Consensus recommendations on the classification, definition and diagnostic criteria of hip-related pain in young and middle-aged active adults from the International Hip-related Pain Research Network, Zurich 2018

The effectiveness of the Copenhagen adduction exercise on improving eccentric hip adduction strength among soccer players with groin injury: a randomized controlled trial

INTRODUCTION

Groin injuries are common in soccer players and often involve adductor muscle strains. The Copenhagen Adduction Exercise (CAE) is a targeted intervention whose effectiveness in rehabilitation for these injuries warrants investigation.

OBJECTIVE

To investigate the impact of a rehabilitation program, which includes the CAE, on eccentric hip adduction (EHAD) strength, hip joint range of motion (ROM), self-reported disability, and pain among soccer players with adductor-related groin pain. It was hypothesized that the addition of CAE to the rehabilitation program would yield greater improvements.

METHODS

Employing a randomized controlled trial with a two-group parallel design, thirty male soccer players with a mean age of 26.4 ± 3.9 years were randomized into an intervention group (IG) including CAE (n = 15) and a control group (CG) without CAE (n = 15), based on a power analysis to ensure 80% power to detect significant differences. Both groups engaged in their respective rehabilitation programs twice a week for eight weeks. The primary outcome measured was EHAD strength, while secondary outcomes included hip joint ROM, self-reported disability measured by the Copenhagen Hip and Groin Outcome Score (HAGOS), and pain levels.

RESULTS

Significant improvements within groups were observed across all measures (p < 0.001). The IG demonstrated a greater increase in EHAD strength (Mean Difference [MD] = 0.49 Nm/kg, 95% Confidence Interval [CI] [0.31, 0.66]), a more pronounced reduction in pain (MD = -1.60, 95% CI [-2.18, -1.02]), and betterment in all HAGOS subscale scores compared to the CG. There were no significant between-group differences in hip joint ROM.

CONCLUSION

Incorporating the CAE into rehabilitation programs significantly improves EHAD strength, decreases pain scores, and reduces self-reported disability in soccer players with adductor-related groin pain.

REGISTRATION

ClinicalTrials.gov identifier: NCT05589623.

Muscle Fat and Volume Differences in People With Hip-Related Pain Compared With Controls: A Machine Learning Approach

BACKGROUND

Hip-related pain (HRP) affects young to middle-aged active adults and impacts physical activity, finances and quality of life. HRP includes conditions like femoroacetabular impingement syndrome and labral tears. Lateral hip muscle dysfunction and atrophy in HRP are more pronounced in advanced hip pathology, with limited evidence in younger populations. While MRI use for assessing hip muscle morphology is increasing, with automated deep-learning techniques showing promise, studies assessing their accuracy are limited. Therefore, we aimed to compare hip intramuscular fat infiltrate (MFI) and muscle volume, in individuals with and without HRP as well as assess the reliability and accuracy of automated machine-learning segmentations compared with human-generated segmentation.

METHODS

This cross-sectional study included sub-elite/amateur football players (Australian football and soccer) with a greater than 6-month history of HRP [n = 180, average age 28.32, (standard deviation 5.88) years, 19% female] and a control group of sub-elite/amateur football players without pain [n = 48, 28.89 (6.22) years, 29% female]. Muscle volume and MFI of gluteus maximus, medius, minimis and tensor fascia latae were assessed using MRI. Associations between muscle volume and group were explored using linear regression models, controlling for body mass index, age, sport and sex. A convolutional neural network (CNN) machine-learning approach was compared with human-performed muscle segmentations in a subset of participants (n = 52) using intraclass correlation coefficients and Sorensen-Dice index.

RESULTS

When considering adjusted estimates of muscle volume, there were significant differences observed between groups for gluteus medius (adjusted mean difference 23 858 mm3 [95% confidence interval 7563, 40 137]; p = 0.004) and tensor fascia latae (6660 mm3 [2440, 13 075]; p = 0.042). No differences were observed between groups for gluteus maximus (18 265 mm3 [-21 209, 50 782]; p = 0.419) or minimus (3893 mm3 [-2209, 9996]; p = 0.21). The CNN was trained for 30 000 iterations and assessed its accuracy and reliability on an independent testing dataset, achieving high segmentation accuracy (mean Sorenson-Dice index >0.900) and excellent muscle volume and MFI reliability (ICC2,1 > 0.900). The CNN outperformed manual raters, who had slightly lower interrater accuracy (Sorensen-Dice index >0.800) and reliability (ICC2,1 > 0.800).

CONCLUSIONS

The increased muscle volumes in the symptomatic group compared with controls could be associated with increased myofibrillar size, sarcoplasmic hypertrophy or both. These changes may facilitate greater muscular efficiency for a given load, enabling the athlete to maintain their normal level of function. In addition, the CNNs for muscle segmentation was more efficient and demonstrated excellent reliability in comparison to manual segmentations.

Cleft Sign in MRI May Represent the Disruption of Cartilage Structure within Pubic Symphysis and Pubic Plate: A Cadaver Case Report

BACKGROUND/OBJECTIVES

Long-standing groin pain is a severe issue for athletes, often associated with the cleft sign on magnetic resonance imaging (MRI) scans, yet its underlying causes are poorly understood. The purpose of this study is to histologically examine the pubic plate structure in cadavers with and without the cleft sign on MRI, shedding light on the pathology behind the cleft sign.

METHODS

Three fresh human pelvic cadavers underwent 3.0T MRI to detect the cleft sign before histological dissection of pubic plates. Pubic plate tissues were fixed in formalin, decalcified, and processed. Of the two cleft sign-negative specimens, one was cut into sagittal sections, and the other was cut into coronal sections for histology. For the cleft sign positive specimen, a sagittal section was cut. Moreover, 5 µm thick sections were cut at different axial levels for each orientation. Sections were subjected to Safranin O, Alcian blue, and Herovici's staining or hematoxylin and eosin staining.

RESULTS

MRI confirmed that one specimen had a cleft sign in the inferior region on both sides of the pubis and that two specimens had no cleft sign. Both sagittal and coronal sections showed the presence of a cartilage structure continuing from the pubic symphysis to 3 mm laterally within the pubic plate. In the specimen with a positive cleft sign, cartilage damage within the pubic symphysis and pubic plate was identified as revealed by Safranin O staining, Herovici's staining, and H&E staining.

CONCLUSIONS

This study elucidated the existence of a cartilage component extending from the pubic symphysis to the pubic plate. The cleft sign in MRI correlated with a disruption in the cartilage component in histology within this specific area.

Femoroacetabular impingement syndrome in middle-aged individuals is strongly associated with the development of hip osteoarthritis within 10-year follow-up: a prospective cohort study (CHECK)

OBJECTIVE

The objective is to determine the association and absolute risk of femoroacetabular impingement syndrome (FAIS) for the development of radiographic hip osteoarthritis (RHOA).

METHODS

This is a nationwide, multicentre prospective cohort study (Cohort Hip and Cohort Knee) with 1002 individuals aged between 45 and 65 years. Hips without definitive RHOA (Kellgren-Lawrence (KL) grade≤1) at baseline and with anteroposterior pelvic radiographs at baseline and 10-year follow-up available (n=1386 hips) were included. FAIS was defined by the baseline presence of a painful hip, limited internal hip rotation≤25° and cam morphology defined by an alpha angle>60°. The outcomes were incident RHOA (KL grade≥2 or total hip replacement (THR)) and incident end-stage RHOA (KL≥3 or THR) within 10 years.

RESULTS

Of the 1386 included hips (80% women; mean age 55.7±5.2 years), 21 hips fulfilled criteria for FAIS and 563 hips did not fulfil any of the FAIS criteria (reference group; no symptoms, no signs, no cam morphology). Within 10-year follow-up, 221 hips (38%) developed incident RHOA and 15 hips (3%) developed end-stage RHOA (including 9 hips with THR). Adjusted for sex, age and body mass index, FAIS with cam morphology resulted in an OR of 6.85 (95% CI 2.10 to 22.35) for incident RHOA and 47.82 (95% CI 12.51 to 182.76) for incident end-stage RHOA, compared with hips not having any FAIS criteria. The absolute risk of FAIS was 81% for incident RHOA and 33% for incident end-stage RHOA.

CONCLUSION

FAIS was strongly associated with the development of RHOA within 10 years. Although the baseline prevalence of FAIS was low, the high absolute risk of FAIS for RHOA warrants further studies to determine preventive strategies.

Assessment of hip abductor and adductor muscle strength with fixed-frame dynamometry: Considerations on the use of bilateral and unilateral tasks

OBJECTIVE

To examine the specificities and limitations of bilateral and unilateral tasks for the assessment of hip abductor and adductor strength with a commercially-available fixed-frame dynamometer.

DESIGN

Correlational/validity study.

METHODS

Maximal voluntary isometric strength of hip abductors and adductors was evaluated in 130 healthy participants using unilateral and bilateral tasks. Surface EMG activity of agonist and stabilizer muscles was concomitantly recorded in a subgroup of 15 participants.

RESULTS

For both muscle groups, bilateral tasks resulted in higher strength values than unilateral tasks (∼25%; p < 0.001). The correlation between left- and right-side data was higher for bilateral than unilateral tasks (p < 0.05), thereby resulting in lower interlimb asymmetries (p < 0.001). Agonist EMG activity was lower for unilateral than bilateral tasks (p < 0.01). Stabilizer EMG activity (external abdominal oblique) was higher for unilateral than bilateral tasks (p < 0.05) on the ipsilateral and contralateral side for hip abductors and adductors, respectively.

CONCLUSIONS

A large (25%) and quasi-systematic bilateral facilitation of strength was observed for both hip abductors and adductors. Bilateral testing led to an underestimation of interlimb asymmetries, due to higher side equivalence than unilateral tasks. Unilateral testing resulted in lower agonist EMG activity and higher stabilizer activity than bilateral tasks, especially in weaker subjects.

Are hip joint imaging findings associated with symptoms and early hip osteoarthritis features in elite male Australian Football League draftees?

1) describe intra-articular features (prevalence and severity) and bony hip morphology (prevalence and size) in elite male Australia Football League (AFL) draftees; 2) examine the relationship between bony hip morphology (cam and pincer morphology) and intra-articular features (cartilage defects and labral tears); and 3) examine the relationship between intra-articular features, bony hip morphology, and the Copenhagen Hip and Groin Outcome Score (HAGOS). Cross-sectional study. 58 male AFL draftees underwent 3-tesla hip MRI. Alpha angle determined cam morphology and acetabular depth defined pincer morphology. For each hip, intra-articular features were scored semi-quantitatively. All players completed the HAGOS to determine hip/groin symptoms and sports function. Logistic regression determined whether bony hip morphology was associated with labral tears and cartilage defects. Mann-Whitney U tests evaluated the difference in HAGOS subscale scores between football players with and without intra-articular features and bony hip morphology. Cam and pincer morphology were evident in 20% and 19% of hips, respectively. Nearly half of hips (41%) had a labral tear, with only 14% having a cartilage defect. Greater alpha angle was associated with the presence of labral tears (OR 1.14, 95%CI 1.07 to 1.21, p < 0.001) but not cartilage defects. Hip imaging findings were not associated with lower (worse) HAGOS scores. Hip joint imaging findings were common in elite male AFL draftees but not associated with worse pain, symptoms, or sport function. Cam morphology may contribute to the development of labral tears in male AFL draftees.

