Knee Surgery, Sports Traumatology, Arthroscopy

https://doi.org/10.1007/s00167-018-5031-2

HIP

Positive FABER distance test is associated with higher alpha angle

in symptomatic patients
Christiano A. C. Trindade1 · Karen K. Briggs1 · Lorenzo Fagotti1 · Kiyokazu Fukui1 · Marc J. Philippon1

Received: 19 January 2018 / Accepted: 22 June 2018

© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2018

Abstract
Purpose  The purpose of this study was to determine the diagnostic value of the flexion abduction external rotation (FABER)
distance test (FDT) for the diagnosis of cam-type femoroacetabular impingement (FAI) as defined by alpha angle.
Methods  For this study, 603 patients with symptomatic, unilateral femoroacetabular impingement were included. Patients
with symptoms of hip instability, bilateral symptoms, bilateral surgery, or bilateral alpha angles over 55 were excluded from
the analysis. A positive FDT was defined as a difference of 4 cm or more between hips. A pathological cam was defined as
an alpha angle of 78° or greater.
Results  The average age was 36.4 ± 12 years, with 344 males and 259 females. Faber distance of the injured hip was cor-
related with age at surgery (rho = 0.148; p < 0.001). Alpha angle on the injured hip was positively correlated with injured
hip FABER distance (rho = 0.276; p < 0.001). The average alpha angle in patients with a positive FABER distance test was
74° (SD = 11°) compared to 68° (SD = 8°) in patients with a negative distance test (p = 0.001). The sensitivity of the FDT to
diagnose pathological cam was 0.848 (0.79–0.89) with a negative predictive value of 86% (81–90%).
Conclusion  This study demonstrated that the FABER distance test is correlated with the alpha angle and is a good diagnostic
exam for pathological cam-type FAI as defined by and alpha angle equal to or greater than 78°.
Clinical relevance  FABER distance test is a simple test that can be used as a screening test to decide if FAI should be sus-
pected and further testing is needed.
Level of evidence III.

Keywords  Femoroacetabular impingement · Alpha angle · Diagnosis · FABER

Introduction
Femoroacetabular impingement (FAI) is known to be cause
of injury to the articular cartilage of the hip and labrum and
lead to osteoarthritis of the hip [4, 6]. There are two types
of FAI, cam and pincer, which may occur separately or com-
bined. Several studies have shown that injuries may proceed
down a cascade of injury leading to osteoarthritis [4, 6]. Pain
and disability can start with a relative mild injury or with
vigorous physical activity.
Patients with symptomatic FAI typically present with
pain in the groin, limited range of motion and positive clini-
cal tests as such as anterior and posterior impingement [5,
* Karen K. Briggs
karen.briggs@sprivail.org
1
Attn: Hip Research, Steadman Philippon Research Institute,
181 W. Meadow Dr., Suite 1000, Vail, CO 81657, USA
9, 12, 16, 18]. The FABER (flexion abduction external rota-
tion) test is a clinical exam used to screen patients for sac-
roiliac joint and hip joint pathology [11, 12, 18]. This test is
widely used by orthopedic surgeons, with good sensitivity
but low specificity for detection of intra-articular pathologies
[10]. Currently, there is limited literature on the best tests for
diagnosing cam impingement without imaging. A systematic
review showed that most diagnostic test have weak diagnos-
tic properties [14]. There is no consensus in the literature
defining diagnostic tests for FAI.
The FABER distance test (FDT) is a modification of the
FABER test, that has been used as a measure of motion
deficit [18] and as a diagnostic test for cam impingement
[2, 11, 12]. This provides a numerical value to compare to
the opposite extremity and based on this difference, a pre-
liminary diagnosis can be made. Bagwell et al. tested the
reliability of the FABER distance test [2]. They found the
inter-rater reliability was good and intra-rater reliability was

