Written by manual therapists Thomas T. Ødegaard and Roar Syltebø

Over recent decades the hip joint has been the subject of a great deal of research and new knowledge, partly as a result of the introduction of hip arthroscopy. Several clinical tests have emerged in its wake. The first good description of the FADIR test comes from a Swiss research group, Klaue and colleagues, in 1991 (Klaue et al., 1991). The FADIR test is regarded as a passive movement test, but also as a provocation test. It is also known as the FADDIR test or the anterior impingement test.

Indication

The FADIR test is indicated in groin pain and anterior/lateral hip pain, when injury or pathology in or around the hip joint is suspected, and when the clinician wants to distinguish hip pain from other possible causes of the patient’s symptoms.

Procedure

The aim of the FADIR test is to stress the anterior part of the acetabular rim. This is done by simultaneously flexing, adducting and internally rotating the patient’s hip. The test is described with slightly different grips in the literature.

The patient lies supine with both legs in a neutral position. The examiner grasps the leg to be tested and flexes the hip joint maximally. The examiner places the proximal hand on the lateral aspect of the patient’s knee, while the distal hand holds the lower leg. The leg is passively brought into full adduction while the hip is internally rotated maximally (Klaue et al., 1991).

Solberg and Kirkesola (2007) describe the test in an almost identical way, except that the examiner’s distal hand holds the patient’s calcaneus (Solberg & Kirkesola, 2007).

Cook and Hegedus (2012) describe a slightly modified version. Here the hip is flexed to 90°, after which adduction and internal rotation are performed as above. This version does not specify that the movements should be taken to end range (Cook & Hegedus, 2012). It is this version, with 90° of hip flexion, that has been used in most of the more recent studies.

Comparison with the unaffected side is essential and is described in all three versions of the FADIR test (Klaue et al., 1991; Solberg & Kirkesola, 2007; Cook & Hegedus, 2012).

Body Examination recommends that passive flexion, passive internal and external rotation, the P4 test, the POSH test, the scour test and the FADIR test be assessed together as a graded examination sequence for the hip joint, with loading increased stepwise through progressive compression, adduction, rotation and range of motion. Clinical experience suggests that sensitivity increases and specificity decreases as provocation is intensified. The early steps are therefore most informative when positive, and the later steps most informative when negative. This has not been studied for the sequence as a whole, but it is consistent with the most provocative hip tests in the literature showing consistently high sensitivity and low specificity. Pain location, the step at which pain is provoked, and any restriction in range of motion should be interpreted together.

Interpretation

The FADIR test is positive if it reproduces the patient’s familiar pain in the hip or groin region and/or produces a click or a sensation of something “giving way” (Klaue et al., 1991; Solberg & Kirkesola, 2007; Cook & Hegedus, 2012).

The starting point for Klaue and colleagues was biomechanical studies. Based on Kapandji’s anatomical and biomechanical studies, they developed the FADIR test. The test brings the proximal, anterior part of the femur into contact with the acetabular rim, and this is probably exactly where the labrum is vulnerable to injury. The test applies a shear force to the labrum and its bony attachment at the acetabular rim. In a labral tear, displacement of the labrum can sometimes be palpated (Klaue et al., 1991).

The study by Klaue and colleagues aimed to give a clinical presentation of patients with hip dysplasia and what the authors call “the acetabular rim syndrome”. Twenty-nine patients were examined with the FADIR test and radiographs, and all subsequently underwent surgery. The test is described and illustrated in the article, but the authors did not investigate its diagnostic properties. The study has a QUADAS score of 7 out of 14 (Klaue et al., 1991; Cook & Hegedus, 2012).

In 2006, Burnett and colleagues published a clinical presentation of patients with acetabular labral tears (Burnett et al., 2006). The study included 47 women and 19 men with a mean age of 38 years. Symptoms had a gradual onset in 40 patients, while 20 had an acute injury and 6 a major trauma. Groin pain was the main symptom in 92% of the patients, and all underwent arthroscopy. The FADIR test was performed with 90° of hip flexion, adduction and internal rotation, and was considered positive if it provoked groin pain. The test was positive in 95% of the hips examined. The study has many limitations and was not designed to investigate the validity of the test (Burnett et al., 2006).

