).

For flexion (forward bending), the maximum ROM in the lumbar spine normally is 40° to 60°. If a tape measure is used, the measurement should increase about 7.5 cm (3 inches) if taken between the T12 spinous process and S1.

• On forward flexion, the lumbar spine should move from its normal lordotic curvature to at least a straight or slightly flexed curve. If this change does not occur, some hypomobility probably is present in the lumbar spine either from tight structures or muscle spasm.

• In a patient with no back pain, when returning to the upright posture from forward flexion, the person first rotates the hips and pelvis to about 45° of flexion; during the last 45° of extension, the low back resumes its lordosis.

• In a patient with back pain, most movement usually occurs in the hips, accompanied by knee flexion; in some cases, the patient also uses hand support, working up the thighs.

• The examiner must differentiate the movement that occurs in the lumbar spine from that occurring in the hips or thoracic spine. Some patients can touch their toes by flexing the hips, even if no movement occurs in the spine. The degree of injury also has an effect. For example, the more severely a disc is injured (e.g., if sequestration has occurred rather than a protrusion), the greater is the limitation of movement.

• Often, an “instability jog” may be seen during one or more movements, especially flexion, returning to neutral from flexion, or side flexion. An instability jog is a sudden movement shift or rippling of the muscles during active movement, which indicates an unstable segment.

• If the patient bends one or both knees on forward flexion, the examiner should watch for nerve root symptoms or tight hamstrings, especially if spinal flexion is decreased when the knees are straight.

Extension

The patient is asked to bend backward. While performing the movement, the patient should place the hands in the small of the back to help stabilize it.

Extension (backward bending) normally is limited to 20° to 35° in the lumbar spine.

• Bourdillon and Day ² recommend having the patient do this movement in the prone-lying position to hyperextend the spine. They called the resulting position the “sphinx position.” The patient hyperextends the spine by resting on the elbows with the hands holding the chin and allows the abdominal wall to relax. The position is held for 10 to 20 seconds to see whether symptoms occur or worsen if already present.

Rotation

The patient is instructed to rotate, or turn, to the left and then to the right, or vice versa, depending on which is the painful side (the painful side is tested last).

Rotation in the lumbar spine normally is 3° to 18° to the left or right is accomplished by a shearing movement of the lumbar vertebrae on each other.

• Although the patient usually is in the standing position, rotation may be performed while the patient is sitting to eliminate or decrease pelvic and hip movement. If the patient stands, the examiner must take care to watch for this accessory movement and try to eliminate it by stabilizing the pelvis.

Side Flexion

The patient is asked to run a hand down the side of the leg and not to bend forward or backward while performing the movement. The examiner can eyeball the movement and compare it with that on the other side. The distance from the fingertips to the floor also may be measured on both sides, and any difference should be noted.

Side (lateral) flexion, or side bending, is approximately 15° to 20° in the lumbar spine. As the patient side-flexes, the examiner should watch the lumbar curve. Normally, the lumbar curve forms a smooth curve on side flexion, and there should be no obvious sharp angulation at only one level. If angulation does occur, it may indicate hypomobility below the level or hypermobility above the level in the lumbar spine.

• If a movement (e.g., side flexion) toward the painful side increases the symptoms, the lesion is probably intra-articular, because the muscles and ligaments on that side are relaxed.

• If a disc protrusion is present and lateral to the nerve root, side flexion to the painful side increases the pain and radicular symptoms on that side.

• If a movement (e.g., side flexion) away from the painful side alters the symptoms, the lesion may be articular or muscular in origin, or it may be a disc protrusion medial to the nerve root.

• In the spine, the movement of side flexion is a coupled movement with rotation. Because of the position of the lumbar facet joints, side flexion and rotation occur together, although the amount and direction of movement may not be the same.

• Patients often deviate into forward flexion instead of remaining in true side flexion. To prevent this, the patient can be cued to run the hand down the back of the thigh instead of the side of the thigh.

TRENDELENBURG’S TEST (MODIFIED)

Figure 8-2 Trendelenburg’s/S1 nerve root test. A, Anterior view, negative test result. B, Side view, negative test result. C, Posterior view, positive test result for a weak right gluteus medius.

To assess for gluteus medius weakness or coxa vara; this test also may be used to assess for S1 nerve root lesions.

The patient stands, unsupported.

The examiner is positioned so as to view the patient’s pelvic position.

The patient is asked to balance on one leg and to go up and down on the toes four or five times.

