Clinical Examination and Physical Assessment of Hip Joint-Related Pain in Athletes

INVITED CLINICAL COMMENTARY CLINICAL EXAMINATION AND PHYSICAL ASSESSMENT OF HIP JOINT-RELATED PAIN IN ATHLETES

Michael P. Reiman, PT, DPT, SCS, OCS, ATC, FAAOMPT, CSCS,1,2 Kristian Thorborg, PT, M. Sportsphysio, PhD3,4 IJSPT

ABSTRACT Evidence-based clinical examination and assessment of the athlete with hip joint related pain is complex. It requires a systematic approach to properly differentially diagnose competing potential causes of athletic pain generation. An approach with an initial broad focus (and hence use of highly sensitive tests/measures) that then is followed by utilizing more specific tests/measures to pare down this imprecise differential diagnosis list is suggested. Physical assessment measures are then suggested to discern impairments, activity and participation restrictions for athletes with hip-join related pain, hence guiding the proper treatment approach. Keywords: Athlete; diagnostic accuracy; examination; hip joint Level of Evidence: 5

CORRESPONDING AUTHOR Michael P. Reiman, PT, DPT, OCS, SCS, ATC, 1 Duke University Medical Center, Department of Orthopedic FAAOMPT, CSCS Surgery, Durham, NC, USA Assistant Professor 2 Co-Director Orthopaedic Fellowship, Duke University Medical Duke University School of Medicine Center, Durham, NC, USA 3 Senior Researcher, Arthroscopic Centre Amager, Sports Department of Community and Family Orthopedic Research Centre - Copenhagen (SORC-C), Medicine Copenhagen University Hospital, Denmark. 4 Physical Medicine & Rehabilitation Research - Copenhagen Doctor of Physical Therapy Division (PMR-C), and Departments of Orthopaedic Surgery and DUMC 104002 Physical Therapy, Copenhagen University Hospital, Denmark Durham, NC 27710 No ﬁ nancial disclosures, IRB approval or acknowledgements to Phone: (919) 668-3014 ; Fax: (919) 684-1846 declare E-mail: [email protected]

The International Journal of Sports Physical Therapy | Volume 9, Number 6 | November 2014 | Page 737 INTRODUCTION generated from other anatomical areas such as the The prevalence of hip pain in the general popula- pelvis and spine also needs to be considered when tion is 10%, and increases with age.1 Pain in the hip examining the athlete with hip problems. Examin- and groin region in athletes is usually characterised ing athletes with hip and groin pain is therefore by longstanding symptoms that often do not resolve complex. Consequently, the purpose of this clini- within 6-12 months.2,3 Hip and groin pain has been cal commentary is to introduce an evidence-based reported to commonly occur in athletes who partici- examination and physical assessment approach for pate in soccer and ice hockey, and approximately athletes with hip joint-related pathology. 10-20% of all injuries in these sports are hip and/or A succinct, systematic approach to clinical exami- groin injuries.4-6 Pelvis, groin, hip and thigh injuries nation is always warranted. This is particularly the in sport include multiple, complex and longstanding case for intra-articular pathology of the hip, which, conditions, causing great frustration among athletes unfortunately continues to suffer from the lack of and sports practitioners. Pain in these regions may high quality evidence support of various examina- originate from many anatomical structures such as tion and testing measures. The approach suggested muscle, tendon, ligament, cartilage or bone. Mus- within this commentary is one of ruling out more culotendinous groin and hamstring injuries are the medically serious pathology initially, by utilization most frequent injuries, and are especially prevalent of highly sensitive tests early in the examination, problems among different forms of football.7-9 More- and narrowing down the differential diagnoses to over, the recurrence rates of these injuries are very improve the likelihood of a particular diagnosis (Fig- high, and a major problem during the rehabilitation ure 1). The athlete’s history, observations of their and return-to-sport phase.8 movements, clinical examination and diagnostic Intra-articular hip injuries are frequent sources of imaging (components of a systematic examination) hip and groin pain in athletes that are not related each have the ability to affect the identification of to the musculotendinous structures around the hip the existence of a particular diagnosis. Diagnostic and groin. In elite soccer athletes, intra-articular hip accuracy values for special tests, diagnostic imaging, injuries account for up to 10% of all hip and groin and occasionally subjective reports include sensitiv- injuries.9 Intra-articular hip injuries include femo- ity (SN), specificity (SP), positive likelihood ratio roacetabular impingement (FAI), acetabular labral (+LR), and negative likelihood ratio (-LR). Tests with tear (ALT), chondral injuries and synovitis. Intra- articular injuries of the hip joint have in recent years been recognised as an important differential diagnose in athletes with hip and groin pain. This is reflected in the 2012 injury-report from the Austra- lian Football League (AFL), where the incidence of hip related injuries seem to have increased during the last ten years, whereas groin injuries seem to have decreased, which may reflect a better under- standing or focus on the contribution of intra-articular hip injury to groin pain in athletes.8 In clinical situations with signs of synovitis with no sign of any intra-articular injury this may reflect hip joint over- use and will often tend to resolve fairly quickly. In situations where specific intra-articular injuries with damage to the labrum/cartilage are present, operative procedures may be necessary, as conservative treatment may not resolve the athlete’s pain and/ Figure 1. Examination Sequence (Funnel Approach) for Hip- or disability. Furthermore, more serious and severe Joint Related Examination with Progression to Determination injury such as high and low energy fractures or pain of Treatment Approach

