Manual Therapy xxx (2013) 1e5

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Manual Therapy
journal homepage: www.elsevier.com/math

Original article

A comparison of the reliability of the trochanteric prominence angle

test and the alternative method in healthy subjectsq
Tae-Lim Yoon, Kyung-Mi Park, Sil-Ah Choi, Ji-Hyun Lee, Hyo-Jung Jeong,
Heon-Seock Cynn*
Applied Kinesiology and Ergonomic Technology Laboratory, Department of Physical Therapy, The Graduate School, Yonsei University, 1 Yonseidae-gil, Wonju,
Kangwon-do 220-710, South Korea

a r t i c l e i n f o

a b s t r a c t

Article history:
Received 12 February 2013
Received in revised form
24 July 2013
Accepted 30 July 2013

A wide range of intra- and inter-rater reliabilities of the trochanteric prominence angle test (TPAT) has
been reported. We introduced the transcondylar angle test (TCAT) as an alternative to the TPAT and
using a smartphone as a reliable measurement tool for femoral neck anteversion (FNA) measurement.
The reliabilities of the TPAT and the TCAT, the reliability of using a smartphone as a clinical measurement tool, and the correlation between the difference value of medial knee joint space (KJS) between
rest and tested positions and the difference value between the TPAT and TCAT were assessed. Two
physical therapists independently determined the reliabilities of the TPAT with a digital inclinometer,
the TCAT with a digital inclinometer, and the TCAT with a smartphone in 19 hips of 10 healthy subjects
(5 male and 5 female, 22.2
1.69 years). The medial KJS in rest and the tested position were assessed
using a sonography. The intra-class correlation coefcients (ICC) for the intra-rater reliabilities of TPAT
with a digital inclinometer (ICC 0.92), TCAT with a digital inclinometer (ICC 0.94) and a smartphone
(ICC 0.95) in both testers were substantial. The inter-rater reliability of TPAT with a digital inclinometer was fair (ICC 0.48) while TCAT with a digital inclinometer (ICC 0.89) and a smartphone
(ICC 0.85) were substantial. The correlation between the difference value of medial KJS between rest
and tested positions and the difference value between TPAT and TCAT was low and statistically nonsignicant (r 0.114; p 0.325). The TCAT would be more reliable than the TPAT in inter-rater test.
Using a smartphone is a clinically comparable measuring tool to a digital inclinometer.
2013 Elsevier Ltd. All rights reserved.

Keywords:
Craigs test
Knee joint space
Smartphone
Inclinometer
Femoral neck anteversion

1. Introduction
Femoral neck anteversion (FNA) is dened as the angle created
by the proximal femoral neck axis and the distal femoral condylar
axis (Davids et al., 2002). FNA usually diminishes with age and may
change via evolution, heredity, fetal development, intrauterine
position, and mechanical forces (Gulan et al., 2000; Fabeck et al.,
2002; Cibulka, 2004). Verifying the existence of an abnormal FNA
is of potential signicance to physical therapists when dealing with
patients with anatomical (tibial torsion, genu valgus, pes planus,
pes equinus, and metatarsus varus) and pathological (osteoarthritis, hip labral tears, and patella femoral pain) disorders of lowerextremity commonly related to increased or decreased FNA. (Crane,
1959; Alvik, 1962; Kling and Hensinger, 1983; Gulan et al., 2000;

q The protocol for this study was approved by Yonsei University Wonju Institutional Review Board.
* Corresponding author. Tel.: 82 1032075760; Fax: 82 337602496.
E-mail address: cynn@yonsei.ac.kr (H.-S. Cynn).

Cibulka, 2004; Souza and Powers, 2009). In addition, presenting

of increased or decreased the FNA may assist physical therapists
identify patients who might be at risk for rising problems related
with in-toeing or out-toeing (Cibulka, 2004).
There are several methods for measuring FNA, including
radiography, computed tomography, magnetic resonance imaging (MRI), and ultrasound sonography (Aamodt et al., 1995;
Tomczak et al., 1995; Kuo et al., 2003). However, only one clinical method, the trochanteric prominence angle test (TPAT, also
known as the Craigs test), has been described to measure FNA by
determining the angle formed by the vertical line and the tibial
crest, when the greater trochanter is most prominent laterally
(Gross, 1995; Davids et al., 2002; Shultz et al., 2006; Souza and
Powers, 2009).
Previous investigations have reported a wide range of reliability
coefcients (0.45e0.97) and measurement errors (1.1e8.4 ) of the
TPAT (Ruwe et al., 1992; Sutlive et al., 2004; Lesher et al., 2006; Piva
et al., 2006; Shultz et al., 2006; Souza and Powers, 2009). The
application of TPAT may be limited by obesity, scarring about the
proximal femur, and ligamentous laxity in the knee joint (Ruwe

