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Bowstring Test
Contents
Test protocol
Context
The Bowstring Test is commonly used in the diagnosis of sciatic pain (sciatica).
The diagnosis of sciatica primarily relies on pain reproduction during lumbar nerve root tensioning. Neurological examination and medical history are generally insufficient to confirm the diagnosis with certainty.
The Lasègue Test, or Straight-Leg Raise (SLR) Test, is the most widely used, involving passive straight leg elevation. However, it is not flawless and is sometimes misperformed or misinterpreted.
Passive dorsiflexion of the ankle at the end of the test, also known as the Bragard sign, can increase sensitivity, but it may remain asymptomatic in certain cases of sciatica. This can lead to diagnostic errors (Berthelot et al., 2021).
Regarding the Bowstring Test, in 1946, during a sciatic nerve suture surgery, it was observed that pressure applied to the posterior tibial nerve at the point where it passes through the popliteal fossa increased tension on the suture line. It was suggested that this observation could serve as the basis for a useful clinical test in evaluating patients with sciatic nerve involvement (Cram, 1953).
Video of the Test
Execution
To perform the test, the patient lies on their back. The therapist begins by lifting the straight leg until the point of pain is reached. The therapist then slightly flexes the knee by approximately 20° to reduce the pain, followed by applying pressure to the popliteal fossa to tension the posterior tibial nerve. The test is positive if it reproduces the patient’s symptoms.
Clinical Value
In their 1994 study, Supik and Broom demonstrated that the bowstring test was positive in 69% of cases where the patient had a lumbar disc herniation causing sciatica (Supik and Broom, 1994).
In the literature, experts suggest that the effectiveness of physical examination for sciatica improves when multiple clinical tests are combined (Van der Windt et al., 2010; Pojskic et al., 2024).
In 2021, Berthelot et al. recommended using a cluster of tests, including the SLR Test, the SLUMP Test, and the Bowstring Test, to increase the relevance of clinical examination (Berthelot et al., 2021).
Bibliography
Berthelot, J.-M., Darrieutort-Laffite, C., Arnolfo, P., Glémarec, J., Goff, B. L., & Maugars, Y. (2021). Inadequacies of the Lasègue test, and how the Slump and Bowstring tests are useful for the diagnosis of sciatica. Joint Bone Spine.
Cram, R. H. (1953). A SIGN OF SCIATIC NERVE ROOT PRESSURE. The Journal of Bone and Joint Surgery. British Volume, 35-B(2), 192–195.
Pojskic, M., Bisson, E., Oertel, J., Takami, T., Zygourakis, C., & Costa, F. (2024). Lumbar disc herniation : Epidemiology, clinical and radiologic diagnosis WFNS spine committee recommendations. World Neurosurgery: X, 22, 100279.
Supik, L. F., & Broom, M. J. (1994). Sciatic Tension Signs and Lumbar Disc Herniation. Spine, 19(9), 1066–1069.
Van der Windt, D. A., Simons, E., Riphagen, I. I., Ammendolia, C., Verhagen, A. P., Laslett, M., … Aertgeerts, B. (2010). Physical examination for lumbar radiculopathy due to disc herniation in patients with low-back pain. Cochrane Database of Systematic Reviews.