The International Journal of Sports Physical Therapy | Volume 9, Number 6 | November 2014 | Page 738 high SN will be positive for most people who actually have the problem and, therefore, have a low rate of false negatives (the test finding was negative, but the pathology is actually present). When it is important to “not miss” a positive case (such as in a fracture), utilization of tests with high SN is necessary. This is crucial for screening tests in which positive findings simply indicate the need for more investigation. Therefore, the most meaningful finding with a highly sensitive test is a negative finding, since it assists the clinician to rule out a disorder with confidence. A suggested useful acronym is SnNout, Figure 2. ICF model of disability. Adapted from WHO, 2002.12 meaning a test with high Sn when Negative is used 10,11 to help rule out the condition. The potential for according to the ICF model.12 Environmental fac- false positives (the test is positive, but the pathology tors that interact with all these components are also is not actually present) exists with highly SN tests. included. Body functions are physiological functions Therefore, these tests, by their nature, are designed of body systems (including psychological functions) to capture several potential competing diagnoses, and body structures are anatomical parts of the body many of which may be not present (false positive). (e.g. organs, limbs and their components). Activities Again, the purpose of these tests is to not miss a are the execution of a particular task or action by an positive case. These tests are therefore utilized early individual, such as running or kicking, while partici- in the examination process to screen for the poten- pation is the involvement in a “real life” situation, tial of more serious pathology and/or rule out other such as participating in a game of football. Therefore potential pain generators. Tests with high SP will be activity limitations are difficulties an individual may appropriately negative in clients who do not have have in executing particular activities, while partici- the disorder and therefore have a low rate of false pation restrictions are problems an individual may positives. Tests with high SP are best to rule in a dis- experience in involvement in “real life” situations. order, and should be performed later in the examina- Environmental factors make up the physical and tion to “rule in” the most likely diagnosis/diagnoses social environment in which people live and con- from the differential diagnosis list generated by the duct their lives. Personal factors are also included in sensitive tests. The acronym SpPin is often used for the model but are not classified (Figure 2).12 these tests. A highly Sp test when Positive is used to 10,11 help rule in the condition. CLINICAL EXAMINATION OF THE HIP It is important to begin the hip examination process As the clinician systematically reasons through as comprehensively as possible (including all poten- the broad to narrow focused clinical examination tial diagnoses) and (as a result of each systematic sequence (funnel approach) they should be able step in the examination process) narrow the differ- to reasonably determine a primary diagnosis and/ ential diagnosis list down as far as possible. Addi- or important differential diagnostic considerations tionally, this broad to narrow approach of the hip including additional investigations that may be examination is an approach of general to more iso- pertinent to proceed to, most notably assessment lated examination procedures. For example, in the of specific impairments, activity limitations, and client interview the clinician asks broad, open-ended participation restrictions in order to optimize a questions that are likely to include multiple poten- structured and individualized rehabilitation for the tial diagnoses. As the examination continues, the individual athlete. Assessment of outcome and func- examination process becomes more focused. This tional ability can be related to body functions and is particularly the case after the triage/screening/ structure (impairments), activities (activity limita- sensitive tests section that is intended to rule out not tions) and participation (participation restrictions) only the potential for red flag/non-musculoskeletal

The International Journal of Sports Physical Therapy | Volume 9, Number 6 | November 2014 | Page 739 disease processes, but to also rule out potential pain seven times more likely to have hip disorder only or generators in other joints, as well as other potential hip and spine disorder versus spine disorder only.19 diagnoses common to the pain generating joint(s). Limited IR in an athlete was 14 times more likely to Determination of necessity of referral to a physician suggest a hip disorder only or hip and spine disorder is also required at this stage of the examination. versus spine disorder only.19

