The Fulcrum Test is an orthopaedic screening test used to assess whether controlled bending stress applied to the femur reproduces familiar thigh pain associated with a possible femoral stress injury. A positive test may increase suspicion of a femoral stress fracture when it matches the client's history, loading pattern and other assessment findings. It does not diagnose, confirm or exclude a stress fracture on its own, and imaging is typically required when a bone stress injury is suspected.

Introduction

Femoral stress fractures are relatively uncommon but clinically important bone stress injuries that can occur in runners, military personnel, athletes and physically active individuals exposed to repetitive loading.

Early symptoms are often vague and may present as:

• Deep thigh pain
• Groin pain
• Activity-related aching
• Pain that increases with impact loading
• Reduced running tolerance

The Fulcrum Test was originally described by Johnson et al. (1994) as a clinical method for identifying femoral shaft stress fractures in athletes. The test uses the examiner's forearm as a fulcrum beneath the thigh while a downward force is applied to the distal femur, creating a bending force through the bone.

It is commonly used when assessing suspected:

• Femoral shaft stress fractures
• Femoral bone stress injuries
• Persistent activity-related thigh pain
• Running-related bone stress injuries

The test should be considered part of a broader assessment and not a stand-alone diagnostic procedure.

Quick Summary

Test name: Fulcrum Test

Region: Femur / thigh

Test type: Orthopaedic stress fracture screening test

Common position: Sitting

Primary movement: Femoral bending stress

Positive finding: Reproduction of sharp, localised familiar thigh pain

Negative finding: No familiar thigh pain reproduced

Best used with: History, load assessment, palpation, hop testing and imaging referral where indicated

Key limitation: Does not confirm or exclude stress fracture independently

What Is the Fulcrum Test?

The Fulcrum Test is a symptom-provocation test designed to apply a controlled bending force through the femoral shaft.

The examiner uses their forearm beneath the thigh as a pivot point while applying downward pressure above the knee.

If a femoral stress injury is present, this loading may reproduce familiar localised pain.

The test is primarily associated with:

• Femoral shaft stress fractures
• Femoral bone stress injuries
• Activity-related femoral pain

It is not designed to assess:

• Hip labral pathology
• Femoroacetabular impingement
• Muscle strains
• Tendinopathy
• Knee pathology

Why It Is Used

The Fulcrum Test may help professionals:

• Reproduce familiar thigh symptoms
• Identify possible femoral bone stress involvement
• Differentiate bone-related symptoms from some soft tissue presentations
• Support referral decisions
• Monitor symptom response over time
• Record findings within Measurz

It is particularly useful when symptoms are:

• Exercise related
• Running related
• Persistent despite rest
• Poorly localised
• Provoked by impact activities

What It Assesses

The Fulcrum Test may assess:

• Mechanical sensitivity of the femur
• Possible femoral shaft stress injury
• Bone stress symptom reproduction
• Localisation of suspected stress fracture pain

It may be associated with:

• Femoral shaft stress fractures
• Femoral bone stress injuries
• High-volume running loads
• Repetitive impact exposure

It does not directly assess:

• Bone healing status
• Fracture severity
• Exact stress fracture grade
• Femoral neck stress fractures
• Hip joint pathology
• Soft tissue injury

Who It Is Useful For

The Fulcrum Test may be useful for:

• Exercise professionals
• Strength and conditioning coaches
• Sports medicine practitioners
• Allied health support staff
• Running coaches
• Athletic development professionals
• Students learning orthopaedic assessment

Common populations include:

• Distance runners
• Track athletes
• Military personnel
• Court sport athletes
• Field sport athletes
• Individuals returning from rapid training increases

When to Use This Test

Consider the Fulcrum Test when assessing:

• Activity-related thigh pain
• Suspected femoral stress injury
• Running-related bone stress symptoms
• Persistent impact-related pain
• Unexplained deep femoral discomfort

Symptoms may include:

• Deep anterior thigh pain
• Mid-thigh pain
• Pain during running
• Pain with hopping
• Pain after training sessions
• Progressive activity-related symptoms

When Not to Use or When to Be Cautious

Use caution if the client has:

• Severe pain
• Suspected complete fracture
• Recent significant trauma
• Inability to weight bear
• Acute worsening symptoms
• Recent surgery

Stop the test if:

• Severe pain occurs
• Symptoms escalate rapidly
• Client requests cessation
• The position is not tolerated

If a high-risk bone stress injury is suspected, medical referral may be more appropriate than provocative testing.