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good to excellent. In addition, they determined the mean
minimal detectable change was 3.7 cm [2].
The value of the FDT to diagnose cam FAI is unclear.
The alpha angle is the most common diagnostic test used
for cam impingement [7–9, 11, 12, 17]. The alpha angle
can be measured on radiographs or other imaging. Johnston
et al. showed that an increasing alpha angle is associated
with a larger cam and intra-articular damage due to FAI
[8]. A systematic review reported an alpha angle > 55° was
the most reported measure of cam impingement [10]; how-
ever, Barrientos et al. suggested an alpha angle greater than
57° be used for improved sensitivity and specificity for cam
impingement [3]. However, in a study by Larson et al. in 998
hips, they found that larger alpha angle was highly predictive
of intra-articular symptoms [9]. In a large epidemiological
study, the authors identified 78° as the cut-off for pathologi-
cal cam [1]. This high alpha angle may be a better definition
in the symptomatic population.
The purpose of this study was to determine if the FABER
distance test (FDT) was associated with the alpha angle as
a diagnostic tool for FAI. In addition, the study determined
the sensitive and specific test for diagnosis of pathological
FAI cam impingement as defined by the alpha angle of 78°.
Higher alpha angles in patients with a positive FDT were
hypothesized. The FDT can be used as a screening test to
determine if FAI should be suspected and more testing is
needed.
Materials and methods
From a prospective database, patients with symptomatic
unilateral femoroacetabular impingement (FAI) who under-
went hip arthroscopy between 2007 and 2014 were eligible
for the study. Patients were included if they had hip pain,
alpha angle 50° or greater, 18 years of age or older, had pro-
spectively documented FDT and alpha angle and complete
physical exam. The FDT was measured by a physician who
also measured the alpha angle on radiographs. The FDT and
the radiographs were performed on the same day. Exclusion
criteria were presence of clinical symptoms for hip laxity
such complains of giving way symptoms, history of hip dis-
location, and positive evaluation for global hypermobility,
bilateral hip pain or disability, history of prior hip surgery on
either hip, alpha angle less than 50° and a lateral center-edge
angle lower than 20° measured on the antero-posterior view.
Physical examination of the hip included range of motion,
anterior and posterior impingement tests, hip dial test, and
the FDT [12]. The FDT was performed with the patient in
the supine position; the leg was flexed and the heel of the
affected leg is placed over the contra-lateral knee, just above
the patella, as in Fig. 4 position. The pelvis is stabilized and
the patient is asked to hold that position. The distance from
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Knee Surgery, Sports Traumatology, Arthroscopy
the lateral femoral epicondyle of the knee to the examina-
tion table was measured (FABER distance), with the pelvis
stabilized. The measurement was taken after the knee natu-
rally came to rest, with no pressure put on the leg by the
examiner. The measurement was repeated on each hip in no
specific order. For this study, a positive test was defined as
greater than 4 cm difference between the sides, based on the
previously reported MDC [2]. A previous study reported
intra-rater reliability and inter-rater reliability to be good to
excellent [2].
Cross-table radiographies were obtained on each affected
hip and the alpha angle measured. In a recent study, patho-
logical cam impingement was defined as 78°, based on the
development of end-stage OA at 5 years follow-up [1]. This
