The Slump Test: The Effects of Head and Lower
Extremity Position on Knee Extension
Evan K. johnson, MS, PT '
Cynthia M. Chiarello, PhD, PT2
A
comprehensive evalua-
tion of patients with
low back pain must in-
clude a method of test-
ing the integrity of re-
lated neural tissues (14,20,34). The
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straight leg raise test is recognized as
the first neural tissue tension test to
appear in the literature (48). During
straight leg raise testing, the leg is
elevated with the knee extended and
Copyright © 1997 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
the patient in a supine position. This
places a tensile stress on the sciatic
nerve and exerts a caudal traction on
the lumbosacral nerve roots from L,
to S, (15,18,21,48).Assessment of the
straight leg raise test requires that
the range of motion (ROM) mea-
sured is compared with the contralat-
era1 side and expected norms (14,41,
Journal of Orthopaedic & Sports Physical Therapy®
45,48).
Confounding the straight leg
raise test, nonneural structures, such
as lumbar zygapophyseal joints, mus-
cles, and connective tissue, can limit
leg elevation and provoke patient
discomfort during testing ( 1 7,41,45,
48). Including supplementaly maneu-
vers in the straight leg raise test p r e
cedure may reduce patient responses
caused by nonneural tissues. Flexing
the cervical spine, dorsiflexing the
ankle, and medially rotating the hip
during the straight leg raise test in-
creases tension exerted on the spinal
cord, spinal dura, and lumbosacral
nerve roots (1-5,26,42,44). Research
conducted by Breig (2) and others
(3-5,27,38,42,43) indicates that flex-
ing the cervical spine during straight
leg raise testing lengthens the spinal
cord and dura (2-5,27,38,42,43),
Maitland's slump test is a widely used neural tissue tension test. During slump testing,
terminal knee extension is assessed for signs of restricted range of motion (ROM), which may
indicate impaired neural tissue mobility. A number of refinements that modih hip and ankle
position has been added to the basic slump test procedure, but no research to date has measured
the effects of ankle and hip position on knee extension ROM during testing. The purpose of this
study was to examine the effect of neural tension-producing movements of the cervical spine and
lower extremity on knee extension ROM during the slump test. Thirty-four males with no
significant history of low back pain were tested in the slump position with the cervical spine flexed
and extended in each of three lower extremity test positions: neutral hip rotation with the ankle in
a position of subject comfort (neutral), neutral hip rotation with ankle doniflexion (ankle
dorsiflexion), and medial hip rotation with ankle doniflexion. Results showed significant decreases
in active knee extension ROM (F,,,, = 29.53, p < 0.0001) in the cervical flexion compared with
the cervical extension conditions. Subjects also exhibited significant decreases in active knee
extension ROM (F2,,,, = 56.76, p < 0.0001) as they were progressed from neutral to the ankle
dorsiflexion to the medial hip rotation with ankle dorsiflexion positions of the lower extremity. The
results of our study indicate that limitations in terminal knee extension ROM may be considered a
normal response to the inclusion of cervical flexion, ankle dorsiflexion, or medial hip rotation in
the slump test in young, healthy, adult males. In addition, the presence of a cumulative effect on
knee extension ROM with the simultaneous application of these motions is noted. These findings
may assist clinicians when assessing knee extension ROM during slump testing.
Key Words: slump test, neural tension, low back pain
'Assistant Chief of Physical Therapy, Physical Medicine and Rehabilitation Cenfer, PA, Englewood, N/.
Address for correspondence: 354 Grigs Avenue, Teaneck, Nl07666. Mr. lohnson completed this study in
partial fulfillment of a master's of science degree, Columbia University, New York, NY.