The American orthopaedic surgeon Philippon and colleagues published a clinical presentation of femoroacetabular impingement (FAI) (Philippon et al., 2007). The aim was to identify subjective complaints and objective findings in patients treated for impingement. A total of 301 patients (153 men and 148 women, mean age 39.9 years) underwent arthroscopy, and the main symptom was groin pain (81%). The mean time from onset of symptoms to arthroscopy was 29.6 months. The FADIR test was performed with 90° of hip flexion, internal rotation and adduction, and was considered positive if it provoked hip pain. The test was positive in 99% of the patients. The study had no control group and therefore says nothing about the specificity of the test (Philippon et al., 2007).

In 2008, Martin and Sekiya published a study of the inter-examiner reliability of four hip tests, including the FADIR test (Martin & Sekiya, 2008). The hip was taken to end range of flexion, adduction and internal rotation, and the test was considered positive if it provoked pain, regardless of location. Seventy patients (mean age 42 years, 54% men) were examined prospectively. The patients in this sample had their main pain located in the lumbosacral region. An orthopaedic surgeon and a physiotherapist examined the patients one hour apart, blinded to each other’s findings and to the diagnosis. The examiners had trained together for two months beforehand to standardise the procedure. The results were:

Kappa (95% CI)	Maximum kappa	Agreement	Prevalence index	Bias index
0.58 (0.29–0.87)	0.72	91%	0.76	0.06

A kappa value of 0.58 corresponds to moderate agreement. The authors suggest that the relatively low reliability may be because the FADIR test was performed in only 87% of the patients. The study is a reliability study and says nothing about the ability of the test to identify a specific diagnosis (Martin & Sekiya, 2008).

Clohisy and colleagues (2009) examined 51 patients (52 hips) with symptomatic anterior hip impingement. The mean age was 35 years, and 29 of the patients were men. All underwent a standardised clinical examination with range of motion tests of both hips and five provocation tests, including the “anterior impingement test”, i.e. the FADIR test. Forty-six of 52 hips (88%) had a positive test. The main symptom was groin pain (88%) and/or lateral hip pain (67%). The study is descriptive and has no control group, the procedure for the test is not described, and the authors point out that the protocol was not standardised across examiners (Clohisy et al., 2009).

Troelsen and colleagues (2009) investigated clinical tests and ultrasound in the diagnosis of labral tears in 18 patients (16 women, mean age 43 years) who had previously undergone periacetabular osteotomy for hip dysplasia. MR arthrography was the reference standard. The FADIR test was performed with 90° of hip flexion, internal rotation and adduction, and was considered positive if it provoked groin pain. MR arthrography showed a labral tear in 17 of 18 patients. Ultrasound had a sensitivity and positive predictive value of 94%. The FADIR test was positive in 10 of the 17 patients with a labral tear, i.e. a sensitivity of 59%. The specificity of 100% is based on a single patient without a labral tear and should therefore not be given any weight. The sample was small and highly selected, and the results are difficult to apply to hip patients in general (Troelsen et al., 2009).

In a systematic review with meta-analysis, Reiman and colleagues (2015) found that the FADIR test has a high pooled sensitivity for FAI and labral tears, 94–99% (95% CI 90–100%). The diagnostic odds ratio, however, was low and highly uncertain, 5.7–7.8, with confidence intervals ranging from below 1 to 58. Only one of 21 studies was judged to be of high methodological quality. The authors concluded that the FADIR test has screening value only: a negative test may help to rule out FAI or a labral tear, but a positive test does not confirm the diagnosis (Reiman et al., 2015).

More recent studies support this picture. A systematic review of clinical tests for cam or pincer morphology in patients with suspected FAI syndrome found that the FADIR test had high sensitivity but low specificity. Combined with two other sensitive tests, a negative result could markedly lower the probability of cam or mixed morphology (negative likelihood ratio about 0.15), but the evidence was rated as low quality (Caliesch et al., 2020). Another systematic review found that sensitivity varied widely depending on the reference standard used (Shanmugaraj et al., 2020).

Pålsson and colleagues (2020) examined 63 patients (69 hips) with longstanding groin and hip pain at a Swedish orthopaedic outpatient clinic. The reference standard combined symptoms, cam and/or pincer morphology on radiographs and at least 50% pain relief after an intra-articular anaesthetic injection. The FADIR test had a sensitivity of 80% but low specificity, and inter-examiner reliability was substantial (kappa above 0.6). The authors conclude that a negative FADIR test may help to rule out FAI syndrome, whereas reduced passive internal rotation of the hip in neutral (specificity 94%) is more useful for confirming the diagnosis. Combining a sensitive provocation test with a specific range of motion test may thus increase diagnostic accuracy (Pålsson et al., 2020).