1356-689X/$ e see front matter 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.math.2013.07.011

Please cite this article in press as: Yoon T-L, et al., A comparison of the reliability of the trochanteric prominence angle test and the alternative
method in healthy subjects, Manual Therapy (2013), http://dx.doi.org/10.1016/j.math.2013.07.011

T.-L. Yoon et al. / Manual Therapy xxx (2013) 1e5

et al., 1992; Davids et al., 2002). In particular, there are several reports that using the tibia as a lever in 90 knee joint exion increases the medial knee joint space (KJS) due to laxity of the knee
joint (Tokuhara et al., 2004; Harris-Hayes et al., 2007; Testa et al.,
2010). Thus, any potential increase in KJS could affect the angle
between the vertical line and the tibial crest during the TPAT.
Consequently, if we directly measure the transcondylar line in
the distal femur, instead of the angle between the vertical line and
the tibial crest, the FNA measurement may be more reliable.
Hence, we designed an alternative method for determining FNA,
called the transcondylar angle test (TCAT), which directly measures the actual angle between the proximal femoral neck axis
(Fig. 1A) and the distal femoral condylar axis (Fig. 1B) in a prone
position.
The use of an accurate measurement tool is an essential part of
physical evaluation. The reliability of digital inclinometers is
considered superior or similar to that of classic goniometric
measurements (de Winter et al., 2004; Mullaney et al., 2010;
Kolber et al., 2011). A research has found that the majority of
healthcare providers own a smartphone and over half of them
regularly use applications in clinical practice (Franko and Tirrell,
2012). In several studies, moderate-to-substantial reliability were
shown between a smartphone and an inclinometer (intra-class
correlation coefcient [ICC] 0.79e0.99) for measuring the
shoulder, knee, and ankle joint angles (Ockendon and Gilbert,
2012; Shaw et al., 2012; Shin et al., 2012; Williams et al., 2013).
Thus, a smartphone can be used in a range of clinical measurement
because of the smartphones ease of use, small size, and portable in
the clinic.
In the present study, we compared the intra- and inter-rater
reliabilities of FNA measurements of the TPAT to that of the TCAT
using a digital inclinometer, examined the reliability of a smartphone as a clinical measurement tool compared to a digital inclinometer, and determined the correlation between the difference
value of medial KJS between rest and tested positions and the
difference value between the TPAT and the TCAT. We hypothesized
that the TCAT would show superior intra- and inter-rater reliabilities compared to the TPAT using a digital inclinometer, that
using a smartphone and the digital inclinometer during the TCAT
would show equivalent intra- and inter-rater reliabilities, and that
there would be a moderate to substantial correlation between the
increased value of medial KJS between rest and tested positions
and the increased difference value between the TPAT and the TCAT
because the medial KJS would affect the angle between the vertical
line and the tibial crest in the TPAT.

