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Diagnostics of Femoroacetabular Impingement and Labral Pathology of the Hip: A Systematic Review of the Accuracy and Validity of Physical Tests

Published:February 27, 2012DOI:https://doi.org/10.1016/j.arthro.2011.12.004

      Purpose

      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.
      • Clohisy J.C.
      • Knaus E.R.
      • Hunt D.M.
      • Lesher J.M.
      • Harris-Hayes M.
      • Prather H.
      Clinical presentation of patients with symptomatic anterior hip impingement.
      • Martin R.L.
      • Irrgang J.J.
      • Sekiya J.K.
      The diagnostic accuracy of a clinical examination in determining intra-articular hip pain for potential hip arthroscopy candidates.
      • Tibor L.M.
      • Sekiya J.K.
      Differential diagnosis of pain around the hip joint.
      The exact prevalence of acetabular labral pathology and FAI in the general population is unknown.
      • Levy B.A.
      • Yuan B.
      • Bartlet R.B.
      • Trousdale R.T.
      • Sierra R.J.
      Screening for femoroacetabular impingement in asymptomatic adolescent athletes.
      Figures in the symptomatic population vary considerably.
      • Singh P.J.
      • O'Donnel J.M.
      The outcome of hip arthroscopy in Australian football league players: A review of 27 hips.
      • Byrd J.W.T.
      • Jones K.S.
      Hip arthroscopy for labral pathology: Prospective analysis with 10-year follow-up.
      However, FAI is increasingly recognized as a causative factor of many intra-articular hip lesions.
      • Byrd J.W.T.
      • Jones K.S.
      Arthroscopic management of femoroacetabular impingement: Minimum 2-year follow-up.
      It is foremost associated with labral pathology.
      • Singh P.J.
      • O'Donnel J.M.
      The outcome of hip arthroscopy in Australian football league players: A review of 27 hips.
      • Byrd J.W.T.
      • Jones K.S.
      Hip arthroscopy for labral pathology: Prospective analysis with 10-year follow-up.
      • Byrd J.W.T.
      Hip arthroscopy: Surgical indications.
      • Larson C.M.
      • Giveans M.R.
      Arthroscopic debridement versus refixation of the acetabular labrum associated with femoroacetabular impingement.
      Both FAI (i.e., cam or pincer impingement) and labral pathology are associated with the development of osteoarthritis of the hip.
      • Singh P.J.
      • O'Donnel J.M.
      The outcome of hip arthroscopy in Australian football league players: A review of 27 hips.
      • Byrd J.W.T.
      • Jones K.S.
      Arthroscopic management of femoroacetabular impingement: Minimum 2-year follow-up.
      • Byrd J.W.T.
      Hip arthroscopy: Surgical indications.
      • Larson C.M.
      • Giveans M.R.
      Arthroscopic debridement versus refixation of the acetabular labrum associated with femoroacetabular impingement.
      Through the development of hip arthroscopy, FAI and labral pathology can now be better treated with fewer complications and a faster rehabilitation rate.
      • Botser I.B.
      • Smith T.W.
      • Nasser R.
      • Domb B.G.
      Open surgical dislocation versus arthroscopy for femoroacetabular impingement: A comparison of clinical outcomes.
      • Awan N.
      • Murray P.
      Role of hip arthroscopy in the diagnosis and treatment of hip joint pathology.
      Recent studies have shown that this treatment is effective.
      • Byrd J.W.T.
      • Jones K.S.
      Hip arthroscopy for labral pathology: Prospective analysis with 10-year follow-up.
      • Byrd J.W.T.
      • Jones K.S.
      Arthroscopic management of femoroacetabular impingement: Minimum 2-year follow-up.
      • Awan N.
      • Murray P.
      Role of hip arthroscopy in the diagnosis and treatment of hip joint pathology.
      It leads to improvements in symptoms and range of motion, as well as a full return to sport activity.
      • Singh P.J.
      • O'Donnel J.M.
      The outcome of hip arthroscopy in Australian football league players: A review of 27 hips.
      • Byrd J.W.T.
      • Jones K.S.
      Arthroscopic management of femoroacetabular impingement: Minimum 2-year follow-up.
      • Awan N.
      • Murray P.
      Role of hip arthroscopy in the diagnosis and treatment of hip joint pathology.
      Furthermore, it is expected that this treatment will delay the progression of osteoarthritis.
      • Larson C.M.
      • Giveans M.R.
      Arthroscopic debridement versus refixation of the acetabular labrum associated with femoroacetabular impingement.
      • Guanche C.A.
      • Bare A.A.
      Arthroscopic treatment of femoroacetabular impingement.
      An adequate and timely diagnosis is important, but studies have shown that the mean time to diagnosis of hip joint pathology is greater than 2 years.
      • Martin R.L.
      • Irrgang J.J.
      • Sekiya J.K.
      The diagnostic accuracy of a clinical examination in determining intra-articular hip pain for potential hip arthroscopy candidates.
      • Byrd J.W.T.
      • Jones K.S.
      Hip arthroscopy for labral pathology: Prospective analysis with 10-year follow-up.
      • Byrd J.W.T.
      Hip arthroscopy: Surgical indications.
      • McCarthy J.C.
      • Noble P.C.
      • Schuck M.R.
      • Wright J.
      • Lee J.
      The role of hip arthroscopy in the diagnosis and treatment of hip disease.
      Patients often see multiple health care providers before the definitive diagnosis is obtained and sometimes even undergo unnecessary surgery. As Martin et al.
      • Martin R.L.
      • Irrgang J.J.
      • Sekiya J.K.
      The diagnostic accuracy of a clinical examination in determining intra-articular hip pain for potential hip arthroscopy candidates.
      and Tibor and Sekiya
      • Tibor L.M.
      • Sekiya J.K.
      Differential diagnosis of pain around the hip joint.
      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).
      • Clohisy J.C.
      • Knaus E.R.
      • Hunt D.M.
      • Lesher J.M.
      • Harris-Hayes M.
      • Prather H.
      Clinical presentation of patients with symptomatic anterior hip impingement.
      • Martin R.L.
      • Irrgang J.J.
      • Sekiya J.K.
      The diagnostic accuracy of a clinical examination in determining intra-articular hip pain for potential hip arthroscopy candidates.
      • Tibor L.M.
      • Sekiya J.K.
      Differential diagnosis of pain around the hip joint.
      • Byrd J.W.T.
      Hip arthroscopy: Surgical indications.
      • Martin R.L.
      • Enseki K.R.
      • Draovitch P.
      • Trapuzzano T.
      • Philippon M.J.
      Acetabular labral tears of the hip: Examination and diagnostic challenges.
      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.
      • Singh P.J.
      • O'Donnel J.M.
      The outcome of hip arthroscopy in Australian football league players: A review of 27 hips.
      • Larson C.M.
      • Giveans M.R.
      Arthroscopic debridement versus refixation of the acetabular labrum associated with femoroacetabular impingement.
      • Clohisy J.C.
      • Keeney J.A.
      • Schoenecker P.L.
      Preliminary assessment and treatment guidelines for hip disorders in young adults.
      • Sink E.L.
      • Gralla J.
      • Ryba A.
      • Dayton M.
      Clinical presentation of femoroacetabular impingement in adolescents.
      There is less evidence regarding the physical tests that are used for examination of the hip joint.
      • Tibor L.M.
      • Sekiya J.K.
      Differential diagnosis of pain around the hip joint.
      • Burgess R.M.
      • Rushton A.
      • Wright C.
      • Daborn C.
      The validity and accuracy of clinical diagnostic tests used to detect labral pathology of the hip: A systematic review.
      • Leibold M.R.
      • Huijbregts P.A.
      • Jensen R.
      Concurrent criterion-related validity of physical examination tests for hip labral lesions: A systematic review.
      • Ochiai D.H.
      • Adib F.
      • Donovan S.
      The twist test: A new test for hip labral pathology.
      • Martin H.D.
      • Shears S.A.
      • Palmer I.J.
      Evaluation of the hip.
      Many different tests are used to diagnose FAI and labral pathology.
      • Leibold M.R.
      • Huijbregts P.A.
      • Jensen R.
      Concurrent criterion-related validity of physical examination tests for hip labral lesions: A systematic review.
      • Martin H.D.
      • Shears S.A.
      • Palmer I.J.
      Evaluation of the hip.
      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.
      • Martin R.L.
      • Irrgang J.J.
      • Sekiya J.K.
      The diagnostic accuracy of a clinical examination in determining intra-articular hip pain for potential hip arthroscopy candidates.
      • Martin R.L.
      • Enseki K.R.
      • Draovitch P.
      • Trapuzzano T.
      • Philippon M.J.
      Acetabular labral tears of the hip: Examination and diagnostic challenges.
      • Burgess R.M.
      • Rushton A.
      • Wright C.
      • Daborn C.
      The validity and accuracy of clinical diagnostic tests used to detect labral pathology of the hip: A systematic review.
      • Leibold M.R.
      • Huijbregts P.A.
      • Jensen R.
      Concurrent criterion-related validity of physical examination tests for hip labral lesions: A systematic review.
      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: hiplow asterisk, groinlow asterisk, examlow asterisk, testlow asterisk, asseslow asterisk, diagnoslow asterisk, arthrometlow asterisk, acetabullow asterisk, labrlow asterisk, intra-articular, impingement, femoro-acetabular impingement, disorderlow asterisk, pathologlow asterisk, painlow asterisk, injurlow asterisk, lesionlow asterisk, tearlow asterisk, reliablow asterisk, validlow asterisk, and accurlow asterisk. 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 TermsPubMedPEDroCochrane LibraryWeb of ScienceCINAHLMedlineTotal
      1.hip*95,51879,943
      2.groin*7,8706,913
      3.1 or 2102,88669,61183.15720,76786,577
      4.exam*1,914,69656,531
      5.test*1,347,47557,687
      6.diagnos*2,414,40075,408
      7.asses*1,529,07862,512
      8.arthromet*494491
      9.4 or 5 or 6 or 7 or 85,750,9150277,82596.867735,18599,994
      10.acetabul*12,85210,934
      11.labr*11,4065,093
      12.intra-articular10,5398,621
      13.impingement4,4334,263
      14.femoro-acetabular impingement33740
      15.10 or 11 or 12 or 13 or 1437,51401,90623,3403,55327,269
      16.disorder*1,199,46880,938
      17.patholog*2,301,14185,804
      18.injur*398,15280,785
      19.pain*416,90085,619
      20.lesion*541,23082,515
      21.tear*28,72225,112
      22.16 or 17 or 18 or 19 or 20 or 214,147,2580148,57896.162394,50799,489
      23.reliab*242,89373,281
      24.valid*305,72467,588
      25.accur*367,03662,386
      26.23 or 24 or 25800,664040,08297.647111,485100,000
      27.3 and 9 and 15 and 22 and 26306046136515
      27 and limits169046126515307
      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.

