Fulcrum Test

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Purpose

A stress fracture is a partial or a complete fracture that is a result of the repetitive application of stress to the bone. This application of excessive load to the bone will result in an imbalance between bone formation and bone resorption. 10% of all sport related injuries are stress fractures. [1] See also: ‘Leg and foot stress fractures’
Between 2.8 and 7% of all sport related stress fractures involve the femur.[1,2]. Although, Johnson et al. found in his study of running athletes that 20% of all the sports-related stress fractures involved the femur. [5]
In the general population there are two main groups that are more susceptible to stress fractures of the femur: Military trainees and athletes (especially runners). [3]Stress fractures of the femur can occur at the neck (highest incidence), the femurshaft and the condyle. [2] It mostly occurs in the proximal third of the femur.[1]
Femoral shaft stress fractures are not easy to diagnose. There are only few clinical signs, but they don’t allow to differentiate a stress fracture from another injury. One of this clinical signs is anterior thigh and hip pain, but this is generally vague and the location of the pain might not correlate with the location of the stress fracture.[1,2] A femoral stress fracture is also difficult to palpate due to the muscles covering the femoral shaft. [3]
Instead there are two clinical tests that can differentiate and diagnose a stress fracture of the femur. This two are the Hop test and the Fulcrum test as described by Johnson et al. [1]
The hop test and fulcrum test are positive during the physical examination. [1] For further information on the purpose and technique of the hop-test see also: ‘Hop test’. The technique of the fulcrum test is explained further below.
If these clinical tests are positive, the diagnosis must still be confirmed by a bone scan or a Magnetic Resonance Imaging scan. [1,4]

Technique

The technique of this test is the fulcrum test as described by Johnson et al. [5]
The patient is seated on the examination table with his lower legs dangling. The examiner places one of his arms under the symptomatic thigh. The palm of the hand is facing up and touching the patient’s leg This arm will serve as a fulcrum. At one side of the fulcrum, the force is created by the patient’s body weight. The patient is sitting, so the force si created by the upper body weight. At the other side of the fulcrum, the force is created by the weight of the lower leg and pressure by the examiner’s hand. The arm is then moved slowly towards the proximal thigh while the examiner applies with his other hand a pressure to the dorsum of the knee. When the arm as fulcrum is located under the stress fracture, the pressure on the dorsum of the knee produces an increased discomfort which is described by the patient as a sharp pain and is usually accompanied by apprehension. These tests are very sensitive and were also used during follow up to determine the eligibility of the patient for transfer to the next phase of the treatment. [1,2,3,5]

Evidence

Provide the evidence for this technique here

Resources

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References

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[1] A Ivkovic, I Bojanic, M Pecina. Stress fractures of the femoral shaft in athletes: a new treatment algorithm. Br J Sports Med 2006;40;518-520 (level B)
[2]John W. O’Kane, MD, Laura Jane Matsen. Mid-third femoral stress fracture with hip pain. JABFP January-February 2001; Vol. 14 No. 1 (level C)
[3]Juha-Petri Ruohola. Fatigue fractures in military conscripts: a study on risk factors, diagnostics and long-term consequences. Department of Orthopaedics and Traumatology, University of Helsinki. March 2007 (level D)
[4]Mark Casterline, MS, ATC; Shawn Osowski, MS, LAT, ATC; Gary Ulrich, DO. Femoral stress fracture. Journal of Athletic training 1996. Volume 31 number 1. (level C)
[5] Johnson A W, Weiss C B, Wheeler D L. Stress fractures of the femoral shaft in athletes: more common than expected. A new clinical test. Am J Sports Med 1994. 22248–256.256 (level C)