Equipment Required

No specialised equipment is required.

Useful resources include:

• Examination plinth
• Pain scale
• Body chart
• Measurz assessment workflow
• Symptom recording sheet

Step-by-Step Protocol / Practice

Setup

Explain the purpose of the test.

Example:

"We're going to apply a controlled load through your thigh bone to see whether it reproduces your familiar symptoms. This helps us understand how your symptoms respond to loading but does not diagnose the cause on its own."

Client Position

• Seated on the edge of a plinth
• Hips flexed
• Knees flexed
• Lower legs hanging freely

Examiner Position

• Beside the tested limb

Hand Placement

• One forearm placed beneath the thigh
• Opposite hand positioned over the distal femur just above the knee

Stabilisation

• Maintain upright sitting posture
• Avoid excessive trunk leaning
• Ensure the client remains relaxed

Movement Sequence

1. Position forearm beneath the distal femur.
2. Apply gentle downward pressure above the knee.
3. Move the forearm progressively proximally.
4. Repeat loading at several points.
5. Monitor symptom response.

Movement Direction

• Downward force applied through distal femur
• Upward counterforce from examiner forearm
• Controlled femoral bending stress

Instructions

Ask:

• "Tell me if you feel anything."
• "Where do you feel it?"
• "Is it your familiar pain?"
• "Rate it from 0–10."

Positive Finding

A positive Fulcrum Test is typically:

• Sharp localised thigh pain
• Reproduction of familiar symptoms
• Apprehension during loading
• Pain localised to a specific femoral region

Negative Finding

A negative test is:

• No familiar thigh pain reproduced
• No sharp focal pain during loading

Stopping Criteria

Stop if:

• Symptoms become severe
• Significant apprehension occurs
• Client requests cessation

Safety Notes

Avoid excessive force.

If stress fracture suspicion is already high, further provocative testing may be unnecessary and referral may be more appropriate.

Positive and Negative Test Interpretation

Positive Test

A positive Fulcrum Test means the applied bending load reproduces familiar thigh pain.

A positive result may increase suspicion of:

• Femoral stress fracture
• Femoral bone stress injury
• Bone-loading sensitivity

It is more meaningful when accompanied by:

• Running history
• Impact-related pain
• Hop-test pain
• Progressive training load
• Localised tenderness

A positive test does not confirm:

• Stress fracture diagnosis
• Fracture grade
• Exact location
• Need for surgery

Negative Test

A negative test means loading did not reproduce familiar symptoms.

A negative result may decrease suspicion of a femoral shaft stress injury.

However, it does not fully exclude:

• Early stress injury
• Low-grade bone stress injury
• Femoral neck stress injury
• Intermittent symptoms

Further assessment may still be warranted if clinical suspicion remains high.

Sensitivity, Specificity and Diagnostic Accuracy

Diagnostic accuracy evidence for the Fulcrum Test is limited and primarily derived from small studies involving suspected femoral stress fractures.

Femoral Stress Fracture

Johnson et al. (1994) originally described the test in athletes with femoral shaft stress fractures and reported accurate localisation of symptoms to the fracture site.

A review of hip examination procedures reported:

• Sensitivity: 88–93%
• Specificity: 13–75%

for suspected femoral stress fractures. These values vary considerably across studies and populations.

Evidence Limitations

Current limitations include:

• Small sample sizes
• Limited prospective studies
• Variable reference standards
• Different test techniques
• Limited modern validation studies

Practical Diagnostic Accuracy Summary

The Fulcrum Test may be useful for increasing suspicion of a femoral stress injury when positive and clinically consistent.

It should not be used as a stand-alone screening tool.

