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Femoroacetabular impingement (FAI) and labral pathology have been recognized as causative factors for hip pain. The clinical diagnosis is now based on MRI-A (magnetic resonance imaging-arthrogram) because the physical diagnostic tests available are diverse and information on diagnostic accuracy and validity is lacking. The purpose of this systematic review was to identify the diagnostic accuracy and validity of physical tests that are used to assess FAI and labral pathology of the hip joint.
Methods
We performed a computerized literature search using PubMed, Medline, Web of Science, PEDro, the Cochrane Library, and CINAHL (Cumulative Index to Nursing and Allied Health Literature) (through EBSCO). Studies describing tests and diagnostic accuracy studies were included. All included studies were assessed by the Levels of Evidence for Primary Research Questions list. All diagnostic accuracy studies were assessed by the QUADAS (Quality Assessment of Diagnostic Accuracy Studies) score.
Results
We included 21 studies in which 18 different tests were described. For 11 of these tests, diagnostic accuracy figures were presented. Sensitivity was examined for all tests. Other diagnostic accuracy figures were often lacking, and when available, these were low. All articles describing tests had Level IV or V evidence. All diagnostic accuracy studies, except 1, had Level II or III evidence. Three articles had a good QUADAS score.
Conclusions
In previous studies a wide range of physical diagnostic tests have been described. Little is known about the diagnostic accuracy and validity of these tests, and if available, these figures were low. The quality of the studies investigating these tests is too low to provide a conclusive recommendation for the clinician. Thus, currently, no physical tests are available that can reliably confirm or discard the diagnoses of FAI and/or labral pathology of the hip in clinical practice.
Level of Evidence
Level III, systematic review of Level III studies.
Femoroacetabular impingement (FAI) and acetabular labral pathology have been recognized as common causes of hip pain and dysfunction.
Through the development of hip arthroscopy, FAI and labral pathology can now be better treated with fewer complications and a faster rehabilitation rate.
Patients often see multiple health care providers before the definitive diagnosis is obtained and sometimes even undergo unnecessary surgery. As Martin et al.
described, an important part of recognizing intra-articular hip pain is the patient's history and physical examination. Furthermore, it is necessary for the clinician to recognize the need for additional investigations such as MRI-A (magnetic resonance imaging-arthrogram).
Several studies on the clinical presentation of FAI and labral pathology have been conducted, and most of these focused on the patient's history and symptoms.
Frequently, these tests have different names but are similar or have the same name but are conducted in different manners. There is also a lack of information regarding the diagnostic accuracy of these tests, such as sensitivity, specificity, likelihood ratios, and predictive values.
Therefore the purpose of this study was to identify the diagnostic accuracy and validity of physical tests that are used to assess FAI and labral pathology of the hip joint.
Methods
The objective of this study was to identify (1) which physical diagnostic tests are used to assess intra-articular hip pathology, especially FAI and labral pathology; (2) the diagnostic accuracy and validity of these tests; and (3) the quality of the diagnostic accuracy studies describing these tests.
Search Strategy
We performed a computerized literature search (Table 1) using PubMed, Medline, Web of Science, PEDro, the Cochrane Library, and CINAHL (Cumulative Index to Nursing and Allied Health Literature) (through EBSCO). All relevant articles published between January 1980 and April 1, 2011, were identified. The search was conducted by 2 reviewers (M.T. and L.W.). The following terms or a combination of terms was used: hip, groin, exam, test, asses, diagnos, arthromet, acetabul, labr, intra-articular, impingement, femoro-acetabular impingement, disorder, patholog, pain, injur, lesion, tear, reliab, valid, and accur. Terms were searched as key words or “free-text” terms in all databases. The reference lists of the retrieved articles were checked for additional references.
Table 1Overview of Search Strategy for Systematic Review
Search Terms
PubMed
PEDro
Cochrane Library
Web of Science
CINAHL
Medline
Total
1.
hip*
95,518
79,943
2.
groin*
7,870
6,913
3.
