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.
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.
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
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
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
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
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
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
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.
No specialised equipment is required.
Useful resources include:
Examination plinth
Pain scale
Body chart
Measurz assessment workflow
Symptom recording sheet
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."
Seated on the edge of a plinth
Hips flexed
Knees flexed
Lower legs hanging freely
Beside the tested limb
One forearm placed beneath the thigh
Opposite hand positioned over the distal femur just above the knee
Maintain upright sitting posture
Avoid excessive trunk leaning
Ensure the client remains relaxed
Position forearm beneath the distal femur.
Apply gentle downward pressure above the knee.
Move the forearm progressively proximally.
Repeat loading at several points.
Monitor symptom response.
Downward force applied through distal femur
Upward counterforce from examiner forearm
Controlled femoral bending stress
Ask:
"Tell me if you feel anything."
"Where do you feel it?"
"Is it your familiar pain?"
"Rate it from 0–10."
A positive Fulcrum Test is typically:
Sharp localised thigh pain
Reproduction of familiar symptoms
Apprehension during loading
Pain localised to a specific femoral region
A negative test is:
No familiar thigh pain reproduced
No sharp focal pain during loading
Stop if:
Symptoms become severe
Significant apprehension occurs
Client requests cessation
Avoid excessive force.
If stress fracture suspicion is already high, further provocative testing may be unnecessary and referral may be more appropriate.
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
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.
Diagnostic accuracy evidence for the Fulcrum Test is limited and primarily derived from small studies involving suspected femoral stress fractures.
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.
Current limitations include:
Small sample sizes
Limited prospective studies
Variable reference standards
Different test techniques
Limited modern validation studies
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.
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
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
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
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
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
Patellar Pubic Percussion Test
Hop Test
Single Leg Hop Test
Hip Quadrant Test
Craig Test
FADIR Test
FABER Test
Reproduction of sharp familiar thigh pain during femoral loading.
It assesses symptom response to mechanical loading of the femur and may support suspicion of a femoral stress injury.
No. It may increase suspicion but does not diagnose or confirm a stress fracture.
Often yes. MRI is commonly considered the preferred imaging method when a bone stress injury is suspected.
Soft tissue irritation, pain sensitisation, local tenderness or other thigh pathology may reproduce symptoms.
It may reduce suspicion but does not fully exclude a bone stress injury.
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.
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.