Imaging remains the preferred method for confirming suspected bone stress injury.

Reliability and Validity

High-quality reliability evidence for the Fulcrum Test appears limited.

Validity is likely improved when findings are interpreted alongside:

• Symptom history
• Running load history
• Hop testing
• Palpation
• Functional assessment
• Imaging findings

Consistency improves when clinicians standardise:

• Sitting position
• Forearm location
• Force application
• Symptom questioning
• Pain recording methods

Common Errors and Limitations

Common Errors

• Applying excessive force
• Not comparing symptom location to familiar pain
• Using the test as a diagnostic tool
• Ignoring training history
• Failing to record pain location
• Continuing despite severe pain

Limitations

• Limited high-quality evidence
• Small validation studies
• Variable diagnostic values
• Does not identify fracture severity
• Does not replace imaging
• Negative results do not fully exclude bone stress injury

Practical Applications

The Fulcrum Test may support:

• Running injury assessment
• Bone stress injury screening
• Sports medicine assessment
• Femoral pain evaluation
• Referral decision-making
• Measurz assessment documentation

It is most useful when combined with:

• Training history
• Hop testing
• Functional loading assessment
• Imaging where indicated

How to Record This in Measurz

Record:

• Test name: Fulcrum Test
• Side tested
• Result: positive, negative, unclear or unable to test
• Pain score
• Pain location
• Familiar symptom reproduction
• Loading point on femur
• Symptom quality
• Comparison side
• Irritability
• Functional findings
• Running load history
• Hop test findings
• Confidence in result
• Interpretation notes
• Referral recommendations
• Retest date if relevant

Recording these details improves:

• Repeatability
• Communication
• Assessment reasoning
• Monitoring over time
• Team consistency

Related Tests / Internal Links

• Patellar Pubic Percussion Test
• Hop Test
• Single Leg Hop Test
• Hip Quadrant Test
• Craig Test
• FADIR Test
• FABER Test

FAQs

What is a positive Fulcrum Test?

Reproduction of sharp familiar thigh pain during femoral loading.

What does the Fulcrum Test assess?

It assesses symptom response to mechanical loading of the femur and may support suspicion of a femoral stress injury.

Can the Fulcrum Test diagnose a stress fracture?

No. It may increase suspicion but does not diagnose or confirm a stress fracture.

Is imaging still needed?

Often yes. MRI is commonly considered the preferred imaging method when a bone stress injury is suspected.

What causes a false positive?

Soft tissue irritation, pain sensitisation, local tenderness or other thigh pathology may reproduce symptoms.

Is a negative test reassuring?

It may reduce suspicion but does not fully exclude a bone stress injury.

Key Takeaways

• The Fulcrum Test is used to assess possible femoral stress injuries.
• It applies a controlled bending force through the femur.
• A positive test reproduces familiar localised thigh pain.
• A positive result may increase suspicion of a femoral stress fracture.
• A negative result does not fully exclude bone stress injury.
• Diagnostic accuracy evidence remains limited.
• Imaging remains important when suspicion is high.
• Findings should be interpreted alongside history and other assessment findings.
• Detailed Measurz recording improves repeatability and assessment quality.

References

Johnson, A. W., Weiss, C. B., & Wheeler, D. L. (1994). Stress fractures of the femoral shaft in athletes—more common than expected: A new clinical test. American Journal of Sports Medicine, 22(2), 248–256.

Reiman, M. P., Mather, R. C., & Cook, C. E. (2015). Physical examination tests for hip dysfunction and injury. British Journal of Sports Medicine, 49(6), 357–361.

Boden, B. P., & Speer, K. P. (1997). Femoral stress fractures. Clinics in Sports Medicine, 16(2), 307–317.

Deutsch, A. L., Coel, M. N., & Mink, J. H. (1997). Imaging of stress injuries to bone. Clinics in Sports Medicine, 16(2), 275–290.

Kaufman, K. R., et al. (2022). Prospective assessment of clinical tests used to evaluate tibial stress fracture. Orthopaedic Journal of Sports Medicine, 10(9). PMID: 36147792.