While the patient balances on one leg, the examiner watches for Trendelenburg’s sign. A positive Trendelenburg sign is indicated if the ilium on the nonstance side drops instead of elevating, as it normally would when a person is standing on one leg. If the nonstance side drops, it is a positive test for a weak gluteus medius on the stance side. Both legs are tested. If the patient is unable to go up and down on the toes four or five times, the examiner should suspect an S1 nerve root lesion.

• This is, in effect, a modified Trendelenburg’s test. A weak gluteus medius muscle or a coxa vara (abnormal shaft-neck angle of the femur) on the stance leg side may produce a positive sign on the nonstance side.

• The examiner should look for patient compensations when completing the test. The most common compensation is trunk side flexion toward the stance leg. The patient side flexes to move his or her center of gravity over the stance leg, thus decreasing the demand on the gluteus medius. Therefore, the test may appear normal because the ilium responds normally, but if the side flexion is corrected, the positive response occurs.

ADVANCED RESISTED MOVEMENTS OF THE LUMBAR SPINE

GENERAL INFORMATION

Provided neutral resisted isometric testing in sitting is normal or causes only a small amount of pain, the examiner can go on to other tests that place greater stress on the muscles. These tests often are dynamic and provide both concentric and eccentric work for the muscles supporting the spine. With all of the following tests, the examiner should make sure the patient can hold a neutral pelvis before doing that test. If excessive movement of the anterior superior iliac spines (ASISs) (supine) or posterior superior iliac spines (PSISs) (prone) is noted when the patient does any of the movements, the tests should be stopped. In normal individuals, the ASIS or PSIS does not move during these tests. Motivation may also affect the results.³

ISOMETRIC ABDOMINAL TEST 4–7

To assess the endurance of the abdominal muscles.

The patient is supine with the hips at 45°, the knees at 90°, and the hands at the sides. Both feet rest flat on the table.

The examiner is positioned so as to observe for altered mechanics.

The patient starts the test in the patient position noted above. The examiner then sequentially asks the patient to move to the end position of each level of testing. The patient is instructed to hold the end position for as long as possible. Testing begins with the Trace Grade and progresses sequentially to the Normal Grade (see Table 8-1).

Table 8-1

Isometric Abdominal Test Grading

Grade	MMT Score	Patient Position
Normal	5	With the hands clasped behind the neck, able to raise the upper body until the scapulae clear the table (20- to 30-second hold)
Good	4	With the arms crossed over the chest, able to raise the upper body until the scapulae clear the table (15- to 20-second hold)
Fair	3	With the arms straight, able to raise the upper body until the scapulae clear the table (10- to 15-second hold)
Poor	2	With the arms extended toward the knees, able to raise the upper body until the top of the scapulae lift from the table (1- to 10-second hold)
Trace	1	Unable to raise more than the head off the table

The number of seconds the patient holds the contraction before cheating (e.g., holding the breath, altered mechanics) or the onset of fatigue is recorded as the manual muscle test (MMT) score. The grading for this isometric abdominal test is described in Table 8-1.

RELIABILITY/SPECIFICITY/SENSITIVITY ⁵

Reliability (interrater) ICC = 0.25

Figure 8-3 Isometric abdominal test. A, Hands behind the neck, scapulae off the table. B, Arms crossed over the chest, scapulae off the table. C, Arms straight, scapulae off the table. D, Hands behind the head, only the head off the table. E, Arms straight, only the head off the table.

DYNAMIC ABDOMINAL ENDURANCE TEST ^5,⁸

Figure 8-4 Dynamic abdominal endurance test. The patient tucks in the chin and curls up the trunk, lifting the trunk off the bed. Ideally, the scapulae should clear the bed.

To assess the endurance of the abdominal muscles.

The patient lies supine with the hips at 45°, the knees at 90°, and the hands at the sides. The feet are flat on the table.

The examiner is positioned so as to observe for altered mechanics.

A line is drawn 8 cm (patients over age 40) or 12 cm (patients under age 40) distal to the fingers. The patient tucks in the chin and curls (flexes) the trunk to touch the line with the fingers and repeats as many curls as possible using a cadence of 25 repetitions per minute.

The number of repetitions possible before cheating (e.g., holding the breath, altered mechanics) or the onset of fatigue is recorded as the score.

CLINICAL NOTE/CAUTION

• This test places significant stress upon the lumbar discs, so if disc pathology is suspected, the examiner should consider whether it is advisable to do the test.

RELIABILITY/SPECIFICITY/SENSITIVITY ⁵

Interrater ICC = 0.78

ISOMETRIC EXTENSOR TEST ^5,^9,¹⁰

Figure 8-5 Isometric extensor test. A, With the hands behind the head, the patient lifts the head, chest, and ribs off the bed. B, With the hands at the side, the patient lifts the head, chest, and ribs off the bed. C, With the hands at the side, the patient lifts the sternum off the bed. D, With the hands at the side, the patient lifts the head off the bed.

