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Straight Leg Raise Test

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Page Summary

  • The straight leg raise (SLR) test is a neurodynamic test that passively lifts the extended leg in supine to detect lumbar disc herniation and nerve root irritation, and is positive when it reproduces symptoms.
  • Many studies define a positive SLR as reproduced or markedly aggravated symptoms, pain at roughly 30° to 70° of hip flexion, or pain shooting down the sciatic nerve territory.
  • The SLR has high sensitivity (about 0.9) but low specificity (about 0.4) for lumbar disc herniation, so it is better for ruling out radiculopathy than confirming it.
  • Adding structural differentiation, such as ankle dorsiflexion (Bragard’s test) or neck flexion, improves SLR reliability to at least a moderate level and is recommended in clinical practice.

Introduction

The Straight Leg Raise (SLR) test is commonly used to identify disc pathology, particularly disc herniation or nerve root irritation, as it mechanically stresses lumbosacral nerve roots.[1][2][3][4] It is also classified as a neurodynamic evaluation test[5] as it can detect excessive nerve root tension[1] or compression.[6] This test is attributed to Dr. Charles Lasegue, and referred to as Lasegues test.[1] However, it is believed that Dr. Lazar K. Lazarevic was the first to establish this test.[1]

Technique

The classic straight leg raise is performed passively.[3][1] Each leg is tested individually with the unaffected leg being tested first.[3] When performing the SLR test, the patient is positioned in supine without a pillow under their head, the clinician stands at the tested side with their distal hand around the patient's heel and proximal hand on patient's distal thigh (anterior) to maintain knee extension.[3] The clinician lifts the patient's leg by the posterior ankle while keeping the knee in a fully extended position.[3] The clinician continues to lift the patient's leg slowly through flexing at the hip, until the patient's symptoms are replicated, or when maximum hip flexion is reached.[3][1]

When pain is provoked, the examiner stops the hip flexion and records the ROM reached and where the pain is felt.[7] The ROM of the affected leg can be compared with that of the unaffected leg and used to track treatment outcomes.[7]

[8]

Interpretation & Reasoning

Neurodynamic tests are usually considered positive when they meet the following conditions:[5]

  1. The test provokes the complaint the patient already experiences
  2. The response clearly differs from the opposite limb or departs substantially from typical values
  3. The complaint can be altered by moving a joint remote from where the symptoms are felt (e.i. sensitising manoeuvre)

However, definitions of a positive SLR vary considerably between studies.[9] Many studies consider the SLR test to be positive when:

  • Raising the leg reproduces the patient’s symptoms or markedly aggravates them[6][10]
  • The leg resists being lifted any further[10]
  • The pain is felt at a hip angle of roughly 30° to 70°[2][10]
  • That pain shoots down the limb in the territory of the sciatic nerve[2][7]

These criteria are applied in different combinations, and sensitising manoeuvres are rarely used.[9]

Sensitising Manoeuvres

A sensitising manoeuvre is a movement added at a joint distant from the symptoms that loads the nerves without affecting the nearby muscle or joint tissue.[5] If the patient’s symptoms change during this movement, the nervous system is the source of the restriction.[5]

The most commonly used cited sensitising manoeuvre is ankle dorsiflexion.[5] It is documented as Bragard's test[1][2][7]

Other sensitising manoeuvres described in literature are:

  • Inclusion of neck flexion in the SLR, documented as Hyndman's sign, Brudzinski's Sign, Linder's Sign, or the Soto-Hall test[7]
  • Inclusion of great toe extension in the SLR (instead of ankle dorsiflexion), documented as Sicard's Test[11]
  • Raising the contralateral leg instead of the affected leg, documented as the crossed straight-leg-raising test (or Fajersztajn’s test)[10]

Modifications

Modifications to the Straight Leg Raise test can be used to stress different peripheral nerves to a greater degree; these are referred to as SLR tests with a particular nerve bias.

SLR test and its Modifications[12]
SLR SLR2 SLR3 SLR4

CROSS LEG

SLR 5

HIP Flexion 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)

Psychometric properties

Reliability

Reliability of the SLR depends on how a positive test is defined:[9]

  • Fair when the test only provokes pain below the knee
  • Moderate to substantial when it provokes the patient’s own symptoms and those symptoms change with structural differentiation.

Reliability is weaker for range of motion, as different clinicians measuring the same patient obtained very different values. Reliability of the symptom-based definitions is therefore unlikely to be the main reason the SLR performs poorly as a diagnostic test.

