Test catalog of the ligamentum capitis femoris pathology
CONTENT [i] Abstract [ii] Introduction [iii] Testing in the supine position [iv] Testing in a standing position [v] Gait study [vi] References [vii] Application |
A description of tests for the
detection and differential diagnosis of ligamentum capitis femoris (LCF)
pathology is presented.
One of the first studies devoted to the diagnosis of
LCF injury demonstrated a variety of symptoms: groin pain, hip stiffness,
sometimes long-standing minimal clinical findings, or signs similar to
osteoarthritis (1997GrayA_VillarRN). More than a decade later, researchers
concluded: "Unfortunately, there is no specific test for detecting LCF
tears." The signs known at that time were nonspecific and were also observed
in other intra-articular pathologies of the hip joint
(2010CerezalL_Pérez-CarroL). The applicability of a specific clinical symptom
for determining LCF status remains unknown (2020ReimanMP_DijkstraHP).
Therefore, the insufficient accuracy of testing for LCF pathological changes
during physical examination necessitates the use of instrumental diagnostic
methods.
- «Physical examination may reveal pain on straight leg raising, decreased extension, and locking of the joint, the latter more common in Group III patients [Group III, the degenerate ligamentum]. … In the Group III, there is a noted degenerate ligamentum teres rupture associated with symptoms of the underlying osteoarthritis.» (2001RaoJ_VillarRN).
- «All patients experienced deep anterior groin pain. Nineteen patients experienced mechanical symptoms (catching, popping, locking, giving way), and 4 patients described pain with activities. On examination, 15 patients showed pain with log rolling of the hip, and all 23 showed pain with maximal flexion combined with internal rotation. Range of motion was reduced in 6 patients, with an average loss of 24° of rotation. This reduced range of motion was caused by inhibition in 3 patients who had full motion when examined under anesthesia.» (2004ByrdJW_JonesKS).
- «Bei der kli ni schen Un ter su chung fin den sich häufig ein Leistendruckschmerz, Schmerzen bei Flexions-Innenrotations-Stress oder lediglich eine Bewe gungseinschränkung, sodass sich ein typischer Untersuchungsbefund mit direktem Hinweis auf die Bandschädigung nicht bietet [5, 8, 9, 12, 24]. Insbe sondere ist kein spezifischer klinischer Test be kannt.» [Clinical examination often reveals tenderness in the groin area, pain with flexion and internal rotation, or simply limited motion, so a typical examination finding directly indicating ligament damage is not always obvious [5, 8, 9, 12, 24]. In particular, no specific clinical tests are known.] (2006RühmannO_BohnsackM).
- «A minimal hip specific examination should include: ... Resisted SLR—intra-articular pain ; Log roll—intra-articular pathology. ... Intra-articular problems are often painful upon deep hip flexion, prolonged hip flexion, flexion under load (uphill walking), and with internal and external rotation of the hip. Straight-line activities are less symptomatic. ... Impingement (FADIR): Flexion/adduction/internal rotation. Reproducible pain with most intra-articular pathology. ; McCarthy’s Hip Extension Sign: With both hips flexed, extend the affected hip in interior and exterior rotation.» (2007NofsingerCC_KellyBT)
- «Das Hauptproblem liegt darin, dass es keine beweisenden Untersuchungen für eine Ruptur oder Teilruptur des LCF gibt, weder klinisch noch bildgebend. Wir konnten aufzeigen, dass der Faber-Test [Flexion Abduction External Rotation Test] in über 80% der Fälle positiv ist bei nachgewiesenen Rupturen, und das Gleiche gilt für den belasteten Rotationstest der Hüfte in Extension (Abb. 1). Auch hier war der Test zu 78% positiv. Zumindest geben diese Tests klare Indizien für eine Pathologie des LCF, insbesondere wenn die Impingementzeichen negativ sind und keine Deformation vorliegt». [The main problem is the lack of definitive tests for a rupture or partial rupture of the ligament of the head of the femur (LCF), either clinical or imaging-based. We were able to demonstrate that the Faber test [flexion, abduction, and external rotation test] is positive in over 80% of cases with confirmed ruptures, as is the hip rotation test with body weight loaded in an extended leg position (Fig. 1). Here, the test was also positive in 78% of cases. At a minimum, these tests provide clear evidence of LCF pathology, especially in the absence of impingement symptoms and deformity.] (2009LampertC).