       Study Selection

      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 CriteriaExclusion Criteria
      Article published in English, German, or Dutch and available as full-text articleAsymptomatic study population
      All study designsIntra-articular hip pathology other than FAI and/or labral pathology
      Study population aged between 10 and 80 yrStudies 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 pathologyStudies 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 pathologyDiagnostic accuracy study using no new data but using data extracted from other research (e.g., systematic reviews)

       Quality Assessment

       General Quality Assessment

      The Levels of Evidence for Primary Research Questions list was used to determine the level of evidence of all included studies.
      • Wright J.W.
      • Swiontkowski M.F.
      • Heckman J.D.
      Introducing levels of evidence to the journal.
      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.
      • Whiting P.
      • Rutjes A.W.
      • Reitsma J.B.
      • Bossuyt P.M.
      • Kleijnen J.
      The development of QUADAS: A tool for the quality assessment of studies of diagnostic accuracy included in systematic reviews.
      • Whiting P.F.
      • Weswood M.E.
      • Rutjes A.W.
      • Reitsma J.B.
      • Bossuyt P.M.
      • Kleijnen J.
      Evaluation of QUADAS, a tool for the quality assessment of diagnostic accuracy studies.
      It consists of 14 items that can be scored yes, no, or unclear. The inter-rater agreement has been reported to be 90% between 2 reviewers.
      • Whiting P.
      • Rutjes A.W.
      • Reitsma J.B.
      • Bossuyt P.M.
      • Kleijnen J.
      The development of QUADAS: A tool for the quality assessment of studies of diagnostic accuracy included in systematic reviews.
      The Cochrane Collaboration recommends this tool for the assessment of the quality of primary studies on diagnostic accuracy.
      • Reitsma J.B.
      • Rutjes A.W.S.
      • Whiting P.
      • Vlassov V.V.
      • Leeflang M.M.G.
      • Deeks J.J.
      Assessing methodological quality.
      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 thumbnail gr1
      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.

