The Mennell Sign Test, also called the Three Phase Hyperextension Test, is used to assess symptom response during staged extension loading of the lumbar spine, sacroiliac joint and hip region. A positive test is usually reproduction of the client’s familiar pain during one phase of the test. The location and phase of symptom reproduction may help guide further assessment, but the test does not diagnose lumbar, sacroiliac or hip pathology on its own.

Introduction

The Mennell Sign Test is commonly described as a prone orthopaedic test that applies staged extension stress to help differentiate whether symptoms appear more lumbar, sacroiliac or hip-related.

It is often associated with:

• low back pain
• sacroiliac joint region pain
• buttock pain
• anterior hip or groin symptoms
• pain during hip extension
• unclear lumbar, SIJ or hip symptom sources

The test is sometimes presented as three phases:

• lumbar spine extension loading
• sacroiliac joint stress
• hip joint extension stress

This can be useful educationally, but it must be interpreted cautiously. Pain location and symptom reproduction can support assessment reasoning, yet they do not confirm the exact tissue or condition.

Current clinical education sources describe the Mennell or Three Phase Hyperextension Test as a quick prone test used to assess lumbar, sacroiliac and hip response, but high-quality diagnostic accuracy evidence for the exact test is limited.  

Quick Summary

• Test name: Mennell Sign Test
• Also known as: Mennell’s Test, Three Phase Hyperextension Test
• Body region: Lumbar spine, sacroiliac joint and hip
• Client position: Prone
• Main movement: Passive hip extension with staged stabilisation
• Positive finding: Reproduction of familiar pain during a specific phase
• Negative finding: No familiar pain or meaningful symptom reproduction
• Main limitation: Limited direct diagnostic accuracy evidence for the exact test

What Is the Mennell Sign Test?

The Mennell Sign Test is a prone orthopaedic test where the professional extends the client’s hip while using different stabilisation positions to bias different regions.

The aim is to observe whether passive extension reproduces familiar symptoms in:

• lumbar spine region
• sacroiliac joint region
• buttock region
• anterior hip or groin region
• posterior thigh region

The test should be treated as a symptom provocation and localisation test, not a diagnostic confirmation test.

Why It Is Used

The test may help professionals:

• explore whether hip extension reproduces familiar symptoms
• compare lumbar, SIJ and hip-region responses
• identify which region may need further assessment
• guide test selection, such as SIJ provocation cluster or hip ROM tests
• record symptom behaviour clearly
• educate clients about movement-related symptom response

It is most useful when combined with history, movement testing, neurological screening where relevant, hip ROM and other sacroiliac or lumbar tests.

What It Assesses

The Mennell Sign Test assesses:

• symptom response to passive hip extension
• pain location during different stabilisation phases
• lumbar, SIJ or hip-region sensitivity to extension loading
• side-to-side symptom difference
• movement tolerance
• guarding or apprehension

It does not directly assess:

• sacroiliac joint structure
• disc pathology
• nerve root compression
• hip labral integrity
• femoroacetabular impingement
• inflammatory sacroiliitis
• tissue healing
• sport or work readiness

Who It Is Useful For

This test may be useful for professionals assessing clients with:

• low back pain
• buttock pain
• SIJ-region pain
• groin or anterior hip symptoms
• pain with walking stride, running or hip extension
• unclear lumbar/hip/SIJ symptom presentation

It is suitable only when the client can safely lie prone and tolerate gentle hip extension.

When to Use This Test

Consider the Mennell Sign Test when:

• symptoms are reproduced with hip extension
• pain location may involve lumbar, SIJ or hip regions
• a client reports pain with stride, running, bridging or prone extension
• you need a structured way to compare left and right sides
• you want to decide whether further lumbar, SIJ or hip testing is appropriate

When Not to Use or When to Be Cautious

Use caution or avoid the test when there is:

• recent trauma
• suspected fracture
• recent hip, pelvis or lumbar surgery
• severe or worsening neurological symptoms
• high-irritability back, hip or groin pain
• inability to lie prone
• hip extension restriction that causes sharp pain
• suspected inflammatory or systemic condition requiring medical review
• pregnancy or postpartum pelvic pain where prone positioning is uncomfortable
• client fear, guarding or distress

Stop if symptoms escalate, become sharp, spread distally, or do not settle when the limb is returned to neutral.