1 or 2
102,886
6
9,611
83.157
20,767
86,577
4.
exam*
1,914,696
56,531
5.
test*
1,347,475
57,687
6.
diagnos*
2,414,400
75,408
7.
asses*
1,529,078
62,512
8.
arthromet*
494
491
9.
4 or 5 or 6 or 7 or 8
5,750,915
0
277,825
96.867
735,185
99,994
10.
acetabul*
12,852
10,934
11.
labr*
11,406
5,093
12.
intra-articular
10,539
8,621
13.
impingement
4,433
4,263
14.
femoro-acetabular impingement
337
40
15.
10 or 11 or 12 or 13 or 14
37,514
0
1,906
23,340
3,553
27,269
16.
disorder*
1,199,468
80,938
17.
patholog*
2,301,141
85,804
18.
injur*
398,152
80,785
19.
pain*
416,900
85,619
20.
lesion*
541,230
82,515
21.
tear*
28,722
25,112
22.
16 or 17 or 18 or 19 or 20 or 21
4,147,258
0
148,578
96.162
394,507
99,489
23.
reliab*
242,893
73,281
24.
valid*
305,724
67,588
25.
accur*
367,036
62,386
26.
23 or 24 or 25
800,664
0
40,082
97.647
111,485
100,000
27.
3 and 9 and 15 and 22 and 26
306
0
46
13
65
15
27 and limits
169
0
46
12
65
15
307
NOTE. Search terms and combinations of search terms are presented in the left column. “Limits” used in the last search term were based on inclusion and exclusion criteria of the study. The number of results per database is presented in the other columns.
The 2 reviewers (M.T. and L.W.) independently screened all publications by title and abstract for possible inclusion in the study. All identified publications were then retrieved in full and independently assessed by the 2 reviewers for inclusion in the study. Inclusion and exclusion criteria are presented in Table 2. Disagreements between reviewers were resolved by consensus. If consensus was not reached, the final decision was made by a third reviewer (R.v.C.). The reviewers were not blinded to the authors, journal of publication, or date of publication.
Table 2Inclusion and Exclusion Criteria Used for Systematic Review
Inclusion Criteria
Exclusion Criteria
Article published in English, German, or Dutch and available as full-text article
Asymptomatic study population
All study designs
Intra-articular hip pathology other than FAI and/or labral pathology
Study population aged between 10 and 80 yr
Studies reporting no separate findings for population with FAI and/or labral pathology v none or other pathology
Study with (among others) goal to specifically investigate which clinical diagnostic tests are available for diagnosis of FAI and/or labral pathology
Studies with research solely into agreement and inter-rater and intrarater reliability
Study with (among others) goal to specifically investigate diagnostic accuracy or validity of clinical diagnostic tests for diagnosis of FAI and/or labral pathology
Diagnostic accuracy study using no new data but using data extracted from other research (e.g., systematic reviews)
This list was developed to define and compare the levels of evidence of studies with different study designs to recommend a clinical advice. It contains 5 levels, Level I being the best and Level V being the worst level of evidence. Each study is scored based on research question, content, and design.
Quality Assessment of Diagnostic Accuracy Studies
The QUADAS (Quality Assessment of Diagnostic Accuracy Studies) tool was used for the quality assessment of the diagnostic accuracy studies.
If half of the items or fewer scored yes, a study was graded “poor.” Studies that scored yes for three-fourths of items or more were graded “good.” All studies in between were graded “moderate.” Before the start of the review process, a pilot study was performed in which the QUADAS tool was used to score 5 articles, achieving an overall agreement of 91% between the 2 reviewers (M.T. and L.W.).
The 2 reviewers (M.T. and L.W.) independently assessed all included articles with the relevant quality-assessment tools. For all quality assessments, any disagreements between reviewers were resolved by consensus. If consensus was not reached, a decision was made by a third reviewer (R.v.C.).
