Abstract
Hip-related pain is a common issue in active adults affecting their quality of life, mobility, and overall function, and it can lead to persistent disability. However, diagnosing hip-related pain is challenging due to the many potential sources and causes, including intra-articular and extra-articular pathology, and referred pain from other areas (lumbar or groin related pain). To address this, there is a need for a clinical algorithm based on the best available evidence and expert consensus. This algorithm could guide healthcare professionals in assessing and managing patients with hip-related pain, during the diagnosis, test selection, intervention, monitoring, and promoting collaboration among various healthcare providers. This clinical algorithm for hip-related pain is a comprehensive, flexible, adaptable to different settings, and regularly updated to incorporate new research findings. This literature review aims to establish a clinical algorithm specifically for prescribing exercise treatment to patients with hip-related pain, addressing their individual needs and enhancing their overall care.
Similar content being viewed by others
Avoid common mistakes on your manuscript.
The algorithm customizes conservative treatment plans for hip-related pain, addressing the specific patient's condition, such as the nature and location of the pain, contributing factors, and individual health considerations. |
The algorithm ensures that treatment recommendations align with the most current and effective evidence-based practices. |
The algorithm’s targeted nature minimizes the need for unnecessary interventions, reducing healthcare costs associated with trial-and-error treatments. |
Introduction
Hip-related pain is a common complaint among adults, especially those who are physically active or have a history of trauma or osteoarthritis, affecting the quality of life, mobility, and function of the patients, and can lead to chronic disability if not properly diagnosed and treated [1, 2]. However, the diagnosis of hip-related pain is challenging, as there are many possible sources and causes of pain, such as intra-articular pathology, extra-articular pathology, or referred pain from other structures [3]. Therefore, it is important to establish a clinical algorithm that can guide the clinicians in the assessment and management of patients with hip-related pain, based on the best available evidence and expert consensus. A clinical algorithm can help to identify the most likely diagnosis, select the appropriate diagnostic tests and interventions, monitor the outcomes and complications of the treatment, and can also facilitate the communication and collaboration among different health professionals involved in the care of patients with hip-related pain, such as primary care physicians, orthopedic surgeons, physiotherapists, radiologists, and rheumatologists [4]. A clinical algorithm for the treatment of patients with hip-related pain should be comprehensive, flexible, and adaptable to different clinical settings and patient preferences. It should also be updated regularly to incorporate new research findings and recommendations. Therefore, the purpose of this review is to establish a clinical algorithm to prescribe exercise treatment for patients with hip-related pain.
Hip-Related Pain Clinical Examination
The clinical diagnosis of patients with orthopedic problems is a complex skill process that primarily consists of patient interview and physical examination. An inadequate subjective history, failure to order appropriate physical examination test, incorrect interpretations of these or failure to create a proper follow-up plan are the most common diagnostic errors [5]. The aim of this systematic and evidence-based examination process is to accurately diagnose hip-related pain. This process has six different stages: (1) subjective history and patient-reported outcome measures; (2) rule out red flags: musculoskeletal and non-musculoskeletal pathology; (3) rule out lumbar spine, pelvic girdle, hip stress fracture pathology, or other groin pain clinical entities; (4) hip architecture determinants; (5) hip-related pathology identification; and (6) hip symptom modification procedure (see Fig. 1). This article is based on previously conducted studies and does not contain any new studies with human participants or animals performed by any of the authors.
Clinical examination algorithm to prescribe conservative treatment in hip-related pain. ER external rotation, FAI femoroacetabular impingement, IR internal rotation, OA osteoarthritis, ROM range of motion
Patient Interview—Subjective History and Patient-Reported Outcome Measures
The patient history remains the keystone of accurate diagnosis and it will provide the diagnosis in most cases. In fact, patient history has been suggested to be instrumental in determining 56–90% of diagnoses in various types of patients [5, 6]. We have to consider the following principles when taking a patient history: allow enough time, be a good listener, know the sport, discover the exact circumstances of the injury, consider the characteristics of patient’s pain or psychological factors, among other factors [6].
Usually, an individual with hip-related pain can have an insidious or gradual onset of symptoms [7]. The pain frequently starts in one region and is unilateral, but it can gradually progress to other regions and become bilateral. It can be explained by the complex anatomy of the anterior relations and muscle attachments of the groin region [8]. The localization of pain is important in determining which clinical entity is present and we can use models such as the “3G approach” with specific anatomical landmarks and borders of the groin triangle to accurate differential diagnosis [8].
Patient-reported outcome measures (PROM) are commonly used to capture treatment response and provide aspects of the patients’ overall health [9]. According to the biopsychosocial model, disability involves dysfunction in one or more of the following levels: impairment, activity limitations, and participation restrictions. In fact, individuals with hip-related disorders often experience pain, functional impairments, and challenges in performing daily life and sports activities [2]. Furthermore, measurement instruments are frequently used and recommended to support clinical decision-making, healthcare policies, and reimbursement processes. This necessitates the systematic collection of these measurement instruments in the clinical setting, which is why these measurement instruments must be valid and possess appropriate psychometric properties [2].
Since several self-administered questionnaires have focused on patients with osteoarthritis or those undergoing hip arthroplasty with a limited activity level that may not be applicable to young patients with different expectations (e.g., Harris Hip Score, Hip disability and Osteoarthritis Outcome Score, Oxford Hip Score, or Lequesne Index Severity for Osteoarthritis of the Hip), the international Hip Outcome Tool (iHOT-33) was developed to measure physical function and quality of life in young and active patients with hip pathology [2]. Subsequently, Griffin et al. developed a shortened version of the iHOT-33 called the iHOT-12, which is based on 12 items from the original version and covers four domains: (1) symptoms and functional limitations, (2) sports and leisure activities, (3) work-related concerns, and (4) social, emotional, and lifestyle issues [10, 11]. Furthermore, the Hip Outcome Score (HOS) questionnaire was initially designed to assess surgical treatment outcomes in patients with hip pain but has also demonstrated high reliability in patients with femoroacetabular impingement (FAI) syndrome and labral tears [12, 13]. These questionnaires have proven to be valuable tools for assessing initial functionality and for monitoring patients with hip-related pain during their follow-up [13, 14].
Rule Out Red Flags and Musculoskeletal and Non-musculoskeletal Pathology
Groin or anterior hip region is a common area for various serious and non-musculoskeletal conditions. The presence of certain signs and symptoms (e.g., a history of trauma, fever, unexplained weight loss, burning during urination, night pain, prolonged corticosteroid use, and a history of cancer) that suggest the possible existence of more severe medical issues is referred to as “red flags.” A thorough clinical examination and a standardized medical questionnaire are necessary to rule out oncological, urological, gynecological, or rheumatological conditions (e.g., prostatitis, genital herpes, or appendicitis) [5, 15]. A musculoskeletal pathology to consider is femoral head osteonecrosis, which can result from prior injuries or common risk factors such as prolonged corticosteroid use, chronic alcohol consumption, and connective tissue diseases, especially systemic lupus erythematosus, although its etiology can be idiopathic. When these risk factors are present alongside deep progressive inguinal pain that worsens with axial loading of the femur, it is necessary to rule out femoral head osteonecrosis [16]. It is important for the clinician in the decision-making process to recognize these conditions to refer to the corresponding specialist.
Rule Out Lumbar Spine, Pelvic Girdle, Hip Stress Fracture Pathology, or Other Groin Pain Clinical Entities
Once red flags are ruled out, the next stage is to attempt to rule out lumbar spine, pelvic girdle, hip stress fracture pathology or others groin pain clinical entities. Repeated and/or sustained lumbar movements test (e.g., flexion, extension, or side-bending) can be performed to determine patterns of pain provocation (centralization and peripheralization) related to lumbar spine pathology. According to the literature, if repeated and/or sustained movements do not reproduce symptoms, the lumbar spine can be ruled out. It has high sensitivity (SN) [90] and small negative likelihood ratio (LR−) (0.12) [5, 17].
Once lumbar spine has been ruled out, the pelvic girdle region or sacroiliac joint should be assessed. The reliability of pelvic palpation tests used to assess sacroiliac joint movement is poor [18]. Pain provocation-based clinical special test have the best diagnostic accuracy for sacroiliac joint [5, 19]. Therefore, Laslett’s cluster (compression, distraction, Gaenslen’s, thigh thrust and sacral thrust test) is performed. If tests do not reproduce symptoms, the pelvic girdle or sacroiliac joint pathology is ruled out. SN and LR− were 91 and 0.08, respectively [18, 19].
Another pathology to consider in anterior hip pain is stress fractures of the femur, pubic rami, or acetabulum. Patients with stress fractures of the pubic ramus experience pain in the front of the hip that extends medially to the adductor region. Acetabular fractures are uncommon but should be considered when a stress pelvic injury is suspected. Stress fractures of the femoral neck can be challenging to detect clinically, but in the patient’s history, there may be signs of swelling and/or effusion with pain that worsens during activity or at night [16]. Stress fractures are frequently observed in endurance athletes or young and healthy recreational runners. Insufficiency-type stress fractures are seen in elderly patients with osteoporosis. It has been described that the Patellar-Pubic Percussion Test (PPPT) and the fulcrum test are the most reliable tests during physical examination [20]. The PPPT appears to be an effective diagnostic test for hip-related fractures due to high SN [92] and small LR− (0.06) [21]. A stethoscope is placed over the pubic symphysis while the examiner either taps or places a tuning fork on the patella. If there is no difference in percussion note, femoral neck fracture can be ruled out. Moreover, the fulcrum test is performed in combination with PPPT. The examiner places one forearm under the thigh and pushes the dorsum of the knee down with the opposite upper extremity. A positive test requires a bone scan to confirmation of a femoral stress fracture. If tests do not reproduce symptoms, femoral stress fracture can be ruled out. SN and LR− were 100 and 0, respectively [21, 22].
Another source of anterior hip pain are groin pain clinical entities that were divided into four defined clinical entities: adductor-related, pubic-related groin pain, inguinal-related and iliopsoas-related [23, 24]. Moreover, athletes can present multiple clinical entities as a source of groin pain.