- «Each had symptomatic femoroacetabular instability on clinical examination, as shown by a positive hip dial test and axial traction test. … Instability was confirmed using fluoroscopy with the axial traction test showing the femoral head subluxing from the joint under anaesthesia before performing the reconstruction. All patients were enrolled in an institutional review boardapproved study.». «The range of movement of the hip was recorded preoperatively using a goniometer; flexion, adduction and abduction were recorded with the patient supine, and internal and external rotation with the patient prone. Instability was assessed using the axial traction apprehension and external rotation dial tests. The axial traction apprehension test assesses global instability of the hip and is performed with the patient supine, unanaesthetised, with an assistant stabilising the patient’s pelvis. Manual axial traction is applied to the leg in an attempt to distract the joint.10 A positive test occurs if apprehension is experienced during distraction. The external rotation dial test more specifically evaluates anterior capsular laxity. It is normal if the leg rests in a neutral position or if a solid end point is reached with manual external rotation. If the leg lies externally rotated and no end point is reached with external rotation, an abnormal test is recorded.10» [10. Philippon MJ, Falvey E, Verrall GM, Briggs KK. Pain the the pelvic, inguinal and hip region. In: Bahr R, ed. The IOC manual of sports injuries. Oxford: Wiley-Blackwell, 2012.]. «We have found two clinical tests, the axial traction apprehension and the external rotation dial test, to be helpful in identifying hip laxity.10,25 Although these tests are not specific for isolating an injury to the ligamentum teres, they do heighten the clinician’s awareness that a ligamentum teres or capsular reconstruction may be necessary. Both these tests were positive in each of the patients in this study before reconstruction. In addition, each patient had a radiological ‘vacuum’ sign with minimal manual axial traction under anaesthesia.» [10. Philippon MJ, Falvey E, Verrall GM, Briggs KK. Pain the the pelvic, inguinal and hip region. In: Bahr R, ed. The IOC manual of sports injuries. Oxford: Wiley-Blackwell, 2012. ; 25. Philippon MJ, Zehms CT, Briggs KK, Manchester DJ, Kuppersmith DA. Hip instability in the athlete. Oper Tech Sports Med 2007;15:189–194.] (2012PhilipponMJ_GaskillTR).
- «The diagnosis of instability includes a complete clinical physical exam including the posterior impingement test, laxity examination, Dial test, and axial distraction/apprehension test. … As described by Ganz and colleagues, the posterior impingement test is performed in extension and external rotation engaging the posterior aspect of the femoral head, providing evidence for anterior capsular laxity.24 [24. Leunig M, Beck M, Dora C, et al: Femoroacetabular impingement: Etiology and surgical concept. Oper Tech Orthop 15:247-255, 2005]». «The Dial test is another test used in the physical examination (Fig. 2). It is performed while the patient is supine and the hip is in neutral extension. To conduct the Dial test, the examiner places their hands on the patient’s femur and tibia and manually internally rotates the leg. The lower limb is released and allowed to externally rotate. A negative Dial test constitutes external rotation of the lower limb less than 45°, as measured vertically, with a firm endpoint. Patients with passive external rotation greater than 45° are considered to have a positive Dial test. 25 [ 25. Philippon MJ, Schenker ML, Briggs KK, et al: The log roll test for assessing hip capsular laxity. Presentation at the biennial meeting of the European Society for Sports Traumatology and Arthroscopy; Innsbruck, Austria, May 2006]. … «The axial distraction/apprehension test has been used as part of the physical examination. With the patient supine, a longitudinal axial force is applied to the symptomatic leg. On the application of this force, patients with capsular pathology will elicit pain or apprehension on distraction.». «The unstable hip may also experience pain during a prone extension– external rotation test of the involved hip.8 On examination, athletes with instability may present with a loud audible “pop” when the hip is brought from flexion to extension.8 Most patients with capsular laxity will present with normal active range of motion, but increased passive range of motion.8 [8. Philippon MJ, Schenker ML: Athletic hip injuries and capsular laxity. Oper Tech Orthop 15:261-266, 2005]» (2007PhilipponMJ_KuppersmithDA).