Females with hip pain walk with altered kinematics at peaks and throughout the gait cycle

BACKGROUND

Females with acetabular dysplasia and/or labral tears (hip pain) exhibit altered walking kinematics, with studies reporting mixed results in sagittal and frontal planes compared to pain-free controls, often conducting only discrete analyses and warranting further investigation. The objective of this study was to investigate discrete and continuous hip and pelvic kinematics between females with and without hip pain in two walking conditions.

METHODS

We collected kinematic walking data from 69 females (35 with hip pain, 34 controls) using motion capture and an instrumented treadmill in two conditions: preferred and fast (125% preferred). We used a general linear model and one-dimensional statistical parametric mapping to conduct discrete and continuous analyses comparing kinematics between groups, with and without adjustment for gait speed.

FINDINGS

The hip pain group walked with reduced peak hip extension (Preferred: P = .046, Cohen's d = 0.41; Fast: P = .028, d = 0.48) and greater peak anterior pelvic tilt (Preferred: P = .011, d = 0.57; Fast: P = .012, d = 0.58) compared to controls. From continuous analyses, the hip pain group walked with reduced hip extension during terminal stance (Fast: P = .040), greater anterior pelvic tilt throughout (Preferred: P = .007; Fast: P = .004), and greater contralateral pelvic drop (Preferred: P = .045) during midstance. Adjusting for speed slightly affected p-values, but significance was retained for all prior variables except pelvic drop.

INTERPRETATION

Kinematic differences between individuals with and without hip pain may provide insight into potential predisposing factors for hip pathology and/or compensations for pain or pathological processes. This work furthers understanding of altered movement patterns in individuals with hip pain and may inform physical therapy treatments.

Is hip capsule morphology associated with hip pain in patients without another structural correlate?

OBJECTIVE

The goals of this study were (i) to assess the association between hip capsule morphology and pain in patients without any other MRI abnormalities that would correlate with pain and (ii) to investigate whether hip capsule morphology in hip pain patients is different from that of controls.

METHODS

In this study, 76 adults with hip pain who did not show any structural abnormalities on MRI and 46 asymptomatic volunteers were included. Manual segmentation of the anterior and posterior hip capsules was performed. Total and mean anterior hip capsule area, posterior capsule area, anterior-to-posterior capsule area ratio, and medial-to-lateral area ratio in the anterior capsule were quantified. Differences between the pain and control groups were evaluated using logistic regression models.

RESULTS

Patients with hip pain showed a significantly lower anterior-to-posterior area ratio as compared with the control group (p = 0.002). The pain group's posterior hip capsule area was significantly larger than that of controls (p = 0.001). Additionally, the ratio between the medial and lateral sections of the anterior capsule was significantly lower in the pain group (p = 0.004).

CONCLUSIONS

Patients with hip pain are more likely to have thicker posterior capsules and a lower ratio of the anterior-to-posterior capsule area and thinner medial anterior capsules with a lower ratio of the medial-to-lateral anterior hip capsule compartment, compared with controls.

CLINICAL RELEVANCE STATEMENT

During MRI evaluations of patients with hip pain, morphology of the hip capsule should be assessed. This study aims to be a foundation for future analyses to identify thresholds distinguishing normal from abnormal hip capsule measurements.

KEY POINTS

• Even with modern image modalities such as MRI, one of the biggest challenges in handling hip pain patients is finding a structural link for their pain. • Hip capsule morphologies that correlated with hip pain showed a larger posterior hip capsule area and a lower anterior-to-posterior capsule area ratio, as well as a smaller medial anterior capsule area with a lower medial-to-lateral anterior hip capsule ratio. • The hip capsule morphology is correlated with hip pain in patients who do not show other morphology abnormalities in MRI and should get more attention in clinical practice.

Will you get what you want? Treatment goals and expectations of patients with femoroacetabular impingement syndrome regarding physiotherapist-led treatment

OBJECTIVE: To (i) investigate the goals and expectations of participants enrolled in a clinical trial of physiotherapist-led treatment for femoroacetabular impingement (FAI) syndrome and (ii) explore associations between their expectations and self-reported hip burden and kinesiophobia. METHODS: Data from 150 participants with FAI syndrome who participated in a clinical trial were analysed. Participants described their most important treatment goal and the expectation of achieving this goal throughout physiotherapy treatment. The International Hip Outcome Tool (iHOT-33) subscales were used to assess self-reported hip burden. The Tampa Scale for Kinesiophobia was used to assess kinesiophobia. Participants goals were qualitatively analysed using content analysis. Linear regression was used to explore associations between patient expectations and iHOT and Tampa Scale for Kinesiophobia scores. RESULTS: Participants with FAI syndrome reported goals relating to exercise (52%), improving activities of daily living quality (23%), improving physical function (15%), and reducing pain (10%). Negative expectations regarding physiotherapist-led treatment were reported by 68% of participants. Those with negative expectations reported worse scores for the iHOT-Total score (mean difference = 12 points, 95%CI = [4 to 19]), and iHOT-Symptoms (14 points, [7 to 21]) and iHOT-Social (11 points, [2 to 21]) subscales compared to those with positive expectations. Treatment expectations were not associated with iHOT-Sport, iHOT-Job, and Tampa Scale for Kinesiophobia scores (p > 0.05). CONCLUSION: Patients with FAI syndrome had a generally negative expectation of physiotherapist-led treatment. There was a mismatch between patients' goals and current treatment approaches. Participants with FAI syndrome and negative expectations reported worse quality of life, symptoms, and social concerns than those with positive expectations.

Automated radiographic hip morphology measurements: An open-access method

Objective

The aim of this study is to present a newly developed automated method to determine radiographic measurements of hip morphology on dual-energy x-ray absorptiometry (DXA) images. The secondary aim was to compare the performance of the automated and manual measurements.

Design

30 DXA scans from 13-year-olds of the prospective population-based cohort study Generation R were randomly selected. The hip shape was outlined automatically using radiographic landmarks from which the acetabular depth-width ratio (ADR), acetabular index (AI), alpha angle (AA), Wiberg and lateral center edge angle (WCEA) (LCEA), extrusion index (EI), neck-shaft angle (NSA), and the triangular index (TI) were determined. Manual assessments were performed twice by two orthopedic surgeons. The agreement within and between observers and methods was visualized using Bland-Altman plots, and the reliability was studied using the intraclass correlation coefficient (ICC) with 95 % confidence intervals (CI).

Results

The automated method was able to perform all radiographic hip morphology measurements. The intermethod reliability between the automated and manual measurements ranged from 0.57 to 0.96 and was comparable to or better than the manual interobserver reliability, except for the AI.

Conclusion

This open-access, automated method allows fast and reproducible calculation of radiographic measurements of hip morphology on right hip DXA images. It is a promising tool for performing automated radiographic measurements of hip morphology in large population studies and clinical practice.

What are participant beliefs regarding physical therapy led treatment? A qualitative study of people living with femoroacetabular impingement syndrome

BACKGROUND

Physical therapist-led treatment programs are recommended for patients with femoroacetabular impingement (FAI) syndrome. Views of people with FAI syndrome regarding such interventions are currently unknown, including perceptions of potential barriers and facilitators to participation and adherence to exercise programs.

OBJECTIVES

To explore participant perceptions of physical therapist-led programs for FAI syndrome, including barriers and facilitators for accessing physical therapy, and adhering to a rehabilitation program.

METHODS

Our qualitative study used semi-structured interviews to explore the perceptions of patients with FAI syndrome undertaking physical therapy-led treatment, where treatment was ceased due to Coronavirus Disease 2019 (COVID-19). The interview topic guide was informed by the Theoretical Domain Framework. Interviews were transcribed verbatim and data categories were developed using inductive thematic analysis. Themes were discussed between researchers until consensus was reached.

RESULTS

Fourteen participants (mean age: 30 years) with a range of physical activity backgrounds undertook interviews. We identified four key themes, 1) Patients believed their hip pain was caused by structural damage worsened through exercise; 2) Barriers and facilitators on the feasibility of physical therapist-led programs; 3) Participants held beliefs regarding the importance of adjunct treatments to exercise; and 4) Impact of FAI syndrome on physical activity participation.

CONCLUSION

People with FAI syndrome believe they have structural damage which leads to their hip pain and are often afraid to exercise due to fear of causing more damage to their hip. Our findings suggest that people with FAI syndrome want clear education about exercise, imaging, and expectations of cost and duration of treatment.

Canadian Association of Radiologists Musculoskeletal System Diagnostic Imaging Referral Guideline

The Canadian Association of Radiologists (CAR) Musculoskeletal System Expert Panel consists of musculoskeletal radiologists, a family physician, a sports and exercise medicine physician, emergency medicine physicians, a patient advisor, and an epidemiologist/guideline methodologist. After developing a list of 25 musculoskeletal clinical/diagnostic scenarios, a systematic rapid scoping review was undertaken to identify systematically produced referral guidelines that provide recommendations for 1 or more of these clinical/diagnostic scenarios. Recommendations from 41 guidelines (50 publications) and contextualization criteria in the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) for guidelines framework were used to develop 124 recommendation statements across the 25 scenarios related to the evaluation of the musculoskeletal system. This guideline presents the methods of development and the recommendations for imaging in the context of musculoskeletal pain, infection, tumors, arthropathies, metabolic bone disease, stress injuries, orthopedic hardware, avascular necrosis/bone infarction, and complex regional pain syndrome.

Pincer Morphology Is Not Associated With Hip Osteoarthritis Unless Hip Pain Is Present: Follow-Up Data From a Prospective Cohort Study

OBJECTIVE

The objective of this study was to assess the relationship between pincer morphology and radiographic hip osteoarthritis (RHOA) over 2, 5, 8, and 10 years' follow-up and to study the interaction between pincer morphology and pain.

METHODS

Individuals from the prospective Cohort Hip and Cohort Knee study were drawn. Anteroposterior pelvic and false profile radiographs were obtained. Hips free of definite RHOA (Kellgren and Lawrence [KL] grade 0 or 1) at baseline were included. Pincer morphology was defined as a lateral or anterior center edge angle or both ≥40° at baseline. Incident RHOA was defined as KL ≥ 2 or total hip replacement at follow-up. Multivariable logistic regression with generalized estimating equations estimated the associations at follow-up. Associations were expressed as unadjusted odds ratios (ORs) and adjusted ORs with 95% confidence intervals (CIs). An interaction term was added to investigate whether pincer morphology had a different effect on symptomatic hips.