Adductor-related groin pain is the most common clinical entity in sports that involve kicking or twisting movements [25]. The diagnostic criteria for adductor-related groin pain are adductor tendon origin tenderness and pain on resisted adduction testing [23, 24]. Palpation of the adductor tendon origin has showed very good intra and inter-rater agreement (K > 0.80) [26]. Absent tenderness at the adductor origin has shown high SN [93] to rule out adductor-related groin pain [27]. Resisted hip adduction testing using hand-held dynamometry has been shown good intra and inter-rater reliability in various testing positions (e.g., 0°, 45°, and 90° of hip flexion) [28, 29]. It has been suggested that there are differences in hip adductors muscles activation due to its hip flexor or extensor role [29]. Adductor longus has greatest activation at 45°, adductor magnus at 0° and 45°, gracilis at 45° and pectineus at 90° of hip flexion [30]. However, it is difficult to isolate adductor muscles due to multiple force vectors across the groin region [31]. Magnetic resonance imaging (MRI) evaluation is necessary to correlate clinical signs and may accurate diagnosis [32]. Abnormal adductor imaging and pubic bone marrow edema (BMO) are common MRI findings in (a)symptomatic soccer players [30]. The presence of pubic BMO is closely correlated to the site of pain, with the diagnosis of adductor origin pathology and several resisted adduction tests [27].
Another clinical entity that may cause groin pain is the pubic-related groin pain [23]. The proposed diagnostic criteria used on this clinical examination process are pubic symphysis tenderness, pain on pubic stress tests, pain on resisted adduction testing and pain on resisted abdominal contraction [23, 24]. Pubic symphysis palpation has showed good to very good intra and inter-rater agreement [26]. Pubic symphysis tenderness is associated with the presence of BMO. Absent tenderness at the pubic symphysis is the most accurate criteria to rule out pubic-related groin pain due to high SN and small LR− [27]. The pubic stress test or “crossover test” has been shown to have very good reliability during testing shear forces across pubic symphysis [27]. The squeeze test at 0° of hip flexion has been associated with pubic aponeurosis injury [27]. It has also shown higher levels of force output and torque production of adductor muscles in comparison to other positions, maximizing pubic symphysis stress [33, 34]. A positive test should be considered if pain over central pubic symphysis on Squeeze test is present. During the physical examination, the clinician should consider assessing an antalgic or waddling gait, or anteroposterior pelvic radiographs to demonstrate chronic degenerative changes at the pubic symphysis joint with the standing single leg stance (flamingo view) radiographs [35]. Moreover, resisted abdominal contraction have showed good to very good intra and inter-rater agreement [26].
Another musculoskeletal condition that can be a source of pain is neuropathies of the femoral, obturator, ilioinguinal, or genitofemoral nerves, which can cause pain in the anterior hip region. Tensioning of the femoral nerve is a neurodynamic maneuver used to detect neuropathy and is performed with the patient lying in a prone position while the knee is passively flexed. Reproduction of neurological symptoms is considered a positive test. Neuropathies of the obturator, ilioinguinal, or genitofemoral nerves are associated with previous surgical history of total hip arthroplasty or inguinal hernia repair.[3, 36].
Inguinal-related groin pain has a prevalence ranging from 2 to 40% [37, 38]. As well as in others clinical entities, different diagnostic criteria have been proposed. The diagnostic criteria for inguinal-related groin pain are tenderness of the inguinal canal, pain with Valsalva maneuver, coughing or sneezing, pain on resisted abdominal contraction, pain relief with block injection and no palpable inguinal hernia [23, 24]. Resisted abdominal contraction reliability has previously been cited. Ultrasound-guided nerve block injection has been found to be a reliable diagnostic approach and can provide near complete pain relief [39, 40]. Moreover, physical therapy can be an effective treatment following surgery [38].
The last clinical entity that we consider is the iliopsoas-related groin pain, with a prevalence ranging from 2.4 to 32% in sports that require repetitive kicking and sprinting [23, 41]. The diagnostic criteria are hip flexor complex tenderness, pain on hip extension stretch (modified Thomas test) and pain on resisted hip flexion in different positions [23, 24]. Hip flexor complex palpation and hip flexor stretch has showed very good intra and inter-observer agreement [26]. The modified Thomas test have demonstrated moderate to good reliability to assess hip flexor flexibility and pain [42,43,44]. Resisted hip flexor strength using hand-held dynamometer has been shown very good reliability in various testing positions [45]. Hip flexion leverage must be considered due to changes in muscle force or length, pelvic tilt, and abdominal muscles activation [31]. Recently, a new hip flexor flexibility assessment, the reactive hip flexor test, has shown excellent reliability to examine the interaction of both limbs, similarly during running or sprinting [46].
Once red flags, lumbar spine, pelvic girdle, hip stress fracture pathology and other groin pain clinical entities have been ruled out, the next stage is to continue with a focused clinical examination to determine hip morphology.
Hip Architecture Assessment
This part of the clinical algorithm both hips must be examined to explore the femoral version of the symptomatic and asymptomatic hip and to differentiate between various hip-related pain pathologies such as FAI syndrome, hip osteoarthritis and hip microinstability in order to prescribe an individualized treatment. This stage is highly important due to hip treatment is closely guided by the clinical examination [4, 47].
The range of motion (ROM) of the hip exhibits significant interindividual variability due to the high morphological variability of the femur and acetabulum, as previously discussed. Several studies have demonstrated that hip morphology strongly influences hip ROM, and that a person's hip morphology can be determined through passive hip ROM [48,49,50,51]. Femoral version (FV), an angle defined as the orientation of the femoral neck axis in relation to the medial–lateral axis across the posterior femoral condyles, has emerged as a potentially crucial factor in hip pain development [48, 50,51,52,53,54]. Normal FV ranges from 0° to 30°, with most studies reporting results between 8° and 20° [49, 51, 55]. Reduced FV (retroverted hips) increases the risk of hip pain and limited range of motion [49, 56], while increased FV (anteverted hips) is associated with various hip conditions [57]. Previous research has noted a strong association between hip ROM and FV, as indicated by several studies [48, 50, 51, 54]. This observation has raised the possibility that FV could potentially be predicted from hip ROM measurements in clinical contexts, as suggested by studies cited above. Chadayammuri et al. [48] found that hip ROM significantly predicts femoral torsion and acetabular version. Specifically, internal rotation ROM (both in a neutral hip position and at 90° of hip flexion) was greater in hips with combined femoral anteversion and acetabular anteversion, while external rotation ROM was correspondingly reduced in such hip morphology. Conversely, internal rotation ROM was lower in hips with femoral retroversion and acetabular retroversion, with opposite trends observed for external rotation ROM. Multivariate analysis indicated that internal rotation ROM in a neutral hip position and patient age were independent predictors of the femoroacetabular torsion-version combination index [48]. Several previous studies have indicated a significant association between internal rotation ROM and femoral torsion or acetabular version [49, 58, 59]. Audenaert et al. [49] showed that 75% of the variance observed in internal rotation ROM measurements at 90° of hip flexion could be attributed to femoral head sphericity, acetabular coverage, and femoral torsion in a cohort study of 30 patients without hip pathology, FAI symptoms, and asymptomatic individuals. Furthermore, Kelly et al. [60] reported that internal rotation at 90° of hip flexion gradually increased by at least 5° between patients with femoral retroversion, normal femoral torsion, and femoral anteversion.
Mechanically, hip internal rotation creates a mechanical conflict between the anterolateral femoral neck-head junction and the acetabulum, whereas external rotation results in a posterior impingement occurring extra-articularly between the greater trochanter and ischium [61] and intra-articularly between the femoral neck-head junction and the posterior-inferior acetabular surface [62]. Several studies have shown that a 10° increase in anterior pelvic tilt (acetabular retroversion) leads to a mechanical conflict between the femur and acetabulum, reducing internal rotation ROM [63,64,65]. Additionally, Ejnisman et al. [66] observed that hips with excessive femoral anteversion were twice as likely to have a labral tear extending beyond the three o'clock position. Another significant finding from the study by Chadayammuri et al. [48] was that abduction ROM was not associated with the degree of femoral torsion or acetabular version. External rotation ROM in a neutral hip position has been shown to depend on the degree of femoral torsion, rather than central acetabular version. This confirms previous studies suggesting that limitations in neutral hip position external rotation ROM primarily result from posterior impingement between the greater trochanter and ischium, with minimal contribution from the acetabular rim [62]. Therefore, limitations in passive ROM are largely determined by bone alignment, rather than pain or apprehension due to intra-articular and extra-articular pathology, as previously suggested [46,47,48].
For the clinical examination process a > 20° of difference between external and internal rotation ROM in 90° of hip flexion or neutral position was established to determine femoral version [51]. Cibulka determined that discrepancies of 30° between hip internal and external rotation ROM could indicate the possibility of abnormal femoral version. To illustrate, if the range of motion for internal rotation exceeded that of external rotation by 30°, it might suggest the presence of excessive femoral anteversion. However, it is important to note that the 30° threshold was primarily derived from studies conducted mainly with children [67].
Additionally, apart from influencing hip ROM, alterations in FV, whether increased or decreased, have the potential to impact the moment arms of muscles and modify muscle architecture. Such alterations may result in changes in hip muscle strength [31, 68, 69]. Two systematic reviews have highlighted the presence of muscle weakness in patients with FAI syndrome when compared to healthy controls [70, 71]. Muscle torque generation is influenced by both muscle length and the muscle moment arm. The muscle moment arm is defined as the perpendicular distance between the muscle's line of action and the instantaneous center of joint rotation. This concept considers both the length of the muscle moment arm and the muscle's line of action. Patients with hip dysplasia displayed significant adaptations in the length of the muscle’s moment arm, while the muscle’s line of action was affected to a lesser extent [72]. Specifically, the reduced length of the muscle’s moment arm in their hip abductor muscle suggests a mechanical disadvantage for this muscle group [31].
Alterations in FV, whether increased or decreased, can affect both muscle length and the muscle moment arm at the hip joint, leading to changes in muscle strength. The greater strength reduction in anteverted hips might be attributed to an excessive decrease in gluteus maximus muscle length (which is already decreased in the neutral position), while the moment arm length increased from zero to 30° of external rotation [54]. This dependence of hip rotator muscle strength on hip test position has been demonstrated previously [73], and it is important for clinicians to be mindful of this factor when conducting hip strength assessments. In summary, understanding the role of FV in hip range of motion and muscle strength may have implications for clinical practice and patient management. Figure 2 shows the different femoral version and hip-related ROM.