- «Examination findings typically included painful provocative tests, and limitation of range of motion in the effected hip due to pain. Currently, there is no specific clinical test to evaluate the LT (1). We have developed a test which aims to assess the LT. The patient’s hip is flexed to full flexion without tilting of the pelvis, and moved back 30 degrees. From this position (full flexion minus 30°), the hip is moved into full abduction and then moved back 30°. The hip is then internally and externally rotated through full range. The aim of the test is to put the bundles of the ligamentum teres on stretch while trying to avoid soft tissue and bony impingement. Pain provocation is considered a positive test (Fig. 1). The production of pain should be relieved with rotation in the opposite direction, and reproducible with rotation in the direction of pain again (11). We have evaluated this LT Test and submitted the results for publication. Four patients were noted to have a positive Dial Test (12), and three had generalised Ligamentous Laxity (GLL) with Beighton score (13) greater than or equal to 4 out of 9.» [11. O’Donnell JM, Pritchard MG, Singh PJ, Bates D. Clinical examination of the ligamentum teres – a description and validation of the LT test. Paper 40: presented at 3rd ISHA Annual Scientific Meeting. October 15, 2011 Paris, France. ; 12. Philippon MJ, et al. Hip instability in the athlete. Oper Tech Sports Med. 2007;15(4):189-94.] (2013AmenabarT_O'DonnellJ).
- «Clinical examination may show a reduced and painful range of movement of the hip joint, either in extension or in combined flexion and internal rotation [25]. [25. Byrd JWT, Jones KS. Traumatic rupture of the ligamentum teres as a source of hip pain. Arthroscopy 2004; 20: 385–91] Tests indicative of intra-articular pathology may be positive in the presence of LT tears, but are non-specific. These include the log-roll test, resisted straight-leg raise and McCarthy’s tests, where, with both hips flexed, the affected hip is passively brought to extension, first in internal and then in external rotation [28] [28. Nofsinger CC, Kelly BT. Methodical approach to the history and physical exam of athletic groin pain. Oper Tech Sports Med 2007; 15: 152–6.]. ... There has, however, been no accepted clinical test for LT tear.». «O’Donnell et al. [30] have described a new clinical test that aims to detect LT pathology specifically known as the LT test. The examined hip is flexed to approximately 70° and abducted 30°, and the knee flexed to 90°. Then the hip is rotated internally and externally to its full extent. Pain provocation represents a positive test. The authors suggest that in this position there should be no bony impingement and that the LT will be selectively tightened.» [30. O’Donnell J, Economopoulos K, Singh P et al. The ligamentum teres test: a novel and effective test in diagnosing tears of the ligamentum teres. Am J Sports Med 2014; 42: 138–43.] (2014O'DonnellJM_SinghPJ).
- «The string model found maximum LT tension to occur when the hip was in: (1) 90 ° flexion, 0 ° adduction, and 60 ° external rotation and (2) 20 ° extension, 0 ° adduction, and 60 ° internal rotation.12 This study noted these two positions of maximal tension were similar with respect to hip orientation to that obtained when an individual: (1) squats and (2) attempts to cross one leg behind the other when standing.12 [12. Martin RL, Palmer I, Martin HD. Ligamentum teres: a functional description and potential clinical relevance. Knee Surg Sports Traumatol Arthrosc 2012; 20: 1209–14.]». Special Tests. O’Donnel et al.24 described the LT test to assess for partial LT tears. This test is performed with the patient supine and in 70 ° of hip flexion and 30 ° short of full abduction. In this position the hip is externally and internally rotated looking for reproduction of pain at end range of motion. This test was developed on previous work and the hypothesis that the LT will be under maximal tension and painful at end range of internal and external rotation.12 In a study of 75 consecutive patients, the LT test was found to be reproducible and accurate, with moderate to high inter-observer reliability and sensitivity and specificity values of 0.90% and 0.85, respectively.24 [24. O’Donnell J, Economopoulos K, Singh P et al. The ligamentum teres test: a novel and effective test in diagnosing tears of the ligamentum teres. Am J Sports Med 2014; 42: 138–43.]» (2019MartinRL_KivlanBR).