To test the strength of the iliocostalis lumborum (erector spinae) and multifidus.

The patient is prone lying.

The examiner is positioned so as to observe for altered mechanics.

Isometric Extensor Test Grading

The patient attempts to extend the spine as far as possible by lifting up the head and trunk. Depending on how the patient does the test (the aim is to get the highest score possible) and how long the position is held (see Table 8-2), the examiner records the MMT score. The patient holds the end position as long as possible.

Table 8-2

Grade	MMT Score	Patient Position
Normal	5	With the hands clasped behind the head, extends the lumbar spine, lifting the head, chest, and ribs from the bed/floor (20- to 30-second hold)
Good	4	With the hands at the side, extends the lumbar spine, lifting the head, chest, and ribs from the bed/floor (15- to 20-second hold)
Fair	3	With the hands at the side, extends the lumbar spine, lifting the sternum off the bed/floor (10- to 15-second hold)
Poor	2	With the hands at the side, extends the lumbar spine, lifting the head off the bed/floor (1- to 10-second hold)
Trace	1	Only slight contraction of the muscle with no movement

The examiner times how long the patient can hold the extended position. The test is graded as described in Table 8-2.

RELIABILITY/SPECIFICITY/SENSITIVITY ⁵

Interrater reliability: ICC = 0.24

INTERNAL/EXTERNAL ABDOMINAL OBLIQUE TEST ^6,¹¹

Figure 8-6 Internal/external abdominal oblique test. A, Test position with the hands at the side. B, Test position with the hands on the shoulders. C, Test position with the hands behind the head.

To check the combined action of the internal oblique muscle of one side and the external oblique muscle on the opposite side.

The patient is supine lying with the hands by the side.

The examiner is positioned so as to observe for altered mechanics.

Internal/External Abdominal Oblique Test Grading

The patient is asked to lift the head and the shoulder on one side and reach over and touch the fingernails of the other hand or to flex and rotate the trunk. Depending on how the patient does the test (the aim is to get the highest score possible) and how long the position is held (see Table 8-3), the examiner records the MMT score. The patient holds the end position as long as possible. The patient’s feet should not be supported, and the patient should breathe normally.

Table 8-3

Grade	MMT Score	Patient Position
Normal	5	Flexes and rotates the lumbar spine fully with the hands behind the head (20- to 30-second hold)
Good	4	Flexes and rotates the lumbar spine fully with the hands across the chest (15- to 20-second hold)
Fair	3	Flexes and rotates the lumbar spine fully with the arms reaching forward (10- to 15-second hold)
Poor	2	Unable to flex and rotate fully
Trace	1	Only slight contraction of the muscle with no movement
None	0	No contraction of the muscle

The number of seconds the contraction is held before cheating (e.g., holding the breath, altered mechanics) or the onset of fatigue is recorded as the score. The test is graded as described in Table 8-3.

• This test also can be done dynamically, to test endurance, by counting the number of repetitions to each side the patient is able to do before cheating.

DOUBLE STRAIGHT LEG LOWERING TEST ^6,^11–13

Figure 8-7 Double straight leg lowering test. A, Flexing the hips to 90°. B, Start position with the knees straight. C, An example of leg lowering. The examiner watches for anterior pelvic rotation, which would indicate an inability to hold a neutral pelvis.

To assess the strength of the abdominal muscles.

The patient lies supine and flexes the hips to 90° and then straightens the knees.

The examiner is positioned so as to palpate the ASIS on one side and to observe for altered mechanics.

The patient positions the pelvis in neutral (i.e., the PSISs are slightly superior to the ASISs) by doing a posterior pelvic tilt and holding the spinous processes tightly against the examining table. The straight legs then are eccentrically lowered.

As soon as the examiner feels the ASIS start to rotate forward during the leg lowering, the test is stopped and the examiner holds the patient’s legs in that position while measuring the angle (plinth to thigh angle). The test must be done slowly, and the patient must not hold the breath. The test is graded as described in Table 8-4.

Table 8-4

Double Straight Leg Lowering Test Grading

Grade	MMT Score	Patient Position
Normal	5	Able to reach 0° to 15° from the table before the pelvis tilts
Good	4	Able to reach 16° to 45° from the table before the pelvis tilts
Fair	3	Able to reach 46° to 75° from the table before the pelvis tilts
Poor	2	Able to reach 75° to 90° from the table before the pelvis tilts
Trace	1	Unable to hold the pelvis in neutral at all

• This test should be performed only if the patient receives a grade of “normal” in the dynamic abdominal endurance test or the abdominal isometric test.