Different femoral versions and hip range of motion. A Retroverted hip; B normal version hip; C anteverted hip. ER external rotation, IR internal rotation
Hip-Related Pathology Assessment
Patients experiencing anterior hip pain often localize their discomfort to the anteromedial region of the inguinal area, commonly referred to as the “C” sign during physical examination [3]. In older patients with limited hip range of motion, primary consideration should be given to hip joint osteoarthritis (OA), whereas in younger patients with anterior hip pain, conditions such as acetabular labral tears, femoroacetabular impingement (FAI) syndrome or hip microinstability should be considered [5].
FAI
FAI is defined as a motion-related clinical disorder of the hip with a triad of mechanical symptoms (anterior hip pain and sensations of locking, clicking or stiffness), clinical signs and relevant radiological findings [74]. Its clinical presentation based on radiological findings is divided into two types of morphologies: (1) CAM-type FAI, characterized by a non-spherical bony prominence or bump at the junction of the femoral neck with the femoral head; (2) PINCER-type FAI, characterized by an excess of acetabular coverage, either focal or diffuse, over the femoral head [75].
The prevalence of CAM-type morphology ranges from 4 to 17% in the population and is influenced by age, gender, ethnicity, physical activity, and the presence or absence of symptoms [76]. It is more common in men, occurring in 13–72% of asymptomatic men and in 0–11.7% of asymptomatic women [77,78,79]. Various studies report that this morphology is less prevalent in East Asian individuals compared to other ethnic groups [80, 81]. CAM-type morphology gradually develops during skeletal maturation until adulthood and is influenced by physical activity [82,83,84]. It has been observed that professional athletes have a higher prevalence compared to sedentary individuals. Furthermore, the presence of this morphology in asymptomatic individuals increases the relative risk of developing hip pain by 4.3 times [85]. Regarding the incidence of PINCER-type morphology between men and women, some studies report small differences [86, 87]. Various studies have not shown any association between PINCER-type morphology and ethnicity [80, 88, 89]. The prevalence in individuals engaged in different sports varies considerably, ranging from 1 to 74% [78, 80, 90, 91].
Both CAM and PINCER morphologies can lead to the development of acetabular labral tears, with a prevalence of these tears ranging from 22 to 55% in individuals with hip pain [92] and being common in asymptomatic individuals [93]. Various studies have reported that symptomatic labral tears are more frequent in women than in men [94, 95]. Most labral tears have an insidious onset of symptoms and are characteristic in sports such as soccer, tennis, hockey, or artistic disciplines like ballet, where rapid movements in the frontal or horizontal plane of the hip are performed [96]. The etiology of labral tears is diverse, including traumatic, congenital, degenerative, capsular laxity-related, and idiopathic factors [97,98,99]. Therefore, labral tears have a multifactorial etiology, so the factors mentioned above and different FAI morphologies should be taken into consideration when symptoms related to labral tears appear.
One of the clinical signs present in patients with FAI and labral tears is a limitation in hip ROM. It has been observed that patients with labral tears exhibit restrictions in hip ROM [95]. The most significant limitation often occurs in hip rotation [100,101,102], but various studies have also shown limitations in hip flexion [102, 103], adduction [102], and abduction [101, 102] of the hip. However, there is controversy regarding the extent of ROM limitations in patients with FAI. Two systematic reviews have reported different conclusions regarding the effect of FAI on hip ROM [71, 104]. Diamond et al. [104] suggest that patients with FAI have reduced ROM in the directions where hip impingement occurs, while Freke et al. [71] reported that hip ROM was not different between individuals with FAI symptoms and their respective controls. The different methodologies used to assess hip ROM (goniometer, inclinometer, or 3D motion analysis systems) and the low methodological quality of some studies may explain the different conclusions in the two systematic reviews.
In addition to limitations in ROM, it has been described that patients with FAI may exhibit lower muscle strength values. Freke et al. [71] reviewed six studies on muscle weakness in patients with FAI and concluded that, overall, hip muscle strength is altered. However, studies comparing FAI patients with control subjects have not reached a consensus on which muscle groups are most affected [70, 105,106,107]. Casartelli et al. [106] demonstrated that patients with FAI had significantly lower isometric voluntary strength in the hip abductors, adductors, flexors, and external rotators. Diamond et al. [70] only found differences in the hip abductors. Additionally, Nepple et al. [107] pointed out that patients with FAI with strength deficits in hip flexion had larger labral tears.
These muscular imbalances in the trunk and hip muscles can lead to a change in pelvic posture. There are various definitions used to describe pelvic tilt. In physical therapy research, it generally refers to the angle formed by a horizontal line and a line bisecting the anterior–superior iliac spine and posterior-superior iliac spine in the sagittal plane. Changes in pelvic tilt have been correlated with various musculoskeletal conditions related to the lumbar spine [108], pelvis [109], and knee [110]. There is controversy in studies investigating changes in pelvic tilt posture in hip musculoskeletal pathologies [111]. Hip ROM is influenced by the position of pelvic tilt; several studies, using different methodologies, have shown that an increase in anterior pelvic tilt results in a decrease in hip flexion and internal rotation ROM, while an increase in posterior pelvic tilt increases hip flexion and internal rotation ROM [63, 65, 112, 113]. Greater anterior pelvic tilt increases lumbar lordosis, whereas posterior pelvic tilt has the opposite effect. Previous studies have investigated muscle activities during pelvic tilt movements using electromyography [114,115,116,117]. Regarding anterior pelvic tilt, it depends on the activity of the erector spinae, multifidus, iliopsoas, rectus femoris, tensor fasciae latae, and sartorius muscles. As for posterior pelvic tilt, it has been observed that the movement depends on the activity of the rectus abdominis, external oblique, internal oblique, and gluteus maximus muscles [117].
Hip ROM and muscle strength vary, and their utility in diagnosing FAI is limited. Therefore, diagnostic precision values are primarily associated with special orthopedic clinical tests. The flexion-adduction-internal rotation (FADIR) test is the most useful for ruling out FAI rather than confirming it [16, 22, 74]. This test replicates the early mechanical contact between the femoral head and the anterosuperior portion of the acetabulum, where acetabular labral tears are more commonly found. The FADIR test has been shown to have high SN (0.94) and low SP (0.09) in diagnosing FAI in patients with groin pain or symptoms suggestive of hip pathology [118, 119].
Finally, regarding radiological findings, FAI is divided, as mentioned earlier, into two types of morphology. Most CAM deformities are located at the anterosuperior junction of the femoral head-neck. To detect a CAM-type deformity in this region, both anteroposterior and lateral hip radiographic projections are needed [82]. According to available evidence, an alpha angle of ≥ 60° is currently the most appropriate for classifying CAM-type morphology [120]. On the other hand, PINCER-type morphology is associated with acetabular overcoverage due to increased acetabular depth, such as coxa profunda or acetabular protrusion. If it is focal, it may be due to acetabular retroversion or a prominent posterior edge. Therefore, the anterior or anterosuperior acetabular rim generally creates contact with the femoral neck, potentially causing associated symptoms and a higher risk of acetabular labral lesions [121].
Hip Microinstability
Hip microinstability is a relatively new and often underestimated pathology characterized by excessive hip mobility that goes beyond the normal range, leading to pain and impairments in hip stability [122]. It is distinct from hyperlaxity by the presence of pain and differs from traumatic macroinstability as it develops gradually due to repeated microtrauma, particularly in individuals engaged in activities requiring flexibility and excessive hip range of motion, such as dancing or gymnastics [123, 124]. This condition is challenging to identify but can result from a combination of factors, including anatomic abnormalities in bone structure, capsule-ligament issues, muscle deficits, and even iatrogenic causes like surgical procedures, such as capsulotomy during hip arthroscopy [125]. Morphological abnormalities in bone structure, such as inadequate acetabular coverage and femoral abnormalities, can contribute to microinstability. These abnormalities can be identified through X-rays and computed tomography (CT) scans. Acetabular dysplasia, defined by a lateral center–edge angle below 25°, is a notable risk factor. Other parameters, like the acetabular roof angle, anterior center–edge angle, and various indices, can also indicate potential risk [124, 126]. Magnetic resonance arthrography can reveal the presence of a capsular defect, thinning of the capsule, or labral pathology [127].
Capsule-ligament structures, including the joint capsule, iliofemoral ligament, ischiofemoral ligament, pubofemoral ligament, and the ligamentum teres, contribute significantly to hip stability. The iliofemoral ligament, in particular, plays a dynamic stabilization role during hip movement [128,129,130]. The labrum acts as a secondary stabilizer of the hip, increasing joint congruence and maintaining femoral head suction in the acetabulum. Patients with microinstability often exhibit a hypertrophic labrum [131, 132]. Muscles, including the iliopsoas, iliocapsularis, tensor fasciae latae, rectus femoris, and adductor muscles, provide a contention effect against microinstability. Muscle hypertrophy can occur in response to structural abnormalities [133]. Microinstability can also result from iatrogenic causes, including surgical interventions that alter the anatomy or stability of the hip. These can include excessive acetabular wall resection, labrum or ligamentum teres resection, and extensive capsulotomy [134].
Diagnosing microinstability involves a combination of patient history, clinical examination, and imaging. Patients often report pain in the inguinal fold and a sensation of instability during activities that stress the hip. Clinical examination may reveal hyperlaxity and limitations in hip motion. Several clinical tests, such as Beighton score, the log-roll test, anterior apprehension test, prone instability test, axial distraction or abduction-hyperextension-external rotation tests can be used to screen for hip microinstability [127, 135]. Patients with hip microinstability exhibited notably increased ROM compared to both symptomatic and asymptomatic groups without hip microinstability. In symptomatic patients, those with a hip flexion + rotation arc of ≥ 200° were highly likely to display positive intraoperative findings indicative of hip microinstability [135]. In summary, microinstability is a complex hip condition that arises from a combination of anatomical, structural, and functional factors. Its diagnosis and management require a comprehensive evaluation of the patient's history, clinical presentation, and imaging findings.
Hip Osteoarthritis
Osteoarthritis is the leading source of hip discomfort and reduced quality of life in older individuals, typically affecting those aged 50 and above with a prevalence ranging from 0.4 to 27%. Interestingly, there is considerable variation in reported hip OA prevalence, with men tending to exhibit a higher rate of radiographic hip OA [136]. In individuals diagnosed with hip osteoarthritis (OA), a reduction in hip internal rotation and hip flexion range is associated with various factors, including the presence of hip osteophytes, morning stiffness, male gender, higher body mass index (BMI), and hip pain [137].
