Phalans test - for spinal canal stenosis Gaenslen's test - for sacroilitis Pelvic compression test - for sacroilitis Flip test Lasegue test Bragard's test Sicard test Bowstring test
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I now have comprehensive information from multiple authoritative textbooks. I also need to note a key correction in the user's list: the Phalen test is classically for carpal tunnel syndrome (CTS), NOT spinal canal stenosis - the user has labeled it incorrectly. Let me now compile the full answer.
Clinical Tests: Detailed Review
Important correction: The Phalen test as listed ("for spinal canal stenosis") is a mislabeling. The Phalen test is the standard provocative test for carpal tunnel syndrome (CTS), not spinal stenosis. The test used for lumbar spinal stenosis is typically the bicycle test (Van Gelderen) or extension provocation. This is addressed below.
1. Phalen's Test
Actual indication: Carpal Tunnel Syndrome (CTS) - not spinal canal stenosis.
Technique: The patient holds both wrists in maximum palmar flexion (wrists bent downward, dorsa of the hands opposed) for 60 seconds.
Positive: Reproduction of paraesthesiae (tingling, numbness) in the distribution of the median nerve (thumb, index, middle finger, radial half of ring finger).
Mechanism: Sustained wrist flexion increases pressure within the carpal tunnel, compressing the median nerve. It is the most sensitive of the carpal tunnel provocative tests.
Evidence:
- Sensitivity ~75%, Specificity ~47% for CTS diagnosis
- A positive result in <30 seconds is a predictor of nonoperative treatment failure (one of 5 factors, alongside age >50, symptoms >10 months, constant paraesthesiae, and stenosing flexor tenosynovitis)
- Campbell's Operative Orthopaedics 15th Ed, Box 82.3
Note on lumbar spinal stenosis: The classic feature is neurogenic claudication (leg pain/weakness on walking that is relieved by sitting or flexing forward). There is no eponymous "Phalen test" for lumbar stenosis. The question may be confusing the Phalen and Dickson test (lumbar extension causing stenosis symptoms), or simply mislabeled.
2. Gaenslen's Test
Indication: Sacroiliac joint (SIJ) pathology / Sacroiliitis
Technique: The patient lies supine at the edge of the examining table. One leg hangs off the edge and is hyperextended at the hip (dropping toward the floor), while the other leg is flexed tightly onto the chest. This creates a torsional / shearing stress across the SIJ.
An alternate description from Miller's Review of Orthopaedics: "performed with patient lying on the affected side without support; direct compression of the pelvis reproducing symptoms is considered a positive exam finding." (Miller's Review of Orthopaedics 9th Ed, p. 782)
Positive: Reproduction of pain in the ipsilateral sacroiliac region.
Mechanism: The test applies opposing forces to each innominate bone, stressing the SIJ on the side of the hyperextended leg.
Limitation: Lacks specificity and sensitivity; may also be positive in hip pathology or lumbar disease. From Firestein & Kelley's Textbook of Rheumatology: "these maneuvers lack specificity and sensitivity... may become negative in late stages as inflammation is replaced by fibrosis or bony ankylosis." (Firestein & Kelley's Textbook of Rheumatology, 2-Vol Set, Section on Sacroiliitis)
3. Pelvic Compression Test (Pelvic Rock Test / Distraction Test)
Indication: Sacroiliac joint pathology / Sacroiliitis
Technique:
- Compression variant: Patient supine. Examiner applies downward pressure on both anterior superior iliac spines (ASIS) simultaneously, compressing the pelvis.
- Distraction variant: Examiner places hands on both ASIS and pushes outward/downward, gapping the anterior SIJ.
Positive: Reproduction of pain in the sacroiliac region.
Mechanism: Compressive or distractive forces stress the SIJ capsule and ligaments, provoking pain in an inflamed or damaged joint.
Context: Mentioned alongside the FABERE and Gaenslen test as provocative SIJ maneuvers in Firestein's rheumatology text. Like other SIJ tests, its sensitivity and specificity are limited individually; a cluster of ≥3 positive SIJ provocation tests has better diagnostic accuracy.
