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Infographic. 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
  1. Michael P Reiman1,
  2. Rintje Agricola2,
  3. Joanne L Kemp3,
  4. Joshua J Heerey3,
  5. Adam Weir4,5,
  6. Pim van Klij6,
  7. Ara Kassarjian7,8,
  8. Andrea B Mosler3,
  9. Eva Ageberg9,
  10. Per Hölmich10,
  11. Kristian Marstrand Warholm11,
  12. Damian Griffin12,13,
  13. Sue Mayes3,
  14. Karim M Khan14,
  15. Kay M Crossley3,
  16. Mario Bizzini15,
  17. Nancy Bloom16,
  18. Nicola C Casartelli17,18,
  19. Laura E Diamond19,20,
  20. Stephanie Di Stasi21,
  21. Michael Drew22,23,
  22. Daniel J Friedman24,
  23. Matthew Freke25,
  24. Sion Glyn-Jones26,
  25. Boris Gojanovic27,28,
  26. Marcie Harris-Hayes16,
  27. Michael A Hunt29,
  28. Franco M Impellizzeri30,
  29. Lasse Ishøi31,
  30. Denise M Jones3,
  31. Matthew G King32,
  32. Peter R Lawrenson33,
  33. Michael Leunig34,
  34. Cara L Lewis35,
  35. Nicolas Mathieu36,
  36. Håvard Moksnes37,
  37. May Arna Risberg38,39,
  38. Mark J Scholes40,
  39. Adam I Semciw3,
  40. Andreas Serner41,
  41. Kristian Thorborg10,
  42. Adam Virgile42,
  43. Tobias Wörner9,
  44. H Paul Dijkstra43,44
  1. 1Orthopedic Surgery, Duke University Medical Center, Durham, North Carolina, USA
  2. 2Department of Orthopaedic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
  3. 3Latrobe Sports Exercise Medicine Research Centre, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria, Australia
  4. 4Department of Orthopaedic Surgery, Erasmus MC Center for Groin Injuries, Erasmus University Medical Centre, Rotterdam, Netherlands
  5. 5Aspetar Sports Groin Pain Centre, Aspetar Orthopaedic and Sports Medicine Hospital, Doha, Ad Dawhah, Qatar
  6. 6Department of Orthopaedic Surgery, Erasmus University Medical Centre, Rotterdam, Netherlands
  7. 7Elite Sports Imaging, SL, Madrid, Spain
  8. 8Musculoskeletal Radiology, Corades, LLC, Brookline, Massachusetts, USA
  9. 9Health Sciences, Lund University, Lund, Sweden
  10. 10Sports Orthopaedic Research Center–Copenhagen (SORC-C), Arthroscopic Center, Department of Orthopedic Surgery, Copenhagen University Hospital, Amager-Hvidovre, Denmark, Amager-Hvidovre Hospital, Hvidovre, Copenhagen, Denmark
  11. 11Division of Orthopeadic surgery, Oslo University Hospital, Oslo, Norway
  12. 12Warwick Orthopaedics, University of Warwick, Coventry, Warwick, UK
  13. 13Orthopaedics Warwick Medical School, University of Warwick, Coventry, Warwick, UK
  14. 14Family Practice & Kinesiology, The University of British Columbia, Vancouver, British Columbia, Canada
  15. 15Research, Schulthess Clinic Human Performance Lab, Zurich, ZH, Switzerland
  16. 16Physical Therapy, Washington University School of Medicine in Saint Louis, Saint Louis, Missouri, USA
  17. 17Human Performance Lab, Schulthess Clinic, Zurich, Switzerland
  18. 18Laboratory of Exercise and Health, ETH Zurich, Schwerzenbach, Switzerland
  19. 19School of Allied Health Sciences, Griffith University, Gold Coast, Queensland, Australia
  20. 20Menzies Health Institute Queensland, Griffith University, Brisbane, Queensland, Australia
  21. 21Division of Physical Therapy, The Ohio State University, Columbus, Ohio, USA
  22. 22Department of Physiotherapy, Australian Institute of Sport, Canberra, Australian Capital Territory, Australia
  23. 23Australian Collaboration for Research into Injury in Sport and its Prevention (ACRISP), Federation University Australia, Ballarat, Victoria, Australia
  24. 24Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
  25. 25School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Queensland, Australia
  26. 26Department of Orthopaedic Surgery, University of Oxford, Institute of Musculoskeletal Sciences, Oxford, UK
  27. 27Swiss Olympic Medical Center, Hopital de la Tour, Meyrin, Geneva, Switzerland
  28. 28Sports Medicine, University Hospital of Lausanne, Lausanne, VD, Switzerland
  29. 29Physical Therapy, University of British Columbia, Vancouver, British Columbia, Canada
  30. 30Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
  31. 31Department of Orthopedic Surgery, Copenhagen University Hospital, Amager-Hvidovre, Sports Orthopedic Research Center - Copenhagen (SORC-C), Hvidovre, Denmark
  32. 32La Trobe Sport and Exercise Medicine Research Centre, School of Allied Health, Human Services, and Sport, La Trobe University, Bundoora, Victoria, Australia
  33. 33School of Health and Rehabilitation Sciences, University of Queensland, Brisbane, Queensland, Australia
  34. 34Department of Orthopaedics, Schulthess Klinik, Zurich, Switzerland
  35. 35Physical Therapy & Athletic Training, Boston University, Boston, Massachusetts, USA
  36. 36Physiotherapy, HES-SO Valais, University of Applied Sciences Western Switzerland, Leukerbad, Valais, Switzerland
  37. 37Oslo Sports Trauma Research Centre (OSTRC), Norwegian School of Sport Sciences, Oslo, Norway
  38. 38Department of Sport Medicine, Norwegian School of Sport Sciences, Oslo, Norway
  39. 39Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
  40. 40La Trobe Sport and Exercise Medicine Research Centre, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria, Australia
  41. 41Research & Scientific Support, Aspetar Orthopaedic and Sports Medicine Hospital, Doha, Qatar
  42. 42College of Nursing and Health Sciences, University of Vermont, Burlington, Vermont, USA
  43. 43Sports Medicine, ASPETAR Orthopedic and Sports Medicine Hospital, Doha, Qatar
  44. 44Department for Continuing Education, University of Oxford, Oxford, UK
  1. Correspondence to Rintje Agricola, Department of Orthopaedic Surgery, Erasmus University Medical Center, 3015 GD Rotterdam, Netherlands; r.agricola{at}erasmusmc.nl