Structural abnormalities, such as defects in cartilage and the existence of bone marrow lesions in the anterior and central superolateral regions of the hip joint, may signify initial damage in the progression of hip OA. Those with hip OA typically display diminished femoral-head cartilage volume, along with an increased prevalence of cartilage defects and bone marrow lesions [138]. Higher BMI is linked to an elevated risk of hip OA, with a consistent risk magnitude observed for both men and women (risk ratio = 1.11) [139]. Living in a community marked by high poverty levels is independently associated with the presence of radiographic OA in one or both hips, while lower educational attainment is independently linked to symptomatic OA in one or both hips (odds ratio [OR] = 1.44) [140]. Individuals with higher bone mass and hip OA have a higher occurrence of osteophytosis and excessive bone formation compared to those with lower bone mass (osteophytosis OR = 2.12, subchondral sclerosis OR = 2.78) [141, 142]. Additionally, individuals with a genetic predisposition to end-stage hip OA tend to exhibit an increased presence of clinical OA signs [140]. Interestingly, individuals experiencing hip pain often lack radiographic signs indicative of hip OA, such as osteophytes or joint space narrowing. Conversely, many individuals with radiographic evidence of hip OA do not experience hip pain [143].
Hip OA is presented with moderate hip anterior or lateral pain on the side during weight-bearing activities, morning stiffness lasting under 1 h upon waking, hip internal rotation range limited to less than 25° or restricted internal rotation and hip flexion by 15° compared to the nonpainful side, and/or increased hip pain during passive hip internal rotation [144]. The cluster of Sutlive is a set of five clinical assessment items used to help make a preliminary diagnosis of hip osteoarthritis in patients who are experiencing one-sided hip pain. This prediction rule is designed to minimize the necessity for X-ray imaging and offers clinicians a useful tool for starting early conservative treatment [144].
Moreover, clinicians should measure balance performance and assess activities that indicate the likelihood of falls in adults with hip osteoarthritis, particularly in cases of reduced physical function or a heightened fall risk due to a previous history of falls. To evaluate activity limitations, participation constraints, and changes in the patient's functional status throughout their treatment, healthcare providers should employ reliable and valid physical performance assessments. These assessments may encompass tests such as the 6-min walk test, 30-s chair stand, stair measure, timed up-and-go test, self-paced walk, timed single-leg stance, 4-square step test, and step test [136]. Table 1 summarizes all clinical criteria of FAI, hip microinstability and hip OA.
Hip Symptom Modification Procedure
Once the patient's hip pathology has been diagnosed, the symptom-modification procedure with mobilization with movement (MWM) and pelvic tilt modification (specially for hip OA and FAI) will be performed to improve symptom-provoking movement if hip mobility was needed and allowed due to hip bony morphology.
Mobilization with Movement
Traditionally, hip traction has been used in the setting of arthrography to increase intra-articular joint space and visualize cartilage [145]. Joint mobilization and manipulation techniques are frequently employed and recommended for patients diagnosed with hip OA. Within this treatment approach, manual traction is applied along the femur's longitudinal axis, commonly referred to as long-axis mobilization or manipulation.
Prior research has documented positive results associated with the longitudinal manipulation or mobilization of the hip joint [146,147,148]. During long-axis mobilization or manipulation, the leg is gently moved in a caudal direction, effectively creating separation between opposing joint surfaces. This maneuver has the potential to enhance the width of the joint space (JSW) and alleviate stress on the joint cartilage by redistributing the load. Mulligan’s Mobilization with Movement (MWM) integrates an additional glide force (longitudinal, inferior, anterior, posterior, or lateral) with an active or passive movement [149]. Numerous studies with a low risk of bias have demonstrated positive clinical outcomes in terms of pain relief and improved function when employing MWM in individuals with hip osteoarthritis [150, 151]. Beselga et al. [151] observed an immediate enhancement in pain levels, hip range of motion (ROM), and physical function tests following a single MWM intervention compared to a placebo. Additionally, Zemadanis et al. [150] presented compelling evidence of both immediate and sustained improvements (up to 3 months) in Visual Analog Scale (VAS) scores and lower extremity function scale after six interventions over a 2-week period, coupled with home exercises involving MWM, in contrast to a placebo. Consequently, there exists moderate-quality evidence supporting the advantageous effects of MWM on pain and function in patients with hip osteoarthritis.
Reiman and Matheson [152] showed different self-mobilization and muscle re-education techniques to improve hip mobility and improve symptoms. These techniques are based on available evidence and clinical experience. Their protocol is proposed to integrate self-mobilization techniques into a multimodal home program that includes warm-up, stretching, dynamic exercises, and neuromuscular control. Therapist supervision and follow-up are recommended.
During the decision-making process, if a particular movement (e.g., hip flexion or internal rotation) results in the complete or partial reduction of symptoms and improve the hip ROM with MWM, the hip mobility management of the patient should include self-hip mobilization techniques with an accessory glide force, provided that the hip's bone morphology allows for it. It is crucial to take into consideration the presence of FAI syndrome or the degree of hip osteoarthritis, as these factors may influence the suitability and effectiveness of such techniques.
Pelvic Tilt Modification
Furthermore, another approach to guide hip mobility management are dynamic changes in pelvic tilt (anterior or posterior pelvic tilt) to improve hip ROM and symptoms.
Pelvic tilt angle is the multifactorial result of muscle tone [153], pain [154], bone morphology [155], and adjacent joint mobility [156]. A reduction in posterior pelvic tilt in patients with hip pain have been observed during kinematic assessment of various basic functional movements, such as walking [157], unilateral step down [158], and performing a squat [159, 160]. Significant differences in pelvic tilt have also been identified during high-speed direction changes in populations with athletic pubalgia or groin pain [161]. It has been proposed that an increased anterior pelvic tilt in patients with FAI could contribute to an increase in symptoms during squats or stepping down, initiating early hip joint contact between the femur and acetabulum [63, 112]. In combination, increased anterior pelvic tilt and reduced hip extension may indicate an unconscious attempt to maintain a more “flexed” hip to avoid increased tensile forces in the anterior hip.
This increased anterior pelvic tilt has been associated with a loss of ROM, especially during hip flexion and internal rotation at 90° of hip flexion in simulated studies [63, 113]. Ross et al. [63] conducted a three-dimensional study and demonstrated that increased posterior pelvic tilt was associated with increased ROM in hip internal rotation and flexion in patients with FAI. This is an important finding, as these patients could potentially improve hip ROM limitation by increasing posterior pelvic tilt. Supporting this theory, several studies in elite skiers with/without CAM-type morphology [64, 65] have shown that hip internal rotation ROM is reduced when the pelvis tilts anteriorly during an upright posture, suggesting that anterior pelvic tilt may produce biomechanical changes within the hip joint.
We can assume that pelvic tilt is a modifiable factor in patients with FAI that may prevent the development of degenerative changes in the hip. In this regard, it has been demonstrated that a multimodal program in healthy individuals (manual therapy, stretching, and muscle strengthening) over 6 weeks can reduce anterior pelvic tilt during walking, increase hamstring muscle flexibility, and trunk muscle endurance [162]. FAI rehabilitation programs include lumbo-pelvic exercises and general hip muscle strengthening, but improving anterior pelvic tilt has not been identified as a target in patients who improve their hip ROM during physical examination [163]. Recently, Brekke et al. [164] have demonstrated that feasible exercise programs targeting anterior pelvic tilt have shown potential benefits for patients with acetabular retroversion, particularly those experiencing moderate hip-related pain. Considering anterior pelvic tilt as a component of future interventions in patients with FAI may be worthwhile.
Given the aforementioned considerations, during the decision-making process, whether a reduction in anterior pelvic tilt results in an improvement of pain symptoms and increase hip ROM during various painful and restricted movements in patients with FAI or hip OA during physical examination. If improvements in patients' signs and symptoms are observed, treatment aimed at enhancing hip ROM and hip self-reported quality of life may involve addressing posterior pelvic tilt.
General Exercise Treatment
The role of strength training or general exercise treatment have been proposed by several authors for patients with FAI [165, 166], hip OA [167, 168], and hip microinstability [169, 170] for improving self-reported pain, quality of life and hip strength. Several studies have reported strength deficits in various hip-related muscle groups in patients with hip-related pain. These findings suggest specific deficiencies in muscle groups such as hip flexors [106, 171, 172], with the iliopsoas appearing to be particularly affected, as well as hip extensors [171, 172], where previous research has indicated weakness in the gluteus maximus. Additionally, studies confirm strength deficits in hip abductors [70, 106, 107, 173]. Similarly, research has shown muscle strength deficits in hip external rotators, with these muscles playing a crucial role in hip stability and function [106, 173,174,175]. These findings underscore the importance of including hip muscle strengthening as a fundamental component of rehabilitation for patients with hip-related pain, irrespective of their specific hip morphology.
However, current exercise protocols often do not consider variations in femoral torsion when prescribing treatment plans. Frasson et al. [54] showed that hip with excessive femoral antetorsion were weaker than hips with femoral retroversion for hip external rotation at 30º of hip flexion, abduction and adduction, and weaker than normal hip femoral version for extension, supporting the theory of previous research [31]. Muscles play a central role in generating movement, and a thorough comprehension of their structure and function is essential for accurately identifying sources of abnormal movement and specific muscle groups to target during exercise interventions for hip-related pain [176]. Muscle architecture also plays a crucial role in assessment and targeting of specific muscles. For instance, the gluteus medius achieves remarkable force production despite its relatively small size by packing numerous short fibers in parallel. However, this design means that the muscle is not optimized for generating very high forces across a wide range of lengths or hip positions. In essence, understanding the unique characteristics of each muscle and femoral torsion helps guide clinical evaluation and exercises-based strategies.
Conclusions
Therefore, the present clinical algorithm for hip-related pain is a comprehensive, flexible, adaptable to different settings, and regularly updated to incorporate new research findings. The combination of physical examination methods with evidence-based rehabilitation principles to restore optimal hip ROM, strength and stabilize the surrounding musculature constitutes the foundation of clinical rehabilitation for patients dealing with hip-related pain. The ongoing utilization of fundamental scientific investigations, clinical education, and research into outcomes will contribute further insights and advancements for treating hip-related pain.
References
Kemp JL, Risberg MA, Mosler A, Harris-Hayes M, Serner A, Moksnes H, et al. Physiotherapist-led treatment for young to middle-aged active adults with hip-related pain: consensus recommendations from the International Hip-related Pain Research Network, Zurich 2018. Br J Sports Med. 2020;54(9):504–11.