Equipment Required

Usually no equipment is required.

Helpful options:

• plinth or firm treatment table
• pillow if prone positioning needs modification
• pain rating scale
• body chart
• Measurz assessment record

Step-by-Step Protocol / Practice

Setup

Explain the test:

“We are going to gently lift your leg while you lie face down and monitor where you feel symptoms. This test does not diagnose a condition by itself. Tell me if the pain is familiar, where you feel it and how strong it is.”

Record baseline:

• pain score
• symptom location
• side tested
• familiar symptoms
• prone comfort
• hip extension tolerance

Client Position

• Client lies prone.
• Head and trunk relaxed.
• Legs straight unless modified.
• Pelvis level.
• Shoes removed if they affect positioning.

Examiner / Professional Position

• Stand beside the tested leg.
• Support the distal thigh or lower leg.
• Use the other hand to stabilise the pelvis or lumbar region depending on the phase.
• Move slowly and monitor symptoms continuously.

Hand Placement and Phases

Phase 1: Lumbar Extension Bias

• Stabilise the pelvis lightly.
• Lift the thigh into gentle hip extension.
• Observe whether symptoms appear in the lumbar region.

Phase 2: Sacroiliac Region Bias

• Stabilise the sacrum or pelvis more firmly.
• Extend the hip again.
• Monitor for familiar SIJ-region or buttock pain.

Phase 3: Hip Region Bias

• Stabilise the pelvis to reduce lumbar and pelvic movement.
• Extend the hip while observing anterior hip, groin or thigh symptoms.
• Compare with hip extension ROM and other hip tests if needed.

Different teaching sources describe these phases slightly differently, so record the exact version used. Current clinical education descriptions commonly frame the test as a staged prone hyperextension test for lumbar, SIJ and hip-region symptom response.  

Movement or Force Direction

• Passive hip extension.
• Slow and controlled.
• Do not force end range.
• Compare left and right sides.

Instructions

Ask:

• “Where do you feel that?”
• “Is that your familiar pain?”
• “Does it feel like back, buttock, groin, hip or leg pain?”
• “Rate it from 0 to 10.”
• “Does it spread, sharpen or ease?”

Positive Finding

A positive finding is reproduction of the client’s familiar symptoms during one phase of the test.

Examples:

• lumbar pain during lumbar-biased phase
• SIJ-region or buttock pain during pelvic/sacral stabilisation
• anterior hip or groin pain during hip-biased extension
• clear side-to-side difference in familiar symptoms

Negative Finding

A negative finding means:

• no familiar pain is reproduced
• symptoms are not meaningfully changed
• hip extension feels similar on both sides
• only non-familiar stretch or pressure is reported

Stopping Criteria

Stop if:

• pain becomes sharp or escalating
• neurological symptoms increase
• symptoms spread further down the leg
• the client cannot relax or tolerate prone
• hip extension feels unsafe
• the client asks to stop

Positive and Negative Test Interpretation

Positive Test

A positive Mennell Sign Test may increase suspicion that the tested movement or region is relevant to the client’s symptoms.

Depending on the phase and symptom location, it may suggest the need to further assess:

• lumbar extension sensitivity
• sacroiliac joint pain provocation
• hip extension restriction
• anterior hip or groin symptoms
• posterior pelvic pain
• lower-limb neural symptoms if symptoms travel distally

A positive test does not confirm a lumbar, SIJ or hip diagnosis. Pain can be influenced by joint sensitivity, muscle guarding, hip flexor stiffness, lumbar extension sensitivity, neural sensitivity or general irritability.

Negative Test

A negative test may reduce suspicion that prone hip extension loading is a major symptom driver at that time.

However, a negative test does not exclude:

• sacroiliac joint pain
• hip pathology
• lumbar-related pain
• nerve involvement
• movement sensitivity in other positions

Further assessment may still be needed if the history, symptoms or function remain suggestive.