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Young and middle-aged active adults with hip and groin pain often present with a confusing overlap of signs and symptoms. There is no consensus on how to define or classify hip disease with different and overlapping intra-articular and extra-articular contributors to symptoms in an anatomically complex region. Several researchers and consensus groups have previously attempted to define aspects of hip and groin pain.1–4 In 2017, the International Hip Pain Research Network (IHiPRN) was established to facilitate collaboration across research groups and disciplines and to improve knowledge dissemination of hip-related pain to clinicians. In this paper,5 published in the British Journal of Sports Medicine, we first describe the general consensus process applied to all topics in this series. We then make recommendations on the first topic on how to classify, define and diagnose hip disease in young and middle-aged active adults, with hip-related pain as the main symptom. Other papers in this series used this classification of hip-related pain in the assessment of (1) patient-reported outcome measures,6 (2) standardised measurement of physical capacity7 and (3) physiotherapist-led treatment.8

For this paper, the working group used a scoping review framework to search the literature for systematic reviews, intervention and observational studies (prospective or retrospective) with a study population of at least 10 young and middle-aged active adults and published in English language, peer-reviewed journals. Evidence summaries and consensus recommendations were then presented to and discussed by the whole group of IHiPRN participants. We reached consensus on three clinical recommendations, one clinical and research recommendation, and two research recommendations (infographic), all of which were an amalgamation of best available evidence and expert opinion. Following discussion, each participant was asked to perform a blinded vote on the recommendation (infographic). Both non-musculoskeletal and serious hip pathology conditions (eg, tumours, infections, slipped capital femoral epiphysis), as well as competing musculoskeletal conditions (eg, lumbar spine) should first be excluded before categorising hip disease in young and middle-aged active adults presenting with hip-related pain. Once these are excluded, hip-related pain should be categorised into (1) femoroacetabular impingement syndrome, (2) acetabular dysplasia and/or hip instability and (3) other conditions without bony morphology causing hip-related pain, such as chondral, labral and ligamentum teres conditions.

The diagnostic clinical utility for the various clinical and radiological measures was stratified according to magnitude of the pretest to post-test probability shift, precision (repeatability of the results), and study quality. Each of these values were represented on a 2×2 quadrant (magnitude×precision) as not recommended (red quadrant), cautiously recommended (yellow quadrants) or recommended (green quadrant) if the study quality was high.

We determined that the diagnostic utility of clinical examination and diagnostic imaging in isolation are limited and recommend a comprehensive diagnostic approach of patient symptoms, clinical signs and diagnostic imaging. We recognise that the diagnostic capability of matching symptoms, clinical signs and diagnostic imaging is unknown for patients with hip-related pain and recommend that future studies be considered in determining such diagnostic utilities.

References

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Footnotes

  • Twitter @MikeReiman, @RintjeAgricola, @JoanneLKemp, @JHeerey, @pimvklij, @AndreaBMosler, @EvaAgeberg, @DamianGriffin, @NicCasartelli, @lauradiamond05, @_mickdrew, @ddfriedman, @drsportsante, @MHarrisHayes, @francoimpell, @LasseIshoei, @mattgmking1, @PeteLawrenson, @ProfCaraLewis, @HMoksnes, @MarkScholes85, @ASemciw, @aserner, @KThorborg, @adamvirgile, @Wuninho, @DrPaulDijkstra

  • Contributors AV, RA, MPR and HPD contributed to the conception of the work. All authors contributed to the interpretation, drafting and revision of the infographic and gave their final approval.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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