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Straight Leg Raise Test

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Straight Leg Raise Test - StatPearls - NCBI Bookshelf 11/4/19 17'07

NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-.

Straight Leg Raise Test

Authors

Gaston O. Camino Willhuber1; Nicolas S. Piuzzi2.

Affiliations
1 Hospital Italiano de Buenos Aires
2 Cleveland Clinic

Last Update: April 1, 2019.

Introduction
The straight leg raise test also called the Lasegue test, is a fundamental neurological maneuver during physical
examination of the patient with lower back pain aimed to assess the sciatic compromise due to lumbosacral nerve root
irritation. This test which was first described by Dr. Lazarevic and wrongly attributed to Dr. Lasegue can be positive
in a variety of conditions, being lumbar disc herniation the most common. Nonetheless, there are multiple causes of a
positive test such as facet joint cyst or hypertrophy.[1][2][3](See Table 1) Overall, this test is one of the most
commonly performed maneuvers across clinical practice and provides important information when making the
clinical decision to refer a patient to a specialist as well as among spinal surgeons to guide therapeutic decision-
making.[4]

Low back pain is one of the most common complaints among active workers and a significant cause of absenteeism
from work. Sciatic pain is radiating pain from the buttocks to the leg and is frequently associated with low back pain.
[5] To this regard, neurological examination is fundamental in discriminating patients with isolated lower back pain
from those with associated radiculopathy. Consequently, early recognition of radiculopathy allows a targeted
treatment and diminishes disability.[6] The specificity of the straight leg raise test has been reported to be low,[7]
making the diagnosis accuracy limited. However, the clinical usefulness of this test remains important both for
general practitioners as for spine surgeons and should still be considered a relevant component of the physical
examination that, associated with proper imaging studies can lead to an accurate diagnosis and treatment.

Therefore the objective of this review is to describe the maneuver technique, pathophysiology, history, and usefulness
of this common test through a review in the literature.

Anatomy
The Lasegue test is basically a provocation test that evidences radicular irritation in the lumbosacral region by lower
limb flexion and can be due to multiple causes [See table 1]. Radicular symptoms are primarily produced by nerve
root inflammation by surrounded structures.[8] The foramina are formed by the pedicle superiorly and inferiorly,
ligamentum flavum posteriorly, disc and vertebral body anteriorly, and this small space normally allows the nerve root
excursion of 4 mm, however during the straight leg raise test this root excursion can be compromised by several
factors (see Table 1). Mechanical compression sole does not always generate radicular symptoms as many patients
have asymptomatic foraminal stenosis in MRI,[9][10] therefore, positive leg raise test may undergo influence by
nerve root irritation secondary to inflammation as well as mechanical compression.

The straight leg raise test is attributed to Charles Lasegue, a French clinician who described two cases of sciatica
aggravated by weight bearing and hip and knee flexion in “Thoughts of Sciatica” in 1864. Nonetheless, Dr. Lasegue
did not describe the test as a provoked pain; instead, his student JJ Forst described the test in his doctoral thesis in
1881, and it was Forst who considered the pain to be produced by hamstring muscle compression to the sciatic nerve.

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Nevertheless, it is believed that a Serbian neurologist, Dr. Lazar Lazarevic,[11] was the first who documented the
straight leg raise test as it is known today in the article named “Ischiac postica cotunnii”, initially published in the
Serbian Archives of Medicine (1880), and republished in Vienna (1884). Dr. Lazarevic described the straight-leg-
raising test by explaining sciatic pain by stretching the sciatic nerve based on his experience with six patients. Based
on this misinterpretation of the original description it is recommended to describe the maneuver as the straight leg
raise test.

Indications
Low back pain

Buttock pain

Leg pain

Technique
The straight leg raise test is performed with the patient in a supine position. The examiner gently raises the patient's
leg by flexing the hip with the knee in extension, and the test is considered positive when the patient experiences pain
along the lower limb in the same distribution of the lower radicular nerve roots (usually L5 or S1).

Furthermore, a positive straight leg raise test is determined when pain is elicited by lower limb flexion in an angle
lower than 45 degrees. During the test, if the pain is reproduced during the leg straightening, patients usually request
that the examiner aborts the maneuver and by flexing the patient’s knee the buttock pain is usually relieved(Figure 1).

Additional maneuvers have been described to enhance the sensitivity of the test such as the Bragaad’s sign, that
consists of concomitant foot dorsiflexion to increase the pain while the examiner completes the leg raise.

An additional maneuver is the crossed straight leg test (crossed over Lasegue), in which the examiner passively flexes
the patient’s uninvolved limb while maintaining the knee in extension. A positive test is when the patient reports pain
in the involved limb at 40 degrees of hip flexion with the uninvolved limb. Crossed straight test is positive in central
disc herniation in cases of severe nerve root irritation.[12]

Clinical Significance
Previous analysis of the sensitivity and specificity of the straight leg raise test shows high sensitivity and low
specificity of lumbar disc protrusion,[7][13] however, most of the literature is limited by poor quality and were
performed in surgical case-series at non primary care level, limiting the external validity of these findings. Also, some
studies have shown restricted diagnosis accuracy of neurological examination in detecting disc herniation with
radiculopathy.[14] As the test demonstrates high sensitivity, it could be useful as a rule out lumbar disc protrusion;
however, the utility is limited due to low specificity as it can be positive in ischialgia secondary to other causes.

Straight leg raise test is an important physical examination finding during primary care to assess the need for imaging
studies such as X-rays and MRI, and the potential need for a referral from primary care to a spine specialist.