Sensitivity, Specificity and Diagnostic Accuracy

At the time of writing, high-quality peer-reviewed diagnostic accuracy evidence reporting sensitivity, specificity or likelihood ratios for the Mennell Sign Test itself appears limited.

This means the test should be interpreted as a clinical reasoning tool rather than a stand-alone diagnostic test.

For sacroiliac joint pain more broadly, the strongest evidence supports clusters of SIJ pain provocation tests, not isolated tests like Mennell’s. A 2021 systematic review with meta-analysis assessed clusters of SIJ pain provocation tests and found that clustered tests may be more useful than a single test, but accuracy still varies by population, study design and reference standard.  

A commonly cited SIJ provocation-test study reported that three or more positive SIJ provocation tests had sensitivity of 94% and specificity of 78% against diagnostic injection in that study context, but this does not apply directly to the Mennell Sign Test unless the same test cluster and reference standard are used.  

Plain-language interpretation:

• A positive Mennell Sign may guide further assessment, but it does not confirm the pain source.
• A negative Mennell Sign may be reassuring, but it does not exclude lumbar, SIJ or hip involvement.
• Likelihood ratios for this exact test are not well established.
• SIJ interpretation is stronger when multiple pain provocation tests reproduce the client’s familiar pain.

Reliability and Validity

Direct reliability and validity evidence for the Mennell Sign Test appears limited.

For SIJ testing more broadly, research suggests that pain provocation clusters have better support than motion palpation or isolated manual tests. A study comparing motion palpation and pain provocation tests with SIJ block as a reference standard found that diagnostic performance depends strongly on test type and reference standard.  

A systematic review on palpatory SIJ mobility tests found limited support for many palpatory tests and reported better intra-examiner agreement for some sitting flexion-type tests, but this evidence should not be transferred directly to Mennell’s Sign.  

Reliability improves when the professional records:

• exact phase used
• side tested
• stabilisation method
• symptom location
• familiar versus unfamiliar pain
• pain score
• movement range
• client guarding
• stopping reason
• comparison side

Common Errors and Limitations

Common errors include:

• calling the test diagnostic
• forcing hip extension
• not recording which phase reproduced symptoms
• not asking whether the pain is familiar
• confusing hip flexor stretch with a positive test
• ignoring lumbar extension compensation
• not comparing both sides
• interpreting SIJ pain from one test alone
• failing to record symptom location clearly

Limitations:

• limited direct diagnostic accuracy evidence
• different protocol variations exist
• pain location can be non-specific
• prone position may not suit all clients
• hip extension restriction may alter the test
• guarding can change results
• positive findings need follow-up testing
• negative findings do not exclude pathology

Practical Applications

The Mennell Sign Test can help professionals:

• document symptom response to hip extension
• compare lumbar, SIJ and hip-region symptom behaviour
• decide whether to assess SIJ provocation cluster tests
• decide whether hip ROM or hip special tests are needed
• monitor symptom irritability over time
• educate clients using safe language
• support referral decisions when symptoms are concerning

It is most useful when combined with:

• lumbar flexion and extension ROM
• hip extension ROM
• hip quadrant or FADIR/FAIR tests if relevant
• SIJ compression, distraction, thigh thrust and sacral thrust tests
• Slump Test or Straight Leg Raise if leg symptoms are present
• pain history and functional task review

How to Record This in Measurz

Record:

• Test name: Mennell Sign Test
• Side tested: left, right or both
• Result: positive, negative, unclear or unable to test
• Phase: lumbar-biased, SIJ-biased or hip-biased
• Pain score: before, during and after
• Symptom location: lumbar, SIJ region, buttock, groin, anterior hip, thigh or leg
• Symptom quality: sharp, ache, stretch, pressure, numbness, tingling
• Familiar pain: yes, no or unsure
• Movement direction: passive hip extension
• Position used: prone, modified prone or unable
• Comparison side: same response, different response or not tested
• Confidence in result: high, moderate or low
• Irritability: low, moderate or high
• Compensations: pelvis lift, lumbar extension, rotation, guarding
• Reason for stopping: pain, guarding, symptoms, client request or no issue
• Related findings: SIJ cluster tests, hip ROM, lumbar ROM, Slump, SLR, gait
• Interpretation note: “Finding supports assessment reasoning but does not diagnose a condition.”
• Retest date: if monitoring over time

Recording these details improves repeatability, communication, client education, assessment reasoning, monitoring over time, team consistency and reporting quality.