If screening is conclusively negative the clinician Groin pain is a common location for multiple hip then determines that it is appropriate to continue pathologies (as well as lumbar spine and pelvic gir- with the rest of the examination process. If screening dle pathologies). Groin and thigh pain was found in is not conclusively negative, the clinician is required 55% and 57% of athletes with hip joint pain, respec- to make a clinically sound judgment on the appro- tively.20 Pain referral was also seen in the buttock and priateness of referral out to the appropriate medi- lower extremity distal to the knee in 71% and 22% cal personnel immediately or whether an attempt at respectively,20 indicating the possibility of combined appropriate intervention will assist in determining lumbar spine and hip pathology. The most common the athlete’s medical status. locations of pain for athletes with ALT were the cen- tral groin and lateral peritrochanteric area.21 The lack Patient Interview - Subjective History of groin pain presentation helps rule out the poten- The subjective history has been suggested to be tial for ALT/FAI with a SN ranging from 96-100%.22,23 instrumental in determining 56-90% of diagnoses in Complaints of clicking, catching, snapping, etc. various types of patients.13-16 Physical examination should cue the clinician to include ALT, intra-artic- components, on the other hand, only contributed to ular pathology, and snapping hip in the differential less than 30% of the diagnoses in the same studies.13-16 diagnosis.24-27 Sharp pain with mechanical symptoms In fact, it has been suggested that subjective history, has a reported SN of 100%, and SP of 85% for ALT/ physical examination, and radiographic examination intra-articular pathology.25,28 Carefully delineating each have their own limitations at each stage and an the source (and relevance) of such symptoms is integrative approach is needed in making a medical imperative in determining a proper diagnosis in the diagnosis with more emphasis on subjective history.17 athlete. For example, 91% of ballet dancers reported Age of the athlete will assist in differential diagno- snapping hip, 60% of them could volitionally pro- sis of hip pain. Pediatric and adolescent pathologies, duce this snapping, yet only 7% were not able to such as Legg-Calve-Perthes (typical age of onset is 3 continue dancing due to the snapping.29 to 12 years old) and Slipped Capital Femoral Epiphy- sis (average age of 12.1 years for girls and 14.4 years Observation for boys) will significantly differ in athlete age com- Observation of the athlete presenting with hip pain pared to acetabular labral tear (ALT) (adolescents should include general postural assessment (both stat- to older adults) and hip osteoarthritis/osteoporotic ically and dynamically), gait, transfers, and potential femoral neck fractures (older athletes). limitations in strength and mobility with daily tasks from both the anterior-posterior view as well as later- Differential diagnosis with regard to the lumbar ally. Asymmetrical landmarks can alert the clinician spine, pelvis and hip is often difficult due to the to some potential structural dysfunctions that may be inter-dependent relationship between these three contributing to the athlete’s hip pain. It is important 18 regions. A few variables have been shown to dem- to recognize that the presence of postural abnormal- onstrate a strong predilection to hip injury. The ity does not necessarily correlate with dysfunction. presence of a limp, groin pain, or limited internal rotation (IR) of the hip significantly predicted diag- The athlete with joint changes may have complaints nosis of a disorder originating primarily from hip with some combination of hip joint positions involv- opposed to from the spine.19 Athletes with limp were ing flexion, adduction, and/or internal rotation.25 seven times more likely to have a hip disorder than Pain with these motions is often described as deep spine disorder, while those with groin pain were in the groin region and indicative of potential intra-