       Clinical Diagnostic Tests

      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
      TestTest ExecutionDiagnoses
      Flexion–adduction–internal rotation tests
       Anterior hip impingement testPatient 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.
      • Clohisy J.C.
      • Knaus E.R.
      • Hunt D.M.
      • Lesher J.M.
      • Harris-Hayes M.
      • Prather H.
      Clinical presentation of patients with symptomatic anterior hip impingement.
      • Martin R.L.
      • Irrgang J.J.
      • Sekiya J.K.
      The diagnostic accuracy of a clinical examination in determining intra-articular hip pain for potential hip arthroscopy candidates.
      • Martin R.L.
      • Enseki K.R.
      • Draovitch P.
      • Trapuzzano T.
      • Philippon M.J.
      Acetabular labral tears of the hip: Examination and diagnostic challenges.
      • Sink E.L.
      • Gralla J.
      • Ryba A.
      • Dayton M.
      Clinical presentation of femoroacetabular impingement in adolescents.
      • Domb B.G.
      • Brooks A.G.
      • Byrd J.W.
      Clinical examination of the hip joint in athletes.
      • Troelsen A.
      • Mechlenburg I.
      • Gelineck J.
      • Bolvig J.
      • Jacobsen S.
      • Soballe K.
      What is the role of clinical tests and ultrasound in acetabular labral tear diagnostics?.
      • Burnett R.S.
      • Della Rocca G.J.
      • Prather H.
      • Curry M.
      • Maloney W.J.
      • Clohisy J.C.
      Clinical presentation of patients with tears of the acetabular labrum.
      • Philippon M.J.
      • Briggs K.K.
      • Yen Y.M.
      • Kuppersmith D.A.
      Outcomes following hip arthroscopy for femoroacetabular impingement with associated chondrolabral dysfunction: Minimum two-year follow-up.
      FAI/labral pathology
       Impingement sign/flexion–internal rotation testPatient 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.
      • Hase T.
      • Ueo T.
      Acetabular labral tear: Arthroscopic diagnosis and treatment.
      • Santori N.
      • Villar R.N.
      Acetabular labral tears: Result of arthroscopic partial limbectomy.
      • Nogier A.
      • Bonin N.
      • May O.
      • 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.
      FAI/labral pathology
       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.
      • Maslowski E.
      • Sullivan W.
      • Forster Harwood J.
      The diagnostic validity of hip provocation maneuvers to detect intra-articular hip pathology.
      • Narvani A.A.
      • Tsiridis E.
      • Kendall S.
      • Chaudhuri R.
      • Thomas P.
      A preliminary report on prevalence of acetabular labrum tears in sports patients with groin pain.
      FAI/labral pathology
       Flexion–adduction–axial compression testPatient 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.
      • Hase T.
      • Ueo T.
      Acetabular labral tear: Arthroscopic diagnosis and treatment.
      Labral pathology
       Flexion–adduction–internal rotation test (FADDIR)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
      • Freehill M.T.
      • Safran M.R.
      The labrum of the hip: Diagnosis and rational for surgical correction.
      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.
      • Martin H.D.
      • Shears S.A.
      • Palmer I.J.
      Evaluation of the hip.
      • Freehill M.T.
      • Safran M.R.
      The labrum of the hip: Diagnosis and rational for surgical correction.
      • Plante M.
      • Wallace R.
      • Busconi B.D.
      Clinical diagnosis of hip pain.
      • Braly B.A.
      • Beall D.P.
      • Martin H.D.
      Clinical examination of the athletic hip.
      • Domb B.G.
      • Brooks A.G.
      • Byrd J.W.
      Clinical examination of the hip joint in athletes.
      FAI/labral pathology
      Abduction–external rotation tests
       FABER test/Patrick signThe 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.
      • Clohisy J.C.
      • Knaus E.R.
      • Hunt D.M.
      • Lesher J.M.
      • Harris-Hayes M.
      • Prather H.
      Clinical presentation of patients with symptomatic anterior hip impingement.
      • Martin R.L.
      • Irrgang J.J.
      • Sekiya J.K.
      The diagnostic accuracy of a clinical examination in determining intra-articular hip pain for potential hip arthroscopy candidates.
      • McCarthy J.C.
      • Noble P.C.
      • Schuck M.R.
      • Wright J.
      • Lee J.
      The role of hip arthroscopy in the diagnosis and treatment of hip disease.
      • Martin R.L.
      • Enseki K.R.
      • Draovitch P.
      • Trapuzzano T.
      • Philippon M.J.
      Acetabular labral tears of the hip: Examination and diagnostic challenges.
      • Martin H.D.
      • Shears S.A.
      • Palmer I.J.
      Evaluation of the hip.
      • Braly B.A.
      • Beall D.P.
      • Martin H.D.
      Clinical examination of the athletic hip.
      • Mitchell B.
      • McCrory P.
      • Brukner P.
      • O'Donnel J.
      • Colson E.
      • Howells R.
      Hip joint pathology: Clinical presentation and correlation between magnetic resonance arthrography, ultrasound and arthroscopic findings in 25 consecutive cases.
      • Domb B.G.
      • Brooks A.G.
      • Byrd J.W.
      Clinical examination of the hip joint in athletes.
      • Martin H.D.
      • Kelly B.T.
      • Leunig M.
      • et al.
      The pattern and technique in the clinical evaluation of the adult hip: The common physical examination tests of hip specialists.
      • Maslowski E.
      • Sullivan W.
      • Forster Harwood J.
      The diagnostic validity of hip provocation maneuvers to detect intra-articular hip pathology.
      • Troelsen A.
      • Mechlenburg I.
      • Gelineck J.
      • Bolvig J.
      • Jacobsen S.
      • Soballe K.
      What is the role of clinical tests and ultrasound in acetabular labral tear diagnostics?.
      FAI/labral pathology
      Flexion-extension maneuvers
       Fitzgerald test/labral stress testThe 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.
      • Freehill M.T.
      • Safran M.R.
      The labrum of the hip: Diagnosis and rational for surgical correction.
      • Fitzgerald Jr, R.H.
      Acetabular labrum tears Diagnosis and treatment.
      Labral pathology
       Dynamic external rotatory impingement test (DEXRIT)/supine abduction–external rotation testThe 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.
      • Martin H.D.
      • Shears S.A.
      • Palmer I.J.
      Evaluation of the hip.
      • Plante M.
      • Wallace R.
      • Busconi B.D.
      Clinical diagnosis of hip pain.
      • Domb B.G.
      • Brooks A.G.
      • Byrd J.W.
      Clinical examination of the hip joint in athletes.
      FAI/labral pathology
       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.
      • Martin H.D.
      • Shears S.A.
      • Palmer I.J.
      Evaluation of the hip.
      • Plante M.
      • Wallace R.
      • Busconi B.D.
      Clinical diagnosis of hip pain.
      • Martin H.D.
      • Kelly B.T.