2. Methods
2.1. Subjects
In total, 19 hips were examined in 10 healthy subjects (5 male, 5
female, aged 22.2
1.69 years) who participated voluntarily from a
university. One hip of one subject was not examined due to a recent
history of trauma and pain in the knee. Characteristics of the subjects are presented in Table 1. The inclusion criteria were subjects
who were at least 18 years old. Exclusion criteria were the
following: a recent history of trauma (within 1 month) to the hip or
knee, excessive laxity of the medial collateral ligament of the knee
joint (by valgus stress test), history of any bony surgical realignment of the lower extremity, stress fractures, medial tibia stress
syndrome, knee pain, or a body mass index (BMI) < 23 (Lesher
et al., 2006; Souza and Powers, 2009). Prior to participation, all
subjects were informed of the purpose of the study, and informed
consent was obtained. This study was approved by Yonsei University Wonju Institutional Review Board.
2.2. Instrumentation
An industrial digital inclinometer (GemRed DBB, Gain Express
Holdings, Ltd., Hong Kong, China) was used for the FNA measurement in both the TPAT and the TCAT. During the TCAT, we also used a
smartphone (iPhone, Apple, Inc., Cupertino, CA, USA) with the Tiltmeter software (IntegraSoftHN) to measure the FNA and compared
it to digital inclinometer measurements (Shaw et al., 2012).
Sonography was performed with a 7.5 MHz linear transducer
(SonoAce X8, Medison Co., Ltd, Seoul, Korea) to conrm precise
palpation of the femoral condyles and to measure the medial KJS
between the femur and tibia in the longitudinal plane at rest and in
the tested positions.
2.3. Procedures
The intra- and inter-rater reliabilities of the TPAT and the TCAT
using a digital inclinometer and a smartphone were examined by
two testers. The testers (testers 1 and 2) were licensed physical
therapists. Before data collection, both testers underwent a 2 h
training session each day for 5 days under the supervision of the
primary investigator (TLY), who has 9 years of clinical experience.
The training consisted of performing the TPAT and the TCAT,
palpating the condyles of the distal femur, and sonographic measurements of the medial KJS. On the last day of the training session,
testers 1 and 2 were checked for competence by the primary
investigator, and both testers demonstrated competence following
the training. To determine the intra-rater reliabilities for the TPAT
with a digital clinometer, TCAT with a digital clinometer and a
smartphone, tester 1 performed three sessions of each FNA
measurement method. To prevent measurement recall, 1 h was
provided between sessions and the FNA measurements were randomized by drawing a sealed envelope from a box to exclude any
potential effects of measurement order. This procedure was
repeated by tester 2 to assess inter-rater reliability. In addition, the
Table 1
General characteristics.

Fig. 1. Femoral neck anteversion is dened as the angle between (A) The proximal
femoral neck axis and (B) the distal femoral condylar axis.

Variables

Male (n 5)

Age (years)
Height (cm)
Weight (kg)
BMI (kg/m2)

21.6
177.1
65.9
21

1.96
3.72
6.54
1.81

Female (n 5)
22.89
162.78
54.11
20.38

1.05
2.39
3.69
1.85

Total (n 10)
22.2
170.3
60.3
20.7

1.69
7.96
8.00
1.81

Abbreviations: BMI; body mass index.

Values are presented as mean
SD.

Please cite this article in press as: Yoon T-L, et al., A comparison of the reliability of the trochanteric prominence angle test and the alternative
method in healthy subjects, Manual Therapy (2013), http://dx.doi.org/10.1016/j.math.2013.07.011

T.-L. Yoon et al. / Manual Therapy xxx (2013) 1e5

medial KJS was determined using sonography after the reliability

study was nished. The sonographic data were measured three
times with a 5-min rest period between, and averaged for the nal
analysis. To prevent measurement recall, 1 h was provided between
sessions and the FNA measurements were randomized by drawing
a sealed envelope from a box to exclude any potential effects of
measurement order.
2.4. Precise palpation of femoral condyles
To conrm the precise palpation of femoral condyles, the distance between the femoral condyles was identied by palpation and
sonography in a pilot study (Evans et al., 2003). The positions of the
femoral condyles by palpation were marked with a dot sticker
(diameter: 3 mm) by both testers. After application of coupling gel,
the positions of the femoral condyles were veried with sonography
by the primary investigator (TLY). Then the differences between the
dot stickers and actual femoral condyles were measured and categorized into two levels of agreement: agreement category, the difference  5 mm; disagreement category, the difference > 5 mm.
Cohens kappa was used to calculate agreement in testers 1 and 2.
Cohens kappa effectively discounts the proportion of agreement
expected by chance, and values range from 1 to 1 (Landis and Koch,
1977). Cohens kappa scores was 1 demonstrating the perfect
interobserver variation during palpation of the femoral condyles.

