How to Perform the Fulcrum and Hop Tests for Tibial Stress Fracture
The fulcrum test is performed by having the patient sit with legs dangling, then applying a three-point bending force to the tibia while the hop test involves having the patient perform a single-leg vertical hop on the affected limb, with pain reproduction indicating a positive result.
Fulcrum Test Technique
The fulcrum test applies a three-point bending stress to the tibia to reproduce pain at the fracture site:
- Patient positioning: Have the patient sit at the edge of an examination table with both legs dangling freely
- Examiner hand placement: Place your forearm under the patient's mid-tibia, creating a fulcrum point
- Force application: Apply gentle downward pressure on the distal tibia/ankle with your other hand, creating a bending moment across the suspected fracture site
- Positive test: Sharp, localized pain at the suspected stress fracture location indicates a positive test
The fulcrum test demonstrates the highest diagnostic accuracy among clinical tests, with specificity of 84.4% and the highest positive likelihood ratio of 2.93, though sensitivity remains low at 45.7% 1. When combined with focal tibial tenderness over a band ≤10cm in length, a positive fulcrum test significantly increases the likelihood of medial tibial stress fracture (odds ratio 52.04) 2.
Hop Test (Vertical Single Leg Hop Test) Technique
The hop test assesses pain reproduction with axial loading:
- Patient positioning: Have the patient stand on the affected leg only
- Test execution: Instruct the patient to perform a maximal vertical single-leg hop for height
- Assessment criteria: Evaluate for three components:
- Pain reproduction or increase during the hop
- Landing mechanics
- Hop height compared to contralateral side
- Positive test: Reproduction or increase in tibial pain during or after the hop
The hop test showing increased pain is the most sensitive clinical test at 72%, though specificity is only 37% 3. The combination of a positive hop test with tibial pain and focal tenderness significantly increases diagnostic accuracy 2.
Clinical Application and Diagnostic Accuracy
Key Diagnostic Criteria
When evaluating for tibial stress fracture, look for this triad:
- Focal tibial tenderness over a band ≤10cm in length
- Positive fulcrum test
- Positive hop test (pain reproduction)
Important Caveats
No single clinical test is both highly sensitive and specific for tibial stress fracture 1, 3. The fulcrum test provides the best balance with moderate-to-high specificity and the lowest negative likelihood ratio (0.64) 1. However, all clinical tests demonstrate low sensitivity, meaning negative tests do not rule out stress fracture.
When combinations of clinical tests are negative, there is high likelihood that a high-grade (grade III/IV) bone stress injury is not present 3. This has important clinical utility—negative tests can help avoid unnecessary imaging in lower-grade injuries.
Clinical Decision-Making Algorithm
If fulcrum AND hop tests are both positive with focal tenderness ≤10cm: High suspicion for tibial stress fracture; initiate 10-14 days of rest and activity modification 2
If symptoms resolve after initial rest period: Continue clinical management without imaging in most cases 2
If symptoms persist after 10-14 days of rest OR immediate diagnosis is required: Proceed to imaging (MRI or bone scan) 2
This approach was validated in 429 elite infantry recruits and successfully managed over two-thirds of cases without imaging 2.