The International Journal of Sports Physical Therapy | Volume 9, Number 6 | November 2014 | Page 740 articular involvement.30 Pain posturing on part of the to a physician is a question that should be answered athlete may be seen when sitting in chairs (especially early in the examination. Presence of potential seri- lower level chairs), stepping up with the involved leg, ous pathology requires referral to the most appro- squatting, and so forth as these motions will replicate priate medical professional. The clinician must be the combinations of these movements in the hip. aware of disorders affecting the abdominal and pelvic organs that can also refer pain to the hip region, Range-of-motion (ROM) of the hip can also be observed mimicking a musculoskeletal dysfunction. Previous without formal assessment. In the supine position, the history of cancer, such as prostate cancer in men or clinician can generally assess for anterior capsular laxity. any reproductive cancer or breast cancer in a woman If an athlete lying supine with relaxed legs demonstrates is a red flag since these cancers may be associated enough external rotation to have the lateral border of with metastases to the hip joint.40 Multiple sources the foot touch the table, he/she likely has laxity of the of pain and pathology were discovered in a study anterior capsule31 or hip retroversion. Alternatively, the examining females with groin pain, further suggest- athlete presenting with very little to no external rotation ing the need for a detailed screen as part of the clini- in this position should heighten the clinician’s concern cal examination.41 Other red flags of concern with for limited anterior capsular mobility or anteversion. respect to the patient presenting with hip and/or Limitations in hip ROM can also be assessed with groin pain include a history of trauma, fever, unex- daily activities. Gait on level surfaces requires only plained weight loss, burning with urination, night 30 to 440 of hip flexion, while ascending and descend- pain, and prolonged corticosteroid use.42-44 ing stairs requires 45 to 660 of hip flexion.32,33 Sitting Special testing for potential red flags from non- in a chair of an average seat height requires 1120 of musculoskeletal and musculoskeletal related causes hip flexion. Putting on socks requires 1200 flexion, (fracture/stress fracture) of the hip should utilize 200 abduction and 200 of external rotation.34 Athletes detailed subjective and objective findings. Testing to with FAI were not able to squat as deeply as those rule out (highly SN tests) non-musculoskeletal, seri- without FAI when measured using motion analy- ous hip pathology are suggested at this stage in the sis.35 Difficulty performing such daily tasks can alert examination. Figure 3 is the suggested sequence of the clinician as to which particular motions to more examination in the triage/screening section of the closely examine during the motion assessment. examination. Table 1 describes the suggested testing Several hip muscles are active during gait, especially for femoral fracture/stress fractures. The patellar- the gluteal muscles. Dysfunction of these muscles pubic percussion test alters post-test probability of a (primarily the gluteus medius and minimus) is femoral neck fracture not existing to an almost con- depicted in an excessive drop of the contralateral (or clusive degree in pooled analysis,45 while the fulcrum non-weight-bearing “swinging”) side of the pelvis, or test alters post-test probability of a femoral stress Trendelenburg gait pattern.36 Athletes with hip osteo- fracture not existing from a very small46 to almost arthritis37 and slipped capital femoral epiphysis,38 conclusive47 degree10 in two studies of lower quality. have demonstrated this type of gait dysfunction. Ath- etes with hip dysfunction involving the strength defi- Screen for Lumbar Spine and Pelvic Girdle cits of the gluteus maximus are likely to present with Pathology functional deficits during stair climbing, step-ups, and Once red flags are ruled out, an efficient way to begin sit to stand maneuvers since these muscles generate to differentiate the many potential pain referral torque in order to propel the upper body of a person sources is through the lower quarter screening exam- upward and forward from a position of hip flexion.36,39 ination. The traditional lower quarter screen consists of testing of dermatomes, myotomes, deep tendon Triage/Screening reflexes, and possible upper motor involvement. Ruling out Serious Pathology - Red Flags The clinician should also differentially diagnose Determining appropriateness for continuation of the potential contribution of the pelvic girdle and the examination with or without potential referral lumbar spine as the primary pain generator for the

The International Journal of Sports Physical Therapy | Volume 9, Number 6 | November 2014 | Page 741 while straight leg raise only to a small degree assists with ruling out the existence of discogenic/radiculopathy pathology10 in two pooled analyses.50,51 Facet joint pathology is almost conclusively ruled out10 with the seated extension-rotation test according to two studies49,53 of low bias.54

Intra-Articular Hip Pathology Special Tests of High Sensitivity Once serious pathology and the lumbar spine/pelvic girdle have been ruled out, the clinician should utilize highly SN hip tests to rule out competing diagnoses, as well as pare down the differential diagnosis of hip pathology (Table 3). The suggested tests/screening examination should focus on the potential presence of intra-articular pathology. The flexion-adduction-internal rotation (FADDIR) test is suggested for the potential determination of intra- articular pathology not existing (screening ability) as it has strong SN and -LR with poor SP and +LR, thereby serving appropriately as a screening test and not a diagnostic test with the ability to alter post-test probability of ruling out intra-articular pathology to a moderate degree. The diagnostic ability of this test though only alters post-test probability of the potential presence of an intra-articular pathology diagnosis to a very small degree or worse.10

Figure 3. Algorithm for Hip Pathology Screening in the Ath- Diagnostic Imaging (potentially for both ruling letic Hip. SN=sensitivity, -LR=negative likelihood ratio, out and/or in) FADDIR=ﬂ exion-adduction-internal rotation test Diagnostic imaging can also be a worthwhile tool to assist the clinician with both potentially ruling athlete’s hip pain. Screening (highly SN) tests for in and ruling out possible intra-articular pathology. these areas are employed to limit the extent of the Radiographic examination of the hip joint, like other differential diagnosis for pathology contributing to regions of the body, is dependent on the type of the athlete’s hip pain (Table 2). Repeated motions pathology. Not unlike other portions of the exami- almost conclusively alters post-test probability,10 nation of the hip joint, the value of diagnostic imag-

Table 1. Screening for Serious Pathology Related to the Hip Joint.

Special Test Performance Positive Result

Fracture/Stress Fracture of the Hip Patellar pubic The athlete is supine with bilateral legs relaxed. Clinician places stethoscope over A diminished percussion test pubic tubercle on ipsilateral side of lower extremity being tested. Clinician listens percussion noted on through stethoscope as they tap the ipsilateral patella. Tapping and placing a the side of pain. tuning fork over the patella can also be used in place of tapping the patella directly.

Stress The athlete is sitting on edge of table with bilateral feet off edge. Clinician places Reproduction of fracture/fulcrum one forearm under athlete’s thigh to be tested and other hand applies downward athlete’s concordant test pressure to the proximal knee. pain.