Assistant Professor of Clinical Physical Therapy, Columbia University, Program in Physical Therapy,
New York, NY
pulling the lumbosacral nerve roots increase the test's diagnostic and pre-
cranially (2-5,38). This may provoke dictive accuracy. The term "sensitiz-
radicular symptoms without stressing ing maneuvers* has been applied to
nonneural tissues in the lower ex- describe the role of cervical spine
tremity (2,5,7,13,29).Adding ankle flexion, ankle dorsiflexion, and me-
dorsiflexion and medial hip rotation dial hip rotation in provoking neural
to the straight leg raise test exerts a tissue responses during neural ten-
stretch on the sciatic nerve, pulling sion testing (10).
the lumbosacral nerve roots caudally Despite the development of re-
(1,5,39,42,43).Troup (44) and Breig finements to the straight leg raise
and Troup (5) demonstrated that test, the test is inadequate in detect-
incorporating cervical flexion, ankle ing neural tension in some cases (13,
dorsiflexion, and medial hip rotation 21,2941). A neural tension test per-
into the straight leg raise test may formed in a sitting position is
Volume 26 Number 6 December 1997 JOSPT
 .. - .. .. - & _. . .-.
necessary to simulate the extremes of
spinal motion seen during symptom-
provoking activities, such as slouched
sitting or entering and exiting a car
(5,13,21,29-31). In Maitland's slump
test, the patient is seated in full flex-
ion of the thoracic and lumbar re-
gions of the spine (32). Sensitizing
maneuvers are then systematically
applied and released to the cervical
spine and lower extremities, while
the tester maintains the patient's
trunk position. The slump test evalu-
ates the excursion of neural tissues
within the vertebral canal and inter-
vertebral foramen (29), detecting
impairments to neural tissue mobility
from a number of sources identified
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by Macnab (28) and Fahrni (15).
Maitland asserted that the slump test
enables the tester to detect adverse
nerve root tension caused by spinal
stenosis, extraforaminal lateral disc
Copyright © 1997 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
herniation, disc sequestration, nerve
root adhesions, and vertebral im-
pingement (29,30).
Research conducted by Smith
(42), Louis (27). and Breig (1.2) il-
lustrated the effects of trunk and
head position on neural structures
within the vertebral canal and inter-
vertebral foramen during slump test-
ing. They found that full spinal flex-
Journal of Orthopaedic & Sports Physical Therapy®
ion, or flexion of the cervical,
thoracic, and lumbar regions of the
spine, produces lengthening of the
vertebral canal. When the vertebral
canal is elongated, the spinal dura is
stretched, transmitting tension to the
spinal cord, lumbosacral nerve root
sleeves, and nerve roots (1,4,21,27,36,
38,42). During full spinal flexion, the
cauda equina becomes taut and the
lumbosacral nerve roots and root
sleeves are pulled into contact with
the pedicle of the superior vertebra
(1,4,21,27). When extension of the
cervical spine is introduced, the dura
and the nerve roots slacken as the
vertebral canal begins to shorten (1,
4,21,27,38,46).Extending the t h e
racic and lumbar spine increases the
slack in the neural tissues as the ver-
tebral canal continues to shorten (1,
4,21,27.36,46).
JOSPT Volume 26 Number 6 December 1997
-- . -.-. -~.- - - . . - .
. .
Maitland investigated responses
to the slump test in 25 physical ther-
apy students between the ages of 19
and 24 years who were asymptomatic
for low back pain (29). He qualita-
tively assessed, but did not gonio-
metrically measure (9,19,25), knee
extension and ankle dorsiflexion
During full spinal
flexion, the cauda
equina becomes taut
and the lumbosacral
newe roots and root
sleeves are pullled into
contact with the
pedicle of the
superior vertebra.
ROM during the slump test. Knee
extension ROM was initially exam-
ined in full spinal flexion. Subjects
who exhibited limitations in knee
extension ROM were asked to extend
their necks and were reassessed while
the tester manually maintained flex-
ion of the thoracolumbar spine and
cervical spine extension. Ankle dorsi-
flexion ROM was then examined with
the subject in full spinal flexion and
the knee maintained in maximal ex-
tension. Subjects who exhibited limi-
tations in ankle dorsiflexion ROM
were reassessed with the cervical
spine extended and the tester main-
taining thoracolumbar spinal flexion
and knee extension.