the sides of the lower portion of the patella. To help locate these
articular surfaces, the knee was slightly exed and extended
repeatedly to form a 90 position so that the moving condyles could
be felt under the testers ngertips (Clippinger, 2007). The tester
marked spots of both the palpated femoral condyles and drew a line
(transcondylar line) between the marked spots of the bilateral
condyles on the patella. The angle subtended by the horizontal line
and the transcondylar line represented the FNA angle (Fig. 2B). In
addition, the side border of the smartphone was aligned on the
transcondylar line (Fig. 2C).
2.7. Sonographic measurement of the medial knee joint space
Sonographic examinations of the medial KJS were completed at
rest and in the tested position in the longitudinal plane (Kleinbaum
and Blankstein, 2008). For testing, subjects assumed a prone position with internal rotated hip and 90 exion of the knee joint, as in
the TPAT. A transducer was applied longitudinally to the medial
side of the knee joint to capture and measure the space between
the femur and the tibia (Fig. 3A). For the rest position, the tester
rotated the hip back to the starting position, with the tibia in a
vertical position from the tested position. A transducer was applied
to the same place as in the tested position, and the space between
the femur and the tibia was measured (Fig. 3B). Real-time imaging
allowed identication of the space between the femur and the tibia
at rest and in the tested position.

2.5. Trochanteric prominence angle test

2.8. Statistical analysis
The TPAT was performed as described previously (Souza and
Powers, 2009). When the participant was in a prone position, the
tester stood on the side of the participant contralateral to the hip
being examined. While the participants pelvis was stabilized by
the testers forearm, the tester palpated the participants greater
trochanter with the more cranial hand. The knee joint of the test
extremity was exed to 90 using the testers more caudal hand.
Then the participants hip was internally and externally rotated
until the tester determined the position of the greater trochanter at
its most prominent position laterally. A wooden frame was placed
to the lateral aspect of the distal tibia to maintain the range of the
hip internal rotation during the TPAT. Then the top of an inclinometer was aligned to the subjects middle-half of the tibial crest
(Fig. 2A). The angle subtended between the vertical line and tibial
crest was measured as the FNA (Gulan et al., 2000; Souza and
Powers, 2009).
2.6. Transcondylar angle test
The TCAT was performed in exactly the same position as the
TPAT. The tester palpated the bilateral condyles of the distal femur,
then palpated a portion of the femoral condyles by exing the
participants knee joint to 90 and pressing the ngertips against

To assess the intra- and inter-rater reliabilities of the TPAT and the
TCAT using a digital inclinometer and a smartphone, the ICC and the
standard error of the measurement (SEM) were calculated. ICC values
and 95% condence intervals were calculated. ICCs were interpreted
using the following criteria: 0.00e0.10, virtually none; 0.11e0.40,
slight; 0.41e0.60, fair; 0.61e0.80, moderate; and 0.81e1.0, substantial reliability (Shrout, 1998; Souza
and Powers,
2009). The SEM was

pP
calculated using the equation
ABS2 =2, where ABS is the absolute difference score (Sachs, 1982). The paired t-test was used to
compare the mean value of FNA difference between the TPAT and the
TCAT. The alpha level was set at 0.05. Also, Pearsons correlation coefcient (r) was used to determine the correlation between the difference value of medial KJS between rest and tested positions and the
difference value between the TPAT and the TCAT. All of the variables
were found to approximate to a normal distribution (Kolmogorove
Smirnov Z test, p > 0.05). All statistical analyses were performed with
the SPSS software (ver. 14.0; SPSS, Inc., Chicago, IL, USA).
3. Results
The intra- and inter-rater reliabilities for the TPAT and the TCAT
are summarized in Table 2. The intra-rater reliabilities for the TPAT

Fig. 2. (A) A digital inclinometer was aligned on the middle-half of the tibial crest during the TPAT. (B) transcondylar line was drawn on patella and measured with a digital
inclinometer and (C) a smartphone during the TCAT.

Please cite this article in press as: Yoon T-L, et al., A comparison of the reliability of the trochanteric prominence angle test and the alternative
method in healthy subjects, Manual Therapy (2013), http://dx.doi.org/10.1016/j.math.2013.07.011

T.-L. Yoon et al. / Manual Therapy xxx (2013) 1e5

Fig. 3. Measurement of the medial knee joint space between femur and tibia. (A) The rest position. (B) The tested position.