The International Journal of Sports Physical Therapy | Volume 9, Number 6 | November 2014 | Page 742 Table 2. Special Tests for Ruling out Lumbar Spine and Pelvic Girdle Contributions to Hip Pain. Special Performance Positive Result Test

Lumbar Spine Radiculopathy Repeated The athlete is standing (loaded spine) or prone/supine Repeated motion in one direction causes pain to Motion (unloaded spine). Athlete is asked to perform repeated centralize (move to the center of the spine) and flexion and extension motions of the lumbar spine. May also repeated motion in another direction causes pain require repeated side-bending. to peripheralize (move further down the involved leg). Straight Leg The athlete is supine with legs relaxed. Clinician passively Reproduction of athlete’s concordant pain that is Raise Test flexes, slightly adducts and internally rotates leg to be relieved by decreasing hip flexion, but then assessed while maintaining knee in extension. increased by passive head/neck flexion

Lumbar Spine Facet Joint Dysfunction Seated The athlete is seated as clinician stabilizes their sacrum as Reproduction of athlete’s concordant pain either Extension- athlete moves into end-range lumbar spine extension and with active motion or passive overpressure. Rotation rotation. If no pain, clinician can provide overpressure into further extension and rotation motion.

SI Joint Dysfunction

Thigh Thrust The clinician places their caudal hand under the sacrum of Reproduction of athlete’s concordant pain either Test the supine athlete and flexes the side to be assessed to 900 with longitudinal overpressure load or thrust(s). hip flexion. The clinician provides longitudinal load force through the femur for up to 30 seconds; if no pain 3-5 thrusts can be implemented.

Table 3. Sensitive Tests of the Hip Joint for Intra-Articular Involvement. Special Performance Positive Result Test

FADDIR Clinician passively moves the supine athlete’s leg to approximately 900 of hip and knee Reproduction of athlete’s Test flexion. The leg is then passively adducted and internally rotated with overpressure to concordant groin pain. both motions.

ing should be cautioned for some diagnosis, such as those athletes in whom femoral neck fractures developmental hip dysplasia and FAI.55 Several stud- are suspected but standard radiographic findings ies have found hip pathological changes in asymp- are negative. tomatic individuals.56-59 Therefore, diagnosis made • Neck-shaft angle: An abnormal head neck offset (or solely on diagnostic imaging interpretation is not pistol grip deformity) can be seen on these views. advisable in clinical practice. • Alpha angle: a parameter typically measured with Radiographs an AP or Dunn view (Figure 4) used to quantify Anterior-posterior (AP) and lateral (axial “frog leg”) the degree of femoral deformity and reflects the views are the standard views utilized in plain film insufficient anterolateral head-neck offset and radiographs. As with all extremity joints comparison femoral head asphericity.60 Alpha angles greater between sides is necessary. Assessment of particu- than 55-600 have been suggested to be associated lar aspects on the AP view includes: with symptomatic impingement,60,61 although recent findings have suggested much higher • Hip dislocations and most fractures are often values to discriminate between subjects with seen on AP and lateral views. pathology and controls.62 A larger than normal • An AP view with the hip internally rotated pro- alpha angle is associated with CAM morphology vides a necessary view of the femoral neck in (not necessarily symptomatic CAM pathology).

The International Journal of Sports Physical Therapy | Volume 9, Number 6 | November 2014 | Page 743 Table 4. Description of Suggested Special Tests for Hip Joint Ligamentous Laxity. Special Performance Positive Result Interpretation Test

Dial Athlete supine with the hip in a neutral flexion/extension A negative Dial test constitutes No reliability or Test and abduction/adduction position, the clinician grasps ER of the lower limb less than diagnostic validity has the client’s leg at the femur and tibia and passively rolls 45°, as measured vertically, with been reported for this test it into full IR. The LE is released and allowed to ER. a firm endpoint.

Log Roll Athlete supine with hip in a neutral flexion/extension and A click reproduced during the Inter-rater reliability: Test abduction/adduction position, the leg is passively rolled test is suggestive of labral tear, ICC = 0.63;92 ĸ = into full IR and ER. while increased ER ROM may 0.6193 indicate iliofemoral ligament Good reliability; No laxity. diagnostic validity has been reported for this

Figure 5. Crossover sign

Figure 4. Dunn lateral radiograph demonstrating α angle.

• Cross-Over Sign: a cross-over sign on the AP view is where a portion of the anterior wall of the acetabulum (dashed white line on Figure 5) projects further laterally, or “crosses over” the posterior wall (solid black line on Figure 5). This sign is associated with pincer morphology of the hip. • Femoral head and acetabulum orientation: assessment for acetabular dysplasia, acetabular protrusio (acetabular overcoverage). Coxa profunda is the medialization of the medial wall of the acetabulum (red arrow in Figure 6) past the ilioischial line (black arrow in figure 6) while acetabular protrusio is when the medial most femoral head overlaps the ilioischial line.63

• Nec k-shaft angle: assessment for coxa vara or Figure 6. Anteroposterior pelvic radiograph demonstrating coxa valga. coxa profunda.

