FABER Test – OSCE Guide

This FABER (flexion, abduction and external rotation) test OSCE guide provides a clear step-by-step approach to performing the FABER test for hip joint pathology.

Background

The FABER test, also known as Patrick’s test, is a pain provocation test to aid in diagnosing hip joint pathology originating from the connective tissues. It is also used to identify a sacroiliac joint (SIJ) pathology. Additionally, it can help confirm the presence of a hip-associated pathology, such as greater trochanteric pain syndrome. The FABER test involves the following sequence of movements:

• Flexion
• ABduction
• ER – external rotation

This sequence of movements is designed to stretch or compress the irritated soft tissues to reproduce the patient’s symptoms. The FABER test is indicated when the patient complains of pain in or around the hip, groin, buttock, or SIJ. It is primarily used to assess for:

• Femoroacetabular impingement (FAI): any disease process which reduces the space between the femoral head and acetabulum may subsequently cause the sensation of pain or impingement. A disease process may be congenital (such as CAM-type deformity or pincer-type deformity) or acquired (such as osteoarthritis, causing inflammation, joint space narrowing and bony spur formation).
• Capsular injuries or degradation: these are classified as intra-capsular (within the joint capsule) and extra-capsular (outside the joint capsule) and can involve several connective tissues. For instance, the acetabular labrum (a fibrocartilaginous ring which overlies the acetabular rim and stabilises the femoral head) can be torn through sudden excessive movements. Degenerative or inflammatory processes (e.g. hip synovitis) may also cause loss of range of motion (ROM) and increased pain sensitivity. 

The FABER test can only indicate whether pathology is present. It does not tell you specifically which tissues are involved. Therefore, the FABER test should not be used as a standalone tool, and a thorough history and examination are necessary to establish a diagnosis and the underlying cause of symptoms.

A lumbar spine assessment is also necessary since a lumbar spine pathology can cause referred hip pain. For more information, see the geeky medics guide to hip examination and back pain history taking.

Functional anatomy

The hip joint (iliofemoral joint) is a synovial ball and socket joint formed by the articulation between the femoral head (ball) and the acetabulum (socket). In contrast to the shoulder joint, the hip joint contains a deeper socket to provide a greater surface area for the femoral head and effectively support the upper body’s weight.

To enhance stability, the hip joint contains several connective tissues which are susceptible to injury or degradation:

• Articular capsule: a gel-like matrix comprised of an outer fibrous layer which envelops the synovial membrane. It is susceptible to injury through sudden excessive movements or degradation through osteoarthritis.
• Acetabular labrum: a fibrocartilaginous ring which overlies the acetabular rim and stabilises the femoral head. The labrum may become injured through direct trauma resulting from sudden excessive movements, which are common in sports.
• Ligaments: various ligaments stabilise the femoral head, such as the iliofemoral, pubofemoral and ischiofemoral ligaments. These may become strained through sudden excessive movements.
• Bursae: around the hip joint and its associated structures are various fluid-filled sacs which reduce friction between contractile and non-contractile tissues. They are susceptible to bursitis resulting from overuse and inflammation. 
• Other connective tissues: all anatomical structures should be considered when assessing hip pain. For example, the tendons of various muscle groups (such as the rectus femoris and iliopsoas) may be a source of hip pain.

Introduction

Wash your hands and don PPE if appropriate.

Introduce yourself to the patient, including your name and role.

Confirm the patient’s name and date of birth.

Briefly explain what the examination will involve using patient-friendly language.

• Explain the test aims to reproduce their symptoms, and they should inform you when their symptoms (e.g. pain) occur
• Emphasise that you can stop the test at any time

Gain consent to proceed with the examination.

Ask the patient if they have any pain before proceeding with the clinical examination.

Perform the FABER test

The FABER test is performed on the asymptomatic side first, followed by the symptomatic side. 

1. Position yourself next to the side you are testing with the patient supine and the examination couch level with your hips.

2. Flex, abduct and externally rotate the patient’s hip so the lateral lower leg rests on the contralateral leg above the knee. This starting position is similar to sitting with a leg crossed (ankle-on-knee).

• If you encounter resistance when trying to flex the knee, you can ask the patient to flex their knee by pulling it towards their chest. Alternatively, you can employ a ‘popliteal unlock‘ by placing one hand under the crease of the knee and using two fingers of the opposite hand to pull the ankle into dorsiflexion and eversion before flexion.

2. Reposition your hands so that one hand is underneath the patient’s knee and the other is over the anterior superior iliac spine (ASIS) on the contralateral side. Stabilise the ASIS during the following step; the aim is to keep the patient’s pelvis as level as possible. 

3. Instruct the patient to relax their leg and slowly release your hold underneath the knee so that it drops downwards. If this does not reproduce the patient’s symptoms, transfer the palm of your hand over the medial surface of the knee and apply gradual downward pressure until you meet a natural resistance, taking care not to exceed the point of pain. 

• Watch the patient’s facial expressions and note the point at which pain is felt. The distance from the lateral femoral condyle to the examination couch can be measured with your handspan or a tape measure if you have an assistant present. 

4. Return the patient’s leg to the starting position, then walk around to the opposite side of the examination couch and repeat the test on the symptomatic side.

5. Document your findings accordingly. For example, “Sharp pain felt in hip with lateral femoral condyle approx. 1 handspan (20cm) from examination couch”.

Interpretation of findings

A positive FABER test is when any pain is reproduced (this may involve pain in or around the hip, groin, buttock, SIJ, and lumbar spine).

A negative FABER test is when pain is not reproduced.

Since pain intensity does not accurately reflect the degree of tissue damage, all pain should be regarded equally.

Ensure to compare the affected and non-affected sides and document any asymmetry in the range of movement. 

To complete the examination…

Explain to the patient that the examination is now finished.

Thank the patient for their time.

Dispose of PPE appropriately and wash your hands.

Summarise your findings.

Reviewer

Dr Richard Armitage

General Practitioner

References

1. Bagwell, J. J., Bauer, L., Gradoz, M., & Grindstaff, T. L. (2016). The reliability of FABER test hip range of motion measurements. International journal of sports physical therapy, 11(7), 1101.
2. Maslowski, E., Sullivan, W., Harwood, J. F., Gonzalez, P., Kaufman, M., Vidal, A., & Akuthota, V. (2010). The diagnostic validity of hip provocation maneuvers to detect intra-articular hip pathology. PM&R, 2(3), 174-181.
3. Trindade, C. A., Briggs, K. K., Fagotti, L., Fukui, K., & Philippon, M. J. (2019). Positive FABER distance test is associated with higher alpha angle in symptomatic patients. Knee Surgery, Sports Traumatology, Arthroscopy, 27, 3158-3161.
4. Martin, R. L., Enseki, K. R., Draovitch, P., Trapuzzano, T., & Philippon, M. J. (2006). Acetabular labral tears of the hip: examination and diagnostic challenges. Journal of Orthopaedic & Sports Physical Therapy, 36(7), 503-515.