      • Leunig M.
      • et al.
      The pattern and technique in the clinical evaluation of the adult hip: The common physical examination tests of hip specialists.
      FAI/labral pathology
       Hip quadrant position/scour testThe 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.
      • Maslowski E.
      • Sullivan W.
      • Forster Harwood J.
      The diagnostic validity of hip provocation maneuvers to detect intra-articular hip pathology.
      described the same test only with axial compression through the joint.
      • Braly B.A.
      • Beall D.P.
      • Martin H.D.
      Clinical examination of the athletic hip.
      • Mitchell B.
      • McCrory P.
      • Brukner P.
      • O'Donnel J.
      • Colson E.
      • Howells R.
      Hip joint pathology: Clinical presentation and correlation between magnetic resonance arthrography, ultrasound and arthroscopic findings in 25 consecutive cases.
      • Domb B.G.
      • Brooks A.G.
      • Byrd J.W.
      Clinical examination of the hip joint in athletes.
      FAI/labral pathology
       McCarthy testThe 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.
      • Plante M.
      • Wallace R.
      • Busconi B.D.
      Clinical diagnosis of hip pain.
      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.
      • Martin H.D.
      • Shears S.A.
      • Palmer I.J.
      Evaluation of the hip.
      but with axial compression during the whole movement and is called the scour test.
      • Martin R.L.
      • Enseki K.R.
      • Draovitch P.
      • Trapuzzano T.
      • Philippon M.J.
      Acetabular labral tears of the hip: Examination and diagnostic challenges.
      • Martin H.D.
      • Shears S.A.
      • Palmer I.J.
      Evaluation of the hip.
      • Plante M.
      • Wallace R.
      • Busconi B.D.
      Clinical diagnosis of hip pain.
      • Braly B.A.
      • Beall D.P.
      • Martin H.D.
      Clinical examination of the athletic hip.
      • Domb B.G.
      • Brooks A.G.
      • Byrd J.W.
      Clinical examination of the hip joint in athletes.
      FAI/labral pathology
       Lateral rim impingement testThe 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.
      • Martin H.D.
      • Shears S.A.
      • Palmer I.J.
      Evaluation of the hip.
      • Braly B.A.
      • Beall D.P.
      • Martin H.D.
      Clinical examination of the athletic hip.
      FAI
      Remaining tests
       Thomas testPatient 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.
      • McCarthy J.C.
      • Noble P.C.
      • Schuck M.R.
      • Wright J.
      • Lee J.
      The role of hip arthroscopy in the diagnosis and treatment of hip disease.
      • Braly B.A.
      • Beall D.P.
      • Martin H.D.
      Clinical examination of the athletic hip.
      • Narvani A.A.
      • Tsiridis E.
      • Kendall S.
      • Chaudhuri R.
      • Thomas P.
      A preliminary report on prevalence of acetabular labrum tears in sports patients with groin pain.
      Labral pathology
       Hyperextension–external rotation testThe 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.
      • Freehill M.T.
      • Safran M.R.
      The labrum of the hip: Diagnosis and rational for surgical correction.
      FAI/labral pathology
       RSLR test/Stinchfield testThe 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.
      • Troelsen A.
      • Mechlenburg I.
      • Gelineck J.
      • Bolvig J.
      • Jacobsen S.
      • Soballe K.
      What is the role of clinical tests and ultrasound in acetabular labral tear diagnostics?.
      and Maslowski et al.
      • Maslowski E.
      • Sullivan W.
      • Forster Harwood J.
      The diagnostic validity of hip provocation maneuvers to detect intra-articular hip pathology.
      performed the same test but only raised the leg until 30°.
      • Clohisy J.C.
      • Knaus E.R.
      • Hunt D.M.
      • Lesher J.M.
      • Harris-Hayes M.
      • Prather H.
      Clinical presentation of patients with symptomatic anterior hip impingement.
      • Martin R.L.
      • Enseki K.R.
      • Draovitch P.
      • Trapuzzano T.
      • Philippon M.J.
      Acetabular labral tears of the hip: Examination and diagnostic challenges.
      • Martin H.D.
      • Shears S.A.
      • Palmer I.J.
      Evaluation of the hip.
      • Freehill M.T.
      • Safran M.R.
      The labrum of the hip: Diagnosis and rational for surgical correction.
      • Domb B.G.
      • Brooks A.G.
      • Byrd J.W.
      Clinical examination of the hip joint in athletes.
      • Martin H.D.
      • Kelly B.T.
      • Leunig M.
      • et al.
      The pattern and technique in the clinical evaluation of the adult hip: The common physical examination tests of hip specialists.
      FAI/labral pathology
       Log-roll test/passive supine rotation testThe 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.
      • Clohisy J.C.
      • Knaus E.R.
      • Hunt D.M.
      • Lesher J.M.
      • Harris-Hayes M.
      • Prather H.
      Clinical presentation of patients with symptomatic anterior hip impingement.
      • Martin R.L.
      • Enseki K.R.
      • Draovitch P.
      • Trapuzzano T.
      • Philippon M.J.
      Acetabular labral tears of the hip: Examination and diagnostic challenges.
      • Martin H.D.
      • Shears S.A.
      • Palmer I.J.
      Evaluation of the hip.
      • Martin H.D.
      • Kelly B.T.
      • Leunig M.
      • et al.
      The pattern and technique in the clinical evaluation of the adult hip: The common physical examination tests of hip specialists.
      FAI/labral pathology
       Posterior hip impingement test/posterior rim impingementThe 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.
      • Clohisy J.C.
      • Knaus E.R.
      • Hunt D.M.
      • Lesher J.M.
      • Harris-Hayes M.
      • Prather H.
      Clinical presentation of patients with symptomatic anterior hip impingement.
      • Martin R.L.
      • Enseki K.R.
      • Draovitch P.
      • Trapuzzano T.
      • Philippon M.J.
      Acetabular labral tears of the hip: Examination and diagnostic challenges.
      • Martin H.D.
      • Shears S.A.
      • Palmer I.J.
      Evaluation of the hip.
      • Martin H.D.
      • Kelly B.T.
      • Leunig M.
      • et al.
      The pattern and technique in the clinical evaluation of the adult hip: The common physical examination tests of hip specialists.
      FAI/labral pathology
       Foveal distractionThe 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.
      • Martin H.D.
      • Shears S.A.
      • Palmer I.J.
      Evaluation of the hip.
      • Plante M.
      • Wallace R.
      • Busconi B.D.
      Clinical diagnosis of hip pain.
      • Braly B.A.
      • Beall D.P.
      • Martin H.D.
      Clinical examination of the athletic hip.
      FAI/labral pathology
      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.
      • Martin H.D.
      • Shears S.A.
      • Palmer I.J.
      Evaluation of the hip.
      • Domb B.G.
      • Brooks A.G.
      • Byrd J.W.