- «The above findings also appear to be consistent with that same group’s previously devised LT test [37] [37. O’Donnell J, Economopoulos K, Singh P et al. The ligamentum teres test: a novel and effective test in diagnosing tears of the ligamentum teres. Am J Sports Med 2014; 42: 138–43.] — pain at the extremes of ER/IR in a position of mid flexion and slight abduction. We believe this test reproduces the endpoint of the LT at the extreme of the assessed multi-planar motion, with an inflamed, and/or torn LT inciting a pain response within the hip. … Of particular interest recently has been the pathological changes to the LT in states of capsular laxity and generalized hypermobility. When the capsular ligaments are lax, as occurs in generalized hypermobility, the hip has an increased range of motion, which increases the excursion and endpoints of the LT and possibly leads to its stretching and eventual tearing.» (2018O’DonnellJM_AroraM).
- «The ligamentum teres test can be used to detect pain associated with partial tears of the ligamentum teres while a squat test may be useful to identify those with hip instability associated with complete ligamentum teres tears and osseous risk factors for instability. … Based on the findings of the previously described string model11 a clinical test was developed to assess for LT lesions.20 This LT test was performed with the hip in 70° of flexion and 30° short of full abduction. The hip was then internally and externally rotated through a full range of motion assessing for reproduction of pain. Using arthroscopy as the gold standard in identifying LT lesions, the test was found to have sensitivity and specificity values of .90 and .85, respectively. Positive and negative predictive values were found to be .84 and .91, respectively. The authors concluded that partial LT tears could be identified by the LT test. It should be noted that the one subject in this study with a complete tear had a negative LT test.20 Because this test relies on the reproduction of pain, it may not be useful for those with complete LT tears.» [11. Martin RL, Palmer I, Martin HD. Ligamentum teres: a functional description and potential clinical relevance. Knee Surg Sports Traumatol Arthrosc 2012; 20: 1209–14. ; 20. O’Donnell J, Economopoulos K, Singh P et al. The ligamentum teres test: a novel and effective test in diagnosing tears of the ligamentum teres. Am J Sports Med 2014; 42: 138–43.]». «The LT test can be used to detect partial tears of the LT (Figure 3), while a squat test may be useful to identify those with hip instability associated with complete LT tears and osseous risk factors for instability. With this squat test, it is important to make sure deep flexion, abduction, and external rotation of the hip are included in the movement (Figure 4). The results of these studies also support theories that the LT could be injured in a highly active population with nontraumatic instabilty or abnormal acetabular geometry.» (2015MartinRL_MartinHD).
- «Other clinical special tests (eg, Thomas test, prone instability test, ligamentum teres tear test) were considered by the expert group, and these tests have a: Very limited ability to confirm FAI syndrome by increasing post-test probability. Limited to substantial ability to help confirm acetabular dysplasia and/or hip instability in lowquality studies. Substantial ability to help rule in labral conditions in only one high-quality study. Unknown ability to rule in chondral conditions. Moderate post- test probability for confirming diagnosis of ligamentum teres conditions. ... The clinical utility of a particular symptom is currently unknown for determination of ligamentum teres conditions existence/non-existence. Limited evidence suggests pain and mechanical symptoms (popping, locking, catching and occasional giving way) are present in those with ligamentum teres tears. ... A positive and negative ligamentum teres (LT) test are both useful to rule in and rule out the presence of pathology; albeit limited to moderate magnitude. These results were from a single, high quality study.» (2020ReimanMP_DijkstraHP).
- «Physical examination of the hip included routine range of motion (ROM) and strength testing in addition to provocative examination maneuvers to detect instability. The anterior impingement test24 [Nunley RM, Prather H, Hunt D, Schoenecker PL, Clohisy JC. Clinical presentation of symptomatic acetabular dysplasia in skeletally mature patients. J Bone Joint Surg Am. 2011;93(suppl 2):17-21.] was used to detect the presence of a labral tear. The dial test was used to detect anterior capsular laxity. This is performed with the patient supine and the hip in neutral extension. The leg is internally rotated and then released and allowed to externally rotate. External rotation of the affected hip greater than the contralateral limb is a positive test. It is the senior author’s preferred method to detect anterior apprehension with a prone, external rotation test. This test is performed with the patient prone and the affected hip maximally externally rotated with posterior pressure applied to the greater trochanter to translate the femoral head anteriorly. A positive test recreates pain in this position.» (2013DombBG_JacksonTJ).