In seven subjects, Maitland o b
served as much as approximately 30"
of limitation in knee extension ROM
on at least one side when the cervical
spine was flexed and the ankle was in
a position of subject comfort. All
seven subjects subsequently achieved
their full knee extension ROM with
cervical spine extension. Sixteen s u b
R E_S _E .A_. __
R .._
CH STUDY
_
jects exhibited restrictions in ankle
dorsiflexion ROM of up to approxi-
mately 50" from the fully dorsiflexed
position with cervical spine flexion.
Full ankle dorsiflexion ROM was re-
stored with extension of the cervical
spine. Maitland concluded that move-
ment of the neural tissues within the
vertebral canal produced neural ten-
sion which resulted in the observed
limitations in knee and ankle motion
(29)
Subsequent research conducted
on responses to the slump test in
healthy individuals has not been p u b
lished in peer-reviewed journals. Re-
sults of unpublished works by Grant
(19) and Butler (9) indicate that
Maitland's estimates of the incidence
of observed motion restrictions in
terminal knee extension ROM during
the slump test were too low. This lack
of research on slump test responses
corroborating Maitland's findings
leaves room to question the sound-
ness of clinical interpretations of this
test. Responses to the slump test are
assessed, in part, by comparing test
outcomes to responses seen in indi-
viduals without low back pain or ra-
dicular signs (7,4O). To accurately
interpret the slump test, the clinician
must be able to distinguish between
motion restrictions, which are indica-
tive of pain or dysfunction, and limi-
tations in motion, which may be con-
sidered normal responses. In
addition, modifications in cervical
spine and lower extremity position
have been widely advocated as in-
creasing the efficacy of the slump test
in evaluating and treating a number
of conditions (6-8,10,11,16,22-24,33,
47). This underscores the importance
of understanding both the separate
and combined effect. of cervical
spine and lower extremity movements
on slump test responses. While a
number of refinements to the slump
test has been introduced that modifv
hip and ankle position, no research
to date has measured the separate
and combined effects of cervical
spine, ankle, and hip position on
 Lower Extretni!y i w,
Measurement
Straight leg raise 77.8 6.2
Knee extension -3.7 4.1
Ankle dorsiflexion 13.2 4.4
TABLE 1. Means, standard deviations, and ranges of
preliminary range of motion in degrees.
knee extension ROM during slump
testing.
The purpose of this study was to
determine limitations in terminal
knee extension ROM during slump
testing in males who are asymptom-
atic for low back pain. This study ex-
amined the effect of cervical flexion,
ankle dorsiflexion, and medial hip
Downloaded from www.jospt.org at on October 5, 2015. For personal use only. No other uses without permission.
rotation on subject terminal knee
extension ROM during slump testing.
This study further examined whether
a cumulative effect on terminal knee
extension ROM could be seen from
the simultaneous application of these
Copyright © 1997 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
neural tension-producing motions in
the cervical spine and lower extrem-
ity. We hypothesized that restrictions
in knee extension ROM would be
seen with cervical flexion, ankle dor-
siflexion, and medial hip rotation.
We further expected to find a p r e
gressive decrease in subject terminal
knee extension ROM with the addi-
Journal of Orthopaedic & Sports Physical Therapy®
tion of each of these sensitizing ma-
neuvers to the testing procedure.
METHODS
Subjects
We tested 34 males between the
ages of 22 and 45 years (mean =
29.6 years) with no history of low
back pain significant enough to have
caused them to seek medical atten-
tion within the past year. Participants
were required to exhibit a straight
leg raise of at least 70°,knee exten-
sion ROM to 0°,and at least 0" of
ankle dorsiflexion ROM with the
knee fully extended (Table 1) . All
pretesting measurements were taken
with the patient in a supine position
with the lower extremity in neutral
hip rotation.
Testing Procedures
All pretesting and measurement
70 to 94
0 to -14
of the six experimental conditions
5 to 18 occurred during a single testing ses-
sion. One measurement of knee ex-
tension ROM was taken for each of
the six experimental conditions. All
subject positioning was performed by
the first author (EJ) and all knee
measurements were performed by a
research assistant who was blinded to
the experimental hypotheses. S u b
jects were briefed on experimental
procedure and required to read and
sign a consent form which had been
accepted by the Columbia Presbyte-
rian Medical Center Institutional Re-
view Board.