      Clinical examination of the hip joint in athletes.
      • Martin H.D.
      • Kelly B.T.
      • Leunig M.
      • et al.
      The pattern and technique in the clinical evaluation of the adult hip: The common physical examination tests of hip specialists.
      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.
      • Martin H.D.
      • Shears S.A.
      • Palmer I.J.
      Evaluation of the hip.
      • Domb B.G.
      • Brooks A.G.
      • Byrd J.W.
      Clinical examination of the hip joint in athletes.
      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 PopulationDiagnoses Made by AuthorsReference Standard Used to Confirm or Discard DiagnosisSensitivitySpecificityLOR+LOR–PPVNPV
      Anterior hip impingement test
       Martin et al.
      • Martin R.L.
      • Irrgang J.J.
      • Sekiya J.K.
      The diagnostic accuracy of a clinical examination in determining intra-articular hip pain for potential hip arthroscopy candidates.
      (2008)
      N = 49 (24 women/25 men); mean age, 42 yr (range, 18-68 yr; SD, 15)Acetabular labral tear50% improvement of VAS after intra-articular injection and MRI-A0.780.100.862.30.530.25
       Sink et al.
      • Sink E.L.
      • Gralla J.
      • Ryba A.
      • Dayton M.
      Clinical presentation of femoroacetabular impingement in adolescents.
      (2008)
      N = 35 (30 female patients/5 male patients); mean age, 16 yr (range, 13-18 yr)FAI in combination with labral pathologyRadiography (35), MRI (4), and MRI-A (24)1.0NANANA1.0NA
       Clohisy et al.
      • Clohisy J.C.
      • Knaus E.R.
      • Hunt D.M.
      • Lesher J.M.
      • Harris-Hayes M.
      • Prather H.
      Clinical presentation of patients with symptomatic anterior hip impingement.
      (2009)
      N = 51 (53 hips); mean age, 35 yr (range, 15-61 yr)Symptomatic FAI in combination with labral pathologyClinical diagnosis with radiography0.88NANANA1.00
       Burnett et al.
      • Burnett R.S.
      • Della Rocca G.J.
      • Prather H.
      • Curry M.
      • Maloney W.J.
      • Clohisy J.C.
      Clinical presentation of patients with tears of the acetabular labrum.
      (2006)
      N = 66 (47 female patients/19 male patients); mean age, 38 yr (range, 15-64 yr)Acetabular labral tearArthroscopy0.95NANANA1.00
       Troelsen et al.
      • Troelsen A.
      • Mechlenburg I.
      • Gelineck J.
      • Bolvig J.
      • Jacobsen S.
      • Soballe K.
      What is the role of clinical tests and ultrasound in acetabular labral tear diagnostics?.
      (2009)
      N = 18 (16 women/2 men); median age, 43 yr (range, 32-56 yr)Labral pathologyMRI-A0.591.000.411.00.13
       Philippon et al.
      • Philippon M.J.
      • Briggs K.K.
      • Yen Y.M.
      • Kuppersmith D.A.
      Outcomes following hip arthroscopy for femoroacetabular impingement with associated chondrolabral dysfunction: Minimum two-year follow-up.
      (2009)
      N = 301 (153 male patients/148 female patients); mean age, 39.9 yr (range, 11-72 yr)FAIArthroscopy0.99NANANANANA
      Impingement sign
       Nogier et al.
      • Nogier A.
      • Bonin N.
      • May O.
      • 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.
      (2010)
      N = 292 (111 women/181 men); mean age, 35 yr (SD, 10)FAIComplete physical examination with radiography0.2-0.70.44-0.861.25-1.550.68-0.930.63-0.670.44-0.53
       Santori and Villar
      • Santori N.
      • Villar R.N.
      Acetabular labral tears: Result of arthroscopic partial limbectomy.
      (2000)
      N = 58 (33 female patients/25 male patients); mean age, 36.7 (range, 10-70 yr)Acetabular labral tearArthroscopy1.0NANANA1.0NA
       Hase and Ueo
      • Hase T.
      • Ueo T.
      Acetabular labral tear: Arthroscopic diagnosis and treatment.
      (1999)
      N = 10 (7 female patients/10 male patients); mean age, 28.7 yr (range, 13-67 yr)Acetabular labral tearArthroscopy0.7NANANA1.0NA
      Internal rotation–flexion–axial compression maneuver/internal rotation over pressure test
       Narvani et al.
      • Narvani A.A.
      • Tsiridis E.
      • Kendall S.
      • Chaudhuri R.
      • Thomas P.
      A preliminary report on prevalence of acetabular labrum tears in sports patients with groin pain.
      (2003)
      N = 18 (5 female patients/13 male patients); mean age, 30.5 yr (range, 17-48 yr; SD, 8.45)Acetabular labral tearMRI-A0.750.431.320.580.270.86
       Maslowski et al.
      • Maslowski E.
      • Sullivan W.
      • Forster Harwood J.
      The diagnostic validity of hip provocation maneuvers to detect intra-articular hip pathology.
      (2010)
      N = 50; mean age, 60.2 yr (range, 22-84 yr)Labral tear, FAI80% improvement of pain on 10-cm VAS after intra-articular hip injection or 80% pain relief0.890.151.050.730.190.86
      Flexion–adduction–axial compression test
       Hase and Ueo
      • Hase T.
      • Ueo T.
      Acetabular labral tear: Arthroscopic diagnosis and treatment.
      (1999)
      N = 10 (7 female patients/10 male patients); mean age, 28.7 yr (range, 13-67 yr)Acetabular labral tearArthroscopy1.0NANANA1.0NA
      FABER test/Patrick sign
       Martin et al.
      • Martin R.L.
      • Irrgang J.J.
      • Sekiya J.K.
      The diagnostic accuracy of a clinical examination in determining intra-articular hip pain for potential hip arthroscopy candidates.
      (2008)
      N = 49 (24 women/25 men); mean age, 42 yr (range, 18-68 yr; SD, 15)Acetabular labral tear50% improvement of VAS after intra-articular injection and MRI-A0.60.180.732.20.450.29
       Clohisy et al.
      • Clohisy J.C.
      • Knaus E.R.
      • Hunt D.M.
      • Lesher J.M.
      • Harris-Hayes M.
      • Prather H.
      Clinical presentation of patients with symptomatic anterior hip impingement.
      (2009)
      N = 51 (53 hips); mean age, 35 yr (range, 15-61 yr)Symptomatic FAI in combination with labral pathologyClinical diagnosis with radiography0.69NANANA1.00
       Mitchell et al.
      • Mitchell B.
      • McCrory P.
      • Brukner P.
      • O'Donnel J.
      • Colson E.
      • Howells R.
      Hip joint pathology: Clinical presentation and correlation between magnetic resonance arthrography, ultrasound and arthroscopic findings in 25 consecutive cases.
      (2003)
      N = 25 (9 female patients/16 male patients); mean age, 30.9 yr (range, 16-56 yr)Labral tear, rim lesionArthroscopy0.88NANANA1.00
       Troelsen et al.
      • Troelsen A.
      • Mechlenburg I.
      • Gelineck J.
      • Bolvig J.
      • Jacobsen S.
      • Soballe K.
      What is the role of clinical tests and ultrasound in acetabular labral tear diagnostics?.
      (2009)
      N = 18 (16 women/2 men); median age, 43 yr (range, 32-56 yr)Labral pathologyMRI-A0.411.000.591.00.09
       Philippon et al.
      • Philippon M.J.
      • Briggs K.K.
      • Yen Y.M.
      • Kuppersmith D.A.
      Outcomes following hip arthroscopy for femoroacetabular impingement with associated chondrolabral dysfunction: Minimum two-year follow-up.
      (2009)