were substantial (ICC 0.92 for both testers). However, the interrater reliability was fair (ICC 0.48). The intra- and inter-rater reliabilities for the TCAT using a digital inclinometer were substantial
(ICC 0.94, 0.89, respectively). The intra- and inter-rater reliabilities of the TCAT using a smartphone were substantial
(ICC 0.95, 0.85, respectively). There was a signicant mean FNA
difference between the TPAT (26.83
7.54) and the TCAT
(30.58
6.78) (t(18) 1.73, p 0.01). In addition, the medial KJS in
the rest and tested positions were 12.7
2.9 mm and 14.6
3.3 mm,
respectively (SEM 0.4 and 0.3 mm). The correlation between the
difference value of medial KJS between rest and tested positions and
the difference value between the TPAT and TCAT were low and
statistically nonsignicant (r 0.114; p 0.325).
4. Discussion
The intra- and inter-rater reliabilities of the TPAT and the TCAT
with a digital inclinometer and the TCAT with a smartphone were
investigated. To the best of our knowledge, this is the rst study to
introduce an alternative method of the FNA assessment by
palpating the femur condyles. Our ndings suggest that the intrarater reliabilities of the TPAT and the TCAT were all substantial.
However, inter-rater reliability of the TPAT was fair versus the
substantial inter-rater reliability for the TCAT. The difference value
of medial KJS between rest and tested positions showed a low correlation with the difference value between the TPAT and the TCAT.
Substantial intra-rater reliabilities were found for both testers
(ICC 0.92; SEM 2.7 for tester 1 and 2.9 for tester 2) in the TPAT.
The intra-rater reliability of the TPAT was similar to previous studies,
with reported ICC values ranging between moderate and substantial
(ICC 0.77e0.97, SEM 1.1e3.2 ) (Shultz et al., 2006; Souza and
Powers, 2009). In addition, inter-rater reliability in the TPAT was
fair between testers (ICC 0.48, SEM 6.5 ), comparable to previous studies that also reported fair agreement (ICC 0.45e0.58,

SEM 4.5e7 ) (Sachs, 1982; Lesher et al., 2006; Piva et al., 2006).
However, Souza and Powers (2009) reported substantial agreement
with the TPAT (ICC 0.83, SEM 3.8), but noted the limitation that
average difference scores can be misleading, as large over- and
underestimations tend to cancel each other out. The TCAT demonstrated substantial intra-rater reliability (both ICC 0.94; SEM 2.5
for tester 1 and 1.9 for tester 2) and inter-rater reliabilities
(ICC 0.89, SEM 3.9 ). A fair ICC value was achieved with the TPAT,
whereas the TCAT showed both substantial intra- and inter-rater
reliabilities, with lower SEM relative to the TPAT. The absolute
FNA mean value of FNA difference in the TPAT using a digital inclinometer was signicantly lower (3.74
5.45 ) than that in the TCAT.
This may indicate that the TPAT underestimated the FNA angle
compared to the TCAT when a digital inclinometer was used. A
previous study also noted a tendency to underestimate FNA when
using the TPAT (Davids et al., 2002). Thus, a greater mean value of
TCAT would be closer to the real value of FNA, indicating a valid test.
However, measurement by MRI is needed to conrm this nding.
We also examined whether a smartphone could be used instead
of a digital inclinometer. The TCAT using a smartphone showed
substantial intra-rater (ICC 0.95 for both testers; SEM 2.2 for
tester 1 and 1.9 for tester 2) and inter-rater reliabilities (ICC 0.85,
SEM 4.1 ), which were comparable to values using a digital
inclinometer. These results are similar to a previous study that
suggested a small measurement bias (2.1
1.7 ) (Shaw et al., 2012).
That study concluded that using a smartphone as a measuring tool
was clinically equivalent to the traditional protractor.
Ligament laxity of the knee joint may inuence the results of
TPAT (Ruwe et al., 1992). In our study, increased medial KJS between rest and tested positions (rest position, 12.7 2.9 mm; tested
position, 14.6 3.3 mm) showed a low correlation with the FNA
difference value between the TPAT and the TCAT. Previous studies
have reported that the medial KJS (6.7 mme9.6 mm) and medial
knee angle (1.7
1.4 ) increase after valgus stress on the knee

Table 2
Means and standard deviations, the reliability coefcient, the 95% CI, and and the standard error of measurement of femoral neck anteversion measurements.
Mean
SD