RESULTS

Incident RHOA developed in 69 hips (5%) at 2 years' follow-up, in 178 hips (14%) at 5 years' follow-up, in 279 hips (24%) at 8 years' follow-up, and in 495 hips (42%) at 10 years' follow-up. No significant associations were found between pincer morphology and incident RHOA (adjusted OR 0.35 [95% CI 0.06-2.15]; adjusted OR 1.50 [95% CI 0.94-2.38]). Significant interactions between pain and anterior pincer morphology in predicting incident RHOA were found at 5, 8, and 10 years' follow-up (OR 1.97 [95% CI 1.03-3.78]; OR 3.41 [95% CI 1.35-8.61]).

CONCLUSION

No associations were found between radiographic pincer morphology and incident RHOA at any follow-up moment. Anteriorly located pincer morphology with hip pain, however, was significantly associated with incident RHOA. This highlights the importance of studying symptoms and hip morphology simultaneously.

Shared decision-making with athletes: a survey study of healthcare professionals' perspectives

Objectives

Shared decision-making (SDM) is a trending topic in athlete health care; however, little is known about its use in a sports context. This study aimed to measure knowledge and self-perceived practice of SDM among healthcare professionals working with athletes. This study evaluates SDM attitudes and preferences and explores how healthcare professionals perceive the factors influencing SDM.

Methods

A web-based cross-sectional survey with open-ended and closed-ended questions.

Results

Our survey was completed by 131 healthcare professionals. The majority (63.6%) reported to prefer SDM and to be confident in their SDM skills (81.1%). Despite this inclination and confidence, only one in four clinicians reported consistent practice of SDM when feasible. Additionally, most clinicians lacked SDM knowledge. The barriers perceived by healthcare professionals included time constraints (17.6%), limited patient knowledge (17.6%), limited patient motivation (13.5%) and language barriers (16.2%). Importantly, two-thirds of the participants believed that SDM in athlete health care differs from SDM in non-athletes due to the high-pressure environment, the tension between performance and health, and the involvement of multiple stakeholders with potentially conflicting interests.

Conclusions

Although healthcare professionals preferred SDM, they did not fully understand nor routinely practice it. Most healthcare professionals perceive SDM in athlete health care to differ from SDM in the general population. Therefore, to inform the implementation of SDM in athlete health care, future research is crucial to understand better what makes practising SDM unique in this setting.

Clinical Presentation Differences Among Four Subtypes of Femoroacetabular Impingement: A Case-Control Study

OBJECTIVE

The aims of this study were to assess the psychological, functional, and physical differences between patients with femoroacetabular impingement (FAI) syndrome and individuals who were asymptomatic (controls) to analyze clinical differences among 4 subtypes of FAI (cam type, cam type with labral tear, pincer type, and pincer type with labral tear), to calculate the correlations among the variables described, and to identify risk factors contributing to the hip function variance.

METHODS

A case-control study was conducted at a hospital rehabilitation unit with a cohort of individuals who were asymptomatic (controls) and a cohort of patients with FAI. Sociodemographic characteristics, pain intensity, psychological health status, hip range of motion (RoM), hip isometric strength, and hip function were assessed.

RESULTS

A total of 69 controls and 69 patients with FAI were analyzed. Although sociodemographic characteristics were comparable between samples, poorer hip RoM, strength, and psychological health were found for the cases. FAI subtypes showed no significant pain intensity, psychological health, or RoM differences (except for hip adduction), but hip strength differed among FAI subtypes. Multiple significant correlations between psychological health, pain intensity, RoM, strength, and hip function were found. The variance values of the International Hip Outcome Tool, Hip Outcome Score (HOS) for daily living activities, and HOS for sports activities were partially explained (47.6%, 36.0%, and 21.6%, respectively) on the basis of kinesiophobia, hip strength, self-efficacy, and anxiety.

CONCLUSION

Patients with FAI showed poorer psychological health, hip RoM, and strength than individuals who were asymptomatic and had similar sociodemographic characteristics. FAI subtype influenced the patients' clinical presentations. Hip strength, kinesiophobia, anxiety, and self-efficacy should be targeted for improving hip function, as they have been demonstrated to be important contributors to hip disability.

IMPACT

This study demonstrated that pain catastrophizing, hip strength, and hip adduction differed among FAI subtypes. However, hip function and pain intensity were comparable between FAI subtypes.

Hip and Pelvis Movement Patterns in Patients With Femoroacetabular Impingement Syndrome Differ From Controls and Change After Hip Arthroscopy During a Step-Down Pivot-Turn Task

Background

Alterations in hip kinematics during functional tasks occur in positions that cause anterior impingement in patients with femoroacetabular impingement (FAI) syndrome. However, tasks that do not promote motions of symptomatic hip impingement remain understudied.

Purpose

To compare movement patterns of the hip and pelvis during a step-down pivot-turn task between patients with FAI and controls as well as in patients with FAI before and after hip arthroscopy.

Study Design

Controlled laboratory study.

Methods

Three-dimensional motion capture was acquired in 32 patients with FAI and 27 controls during a step-down pivot-turn task. An FAI subsample (n = 14) completed testing 9.2 ± 2.0 months (mean ± SD; range, 5.8-13.1 months) after hip arthroscopy. Statistical parametric mapping analysis was used to analyze hip and pelvis time series waveforms (1) between the FAI and control groups, (2) in the FAI group before versus after hip arthroscopy, and (3) in the FAI group after hip arthroscopy versus the control group. Continuous parametric variables were analyzed by paired t test and nonparametric variables by chi-square test.

Results

There were no significant differences in demographics between the FAI and control groups. Before hip arthroscopy, patients with FAI demonstrated reduced hip flexion (P = .041) and external rotation (P = .027), as well as decreased anterior pelvic tilt (P = .049) and forward rotation (P = .043), when compared with controls. After hip arthroscopy, patients demonstrated greater hip flexion (P < .001) and external rotation of the operative hip (P < .001), in addition to increased anterior pelvic tilt (P≤ .036) and pelvic rise (P≤ .049), as compared with preoperative values. Postoperatively, the FAI group demonstrated greater hip flexion (P≤ .047) and lower forward pelvic rotation (P = .003) as compared with the control group.

Conclusion

Movement pattern differences between the FAI and control groups during the nonimpingement-related step-down pivot-turn task were characterized by differences in the sagittal and transverse planes of the hip and pelvis. After hip arthroscopy, patients exhibited greater hip flexion and external rotation and increased pelvic anterior tilt and pelvic rise as compared with presurgery. When compared with controls, patients with FAI demonstrated greater hip flexion and lower pelvic forward rotation postoperatively.

Clinical Relevance

These findings indicate that hip and pelvis biomechanics are altered even during tasks that do not reproduce the anterior impingement position.

Dynamic joint stiffness in individuals with femoroacetabular impingement syndrome pre- and post-hip arthroscopy

BACKGROUND

Patients with hip-related pain often fail to return to their desired level of activity following hip arthroscopy. Lasting biomechanics alterations may be one potential explanation. Dynamic joint stiffness assesses the mechanistic controls of the lower limb during high impact movements, and thus, may provide valuable clinical targets to improving movement and optimizing return to activity after surgery.

METHODS

Twenty-five participants (13 females) with hip-related pain underwent 3D motion capture during a drop jump task before surgery and six months post-operatively. Nineteen healthy controls (9 females) were collected for comparison. Sagittal plane dynamic joint stiffness was calculated during the initial landing phase. Baseline and 6-month dynamic joint stiffness data were compared 1) between males and females with hip-related pain and 2) between individuals with hip-related pain and controls using Wilcoxon Signed-Rank and Mann Whitney U tests. Sexes were analyzed separately.

FINDINGS

From baseline to 6 months post-operatively, females with hip-related pain demonstrated decreased dynamic ankle stiffness (2.26 Nm/deg. [0.61] to 1.84 Nm/deg. [0.43]) (p = .005) and males with hip-related pain demonstrated increased dynamic hip stiffness (2.73 [0.90] to 3.88 [1.73]) (p = .013). There were no differences in dynamic stiffness at any joint between individuals with hip-related pain at either timepoint when compared to controls (p ≥ .099).

INTERPRETATION

Females and males with hip-related pain may demonstrate unique changes in dynamic joint stiffness after surgery, indicating return to activity may follow different trajectories for each sex. Additional work should examine the relationship between hip joint stiffness and treatment outcomes and identify additional movement-related rehabilitation targets.

In vivo interrelationships between the gluteus minimus and hip joint capsule in the hip internal rotation position with flexion

BACKGROUND

The flexion adduction internal rotation (FADIR) test is performed by the combined motions of hip flexion (with knee flexion), adduction, and internal rotation, and can often reproduce anterior hip pain consistent with an individual's presenting pain. Since it has high sensitivity for intraarticular pathology diagnosis but low specificity, understanding the extraarticular pathology that can induce anterior hip pain in the FADIR test may also be essential. This study hypothesized that the interrelationships between the joint capsule and gluteus minimus differ in individuals with and without FADIR-positive pain and aimed to elucidate the in vivo interrelationships at hip internal rotation in 90°-flexion, which is also often restricted in individuals with FADIR-positive pain.

METHODS

Ten hips were included in the FADIR-positive group, and ten hips without hip pain in the FADIR test were included in a control group. Based on the ultrasound images at the four hip rotation conditions (20° and 10° external rotations, 0° external/internal rotation, and 10° internal rotation), orientation measurements of the gluteus minimus (muscle belly portion) and joint capsule were performed and quantitatively compared between the FADIR-positive and control groups. Additionally, 3 hips of 3 participants were randomly selected from each of the control and FADIR-positive groups for magnetic resonance imaging analysis.

RESULTS

At 0°-external/internal and 10°-internal rotation, on ultrasound images, fibers of the gluteus minimus and joint capsule in the FADIR-positive group were significantly more oriented in the same direction than those in the control group. Magnetic resonance imaging showed that the loose connective tissue between the gluteus minimus and joint capsule was prominent at 10°-internal rotation in the control group, although this was not apparent in the FADIR-positive group.

CONCLUSIONS

At hip internal rotation in 90° flexion, the muscular belly portion of the gluteus minimus and joint capsule were oriented in the same direction to a greater extent in the FADIR-positive group than in the control group owing to a morphological change in the loose connective tissue between them. The pathological changes in the loose connective tissue may inhibit smooth movement of the gluteus minimus relative to the joint capsule in individuals with FADIR-positive pain.

Pain, function and quality of life are impaired in adults undergoing periacetabular osteotomy (PAO) for hip dysplasia: a systematic review and meta-analysis

BACKGROUND

Hip dysplasia is a common condition in active adults with hip pain that can lead to joint degeneration. Periacetabular osteotomy (PAO) is a common surgical treatment for hip dysplasia. The effect of this surgery on pain, function and quality of life (QOL) has not been systematically analysed.

PURPOSE

In adults with hip dysplasia: (1) evaluate differences in pain, function and QOL in those undergoing PAO and healthy controls; (2) evaluate pre- to post-PAO changes in pain, function and QOL; (3) evaluate differences in pain, function and QOL in those with mild versus severe dysplasia, undergoing PAO; and (4) evaluate differences in pain, function and QOL in those having primary PAO versus those with previous hip arthroscopy.

METHODS

A comprehensive, reproducible search strategy was performed on 5 different databases. We included studies that assessed pain, function and QOL in adults undergoing PAO for hip dysplasia, using hip-specific patient reported outcomes measures.