Results
The search identified a total of 307 studies. Based on the title and abstract, 245 studies were excluded. There were 16 doubles, and 25 studies were excluded based on full-text assessment, which left a total of 21 studies to be included (Fig 1) . Of these studies, 7 described tests for diagnosing FAI and/or labral pathology and 14 focused on diagnostic accuracy. There were minor disagreements between reviewers regarding inclusion of studies, but consensus was reached in all cases.
Figure 1Overview of selection procedure for inclusion of studies in systematic review. The number of studies excluded per criteria is presented in the right column. The total search led to 307 studies, of which 21 were included.
In the 21 included studies, a total of 18 different physical tests were described (Table 3). Ten tests appeared under multiple names or test executions.
Table 3Clinical Diagnostic Tests With Test Executions and Corresponding Diagnoses
Test
Test Execution
Diagnoses
Flexion–adduction–internal rotation tests
Anterior hip impingement test
Patient lies supine while the examiner moves the affected leg into 90° of flexion, adduction, and internal rotation until end range is achieved. Pain in any location marks a positive result.
Patient lies supine while the researcher brings the involved leg into flexion/internal rotation. Pain predominating in flexion/internal rotation, pain exclusively in flexion/internal rotation, and reduced pain-free flexion amplitude under internal rotation all are positive results.
Descriptive epidemiology of mechanical hip pathology in adults under 50 years of age Prospective series of 292 cases: Clinical and radiological aspects and physiopathological review.
Internal rotation–flexion–axial compression maneuver/internal rotation over pressure test (IROP)
Patient lies supine while the researcher brings the affected leg into internal rotation and flexion, followed by axial compression through the knee. Pain is a positive result.
Patient lies supine while the researcher brings the affected leg into 90° of flexion and slight adduction. Then, axial compression on the joint is performed. Pain is a positive result.
The patient lies in the lateral recumbent position. The examiner stands behind the patient. The leg is positioned into the FADDIR position. Reproduction of the patient's pain is a positive result for FAI. Freehill and Safran
described the same test but using in a supine position. The point where the combination of flexion/adduction and internal rotation causes pain should be noted.
The patient lies supine. The affected leg is simultaneously flexed, abducted, and externally rotated so that the patient's lateral ankle rests on the contralateral leg just proximal to the knee. While the SIAS is being stabilized, the knee is lowered toward the table. A positive test result may be indicated by either a decrease in ROM compared with the nonaffected leg or reproduction of pain.
Hip joint pathology: Clinical presentation and correlation between magnetic resonance arthrography, ultrasound and arthroscopic findings in 25 consecutive cases.
The hip is brought into acute flexion, external rotation, and full abduction and is then extended with internal rotation and adduction. The patient lies supine. Extension with abduction and external rotation from the fully flexed, adducted, and internally rotated position completes the test. Pain or a click is a positive result.
Dynamic external rotatory impingement test (DEXRIT)/supine abduction–external rotation test
The patient is in the supine position and is instructed to hold the contralateral leg in flexion beyond 90°. The examined hip is brought into 90° of flexion or beyond and is passively taken through a wide arc of abduction and external rotation. A positive test will re-create the patient's pain.
Dynamic internal rotatory impingement test (DIRIT/DIRI)
The patient is in the supine position and is instructed to hold the contralateral leg in flexion beyond 90°. The examined hip is brought into 90° of flexion or beyond and is passively taken through a wide arc of adduction and internal rotation. A positive test will re-create the patient's pain.
The patient lies supine while the examiner brings the affected leg into flexion and adduction. The leg is then rotated. A positive test will re-create the patient's pain or shows a restriction in ROM. Maslowski et al.
Hip joint pathology: Clinical presentation and correlation between magnetic resonance arthrography, ultrasound and arthroscopic findings in 25 consecutive cases.