The International Journal of Sports Physical Therapy | Volume 9, Number 6 | November 2014 | Page 744 • Joint space width and osteophytes for assess- the prospect of multidimensional imaging. How- ment of osteoarthritis. ever, opinions differ on the diagnostic efficacy of MRI/MRA and on the question of which MRI/MRA • Bone disease such as bony cysts (suggestive of technique is most appropriate.71 OA), tumors, Legg-Calve-Perthes disease. Diagnostic accuracy pooled analysis for FAI assess- Lateral view radiograph: this view is performed with ment with MRI revealed SN of 66% and SP of 79% the athlete’s hip flexed, abducted, and externally while MRA pooled analysis was 91% SN and 80% rotated while they are lying supine. This view allows SP.69 Pooled analysis for detection of articular car- for the capability to view for any possible pelvic tilage lesions in the hip was SN 59% and SP 94%.72 obliquity or slipped capital femoral epiphysis. Chil- The most recent diagnostic accuracy values for MRI dren with suggestive groin symptoms should have for gluteal tendon tear range from 33-100% SN and hip AP and frog-leg lateral radiographs to rule out 92-100% SP.70 Also, similar to radiographs, MRI/ 64 slipped capital femoral epiphysis. MRA, have shown some limitations in inter-rater 73 Measures of joint space, the maximum thickness reliability. of subchondral sclerosis, and the size of the larg- est osteophyte have been utilized to diagnose hip Computed Tomography (CT) OA with radiographs. Minimal joint space (i.e., the These scans are traditionally utilized for acetabular shortest distance between the femoral head margin wall and femoral head fractures, as well as the more and the acetabulum) was the index most strongly subtle hip dislocations. The assessment of osseous associated with other radiologic features of OA.64 abnormalities, such as shape and size of the femoral head (as in a bony exostosis for cam impingement) The diagnostic accuracy of radiography is much bet- and acetabulum, anteversion and retroversion mea- ter for fractures, especially of the proximal femur surements are important uses of CT scan. (SN 90-95%/SP 68-100%)65 than for other pathologies of the hip, particularly FAI. Furthermore, radiogra- Computed tomography generally shows stronger phy of the hip has shown limited reliability,55,66,67 diagnostic accuracy for FAI and ALT (SN 92-97%, 74,75 meaning that disagreement between even experi- SP 87-100%) than detection of articular cartilage 74 enced raters is not unusual. lesions (SN 88%, SP 82%). As with radiographs and MRI/MRA,56,76 findings of abnormalities in asymp- 57 Magnetic Resonance Imaging (MRI) tomatic individuals require caution in diagnostic Both soft tissue (e.g. tendon, labral, and bursal interpretation of CT findings in the hip joint. Addi- lesions) and osseous tissue (e.g. stress fractures and tional radiation exposure is also a concern of CT. osteonecrosis) can reliably be assessed with MRI. Since MRI is more SN to bone marrow edema, it is Diagnostic Ultrasonography (US) often used to assess subtle occult fractures and diag- An advantage of US is that it does not involve radia- nosis such as sports related groin pain, pubic bone tion. It is typically used for the assessment of muscle 70 marrow edema and/or bone stress injuries of the and tendon pathology in the hip, although it has pubis bone.68 Combining arthrography [magnetic also been suggested for its diagnostic utility of vari- resonance arthrography (MRA)] has recently been ous other soft-tissue hip and lower extremity pathol- 77 shown to be both more SN and SP for the diagnosis ogies. Ultrasonography has even been suggested for of hip pathological lesions such as ALTs than MRI,69 the use of screening for developmental hip dyspla- 78 although less SN and SP for diagnosis such as gluteal sia, although a recent systematic review cautions tendinopathy.70 its use in this manner due to weak evidence support for this clinical utility of US.79 Generally, the clinical For imaging of intra-articular hip pathology, MRI/ value of US has not been widely investigated scientif- MRA represents the best technique because it ically in relation to hip and groin injuries in athletes, enables clinicians to directly visualize cartilage, it although many clinicians use this modality in their provides superior soft tissue contrast, and it offers examination.80,81