Once oriented, subjects were di-
rected to gently reach toward their
toes in standing with knees extended
and maintain the position until cued
by the researcher. Fifteen seconds
were allowed to elapse before the
subject was instructed to slowly bring
himself to an erect posture. This pro-
cedure was repeated three times over
a 1-minute period to lengthen the
muscles in the posterior aspect of the
lower extremity in preparation for
testing. Bony landmarks were pal-
pated and marked at the hip, knee,
and ankle with washable ink. The
marks remained in place for the du-
ration of the testing period and were
used for subsequent measurements.
Each subject was then asked to lie
supine on a plinth while knee exten-
sion and ankle dorsiflexion ROM of
the right lower extremity were as-
sessed using the methodology de-
scribed by Palmer and Epler (35).
Straight leg raise elevation was mea-
TABLE 2. Cervical spine, ankle, and hip positions in tested conditions.
sured in supine by flexing the hip to
the limit of motion while maintaining
knee extension as described by Clark-
son and Gilewich (12). Thirty-four of
the 35 tested subjects met the inclu-
sion criteria.
Subjects were tested in the six
experimental conditions delineated
in Table 2. Note that the difference
between each slump position or con-
dition and its complement (a) is cer-
vical spine flexion or extension. For
example, the cervical spine was
flexed in condition 1 and extended
in condition la. To minimize the ef-
fect of condition order, subjects were
assigned to one of six possible testing
orders according to a predetermined
randomized list. When measuring
limitations in knee extension ROM of
the three lower extremity positions,
cervical spine flexion always preceded
cervical spine extension.
To place the subject in the slump
position, we modified the hand and
arm placements specified by Maitland
(31) and the sequence of movements
as described by Philip et a1 (37) as
follows.
Conditions 1 and l a
Subjects sat on a plinth with p o p
liteal creases flush against the edge of
the plinth and were instructed to
place their hands behind their back.
Subjects were then asked to let their
back slump through the full range of
thoracic and lumbar flexion while
keeping their gaze directly forward so
as to avoid cervical flexion. Overpres-
sure was applied directly downward
to the subject's upper thoracic spine
Volume 26 Number 6 December 1997 JOSPT

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Copyright © 1997 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
FIGURE. Condition 3: Cervical spine ilexion and ankle dorsiilexion with medial hip rotation
and shoulder area to maintain the
trunk in full flexion (full slump posi-
tion). Visual assessments ensured that
the hips were held in neutral rotation
and adduction and that the sacrum
was vertical. Each subject was then
asked to fully flex his head and neck,
Journal of Orthopaedic & Sports Physical Therapy®
approximating the chin to the ster-
num. The head and trunk position
was sustained via continued overpres-
sure. The subject was then asked to
extend the right knee as far as possi-
ble while maintaining his ankle in a
comfortable position. The research
assistant, using a universal goniome-
ter with 25 cm stationary and mov-
able arms, measured knee extension
TABLE 3. Means, standard deviations, and ranges ior limitations o i knee extension range o i motion ior all
cervical spine and lower extremity positions in degrees.
JOSPT Volume 26 0 Number 6 December 1997
ROM for condition 1. The subject's
head was releaqed while the re-
searcher kept the trunk in full flex-
ion. The subject was asked to direct
his gaze directly forward, thereby ex-
tending the cervical spine. Knee ex-
tension ROM was then recorded for
condition la.
Conditions 2 and 2a
In the full slump position with
head and neck flexion, the subject
was asked to fully dorsiflex his right
ankle. The researcher (EJ) main-
tained dorsiflexion as the subject ex-
RESEARCH STUDY
- . .
tended his right knee. Knee exten-
sion ROM was recorded for con-
dition 2. With overpressure supplied
by the researcher to maintain subject
trunk and ankle position, the head
was released and the subject was in-
structed to direct his gaze directly
forward, thereby extending the cervi-
cal spine. Knee extension ROM was
then measured for condition 2a.