RESULTS

From 5017 titles and abstracts screened, 62 studies were included. Meta-analysis showed PAO patients had worse outcomes pre- and post-PAO compared to healthy participants. Specifically, pain (standardised mean difference [SMD] 95% confidence interval [CI]): -4.05; -4.78 to -3.32), function (-2.81; -3.89 to -1.74), and QOL (-4.10; -4.43 to -3.77) were significantly poorer preoperatively.Meta-analysis found patients experienced improvements following PAO. Pain improved from pre-surgery to 1-year (standardised paired difference [SPD] 1.35; 95% CI, 1.02-1.67) and 2 years postoperatively (1.35; 1.16-1.54). For function, the activities of daily living scores at 1 year (1.22; 1.09-1.35) and 2 years (1.06; 0.9-1.22) and QOL at 1 year (1.36; 1.22-1.5) and 2 years (1.3; 1.1-1.5) all improved. No difference was found between patients undergoing PAO with mild versus severe dysplasia.

CONCLUSIONS

Before undergoing PAO surgery, adults with hip dysplasia have worse levels of pain, function and QOL compared to healthy participants. These levels improve following PAO, but do not reach the same level as their healthy participants.

REGISTRATION

PROSPERO (CRD42020144748).

Remote assessment of pelvic kinematics during single leg squat using smartphone sensors: Between-day reliability and identification of acute changes in motor performance

The biomechanical assessment of pelvic kinematics during a single leg squat (SLS) commonly relies on expensive equipment, which precludes its wider implementation in ecological settings. Smartphone sensors could represent an effective solution to objectively quantify pelvic kinematics remotely, but their measure properties need to be evaluated before advocating their use in practice. This study aimed to assess whether measures of pelvic kinematics collected remotely using smartphones during SLS are repeatable between days, and if changes in pelvic kinematics can be identified during an endurance task. Thirty-three healthy young adults were tested remotely on two different days using their own smartphones placed on the lumbosacral region. Pelvic orientation and acceleration were collected during three sets of seven SLS and an endurance task of twenty consecutive SLS. The intersession reliability was assessed using Intraclass Correlation Coefficient (ICC2,k), Standard Error of Measurement, and Minimal Detectable Change. T-tests were used to identify pelvic kinematics changes during the endurance task and to assess between-day bias. Measures of pelvic orientation and frequency features of the acceleration signals showed good to excellent reliability (multiple ICC2,k ≥ 0.79), and a shift of the power spectrum to lower frequencies on the second day (multiple p<0.05). The endurance task resulted in larger contralateral pelvic drop and rotation (multiple p<0.05) and increased spectral entropy (multiple p<0.05). Our findings demonstrate that reliable measures of pelvic kinematics can be obtained remotely using participants' smartphones during SLS. Smartphone sensors can also identify changes in motor control, such as contralateral pelvic drop during an endurance task.

Comparison of Joint Mobilization and Movement Pattern Training for Patients With Hip-Related Groin Pain: A Pilot Randomized Clinical Trial

OBJECTIVE

The objective of this study was to assess the feasibility of completing a randomized clinical trial (RCT) and examine the preliminary effects of 2 interventions for hip-related groin pain (HRGP).

METHODS

In this pilot RCT, patients with HRGP, who were 18 to 40 years old, were randomized (1:1 ratio) to a joint mobilization (JtMob) group or a movement pattern training (MoveTrain) group. Both treatments included 10 supervised sessions and a home exercise program. The goal of JtMob was to reduce pain and improve mobility through peripherally and centrally mediated pain mechanisms. The key element was physical therapist-provided JtMob. The goal of MoveTrain was to reduce hip joint stresses by optimizing the biomechanics of patient-specific tasks. The key element was task-specific instruction to correct abnormal movement patterns displayed during tasks. Primary outcomes were related to future trial feasibility. The primary effectiveness outcome was the Hip Disability and Osteoarthritis Outcome Score. Examiners were blinded to group; patients and treatment providers were not. Data collected at baseline and immediately after treatment were analyzed with analysis of covariance using a generalized linear model in which change was the dependent variable and baseline was the covariate. The study was modified due to the coronavirus disease 2019 (COVID-19) pandemic.

RESULTS

The COVID-19 pandemic affected participation; 127 patients were screened, 33 were randomized (18 to the JtMob group and 15 to the MoveTrain group), and 29 (88%) provided posttreatment data. Treatment session adherence was 85%, and home exercise program component adherence ranged from 71 to 86%. Both groups demonstrated significant mean within-group improvements of ≥5 points on Hip Disability and Osteoarthritis Outcome Score scales. There were no between-group differences in effectiveness outcomes.

CONCLUSIONS

A large RCT to assess the effects of JtMob and MoveTrain for patients with HRGP may be feasible. Preliminary findings suggested that JtMob or MoveTrain may result in improvements in patient-reported pain and activity limitations.

IMPACT

The COVID-19 pandemic interfered with participation, but a randomized controlled trial may be feasible. Modification may be needed if the trial is completed during future pandemics.

Does hip muscle strength and functional performance differ between football players with and without hip dysplasia?

OBJECTIVE

To compare hip muscle strength and functional performance in football players with and without hip dysplasia and investigate if the relationships were modified by sex.

DESIGN

Cross-sectional study.

METHODS

This study compared football players with hip dysplasia (HD group) and without hip dysplasia (control group). Hip muscle strength (Nm/kg) and functional task performance were assessed in both groups. Linear regression with generalized estimating equations were used to assess differences between groups. Sex was assessed as a potential effect modifier.

RESULTS

101 football players were included (HD group, n = 50, control group, n = 51). There was no difference in hip muscle strength or functional performance between the HD group and the control group. Results ranged from hip extension strength (Estimate -0.13.95%CI: 0.29 to 0.02, P = 0.087) to hip external rotation strength (Estimate 0.00.95%CI: 0.05 to 0.05, P = 0.918). No relationships were modified by sex or age.

CONCLUSIONS

Similar levels of hip muscle strength and functional performance were found in active football players with and without hip dysplasia. These findings differ from other studies. This may be due to our cohort having less advanced hip dysplasia than the surgical populations that have been previously investigated, or due to a beneficial effect of football participation on muscle strength and functional performance in people with hip dysplasia.

Radiographic assessment of the pubic symphysis in elite male adolescent football players: Development and reliability of the Maturing Adolescent Pubic Symphysis (MAPS) classification

INTRODUCTION

The pubic symphysis is susceptible to growth related injuries long after the adolescent growth spurt. Our study describes the radiographic maturation of the pubic symphysis on pelvic radiographs in adolescent football players and introduces the Maturing Adolescent Pubic Symphysis classification (MAPS classification).

METHODS

Anteroposterior pelvic radiographs of 105 healthy adolescent male football players between 12 and 24 years old were used to develop the classification system. The radiological scoring of the symphyseal joint was developed over five rounds. The final MAPS classification items were scored in random order by two experienced readers, blinded to the age of the participant and to each other's scoring. The inter- and intra-rater reliability were examined using weighted kappa (κ).

RESULTS

We developed a classification system with descriptive definitions and an accompanying pictorial atlas. The symphyseal joint was divided into three regions: the superior corners, and the upper and lower regions of the joint line. Inter-rater reliability was substantial to almost perfect: superior region: κ = 0.70 (95% CI 0.60---0.79), upper region of the joint line: κ = 0.89 (95% CI 0.86---0.92), lower region of the joint line: κ = 0.65 (95% CI 0.55---0.75). The intra-observer reliability showed similar results.

CONCLUSION

The Maturing Adolescent Pubic Symphysis classification (MAPS classification) is a reliable descriptive classification of the radiographic maturation of the pubic symphysis joint in athletic males. The stages can provide a basis for understanding in clinical practice and will allow future research in this field.

Females with hip-related pain demonstrate reduced kinetics at the hip and ankle during terminal stance of gait

BACKGROUND

Individuals with hip-related pain (HRP) commonly report pain with walking and demonstrate altered movement patterns compared to healthy controls (HCs). Individuals with HRP may attempt to reduce pain during walking by decreasing kinetics and joint forces at the hip through increased use of the ankle during pushoff.

RESEARCH QUESTION

Do individuals with HRP have increased kinetics at the ankle and decreased kinetics at the hip during pushoff in gait compared to HCs, and do kinetic patterns differ between males and females with HRP?

METHODS

This retrospective observational study included 42 individuals with HRP and 20 HCs. Participants completed overground gait trials at their self-selected speed while kinematics and kinetics were recorded through a motion capture system and force plates. Peak internal hip and ankle moments and hip flexion and ankle plantarflexion angular impulse during terminal stance were used in general estimating equations for comparison of group by limb interactions for males and females separately, as well as a comparison of males and females within the HRP group.

RESULTS

Females with HRP demonstrated reduced hip flexion impulse on their involved limb (.070 Nm*s/kg*m) compared to female HCs (.083Nm*s/kg*m; p = .032), as well as reduced peak ankle plantarflexion moment (-.94Nm/kg*m) compared to their contralateral limb (-.99Nm/kg*m) and the involved limb of HRP males (-1.00Nm/kg*m) (p ≤ .007). There were no between-limb or between-group differences in hip or ankle peak moments or impulses in males.

SIGNIFICANCE

Females with HRP show decreased kinetics at both the hip and ankle; these patterns were not identified in males. Future investigations should examine whether increasing ankle kinetics during pushoff reduces pain at the hip, as this may be a valuable clinical treatment strategy.

Relationships between self-perceived and clinical expression of pain and function differ based on the underlying pathology of the human hip

BACKGROUND

Patient-reported outcomes are commonly used to assess patient symptoms. The effect of specific hip pathology on relationships between perceived and objectively measured symptoms remains unclear. The purpose of this study was to evaluate differences of function and pain in patients with FAIS and DDH, to assess the correlation between perceived and objective function, and to determine the influence of pain on measures of function.

METHODS

This prospective cross-sectional study included 35 pre-operative patients (60% female) with femoroacetabular impingement syndrome (FAIS) and 37 pre-operative patients (92% female) with developmental dysplasia of the hip (DDH). Objectively measured function (6-min walk [6MWT], single leg hop [SLHT], Biodex sway [BST], hip abduction strength [HABST], and STAR excursion balance reach [STAR] tests), patient-reported function (UCLA Activity, Hip Outcome Score [HOS], Short Form 12 [SF-12], and Hip Disability and Osteoarthritis Outcome Score [HOOS]), and patient-reported pain (HOOS Pain, visual analogue scale (VAS), and a pain location scale) were collected during a pre-surgical clinic visit. Between-group comparisons of patient scores were performed using Wilcoxon Rank-Sum tests. Within-group correlations were analyzed using Spearman's rank correlation coefficients. Statistical correlation strength was defined as low (r =  ± 0.1-0.3), moderate (r =  ± 0.3-0.5) and strong (r >  ± 0.5).