• This is an abdominal eccentric test that can put a great deal of stress on the spine; therefore, the examiner must make sure the patient is able to hold a neutral pelvis before doing the exercise. If the patient cannot hold neutral spine or if the patient is symptomatic with the test, the test should not be completed. This test also causes greater abdominal activation than curl-ups.

DYNAMIC HORIZONTAL SIDE SUPPORT (SIDE BRIDGE OR SIDE PLANK) TEST ^14,¹⁵

Figure 8-8 Dynamic horizontal side support. A, Start position. B, Lifting the pelvis off the bed using the knees as support. C, Lifting the pelvis off the bed using the feet and ankles as support.

To test the quadratus lumborum muscle.

The patient is side lying, resting the upper body on the elbow.

The examiner is positioned so as to observe for altered mechanics.

To begin, the patient is side lying with the knees flexed to 90°. The examiner asks the patient to lift the pelvis off the examining table and straighten the spine. The weight of the body is supported by the forearm and elbow proximally and the lateral knee distally. If the patient can do the first test easily, the test can be made more difficult by having the patient keep the legs straight and then lift the knees and pelvis off the examining table with the feet as the base, so that the whole body is straight.

The patient should not roll forward or backward when doing the test. The examiner times how long the patient can hold the position without cheating. The test is graded as described in Table 8-5.

Table 8-5

Dynamic Horizontal Side Support (Side Bridge) Test Grading

Grade	MMT Score	Patient Position
Normal	5	Able to lift the pelvis off the examining table and hold the spine straight (10- to 20-second hold)
Good	4	Able to lift the pelvis off the examining table but has difficulty holding the spine straight (5- to 10-second hold)
Fair	3	Able to lift the pelvis off the examining table but cannot hold the spine straight (<5-second hold)
Poor	2	Unable to lift the pelvis off examining table

• The test may also be done dynamically, to test endurance, by having the patient repeat the side bridging as many times as possible on each side.

• McGill et al.¹⁵ reported that the side bridge should be able to be held 65% of the extensor time for men and 39% for women, and 99% of the flexor time for men and 79% for women.

PERIPHERAL JOINT SCANNING EXAMINATION

PERIPHERAL JOINT SCAN ¹⁶

To rule out obvious pathological conditions in the lower extremities and to assess the peripheral joints of the lower extremity to determine whether more in-depth testing is required.

The patient is standing or supine, depending on the joint to be scanned.

The examiner’s position varies, depending on the joint to be scanned.

Figure 8-9 Tests to demonstrate left sacroiliac fixation. A, The examiner places the left thumb on the posterior superior iliac spine and the right thumb over one of the sacral spinous processes. B, With normal movement, the examiner’s left thumb moves downward as the patient raises the left leg with full hip flexion. C, If the joint is fixed, the examiner’s left thumb moves upward as the patient raises the left leg. D, The examiner places the left thumb over the ischial tuberosity and the right thumb over the apex of the sacrum. E, With normal movement, the examiner’s left thumb moves laterally as the patient raises the left leg with full hip flexion. F, If the joint is fixed, the examiner’s left thumb moves slightly upward as the patient raises the left leg. (Modified from Kirkaldy-Willis WH: *Managing low back pain,* p 94, New York, 1983, Churchill Livingstone.)

Figure 8-10 A, Knee extension. B, Knee flexion.

Sacroiliac Joints

With the patient standing, the examiner palpates the PSIS on the test side with one thumb or finger and one of the sacral spines with the thumb or finger of the other hand. The patient then flexes the hip on the test side as far as possible. The examiner compares the findings with those of the other side. The examiner next places one thumb or finger on the patient’s ischial tuberosity on the test side and one thumb or finger of the other hand on the sacral apex. The patient then is asked to flex the hip on the test side.

For the first part of the test, if the PSIS drops as it normally should, the test result is negative. Elevation of the PSIS indicates fixation of the sacroiliac joint on that side. If the second movement is normal, the thumb on the ischial tuberosity moves laterally. If the sacroiliac joint on that side is fixed, the thumb moves up. The other side then is tested for comparison. The unaffected side should be tested first.

• This test has also been called Gillet’s test or the sacral fixation test.

• If any positive signs occur, the examiner should do a detailed examination of the pelvic joints.

Hip Joints

With the patient supine, the hip joints are actively moved through flexion, abduction, adduction, and medial and lateral rotation in as full ROM as possible. To test extension, the patient is positioned prone.