Conditions 3 and 3a
The subject was positioned in the
full slump position with the head and
neck fully flexed and the ankle in
maximum dorsiflexion and asked to
medially rotate his right hip as much
as possible. The researcher main-
tained the subject's hip and ankle
position as the subject extended the
right knee (Figure). Knee extension
ROM was then measured for condi-
tion 3. With the subject in the same
position as condition 3, the subject's
head was released. To extend the
cervical spine, the subject directed
his gaze directly forward. Knee exten-
sion ROM was then measured for
condition 3a.
Data Analyses
The means and standard devia-
tions for the limitation of knee exten-
sion ROM were calculated for each
combination of lower extremity and
head position. A 3 X 2 analysis of
variance (ANOVA) was used to exam-
ine the main and interactive effects
of lower extremity position (neutral,
ankle dorsiflexion, and ankle dorsi-
flexion with medial hip rotation) and
head position (cervical spine flexion
and cervical spine extension) on limi-
tations of knee extension ROM. We
planned nine paired t test compari-
sons examining the individual effects
of cervical spine position and each of
the three lower extremity test posi-
tions on knee extension ROM. The
Bonferroni correction was used to set
the alpha level of significance at p <
0.0055 for each of the nine a @on'
comparisons conducted.
 Source SS
Model 12397.4502
Error 17038.0588
LE 9768.1 274
Head 2541.1 765
LE x Head
- 88.1471
LE = Lower eutrernitv position.
Head = Cervical spine position.
TABLE 4. The 3 x 2 analysis of variance results for the main and interactive effects of lower extremity
position (neutral, ankle dorsiflexion, and ankle dorsiflexion with medial hip rotation) and head position
(cervical spine flexion and cervical spine extension) on limitations of knee extension.
RESULTS
The means, standard deviations,
and ranges for limitations in knee
extension ROM for all cervical spine
and lower extremity positions are
Downloaded from www.jospt.org at on October 5, 2015. For personal use only. No other uses without permission.
presented in Table 3. For all three
lower extremity positions, there was a
greater limitation in knee extension
ROM when the cervical spine was
flexed compared to when the cervical
Copyright © 1997 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
spine was extended. For both the cer-
vical spine flexion and extension con-
ditions, increasing limitations in knee
extension ROM were evident as s u b
jects were progressed from the neu-
tral to the ankle dorsiflexion to the
ankle dorsiflexion with medial hip
rotation positions of the lower ex-
tremity.
The result5 of the 3 X 2 ANOVA
Journal of Orthopaedic & Sports Physical Therapy®
for limitations in knee extension
ROM reveal that the overall model
was statistically significant (F5,,,, =
28.82, p < 0.0001) and are presented
in Table 4. The ANOVA revealed sig-
nificant main effects for lower ex-
tremity position (neutral, ankle dorsi-
flexion, and ankle dorsiflexion with
medial hip rotation; I$,,, = 56.76,
p < 0.0001) and cervical spine posi-
tion (flexion vs. extension; F,.,,, =
29.53, p < 0.0001). There was no sig-
nificant interaction between lower
extremity position and cervical spine
position (F,,,,, = 0.51, p > 0.05).
The results of the nine planned
Bonferroni comparisons revealed that
there was a statistically significant dif-
ference for the limitations seen in
knee extension ROM between each
of the three tested lower extremity
positions (p < 0.0055) and between
df MS F P
5 2479.4909 28.81
198 86.050
2 4884.0637 56.76
1 2541.1 765 29.53
2 44.0735 0.51
cervical spine flexion and cervical
spine extension (p < 0.0055). Thus,
the differences found between each
of the three lower extremity positions
(neutral vs. ankle dorsiflexion, neu-
tral vs. ankle dorsiflexion with medial
hip rotation, and ankle dorsiflexion
vs. ankle dorsiflexion with medial hip
rotation) with the cervical spine
flexed were statistically significant.
These differences were also signifi-
cant with the cervical spine extended.
Likewise, the differences seen be-
tween cervical spine flexion and cer-
vical spine extension in each of the
tested lower extremity positions were
statistically significant.