RESULTS

Patients with DDH reported greater pain and lower function compared to patients with FAIS. 6MWT distance was moderately-to-strongly correlated with a number of patient-reported measures of function (FAIS: r = 0.37 to 0.62, DDH: r = 0.36 to 0.55). Additionally, in patients with DDH, SLHT distance was well correlated with patient reported function (r = 0.37 to 0.60). Correlations between patient-reported pain and objectively measured function were sparse in both patient groups. In patients with FAIS, only 6MWT distance and HOOS Pain (r = -0.53) were significantly correlated. In patients with DDH, 6MWT distance was significantly correlated with VAS Average (r = -0.52) and Best (r = -0.53) pain.

CONCLUSION

Pain is greater and function is lower in patients with DDH compared to patients with FAIS. Moreover, the relationship between pain and function differs between patient groups. Understanding these differences is valuable for informing treatment decisions. We recommend these insights be incorporated within the clinical continuum of care, particularly during evaluation and selection of surgical and therapeutic interventions.

Stratified care in hip arthroscopy: can we predict successful and unsuccessful outcomes? Development and external temporal validation of multivariable prediction models

OBJECTIVE

Although hip arthroscopy is a widely adopted treatment option for hip-related pain, it is unknown whether preoperative clinical information can be used to assist surgical decision-making to avoid offering surgery to patients with limited potential for a successful outcome. We aimed to develop and validate clinical prediction models to identify patients more likely to have an unsuccessful or successful outcome 1 year post hip arthroscopy based on the patient acceptable symptom state.

METHODS

Patient records were extracted from the Danish Hip Arthroscopy Registry (DHAR). A priori, 26 common clinical variables from DHAR were selected as prognostic factors, including demographics, radiographic parameters of hip morphology and self-reported measures. We used 1082 hip arthroscopy patients (surgery performed 25 April 2012 to 4 October 2017) to develop the clinical prediction models based on logistic regression analyses. The development models were internally validated using bootstrapping and shrinkage before temporal external validation was performed using 464 hip arthroscopy patients (surgery performed 5 October 2017 to 13 May 2019).

RESULTS

The prediction model for unsuccessful outcomes showed best and acceptable predictive performance on the external validation dataset for all multiple imputations (Nagelkerke R2 range: 0.25-0.26) and calibration (intercept range: -0.10 to -0.11; slope range: 1.06-1.09), and acceptable discrimination (area under the curve range: 0.76-0.77). The prediction model for successful outcomes did not calibrate well, while also showing poor discrimination.

CONCLUSION

Common clinical variables including demographics, radiographic parameters of hip morphology and self-reported measures were able to predict the probability of having an unsuccessful outcome 1 year after hip arthroscopy, while the model for successful outcome showed unacceptable accuracy. The externally validated prediction model can be used to support clinical evaluation and shared decision making by informing the orthopaedic surgeon and patient about the risk of an unsuccessful outcome, and thus when surgery may not be appropriate.

Hip muscle activity in people with hip-related pain compared to asymptomatic controls: A systematic review

BACKGROUND

Altered hip and thigh muscle activity have been observed across a spectrum of articular hip pathologies, including hip osteoarthritis, femoroacetabular impingement syndrome, and labral pathology. No systematic reviews have examined muscle activity associated with hip pathology and hip-related pain across the life span. A greater understanding of impairments in hip and thigh muscle activity during functional tasks may assist in the development of targeted treatment strategies.

METHODS

We conducted a systematic review using the PRISMA guidelines. A literature search was performed in five databases (MEDLINE, CINAHL, EMBASE, Sports Discuss, and PsychINFO). Studies were included that (i) investigated people with hip-related pain (femoroacetabular impingement syndrome, labral tears) or hip osteoarthritis; and (ii) reported on muscle activity using electromyography of hip and thigh muscles during functional tasks such as walking, stepping, squatting, or lunging. Two independent reviewers performed data extraction and assessed risk of bias using a modified version of the Downs and Black checklist.

RESULTS

Non-pooled data demonstrated a limited level of evidence. Overall, differences in muscle activity appeared to be more prevalent in people with more advanced hip pathology.

CONCLUSIONS

We found that impairments in muscle activity in those with intra-articular hip pathology measured using electromyography were variable but appeared to be greater in severe hip pathology (e.g., hip OA).

Patient characteristics cannot predict the long-term effect of an intra-articular bupivacaine and corticosteroid injection in patients with femoroacetabular impingement: A retrospective cohort study

Background

To evaluate predictors for effect of an intra-articular (IA) bupivacaine and corticosteroid injection in patients with femoroacetabular impingement syndrome (FAIS).

Methods

All patients between 18 and 50 years old with FAIS who received an intra-articular (IA) bupivacaine and corticosteroid injection between 2016 and 2019 were eligible for this retrospective study. Two groups were made, the non-arthroscopy group (patients for whom conservative treatment with physiotherapy and an IA bupivacaine and corticosteroid injection was sufficient) and the arthroscopy group (patients who needed an arthroscopy because conservative treatment and an IA bupivacaine and corticosteroid injection failed). Multiple regression analysis was performed to analyse the effect of the IA corticosteroid injection and to predict arthroscopic intervention based on sex, age, body mass index, duration of complaints, alpha angle and abnormal bone morphology.

Results

In total 103 patients were included; 46 in the arthroscopy group and 57 in the non-arthroscopy group. The groups had similar baseline characteristics. A total of 37 (36%) patients had an effect of 3 months or longer from the IA corticosteroid injection; 31 (54%) were patients in the non-arthroscopy group versus 6 (13%) patients in the arthroscopy group (P < 0.001). Male sex seems to have an negative influence on the duration of the effect of the injection. None of the variables could significantly predict if a patient would undergo arthroscopic intervention (F(7,103) = 8.54, p = 0.3, R2 = 0.11). The effect of the IA injection could not be predicted (p = 0.1; R2 = 0.13).

Conclusion

There are no patient characteristics that predict who would and who would not benefit from the IA bupivacaine and corticosteroid injection in patients with FAIS and who would need an arthroscopic intervention within 1 year after the injection. Only male sex seems to have an negative influence on the duration of the effect of the injection.

Does femoroacetabular impingement syndrome affect range of motion? A systematic review with meta-analysis

BACKGROUND

It is unclear whether femoroacetabular impingement syndrome (FAIS) affect hip range of motion (ROM).

SOURCES OF DATA

We performed a systematic review with meta-analysis searching six electronic databases from inception to March 21, 2022. We included studies assessing hip ROM in FAIS, FAI morphology without symptoms (FAIm), and healthy controls. Mean differences between groups were measured in ROM degrees with 95% confidence interval (CI).

AREAS OF AGREEMENT

A total of 17 studies (1702 hips) were included. Comparison of FAIS patients versus healthy controls showed that hip ROM was clinically and statistically reduced in FAIS for internal rotation (90° hip flexion, -8.01°, 95% CI: -11.21, -4.90; 0° hip flexion -6.38°, 95% CI: -9.79, -2.97); adduction (90° hip flexion, -4.74°, 95% CI: -8.13, -1.34); flexion (-5.41°, 95% CI: -7.05, -3.49), abduction (0° hip flexion, -5.76°, 95% CI: -8.38, -3.23), and external rotation (90° hip flexion, -3.5°, 95% CI: -5.32, -1.67) ranging from low to high certainty of evidence. Comparison of FAIm versus healthy controls showed no statistically significant differences in any direction of movement, albeit with uncertainty of evidence.

AREAS OF CONTROVERSY

The certainty of evidence was unclear, particularly for asymptomatic FAIm.

GROWING POINTS

Hip ROM may be reduced in all directions except extension in FAIS compared to controls. Hip ROM may not be restricted in asymptomatic FAIm.

AREAS TIMELY FOR DEVELOPING RESEARCH

Further studies are needed to resolve the uncertainty of evidence about ROM restrictions in asymptomatic FAIm compared to healthy controls.

The Effect of a Formal Nonoperative Management Program Combining a Hip Injection With Structured Adjunctive Exercise Rehabilitation in Patients With Symptomatic Femoroacetabular Impingement Syndrome

BACKGROUND

Although the initial treatment recommendations for femoroacetabular impingement syndrome (FAIS) may include nonsurgical therapies such as injections and rehabilitation, many patients undergo isolated injections or a rudimentary exercise regimen.

PURPOSE

To investigate the benefit of an intra-articular hip injection and concomitant structured exercise rehabilitation program in patients with symptomatic FAIS ≥6 months.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

For this study we recruited 49 patients with a mean age of 32.8 years (range, 16-56 years) and symptoms ≥6 months (range, 6-250 months) associated with FAIS, as confirmed via magnetic resonance imaging and radiography. After a guided intra-articular injection of corticosteroid and local anesthetic, patients underwent a structured 12-week rehabilitation program. Patients were assessed before and after injection (8 weeks and 4, 6, 12, and 24 months) with a range of patient-reported outcome measures (PROMs), including the 33-item International Hip Outcome Tool, Hip Outcome Score, modified Harris Hip Score, the Tegner Activity Score, a visual analog scale assessing the frequency and severity of hip pain, and a Global Rating of Change scale. Range of motion, peak isometric hip strength, and hop tests were assessed. Absolute scores and limb symmetry indices were calculated. The percentage of patients transitioning toward surgery over the period was evaluated.

RESULTS

Of the 44 patients who underwent the injection and completed the initial 8-week rehabilitation component, 14 (31.8%) progressed toward surgical intervention over the 24-month postinjection period owing to dissatisfaction and/or symptom recurrence. Patients who progressed toward surgery, as compared with those who did not, reported significantly worse (P < .05) PROMs presurgery and more pain within the first 4 weeks after injection. In the nonoperative cohort, a significant improvement (P < .05) in all PROMs was observed, with 93% of these patients satisfied overall. The Global Rating of Change did not improve, although this was measured only after the injection, reflecting no further significant perceived global change from 8 weeks to 24 months. A significant increase (P < .05) in all hip range of motion and most isometric strength measures was observed at 8 weeks after injection, with these improvements largely sustained until 24 months. Bilateral improvements in hop capacity were observed, with hop test LSIs significantly improving for the single (p = 0.009), triple (p = 0.029) and triple crossover (p = 0.005) hop tests for distance.

CONCLUSION

Although 32% of patients progressed toward surgery, significant improvement in hip pain, symptoms, and physical function was observed in the majority of patients with symptomatic FAIS as a result of a targeted nonoperative management pathway consisting of an intra-articular injection and a structured exercise program.

Are Exercise Therapy Protocols For The Treatment of Hip-Related Pain Adequately Described? A Systematic Review of Intervention Descriptions

Background

Hip-related pain is an umbrella term encompassing pain from non-arthritic hip joint pathologies, such as femoroacetabular impingement syndrome, hip dysplasia, and labral tears. Exercise therapy is commonly recommended for these conditions, but the reporting completeness of these interventions is currently unclear.

Purpose

The aim of this systematic review was to assess the reporting completeness of exercise therapy protocols for people with hip-related pain.

Study design

Systematic review according to PRISMA guidelines.