      N = 301 (153 male patients/148 female patients); mean age, 39.9 yr (range, 11-72 yr)FAIArthroscopy0.97NANANANANA
       Maslowski et al.
      • Maslowski E.
      • Sullivan W.
      • Forster Harwood J.
      The diagnostic validity of hip provocation maneuvers to detect intra-articular hip pathology.
      (2010)
      N = 50; mean age, 60.2 yr (range, 22-84 yr)Labral tear, FAI80% improvement of pain on 10-cm VAS after intra-articular hip injection or 80% pain relief0.880.241.160.50.180.91
      Fitzgerald test
       Fitzgerald
      • Fitzgerald Jr, R.H.
      Acetabular labrum tears Diagnosis and treatment.
      (1995)
      N = 56; mean age, 36.5 yr (range, 18-75 yr)Labral tearHip joint surgery (marcainisation in 7 subjects)0.96NANANA1.00
      Hip quadrant position/scour test
       Mitchell et al.
      • Mitchell B.
      • McCrory P.
      • Brukner P.
      • O'Donnel J.
      • Colson E.
      • Howells R.
      Hip joint pathology: Clinical presentation and correlation between magnetic resonance arthrography, ultrasound and arthroscopic findings in 25 consecutive cases.
      (2003)
      N = 25 (9 female patients/16 male patients); mean age, 30.9 yr (range, 16-56 yr)Labral tear, rim lesionArthroscopy1.0NANANA1.0NA
       Maslowski et al.
      • Maslowski E.
      • Sullivan W.
      • Forster Harwood J.
      The diagnostic validity of hip provocation maneuvers to detect intra-articular hip pathology.
      (2010)
      N = 50; mean age, 60.2 yr (range, 22-84 yr)Labral tear, FAI80% improvement of pain on 10-cm VAS after intra-articular hip injection or 80% pain relief0.880.431.540.280.230.95
      Thomas test
       McCarthy et al.
      • McCarthy J.C.
      • Noble P.C.
      • Schuck M.R.
      • Wright J.
      • Lee J.
      The role of hip arthroscopy in the diagnosis and treatment of hip disease.
      (1995)
      N = 59 (32 female patients/27 male patients); mean age, 37 yr (range, 17-69 yr)Acetabular labral tearArthroscopy0.890.9211.1250.120.940.86
      RSLR test/Stinchfield test
       Clohisy et al.
      • Clohisy J.C.
      • Knaus E.R.
      • Hunt D.M.
      • Lesher J.M.
      • Harris-Hayes M.
      • Prather H.
      Clinical presentation of patients with symptomatic anterior hip impingement.
      (2009)
      N = 51 (53 hips); mean age, 35 yr (range, 15-61 yr)Symptomatic FAI in combination with labral pathologyClinical diagnosis with radiography0.56NANANA1.00
       Troelsen et al.
      • Troelsen A.
      • Mechlenburg I.
      • Gelineck J.
      • Bolvig J.
      • Jacobsen S.
      • Soballe K.
      What is the role of clinical tests and ultrasound in acetabular labral tear diagnostics?.
      (2009)
      N = 18 (16 women/2 men); median age, 43 yr (range, 32-56 yr)Labral pathologyMRI-A0.061.000.941.00.06
       Maslowski et al.
      • Maslowski E.
      • Sullivan W.
      • Forster Harwood J.
      The diagnostic validity of hip provocation maneuvers to detect intra-articular hip pathology.
      (2010)
      N = 50; mean age, 60.2 yr (range, 22-84 yr)Labral tear, FAI80% improvement of pain on 10-cm VAS after intra-articular hip injection or 80% pain relief0.750.381.210.660.190.89
      Log-roll test
       Clohisy et al.
      • Clohisy J.C.
      • Knaus E.R.
      • Hunt D.M.
      • Lesher J.M.
      • Harris-Hayes M.
      • Prather H.
      Clinical presentation of patients with symptomatic anterior hip impingement.
      (2009)
      N = 51 (53 hips); mean age, 35 yr (range, 15-61 yr)Symptomatic FAI in combination with labral pathologyClinical diagnosis with radiography0.30NANANANANA
      Posterior impingement test
       Clohisy et al.
      • Clohisy J.C.
      • Knaus E.R.
      • Hunt D.M.
      • Lesher J.M.
      • Harris-Hayes M.
      • Prather H.
      Clinical presentation of patients with symptomatic anterior hip impingement.
      (2009)
      N = 51 (53 hips); mean age, 35 yr (range, 15-61 yr)Symptomatic FAI in combination with labral pathologyClinical diagnosis with radiography0.21NANANANANA
      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.
      Only Maslowski et al.
      • Maslowski E.
      • Sullivan W.
      • Forster Harwood J.
      The diagnostic validity of hip provocation maneuvers to detect intra-articular hip pathology.
      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.
      • Cook C.
      • Cleland J.
      • Huijbregts P.
      Creation and critique of studies of diagnostic accuracy: Use of the STARD and QUADAS methodological quality assessment tools.
      Only McCarthy et al.
      • McCarthy J.C.
      • Noble P.C.
      • Schuck M.R.
      • Wright J.
      • Lee J.
      The role of hip arthroscopy in the diagnosis and treatment of hip disease.
      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.
      • Cook C.
      • Cleland J.
      • Huijbregts P.
      Creation and critique of studies of diagnostic accuracy: Use of the STARD and QUADAS methodological quality assessment tools.
      McCarthy et al.
      • McCarthy J.C.
      • Noble P.C.
      • Schuck M.R.
      • Wright J.
      • Lee J.
      The role of hip arthroscopy in the diagnosis and treatment of hip 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.
      • Martin R.L.
      • Irrgang J.J.
      • Sekiya J.K.
      The diagnostic accuracy of a clinical examination in determining intra-articular hip pain for potential hip arthroscopy candidates.
      • Maslowski E.
      • Sullivan W.
      • Forster Harwood J.
      The diagnostic validity of hip provocation maneuvers to detect intra-articular hip pathology.
      • Cook C.
      • Cleland J.
      • Huijbregts P.
      Creation and critique of studies of diagnostic accuracy: Use of the STARD and QUADAS methodological quality assessment tools.
      • Narvani A.A.
      • Tsiridis E.
      • Kendall S.
      • Chaudhuri R.
      • Thomas P.
      A preliminary report on prevalence of acetabular labrum tears in sports patients with groin pain.
      • Nogier A.
      • Bonin N.
      • May O.
      • 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.
      • Troelsen A.
      • Mechlenburg I.
      • Gelineck J.
      • Bolvig J.
      • Jacobsen S.
      • Soballe K.
      What is the role of clinical tests and ultrasound in acetabular labral tear diagnostics?.
      With the exception of the studies by Troelsen et al.,
      • Troelsen A.
      • Mechlenburg I.
      • Gelineck J.
      • Bolvig J.
      • Jacobsen S.
      • Soballe K.
      What is the role of clinical tests and ultrasound in acetabular labral tear diagnostics?.
      McCarthy et al.,
      • McCarthy J.C.
      • Noble P.C.
      • Schuck M.R.
      • Wright J.
      • Lee J.
      The role of hip arthroscopy in the diagnosis and treatment of hip disease.
      and Maslowski et al.,
      • Maslowski E.
      • Sullivan W.
      • Forster Harwood J.
      The diagnostic validity of hip provocation maneuvers to detect intra-articular hip pathology.
      the reported values were moderate to low.