Comparison
TPAT using a digital inclinometer

TCAT using a digital inclinometer

TCAT using a smartphone

Tester
Tester
Tester
Tester
Tester
Tester
Tester
Tester
Tester

1
2
1
1
2
1
1
2
1

versus
versus
versus
versus
versus
versus
versus
versus
versus

Tester
Tester
Tester
Tester
Tester
Tester
Tester
Tester
Tester

1
2
2
1
2
2
1
2
2

(intra-rater
(intra-rater
(inter-rater
(intra-rater
(intra-rater
(inter-rater
(intra-rater
(intra-rater
(inter-rater

reliability)
reliability)
reliability)
reliability)
reliability)
reliability)
reliability)
reliability)
reliability)

29.38
24.28
27.10
32.02
29.13
30.62
31.99
28.91
30.07

7.17
7.11
7.41
7.45
5.78
6.55
7.21
5.28
6.57

ICC2,3 (95% CI)

SEM (deg)

0.92
0.92
0.48
0.94
0.94
0.89
0.95
0.95
0.85

2.7
2.9
6.5
2.5
1.9
3.9
2.2
1.9
4.1

(0.80e0.97)
(0.79e0.97)
(0.34e0.80)
(0.85e0.98)
(0.86e0.98)
(0.70e0.96)
(0.87e0.98)
(0.87e0.98)
(0.61e0.94)

Abbreviations: TPAT, trochanteric prominence angle test; TCAT, transcondylar angle test; CI, condence interval; ICC, intraclass correlation coefcient; SEM, standard error of
the measurement.
Signicance level set at 0.05.

Please cite this article in press as: Yoon T-L, et al., A comparison of the reliability of the trochanteric prominence angle test and the alternative
method in healthy subjects, Manual Therapy (2013), http://dx.doi.org/10.1016/j.math.2013.07.011

T.-L. Yoon et al. / Manual Therapy xxx (2013) 1e5

(Okazaki et al., 2006; Kleinbaum and Blankstein, 2008). Other

studies have found that women or younger people may have, on
average, a larger medial KJS with valgus stress (Bryant and Cooke,
1988; Magnusson, 1998; Tokuhara et al., 2004; Wang et al., 2004).
These results suggest that using the TCAT, which is unaffected by
medial KJS, may be benecial for someone who has laxity of the
knee joint.
We had expected that the FNA measured during the TPAT would
be greater than that during the TCAT because the medial KJS would
inuence the angle between the vertical line and the tibial crest
during the TPAT. However, the mean value of FNA measured during
the TPAT was signicantly less than the FNA during the TCAT. This
unexpected nding may be explained by the difculty in identifying the reference points on the tibial crest. A previous study
demonstrated that different degrees of FNA may be measured
when different anatomical references of the tibial crest (tibial tuberosity, the proximal one third, and middle half of the tibial crest)
are used (Lee et al., 2012). In that study, the measured FNA was
signicantly greater in the tibial tuberosity compared to the proximal one-third or middle-half of the tibial crest. In the present
study, because an inclinometer was placed at the middle-half of the
tibia, a lower FNA value could have been measured.
Our study has some limitations. First, only young healthy individuals (i.e., without laxity of the medial KJS or damaged ligaments) were recruited, potential effect of laxity of the medial KJS was
not examined and the studys generalizability is limited. Second, the
validity of the TCAT was not investigated. Third, power analysis was
not performed to calculate the number of subject in this study.
Further research should be performed on the agreement between the TCAT and FNA angle through radiography, computed
tomography, MRI, and ultrasound sonography, to validate this
alternative method (TCAT), and the contribution of the increase in
medial KJS to FNA value during the TPAT should be explored.
5. Conclusion
The TCAT demonstrated substantial intra- and inter-rater reliabilities, whereas a fair ICC value of inter-rater reliability was
achieved with the TPAT. These results suggest that the TCAT provides
a more reliable measurement than the TPAT for assessing the FNA
angle. Using a smartphone with an inclinometer application during
the TCAT showed comparable reliability to a digital inclinometer.
Health practitioners can readily use smartphone technology within
their clinical practice for assessing the FNA during the TCAT.
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Please cite this article in press as: Yoon T-L, et al., A comparison of the reliability of the trochanteric prominence angle test and the alternative
method in healthy subjects, Manual Therapy (2013), http://dx.doi.org/10.1016/j.math.2013.07.011