Impellizzeri FM, Jones DM, Griffin D, Harris-Hayes M, Thorborg K, Crossley KM, et al. Patient-reported outcome measures for hip-related pain: a review of the available evidence and a consensus statement from the International Hip-related Pain Research Network, Zurich 2018. Br J Sports Med. 2020;54(14):848–57.
Battaglia PJ, D’Angelo K, Kettner NW. Posterior, lateral, and anterior hip pain due to musculoskeletal origin: a narrative literature review of history, physical examination, and diagnostic imaging. J Chiropr Med. 2016;15(4):281–93. https://doi.org/10.1016/j.jcm.2016.08.004.
Guanche CA. Why examine a hip? J Bone Jt Surg. 2016;98(2): e9.
Reiman MP, Thorborg K. Clinical examination and physical assessment of hip joint-related pain in athletes. Int J Sports Phys Ther. 2014;9(6):737–55.
Flugelman MY. History-taking revisited: Simple techniques to foster patient collaboration, improve data attainment, and establish trust with the patient. GMS J Med Educ. 2021;38(6):Doc109.
Retchford THTH, Tucker KJKJ, Weinrauch P, Cowan SMSM, Alison G, Kemp JLJL, et al. Clinical features of people with hip-related pain, but no clinical signs of femoroacetabular impingement syndrome. Phys Ther Sport. 2018;1(34):201–7.
Falvey EC, Franklyn-Miller A, McCrory PR. The groin triangle: a patho-anatomical approach to the diagnosis of chronic groin pain in athletes. Br J Sports Med. 2009;43(3):213–20.
Mosler AB, Kemp J, King M, Lawrenson PR, Semciw A, Freke M, et al. Standardised measurement of physical capacity in young and middle-aged active adults with hip-related pain: recommendations from the first International Hip-related Pain Research Network (IHiPRN) meeting, Zurich, 2018. Br J Sports Med. 2020;54(12):702–10.
Griffin DR, Parsons N, Mohtadi NGH, Safran MR. A short version of the International Hip Outcome Tool (iHOT-12) for use in routine clinical practice. Arthrosc J Arthrosc Relat Surg. 2012;28(5):611–8.
González-de-la-Flor Á, López-de-Uralde-Villanueva I, Valera-Calero JA, Almazán-Polo J, López-Marcos JJ, Fernández-de-las-Peñas C, et al. Validity and test-retest reliability of the Spanish Version of the International Hip Outcome Tool (iHOT-12Sv). J Clin Med. 2022;11(21):6232.
Martin RL, Kelly BT, Philippon MJ. Evidence of validity for the hip outcome score. Arthroscopy. 2006;22(12):1304–11.
Lodhia P, Slobogean GP, Noonan VK, Gilbart MK. Patient-reported outcome instruments for femoroacetabular impingement and hip labral pathology: a systematic review of the clinimetric evidence. Arthroscopy. 2011;27(2):279–86.
Hinman RS, Dobson F, Takla A, O’Donnell J, Bennell KL. Which is the most useful patient-reported outcome in femoroacetabular impingement? Test-retest reliability of six questionnaires. Br J Sports Med. 2014;48(6):458–63.
Wright AA, Ness BM, Donaldson M. Diagnostic accuracy of patient history in the diagnosis of hip-related pain: a systematic review. Arch Phys Med Rehabil. 2021;102(12):2454-2463.e1.
Reiman MP, Agricola R, Kemp JL, Heerey JJ, Weir A, Van Klij P, et al. 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. Br J Sports Med. 2018;2020:1–11.
Donelson R, Aprill C, Medcalf R, Grant W. A prospective study of centralization of lumbar and referred pain. Spine (Phila Pa 1976). 1997;22(10):1115–22.
Laslett M. Evidence-based diagnosis and treatment of the painful sacroiliac joint. J Manual Manip Ther. 2008;16(3):142–52.
Laslett M, Aprill CN, McDonald B, Öberg B. Clinical predictors of lumbar provocation discography: a study of clinical predictors of lumbar provocation discography. Eur Spine J. 2006;15(10):1473–84.
Reiman MP, Goode AP, Hegedus EJ, Cook CE, Wright AA. Diagnostic accuracy of clinical tests of the hip: a systematic review with meta-analysis. Br J Sports Med. 2013;47(14):893–902.
Johnson AW, Weiss CB, Wheeler DL. Stress fractures of the femoral shaft in athletes—more common than expected. Am J Sports Med. 1994;22(2):248–56.
Reiman MP, Mather RC, Cook CE. Physical examination tests for hip dysfunction and injury. Br J Sports Med. 2015;49(6):357–61.
Weir A, Brukner P, Delahunt E, Ekstrand J, Griffin D, Khan KM, et al. Doha agreement meeting on terminology and definitions in groin pain in athletes. Br J Sports Med. 2015;49(12):768–74.
Heijboer WMP, Weir A, Vuckovic Z, Fullam K, Tol JL, Delahunt E, et al. Inter-examiner reliability of the Doha agreement meeting classification system of groin pain in male athletes. Scand J Med Sci Sports. 2023;33(2):189–96.
Belhaj K, Meftah S, Mahir L, Lmidmani F, Elfatimi A. Isokinetic imbalance of adductor–abductor hip muscles in professional soccer players with chronic adductor-related groin pain. Eur J Sport Sci. 2016;16(8):1226–31.
Hölmich P, Hölmich LR, Bjerg AM. Clinical examination of athletes with groin pain: an intraobserver and interobserver reliability study. Br J Sports Med. 2004;38(4):446–51.
Falvey C, King E, Kinsella S, Franklyn-Miller A. Athletic groin pain (part 1): a prospective anatomical diagnosis of 382 patients—clinical findings, MRI findings and patient-reported outcome measures at baseline. Br J Sports Med. 2016;50(7):423–30.
Nevin F, Delahunt E. Adductor squeeze test values and hip joint range of motion in Gaelic football athletes with longstanding groin pain. J Sci Med Sport. 2014;17(2):155–9.
Delahunt E, Kennelly C, McEntee BL, Coughlan GF, Green BS. The thigh adductor squeeze test: 45° of hip flexion as the optimal test position for eliciting adductor muscle activity and maximum pressure values. Man Ther. 2011;16(5):476–80. https://doi.org/10.1016/j.math.2011.02.014.
Verrall GM, Slavotinek JP, Barnes PG, Fon GT. Description of pain provocation tests used for the diagnosis of sports-related chronic groin pain: Relationship of tests to defined clinical (pain and tenderness) and MRI (pubic bone marrow oedema) criteria. Scand J Med Sci Sports. 2005;15(1):36–42.
Neumann DA. Kinesiology of the hip: a focus on muscular actions. J Orthop Sports Phys Ther. 2010;40(2):82–94. https://doi.org/10.2519/jospt.2010.3025.
Pesquer L, Reboul G, Silvestre A, Poussange N, Meyer P, Dallaudière B. Imaging of adductor-related groin pain. Diagn Interv Imaging. 2015;96(9):861–9. https://doi.org/10.1016/j.diii.2014.12.008.
Drew MK, Palsson TS, Izumi M, Hirata RP, Lovell G, Chiarelli P, et al. Resisted adduction in hip neutral is a superior provocation test to assess adductor longus pain: an experimental pain study. Scand J Med Sci Sports. 2016;26(8):967–74.
Audenaert EA, Mahieu P, Pattyn C, Peeters I, Vigneron L, Baelde N, et al. EMG of the hip adductor muscles in six clinical examination tests. Phys Ther Sport. 2012;13(1):134–40. https://doi.org/10.1016/j.ptsp.2011.08.004.
Birmingham PM, Kelly BT, Jacobs R, McGrady L, Wang M. The effect of dynamic femoroacetabular impingement on pubic symphysis motion: a cadaveric study. Am J Sports Med. 2012;40(5):1113–8.
Zacest AC, Magill ST, Anderson VC, Burchiel KJ. Long-term outcome following ilioinguinal neurectomy for chronic pain. J Neurosurg. 2010;112(4):784–9.
Heijboer WMP, Vuckovic Z, Weir A, Tol JL, Hölmich P, Serner A. Clinical examination for athletes with inguinal-related groin pain: interexaminer reliability and prevalence of positive tests. BMJ Open Sport Exerc Med. 2023;9(1): e001498.
Otten R, Vuckovic Z, Weir A, Serner A. Rehabilitation and return to play following surgery for inguinal-related groin pain. Oper Tech Sports Med. 2017;25(3):172–80. https://doi.org/10.1053/j.otsm.2017.07.005.
Soneji N, Peng PWH. Ultrasound-guided pain interventions—a review of techniques for peripheral nerves. Korean J Pain. 2013;26(2):111–24.
Thomassen I, van Suijlekom JA, van de Gaag A, Ponten JEH, Nienhuijs SW. Ultrasound-guided ilioinguinal/iliohypogastric nerve blocks for chronic pain after inguinal hernia repair. Hernia. 2013;17(3):329–32.
Rauseo C. The rehabilitation of a runner with iliopsoas tendinopathy using an eccentric-biased exercise—a case report. Int J Sports Phys Ther. 2017;12(7):1150–62.
Vigotsky AD, Lehman GJ, Beardsley C, Contreras B, Chung B, Feser EH. The modified Thomas test is not a valid measure of hip extension unless pelvic tilt is controlled. PeerJ. 2016;4(8):e2325.
Cady K, Powis M, Hopgood K. Intrarater and interrater reliability of the modified Thomas test. J Bodyw Mov Ther. 2022;29:86–91.
Vigotsky AD, Lehman GJ, Contreras B, Beardsley C, Chung B, Feser EH. Acute effects of anterior thigh foam rolling on hip angle, knee angle, and rectus femoris length in the modified Thomas test. PeerJ. 2015;2015(9):1–13.
Thorborg K, Petersen J, Magnusson SP, Hölmich P. Clinical assessment of hip strength using a hand-held dynamometer is reliable. Scand J Med Sci Sports. 2010;20(3):493–501.
González-de-la-Flor Á, García-Pérez-de-Sevilla G, Domínguez-Balmaseda D, del-Blanco-Muñiz JÁ. Validity and reliability of a new hip flexor muscles flexibility assessment tool: the reactive hip flexor (RHF) test. Phys Ther Sport. 2023;64:41–7.
O’Sullivan K, Darlow B, O’Sullivan P, Forster BB, Reiman MP, Weir A. Imaging for hip-related groin pain: don’t be hip-notised by the findings. Br J Sports Med. 2017. https://doi.org/10.1136/bjsports-2017-097889.