was used as the threshold to determine the diagnostic ability
of the FDT to determine pathological cam.
This study was IRB approved by the Vail Valley Medical
Center IIRB under IRB protocol #2002-03.
Statistical analysis
The sensitivity, specificity, positive predictive value, nega-
tive predictive value, positive likelihood ratio, and negative
likelihood ratio for the FDT were calculated. Sensitivity
determined the probability of a positive FDT in individu-
als with alpha angle 78° or over. Specificity determined the
probability a negative FDT in individuals with alpha angle
less than 78°. The positive predictive value showed the per-
centage of individuals with a positive FDT who have an
alpha angle of 78° or greater and negative predictive value
was the percentage of individuals with a negative FDT who
have an alpha angle of less than 78°. All were calculated
using standard formulas [15]. Using Kolmogorov–Smirnov
test, it was determined that Faber distance was not normally
distributed. For comparison of other factors to the FABER
distance, the Spearman’s rho correlation coefficient was used
for assessing associations. Nonparametric univariate analy-
sis was performed with the Mann–Whitney U test for com-
parison of the FABER distance. For this study, sensitivity
was estimated to be 0.80 and precision = 0.05 with 95% con-
fidence level (two-tailed) and expected prevalence = 0.50.
For adequate power, 600 patients were needed.
Results
Six hundred and three patients met the inclusion criteria. The
average age was 36.4 ± 12 years (range 18–71 years), with
344 males and 259 females. The average alpha angle on the
injured hip was 72° ± 11° (range 50°–110°) and the average
FABER distance difference was 6 (range − 11 to 26) cm. The
average FABER distance on the injured hip was 25 ± 7.4 cm
and 19 ± 6.2 on the non-injured hip. Faber distance was
Knee Surgery, Sports Traumatology, Arthroscopy
correlated with age at surgery (rho = 0.148; p < 0.001). Four
hundred and fifteen (69%) patients had a positive FDT and
188 (31%) had a negative FDT. Alpha angle was positively
correlated with FABER distance (rho = 0.276; p < 0.001).
The average alpha angle in patients with a positive FABER
distance test was 74° (SD = 11°) compared to 68° (SD = 8°)
in patients with a negative distance test (p = 0.001). There
were 432 patients who had alpha angle of 78° or greater and
171 patients had less than 78°. The diagnostic and predictive
values are shown in Table 1.
Discussion
The most important finding of the present study was in
symptomatic FAI, patients with a positive FDT had higher
alpha angle than the patients with a negative FDT. A larger
FDT was associated with a larger alpha angle and for patho-
logical cam, the FDT had a sensitivity of 84.8% and a nega-
tive predictive value of 86%. The physical examination of
the hip is an essential step for the diagnosis of FAI. The
FDT may provide a sensitivity test for assisting with the
diagnosis of FAI.
This study presents a variation of the classic FABER test.
The FABER test or Patrick test has alone a low specificity
for detecting intra-articular pathologies [10, 17], with mod-
erate levels of agreement [10, 17]. The FABER distance test
(FDT), which provides a distance measurement that may be
used as a diagnostic criteria [2, 11, 12]. With the traditional
FABER test, a positive exam is based on pain [12], and this
may vary based on how much pressure is placed on the leg
by the examiner and may vary by examiner. During the
measurement of the FDT, the patient is supine and relaxed.
No pressure is placed on the leg and the patient leg stays in
the same position while the measurement is taken, result-
ing in less variability. Inter-tester and intra-tester reliability