DISCUSSION
We intended to identify re-
sponses to the slump test and the
component sensitizing movements of
cervical spine flexion, ankle dorsiflex-
ion, and medial hip rotation in males
without low back pain or injury. The
mean decrease in subject terminal
knee extension ROM of 6.0-8.9"
when cervical flexion was substituted
for cervical extension in our study
(Table 3) suggests that such limita-
tions in knee motion can be consid-
ered within normal limits for the
tested lower extremity positions. This
finding expands upon the results re-
ported by Maitland (29), who found
that limitations in knee extension
and ankle dorsiflexion ROM with the
cervical spine flexed were eliminated
by extending the cervical spine dur-
ing slump testing.
Although we found that signifi-
cant increases in terminal knee ex-
tension ROM occurred when the cer-
vical spine is moved from a flexed to
0.0001
an extended position, we did not
0.0001 find that full terminal knee extension
0.0001 ROM was restored (Table 3). We at-
0.6000
tribute this contrast primarily to dif-
ferences in methodology. While Mait-
land (29) superimposed available
ankle dorsiflexion ROM on an al-
ready extended knee and did not test
the effects of medial hip rotation, we
performed ankle dorsiflexion and
medial hip rotation prior to knee
extension in our study. We per-
formed the test in this manner so
that restrictions in motion could be
assessed uniformly at the knee. Fur-
ther, Maitland excluded 24 of 49 po-
tential subjects from his study for un-
specified back symptoms and
scoliosis, and his subjects were pre-
dominantly female and younger
(mean = 20 years) than the all-male
sample we tested. Lastly, we mea-
sured knee extension ROM gonio-
metrically, whereas Maitland visually
assessed ROM without instrumenta-
tion (19). The results of this study
indicate that limitations in terminal
knee extension ROM of 6.0-8.9"
should be considered a normal re-
sponse to the application of cervical
flexion during slump testing.
In addition, we found that apply-
ing the tested neural sensitizing ma-
neuvers of the lower extremity during
slump testing leads to decreased ter-
minal knee extension ROM with the
cervical spine flexed as well as ex-
tended. Subjects exhibited mean de-
creases of 7.0" (with cervical spine
flexion) and 7.3" (with cervical spine
extension) in terminal knee exten-
sion ROM when ankle dorsiflexion
was performed prior to knee exten-
sion. Additional mean decreases in
terminal knee extension ROM of
11.2" (with cervical spine flexion)
and 8.3" (with cervical spine exten-
sion) occurred when the hip was ro-
tated medially with the ankle main-
tained in dorsiflexion. These results
indicate that clinicians should con-
sider a limitation in knee extension
ROM of 7-1 1.2" as a normal re-
Volume 26 Number 6 December 1997 JOSPT

sponse to the application of ankle
dorsiflexion or medial rotation of the
hip with ankle dorsiflexion during
the slump test.
The progressive decreases in
mean subject knee extension ROM
found with the successive addition of
each of these sensitizing maneuvers
indicate the presence of a cumulative
effect. Examination of Table 3 reveals
that the simultaneous application of
ankle dorsiflexion and medial hip
rotation resulted in the greatest re-
strictions in knee extension ROM
during both cervical spine flexion
(X = 29.4") and cervical spine exten-
sion (X = 20.5").Further, the pre-
sumed position of greatest neural
Downloaded from www.jospt.org at on October 5, 2015. For personal use only. No other uses without permission.
tension (cervical flexion, ankle dorsi-
flexion, and medial hip rotation) re-
sulted in the greatest limitations of
terminal knee extension ROM (X =
29.4").