A 2025 systematic review of clinical tests for prearthritic intra-articular hip pathology found that sensitivity and specificity vary greatly between studies. No single test can confirm the diagnosis on its own, and the authors recommend combining clinical tests with the history and imaging (Dhillon et al., 2025).

In a review of the hip examination, Martin and colleagues (2010) point out that the way hip tests are performed and the terminology used vary considerably, and that research on the validity of the tests is lacking (Martin et al., 2010). Although the FADIR test is now one of the most studied hip tests, the picture remains the same: the test is highly sensitive but has low specificity.

The FADIR test in conditions other than FAI: osteoarthritis and arthritis

The FADIR test has mainly been validated for femoroacetabular impingement (FAI) syndrome and labral tears, and most diagnostic accuracy studies excluded patients with established osteoarthritis. Its diagnostic accuracy for hip osteoarthritis (OA) and inflammatory arthritis is therefore not established. However, the test is regarded as a general provocation test for intra-articular hip pain. Studies using an intra-articular anaesthetic injection as the reference standard show that other hip provocation tests are also sensitive but non-specific (Maslowski et al., 2010). The low specificity probably partly reflects that other intra-articular conditions, including OA and synovitis, may also produce a positive test.

In hip OA, painful and reduced passive adduction and internal rotation are among the most useful clinical findings, whereas normal passive adduction makes OA unlikely (Metcalfe et al., 2019). These are exactly the movements the FADIR test combines. The UK osteoarthritis guideline from the National Institute for Health and Care Excellence (NICE) states that OA can be diagnosed clinically in people aged 45 or over who have activity-related joint pain and either no morning stiffness or morning stiffness lasting no longer than 30 minutes (NICE, 2022). A positive FADIR test in patients aged 45 or over should therefore prompt consideration of OA, and in patients with systemic or inflammatory features, of arthritis. This is based on clinical reasoning and indirect evidence rather than dedicated diagnostic studies.

Body Examination suggests the following interpretation of the FADIR test

• The FADIR test is positive if it reproduces the patient’s familiar pain in the groin or anterior hip.
• Body Examination suggests that the FADIR test should be used to assess not only pain, but also range of motion and end-feel.
• The unaffected side should always be examined as a control.
• The FADIR test is highly sensitive but has low specificity. A negative test makes intra-articular hip involvement such as FAI or a labral tear less likely, whereas a positive test does not confirm the diagnosis on its own.
• A positive FADIR test should be interpreted in light of the history and the rest of the hip examination. Reduced passive internal rotation of the hip may strengthen the suspicion of intra-articular involvement.
• Body Examination considers the FADIR test to be a relatively simple test to perform, which all clinicians who examine hip patients should master.
• Body Examination recommends applying overpressure and taking the joint fully to end range in all directions. This provokes the joint maximally, making it easier to reproduce the patient’s familiar pain.
• In younger patients with a positive FADIR test and persistent symptoms, further investigation with imaging may be appropriate, with a view to cam/pincer morphology and labral tears.
• In patients aged 45 or over, a positive FADIR test should also raise suspicion of osteoarthritis, and in the presence of systemic or inflammatory features, of arthritis.

Literature search, updating and translation were carried out with the assistance of AI (Claude, Anthropic). The professional content has been reviewed and quality-assured by the editor-in-chief, Roar Syltebø.

References

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• Caliesch R, Sattelmayer M, Reichenbach S, Zwahlen M, Hilfiker R. Diagnostic accuracy of clinical tests for cam or pincer morphology in individuals with suspected FAI syndrome: a systematic review. BMJ Open Sport Exerc Med. 2020;6(1):e000772.
• Clohisy JC, Knaus ER, Hunt DM, Lesher JM, Harris-Hayes M, Prather H. Clinical presentation of patients with symptomatic anterior hip impingement. Clin Orthop Relat Res. 2009 Mar;467(3):638-44.
• Cook CE, Hegedus EJ (2012): Orthopedic Physical Examination Tests: An Evidence-Based Approach (2nd Edition). New Jersey: Prentice Hall.
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• National Institute for Health and Care Excellence (2022): Osteoarthritis in over 16s: diagnosis and management (NICE guideline NG226). London: NICE.
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