Materials and Methods

A systematic search was conducted, searching the MEDLINE, CINAHL, and Cochrane databases. The search results were independently screened by two researchers. Inclusion criteria were studies using exercise therapy in people with non-arthritic hip-related pain. Two independent researchers used the Cochrane risk of bias tool version 2 to analyze risk of bias, and the Consensus on Exercise Reporting Template (CERT) checklist and score (1-19) to synthesize reporting completeness.

Results

Fifty-two studies used exercise therapy for hip-related pain, but only 23 were included in the synthesis as 29 studies had no description of the intervention. CERT scores ranged from 1 to 17 (median 12, IQR 5-15). The most well-described items were tailoring (87%), and the least well-described items were motivation strategies (9%) and starting level (13%). Studies used exercise therapy alone (n=13), or in combination with hip arthroscopy (n=10).

Conclusion

Only 23 of 52 eligible studies reported sufficient details to be included in the CERT synthesis. The median CERT score was 12 (IQR 5-15), with no study reaching the maximum score of 19. Lack of reporting makes it difficult to replicate interventions in future research, and to draw conclusions on efficacy and dose-response to exercise therapy for hip-related pain.

Level of evidence

Level 1, systematic review.

Desmoid fibromatosis presenting as lateral hip pain in an outpatient physical therapy clinic: A case report

CASE DESCRIPTION

A 21-year-old healthy female presented with severe left lateral hip pain beginning suddenly two weeks prior. Physical examination revealed zero degrees of left hip external rotation passive range of motion with a firm end feel and pain severity and irritability out of proportion to an expected musculoskeletal presentation. She was referred to her physician with a recommendation for imaging to determine the source of pain and appropriateness of physical therapy.

OUTCOME

Magnetic resonance imaging revealed a foreign mass in her left gluteus medius muscle which biopsy revealed to be a desmoid fibromatosis.

CONCLUSION

This case demonstrates a thorough differential diagnostic process leading to medical imaging referral in a patient with a non-musculoskeletal source of pain. Physical therapists must be diligent in their differential diagnostic process to ensure appropriateness of their treatments or the need for referral.

Results of Arthroscopic Treatment for Femoroacetabular Impingement

Background. Femoroacetabular impingement (FAI) is one of the most frequent causes of hip pain and limited hip mobility in young and middle-aged patients. It is a result of repeated injury of hip structures, that leads to degenerative changes in hip labrum, cartilage and subchondral bone and provokes progressive development of hip osteoarthritis. Aim of study to analyze own experience of treating patients with femoroacetabular impingement and identify factors affecting its outcomes. Methods. Retrospective, uncontrolled, single-center clinical study included 128 patients with FAI which had 150 surgeries on 149 joints in in the period from 2013 to 2021. All patients underwent physical examination and X-ray diagnostics, their FAI type was identified. The alpha angle of external part of femoral head in anterior-posterior position and in the modified Dunn 45 position, as well as Tonnis angle, lateral central-marginal angle in Ogata modification and the height of articular gap along the lateral (LS) and medial edges (MS) of sclerosed acetabulum part were calculated. The i-HOT-33 and HOS scales were used to assess preoperative status and postoperative results. Results. The average follow-up period was 3.9 years (SD 1.71; min 1.05 and max 8.16). The study included 55 (43.0%) women and 73 (57.0%) men which underwent 64 (42.7%) and 86 (57.3%) surgeries respectively. The most common types of FAI, according to our data, were mixed type (53% of joints) and сam type (27.5% of joints). Insufficient coverage of the femoral head by the acetabulum (borderline dysplasia) in combination with the сam deformity of the femoral head was observed in 18.1%. Pincer-type FAI was observed in 1.4% of joints. We obtained the worst results with a combination of сam deformity and borderline dysplasia in comparison with cam- and mix-type FAI according to the i-HOT-33 and HOS scales. Patients age, deep cartilage damage, irreparable labrum damage and height decrease of the lateral part of the articular gap determined negative effect on treatment results according to the i-HOT-33 and HOS scales. Conclusion. Hip arthroscopy showed good short- and midterm outcomes in patients with FAI. Pain syndrome is most often manifested in patients with pathology of hip soft tissue structures concomitant to FAI. The combination of сam deformity and insufficient femoral head coverage, deep cartilage damage and a height decrease of the articular gap are important predictors of poor treatment results.

The traction force of the pulled limb in hip arthroscopic surgery is determined by stiffness coefficient which is significantly related to muscle volume

PURPOSE

To verify the relationship between muscle volume, lateral centre-edge angle (LCEA), alpha angle (AA), body mass index (BMI) and Beighton score with stiffness coefficient (SC). To analyse the difference of traction force at different physical states of hip joint capsule.

METHODS

Thirty-six patients who underwent hip arthroscopy operation were included. The volumes of some related muscles were measured in MRI images by 3D Slicer. We recorded and tested differences in traction force of five joint capsule physical states, including before (State 1) and after joint capsule puncture (State 2), after the establishment of anterolateral and mid-anterior approaches (State 3) and after incision of the joint capsule through these two approaches (States 4, 5). The correlation between muscle volume, BMI, LCEA, AA and SC was verified by Spearman test. Poisson regression was used to explain confounding variables.

RESULTS

The average force at State 1 was 531.8 N. There were significant differences in traction force between these five states (p < 0.001). There was a significant positive correlation between muscle volumes and SC (p < 0.001). BMI had no correlation with SC (n.s.). The preoperative LCEA of the affected side was correlated with SC (p = 0.043). AA and SC were not correlated (n.s.).

CONCLUSION

The physical states of the hip joint capsule affected traction force. Muscle volume rather than BMI is an ideal index to estimate preoperative traction force. LCEA affected traction force, whilst AA and Beighton score did not. Measuring the muscle volume can help estimate the most suitable traction force for the patient.

LEVELS OF EVIDENCE

IV.

Oxford consensus on primary cam morphology and femoroacetabular impingement syndrome: part 2-research priorities on conditions affecting the young person's hip

INTRODUCTION

Primary cam morphology is highly prevalent in many athlete populations, causing debilitating hip osteoarthritis in some. Existing research is mired in confusion partly because stakeholders have not agreed on key primary cam morphology elements or a prioritised research agenda. We aimed to inform a more rigorous, inclusive and evidence-based approach to research on primary cam morphology and its natural history by working towards agreement on a set of research priorities for conditions affecting the young person's hip.

METHODS

An international expert panel-the Young Athlete's Hip Research (YAHiR) Collaborative-rated research priority statements through an online two-round Delphi exercise and met online to explore areas of tension and dissent. Panellists ranked the prioritised research statements according to the Essential National Health Research (ENHR) ranking strategy. Reporting of results followed REPRISE (REporting guideline for PRIority SEtting of health).

RESULTS

A diverse Delphi panel (n=65, Delphi rounds 1 and 2; three ENHR strategy surveys: n=49; n=44; n=42) from 18 countries representing six stakeholder groups, prioritised and ranked 18 of 38 research priority statements. The prioritised statements outlined seven research domains: (1) best practice physiotherapy, (2) rehabilitation progression and return to sport, (3) exercise intervention and load management, (4) primary cam morphology prognosis and aetiology, (5) femoroacetabular impingement syndrome prognosis and aetiology, (6) diagnostic criteria, and (7) screening. The panel recommended areas of tension and dissent for the research community to focus on immediately.

CONCLUSION

While informing more rigorous, inclusive and evidence-based research, this consensus is a roadmap for researchers, policy-makers and funders to implement research dedicated to reducing the cost and burden of hip disease related to primary cam morphology.

Females with hip-related pain display altered lower limb mechanics compared to their healthy counterparts in a drop jump task

BACKGROUND

Hip-related pain describes femoroacetabular impingement syndrome, acetabular dysplasia, and other hip pain conditions without clear morphological features. Movement strategies in this population, notably sex-related patterns, are poorly understood and may provide insights into why females report more pain and worse function. This study examined the sex-related differences during a drop vertical jump task between those with hip-related pain and healthy controls.

METHODS

Patients with hip-related pain and healthy controls completed five repetitions of a drop jump while their kinematics and kinetics were recorded using a motion capture system and force plates. Hip, knee, and ankle joint angles and external joint moments during landing were used in general estimating equations for comparison of group by sex by limb interactions. Time series data were further investigated using statistical parametric mapping.

FINDINGS

Females with hip-related pain had 9.1° less hip flexion (P = .041) and 9.2° less knee flexion (P = .024) than healthy females, and 8.3° less knee flexion than male counterparts with hip-related pain (P = .039). Males demonstrated 1.4° less hip flexion on the affected side compared to their uninvolved side (P = .004). Statistical parametric mapping results showed significant differences in knee flexion angle for females with hip-related pain compared to healthy females (P = .042). There were no significant differences in hip, knee, or ankle moments.

INTERPRETATION

Females with hip-related pain showed kinematic patterns distinct from healthy controls. Sex may be an important variable of interest in characterizing movement impairments in this population and movement impairments may be an appropriate target for intervention for these patients.

Diagnostic Accuracy of Clinical Tests and Imaging Exams for Femoroacetabular Impingement: An Umbrella Review of Systematic Reviews

OBJECTIVE

To synthesize available evidence about diagnostic accuracy of clinical tests and imaging examinations for femoroacetabular impingement (FAI) syndrome.

DESIGN

Umbrella review.

SETTING

N/A.

PARTICIPANTS

N/A.

INTERVENTIONS

N/A.

MAIN OUTCOME MEASURES

Systematic reviews (SR) indexed in Embase, LIVIVO, PubMed, SCOPUS, the Cochrane Library, and Web of Science were searched in a 2-phase process. SR assessing diagnostic accuracy were considered eligible.

RESULTS

From 1520 studies, 6 SR were included, which evaluated 24 primary studies related to FAI syndrome. Of these, 5 SR assessed clinical tests, and a substantial heterogeneity was found concerning reference standards adopted across primary studies, which included arthroscopy, clinical examination (associated or not with imaging exams), intra-articular injections, and open surgery. Most clinical tests presented higher values of sensitivity compared with specificity, although evidence was considered limited because the same primary studies were often included across SR. Nonetheless, evidence around the flexion adduction internal rotation (FADIR) test was considered stronger and its use as a screening tool was consistently supported. Only one SR assessed the accuracy of imaging examinations, which adopted open surgery as the sole reference standard. Most imaging exams presented considerably high values of sensitivity, although specificity values were notably lower.

CONCLUSIONS

No robust recommendations can be provided for most clinical tests, although the FADIR test, in particular, was consistently supported as a screening tool. Moreover, although imaging examinations showed considerably high sensitivity values, evidence was considered sparse and further research is strongly recommended to validate its use as reference standards for diagnostic accuracy data.

Does Femoroacetabular Impingement Syndrome Affect Self-Reported Burden in Football Players With Hip and Groin Pain?

BACKGROUND

It is unknown if football players with femoroacetabular impingement (FAI) syndrome report worse burden than those with other causes of hip/groin pain, and to what extent this is mediated by cartilage defects and labral tears.

HYPOTHESIS

Football players with FAI syndrome would report worse burden than other symptomatic players, with the effect partially mediated by cartilage defects and/or labral tears.

STUDY DESIGN

Cross-sectional study.

LEVEL OF EVIDENCE

Level 4.