Chadayammuri V, Garabekyan T, Bedi A, Pascual-Garrido C, Rhodes J, O’Hara J, et al. Passive hip range of motion predicts femoral torsion and acetabular version. J Bone Jt Surg Am. 2016;98(2):127–34.
Audenaert EA, Peeters I, Vigneron L, Baelde N, Pattyn C. Hip morphological characteristics and range of internal rotation in femoroacetabular impingement. Am J Sports Med. 2012;40(6):1329–36.
Kraeutler MJ, Chadayammuri V, Garabekyan T, Mei-Dan O. Femoral version abnormalities significantly outweigh effect of cam impingement on hip internal rotation. J Bone Jt Surg. 2018;100(3):205–10.
Uding A, Bloom NJ, Commean PK, Hillen TJ, Patterson JD, Clohisy JC, et al. Clinical tests to determine femoral version category in people with chronic hip joint pain and asymptomatic controls. Musculoskelet Sci Pract. 2019;39:115–22.
Hartel MJ, Petersik A, Schmidt A, Kendoff D, Nüchtern J, Rueger JM, et al. Determination of femoral neck angle and torsion angle utilizing a novel three-dimensional modeling and analytical technology based on CT datasets. PLoS ONE. 2016;11(3):1–10.
Koerner JD, Patel NM, Yoon RS, Sirkin MS, Reilly MC, Liporace FA. Femoral version of the general population: does “normal” vary by gender or ethnicity? J Orthop Trauma. 2013;27(6):308–11.
Frasson VB, Herzog W, Johnston K, Pauchard Y, Vaz MA, Baroni BM. Do femoral version abnormalities play a role in hip function of patients with hip pain? Clin Biomech. 2022;97: 105708.
Lerch TD, Todorski IAS, Steppacher SD, Schmaranzer F, Werlen SF, Siebenrock KA, et al. Prevalence of femoral and acetabular version abnormalities in patients with symptomatic hip disease: a controlled study of 538 hips. Am J Sports Med. 2018;46(1):122–34.
Bouma HW, Hogervorst T, Audenaert E, Krekel P, van Kampen PM. Can combining femoral and acetabular morphology parameters improve the characterization of femoroacetabular impingement? Clin Orthop Relat Res. 2015;473(4):1396–403.
Botser IB, Ozoude GC, Martin DE, Siddiqi AJ, Kuppuswami S, Domb BG. Femoral anteversion in the hip: comparison of measurement by computed tomography, magnetic resonance imaging, and physical examination. Arthrosc J Arthrosc Relat Surg. 2012;28(5):619–27.
Mascarenhas VV, Rego P, Dantas P, Caetano AP, Jans L, Sutter R, et al. Can we discriminate symptomatic hip patients from asymptomatic volunteers based on anatomic predictors? A 3-dimensional magnetic resonance study on cam, pincer, and spinopelvic parameters. Am J Sports Med. 2018;46(13):3097–110.
Ng KCG, Lamontagne M, Jeffers JRT, Grammatopoulos G, Beaulé PE. Anatomic predictors of sagittal hip and pelvic motions in patients with a cam deformity. Am J Sports Med. 2018;46(6):1331–42.
Kelly BT, Bedi A, Robertson CM, Dela Torre K, Giveans MR, Larson CM. Alterations in internal rotation and alpha angles are associated with arthroscopic cam decompression in the hip. Am J Sports Med. 2012;40(5):1107–12.
Bedi A, Thompson M, Uliana C, Magennis E, Kelly BT. Assessment of range of motion and contact zones with commonly performed physical exam manoeuvers for femoroacetabular impingement (FAI): what do these tests mean? Hip Int. 2013;23(Suppl 9):S27-34.
Clohisy JC, McClure JT. Treatment of anterior femoroacetabular impingement with combined hip arthroscopy and limited anterior decompression. Iowa Orthop J. 2005;25:164–71.
Ross JR, Nepple JJ, Philippon MJ, Kelly BT, Larson CM, Bedi A. Effect of changes in pelvic tilt on range of motion to impingement and radiographic parameters of acetabular morphologic characteristics. Am J Sports Med. 2014;42(10):2402–9.
Agnvall C, Swärd Aminoff A, Todd C, Jonasson P, Thoreson O, Swärd L, et al. Range of hip joint motion is correlated with MRI-verified cam deformity in adolescent elite skiers. Orthop J Sports Med. 2017;5(6):1–11.
Swärd Aminoff A, Agnvall C, Todd C, Jónasson P, Sansone M, Thoreson O, et al. The effect of pelvic tilt and cam on hip range of motion in young elite skiers and nonathletes. Open Access J Sports Med. 2018;9:147–56.
Ejnisman L, Philippon MJ, Lertwanich P, Pennock AT, Herzog MM, Briggs KK, et al. Relationship between femoral anteversion and findings in hips with femoroacetabular impingement. Orthopedics. 2013;36(3):e293-300.
Cibulka MT. Determination and significance of femoral neck anteversion. Phys Ther. 2004;84(6):550–8.
Souza RB, Powers CM. Predictors of hip internal rotation during running: an evaluation of hip strength and femoral structure in women with and without patellofemoral pain. Am J Sports Med. 2009;37(3):579–87.
Souza RB, Powers CM. Concurrent criterion-related validity and reliability of a clinical test to measure femoral anteversion. J Orthop Sports Phys Ther. 2009;39(8):586–92.
Diamond LELE, Wrigley TVTV, Hinman RSRS, Hodges PWPW, O’Donnell J, Takla A, et al. Isometric and isokinetic hip strength and agonist/antagonist ratios in symptomatic femoroacetabular impingement. J Sci Med Sport. 2016;19(9):696–701. https://doi.org/10.1016/j.jsams.2015.10.002.
Freke MD, Kemp J, Svege I, Risberg MA, Semciw A, Crossley KM. Physical impairments in symptomatic femoroacetabular impingement: a systematic review of the evidence. Br J Sports Med. 2016;50(19):1180.
Song K, Gaffney BMM, Shelburne KB, Pascual-Garrido C, Clohisy JC, Harris MD. Dysplastic hip anatomy alters muscle moment arm lengths, lines of action, and contributions to joint reaction forces during gait. J Biomech. 2020;110: 109968.
Cibulka MT, Strube MJ, Meier D, Selsor M, Wheatley C, Wilson NG, et al. Symmetrical and asymmetrical hip rotation and its relationship to hip rotator muscle strength. Clin Biomech. 2010;25(1):56–62. https://doi.org/10.1016/j.clinbiomech.2009.09.006.
Griffin DR, Dickenson EJ, O’Donnell J, Agricola R, Awan T, Beck M, et al. The Warwick Agreement on femoroacetabular impingement syndrome (FAI syndrome): an international consensus statement. Br J Sports Med. 2016;50(19):1169–76.
Kaplan KM, Shah MR, Youm T. Femoroacetabular impingement: diagnosis and treatment. Bull NYU Hosp Jt Dis. 2010;68(2):70–5.
Dickenson E, Wall PDH, Robinson B, Fernandez M, Parsons H, Buchbinder R, et al. Prevalence of cam hip shape morphology: a systematic review. Osteoarthr Cartil. 2016;24(6):949–61.
Leunig M, Jüni P, Werlen S, Limacher A, Nüesch E, Pfirrmann CW, et al. Prevalence of cam and pincer-type deformities on hip MRI in an asymptomatic young Swiss female population: a cross-sectional study. Osteoarthr Cartil. 2013;21(4):544–50.
Kapron AL, Peters CL, Aoki SK, Beckmann JT, Erickson JA, Anderson MB, et al. The prevalence of radiographic findings of structural hip deformities in female collegiate athletes. Am J Sports Med. 2015;43(6):1324–30.
Pollard TCB, Villar RN, Norton MR, Fern ED, Williams MR, Simpson DJ, et al. Femoroacetabular impingement and classification of the cam deformity: the reference interval in normal hips. Acta Orthop. 2010;81(1):134–41.
Mosler AB, Crossley KM, Waarsing JH, Jomaah N, Weir A, Hölmich P, et al. Ethnic differences in bony hip morphology in a cohort of 445 professional male soccer players. Am J Sports Med. 2016;44(11):2967–74.
Van Houcke J, Yau WP, Yan CH, Huysse W, Dechamps H, Lau WH, et al. Prevalence of radiographic parameters predisposing to femoroacetabular impingement in young asymptomatic Chinese and white subjects. J Bone Jt Surg Am Vol. 2015;97(4):310–7.
Agricola R, Bessems JHJM, Ginai AZ, Heijboer MP, Van Der Heijden RA, Verhaar JANN, et al. The development of cam-type deformity in adolescent and young male soccer players. Am J Sports Med. 2012;40(5):1099–106.
Agricola R, Heijboer MP, Ginai AZ, Roels P, Zadpoor AA, Verhaar JANN, et al. A cam deformity is gradually acquired during skeletal maturation in adolescent and young male soccer players: a prospective study with minimum 2-year follow-up. Am J Sports Med. 2014;42(4):798–806.
Palmer A, Fernquest S, Gimpel M, Birchall R, Judge A, Broomfield J, et al. Physical activity during adolescence and the development of cam morphology: a cross-sectional cohort study of 210 individuals. Br J Sports Med. 2017;52(9):bjsports-2017-097626.
Khanna V, Caragianis A, Diprimio G, Rakhra K, Beaulé PE. Incidence of hip pain in a prospective cohort of asymptomatic volunteers: is the cam deformity a risk factor for hip pain? Am J Sports Med. 2014;42(4):793–7.
Li Y, Helvie P, Mead M, Gagnier J, Hammer MR, Jong N. Prevalence of femoroacetabular impingement morphology in asymptomatic adolescents. J Pediatr Orthop. 2017;37(2):121–6.
Nepple JJ, Riggs CN, Ross JR, Clohisy JC. Clinical presentation and disease characteristics of femoroacetabular impingement are sex-dependent. J Bone Jt Surg Am Vol. 2014;96(20):1683–9.
Ahn T, Kim CH, Kim TH, Chang JS, Jeong MY, Aditya K, et al. What is the prevalence of radiographic hip findings associated with femoroacetabular impingement in asymptomatic Asian volunteers? Clin Orthop Relat Res. 2016;474(12):2655–61.
Tannenbaum E, Kopydlowski N, Smith M, Bedi A, Sekiya JK. Gender and racial differences in focal and global acetabular version. J Arthroplast. 2014;29(2):373–6.