Copyright © 1997 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Breig's tissue-borrowing phenom-
enon offers a plausible explanation
of the above limitations in terminal
knee extension ROM found in our
study (1). He observed that tension
produced in a lumbosacral nerve
root results in displacement of the
neighboring dura, nerve roots, and
the lumbosacral plexus toward the
Journal of Orthopaedic & Sports Physical Therapy®
site of tension (1,4,5).In effect, a
borrowing of the resting slack in
neighboring meningeal tissues occurs
as neural structures are pulled toward
the site of increased tension. This
results in a decrease in the available
slack and potential mobility of the
neural tissues throughout the region
(1,2,4,5,38,42).Breig and others
demonstrated that cervical spine flex-
ion produces tension in the spinal
cord and dura which is transmitted
caudally, pulling the nerve roots of
the cauda equina cranially (1-5,38,
42). This stretching and cephalad
displacement of the lumbosacral
nerve roots and sacral plexus reduces
the available caudal mobility of the
sciatic nerve (1-5,21,42). As a result,
subsequent lower extremity motions
which exert a caudal pull on the lum-
bosacral trunk and nerve roots may
be restricted (1,9,19,25,29,33).
JOSIT Volume 26 Number 6 December 1997
Maitland (29) and Massey (33)
reasoned that observed limitations
found in knee extension ROM dur-
ing slump testing were caused by re-
strictions in the excursion of neural
tissues that occurred as a result of
cervical spine flexion. Mobility of the
lumbosacral nerve roots and sciatic
and tibial nerves relative to interfac-
ing tissues is a necessary component
of lower extremity ROM (1,6,42).
Smith's research on monkeys and a
human fetus revealed that knee ex-
tension in sitting results in a shift of
the sciatic nerve between the hip and
the knee and the tibial nerve be-
tween the ankle and the knee toward
the popliteal region (42). Butler re-
fers to the popliteal region as a neu-
ral tissue tension point, where mo-
tion between the tibial nerve and
interfacing tissues is restricted (6). It
appears that limitations in knee ex-
tension ROM may occur if increased
tension in neighboring neural tissues
impedes the movement of the sciatic
and tibial nerves toward the popliteal
region (6,13,42).This may explain
the mechanism by which flexing the
cervical spine limits terminal knee
extension ROM during slump testing
(9,19,25,29,33).
Medial hip rotation and ankle
dorsiflexion have been reported to
create a similar neural tissue-borrow-
ing effect in cadaver and roentgeno-
graph studies (5,42,43).Increased
tension occurring in neural tissues
between the dura of the spinal cord
and the tibial nerve in the popliteal
region is transmitted cranially and
caudally, increasing tension through-
out the neural tissues of the region
(5). Breig and Troup showed that
medial hip rotation performed on a
straight and elevated lower extremity
resulted in a 2-10 mm caudal dis-
placement of the sacral plexus (5).
Smith found that ankle dorsiflexion
performed prior to knee extension
resulted in a displacement of the t i b
ial nerve distally and, when combined
with hip flexion and knee extension
in a seated position, pulls the l u m b e
sacral trunk 4 mm caudally (42). A p
--- RESEARCH
- - - . . .
STUDY
.. .. ... - ... .
parently, the successive application of
sensitizing movements leads to a pro-
gressive uptake of the normal resting
slack in the spinal dura, lurnbosacral
nerve roots, and sciatic and tibial
nerves (5,42,44).It follows that apply-
ing ankle dorsiflexion and medial hip
rotation in our study increased the
resting tension along the sciatic and
tibial nerves.
We do, however, advise caution
in interpreting these results since the
exact mechanism by which increased
tension in neural tissues may have
reduced knee extensibility was not
investigated. The possibility exists
that other local structures were at
least in part responsible for limiting
knee extension ROM in this study.
The twejoint gastrocnemius and the
long head of the biceps femoris mus-
cles and their investing fascia as well
as skin tissue have been cited as pos-
sible sources of limitations in leg ele-
vation during the straight leg raise
test ( 1 7,41,45).The gastrocnemius,
semitendinosus, semirnembranosus,
and the long head of the biceps fem-
oris muscles are flexors of the knee
. ----- - --"-,--. - .--.-
.-* .-- .-- .
Caution is advised in
interpreting these
results since the exact
mechanism by which
increased tension in
neural tissues may
have reduced knee
extensibility was
not investigated.
which may have played a role in the
observed limitations in knee exten-
sion ROM during this study.
