How is the FADIR (Flexion‑Adduction‑Internal‑Rotation) test performed, interpreted, and what are its contraindications?

FADIR Test: Procedure and Interpretation

How to Perform the FADIR Test

The FADIR test is performed by placing the patient supine, flexing the hip to 90° with the knee at 90° flexion, then passively adducting the hip (bringing the knee toward the opposite shoulder) and internally rotating the hip—pain reproduction during this combined motion indicates a positive test. 1

Patient Positioning

• Position the patient supine on the examination table with both legs straight and toes pointing upward to establish a standardized starting position 1
• Ensure the pelvis is level and not rotated, as pelvic obliquity can produce false-positive findings 1
• Align the limbs and trunk with the body's midline to establish a neutral reference posture before beginning the maneuver 1

Test Execution

• Flex the hip to 90° while maintaining the knee in 90° flexion 1
• Passively adduct the hip by bringing the knee toward the opposite shoulder 1
• Internally rotate the hip while maintaining the flexed and adducted position, ensuring the full FADIR arc is achieved 1
• Observe the patient for reproduction of hip pain during the maneuver 1

Interpretation of Results

Negative Test (Most Clinically Useful)

A negative FADIR test helps rule out hip disease in young and middle-aged active adults presenting with hip-related pain. 2, 1

• The primary clinical utility of the FADIR test lies in its ability to exclude hip pathology when negative rather than to confirm a specific diagnosis when positive 1
• When the FADIR test is negative but hip-related pain persists, consider alternative diagnoses such as lumbar spine pathology, sacroiliac joint dysfunction, or other competing musculoskeletal conditions 3
• Exclude serious pathology including tumors, infections, stress fractures, and slipped capital femoral epiphysis (SCFE) 3, 4

Positive Test (Limited Specificity)

Pain reproduced during the FADIR maneuver suggests intra-articular hip pathology but is not specific to a single condition. 1

• Possible diagnoses include femoroacetabular impingement (FAI) syndrome, labral tear, acetabular dysplasia, hip instability, or other intra-articular disorders 1, 4
• The test demonstrates high sensitivity but low specificity, making it ideal for ruling out disease when negative but poor for confirming disease when positive 3
• A positive test in healthy young adults is not uncommon, occurring in approximately 7.3% of men and 4.8% of women 5

Clinical Pitfalls and Contraindications

Critical Warnings

• Never rely solely on the FADIR test for diagnosis—imaging studies and the overall clinical picture must be integrated before confirming any hip pathology. 1
• Labral tears, chondral lesions, and ligamentum teres findings are frequently present on imaging in asymptomatic people; their presence alone does not confirm they are the source of pain 1, 4
• Before attributing symptoms to FAI or labral pathology, systematically exclude tumors, infections, stress fractures, SCFE, and lumbar spine disorders 1, 4

Technical Considerations

• Stabilize the pelvis throughout the examination to prevent compensatory pelvic tilting, which can create misleading findings 1
• The test should be standardized, as poor to moderate interrater reliability and large minimal detectable difference values have been reported 6
• Decreased abduction, internal rotation in men, and decreased flexion in both genders are associated with positive tests 5

Recommended Imaging After Positive Test

• Initial imaging should include anteroposterior (AP) pelvis and lateral femoral head-neck radiographs to assess for osseous morphology 1, 4
• For suspected labral tears specifically, MR arthrography (MRA) is superior to CT arthrography and non-contrast MRI 4
• Advanced imaging (MRI/MRA or CT) should be used when three-dimensional morphological assessment is needed or to evaluate intra-articular structures 2, 3

Initial Management Approach

• Prescribed physiotherapy consisting of education should be part of the initial treatment approach for hip-related pain 4
• Intra-articular injections can serve both diagnostic and therapeutic purposes, helping confirm intra-articular pathology as the pain source when symptoms improve following injection 4