       General Quality Assessment

      The general quality assessment performed by the levels of evidence list
      • Wright J.W.
      • Swiontkowski M.F.
      • Heckman J.D.
      Introducing levels of evidence to the journal.
      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.,
      • Nogier A.
      • Bonin N.
      • May O.
      • 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.
      which was rated Level IV.
      Table 5Overview of Included Studies With Corresponding Level of Evidence
      Author (Year of Publication)Test Description or Diagnostic Accuracy StudyLevel of Evidence
      Braly et al.
      • Braly B.A.
      • Beall D.P.
      • Martin H.D.
      Clinical examination of the athletic hip.
      (2006)
      Test descriptionV
      Domb et al.
      • Domb B.G.
      • Brooks A.G.
      • Byrd J.W.
      Clinical examination of the hip joint in athletes.
      (2009)
      Test descriptionV
      Freehill and Safran
      • Freehill M.T.
      • Safran M.R.
      The labrum of the hip: Diagnosis and rational for surgical correction.
      (2011)
      Test descriptionV
      Martin et al.
      • Martin R.L.
      • Enseki K.R.
      • Draovitch P.
      • Trapuzzano T.
      • Philippon M.J.
      Acetabular labral tears of the hip: Examination and diagnostic challenges.
      (2006)
      Test descriptionV
      Martin et al.
      • Martin H.D.
      • Kelly B.T.
      • Leunig M.
      • et al.
      The pattern and technique in the clinical evaluation of the adult hip: The common physical examination tests of hip specialists.
      (2010)
      Test descriptionV
      Martin et al.
      • Martin H.D.
      • Shears S.A.
      • Palmer I.J.
      Evaluation of the hip.
      (2010)
      Test descriptionIV
      Plante et al.
      • Plante M.
      • Wallace R.
      • Busconi B.D.
      Clinical diagnosis of hip pain.
      (2011)
      Test descriptionV
      Burnett et al.
      • Burnett R.S.
      • Della Rocca G.J.
      • Prather H.
      • Curry M.
      • Maloney W.J.
      • Clohisy J.C.
      Clinical presentation of patients with tears of the acetabular labrum.
      (2006)
      AccuracyII
      Clohisy et al.
      • Clohisy J.C.
      • Knaus E.R.
      • Hunt D.M.
      • Lesher J.M.
      • Harris-Hayes M.
      • Prather H.
      Clinical presentation of patients with symptomatic anterior hip impingement.
      (2009)
      AccuracyII
      Fitzgerald
      • Fitzgerald Jr, R.H.
      Acetabular labrum tears Diagnosis and treatment.
      (1995)
      AccuracyII
      Hase and Ueo
      • Hase T.
      • Ueo T.
      Acetabular labral tear: Arthroscopic diagnosis and treatment.
      (1999)
      AccuracyIII
      Martin et al.
      • Martin R.L.
      • Irrgang J.J.
      • Sekiya J.K.
      The diagnostic accuracy of a clinical examination in determining intra-articular hip pain for potential hip arthroscopy candidates.
      (2008)
      AccuracyIII
      Maslowski et al.
      • Maslowski E.
      • Sullivan W.
      • Forster Harwood J.
      The diagnostic validity of hip provocation maneuvers to detect intra-articular hip pathology.
      (2010)
      AccuracyIII
      McCarthy et al.
      • McCarthy J.C.
      • Noble P.C.
      • Schuck M.R.
      • Wright J.
      • Lee J.
      The role of hip arthroscopy in the diagnosis and treatment of hip disease.
      (1995)
      AccuracyIII
      Mitchell et al.
      • Mitchell B.
      • McCrory P.
      • Brukner P.
      • O'Donnel J.
      • Colson E.
      • Howells R.
      Hip joint pathology: Clinical presentation and correlation between magnetic resonance arthrography, ultrasound and arthroscopic findings in 25 consecutive cases.
      (2003)
      AccuracyIII
      Narvani et al.
      • Narvani A.A.
      • Tsiridis E.
      • Kendall S.
      • Chaudhuri R.
      • Thomas P.
      A preliminary report on prevalence of acetabular labrum tears in sports patients with groin pain.
      (2003)
      AccuracyIII
      Nogier et al.
      • Nogier A.
      • Bonin N.
      • May O.
      • 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.
      (2010)
      AccuracyIV
      Philippon et al.
      • Philippon M.J.
      • Briggs K.K.
      • Yen Y.M.
      • Kuppersmith D.A.
      Outcomes following hip arthroscopy for femoroacetabular impingement with associated chondrolabral dysfunction: Minimum two-year follow-up.
      (2009)
      AccuracyII
      Santori and Villar
      • Santori N.
      • Villar R.N.
      Acetabular labral tears: Result of arthroscopic partial limbectomy.
      (2000)
      AccuracyIII
      Sink et al.
      • Sink E.L.
      • Gralla J.
      • Ryba A.
      • Dayton M.
      Clinical presentation of femoroacetabular impingement in adolescents.
      (2008)
      AccuracyIII
      Troelsen et al.
      • Troelsen A.
      • Mechlenburg I.
      • Gelineck J.
      • Bolvig J.
      • Jacobsen S.
      • Soballe K.
      What is the role of clinical tests and ultrasound in acetabular labral tear diagnostics?.
      (2009)
      AccuracyIII
      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).

       Quality of Diagnostic Accuracy Studies

      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.,
      • Narvani A.A.
      • Tsiridis E.
      • Kendall S.
      • Chaudhuri R.
      • Thomas P.
      A preliminary report on prevalence of acetabular labrum tears in sports patients with groin pain.
      a disadvantage of all studies was the use of a study population in which there was a high suspicion or confirmation of intra-articular hip pathology.
      Table 6Quality Assessment of Diagnostic Accuracy Studies for FAI and/or Labral Pathology by Means of QUADAS Tool
      Author (Year of Publication)Q1Q2Q3Q4Q5Q6Q7Q8Q9Q10Q11Q12Q13Q14Final Score
      Burnett et al.
      • Burnett R.S.
      • Della Rocca G.J.
      • Prather H.
      • Curry M.
      • Maloney W.J.
      • Clohisy J.C.
      Clinical presentation of patients with tears of the acetabular labrum.
      (2006)
      NYYUYYYYYYNYYYGood
      Clohisy et al.
      • Clohisy J.C.
      • Knaus E.R.
      • Hunt D.M.
      • Lesher J.M.
      • Harris-Hayes M.
      • Prather H.
      Clinical presentation of patients with symptomatic anterior hip impingement.
      (2009)
      NUYYYUNNNUUYYYPoor
      Fitzgerald
      • Fitzgerald Jr, R.H.
      Acetabular labrum tears Diagnosis and treatment.
      (1995)
      NNYUYNYYYYNYYYModerate
      Hase and Ueo
      • Hase T.
      • Ueo T.
      Acetabular labral tear: Arthroscopic diagnosis and treatment.
      (1999)
      NNYUYYYUNNNYYYPoor
      Martin et al.
      • Martin R.L.
      • Irrgang J.J.
      • Sekiya J.K.
      The diagnostic accuracy of a clinical examination in determining intra-articular hip pain for potential hip arthroscopy candidates.
      (2008)
      NYNUYYYNYUUYYYModerate
      Maslowski et al.
      • Maslowski E.
      • Sullivan W.
      • Forster Harwood J.
      The diagnostic validity of hip provocation maneuvers to detect intra-articular hip pathology.
      (2010)
      NYNYYYYYYNNYYYModerate
      McCarthy et al.
      • McCarthy J.C.
      • Noble P.C.
      • Schuck M.R.
      • Wright J.
      • Lee J.
      The role of hip arthroscopy in the diagnosis and treatment of hip disease.
      (1995)
      NYYUYYYNYUNYYYModerate
      Mitchell et al.
      • Mitchell B.
      • McCrory P.
      • Brukner P.
      • O'Donnel J.
      • Colson E.
      • Howells R.
      Hip joint pathology: Clinical presentation and correlation between magnetic resonance arthrography, ultrasound and arthroscopic findings in 25 consecutive cases.
      (2003)
      NNYUYYYNYYNYYYModerate
      Narvani et al.
      • Narvani A.A.
      • Tsiridis E.
      • Kendall S.
      • Chaudhuri R.
      • Thomas P.
      A preliminary report on prevalence of acetabular labrum tears in sports patients with groin pain.
      (2003)
      YNNNYNYNYYYYNYModerate
      Nogier et al.
      • Nogier A.
      • Bonin N.
      • May O.
      • 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.
      (2010)
      NYNYYYNNNNNYNNPoor
      Philippon et al.
      • Philippon M.J.
      • Briggs K.K.
      • Yen Y.M.
      • Kuppersmith D.A.
      Outcomes following hip arthroscopy for femoroacetabular impingement with associated chondrolabral dysfunction: Minimum two-year follow-up.
      (2009)
      NYYUYYYYYYNYYYGood
      Santori and Villar
      • Santori N.
      • Villar R.N.
      Acetabular labral tears: Result of arthroscopic partial limbectomy.
      (2000)
      NNYUYUYUYNNYYYPoor
      Sink et al.
      • Sink E.L.
      • Gralla J.
      • Ryba A.
      • Dayton M.
      Clinical presentation of femoroacetabular impingement in adolescents.
      (2008)
      NYNUYUYYYUUYYYModerate
      Troelsen et al.
      • Troelsen A.
      • Mechlenburg I.
      • Gelineck J.
      • Bolvig J.
      • Jacobsen S.
      • Soballe K.
      What is the role of clinical tests and ultrasound in acetabular labral tear diagnostics?.
      (2009)
      NYNUYYYYYYYYYYGood
      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.
      • Whiting P.
      • Rutjes A.W.
      • Reitsma J.B.
      • Bossuyt P.M.
      • Kleijnen J.
      The development of QUADAS: A tool for the quality assessment of studies of diagnostic accuracy included in systematic reviews.
      (2003); Y, yes (information is provided and correct).