METHODS

Football (soccer and Australian football) players (n = 165; 35 women) with hip/groin pain (≥6 months and positive flexion-adduction-internal rotation test) were recruited. Participants completed 2 patient-reported outcome measures (PROMs; the International Hip Outcome Tool-33 [iHOT-33] and Copenhagen Hip and Groin Outcome Score [HAGOS]) and underwent hip radiographs and magnetic resonance imaging (MRI). FAI syndrome was determined to be present when cam and/or pincer morphology were present. Cartilage defects and labral tears were graded as present or absent using MRI. Linear regression models investigated relationships between FAI syndrome (dichotomous independent variable) and PROM scores (dependent variables). Mediation analyses investigated the effect of cartilage defects and labral tears on these relationships.

RESULTS

FAI syndrome was not related to PROM scores (unadjusted b values ranged from -4.693 (P = 0.23) to 0.337 (P = 0.93)) and cartilage defects and/or labral tears did not mediate its effect (P = 0.22-0.97).

CONCLUSION

Football players with FAI syndrome did not report worse burden than those with other causes of hip/groin pain. Cartilage defects and/or labral tears did not explain the effect of FAI syndrome on reported burden.

CLINICAL RELEVANCE

FAI syndrome, cartilage defects, and labral tears were prevalent but unrelated to reported burden in symptomatic football players.

Validity and Test-Retest Reliability of the Spanish Version of the International Hip Outcome Tool (iHOT-12Sv)

Objective: To develop a Spanish version of the international Hip Outcome Tool questionnaire (iHOT-12Sv) for assessing the psychometric characteristics (internal consistency, convergent validity, test−retest reliability, and floor and ceiling effects) of this version in physically active patients with hip pain. Methods: After conducting the translation and transcultural adaptation, a consecutive sample of patients with labral tear injury and/or femoroacetabular impingement (Pincer or Cam type) were recruited in a Spanish Hospital. Patients completed the iHOT-12Sv and the Spanish version of the iHOT-33 and the Hip Outcome Score (HOS). Internal consistency was calculated using Cronbach’s alpha; convergent validity was evaluated using Spearman correlation coefficients (Rho) with iHOT-33 and HOS; test−retest reliability was examined using the intraclass correlation coefficient (ICC), standard error of measurement (SEM), and minimal detectable changes (MDC); and floor and ceiling effects were calculated as the percentage of patients who obtained the minimum and maximum score. Results: One hundred and fifty-three patients (64.7% males) participated in this study. Cronbach’s alpha of 0.92 revealed the excellent internal consistency. In addition, the iHOT-12Sv demonstrated strong to very strong correlations with the HOS (Rho ranged from 0.741 to 0.827; p < 0.001) and the iHOT-33 (Rho = 0.932; p < 0.001), respectively; acceptable test-retest reliability (ICC = 0.86 to 0.94); SEM = 6.21 and MDC = 17.22; and no floor or ceiling effects were found. Conclusions: The iHOT-12Sv can be used as a valid and reliable tool for clinical evaluation of physically active patients with hip pathology. However, the full version is preferable for research purposes aiming to assess changes in hip function.

Evaluation of additional causes of hip pain in patients with femoroacetabular impingement syndrome

Femoroacetabular impingement syndrome (FAIS) is an increasingly prevalent pathology in young and active patients, that has contributing factors from both abnormal hip morphology as well as abnormal hip motion. Disease progression can be detrimental to patient quality of life in the short term, from limitations on sport and activity, as well as the long term through early onset of hip arthritis. However, several concurrent or contributing pathologies may exist that exacerbate hip pain and are not addressed by arthroscopic intervention of cam and pincer morphologies. Lumbopelvic stiffness, for instance, places increased stress on the hip to achieve necessary flexion. Pathology at the pubic symphysis and sacroiliac joint may exist concurrently to FAIS through aberrant muscle forces. Additionally, both femoral and acetabular retro- or anteversion may contribute to impingement not associated with traditional cam/pincer lesions. Finally, microinstability of the hip from either osseous or capsuloligamentous pathology is increasingly being recognized as a source of hip pain. The present review investigates the pathophysiology and evaluation of alternate causes of hip pain in FAIS that must be evaluated to optimize patient outcomes.

No Difference in Hip Muscle Volumes and Fatty Infiltration in Those With Hip-Related Pain Compared to Controls

Background

Little is known about muscle morphology in people with hip-related pain, without signs of femoro-acetabular impingement syndrome (FAIS). Identifying changes in hip muscle volume, fatty infiltrate and establishing relationships between muscle volume and strength, may provide insight into potential early treatment strategies.

Purposes

To: (i) compare the volumes and fatty infiltrate of gluteus maximus, gluteus medius, gluteus minimis, tensor fascia latae and quadratus femoris between symptomatic and less-symptomatic sides of participants with hip-related pain; (ii) compare the volumes and fatty infiltrate of hip muscles between healthy controls and symptomatic participants; and (iii) explore relationships of hip muscle volumes to muscle strength and patient-reported outcome measures in people with hip-related pain.

Study Design

Cross-sectional study.

Methods

Muscle volume and fatty infiltrate (from magnetic resonance imaging), hip muscle strength, patient-reported symptoms, function and quality of life (QOL) were determined for 16 participants with hip-related pain (no clinical signs of FAIS; 37±9 years) and 15 controls (31±9 years). Using One Way Analysis of Co-Variance tests, muscle volume and fatty infiltrate was compared between the symptomatic and less-symptomatic sides in participants with hip-related pain as well as between healthy controls and symptomatic participants. In addition, hip muscle volume was correlated with hip muscle strength, hip-reported symptoms, function and QOL.

Results

No differences in all the studied muscle volumes or fatty infiltrate were identified between the symptomatic and less-symptomatic hips of people with hip-related pain; or between people with and without hip-related pain. Greater GMED volume on the symptomatic side was associated with less symptoms and better function and QOL (ρ=0.522-0.617) for those with hip-related pain. Larger GMAX volume was associated with greater hip abduction and internal rotation strength, larger GMED volume was associated with greater hip extension strength, and larger QF volume was associated with greater hip abduction strength (rho=0.507-0.638).

Conclusion

People with hip-related pain and no clinical signs of FAIS have hip muscle volumes that are not significantly different than those of matched pain-free controls or their less-symptomatic hip. Larger GMED muscle volume was associated with fewer symptoms and greater strength.

Level of evidence

Level 3a.

Hip Pain Associated with Acetabular Dysplasia in Patients with Suspected Axial Spondyloarthritis: DESIR Cohort Data

Objectives

To determine whether acetabular dysplasia is associated with hip pain at physical examination among adults with recent-onset inflammatory back pain (IBP) suggesting axial spondyloarthritis (axSpA).

Methods

This cross-sectional ancillary study was conducted on the prospective DESIR cohort, which enrolled patients aged 18–50 years who had recent-onset IBP. Two readers used antero-posterior pelvic radiographs to assess the Tönnis angle, acetabular angle (AA), lateral centre-edge angle (LCEA), and femoral head extrusion index (FHEI). Abnormality of one or more of these four variables defined acetabular dysplasia. Hip pain upon physical examination was assessed based on Ritchie’s articular index.

Results

The overall prevalence of acetabular dysplasia was 22% (139/636). The proportion of females was higher in the group with acetabular dysplasia. Hip pain was found in 21% (29/139) of patients with versus 12% (59/497) without acetabular dysplasia (OR, 1.96; 95% CI, 1.20 to 3.20); the association was significant in males (OR, 3.14; 95% CI, 1.44 to 6.86) but not females (OR, 1.39; 95% CI, 0.74 to 2.62). Results were similar when acetabular dysplasia was defined on the basis of LCEA alone (OR, 2.15; 95% CI, 1.18 to 2.62).

Conclusion

Among patients with recent-onset IBP suggesting axSpA, acetabular dysplasia was significantly associated with hip pain in males. Hip pain related to acetabular dysplasia might result in overdiagnosis of hip involvement by axSpA.

Soccer players show the highest seasonal groin pain prevalence and the longest time loss from sport among 500 athletes from major team sports

PURPOSE

Groin pain is a widely recognized medical issue among athletes. Groin pain can affect both player and team performance and sometimes can be a career-ending injury. The aim of this study was to assess seasonal groin pain prevalence and the average seasonal time loss from sport for each injury in different team sport athletes. The hip and groin functionality at the beginning of the following season was also investigated.

METHODS

A cross-sectional study was undertaken on 600 team sport athletes (soccer, futsal, basketball, volleyball, and water polo players). The seasonal prevalence of groin pain, level of competition (professional and non-professional), time loss, and concomitant injuries in addition to groin pain were reported and analyzed. The Copenhagen Hip and Groin Outcome Score (HAGOS) was used to assess hip and groin pain and function related to sport and activity.

RESULTS

Among the 506 (84%) players included, 123 players (24.3%) reported groin pain. Overall, soccer players reported the highest groin pain prevalence (32.5%) followed by futsal (25.5%), basketball (25.2%), water polo (17.6%) and volleyball players (13.6%). Professional soccer, futsal and basketball athletes showed higher groin pain prevalence in comparison with non-professional athletes (p = 0.02, p = 0.005 and p = 0.004, respectively). The mean time loss from sport due to groin pain was 60.3 ± 66 days in soccer, 41.1 ± 16.6 days in futsal, 31.5 ± 18 days in water polo, 37.2 ± 14.2 days in basketball and 50.8 ± 24.6 days in volleyball. Significantly lower HAGOS values were found in athletes with groin pain for all sports evaluated compared to athletes with no groin pain history (p =  0.0001). Longer time loss from sport was correlated with lower HAGOS values in soccer (p = 0.002) and futsal (p = 0.002) players with groin pain. Concomitant injuries were correlated with lower HAGOS values in water polo players (p = 0.03).

CONCLUSIONS

Seasonal groin pain occurs in as many as one in four team sport athletes. Soccer players show the highest groin pain prevalence and the longest time loss from sport. Professional athletes report higher prevalence of groin pain in comparison with non-professional athletes. HAGOS appears to be a valid outcome instrument to measure groin pain, correlating with both time loss from sport and concomitant injuries in athletes.

LEVEL OF EVIDENCE

Level IV.

Five-Year Follow-up After Hip Arthroscopic Surgery in the Horsens-Aarhus Femoroacetabular Impingement (HAFAI) Cohort

Background:

Patients with femoroacetabular impingement syndrome (FAIS) are offered hip arthroscopic surgery to decrease hip pain, improve their function, and decrease development of hip osteoarthritis (OA). Nonetheless, long-term follow-up data are few.

Purpose:

To investigate patient-reported outcomes, clinical tests, reoperations, and radiographic status 5 years after primary hip arthroscopy in patients with FAIS.

Study Design:

Case series; Level of evidence, 4.

