Craig Test

The Craig test (or Femoral Anteversion test) is used to assess anteversion/ retroversion of the femoral neck.

How do you do the Craig Test?

• The patient is positioned in prone with the knee flexed to 90 degrees.
• The clinician rotates the hip through the full ranges of hip internal and external rotation, while palpating the greater trochanter and determining the point in the range at which the greater trochanter is the most prominent laterally.

How to measure the femoral anteversion angle with Craig’s Test?

The femoral anteversion angle can be measured when the greater trochanter is most prominent laterally.

If at this point the angle is greater than 8–15 degrees in the direction of internal rotation, when measured from the vertical and long axis of the tibia, the femur is considered to be in anteversion.

The femoral anteversion angle can be estimated directly on the basis of the angle by which the lower leg deviates from the vertical. In this position, the femoral neck lies in the horizontal plane while the condyles of the knee and the lower leg indicate the anteversion angle.

The precision of this measurement performed by an experienced examiner is comparable to that of radiographic measurement.

Craig Test Accuracy

One study ¹ showed this test to be accurate to within 4 degrees of intraoperative measurements, for the assessment of femoral anteversion/ retroversion, and was more accurate than radiographic measurement techniques.

Torsion angle of Femur

The torsion angle of the femur describes the relative rotation that exists between the shaft and the neck of the femur.

Normally, as viewed from above, the femoral neck projects on average 5–15 degrees anterior to a mediolateral axis to the femoral condyles.

• Anteversion: An anterior orientation of the femoral neck to the transverse axis of the femoral condyles.
• Retroversion: a reverse orientation (posterior) of the femoral neck to the transverse axis of the femoral condyles.

The normal range for femoral alignment in the transverse plane in adults is 5 degrees of anteversion.

Typically, an infant is born with about 30 degrees of femoral anteversion. This angle usually decreases to 15 degrees by 6 years of age because of bone growth and increased muscle activity.

Subjects with excessive anteversion usually have more hip internal rotation ROM than external rotation, and gravitate to the typical “frog-sitting” posture as a position of comfort. There is also associated in-toeing while weight-bearing.

Excessive anteversion directs the femoral head toward the anterior aspect of the acetabulum when the femoral condyles are aligned in their normal orientation.

Some studies have supported the hypothesis that a persistent increase in femoral anteversion predisposes to osteoarthritis (OA) of the hip and knee, although other studies have refuted this.

Refernces

1. Ruwe PA, Gage JR, Ozonoff MB, DeLuca PA. Clinical determination of femoral anteversion. A comparison with established techniques. J Bone Joint Surg Am. 1992 Jul;74(6):820-30. PMID: 1634572.
2. Choi BR, Kang SY. Intra- and inter-examiner reliability of goniometer and inclinometer use in Craig’s test. J Phys Ther Sci. 2015 Apr;27(4):1141-4. doi: 10.1589/jpts.27.1141. Epub 2015 Apr 30. PMID: 25995575; PMCID: PMC4433996.
3. Gelberman RH, Cohen MS, Desai SS, Griffin PP, Salamon PB, O’Brien TM. Femoral anteversion. A clinical assessment of idiopathic intoeing gait in children. J Bone Joint Surg Br. 1987 Jan;69(1):75-9. doi: 10.1302/0301-620X.69B1.3818738. PMID: 3818738.
4. Reikerås O, Bjerkreim I, Kolbenstvedt A. Anteversion of the acetabulum and femoral neck in normals and in patients with osteoarthritis of the hip. Acta Orthop Scand. 1983 Feb;54(1):18-23. doi: 10.3109/17453678308992864. PMID: 6829278.
5. Souza AD, Ankolekar VH, Padmashali S, Das A, Souza A, Hosapatna M. Femoral Neck Anteversion and Neck Shaft Angles: Determination and their Clinical Implications in Fetuses of Different Gestational Ages. Malays Orthop J. 2015 Jul;9(2):33-36. doi: 10.5704/MOJ.1507.009. PMID: 28435607; PMCID: PMC5333666.
6. Giunti A, Moroni A, Olmi R, et al: The importance of the angle of anteversion in the development of arthritis of the hip. Ital J Orthop Traumatol 11:23–27, 1985
7. Terjesen T, Benum P, Anda S, et al: Increased femoral anteversion and osteoarthritis of the hip. Acta Orthop Scand 53:571–575, 1982.
8. Eckhoff DG: Femoral anteversion in arthritis of the knee [letter]. J Pediat Orthop 15:700, 1995.
9. Aranow S, Zippel H: Untersuchung zur femoro-tibialen Torsion bei Patellainstabilitaten. Ein Beitrag zur Pathogenese rezidivierender und habitueller Patellaluxationen. Beitr Orthop Traumat 37:311–326, 1990.
10. Clinical Tests for the Musculoskeletal System 3rd Edition.
11. Dutton’s Orthopaedic Examination, Evaluation, And Intervention 3rd Edition.