Harris JD, Gerrie BJ, Varner KE, Lintner DM, McCulloch PC. Radiographic prevalence of dysplasia, cam, and pincer deformities in elite ballet. Am J Sports Med. 2016;44(1):20–7.
Frank JM, Harris JD, Erickson BJ, Slikker W 3rd, Bush-Joseph CA, Salata MJ, et al. Prevalence of femoroacetabular impingement imaging findings in asymptomatic volunteers: a systematic review. Arthroscopy. 2015;31(6):1199–204.
Narvani AA, Tsiridis E, Kendall S, Chaudhuri R, Thomas P. A preliminary report on prevalence of acetabular labrum tears in sports patients with groin pain. Knee Surg Sports Traumatol Arthrosc. 2003;11(6):403–8.
Vahedi H, Aalirezaie A, Azboy I, Daryoush T, Shahi A, Parvizi J. Acetabular labral tears are common in asymptomatic contralateral hips with femoroacetabular impingement. Clin Orthop Relat Res. 2019;477(5):974–9.
McCarthy JC, Noble PC, Schuck MR, Wright J, Lee J. The Otto E. Aufranc Award: the role of labral lesions to development of early degenerative hip disease. Clin Orthop Relat Res. 2001;393:25–37.
Lewis CLSS. Acetabular labral tears. Phys Ther. 2006;86:1110–21.
Reiman MP, Mather RC, Hash TW, Cook CE. Examination of acetabular labral tear: a continued diagnostic challenge. Br J Sports Med. 2014;48(4):311–9.
Bharam S. Labral tears, extra-articular injuries, and hip arthroscopy in the athlete. Clin Sports Med. 2006;25(2):279–92, ix.
Beaulé PE, O’Neill M, Rakhra K. Acetabular labral tears. J Bone Jt Surg Am. 2009;91(3):701–10.
Martin RRL, Enseki KR, Draovitch P, Trapuzzano T, Philippon MJ. Acetabular labral tears of the hip: examination and diagnostic challenges. J Orthop Sports Phys Ther. 2006;36(7):503–15.
Nelson MC, Lauerman WC, Brower AC, Wells JR. Avulsion of the acetabular labrum with intraarticular displacement. Orthopedics. 1990;13(8):889–91.
Binningsley D. Tear of the acetabular labrum in an elite athlete. Br J Sports Med. 2003;37(1):84–8.
Altenberg AR. Acetabular labrum tears: a cause of hip pain and degenerative arthritis. South Med J. 1977;70(2):174–5.
Givens-Heiss DL, Krebs DE, Riley PO, Strickland EM, Fares M, Hodge WA, et al. In vivo acetabular contact pressures during rehabilitation. Part II: postacute phase. Phys Ther. 1992;72(10):700–10.
Diamond LE, Dobson FL, Bennell KL, Wrigley TV, Hodges PW, Hinman RS. Physical impairments and activity limitations in people with femoroacetabular impingement: a systematic review. Br J Sports Med. 2015;49(4):230–42.
Casartelli NC, Leunig M, Item-Glatthorn JF, Lepers R, Maffiuletti NA. Hip flexor muscle fatigue in patients with symptomatic femoroacetabular impingement. Int Orthop. 2012;36(5):967–73.
Casartelli NCC, Maffiuletti NAA, Item-Glatthorn JFF, Staehli S, Bizzini M, Impellizzeri FMM, et al. Hip muscle weakness in patients with symptomatic femoroacetabular impingement. Osteoarthr Cartil. 2011;19(7):816–21.
Nepple JJ, Goljan P, Briggs KK, Garvey SE, Ryan M, Philippon MJ. Hip strength deficits in patients with symptomatic femoroacetabular impingement and labral tears. Arthrosc J Arthrosc Relat Surg. 2015;31(11):2106–11.
Król A, Polak M, Szczygieł E, Wójcik P, Gleb K. Relationship between mechanical factors and pelvic tilt in adults with and without low back pain. J Back Musculoskelet Rehabil. 2017;30(4):699–705.
Christopher SM, Garcia AN, Snodgrass SJ, Cook C. Common musculoskeletal impairments in postpartum runners: an international Delphi study. Arch Physiother. 2020;10:19.
Crossley KM, Schache AG, Ozturk H, Lentzos J, Munanto M, Pandy MG. Pelvic and hip kinematics during walking in people with patellofemoral joint osteoarthritis compared to healthy age-matched controls. Arthritis Care Res (Hoboken). 2018;70(2):309–14.
Suits WH. Clinical measures of pelvic tilt in physical therapy. Int J Sports Phys Ther. 2021;16(5):1366–75.
Patel RV, Han S, Lenherr C, Harris JD, Noble PC. Pelvic tilt and range of motion in hips with femoroacetabular impingement syndrome. J Am Acad Orthop Surg. 2020;28(10):e427–32.
Kobayashi N, Higashihira S, Kitayama H, Kamono E, Yukizawa Y, Oishi T, et al. Effect of decreasing the anterior pelvic tilt on range of motion in femoroacetabular impingement: a computer-simulation study. Orthop J Sports Med. 2021;9(4):2325967121999464.
Andersson E, Oddsson L, Grundström H, Thorstensson A. The role of the psoas and iliacus muscles for stability and movement of the lumbar spine, pelvis and hip. Scand J Med Sci Sports. 1995;5(1):10–6.
Floyd WF, Silver PH. The function of the erectores spinae muscles in certain movements and postures in man. J Physiol. 1955;129(1):184–203.
Blackburn SE, Portney LG. Electromyographic activity of back musculature during Williams’ flexion exercises. Phys Ther. 1981;61(6):878–85.
Takaki S, Kaneoka K, Okubo Y, Otsuka S, Tatsumura M, Shiina I, et al. Analysis of muscle activity during active pelvic tilting in sagittal plane. Phys Ther Res. 2016;19(1):50–7.
Casartelli NC, Brunner R, Maffiuletti NA, Bizzini M, Leunig M, Pfirrmann CW, et al. The FADIR test accuracy for screening cam and pincer morphology in youth ice hockey players. J Sci Med Sport. 2018;21(2):134–8.
Reiman MP, Goode AP, Cook CE, Hölmich P, Thorborg K. Diagnostic accuracy of clinical tests for the diagnosis of hip femoroacetabular impingement/labral tear: a systematic review with meta-analysis. Br J Sports Med. 2015;49(12):811.
van Klij P, Reiman MP, Waarsing JH, Reijman M, Bramer WM, Verhaar JANN, et al. Classifying cam morphology by the alpha angle: a systematic review on threshold values. Orthop J Sports Med. 2020;8(8):2325967120938312.
Sabetta E, Scaravella E. Treatment of pincer-type femoroacetabular impingement. Joints. 2015;3(2):78–81.
Jackson TJ, Peterson AB, Akeda M, Estess A, McGarry MH, Adamson GJ, et al. Biomechanical effects of capsular shift in the treatment of hip microinstability. Am J Sports Med. 2016;44(3):689–95.
Cerezal L, Arnaiz J, Canga A, Piedra T, Altónaga JR, Munafo R, et al. Emerging topics on the hip: ligamentum teres and hip microinstability. Eur J Radiol. 2012;81(12):3745–54.
Dangin A, Tardy N, Wettstein M, May O, Bonin N. Microinstability of the hip: a review. Orthop Traumatol Surg Res. 2016;102(8):S301–9.
Khan M, Habib A, De SAD, Larson CM, Kelly BT, Bhandari M, et al. Arthroscopy up to date: hip femoroacetabular impingement. Arthrosc J Arthrosc Relat Surg. 2016;32(1):177–89.
Tannast M, Hanke MS, Zheng G, Steppacher SD, Siebenrock KA. What are the radiographic reference values for acetabular under- and overcoverage? Clin Orthop Relat Res. 2015;473(4):1234–46.
Curtis DM, Murray IR, Money AJ, Pullen WM, Safran MR. Hip microinstability: understanding a newly defined hip pathology in young athletes. Arthrosc J Arthrosc Relat Surg. 2022;38(2):211–3.
Walters BL, Cooper JH, Rodriguez JA. New findings in hip capsular anatomy: dimensions of capsular thickness and pericapsular contributions. Arthrosc J Arthrosc Relat Surg. 2014;30(10):1235–45.
Domb BG, Philippon MJ, Giordano BD. Arthroscopic capsulotomy, capsular repair, and capsular plication of the hip: relation to atraumatic instability. Arthrosc J Arthrosc Relat Surg. 2013;29(1):162–73.
Johannsen AM, Ejnisman L, Behn AW, Shibata K, Thio T, Safran MR. Contributions of the capsule and labrum to hip mechanics in the context of hip microinstability. Orthop J Sports Med. 2019;7(12):232596711989084.
Sandell LJ, Takebe K, Hashimoto S, Gill CS. Articular cartilage and labrum: composition, function, and disease. Adult Hip Hip Preserv Surg. 2014;10:31–41.
Crawford MJ, Dy CJ, Alexander JW, Thompson M, Schroder SJ, Vega CE, et al. The biomechanics of the hip labrum and the stability of the hip. Clin Orthop Relat Res. 2007;465:16–22.
Babst D, Steppacher SD, Ganz R, Siebenrock KA, Tannast M. The iliocapsularis muscle: an important stabilizer in the dysplastic hip. Clin Orthop Relat Res. 2011;469(6):1728–34.
Harris JD, McCormick FM, Abrams GD, Gupta AK, Ellis TJ, Bach BR, et al. Complications and reoperations during and after hip arthroscopy: a systematic review of 92 studies and more than 6,000 patients. Arthrosc J Arthrosc Relat Surg. 2013;29(3):589–95.
Curtis DM, Pullen WM, Hopkins JN, Murray IR, Money A, Segovia NA, et al. Can hip passive range of motion predict hip microinstability? A comparative study. Orthop J Sports Med. 2023;11(6):232596712311699.
Cibulka MT, Bloom NJ, Enseki KR, Macdonald CW, Judith Woehrle D, Mcdonough CM, et al. Clinical practice guidelines hip pain and mobility deficits-hip osteoarthritis: revision 2017 summary of recommendations. J Orthop Sports Phys Ther. 2017;47(6):1–37.
Holla JFM, Steultjens MPM, van der Leeden M, Roorda LD, Bierma-Zeinstra SMA, den Broeder AA, et al. Determinants of range of joint motion in patients with early symptomatic osteoarthritis of the hip and/or knee: an exploratory study in the CHECK cohort. Osteoarthr Cartil. 2011;19(4):411–9.