The patient lies supine while the examiner rolls the affected hip in a wide arc of internal and external rotation from flexion to extension. A positive sign re-creates the patient's pain in a specific position. Plante et al.
described the same test but with internal rotation and adduction combined and with external rotation and abduction combined. This test is also described by Martin et al.
The patient lies in the lateral position while the examiner brings the affected leg from flexion to extension in continuous abduction while externally rotating the hip. A reproduction of the patient's pain is a positive result.
Patient lies supine with the legs pulled to the chest. The affected leg is lowered off the edge of the table (from flexion to extension). A click (as perceived by patient/researcher) or recognizable pain marks a positive result.
The patient lies in the end position of the Thomas test (1 leg bent and 1 leg free of the table). The examiner externally rotates the leg in neutral abduction-adduction and in adduction. Pain reproduction is a positive result.
The patient lies supine and is asked to raise the straight leg to 45° of hip flexion. The patient is asked to resist manual force applied just proximal to the knee by the researcher. Recognizable pain or weakness is a positive result. Troelsen et al.
The patient lies supine while the examiner places both hands on the upper leg. The involved leg is then rolled inward and outward. Pain or a restriction during this maneuver is a positive result.
Posterior hip impingement test/posterior rim impingement
The patient lies at the edge of the examining table and the legs hang freely at the hip. Both legs are drawn up to the chest and then the affected leg is lowered off the table, fully abducted, and externally rotated. Pain is a positive result.
The patient lies in the supine position with the affected leg 30° abducted. Axial traction is placed on the leg. A relief of pain or pain reduction is a positive result.
NOTE. Tests are divided into categories based on similarities in execution. Tests with several names but the same execution are presented in 1 row, and the names are divided by virgules.
Abbreviations: ROM, range of motion; SIAS, spina iliaca anterior inferior.
Twenty studies described a combined flexion, adduction, and internal rotation maneuver of the hip. The anterior hip impingement test, in which the leg was specifically moved into 90° of flexion, adduction, and internal rotation simultaneously, was described most.
The FABER (flexion-abduction-exorotation) test, also called the Patrick sign, was described in 12 studies. This test is a combination of flexion, abduction, and external rotation of the hip. Because this test was originally designed to diagnose sacroiliac pathology, authors have stated that it is important to distinguish between pain posterior or anterior to the hip.
Flexion-extension maneuvers were described in 9 studies. These maneuvers often had several different names and executions. Common factors were the movement from flexion to extension with several rotations and abductions/adductions. These tests can be compared with the McMurray tests of the knee.
The resisted straight-leg raise (RSLR) test was described in 8 studies. This test consisted of hip flexion against resistance of the examiner with the fully extended leg in 30° or 45° of hip flexion while the patient lay supine.
Several other tests were sporadically described. Most of these tests were derived from existing hip maneuvers, such as the Thomas test.
Diagnostic Accuracy of Clinical Tests
A total of 14 studies examined 11 physical tests (Table 4). For the anterior hip impingement test, the impingement sign, the flexion–adduction–axial compression test, the FABER test, the Fitzgerald test, and the hip quadrant position, a high sensitivity was reported (0.9 to 1.0). For the other tests, the sensitivity was low to moderate.
Table 4Clinical Diagnostic Tests for FAI and/or Labral Pathology With Diagnostic Accuracy and Validity
Author (Year of Publication)
Study Population
Diagnoses Made by Authors
Reference Standard Used to Confirm or Discard Diagnosis
Descriptive epidemiology of mechanical hip pathology in adults under 50 years of age Prospective series of 292 cases: Clinical and radiological aspects and physiopathological review.
Hip joint pathology: Clinical presentation and correlation between magnetic resonance arthrography, ultrasound and arthroscopic findings in 25 consecutive cases.
Hip joint pathology: Clinical presentation and correlation between magnetic resonance arthrography, ultrasound and arthroscopic findings in 25 consecutive cases.