Any pattern of restriction or pain should be noted. ROM deficits and symptom reproduction both are indicators of a positive test result. The two sides should be compared, and any restriction of movement or abnormal signs and symptoms should be noted.

• As the patient flexes the hip, the examiner may palpate the ilium, sacrum, and lumbar spine to determine when movement begins at the sacroiliac joint on that side and at the lumbar spine during the hip movement. The two sides should be compared.

• If any positive signs occur, the examiner should do a detailed examination of the hip joints.

Knee Joints

The patient is supine, and the knee joint is actively moved through as full a range of flexion and extension as possible.

Any restriction of movement or abnormal signs and symptoms should be noted. ROM deficits and symptom reproduction both are indicators of a positive test result. The two sides should be compared, and any restriction of movement or abnormal signs and symptoms should be noted.

• If any positive signs occur, the examiner should do a detailed examination of the knee joints.

Foot and Ankle Joints

With the patient supine, plantar flexion, dorsiflexion, supination, and pronation of the foot and ankle, as well as flexion and extension of the toes, are actively performed through a full ROM.

Any alteration in signs and symptoms should be noted. ROM deficits and symptom reproduction both are indicators of a positive test result. The two sides should be compared, and any restriction of movement or abnormal signs and symptoms should be noted.

• It is important to note that the scanning process is meant to be a general clearing examination.

• If any positive signs occur, the examiner should do a detailed examination of the foot and ankle joints.

QUICK TEST OF THE LOWER PERIPHERAL JOINTS

The quick test is designed to enable the examiner to quickly assess the peripheral joints of the lower extremity and to determine whether more in-depth testing is required. This test can be substituted for the general lower limb peripheral joint scan, provided the patient believes that he or she can squat and return to standing and provided the examiner believes the patient is able to perform the test.

The patient is standing.

The examiner is positioned to view the patient’s motions and to observe any compensations that may occur during the squat and return to standing.

The patient squats down as far as possible, bounces two or three times, and returns to the standing position. This action quickly tests the ankles, knees, and hips, as well as the sacrum, for any pathological condition.

If the patient can fully squat and bounce without any signs and symptoms, the peripheral joints probably are free of any pathological condition related to the complaint. If this test result is negative, the examiner need not test the general peripheral joints (general peripheral joint scan) with the patient in the lying position.

• This test should be used only with caution and should not be done with patients suspected of having arthritis or a pathological condition in the lower limb joints, pregnant patients, or older patients who show weakness and hypomobility.

MYOTOME TESTING

Figure 8-12 Positioning for testing myotomes. A, Hip flexion (L2). B, Knee extension (L3). C, Foot dorsiflexion (L4). D, Ankle eversion (S1). E, Extension of the big toe (L5). F, Hip extension (S1). G, Knee flexion (S1-S2).

To assess the integrity of the lumbar spine nerve roots.

SUSPECTED INJURY

Spinal nerve root pathology

The patient is supine or prone, depending on the nerve root to be tested.

The examiner is positioned directly adjacent to the patient’s lower extremity.

When testing myotomes, ideally the examiner should place the test joint or joints close to the neutral or resting position and then apply a resisted isometric pressure in a gradually increasing manner. The contraction should be held for at least 5 seconds to allow time for any myotomal weakness to become evident. The unaffected side is tested first.

L2 myotome (hip flexion). The examiner flexes the patient’s hip to 80° to 90° and then applies a resisted force into hip extension. The other side then is tested for comparison. To prevent excessive stress on the lumbar spine, the examiner must make sure the patient does not increase the lumbar lordosis while doing the test. The more the hip is flexed, the less is the stress on the lumbar spine. Only one leg is tested at a time.

L3 myotome (knee extension). The examiner flexes the patient’s knee to 25° to 35° (over a pillow or the examiner’s knee) and then applies a resisted flexion force at the midshaft of the tibia, making sure the heel is not resting on the examining table. The other side is tested for comparison.

L4 myotome (ankle dorsiflexion). The examiner asks the patient to place the feet at 90° relative to the leg (plantigrade position). The examiner applies a resisted force to the dorsum of each foot and compares the two sides. In this case, the two sides may be tested at the same time.

L5 myotome (toe extension). The patient is asked to hold both big toes in a neutral position. The examiner applies resistance to the nails of both toes and compares the two sides. It is imperative that the resistance be isometric; therefore, the amount of force in this case is less than that applied, for example, during knee extension. The two sides may be tested at the same time.

