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Spine Health SPINE HEALTH Passive Straight Leg Raise Test: Definition, Interpretation, Limitations and Utilization ABSTRACT This article highlights the myths and misunderstandings surrounding the straight leg raise (SLR) test for sciatica. Unfortunately, neither intra- nor inter-observer reliability of the passive SLR test has ever been agreed upon. In addition, there is poor consensus about what constitutes a positive SLR test in terms of pain location, leg elevation limitation or clinical significance. Until there are stricter performance standards and uniform agreement, researchers and clinicians should interpret the test with caution. We believe a true positive SLR should be the reproduction or exacerbation of the typical leg dominant pain in the affected limb at any degree of passive elevation. Those with only increased back pain or any leg pain other than that presenting as the chief complaint should be regarded as false positives. KEYWORDS: low back pain, straight leg raise, sciatica, irritative test CME Pre-test Quiz ciatica is constant leg dominant pain anywhere from the gluteal fold and lower buttock down to the knee, calf or foot.1 It results from irritation, usually inflam- Smatory, within or adjacent to the spinal canal of one or more of the roots of the nerves that combine to form the sciatic nerve (L4, L5, S1, S2). Charles Lasegue first published the effects of stretching the sciatic nerve by extending the knee with the hip flexed. Lasegue’s medical student JJ Forst was the first to describe the more common passive straight leg raise in his medical thesis of 1881.2 Today, the passive straight leg raise (SLR) is a common component of a low back examination3,4 and Dr. Hamilton Hall, MD, FRCSC, is a Professor in the Greg McIntosh, MSc, completed his Masters in Department of Surgery at the University of Toronto. He is the Epidemiology from the University of Toronto’s Faculty of Medical Director, CBI Health Group and Executive Director of Medicine. He is currently the Director of Clinical Research the Canadian Spine Society in Toronto, Ontario. for CBI Health Group and research consultant to the Canadian Spine Society. Passive Straight Leg Raise Test is the test of nerve root irritation ers19 have suggested that less than most often associated with the des- 70 degrees is clinically meaning- ignation of sciatica and the concur- ful. Unfortunately, some clinicians rent diagnosis of an acute lumber misinterpret pain produced above disc herniation.5 that level as a negative result. A While only a few studies have positive test is one that reproduces concluded that the passive SLR a patient’s typical leg dominant has high specificity;6,7 several stud- pain. A clinically meaningful test ies have shown high sensitivity and is one that indicates a level of root low specificity4,8-10 indicating that a irritation requiring treatment. The negative test is diagnostically more higher the leg can be lifted before important than a positive one.11 the typical pain is produced, the The chief diagnostic value of the less irritability that is present. SLR may be in ruling out the pres- Patients suffering severe sciatica ence of sciatic nerve root irritation. may be unable to even fully extend We consider a test that does not the knee, much less allow the leg reproduce a patient’s typical leg to be lifted. By the time the root dominant pain to indicate there is irritation has subsided to the point no irritation of the roots of the sci- where a patient can tolerate over atic nerve.1 70 degrees of elevation, recovery Unfortunately, neither intra- without aggressive medical inter- nor inter-observer reliability of the vention is almost assured. An SLR passive SLR test has been estab- test remains positive however, lished.5 In addition, there is little when it produces or increases agreement about what constitutes the typical leg pain regardless of a positive passive SLR test in terms the degree of elevation.20 From of pain location, leg elevation limi- a purely diagnostic perspective, tation or clinical significance.12 The reproduction of leg pain is more location of the pain in a positive important than the degree of limi- test has varied from ipsilateral leg tation.1,20-22 pain below the knee, to general A second problem with inter- leg pain, to a combination of back preting the test at elevations above and leg pain.1,5,13-16 The reproduc- 70 degrees is the appearance of tion/exacerbation of pain as the pain from tight hamstrings. When examiner lifts the affected leg is a patient reports pain in the back generally considered to indicate of the thigh, this is frequently con- the presence of root irritation17 but fused with the radicular pain of there is wide variation in the sig- true sciatica. To significantly reduce nificance attributed to the angle of this confusion, the SLR can be per- elevation