Teichtahl AJ, Wang Y, Smith S, Wluka AE, Giles GG, Bennell KL, et al. Structural changes of hip osteoarthritis using magnetic resonance imaging. Arthritis Res Ther. 2014;16(5):466.
Jiang L, Rong J, Wang Y, Hu F, Bao C, Li X, et al. The relationship between body mass index and hip osteoarthritis: a systematic review and meta-analysis. Jt Bone Spine. 2011;78(2):150–5.
Cleveland RJ, Schwartz TA, Prizer LP, Randolph R, Schoster B, Renner JB, et al. Associations of educational attainment, occupation, and community poverty with hip osteoarthritis. Arthritis Care Res (Hoboken). 2013;65(6):954–61.
Hawker GA, Davis AM, French MR, Cibere J, Jordan JM, March L, et al. Development and preliminary psychometric testing of a new OA pain measure—an OARSI/OMERACT initiative. Osteoarthr Cartil. 2008;16(4):409–14.
Hardcastle SA, Dieppe P, Gregson CL, Arden NK, Spector TD, Hart DJ, et al. Osteophytes, enthesophytes, and high bone mass: a bone-forming triad with potential relevance in osteoarthritis. Arthr Rheumatol. 2014;66(9):2429–39.
Kim C, Nevitt MC, Niu J, Clancy MM, Lane NE, Link TM, et al. Association of hip pain with radiographic evidence of hip osteoarthritis: diagnostic test study. BMJ. 2015;2: h5983.
Sutlive TG, Lopez HP, Schnitker DE, Yawn SE, Halle RJ, Mansfield LT, et al. Development of a clinical prediction rule for diagnosing hip osteoarthritis in individuals with unilateral hip pain. J Orthop Sports Phys Ther. 2008;38(9):542–50.
Sato T, Sato N, Masui K, Hirano Y. Immediate effects of manual traction on radiographically determined joint space width in the hip joint. J Manip Physiol Ther. 2014;37(8):580–5.
Hoeksma HL, Dekker J, Ronday HK, Heering A, Van Der Lubbe N, Vel C, et al. Comparison of manual therapy and exercise therapy in osteoarthritis of the hip: a randomized clinical trial. Arthritis Care Res (Hoboken). 2004;51(5):722–9.
MacDonald CW, Whitman JM, Cleland JA, Smith M, Hoeksma HL. Clinical outcomes following manual physical therapy and exercise for hip osteoarthritis: a case series. J Orthop Sports Phys Ther. 2006;36(8):588–99.
Mosler AB, Blanch PD, Hiskins BC. The effect of manual therapy on hip joint range of motion, pain and eggbeater kick performance in water polo players. Phys Ther Sport. 2006;7(3):128–36.
Metgud SC, D’Silva PV, Kamat PS. Immediate effect of MWM adductor stretch, myofascial release, and conventional stretching in asymptomatic individuals with hip adductor tightness: a randomized controlled trial. J Bodyw Mov Ther. 2022;1(32):213–7.
Zemadanis K, Betsos T, Mandalidis D. The short and long-term effect of weight-bearing mobilization-with-movement (MWM) and automobilization—MWM techniques on pain and functional status in patients with hip osteoarthritis. Int J Physiother. 2017;4(3):160–7.
Beselga C, Neto F, Alburquerque-Sendín F, Hall T, Oliveira-Campelo N. Immediate effects of hip mobilization with movement in patients with hip osteoarthritis: a randomised controlled trial. Man Ther. 2016;22:80–5.
Reiman MP, Matheson JW. Restricted hip mobility: clinical suggestions for self-mobilization and muscle re-education. Int J Sports Phys Ther. 2013;8(5):729–40.
Böhm H, Hösl M, Döderlein L. Predictors for anterior pelvic tilt following surgical correction of flexed knee gait including patellar tendon shortening in children with cerebral palsy. Gait Posture. 2017;54:8–14.
Van Goeverden W, Langhout RFH, Barendrecht M, Tak IJR. Active pelvic tilt is reduced in athletes with groin injury; a case-controlled study. Phys Ther Sport. 2019;36:14–21.
Preece SJ, Willan P, Nester CJ, Graham-Smith P, Herrington L, Bowker P. Variation in pelvic morphology may prevent the identification of anterior pelvic tilt. J Man Manip Ther. 2008;16(2):113–7.
Foster SN, Harris MD, Hastings MK, Mueller MJ, Salsich GB, Harris-Hayes M. Static ankle dorsiflexion and hip and pelvis kinematics during forward step-down in patients with hip-related groin pain. J Sport Rehabil. 2020;30(4):638–45.
Brown-Taylor L, Schroeder B, Lewis CL, Perry J, Hewett TE, Ryan J, et al. Sex-specific sagittal and frontal plane gait mechanics in persons post-hip arthroscopy for femoroacetabular impingement syndrome. J Orthop Res. 2020;38(11):2443–53.
Lewis CL, Loverro KL, Khuu A. Kinematic differences during single-leg step-down between individuals with femoroacetabular impingement syndrome and individuals without hip pain. J Orthop Sports Phys Ther. 2018;48(4):270–9.
Bagwell JJ, Powers CM. Persons with femoroacetabular impingement syndrome exhibit altered pelvifemoral coordination during weightbearing and non-weightbearing tasks. Clin Biomech (Bristol, Avon). 2019;65:51–6.
Catelli DS, Kowalski E, Beaulé PE, Smit K, Lamontagne M. Asymptomatic participants with a femoroacetabular deformity demonstrate stronger hip extensors and greater pelvis mobility during the deep squat task. Orthop J Sports Med. 2018. https://doi.org/10.1177/2325967118782484.
King E, Franklyn-Miller A, Richter C, O’Reilly E, Doolan M, Moran K, et al. Clinical and biomechanical outcomes of rehabilitation targeting intersegmental control in athletic groin pain: prospective cohort of 205 patients. Br J Sports Med. 2018;52(16):1054–62.
Mendiguchia J, Gonzalez De la Flor A, Mendez-Villanueva A, Morin JB, Edouard P, Garrues MA. Training-induced changes in anterior pelvic tilt: potential implications for hamstring strain injuries management. J Sports Sci. 2020;39(7):1–8.
Wright AA, Tarara DT, Gisselman AS, Dischiavi SL. Do currently prescribed exercises reflect contributing pathomechanics associated with femoroacetabular impingement syndrome? A scoping review. Phys Ther Sport. 2021;47:127–33.
Falk Brekke A, Overgaard S, Mussmann B, Poulsen E, Holsgaard-Larsen A. Exercise in patients with acetabular retroversion and excessive anterior pelvic tilt: a feasibility and intervention study. Musculoskelet Sci Pract. 2022;61:102613.
Dwyer T, Whelan D, Shah PS, Ajrawat P, Hoit G, Chahal J. Operative versus nonoperative treatment of femoroacetabular impingement syndrome: a meta-analysis of short-term outcomes. Arthroscopy. 2020;36(1):263–73.
Anzillotti G, Iacomella A, Grancagnolo M, Bertolino EM, Marcacci M, Sconza C, et al. Conservative vs. surgical management for femoro-acetabular impingement: a systematic review of clinical evidence. J Clin Med. 2022;11(19):5852.
Efficacy of rehabilitation programs for improving muscle strength in people with hip or knee osteoarthritis: a systematic review with meta-analysis. [cited 2023 Oct 10]. https://pubmed.ncbi.nlm.nih.gov/25065642/
Rostron ZPJ, Zacharias A, Semciw AI, Kingsley M, Pizzari T, Woodley SJ, et al. Effects of a targeted resistance intervention compared to a sham intervention on gluteal muscle hypertrophy, fatty infiltration and strength in people with hip osteoarthritis: analysis of secondary outcomes from a randomised clinical trial. BMC Musculoskelet Disord. 2022. https://doi.org/10.1186/s12891-022-05907-4.
Ejnisman L, Elisman K, Safran MR. Effectiveness of nonoperative management of hip microinstability. Am J Sports Med. 2022;50(4):1013–9.
McNeill W, Scott S. Treatment of hip microinstability and gluteal tendinopathies involves movement control and exercise. J Bodyw Mov Ther. 2016;20(3):588–94.
Kemp JL, Schache AG, Makdissi M, Pritchard MG, Sims K, Crossley KM. Is hip range of motion and strength impaired in people with hip chondrolabral pathology? J Musculoskelet Neuronal Interact. 2014;14(3):334–42.
Kierkegaard S, Mechlenburg I, Lund B, Søballe K, Dalgas U. Impaired hip muscle strength in patients with femoroacetabular impingement syndrome. J Sci Med Sport. 2017;20(12):1062–7.
Harris-Hayes M, Hillen TJ, Commean PK, Harris MD, Mueller MJ, Clohisy JC, et al. Hip kinematics during single-leg tasks in people with and without hip-related groin pain and the association among kinematics, hip muscle strength, and bony morphology. J Orthop Sports Phys Ther. 2020;50(5):243–51.
Harris-Hayes M, Mueller MJ, Sahrmann SA, Bloom NJ, Steger-May K, Clohisy JCJC, et al. Persons with chronic hip joint pain exhibit reduced hip muscle strength. J Orthop Sports Phys Ther. 2014;44(11):890–8.
Mayne E, Memarzadeh A, Raut P, Arora A, Khanduja V. Measuring hip muscle strength in patients with femoroacetabular impingement and other hip pathologies. Bone Jt Res. 2017;6(1):66–72.
Ward SR, Winters TM, Blemker SS. The architectural design of the gluteal muscle group: implications for movement and rehabilitation. J Orthop Sports Phys Ther. 2010;40(2):95–102.
Funding
No funding or sponsorship was received for this study or publication of this article. The rapid service fee was funded by the author.
Author information
Authors and Affiliations
Contributions
Ángel González de la Flor conceptualized and designed the manuscript.
Corresponding author
Ethics declarations
Conflict of Interest
Ángel González de la Flor has nothing to disclose.
Ethical Approval
This article is based on previously conducted studies and does not contain any new studies with human participants or animals performed by any of the authors.
Rights and permissions
Open Access This article is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, which permits any non-commercial use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc/4.0/.
About this article
Cite this article
González-de-la-Flor, Á. A New Clinical Examination Algorithm to Prescribe Conservative Treatment in People with Hip-Related Pain. Pain Ther 13, 457–479 (2024). https://doi.org/10.1007/s40122-024-00604-7
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s40122-024-00604-7