S1 myotome (ankle plantar flexion). The patient is asked to place the feet at 90° relative to the leg (plantigrade position). The examiner then applies resistance to the sole of the foot. Because of the strength of the plantar flexor muscles, this myotome is best tested with the patient standing. The patient slowly moves up and down on the toes of each foot (for at least 5 seconds) in turn (see modified Trendelenburg’s test), and the examiner compares the differences between the two sides.

S1 myotome (ankle eversion). The patient is supine lying. The examiner applies a force to move the patient’s foot into inversion while the patient isometrically resists.

S1 myotome (hip extension). The patient is prone lying, and the knee is flexed to 90°. The examiner then lifts the patient’s thigh slightly off the examining table while stabilizing the leg. A downward force is applied to the posterior thigh with one hand while the other hand ensures that the patient’s thigh is not resting on the table.

S1-S2 myotomes (knee flexion). The patient is prone with the knee flexed to 80° to 90°. The examiner applies an extension isometric force just above the ankle. Although the two knee flexors can be tested at the same time, this is not advisable because of the stress it places on the lumbar spine.

Muscle weakness during testing indicates a positive test result.

• For the S1 myotome, only one of the tests needs to be done.

• When appropriate, the examiner should test the two sides simultaneously for comparison. Simultaneous bilateral comparison is not possible for movements involving the hip and knee joints because of the weight of the limbs and the stress on the low back; therefore, in these cases the two sides must be done individually.

• The examiner should not apply pressure over the joints, because this may cause symptoms unrelated to the myotomes.

• The ankle movements should be tested with the knee flexed approximately 30°, especially if the patient complains of sciatic pain, because full dorsiflexion is considered a provocative maneuver for stretching neurological tissue. Likewise, the extended knee increases the stretch on the sciatic nerve and may result in false signs, such as weakness that results from pain rather than from pressure on the nerve root.

• Hamstring cramping may occur during testing of knee flexion. It does not indicate a positive test result, but the examiner should be aware that cramping may occur.

• If the patient is in extreme pain, all tests in the supine position should be completed before the patient is tested in the prone position. This reduces the amount of movement the patient must do, decreasing the patient’s discomfort. Ideally, all tests in the standing position should be performed first, followed by tests in the sitting, supine, side-lying, and prone positions.

SPECIAL TESTS FOR NEUROLOGICAL DYSFUNCTION

• Butler ²⁶ recommended doing bilateral knee extension in the slump position, on the grounds that any asymmetry in the amount of knee extension is easier to note this way.

• The effect of releasing neck flexion on the patient’s symptoms should be noted. In hypermobile patients, more hip flexion (more than 90°), as well as hip adduction and medial rotation, may be required to elicit a positive response. If symptoms are produced in any phase of the sequence, it is important to stop the provocative maneuvers to prevent undue discomfort for the patient.

• Some people do knee extension last, because it often is easier to measure knee ROM to determine whether it has improved with treatment.

• Butler ²⁶ has suggested modifications to the slump test to stress individual nerves (Table 8-6)

Table 8-6

Slump Test and Modifications

	Slump Test (ST 1)	Slump Test (ST2)	Side Lying Slump Test (ST3)	Long Sitting Slump Test (ST4)
Cervical spine	Flexion	Flexion	Flexion	Flexion, rotation
Thoracic and lumbar spine	Flexion (slump)	Flexion (slump)	Flexion (slump)	Flexion (slump)
Hip	Flexion (90° +)	Flexion (90° +), abduction	Flexion (20°)	Flexion (90° +)
Knee	Extension	Extension	Flexion	Extension
Ankle	Dorsiflexion	Dorsiflexion	Plantar flexion	Dorsiflexion
Foot	—	—	—	—
Toes	—	—	—	—
Nerve bias	Spinal cord, cervical and lumbar nerve roots, sciatic nerve	Obturator nerve	Femoral nerve	Spinal cord, cervical and lumbar nerve roots, sciatic nerve

Data from Butler DA: Mobilisation of the nervous system, Melbourne, 1991, Churchill Livingstone.

STRAIGHT LEG RAISE TEST (LASÈGUE’S TEST)26–42

Figure 8-13 Sequence of subject postures in the slump test. A, The patient sits erect with the hands behind the back. B, The patient slumps the lumbar and thoracic spine while either the patient or the examiner keeps the head in neutral. C, The examiner pushes down on the shoulders while the patient holds the head in neutral. D, The patient flexes the head. E, The examiner carefully applies overpressure to the cervical spine. F, The examiner extends the patient’s knee while holding the cervical spine flexed. G, While holding the knee extended and the cervical spine flexed, the examiner dorsiflexes the foot. H, The patient extends the head, which should relieve any symptoms. If symptoms are reproduced at any stage, further sequential movements are not attempted.

