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Return to sport (RTS) is undoubtedly of great importance to many patients. Patients often aim to return to their previous sport following hip arthroscopy, and those who return are most satisfied following surgery and rehabilitation [10]. Unfortunately, only 50% of patients with femoroacetabular impingement syndrome undergoing hip arthroscopy return to their pre-injury sport, and only 1 in 5 return to their previous level of performance [4, 10]. In this editorial, we look beyond anatomy and physical recovery following surgery, and consider alternative explanations as to why some patients may or may not return to sport following hip arthroscopy – are you ready for it?

A shift from the hip to the head: a missing piece of the puzzle?

Physical factors, such as injury and deficits, often form the basis of surgical indications. Hip arthroscopy for femoroacetabular impingement syndrome alters hip morphology, reduces or repairs chondrolabral damage, and supposedly improves joint kinematics. Combined with appropriate post-operative rehabilitation, hip arthroscopy reduces pain, symptoms, and improves the way patients perceive their joint health during activities of daily living [3, 6]. However, patient-reported outcome measures show that hip-related function regarding participation in sports and physical activity is often still impaired [7]. Why is that? As clinicians we tend to look to explain these impairments by investigating morphological features or assessing physical function such as range of motion, strength, and functional performance. However, physical factors alone may not explain why so many patients do not RTS following hip arthroscopy. In other orthopedic populations such as ACL reconstructed patients, psychological readiness has been shown to be an important predictor of RTS [2, 9]. Therefore, in our attempt to address RTS following hip arthroscopy, we may have to redirect our focus from our arthroscope, dynamometer, or inclinometer to the question: “Are you ready to return to sport?”.

How ready are you on a scale from 0 to 100?

Until recently, there has been no existing tool to measure psychological readiness to RTS in hip arthroscopy patients. In this issue of KSSTA you will find the Hip-Return to Sport after Injury scale (Hip-RSI), an item reduced and modified version of the ACL-RSI [8], adapted to hip patients [11]. The Hip-RSI assesses psychological readiness to RTS following hip arthroscopy by asking patients to rate 6 questions about emotions, confidence in performance, and risk appraisal on a 0–100 visual analogue scale (0 represents extremely negative psychological responses; 100 represents no negative psychological responses). A total score is presented as an average of the individual item scores (Fig. 1).

Fig. 1
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Short (6-item) version of the Hip-RSI [11]

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The RTS puzzle—perhaps not that joint-specific?

In a cross-sectional comparison, we found progressively higher Hip-RSI-scores among patient groups that have reached higher RTS levels on the RTS continuum [1]. This is interesting as the patients returning to sport performance at the pre-injury level are also the ones most satisfied with their current activity level (Fig. 2).

Fig. 2
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Psychological readiness to return to sport (Hip-RSI) [11], return to sport rates[10], and satisfaction with the reached level of return to sport [10] (green = satisfied) on the return to sport continuum following hip arthroscopy

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Psychological readiness to RTS, as measured by the ACL- and Hip-RSI, appears to follow the same pattern throughout the RTS-continuum (see Fig. 2) among ACL-reconstructed patients and hip arthroscopy patients [8, 11]. Research on ACL reconstructed patients indicates that psychological recovery (as measured with ACL-RSI) and physiological recovery (joint related physical performance) are two different constructs and should thus be assessed separately in the RTS-process [5]. However, the relationship between physical and psychological function in the RTS process following hip arthroscopy patients is unknown.

The Hip-RSI: a powerful tool!

With Hip-RSI, we can now measure and follow the development of psychological readiness to RTS in patients who have undergone hip arthroscopy. Unlike the ACL-RSI which has been used for some time, Hip-RSI has only recently been validated for hip arthroscopy patients and thus has not yet been extensively used in clinical research. Our clinical measures of physical function prompt clear clinical approaches—impaired muscle strength can be addressed by strength training, and movement strategies can be modified to avoid pain. However, we do not know how to best address psychological readiness in the RTS process. Therefore, identifying factors that may impact psychological readiness to RTS and developing strategies to address psychological factors alongside functional performance is paramount. We encourage future research to investigate the role of psychological readiness in the RTS process and identify factors that affect psychological readiness. Using measures such as the Hip-RSI provides valuable information about your patient’s psychological readiness to RTS and can potentially provide insights regarding previously unexplored aspects of the RTS process following hip arthroscopy. The Hip-RSI can therefore be a powerful tool for all clinicians and researchers working with hip arthroscopy patients—Are you ready to use it?