4. Flip Test
Indication: Lumbar disc herniation / Nerve root irritation (distinguishing organic from non-organic)
Technique:
- With the patient supine, a straight leg raise (SLR) is performed and the angle at which pain is provoked is noted.
- The patient is then asked to sit up with legs hanging off the edge of the table (or is brought to sitting position).
- The examiner then extends the knee (performing a seated SLR) while appearing to examine the knee or foot.
Positive (organic sign): In a patient with true nerve root irritation, extending the knee in the sitting position reproduces sciatic pain - and the patient will lean back ("flip" backwards) to reduce tension on the sciatic nerve, just as they would resist SLR when supine.
Positive (inconsistency / non-organic sign): If a patient has a very low supine SLR angle (e.g., pain at 30°) but tolerates full knee extension while seated without leaning back or showing pain, this inconsistency suggests a non-organic or functional component to their pain.
Significance: The flip test is primarily a validity/consistency check. A seated SLR is functionally equivalent to a supine SLR because both place equal tension on the sciatic nerve. Discrepancy between the two positions suggests symptom magnification.
From Goldman-Cecil Medicine: "Positive seated straight leg raising when the knee is fully extended is about as useful as a positive test at 65 degrees elevation when the patient is supine." (Goldman-Cecil Medicine, Section on History and Clinical Examination)
From Miller's Review: "Seated straight-leg test - variation of supine straight-leg raise, performed while patient in seated position; in positive result, hip flexion with knee extension reproduces and/or exaggerates symptoms radiating down leg; less sensitive than supine straight-leg raise." (Miller's Review of Orthopaedics 9th Ed)
5. Lasègue's Test (Straight Leg Raise / SLR)
Indication: Lumbar disc herniation, L4/L5/S1 nerve root compression, sciatica
Technique: With the patient supine, the examiner holds the heel and slowly raises the leg with the knee kept fully extended. Normal individuals can raise to nearly 90° without pain.
Positive: Reproduction of the patient's sciatica (shooting pain radiating from the buttock down the posterior thigh, calf, and foot) when the leg is elevated between 30° and 70°. Pain produced only in the back, or only hamstring tightness, does NOT constitute a positive test.
Mechanism: Raising the straight leg places the sciatic nerve and its L4, L5, S1 roots under progressive tension. In the presence of disc herniation compressing a root, this tension reproduces radicular pain.
Crossed SLR (Fajersztajn sign): Raising the contralateral (unaffected) leg reproduces sciatica in the symptomatic leg. This is more specific but less sensitive than the ipsilateral SLR, and suggests a large, often axillary/medial disc herniation.
Diagnostic accuracy (from Symptom to Diagnosis, 4th Ed):
| Finding | Sensitivity | Specificity | LR+ | LR- |
|---|---|---|---|---|
| Sciatica | 95% | 88% | 7.9 | 0.06 |
| Ipsilateral SLR positive | 85-91% | 26-50% | 1.2-1.8 | 0.18-0.3 |
| Crossed SLR positive | 25% | 90% | 2.5 | 0.83 |
From Adams and Victor's Principles of Neurology: "The most helpful sign in detecting L5 or S1 nerve root compression is elicitation of sciatic pain with passive straight-leg raising when the patient is supine (Lasègue sign)." (Adams & Victor's Principles of Neurology, 12th Ed, Examination of the Lower Back)
6. Bragard's Test
Indication: Lumbar disc herniation / Sciatic nerve root irritation (SLR variant/modifier)
Technique: The SLR is performed until the patient reports radicular pain (or just below the pain threshold). The leg is then slightly lowered to relieve pain, and the foot is then passively dorsiflexed by the examiner.
Positive: Return of the radicular (sciatic) pain with ankle dorsiflexion.
Mechanism: Dorsiflexion of the foot stretches the tibial branch of the sciatic nerve, adding further tension to an already irritated nerve root. It increases the sensitivity of the SLR.
Significance: Bragard's test is essentially a reinforcement/sensitization of the Lasègue test. It helps confirm genuine nerve root irritation rather than hip or hamstring pain.