- «Stability of the hip should be evaluated by a combination of tests evaluating both anterior and global joint instability. … Generalized laxity. Axial traction test: Done under anesthesia and muscle relaxation. Traction is placed on the leg, and fluoroscopy is used to evaluate distraction. Axial distraction test: Patient is supine with hip and knee slightly flexed. The pelvis is stabilized by placing the examiner’s knee against the patient’s ischium. The examiner then applies axial traction. Dial test: Patient is supine. Foot passively fully internally and externally rotated. … The anterior “shuck” test, also known as the anterior apprehension test, is done with the patient prone. The tested extremity is placed in a “reverse-figure-of-four” position (hip abduction and external rotation, knee in flexion). An anteriorly directed force is then directed at the posterior aspect of the greater tuberosity. This maneuver should reproduce the patient’s anterior pain or apprehension. … The posterior “shuck” test, also known as the posterior apprehension test, is done with the patient supine. The tested hip is placed in 90° of flexion and 30° external rotation with the knee at 90° of flexion. A posteriorly directed force is placed at the knee. This maneuver should reproduce the patient’s posterior hip pain or apprehension. … With the new concept of hip microinstability, we can now view the LT as an important stabilizer, especially in these specific cases.» (2020RosinskyPJ_DombBG).
- «Wir konnten aufzeigen, dass der Faber-Test [Flexion Abduction External Rotation Test] in über 80% der Fälle positiv ist bei nachgewiesenen Rupturen, und das Gleiche gilt für den belasteten Rotationstest der Hüfte in Extension (Abb. 1). Auch hier war der Test zu 78% positiv. Zumindest geben diese Tests klare Indizien für eine Pathologie des LCF, insbesondere wenn die Impingementzeichen negativ sind und keine Deformation vorliegt». [We were able to demonstrate that the Faber test [flexion, abduction, and external rotation test] is positive in over 80% of cases with confirmed ruptures, as is the hip rotation test with body weight loaded in an extended leg position (Fig. 1). Here, the test was also positive in 78% of cases. At a minimum, these tests provide clear evidence of LCF pathology, especially in the absence of impingement symptoms and deformity.] (2009LampertC).
- «This study noted these two positions of maximal tension were similar with respect to hip orientation to that obtained when an individual: (1) squats and (2) attempts to cross one leg behind the other when standing.12 [12. Martin RL, Palmer I, Martin HD. Ligamentum teres: a functional description and potential clinical relevance. Knee Surg Sports Traumatol Arthrosc 2012; 20: 1209–14.]» (2019MartinRL_KivlanBR). «… a squat test may be useful to identify those with hip instability associated with complete LT tears and osseous risk factors for instability. With this squat test, it is important to make sure deep flexion, abduction, and external rotation of the hip are included in the movement (Figure 4). The results of these studies also support theories that the LT could be injured in a highly active population with nontraumatic instabilty or abnormal acetabular geometry.» (2015MartinRL_MartinHD).
- We propose a test for diagnosing LCF dysfunction in upright postures without additional support. When testing maintaining an upright posture with support on one leg, the patient is asked to reproduce a pelvic tilt toward the unsupported side in the frontal plane, which is typical for a relaxed, single-leg orthostatic posture. Seven visually determined and subjective parameters are included: "tremor of the supporting lower limb," "stability," "support time," "hip pain," "comfort," "pelvic position," and "spine position." In cases of LCF pathology, upon transitioning to a relaxed, single-leg orthostatic posture, the body tilts toward the supporting side. In the frontal plane, the pelvis progressively shifts toward the supporting leg and assumes a position tilted toward it. It has been observed that when testing young patients with hip pathology, the transverse axis of the pelvis is usually approximately parallel to the horizon. In almost all subjects tested, the longitudinal axis of the spine acquired a noticeable C-shaped curve. Lumbar lordosis increased, and the shoulder girdle became oblique in the frontal plane, tilting toward the support side. Most patients reported instability, postural discomfort, and emerging or increasing pain in the area of the supporting hip joint, sometimes radiating to the knee joint, lumbar spine, sacrum, groin, and buttock. Oscillatory body movements were observed in the frontal plane, and the posture was often unnatural. Some subjects involuntarily sought additional support, balancing wildly with their arms. Muscle tension in the supporting leg noticeably increased, and tremors developed. Patients described the pain and increased muscle tension as a sensation of a "driven rod" in the area of the greater trochanter and abductor muscles of the supporting hip joint. This position was often maintained for less than a minute due to increasing pain and loss of stability. The presence of pain in the hip joint, discomfort, unnatural posture, as well as a raised or horizontal position of the pelvis indicates the presence of LCF pathology (2012,2023АрхиповСВ).