Diagnostic accuracy

For lumbar disc herniation, the SLR has high sensitivity (about 0.9) but low specificity (about 0.4).[1][2][10] Low specificity can be explained by the fact that sciatic pain has causes other than disc herniation, and these patients also test positive.[1] However, a recent study found a more balanced profile for nerve root compression, with a sensitivity of 0.77 and a specificity of 0.81.[6]

Variants

  • The crossed SLR has high specificity (≥ 0.90) for disc herniation but low sensitivity.[1][10]
  • The Bragard test may make the SLR more specific for sciatic symptoms, although the supporting evidence is sparse.[2] It also has several limitations:[2]
    • There is no standard way of performing it
    • It is uncertain whether it can be used when the leg is raised beyond 70°
    • No study has assessed whether examiners or repeated tests give consistent results.

Clinical Relevance

Most clinical practice guidelines suggest the SLR test as an assessment to identify radicular pain or radiculopathy.[9] However, there is low level evidence that the SLR test can detect radiculopathy.[13] The SLR test is more sensitive than specific, hence useful for ruling out lumbo-sacral radiculopathy.[14] Adding structural differentiation (e.g., neck flexion, ankle dorsiflexion, hip adduction) improves the reliability of the SLR test to at least a moderate level, and is recommended in clinical practice.[9]

Summary

The SLR test is a neurodynamic test used to detect lumbar disc herniation and nerve root irritation. Definitions of a positive test vary, but structural differentiation raises its reliability to at least a moderate level. It is highly sensitive but poorly specific, so it is better for ruling out radiculopathy than confirming it.

References

  1. ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 Kamath SU. Kamath SS. Lasègue’s sign. J. Clin. Diagn. Res. 2017;11(5).
  2. ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 Pesonen J, Shacklock M, Rantanen P, Mäki J, Karttunen L, Kankaanpää M, Airaksinen O, Rade M. Extending the straight leg raise test for improved clinical evaluation of sciatica: reliability of hip internal rotation or ankle dorsiflexion. BMC Musculoskeletal Disorders. 2021 Dec;22(1):1-8.
  3. ↑ 3.0 3.1 3.2 3.3 3.4 3.5 Magee DJ. Lumbar spine. In: Orthopaedic physical assessment. 5th ed. St. Louis (MO): Saunders Elsevier; 2008. p. 558-64.
  4. ↑ Dutton M. Orthopaedic examination, evaluation, and intervention. 2nd ed. New York (NY): McGraw-Hill Medical; 2008.
  5. ↑ 5.0 5.1 5.2 5.3 5.4 Boyd BS, Wanek L, Gray AT, Topp KS. Mechanosensitivity of the lower extremity nervous system during straight-leg raise neurodynamic testing in healthy individuals. Journal of orthopaedic & sports physical therapy. 2009 Nov;39(11):780-90.
  6. ↑ 6.0 6.1 6.2 Hussein HM, Kamel E, Ragab M, Elerian A. Diagnostic accuracy of the passive straight leg raise test in detecting compression of the lower lumbar nerve roots. Internet Journal of Allied Health Sciences and Practice. 2024;22(2):8.
  7. ↑ 7.0 7.1 7.2 7.3 7.4 Dhatt SS, Siva Swaminathan S. Examination of Lumbar Spine. InHandbook of Clinical Examination in Orthopedics: An Illustrated Guide 2018 Oct 2 (pp. 185-218). Singapore: Springer Singapore.
  8. ↑ Educom Continuing Education. (2022, April 14). Straight leg raise test [Video]. YouTube. https://www.youtube.com/watch?v=jxoBKLLLKj8
  9. ↑ 9.0 9.1 9.2 9.3 9.4 Nee RJ, Coppieters MW, Boyd BS. Reliability of the straight leg raise test for suspected lumbar radicular pain: A systematic review with meta-analysis. Musculoskeletal Science and Practice. 2022 Jun 1;59:102529.
  10. ↑ 10.0 10.1 10.2 10.3 10.4 10.5 Ropper AH, Zafonte RD. Sciatica. New England Journal of Medicine. 2015 Mar 26;372(13):1240-8.
  11. ↑ Suri V. Miscellaneous Neurological Signs. InClinical Neurological Examination and Localization 2024 May 18 (pp. 377-381). Singapore: Springer Nature Singapore.
  12. ↑ Butler DS, Jones MA. Mobilisation of the nervous system. (No Title). 1991 Jan.
  13. ↑ Mistry J, Heneghan NR, Noblet T, Falla D, Rushton A. Diagnostic utility of patient history, clinical examination and screening tool data to identify neuropathic pain in low back related leg pain: a systematic review and narrative synthesis. BMC Musculoskeletal Disorders. 2020 Aug 10;21(1):532.
  14. ↑ Tawa N, Rhoda A, Diener I. Accuracy of clinical neurological examination in diagnosing lumbo-sacral radiculopathy: a systematic literature review. BMC musculoskeletal disorders. 2017 Feb 23;18(1):93.
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