From Adams & Victor's Principles of Neurology: "The many derivatives of the straight-leg raising sign include accentuation of pain by dorsiflexion of the foot (Bragard sign) or of the great toe (Sicard sign)." (Adams & Victor's Principles of Neurology, 12th Ed)
7. Sicard's Test
Indication: Lumbar disc herniation / Sciatic nerve root irritation (SLR variant)
Technique: Similar to Bragard's test but instead of dorsiflexion of the whole foot, the examiner passively extends/dorsiflexes the great toe (hallux) after performing SLR to just below the pain threshold.
Positive: Reproduction of radicular (sciatic) pain with great toe dorsiflexion.
Mechanism: Extension of the great toe stretches the tibial nerve (and specifically the nerve to extensor hallucis longus), adding tension to the sciatic nerve root. It is particularly sensitive for L5 root irritation (since EHL is primarily an L5 function).
Significance: Like Bragard's sign, this sensitizes the SLR. Sicard's test = Bragard's, but using the great toe rather than the ankle.
(Adams & Victor's Principles of Neurology, 12th Ed - both listed as "derivatives of the straight-leg raising sign")
8. Bowstring Test (Cram Test / Popliteal Compression Sign)
Indication: Lumbar disc herniation / Sciatic nerve root irritation
Technique:
- The SLR is performed until the patient reports radicular pain.
- The knee is then slightly flexed (to about 20°) to relieve pain - this relaxes hamstring tension.
- The examiner then applies firm digital pressure directly into the popliteal fossa (over the posterior tibial nerve / common sciatic nerve).
Positive: Reproduction of radicular (sciatic) pain with popliteal pressure, even with the knee slightly bent.
Mechanism: Direct compression of the sciatic nerve at the popliteal fossa in an already taut/irritated state reproduces radicular symptoms. By flexing the knee to eliminate hamstring stretch, the test specifically implicates the sciatic nerve rather than musculotendinous tightness.
Significance: The bowstring test is highly specific for sciatic nerve root irritation because it rules out hamstring pathology as a cause of pain during SLR. Also called the "popliteal compression sign" or "Cram test."
Summary Table
| Test | For | Technique | Positive Sign |
|---|---|---|---|
| Phalen's | Carpal tunnel syndrome (NOT spinal stenosis) | Wrist palmar flexion x60 sec | Median nerve paraesthesiae |
| Gaenslen's | Sacroiliac joint / Sacroiliitis | Hip hyperextension off table edge with opposite hip flexed | Ipsilateral SIJ pain |
| Pelvic Compression | Sacroiliac joint / Sacroiliitis | Downward/outward pressure on ASIS | SIJ pain reproduction |
| Flip Test | Organic vs. non-organic nerve root signs | Seated knee extension vs. supine SLR consistency | Patient "flips" back OR discordance reveals non-organic |
| Lasègue's (SLR) | L4/L5/S1 disc herniation, sciatica | Supine passive leg raise, knee extended | Radicular pain at 30-70° |
| Bragard's | Sciatic nerve root irritation (SLR modifier) | SLR + ankle dorsiflexion | Return of radicular pain |
| Sicard's | Sciatic nerve root irritation (SLR modifier) | SLR + great toe dorsiflexion | Return of radicular pain |
| Bowstring | Sciatic nerve root irritation | SLR to pain, slightly flex knee, press popliteal fossa | Radicular pain with compression |
Sources:
- Adams & Victor's Principles of Neurology, 12th Ed - Examination of the Lower Back
- Miller's Review of Orthopaedics, 9th Ed - Lumbar Herniated Disc; SIJ Dysfunction
- Firestein & Kelley's Textbook of Rheumatology, 2-Vol Set - Sacroiliitis
- Symptom to Diagnosis: An Evidence Based Guide, 4th Ed - Table 7-5
- Goldman-Cecil Medicine - History and Clinical Examination
- Campbell's Operative Orthopaedics, 15th Ed - Carpal Tunnel / CTS
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