was not tested; however, it has been previously reported as
good to excellent [2]. In addition, the distance of more than
4 cm, as a definition of a positive test, is based on previous
research [2]. This distance has proven to be an excellent test
as seen with the sensitivity in this study; however, further
research is needed to determine if this is the correct value.
Table 1  Diagnostic test of FABER distance test (> 3.7 cm difference
between hips) for radiographic large alpha angle (≥ 78°; n = 171)
compared to small alpha angle (50°–77°; n = 432) in patients with
symptomatic FAI
Symptomatic FAI (95% CI)
Sensitivity 0.848 (0.79–0.89)
Specificity 0.38 (0.35–0.39)
Positive predictive value 35% (33–37%)
Negative predictive value 86% (81–90%)
Two systematic reviews reported on the accuracy and
validity of physical tests to detect labral pathology and FAI
[14, 17]. In the first review, the FABER test with pain or
as a measure of range of motion was one of tests that were
included. In six studies the sensitivity of the FABER ranged
from 0.41 to 0.97 [17]. However, each study had a different
reference standard used to confirm the diagnosis. The sensi-
tivity of the FDT in this study was 0.71 for the symptomatic
FAI group. The other systematic review identified 3 studies
with FABER test [14]. The positive predictive value of the
test ranged from 45.5 to 93.8%. As with the other review,
the definitions of a positive test and the reference standard
differed between studies. Both systematic reviews concluded
that there was not adequate research on clinical exam tests
[14, 17].
In the individual with cam impingement, the “bump”,
impinging against the labrum, puts the hip is “at-risk” of
intra-articular damage [11]. The concern with the hip “at-
risk” hip is that the hip may rapidly deteriorate as the labrum
and chondrolabral junction continue to be injured [11]. The
only way to stop the damage caused by the bony impinge-
ment is to change the mechanical environment of the hip. A
positive FDT may be an indication that intervention, such
as a change in training technique or surgery, is necessary
in patients with symptomatic FAI. Johnston et al. showed
more intraarticular damage in patients with a higher alpha
angle, including detachment of the labrum and full thick-
ness delamination of the articular cartilage [8]. In another
study, patients who waited longer than 1 year and had an
alpha angle of greater than 55° were 9.5 times more likely
to have grade III/IV chondral lesions than those who did
not wait [13].
Early detection of pathology may prevent further chon-
dral damage and help preserve the hip joint. This test can
be useful in the clinical situation in symptomatic patients
to identify those patients who may have cam impingement.
With a positive FDT, patients can then be referred to an
MRI to evaluate the status of the labrum and cartilage. If a
patient has a negative test, other test should be used to rule
out the diagnosis of cam impingement. A patient with mild
symptoms and a negative FDT may need to be monitored to
determine when symptoms increase when the FDT is posi-
tive. At that point, surgical intervention may be necessary.
This study has several limitations. All measurements
were not measured by one observer. To limit the impact of
the variability, the same person who measured the FDT also
measured the alpha angle. It is still unclear if the reliability
of the FDT in our hands is as reliable as that previously
reported. Bias was also introduced by the individual measur-
ing the FDT having access to the MRI findings. While the
measurements were made prior to review of the MRI, it is
possible that the individual measuring the distance may have
reviewed in first. The subjects in this study had hip pain and
13