The International Journal of Sports Physical Therapy | Volume 9, Number 6 | November 2014 | Page 745 The diagnostic accuracy of US for ALT (SN 82%, SP tion of their performance and diagnostic accuracy 60%)82 is not equal to that of other utilized modalities are outlined in Table 4 & 5. such as MRI/MRA and CT. Additionally, although suggested for tendon assessment, limitations in diag- PHYSICAL ASSESSMENT OF THE HIP nostic accuracy (SN 61%, SP 100%) seem to exist.83 (IMPAIRMENTS, ACTIVITY LIMITATIONS & PARTICIPATION RESTRICTIONS) Bone Scan (Scintigraphy) As mentioned previously, the tests included in the Bone scans are typically utilized to help diagnosis physical examination are not specifically aimed for tumors, necrosis and stress fractures of the hip. This establishing the athlete’s diagnosis of intra-articular is particularly the case with proximal femoral (femo- hip pain, but are extremely valuable in guiding the ral neck and inter-trochanteric) fractures (SN 91%, establishment of the treatment plan. While there are SP 100%).84 some correlative findings of these impairments in particular intra-articular pathologies, their diagnos- Intra-articular Joint Injection tic value is often limited.95-97 Several authors have documented the diagnostic usefulness of an intra-articular hip injection in Motion tests (AROM, PROM, Accessory order to identify intra-articular hip abnormalities85,86 Motions, & Flexibility) although having stronger SN (85%) than SP (26%).87 Motion and strength testing of the hip joint cur- These injections are supported much more strongly rently suffers from inconclusive findings in those as a better determinant of those athletes less likely with impairments in many instances. As such, it has to do well with surgical correction of FAI.87 been recommended these findings should be inter- preted with caution.96 These findings again under- “Ruling In” Intra-Articular Pathology lie the importance of a comprehensive examination The use of SP clinical special tests, along with diag- when assessing the athlete for hip pain. The hip nostic imaging as outlined previously, is suggested joint motion assessment characteristics are listed in at this point in the examination to rule in the partic- Table 6. ular hip joint pathology. The clinician is cautioned regarding study findings suggesting limitations in the Patterns of lower extremity ROM deficits are often clinical applicability of many hip special tests.45,88-91 noticed in athletes with FAI and ALT. Most notably, Clinical special tests are a very small component of athletes tend to exhibit reduced hip motions of flexion, the overall orthopedic/sports examination. Reliance internal/external rotation, and/or abduction,28,98-101 of findings on special testing alone is unsatisfactory although abduction was the only significant restric- clinical practice. The recommended tests, description in a recent higher quality study.97

Table 5. Description of Suggested Special Tests for Intra-Articular Pathology. Special Performance Positive Result Interpretation Test

Ligamentum Clinician passively flexes hip fully, then extends Reproduction of SN 90%, -LR 0.11; SP 85%, +LR 6.594 Teres Tear 300, leaving the hip at about 700 flexion (knee is concordant pain with Both a (-) and (+) test alters post-test Test flexed 900). The hip is then abducted fully and either internal or probability of a ligamentum teres tear then adducted 300, typically leaving it at about external rotation. not existing/existing to a moderate 300 abduction. The leg is then passively degree in one high quality study. internally and externally rotated to available end-range. Thomas Test The athlete sits at the edge of the plinth. The Reproduction of SN 89%, -LR 0.12, SP 92%, +LR athlete is then instructed to lie back, pulling both athlete’s concordant 11.123 knees to his or her chest. pain with/without a A (-) test alters post-test probability of One knee (the asymptomatic side) is held to the click. ALT not existing to a moderate chest and the other is slowly lowered into degree, while a (+) test alters post- extension of the hip by the clinician. The knee is test probability of ALT existing to an allowed to extend. Internal and external rotation almost conclusive degree with one of the leg has also been suggested. high quality study.

The International Journal of Sports Physical Therapy | Volume 9, Number 6 | November 2014 | Page 746 Table 6. Hip Joint Motion Assessment Properties. Joint Closed Packed Resting Position Capsular Pattern ROM Norms End Feel Position Femoral- Full extension, 300 flexion, 300 abduction, Flexion, abduction, Flexion: 1400 with Firm for all acetabular abuction, internal slight external rotation internal rotation knee flexed motions rotation Extension: 200 Internal rotation: 450 External rotation: 450 Abduction: 400 Adduction: 250

Additionally, since the greatest strain on the labrum patients, but cannot quantify degrees of strength or occurs in the position of hip flexion and adduction,102 weakness. assessment of hip joint mobility is suggested. Hip anterior-posterior glide (motions of hip flexion and The squeeze test has recently been introduced which internal rotation) and lateral glide (hip adduction) quantifies adduction strength by using the cuff of a should be assessed.103,104 sphygmomanometer placed between the athlete’s knees with the instruction to squeeze the cuff as hard Functional limitations can be correlated with hip as they can using both legs. The highest pressure dis- ROM limitations. Hip flexion ROM was shown to played on the sphygmomanometer dial (to the nearest explain up to 95% of variance in the star excursion 5 mmHg) during the test is then recorded. Malliaris et balance test (SEBT) performance.105 al, showed that athletes with groin pain had reduced hip adduction pressure (force) in the squeeze test of Muscle testing approximately 20%, compared to healthy controls.107 Hip strength assessment plays an important role in However, when applying the squeeze test the meas- clinical examination of the hip and groin region, and ured pressure is produced by hip adduction of both clinical outcome measures quantifying hip muscle legs. By introducing a hand-held dynamometer, a strength are needed.106 Decreased muscle strength testing method that can be used for each leg individu- seems to be a consistent finding in athletes with ally, it would be possible to achieve a greater depic- hip and groin pathology.107,108 Manual muscle test- tion of the actual muscle strength in hip adduction in ing (MMT) is often used. The advantage of MMT is both the injured and uninjured limb; therefore, a uni- that no equipment is necessary. However, MMT has lateral and reliable quantitative strength assessment certain limitations when testing patients stronger method seems warranted for athletes with hip and than a grade 3 (able to raise body segment against groin pain.108 The hand-held dynamometer (HHD) gravity). In a classic study performed in 1956, Beas- is a quantitative strength measurement method that ley showed that muscle-strength deficits up to 50%, has been used since the 1940’s. It is a portable mea- assessed by quantitative measurement methods surement device that has been shown to be reliable in (dynamometer), could not be identified by MMT.109 assessing hip muscle strength.110