Methods:

A total of 60 patients (age, 36 ± 9 years; 63% female) diagnosed with FAIS were included in the study and followed for 5 years after hip arthroscopy. Follow-up included Copenhagen Hip and Groin Outcome Score (HAGOS); Hip Sports Activity Scale; and clinical tests (flexion, adduction, internal rotation [FADIR]; flexion, abduction, external rotation [FABER]; and psoas muscle/tendon major pain provocation). Radiographic evaluation included lateral joint-space width (LJSW) and Tönnis classification for hip OA. Reoperations and conversion to total hip replacement (THR) were recorded. We calculated the proportion of patients who exceeded the minimal important change (MIC), achieved the Patient Acceptable Symptom State (PASS), and were within the 95% reference interval of age- and sex-matched persons with no hip problems. Changes were investigated using paired t tests.

Results:

Compared with preoperatively, all HAGOS subscales were improved substantially 5 years after surgery (mean, ≥21 points; P < .001), and 67% to 89% of patients reported improvements exceeding MIC. Between 56% and 80% achieved PASS, but only 7% to 24% reached the 95% reference interval for the HAGOS subscales. A total of 36% had a positive FADIR test and 25% had a positive FABER test, which were improvements compared with preoperatively (P < .001 for both). Patients with a positive FADIR test had significantly worse HAGOS subscales. Six patients (10%) had a THR since their primary hip arthroscopy. In the remaining patients, the mean LJSW was decreased (-0.4 mm; P = .043), and hip OA had worsened in 9 patients (23%; P = .003).

Conclusion:

Five years after surgery, the majority of patients experienced HAGOS improvements exceeding MIC while also showing an acceptable PASS. However, clinical tests, participation in physical activities, and quality of life indicated that many patients still experience hip problems.

Registration:

NCT04590924 (ClinicalTrials.gov identifier).

[Femoroacetabular impingement syndrome in adolescents-How to adivse? How to treat?]

Hintergrund

Das Femoroazetabuläre Impingement-Syndrom (FAIS) ist eine relevante Ursache für Leistenschmerzen beim Jugendlichen. Insbesondere sind Sportler betroffen.

Ziel der Arbeit

Die Arbeit soll einen evidenzbasierten Hintergrund für Beratung und Therapie des FAIS beim Adoleszenten bieten.

Material und Methoden

Anhand der aktuellen Literatur wurde eine Übersicht zu Prävalenz und Pathogenese, Abklärung und Diagnostik sowie therapeutischen Empfehlung des FAIS beim Adoleszenten erarbeitet.

Ergebnisse und Diskussion

Das FAIS beim Jugendlichen betrifft vor allem sportlich aktive Patienten. Bestimmte Sportarten begünstigen die Entstehung eines FAIS. Cam-Impingement, Pincer-Impingement und kombiniertes FAIS sind die häufigsten Entitäten in dieser Altersgruppe. Die Cam-Morphologie entsteht kurz vor Schluss der proximalen Femurwachstumsfuge. Beim Cam-Impingement muss die Epiphyseolysis capitis femoris (ECF) von der primären Cam-Morphologie unterschieden werden. Die ECF verlangt eine rasche operative Versorgung mit Stabilisierung der Epiphyse, während das primäre Cam-Impingement elektiv abgeklärt werden kann und ein konservativer Behandlungsversuch sinnvoll ist. Schäden an Labrum und Knorpel werden regelhaft beobachtet. Eine systematische radiologische Abklärung mittels Projektionsröntgen und MRT ist obligat, um einen adäquaten Therapieplan zu entwickeln. Bei jugendlichen Patienten mit FAIS sollte immer ein konservativer Therapieversuch erfolgen. Ist dieser nicht erfolgreich, ist die operative Sanierung mit Hüftarthroskopie indiziert. Die postoperativen Ergebnisse zeigen bei Jugendlichen sehr gute Erfolge mit rascher Besserung der Beschwerden, geringen Komplikationen und einer hohen „Return-to-sport“-Rate.

Adding false-profile radiographs improves detection of developmental dysplasia of the hip, data from the CHECK cohort

The aim of this study was to determine the additional value of the false-profile (FP) view radiograph in the diagnosis of developmental dysplasia of the hip (DDH), as compared with an anteroposterior (AP) pelvic radiograph only, and evaluate the correlation between the Wiberg-lateral center edge angle (W-LCEA) and Wiberg-anterior center edge angle (W-ACEA). We used baseline data from a nationwide prospective cohort study (Cohort Hip and Cohort Knee). DDH was quantified on AP pelvic and FP hip radiographs using semi-automatic measurements of the W-LCEA and W-ACEA. A threshold of <20° was used to determine DDH for both the W-LCEA and the W-ACEA. The proportion of DDH only present on the FP view determined the FP view additional value. The correlation between the W-LCEA and W-ACEA was determined. In total 720 participants (1391 hips) were included. DDH was present in 74 hips (5.3%), of which 32 were only present on the FP view radiograph (43.2%). The Pearson correlation coefficient between W-LCEA and W-ACEA of all included hips was 0.547 (95% confidence interval: 0.503–0.591) and 0.441 (95% confidence interval: 0.231–0.652) in hips with DDH. A mean difference of 9.4° (SD 8.09) was present between the W-LCEA and the W-ACEA in the hips with DDH. There is a strong additional value of the FP radiograph in the diagnosis of DDH. Over 4 out of 10 (43.2%) individuals’ DDH will be missed when only using the AP radiograph. In hips with DDH a moderate correlation between W-LCEA and W-ACEA was calculated indicating that joints with normal acetabular coverage on the AP view can still be undercovered on the FP view.

Cam morphology is associated with MRI-defined cartilage defects and labral tears: a case-control study of 237 young adult football players with and without hip and groin pain

Objective

Football players are at risk of developing hip osteoarthritis (OA). Cam morphology (present in almost two of every three football players) may explain this heightened risk, but there is limited research on its role in hip OA development in younger athletes. Knowledge of this relationship will advance our understanding of the aetiology of hip OA in football players. We aimed to study the relationship between cam morphology size and MRI-defined cartilage defects and labral tears, and if this relationship differs by symptomatic state in young adult football players.

Methods

For this case–control study, 182 (288 hips) symptomatic (hip and/or groin pain >6 months and positive flexion-adduction-internal-rotation (FADIR) test) and 55 (110 hips) pain-free football players (soccer or Australian football) underwent anteroposterior and Dunn 45° radiographs, and 3-Tesla MRI. Cam morphology size was defined using alpha angle, and cartilage defects and labral tears were scored semiquantitatively. Presence, location and score (severity) of cartilage defects and labral tears were determined. Each participant completed the International Hip Outcome Tool 33 and Copenhagen Hip and Groin Outcome Score.

Results

Greater alpha angle was associated with cartilage defects (OR 1.03, 95% CI 1.01 to 1.04) and labral tears (OR 1.02, 95% CI 1.01 to 1.04). Greater alpha angle was associated with superolateral cartilage defects (OR 1.03, 95% CI 1.02 to 1.05) and superior labral tears (OR 1.03, 95% CI 1.02 to 1.05). The association of alpha angle with MRI-defined cartilage defects and labral tears was no greater in football players with symptoms than in those without (p=0.189–0.937)

Conclusion

Cam morphology size was associated with cartilage defects and labral tears in young adult football players with and without pain. This study provides evidence that cam morphology may contribute to the high prevalence of hip OA in football players. Prospective studies of football players are now needed to establish if cam morphology causes progression of cartilage defects and labral tears and development of hip OA.

Are cam morphology size and location associated with self‐reported burden in football players with FAI syndrome?

Cam morphology size and location might affect the severity of reported burden in people with femoroacetabular impingement (FAI) syndrome. We investigated the relationship between cam morphology size (i.e., alpha angle) and self‐reported hip/groin burden (i.e., scores for the International Hip Outcome Tool‐33 (iHOT‐33) and Copenhagen Hip and Groin Outcome Score (HAGOS)), examined separately for the anteroposterior pelvis (AP) and Dunn 45° radiographs in football players with FAI syndrome. In total, 118 (12 women) subelite football (soccer or Australian football) players with FAI syndrome with cam morphology (alpha angle ≥60°) participated. One blinded assessor quantified superior and anterosuperior cam morphology size by measuring alpha angles for the AP and Dunn 45° radiographs, respectively. Linear regression models investigated relationships between alpha angle (continuous independent variable, separately measured for the AP and Dunn 45° radiographs) and iHOT‐33 and HAGOS scores (dependent variables). Larger anterosuperior cam morphology (seen on the Dunn 45° radiograph) was associated with lower (i.e., worse) scores for the iHOT‐Total, iHOT‐Symptoms, iHOT‐Job, and iHOT‐Social subscales (unadjusted estimate range −0.553 to −0.319 [95% confidence interval −0.900 to −0.037], p = 0.002 to 0.027), but not the iHOT‐Sport (p = 0.459) nor any HAGOS scores (p = 0.110 to 0.802). Superior cam morphology size (measured using the AP radiograph) was not associated with any iHOT‐33 or HAGOS scores (p = 0.085 to 0.975). Larger anterosuperior cam morphology may be more relevant to pain and symptoms in football players with FAI syndrome than superior cam morphology, warranting investigation of its effects on reported burden and hip disease over time.

Incidence, Prevalence, and Severity of and Risk Factors for Hip and Groin Problems in Swedish Male Ice Hockey Players: A 1-Season Prospective Cohort Study

CONTEXT

The epidemiologic focus on time loss may underestimate the true magnitude of hip and groin problems in male ice hockey players.

OBJECTIVE

To describe the prevalence, incidence, and severity of hip and groin problems (time loss and non-time loss) in Swedish ice hockey players over the course of a season and explore potential preseason risk factors for these conditions.

DESIGN

Prospective 1-season cohort study.

SETTING

Professional and semiprofessional Swedish ice hockey players.

PATIENTS OR OTHER PARTICIPANTS

A total of 12 professional and semiprofessional male ice hockey teams were invited to participate. Of those, 9 teams agreed, and 163 players were included in the analyses.

MAIN OUTCOME MEASURE(S)

Hip and groin problems in the previous season (time loss, non-time loss), isometric adduction and abduction strength, and 5-second squeeze test results were recorded before the season and served as independent variables in the risk factor analysis. Main outcome measures were cumulative incidence of hip and groin problems, average prevalence, and odds ratios (ORs) for groin problems in season.

RESULTS

Cumulative incidence was 45.4% (95% CI = 37.6%, 53.4%) for all problems and 19% (95% CI = 13.3%, 25.9%) for substantial problems. Average prevalence was 14.1% (95% CI = 10.8%, 17.5%) for all and 5.7% (95% CI = 4.3%, 7.2%) for substantial problems. Among reported problems, 69.2% had a gradual onset, and only 17% led to time loss. Players with non-time-loss problems in the previous season had higher odds for new problems (all: OR = 3.3 [95% CI = 1.7, 6.3]; substantial: OR = 3.6 [95% CI = 1.8, 8.4]). Preseason strength was not significantly associated with the odds for subsequent problems.

CONCLUSION

Hip and groin problems are common in ice hockey players and may lead to substantial impairments in performance. Only 1 in 5 problems led to time loss, and 7 in 10 had a gradual onset. Non-time-loss problems in the previous season were a significant risk factor for new problems, whereas decreased preseason hip-adduction and -abduction strength was not.