at which that pain is elic- formed in sitting or, with a patient ited. Brieg and Troup18 and oth- supine and the contralateral hip 25 Journal of Current Clinical Care Volume 4, Issue 6, 2014 Passive Straight Leg Raise Test and knee flexed so that the foot is will aggravate sciatica. But these as close to the buttock as possi- secondary tests and additional ble. Both of these positions rotate discomfort that they create are the pelvis backward relaxing the not required when the SLR is cor- hamstring muscles and allowing rectly interpreted as reproduction the straight leg to be lifted about or exacerbation of the patient’s typical leg dominant symptoms as identified on history and not just THE TERM SCIATICA, AS IT IS FREQUENTLY any leg pain. EMPLOYED, HAS SEVERAL CHARACTERISTICS The term sciatica, as it is fre- quently employed, has several THAT ARE EITHER POORLY DOCUMENTED characteristics that are either OR SIMPLY ASSUMED TO BE VALID S A poorly documented or simply . A assumed to be valid. As a result RESULT THE LINK BETWEEN SLR TESTING the link between SLR testing and true sciatic pain is surrounded in AND TRUE SCIATIC PAIN IS SURROUNDED controversy. Conflicting opinions, IN CONTROVERSY. lack of standardized test methods and divergent interpretations of what constitutes a positive test an additional 20 degrees without yield misleading and perplexing discomfort. The altered starting results and confounds treatment position does not reduce the sen- decisions.1,2,23-25 The result is a sitivity of the test for nerve root high number of false positives irritation. (those who have no sciatic root Differentiating between root irritation but who are reported and hamstring pain is a reason to exhibit a positive straight leg that many clinicians employ a raise).26 variety of secondary tests to con- For example, in a recent study firm the existence of radicular of 2154 patients, clinical out- symptoms; a common example comes for different presentations is Braggard’s test: elevating the of an apparently positive find- affected leg to the point of pain, ing on straight leg raising were lowering it 10 degrees to reduce used to help define true positive the pain than dorsiflexing the test results (increased leg domi- foot to intensify the pain again. nant pain with straight leg rais- The “bowstring sign”, where pres- ing) from false positive ones sure placed in the popliteal fossa, (increased back pain with straight increases the leg pain is another leg raising). There were three dis- example. In each case, the test tinct study groups: will not affect hamstring pain but 1. positive leg pain: SLR testing 26 Journal of Current Clinical Care Volume 4, Issue 6, 2014 Passive Straight Leg Raise Test Passive Straight Leg Raise 70° (SLR) Test 0°-70° Range An SLR test remains (Clinically positive however, when it Meaningful) produces or increases the typical leg pain regardless of the degree of elevation. 0° Supine with contralateral hip/knee exed Preferred Positions for the SLR Test These positions rotate the pelvis and reduce the chance of a "false positive" from painful hamstring tightness. Seated 28 Journal of Current Clinical Care Volume 4, Issue 6, 2014 Passive Straight Leg Raise Test increased the leg dominant pain situations where back dominant 2. positive back pain: SLR testing pain radiates to the leg, the back increased only the back domi- pain is still reported to be the most nant pain painful. Back dominant pain is 3. no change: no increase in back or referred pain without direct nerve leg pain with straight leg raising root involvement and since the SLR is a test of nerve irritation, the test cannot be positive. It is not A PATIENT WITH A HISTORY OF BACK pathologically possible to have a patient with a history of back dom- PAIN ONLY, WITH NO SYMPTOMS inant pain and a physical exami- BELOW THE BUttOCKS, WILL NEVER nation showing a positive straight HAVE A TRUE POSITIVE leg raise; there was either an error SLR. made in recording the history or performing the examination. To Given the striking similarity in state it even more simply, a patient outcomes between the back pain with a history of back pain only, and no change groups, increased with no symptoms below the but- back pain with a passive straight tocks, will never have a positive leg raise test should be consid- SLR. You cannot reproduce radic- ered a false positive. The Positive ular pain when a patient has never Leg Pain group’s outcomes were truly experienced it. significantly worse and different Also essential to an accurate from the Positive Back Pain group, history of true sciatica is determin- offering further evidence that ing the presence of constant leg increased back pain on straight pain.1,20 The nerve root irritation leg raising should be considered a pain is predominantly inflamma- false positive.26 tory, not simply mechanical.
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