This test is also relevant among spine specialists to guide proper treatment options,[14] being positive Lasegue test a
sign of nerve root irritation and possible entrapment, which might require a nerve root injection or surgery.[15]

A positive straight leg raise test (or Lasegue sign) results from gluteal or leg pain by passive straight leg flexion with
the knee in extension, and it may correlate with nerve root irritation and possible entrapment with decreased nerve
excursion. This clinical neurological test has a high sensibility and low specificity, being an important diagnostic
work-up in patients with lower back pain and suspected radiculopathy. This test is relevant to guide referrals among
primary care providers as well as to guide treatment among spinal surgeons especially when considering a surgical

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decision.

Enhancing Healthcare Team Outcomes

Low back pain is among the most common complaints among active workers and a significant cause of absenteeism
from work. Sciatic pain is radiating pain from the buttocks to the leg and is frequently associated with low back pain.
In this regard, neurological examination is fundamental in discriminating patients with isolated lower back pain from
those with associated radiculopathy. Consequently, early recognition of radiculopathy allows a targeted treatment and
diminishes disability. Performing this maneuver correctly, when indicated, helps primary care providers, nurse
practitioners, emergency department physicians, and internists assess the need for imaging studies such as X-rays and
MRI and the potential need for a referral from primary care to a spine specialist.

Questions
To access free multiple choice questions on this topic, click here.

References
1. Beith I, Thacker M. Re: Schäfer A, Hall T, Briffab K. Classification of low back-related leg pain--a proposed
patho-mechanism-based approach. Manual Therapy (2007) doi:10.1016/j.math.2007.10.003. Man Ther. 2009
Aug;14(4):e1; author reply e2. [PubMed: 18793866]
2. Tawa N, Rhoda A, Diener I. Accuracy of clinical neurological examination in diagnosing lumbo-sacral
radiculopathy: a systematic literature review. BMC Musculoskelet Disord. 2017 Feb 23;18(1):93. [PMC free
article: PMC5324296] [PubMed: 28231784]
3. Van Boxem K, Cheng J, Patijn J, van Kleef M, Lataster A, Mekhail N, Van Zundert J. 11. Lumbosacral radicular
pain. Pain Pract. 2010 Jul-Aug;10(4):339-58. [PubMed: 20492580]
4. van den Hoogen HJ, Koes BW, Devillé W, van Eijk JT, Bouter LM. The inter-observer reproducibility of
Lasègue's sign in patients with low back pain in general practice. Br J Gen Pract. 1996 Dec;46(413):727-30.
[PMC free article: PMC1239862] [PubMed: 8995852]
5. Hill JC, Konstantinou K, Egbewale BE, Dunn KM, Lewis M, van der Windt D. Clinical outcomes among low
back pain consulters with referred leg pain in primary care. Spine. 2011 Dec 01;36(25):2168-75. [PubMed:
21358478]
6. Bertilson BC, Brosjö E, Billing H, Strender LE. Assessment of nerve involvement in the lumbar spine: agreement
between magnetic resonance imaging, physical examination and pain drawing findings. BMC Musculoskelet
Disord. 2010 Sep 10;11:202. [PMC free article: PMC2944219] [PubMed: 20831785]
7. Devillé WL, van der Windt DA, Dzaferagić A, Bezemer PD, Bouter LM. The test of Lasègue: systematic review
of the accuracy in diagnosing herniated discs. Spine. 2000 May 01;25(9):1140-7. [PubMed: 10788860]
8. Stafford MA, Peng P, Hill DA. Sciatica: a review of history, epidemiology, pathogenesis, and the role of epidural
steroid injection in management. Br J Anaesth. 2007 Oct;99(4):461-73. [PubMed: 17704089]
9. Jensen MC, Brant-Zawadzki MN, Obuchowski N, Modic MT, Malkasian D, Ross JS. Magnetic resonance
imaging of the lumbar spine in people without back pain. N. Engl. J. Med. 1994 Jul 14;331(2):69-73. [PubMed:
8208267]
10. Tachihara H, Kikuchi S, Konno S, Sekiguchi M. Does facet joint inflammation induce radiculopathy?: an
investigation using a rat model of lumbar facet joint inflammation. Spine. 2007 Feb 15;32(4):406-12. [PubMed:
17304129]
11. Drača S. Lazar K. Lazarević, the author who first described the straight leg raising test. Neurology. 2015 Sep
22;85(12):1074-7. [PubMed: 26391412]
12. Hudgins WR. The cross-straight-leg-raising test. N. Engl. J. Med. 1977 Nov 17;297(20):1127. [PubMed:
909576]

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13. Rabin A, Gerszten PC, Karausky P, Bunker CH, Potter DM, Welch WC. 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. Arch Phys Med Rehabil. 2007 Jul;88(7):840-3. [PubMed: 17601462]
14. Majlesi J, Togay H, Unalan H, Toprak S. The sensitivity and specificity of the Slump and the Straight Leg
Raising tests in patients with lumbar disc herniation. J Clin Rheumatol. 2008 Apr;14(2):87-91. [PubMed:
18391677]
15. Manchikanti L, Cash KA, Pampati V, Falco FJ. Transforaminal epidural injections in chronic lumbar disc
herniation: a randomized, double-blind, active-control trial. Pain Physician. 2014 Jul-Aug;17(4):E489-501.
[PubMed: 25054399]

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Figures

Figure 1.A) Straight leg raise test. B) Bragaad’s Test to increase the test sensitivity. C) When flexing the knee the
patient usually experience pain relief. Contributed By Gaston Camino Willhuber, MD

Copyright © 2019, StatPearls Publishing LLC.

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