To assess for impingement of the dura and spinal cord or nerve roots of the lower lumbar spine, especially the sciatic nerve.

The patient lies supine. The hip is medially rotated and adducted, and the knee is extended. The head should be in a neutral position, and the hands should be at the sides.

The examiner stands adjacent to the pelvis of the test leg. The examiner places one hand on the patient’s knee to stabilize it in extension. The other hand grasps the patient’s ankle and is used to lift the leg upward.

The examiner flexes the patient’s hip until the patient complains of pain or tightness in the back or back of the leg. The examiner then slowly and carefully lowers the leg back slightly (extends it) until the patient feels no pain or tightness. The examiner passively dorsiflexes the patient’s foot or asks the patient to actively flex the neck so that the chin is on the chest; or, the two actions may be done simultaneously. Most commonly, foot dorsiflexion is done first.

If the pain is primarily back pain, it is more likely a disc herniation from pressure on the anterior theca of the spinal cord, or the pathological condition causing the pressure is more centrally located. “Back pain only” patients who have a disc prolapse have smaller, more central prolapses. If the pain is primarily in the leg, the pathological condition causing the pressure on neurological tissues is more likely to be laterally located. A disc herniation or pathological condition causing pressure between the two extremes is more likely to cause pain in both areas.

Figure 8-14 Straight leg raise test. A, Radicular symptoms are precipitated on the same side with straight leg raising. B, The leg is lowered slowly until pain is relieved. C, The foot then is dorsiflexed, causing a return of symptoms; this indicates a positive test result. D, To make the symptoms more provocative, the neck can be flexed by lifting the head at the same time the foot is dorsiflexed.

• The uninvolved side should be tested first.

• Both the neck flexion and foot dorsiflexion are considered provocative or sensitizing tests for neurological tissue.

• Straight leg raise testing is one of the most common neurological tests of the lower limb.

• This test is a passive test, and each leg is tested individually; the normal leg is tested first.

• Modifications of the straight leg raise test can be used to stress different peripheral nerves to a greater degree; these are referred to as straight leg raise tests with a particular nerve bias (Table 8-7).

Table 8-7

Straight Leg Raise (SLR) Test and Modifications

	SLR (Basic)	SLR2	SLR3	SLR4	Cross (Well Leg) SLR5
Hip	Flexion and adduction	Flexion	Flexion	Flexion and medial rotation	Flexion
Knee	Extension	Extension	Extension	Extension	Extension
Ankle	Dorsiflexion	Dorsiflexion	Dorsiflexion	Plantar flexion	Dorsiflexion
Foot	—	Eversion	Inversion	Inversion	—
Toes	—	Extension	—	—	—
Nerve bias	Sciatic nerve and tibial nerve	Tibial nerve	Sural nerve	Common peroneal nerve	Nerve root (disc prolapse)

Data from Butler DA: Mobilisation of the nervous system, Melbourne, 1991, Churchill Livingstone.

• The neck flexion movement has also been called Hyndman’s sign, Brudzinski’s sign, and Lidner’s sign.

• A contralateral positive test result is called the crossover sign or well leg test of Fajersztjan. A positive crossover sign usually indicates a large disc protrusion and a poor prognosis for conservative treatment.

RELIABILITY/SPECIFICITY/SENSITIVITY 40–42

PRONE KNEE BENDING TEST ^26,^43,⁴⁴

Figure 8-15 Prone knee bending test (PKB1), which stresses the femoral nerve and L2-L4 nerve root. The examiner points to the location in the lumbar spin where pain may be expected with a positive test result.

To test for femoral nerve entrapment or L2-L3 nerve root involvement.

SUSPECTED INJURY

• Upper lumbar radiculopathy

• Femoral nerve entrapment

The patient lies prone.

The examiner stands adjacent to the pelvis on the side of the test limb.

One of the examiner’s hands is placed on the patient’s pelvis to feel for compensations. The examiner’s other hand grasps the ankle of the lower extremity being tested. The examiner passively flexes the knee as far as possible so that the patient’s heel rests against the buttock. At the same time, the examiner makes sure the patient’s hip is not rotated. The flexed knee position should be maintained for 45 to 60 seconds.

Unilateral neurological pain in the lumbar area, buttock, or anterior thigh may indicate an L2 or L3 nerve root lesion. This test also stretches the femoral nerve. Pain in the anterior thigh may indicate tight quadriceps muscles or stretching of the femoral nerve. A careful history and pain differentiation help delineate the problem.

• If the examiner is unable to flex the patient’s knee past 90° because of a pathological condition in the knee, the test may be performed by passive extension of the hip while the knee is flexed as much as possible.