- The visual symptom of LCF injury and its pathomorphology are described at the conclusion of chapter 32 of the book of Genesis:
«32 And the sun rose unto him as he passed by Penuёl, and he halted upon his thigh.
33 Therefore do the children of Israel not eat the sinew which shrank, which is upon the hollow of the thigh, unto this day; because he struck against the hollow of Jacob's thigh on the sinew that shrank.»
- A differential diagnostic test that allows us to exclude pathology of the sciatic nerve, spinal nerve roots, and spinal injury is found in the following chapter, chapter 33:
«3 And he himself passed on before them, and bowed himself to the ground seven times, until he came near to his brother.»
- The same chapter describes another sign of LCF damage – slow walking:
«14 Let my lord, I pray thee, pass on before his servant : and I will lead on slowly, according as the cattle that goeth before me and the children may be able to travel, until I come unto my lord unto Seïr.» (1922LeeserI).
- Macroinstability of the hip joint, caused by damage to the LCF, is mentioned by Galen of Pergamon, a physician in the 2nd and 3rd centuries. He discusses the gait of such patients in his commentary on Hippocrates' book On Joints: « And if, due to a rupture of the ligament, the hip is dislocated, then even with immediate setting it will not be able to remain in its place. Since the acetabulum is sloping and <to this is added> the great weight of the entire leg, the hip will easily immediately come out of place if someone tries to walk a little faster or step over something under his feet. Thus, if someone were to make small movements with the thigh on a level surface, it could always maintain its natural position, but this is apparently impossible. For even if a person could do nothing else, he would certainly be forced to lift his legs to enter the bath.» (1829KühnCG; 2020ArkhipovSV_ProlyginaIV).
- «The testing we developed is also possible by observing the patient's gait without the use of technical means. We were able to identify seven visually detectable and subjective parameters during the single-support phase of the gait: "limping, asymmetry, arrhythmia of limb movements and single steps," "pain or discomfort in the hip joint and pelvis during the stance phase," "spine deviation toward the support side during the single-support phase of the gait," "forced forward body tilt during the single-support phase of the gait," "absence of pelvic tilt toward the non-support side during the single-support phase of the gait," "arm imbalance, arm abduction during the single-support phase of the gait," and "head deviation toward the support side during the single-support phase of the gait." In cases of LCF pathology, in the overwhelming majority of cases during gait, the non-support half of the pelvis was significantly above the horizontal in the middle of the single-support phase of the gait. In a smaller number of observations, the transverse axis assumed a horizontal position, and pain appeared or worsened during the single-support phase of the gait. In some cases, discomfort in the area of the supporting hip joint was noted. Spontaneous rotational movements of the pelvis in the horizontal plane were impaired. To shift the body's overall center of mass forward and move the pelvis forward, the patient often forced a forward bend of the body. Excessive abduction of the arm on the affected side was observed, along with deviation of the cervical spine and head toward the supporting leg. There was no horizontal rotation of the shoulder girdle during the support phase on the affected leg, leading to imbalance of the same-sided arm. Due to LCF pathology, the amplitude and direction of movements performed by the head, spine, and arms also changed, causing overall asymmetry and arrhythmia of limb segment movements» (2012,2023АрхиповСВ). (2012,2023АрхиповСВ).
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Author of the article
Arkhipov S.V. – Independent Researcher, MD, PhD, Orthopedic Surgeon, Medical Writer, Joensuu, Finland.
Correspondence: Sergey Arkhipov, email: archipovsv @ gmail.com
Article history
November 12, 2025 - online version of the article published.
Suggested citation
Arkhipov S.V. Test catalog of the ligamentum
capitis femoris, pathology. About round ligament of femur. November 12, 2025.
Note
Keywords
ligamentum capitis femoris, ligamentum teres, ligament of head of femur, diagnostics, test, examination, biomechanics, pathomechanics
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