N = 51 (53 hips); mean age, 35 yr (range, 15-61 yr)
Symptomatic FAI in combination with labral pathology
Clinical diagnosis with radiography
0.21
NA
NA
NA
NA
NA
NOTE. Data are arranged per test and then per study. Therefore some studies are cited more than once. Tests with several names but the same execution are presented in 1 row; the names are divided by virgules.
Abbreviations: MRI, magnetic resonance imaging; MRI-A, magnetic resonance imaging-arthrogram; NA, not applicable (data were not calculated in study and/or could not be calculated based on available figures); VAS, visual analog scale.
The specificity was described for 7 physical tests and was not available for the flexion–adduction–axial compression test, the Fitzgerald test, the log-roll test, and the posterior impingement test. A specificity of 0.9 to 1.0 was reported for the anterior hip impingement test, the FABER test, the RSLR test, and the Thomas test.
A high positive predictive value (PPV) of 0.9 to 1.0 was reported for all tests except for the internal rotation–flexion–axial compression maneuver, the log-roll test, and the posterior impingement test.
described the FABER test and the hip quadrant position and provided a negative predictive value (NPV) of 0.90 and higher. All other values were low to moderate or not calculable.
The positive likelihood ratio (LOR+) was considered large if values above 10 were produced.
showed an LOR+ of 11.125 for the Thomas test. All other authors' values varied between 0.73 and 1.55, presenting no or minimal changes in the positive likelihood of the disease.
also produced a moderate negative likelihood ratio (LOR–) of 0.12, whereas all other studies showed small or minimal decreases in the likelihood of the disease.
For the log-roll test and the posterior impingement test, no PPV, NPV, LOR+, or LOR–values were provided. Overall, 6 studies examining 7 tests provided information for all diagnostic accuracy figures.
Descriptive epidemiology of mechanical hip pathology in adults under 50 years of age Prospective series of 292 cases: Clinical and radiological aspects and physiopathological review.
showed that all studies describing physical diagnostic tests were rated Level IV or V (Table 5). All diagnostic accuracy studies were rated Level II or III except for the study by Nogier et al.,
Descriptive epidemiology of mechanical hip pathology in adults under 50 years of age Prospective series of 292 cases: Clinical and radiological aspects and physiopathological review.
Hip joint pathology: Clinical presentation and correlation between magnetic resonance arthrography, ultrasound and arthroscopic findings in 25 consecutive cases.
Descriptive epidemiology of mechanical hip pathology in adults under 50 years of age Prospective series of 292 cases: Clinical and radiological aspects and physiopathological review.
NOTE. The second column describes whether the research described tests (test description) and, if so, investigated the diagnostic accuracy and validity of the tests (accuracy).
All included diagnostic accuracy studies were cohort studies or cross-sectional studies, and the QUADAS score was used for quality assessment. Based on the overall score, 4 articles were graded as poor, 7 as moderate, and 3 as good (Table 6). With the exception of the study by Narvani et al.,
Hip joint pathology: Clinical presentation and correlation between magnetic resonance arthrography, ultrasound and arthroscopic findings in 25 consecutive cases.
Descriptive epidemiology of mechanical hip pathology in adults under 50 years of age Prospective series of 292 cases: Clinical and radiological aspects and physiopathological review.
NOTE. The final score was deemed poor if there were 7 yes answers or fewer; moderate, 8 to 10 yes answers; and good, 11 yes answers or more.
Abbreviations: N, no (information is not provided or adequate); U, unclear (insufficient information available to make a judgment); Q, questions from QUADAS score according to Whiting et al.
This review identified 21 studies describing 18 physical diagnostic tests for the assessment of FAI and/or labral pathology of the hip joint. Of the studies, 7 gave a description of these tests and 14 were diagnostic accuracy studies. Many physical tests were the objective of previous studies, but results show that there was a lack of diagnostic accuracy parameters or these parameters had poor values. This was supported by our finding that based on the QUADAS score, only 3 of 14 diagnostic accuracy studies were of good quality. These 3 studies investigated the anterior hip impingement test, the FABER test, and the RSLR test (Video 1, available at www.arthroscopyjournal.org).
