Fulcrum Test

The Fulcrum Test is primarily used to detect femoral stress fractures, most often in athletes or military recruits presenting with activity-related thigh or groin pain. The test applies a mechanical lever force (hence the name fulcrum) to provoke pain in the femur when microfractures or cortical defects are present¹. It is particularly helpful for differentiating bone stress injuries from muscular pain, groin strain, or hip joint pathology.

Advantages and Limitations

Advantages:

• Quick and simple to perform

• No special equipment required

• High specificity for femoral stress fractures²

• Useful as a screening tool in athletes and military populations

Limitations:

• Low sensitivity – a negative test does not rule out fracture²

• Interpretation can be difficult in patients with low pain threshold

• Only suitable for patients who can tolerate moderate pain provocation

• Excessive repetition may worsen symptoms³

Relevant Anatomy

The femur is the body’s strongest long bone. Stress fractures typically occur in the proximal or mid-diaphyseal region, resulting from repetitive loading (running, jumping, marching). These fractures develop gradually when bone remodeling cannot keep up with repetitive microtrauma.

Common locations for stress fractures:

• Mid-shaft femur

• Subtrochanteric region

• Proximal femur (less frequent)

They are most common in young, active individuals, particularly women with low bone density, disordered eating, or menstrual dysfunction (female athlete triad)⁴.

Test Procedure

Patient position:

• Sitting on the edge of an examination table with knees flexed at 90° and feet supported on the floor.

Execution:

1. Examiner places their forearm horizontally under the patient’s thigh, near the distal femur.

2. The opposite hand applies gentle downward pressure near the proximal femur (groin region).

3. This creates a lever (fulcrum) effect, stressing the femoral shaft.

4. The maneuver is repeated with the examiner’s arm placed progressively more proximally under the thigh to localize painful sites.

Positive test:

• Sharp, localized pain in the femur during compression.

• Patient may withdraw the leg or display pain behavior.

Interpretation and Differential Diagnosis

Positive Fulcrum Test: Strongly suggests femoral stress fracture, especially if pain is localized and reproducible.Negative Fulcrum Test: Does not exclude fracture – further imaging is required if suspicion remains.

Differential diagnoses:

• Quadriceps myalgia

• Iliopsoas syndrome

• Adductor-related groin pain

• Snapping hip syndrome

• Hip joint pathology (e.g., CAM impingement, labral tear)

• Meralgia paresthetica

Imaging:

• MRI is the most sensitive modality, able to detect stress reactions before cortical fracture develops³.

• Bone scintigraphy may also be considered if MRI is unavailable.

Evidence and Diagnostic Value

• Specificity: 93–100 %²

• Sensitivity: 18–43 %²

• Inter-rater reliability: Good with standardized technique, but influenced by patient pain tolerance

Clinical implication:

• Positive test → high suspicion, refer for MRI/orthopedic evaluation

• Negative test → cannot rule out stress fracture

Clinical Application

The Fulcrum Test is particularly valuable in first-line care, where access to imaging may be limited. It is commonly used in:

• Athletes with unexplained thigh pain

• Military recruits with activity-related groin or femoral pain

• Screening for overuse injuries during high-load training

Red flag combination:

• Activity-related thigh pain

• Night pain

• Positive Fulcrum Test

→ Strongly indicative of stress fracture → requires further imaging and management⁵.

Safety and Practical Considerations

• Perform only 1–2 times per site – excessive repetitions may exacerbate symptoms

• Stop immediately if sharp pain is elicited

• In severe pain cases, consider bypassing test and refer directly for imaging

• Always interpret in context of history, risk factors, and clinical findings

Summary

The Fulcrum Test is a fast, specific, and practical clinical maneuver for detecting femoral stress fractures. While highly specific, its low sensitivity means it is best at confirming suspicion rather than excluding the condition. Used in combination with clinical history and imaging, it remains a valuable tool in the assessment of activity-related femoral pain in athletes and military populations.

Kilder:

1. Boden BP, Speer KP. Femoral stress fractures. Clinics in sports medicine. 1997 Apr 1;16(2):307-17.

2. Deutsch AL, Coel MN, Mink JH. Imaging of stress injuries to bone: radiography, scintigraphy, and MR imaging. Clinics in sports medicine. 1997 Apr 1;16(2):275-90.

3. Martin SD, Healy JH, Horowitz S. Stress fracture MRI. Orthopedics. 1993 Jan 1;16(1):75-8.

4. Johnson AW, Weiss Jr CB, Wheeler DL. Stress fractures of the femoral shaft in athletes—more common than expected: a new clinical test. The American Journal of Sports Medicine. 1994 Mar;22(2):248-56.

5. Snyder J. John Snyder, DPT.

6. Kiel J, Kaiser K. Stress reaction and fractures. InStatPearls [Internet] 2019 Jun 4. StatPearls Publishing.