If the muscle attained a fully
lengthened state when the ankle was
dorsiflexed, stretching of the gastroc-
 RESEARCH STUDY
nemius muscle via the Achilles ten-
don insertion to the calcaneus could
conceivably have limited knee exten-
sibility. However, the gastrocnemius
muscle was unlikely to have fully
lengthened at the knee joint during
testing as the mean limitations in
knee extension ROM with the ankle
dorsiflexed were not less than 12.2"
(condition 2a) and were as much as
29.4" (condition 3). During knee ex-
tension, tension may have been pro-
duced in the long head of the biceps
femoris muscle with the hip medially
rotated and the medial hamstring
and long head of the biceps femoris
muscles with neutral rotation of the
hip. This could have contributed to
Downloaded from www.jospt.org at on October 5, 2015. For personal use only. No other uses without permission.
observed limitations in knee exten-
sion ROM. However, stretching of
the hamstring or gastrocnemius mus-
cles does not explain the mechanism
by which flexing the cervical spine
Copyright © 1997 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
resulted in decreased knee extension
ROM (Table 3) in each of the tested
positions of the lower extremity (9,
19,25,29).
Our findings for mean limita-
tions in terminal knee extension
ROM indicate that when interpreting
slump test responses clinicians need
to consider restrictions in terminal
Journal of Orthopaedic & Sports Physical Therapy®
knee extension ROM as normal re-
sponses to the addition of cervical
spine flexion, ankle dorsiflexion, and
medial hip rotation (Table 3). These
findings further indicate that the cli-
nician can anticipate increasing limi-
tations in knee extension ROM to
occur with the combined use of these
multiple sensitizing maneuvers in in-
dividuals without low back pain or
injury.
Limitations of this study include
the fact that subject trunk and lower
extremity positions during testing
were maintained by manual overpres-
sure and were susceptible to human
variability. Moreover, the mainte-
nance of subjects' ankles in a posi-
tion of comfort in the neutral lower
extremity position was uncontrolled
and therefore open to variability. In
addition, although we present a plau-
sible explanation of the limitations of
motion observed in our study based
on neural tissue mobility, we recog-
nize that we did not directly investi-
gate the mechanism responsible for
restrictions in subject knee extension
ROM. Further investigation is needed
to clarify the effect of subject discom-
fort as well as the role of the ham-
string and gastrocnemius muscles in
limitations of terminal knee exten-
sion ROM seen during slump testing.
Additional research is also needed to
determine the effect of applying sen-
sitizing maneuvers in different orders
of sequence during the slump test.
CONCLUSIONS
Cervical spine flexion, ankle dor-
siflexion, and medial hip rotation
have been shown to apply mechani-
cal tension to neural structures,
which is transmitted via the contin-
uum of neural tissues formed by the
spinal cord, spinal dura, lumbosacral
nerve roots, and sciatic and tibia1
nerves (1-5,38,42). As such, these
motions have been incorporated into
neural tension testing as neural sensi-
tizing maneuvers. As we hypothe-
sized, this study revealed that each of
these sensitizing movements limited
subject active knee extension ROM
during slump testing. These results
further indicate that an increase in
terminal knee extension ROM can be
expected when cervical extension is
substituted for cervical flexion during
the slump test in young, healthy,
adult males. Findings from this study
also provide evidence that the simul-
taneous application of these sensitiz-
ing movements during the slump test
results in the greatest restrictions in
terminal knee extension ROM in
young, healthy, adult males. We ex-
pected to find a progressive decrease
in subject terminal knee extension
ROM with the addition of each of
the tested sensitizing maneuvers to
the testing procedure. The results of
this study support this contention,
indicating that progressive decreases
in terminal knee extension ROM may
be considered a normal response to
the successive addition of cervical
spine flexion, ankle dorsiflexion, and
medial hip rotation to the slump po-
sition in adult males without low back
pain or injury. JOSFT
ACKNOWLEDGMENTS
We wish to express our gratitude
to Laurel Daniels, MS, PT,for her
research assistance, the library and
alumni of the School of Physiother-
apy, South Australia University, Ad-
elaide, South Australia, for their kind
permission giving us access to their
research, and Wendy Haberman-
Johnson, PT,for her invaluable assis-
tance and support.
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