Related Tests / Internal Links

• Sacral Thrust Test
• Sacroiliac Compression Test
• Sacroiliac Distraction Test
• Seated Flexion Test
• Standing Flexion Test
• Slump Test
• Straight Leg Raise Test
• Yeoman Test

FAQs

What does the Mennell Sign Test assess?

It assesses symptom response during passive hip extension in prone, with staged stabilisation intended to bias lumbar, sacroiliac or hip-region loading.

What is a positive Mennell Sign Test?

A positive test is reproduction of the client’s familiar pain during one phase of the test. The phase and symptom location help guide further assessment.

Does a positive Mennell Sign diagnose sacroiliac joint pain?

No. It may increase suspicion when symptoms match the history and other findings, but it does not confirm SIJ pain on its own.

Why are there three phases?

The phases are used to observe whether symptoms appear more lumbar, SIJ-region or hip-region related during controlled hip extension loading.

What does a negative test mean?

A negative test means familiar symptoms were not reproduced. It may reduce suspicion for symptoms related to this movement, but it does not exclude lumbar, SIJ or hip involvement.

Should I use this test alone?

No. It is best used with history, lumbar and hip ROM, SIJ provocation tests and neurological screening where relevant.

Can this test clear someone for sport or work?

No. It can support assessment reasoning, but readiness decisions need symptoms, strength, function, workload, confidence and professional judgement.

Key Takeaways

• The Mennell Sign Test is a prone staged hip extension test.
• It is used to observe lumbar, SIJ and hip-region symptom response.
• A positive test reproduces familiar symptoms during one phase.
• A negative test does not exclude lumbar, SIJ or hip involvement.
• Direct diagnostic accuracy evidence for this exact test is limited.
• SIJ interpretation is stronger when using validated provocation clusters.
• Record side, phase, pain score, symptom location and familiar pain.
• Use the result as part of a broader assessment, not as a diagnosis.

References

Cattley, P., Winyard, J., Trevaskis, J., & Eaton, S. (2002). Validity and reliability of clinical tests for the sacroiliac joint: A review of the literature. Australasian Chiropractic & Osteopathy, 10(2), 73–80. https://pmc.ncbi.nlm.nih.gov/articles/PMC2051081/

Dreyfuss, P., Michaelsen, M., Pauza, K., McLarty, J., & Bogduk, N. (2009). Validity of physical exam maneuvers in the diagnosis of sacroiliac joint pain. Pain Medicine, 10(2), 255–262. https://doi.org/10.1111/j.1526-4637.2008.00531.x

Nejati, P., Safarcherati, A., & Karimi, F. (2020). Accuracy of the diagnostic tests of sacroiliac joint dysfunction. Journal of Chiropractic Medicine, 19(1), 28–37. https://doi.org/10.1016/j.jcm.2019.12.002

Saueressig, T., Owen, P. J., Diemer, F., Zebisch, J., & Belavy, D. L. (2021). Diagnostic accuracy of clusters of pain provocation tests for detecting sacroiliac joint pain: Systematic review with meta-analysis. Journal of Orthopaedic & Sports Physical Therapy, 51(9), 422–431. https://doi.org/10.2519/jospt.2021.10469

Szadek, K. M., van der Wurff, P., van Tulder, M. W., Zuurmond, W. W. A., & Perez, R. S. G. M. (2009). Diagnostic validity of criteria for sacroiliac joint pain: A systematic review. The Journal of Pain, 10(4), 354–368. https://doi.org/10.1016/j.jpain.2008.09.014