the FDT may have been more affected by symptoms com-
pared to actual impingement. It is still unclear what mecha-
nism causes the limited motion on the FDT. It is also unclear
what role ligament laxity may play in the measurement of
FD. To limit this factor, patients who reported instability
in their hip were excluded from the study. While patients
with bilateral symptoms, surgery or high alpha angles were
excluded, it was impossible to exclude patients who may
develop symptomatic FAI on the other hip. However, all
patients were older than 18 and likely had closed physis,
possibly limiting the risk of further formation of CAM
deformity due to stress on an open physeal plate. This study
included a single timepoint for each patient at the time of
presentation. More research is needed to determine which
patients develop bilateral FAI and which patients do not.
Conclusion
This study demonstrated that the FABER distance test is cor-
related with the alpha angle and is a good diagnostic exam
for pathological cam-type FAI as defined by alpha angle
equal to or greater than 78°.
Funding  No outside funding was provided for this study.
Compliance with ethical standards  12. Philippon MJ, Maxwell RB, Johnston TL, Schenker M, Briggs KK
Conflict of interest  Board member/owner/officer/committee appoint-
ments: Arthrocare (MJP), ISHA (MJP). Royalties: Arthrocare, Don-
Joy, Bledsoe, Linvatec (MJP), Vail Valley Surgery Center. Paid con-
sultant or employee: Smith & Nephew (MJP). Research or institutional
support from companies: Smith & Nephew, Ossur, Arthrex, Siemens,
Vail Valley Medical Center (MJP).
Ethical approval  This study was IRB approved by the Vail Valley
Medical Center IIRB under IRB protocol #2002-03.
References
1. Agricola R, Waarsing JH, Thomas GE, Carr AJ, Reijman M,
Bierma-Zeinstra SM, Glyn-Jones S, Weinans H, Arden NK (2014)
Cam impingement: defining the presence of a cam deformity by
the alpha angle: data from the CHECK cohort and Chingford
cohort. Osteoarthr Cartil 22(2):218–225
2. Bagwell JJ, Bauer L, Gradoz M, Grindstaff TL (2016) The reli-
ability of FABER test hip range of motion measurements. Int J
Sports Phys Ther 11(7):1101–1105
13
Knee Surgery, Sports Traumatology, Arthroscopy
3. Barrientos C, Barahona M, Diaz J, Branes J, Chaparro F, Hins-
peter J (2016) Is there a pathological alpha angle for hip impinge-
ment? A diagnostic test study. J Hip Preserv Surg 3(3):223–228
4. Beck M, Kalhor M, Leunig M, Ganz R (2005) Hip morphology
influences the pattern of damage to the acetabular cartilage: femo-
roacetabular impingement as a cause of early osteoarthritis of the
hip. J Bone Jt Surg Br 87(7):1012–1018
5. Braly BA, Beall DP, Martin HD (2006) Clinical examination of
the athletic hip. Clin Sports Med 25(2):199–210
6. Ganz R, Parvizi J, Beck M, Leunig M, Notzil H, Siebenrock KA
(2003) Femoroacetabular impingement: a cause for osteoarthritis
of the hip. Clin Orthop Relat Res 417:112–120
7. Haldane CE, Ekhtiari S, de Sa D, Simunovic N, Ayeni OR (2017)
Preoperative physical examination and imaging of femoroacetabu-
lar impingement prior to hip arthroscopy—a systematic review. J
Hip Preserv Surg 4(3):201–213
8. Johnston TL, Schenker ML, Briggs KK, Philippon MJ (2008)
Relationship between offset angle alpha and hip chondral injury
in femoroacetabular impingement. Arthroscopy 24(6):669–675
9. Larson CM, Safran MR, Brcka DA, Vaughn ZD, Giveans MR,
Stone RM (2018) Predictors of clinically suspected intra-articular
hip symptoms and prevalence of hip pathomorphologies present-
ing to sports medicine and hip preservation orthopaedic surgeons.
Arthroscopy 34(3):825–831
10. Maslowski E, Sullivan W, Forster Harwood J, Gonzalez P, Kauf-
man M, Vidal A, Akuthota V (2010) The diagnostic validity of
hip provocation maneuvers to detect intra-articular hip pathology.
PMR 2(3):174–181
11. Philippon MJ, Ho CP, Briggs KK, Stull J, LaPrade RF (2013)
Prevalence of increased alpha angles as a measure of cam-type
femoroacetabular impingement in youth ice hockey players. Am
J Sports Med 41(6):1357–1362
(2007) Clinical presentation of femoroacetabular impingement.
Knee Surg Sports Traumatol Arthrosc 15(8):1041–1047
13. Philippon MJ, Weiss DR, Kuppersmith DA, Briggs KK, Hay CJ
(2010) Arthroscopic labral repair and treatment of femoroacetabu-
lar impingement in professional hockey players. Am J Sports Med
38(1):99–104
14. Reiman MP, Goode AP, Cook CE, Holmich P, Throborg K (2015)
Diagnostic accuracy of clinical tests for the diagnosis of hip femo-
roacetabular impingement/labral tear: a systematic review with
meta-analysis. Br J Sports Med 49(12):811
15. Rosner B (2006) Fundamentals of biostatistics, 6th edn. Thomson
Brooks/Cole, Duxbury
16. Scopp JM, Moorman CT III (2001) The assessment of athletic hip
injury. Clin Sports Med 20(4):647–659
17. Tijssen M, van Cingel R, Willemsen L, de Visser E (2012) Diag-
nostics of femoroacetabular impingement and labral pathology
of the hip: a systematic review of the accuracy and validity of
physical tests. Arthroscopy 28(6):860–871
18. Vad VB, Bhat AL, Basrai D, Gebeh A, Aspergren DD, Andrews
JR (2004) Low back pain in professional golfers. The role of asso-
ciated hip and low back range-of-motion deficits. Am J Sports
Med 32(2):494–497