      Discussion

      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).
      • Troelsen A.
      • Mechlenburg I.
      • Gelineck J.
      • Bolvig J.
      • Jacobsen S.
      • Soballe K.
      What is the role of clinical tests and ultrasound in acetabular labral tear diagnostics?.
      • Burnett R.S.
      • Della Rocca G.J.
      • Prather H.
      • Curry M.
      • Maloney W.J.
      • Clohisy J.C.
      Clinical presentation of patients with tears of the acetabular labrum.
      • Philippon M.J.
      • Briggs K.K.
      • Yen Y.M.
      • Kuppersmith D.A.
      Outcomes following hip arthroscopy for femoroacetabular impingement with associated chondrolabral dysfunction: Minimum two-year follow-up.
      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.
      • Troelsen A.
      • Mechlenburg I.
      • Gelineck J.
      • Bolvig J.
      • Jacobsen S.
      • Soballe K.
      What is the role of clinical tests and ultrasound in acetabular labral tear diagnostics?.
      • Burnett R.S.
      • Della Rocca G.J.
      • Prather H.
      • Curry M.
      • Maloney W.J.
      • Clohisy J.C.
      Clinical presentation of patients with tears of the acetabular labrum.
      • Philippon M.J.
      • Briggs K.K.
      • Yen Y.M.
      • Kuppersmith D.A.
      Outcomes following hip arthroscopy for femoroacetabular impingement with associated chondrolabral dysfunction: Minimum two-year follow-up.
      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.
      • Troelsen A.
      • Mechlenburg I.
      • Gelineck J.
      • Bolvig J.
      • Jacobsen S.
      • Soballe K.
      What is the role of clinical tests and ultrasound in acetabular labral tear diagnostics?.
      • Burnett R.S.
      • Della Rocca G.J.
      • Prather H.
      • Curry M.
      • Maloney W.J.
      • Clohisy J.C.
      Clinical presentation of patients with tears of the acetabular labrum.
      • Philippon M.J.
      • Briggs K.K.
      • Yen Y.M.
      • Kuppersmith D.A.
      Outcomes following hip arthroscopy for femoroacetabular impingement with associated chondrolabral dysfunction: Minimum two-year follow-up.
      In addition, only Troelsen et al.
      • Troelsen A.
      • Mechlenburg I.
      • Gelineck J.
      • Bolvig J.
      • Jacobsen S.
      • Soballe K.
      What is the role of clinical tests and ultrasound in acetabular labral tear diagnostics?.
      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.
      • Troelsen A.
      • Mechlenburg I.
      • Gelineck J.
      • Bolvig J.
      • Jacobsen S.
      • Soballe K.
      What is the role of clinical tests and ultrasound in acetabular labral tear diagnostics?.
      • Burnett R.S.
      • Della Rocca G.J.
      • Prather H.
      • Curry M.
      • Maloney W.J.
      • Clohisy J.C.
      Clinical presentation of patients with tears of the acetabular labrum.
      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.
      • Martin R.L.
      • Irrgang J.J.
      • Sekiya J.K.
      The diagnostic accuracy of a clinical examination in determining intra-articular hip pain for potential hip arthroscopy candidates.
      • Levy B.A.
      • Yuan B.
      • Bartlet R.B.
      • Trousdale R.T.
      • Sierra R.J.
      Screening for femoroacetabular impingement in asymptomatic adolescent athletes.
      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.
      • Philippon M.J.
      • Briggs K.K.
      • Yen Y.M.
      • Kuppersmith D.A.
      Outcomes following hip arthroscopy for femoroacetabular impingement with associated chondrolabral dysfunction: Minimum two-year follow-up.
      consisted of a decreased range of motion, whereas Troelsen et al.
      • Troelsen A.
      • Mechlenburg I.
      • Gelineck J.
      • Bolvig J.
      • Jacobsen S.
      • Soballe K.
      What is the role of clinical tests and ultrasound in acetabular labral tear diagnostics?.
      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.
      • Martin H.D.
      • Shears S.A.
      • Palmer I.J.
      Evaluation of the hip.
      • Martin H.D.
      • Kelly B.T.
      • Leunig M.
      • et al.
      The pattern and technique in the clinical evaluation of the adult hip: The common physical examination tests of hip specialists.
      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.
      • Burgess R.M.
      • Rushton A.
      • Wright C.
      • Daborn C.
      The validity and accuracy of clinical diagnostic tests used to detect labral pathology of the hip: A systematic review.
      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.
      • Leibold M.R.
      • Huijbregts P.A.
      • Jensen R.
      Concurrent criterion-related validity of physical examination tests for hip labral lesions: A systematic review.
      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.
      • Burgess R.M.
      • Rushton A.
      • Wright C.
      • Daborn C.
      The validity and accuracy of clinical diagnostic tests used to detect labral pathology of the hip: A systematic review.
      • Leibold M.R.
      • Huijbregts P.A.
      • Jensen R.
      Concurrent criterion-related validity of physical examination tests for hip labral lesions: A systematic review.
      In the absence of major trauma, isolated labral pathology is uncommon.
      • Byrd J.W.T.
      • Jones K.S.
      Hip arthroscopy for labral pathology: Prospective analysis with 10-year follow-up.
      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.
      • Byrd J.W.T.
      Hip arthroscopy: Surgical indications.
      • Stevens M.S.
      • LeGay D.A.
      • Glazebrook M.A.
      • Amirault D.
      The evidence for hip arthroscopy: Grading the current indications.
      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.

      Supplementary data

      • Video 1

        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.,

        • Philippon M.J.
        • Briggs K.K.
        • Yen Y.M.
        • Kuppersmith D.A.
        Outcomes following hip arthroscopy for femoroacetabular impingement with associated chondrolabral dysfunction: Minimum two-year follow-up.
        Burnett et al.,
        • Burnett R.S.
        • Della Rocca G.J.
        • Prather H.
        • Curry M.
        • Maloney W.J.
        • Clohisy J.C.
        Clinical presentation of patients with tears of the acetabular labrum.
        and Troelsen et al.
        • Troelsen A.
        • Mechlenburg I.
        • Gelineck J.
        • Bolvig J.
        • Jacobsen S.
        • Soballe K.
        What is the role of clinical tests and ultrasound in acetabular labral tear diagnostics?.
        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.
        • Philippon M.J.
        • Briggs K.K.
        • Yen Y.M.
        • Kuppersmith D.A.
        Outcomes following hip arthroscopy for femoroacetabular impingement with associated chondrolabral dysfunction: Minimum two-year follow-up.
        and Troelsen et al.
        • Troelsen A.
        • Mechlenburg I.
        • Gelineck J.
        • Bolvig J.
        • Jacobsen S.
        • Soballe K.
        What is the role of clinical tests and ultrasound in acetabular labral tear diagnostics?.
        used a slightly different test execution for the FABER test, and these are both incorporated in the video.

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