However, because of several methodologic problems, none of these tests are appropriate to reliably confirm or discard the diagnosis of FAI and/or labral pathology.
The first methodologic issue is that in each of the 3 studies, there were some flaws that resulted in a lower strength of evidence. The number of subjects per study differed from 18 to 301.
Because variation among subjects can be expected, a group of 18 subjects is too small to reliably interpret diagnostic accuracy figures. Furthermore, all 3 studies used a study population in which there was a high suspicion of intra-articular hip pathology, increasing the risk of spectrum bias. These 2 flaws led to difficulties in interpretation of the diagnostic accuracy figures. This was confirmed by the fact that the sensitivity ranged from 0.59 to 0.99 for the anterior hip impingement test and from 0.41 to 0.97 for the FABER test.
provided the specificity, resulting in an LOR+ and LOR–. However, the usefulness of these figures is questionable because these were based on 18 subjects only. Two studies reported high PPV values of 1.0 for all 3 investigated tests.
Yet, the PPV and NPV were of limited use because the disease prevalence figures in these studies were not comparable to those in clinical practice. This was because of study populations in which there was a high suspicion or even confirmation of the disease but also because general prevalence figures for FAI and/or labral pathology are unknown.
The second methodologic issue is that the results of these 3 studies could not be combined because of slight differences in test executions. For example, a positive FABER test described by Philippon et al.
described pain as a positive result (Video 1). This was seen more often in the literature, where many tests have different names but are similar or have the same name but are conducted in different manners.
To a certain extent, the results of this systematic review are comparable to those presented in 2 previous systematic reviews concerning labral pathology. Burgess et al.
studied the validity and accuracy of clinical diagnostic tests for labral pathology and concluded that there is too little information to draw a conclusion for clinical practice. They included only 5 articles with an equal number of tests, for which only the sensitivity and specificity values were reported. Moreover, the tests were not described as they were originally developed. Leibold et al.
investigated the concurrent criterion-related validity of physical examination tests for hip labral lesions. They found that a negative result on the flexion–adduction–internal rotation test, the impingement provocation test, the flexion–internal rotation test, the flexion–adduction–axial compression test, the Fitzgerald test, or a combination of these provided the clinician with the greatest confidence that labral pathology was absent. However, this conclusion was premature because it was based on sensitivity data and a narrative discussion only. Both reviews included labral pathology only.
Therefore other causative factors of hip pain should be considered and investigated. FAI is increasingly recognized as a causative factor for many intra-articular hip lesions, and FAI and labral pathology are the most common indications for hip arthroscopy.
Therefore we included studies investigating physical diagnostic tests for these 2 pathologies. To our knowledge, this is the first systematic review that addresses the accuracy and validity of physical diagnostic tests for FAI and/or labral pathology. A possible limitation of this study was that other intra-articular pathology and radiographic investigations were not included.
Conclusions
There exists a wide range of physical diagnostic tests for FAI and/or labral pathology and little information on the diagnostic accuracy and validity. The methodologic quality of the diagnostic accuracy studies is moderate to poor. Uniformity in test executions is warranted, and these should be thoroughly investigated for diagnostic accuracy and validity. For now, no (combination of) physical diagnostic tests are available that can reliably confirm or discard the diagnoses of FAI and/or labral pathology in clinical practice.
Execution of best investigated tests based on the systematic review. This video contains the test execution of the anterior hip impingement test, the FABER test, and the RSLR test as described by Philippon et al.,
The authors provided good-quality research for these tests, but they are not appropriate to reliably confirm or discard the diagnosis of FAI and/or labral pathology in clinical practice. Philippon et al.
Hip joint pathology: Clinical presentation and correlation between magnetic resonance arthrography, ultrasound and arthroscopic findings in 25 consecutive cases.
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