• If the rectus femoris is tight, the examiner should remember that taking the heel to the buttock may cause anterior torsion to the ilium, which could lead to sacroiliac or lumbar pain.

• The test may be modified to stress different peripheral nerves (Table 8-8).

Table 8-8

Prone Knee Bending (PBK) Test and Modifications

	Basic Prone Knee Bending (PKB1)	Prone Knee Bending (PKB2)	Prone Knee Extension (PKE)
Cervical spine	Rotation to test side	Rotation to test side	—
Thoracic and lumbar spine	Neutral	Neutral	Neutral
Hip	Neutral	Extension, adduction	Extension, abduction, lateral rotation
Knee	Flexion	Flexion	Extension
Ankle	—	—	Dorsiflexion
Foot	—	—	Eversion
Toes	—	—	—
Nerve bias	Femoral nerve, L2-L4 nerve root	Lateral femoral cutaneous nerve	Saphenous nerve

Data from Butler DA: Mobilisation of the nervous system, Melbourne, 1991, Churchill Livingstone.

FEMORAL NERVE TRACTION TEST ^45,⁴⁶

Figure 8-16 Femoral nerve traction test. A, Hip and knee are extended. B, Then knee is flexed.

To test for femoral nerve entrapment or a pathological condition of the L2-L4 nerve root.

The patient lies on the side. Initially, for testing of the uninvolved leg, the patient lies on the involved side with the affected limb flexed slightly at the hip and knee to prevent pelvic rotation. The back should be straight, not hyperextended. The head should be slightly flexed and placed on a pillow to keep it in neutral alignment. For testing of the affected side, the patient lies on the unaffected side and the test is repeated.

The examiner stands behind the patient’s gluteal region.

One of the examiner’s hands is placed on the patient’s pelvis to provide stability to the trunk and prevent hip and lumbar rotation. The examiner’s other arm cradles the patient’s test knee and leg. The examiner extends the knee while gently extending the hip approximately 15°. The patient’s knee is then flexed on the affected side; this movement further stretches the femoral nerve.

Neurological pain radiates down the anterior thigh if the test result is positive.

• This is also a traction test for the nerve roots at the midlumbar area (L2-L4).

• As with the straight leg raise test, there is also a contralateral positive test. That is, when the test is performed, the symptoms occur in the opposite limb. This is called the crossed femoral stretching test.

• Pain in the groin and hip that radiates along the anterior medial thigh indicates an L3 nerve root problem; pain extending to the midtibia indicates an L4 nerve root problem.

• This test is similar to Ober’s test for a tight iliotibial band, so the examiner must be able to differentiate between the two conditions. If the iliotibial band is tight, the test leg does not adduct but remains elevated away from the table, because the tight tendon riding over the greater trochanter keeps the leg abducted.

• Femoral nerve injury presents with a different history, and the referred pain (anteriorly) tends to be stronger.

BOWSTRING TEST (CRAM TEST OR POPLITEAL PRESSURE SIGN)47–51

Figure 8-17 Bowstring test. A, The examiner does a straight leg raise test. If the test result is positive, the examiner relieves the pain by flexing the knee slightly. The examiner then pushes into the popliteal space **(B)** to increase the stress on the sciatic nerve and looks for a return of the symptoms seen with the straight leg raise test.

To detect tension or pressure on the sciatic nerve (this test is a modification of the straight leg raise test).

The patient is supine with the hip slightly medially rotated and adducted and the knee extended. Care should be taken to make sure the head is in a neutral position and the arms are resting comfortably at the sides.

The examiner stands directly adjacent to the test limb.

The patient’s ankle is placed on the examiner’s shoulder. Both of the examiner’s hands are placed around the patient’s knee. The examiner’s thumbs are placed in the popliteal area of the patient’s knee. The examiner flexes the patient’s hip until the patient complains of pain or tightness in the back or back of the leg. While maintaining the thigh in this position, the examiner flexes the knee slightly (20°), reducing the symptoms. Thumb or finger pressure then is applied to the popliteal area to re-establish the painful radicular symptoms.

Pain or symptoms such as tightness or tingling as a result of these maneuvers indicate a positive test result and pressure or tension on the sciatic nerve.

• The test also may be done with the patient in the sitting position and the examiner passively extending the knee to produce pain. The examiner then slightly flexes the knee so that the pain and symptoms disappear. The examiner holds this slightly flexed position by clasping the patient’s leg between the examiner’s knees. The examiner then presses the fingers of both hands into the popliteal space. In this case, the test is called the sciatic tension test or Deyerle’s sign.