In athletes with longstanding groin pain, a subjective HHD using eccentric strength testing (break testing) manual assessment method during hip muscle test- has generally shown greater strength values than ing by Hölmich et al has also been proposed.106 This isometric testing (make testing),111,112 about the hip,108 method divides muscle strength into one of three but a high correlation exists between the two types levels; weak, intermediate and strong. Kappa val- of tests (contraction types).111,113 This means that the ues of the intra-observer reliability of this procedure make and break test presumably measure the same ranged from 0.58-0.72, and the kappa values of the construct (maximal voluntary strength), just under inter-observer reliability ranges from 0-0.22, indicat- different conditions. Both tests have clinical advan- ing that the procedure is observer-dependable.106 As tages and disadvantages that should be considered with the 0-5 assessment method, this kind of scale before use. An advantage of the make test is that may be able to distinguish between weak and strong isometric loading induces less stress to the muscu-

The International Journal of Sports Physical Therapy | Volume 9, Number 6 | November 2014 | Page 747 loskeletal system than eccentric loading, thus mini- for athletes with hip pathology. Athletes with FAI mising the risk of injury and delayed-onset muscle had decreased mean peak squat depth compared to soreness.114,115 In situations in clinical practice where controls, suggesting that maximal squat depth is a eccentric testing is not feasible due to the pathologi- potentially valid measure of assessment for FAI.35 cal state of the athlete, isometric testing should be The SEBT, a purported measure of balance, range-of- preferred. motion, and muscle performance,105,126,127 recruited the gluteus medius at 49% of maximal volitional Strength data obtained by HHD can be used clini- isometric contraction with a medial reach.128 The cally in different ways. One possibility is to use single-leg squat also demonstrated a relationship to normative values. However, normative values do hip abductor function.129 Dysfunction in any of these not often exist for different age groups and levels PPMs should alert the clinician to perform measures of physical activity, and is therefore not always an previously discussed (motion tests, muscle perfor- option.116 Another possibility is to use the unaffected mance tests, and so on). limb as a control. A lower limb symmetry index (LSI) can then be calculated by dividing the strength Normative and discriminatory values for involved of the affected limb by the unaffected limb. Gener- to non-involved lower extremities on various hop, ally, it has been suggested that leg strength deficits speed and agility tests have been reported.130 Most of of less than 10% on the injured side compared to these tests are reported for either normative values the uninjured side should be considered the clini- or on knee and ankle pathologies. The reliability of cal milestone before returning an athlete to sport these measures specifically for hip dysfunction has following an injury.117,118 However, Thorborg et al not been established. showed that eccentric hip adduction symmetry can- The “Sport Test” has been advocated by Wahoff et al not be assumed in injury-free soccer players.7,119 In to objectively assess an athlete’s readiness to return fact, the dominant side was 14% stronger than the to sport following hip arthroscopy.131 Rather than non-dominant side with regards to eccentric hip measuring isolated movements, it analyzes an indi- adduction strength, although hip abduction strength vidual’s coordinated movement patterns and power was similar.119 This finding of asymmetric eccentric of an involved extremity. The Sport Test includes hip adduction strength in injury-free soccer players, single knee bends, side-to-side lateral movement, between the dominant and non-dominant leg, indi- diagonal side-to-side movement, and forward box cates that using contralateral eccentric hip adduc- lunges. Athletes must score 17/20 or higher to pass tion strength as a reference-point for hip adductor each of the four components of the test.131 Although muscle recovery may be questionable.119 the application of this test on those with ALT has not Hip muscle performance deficits have been demon- been investigated, it seems plausible that this test strated in athletes with symptomatic FAI,120 as well as could function as an advanced assessment of sport- osteoarthritis.121 Athletes with symptomatic FAI have related ability for those athletes with ALT since it demonstrated hip muscle weakness and an impaired replicates most components of sporting activity. ability to produce maximal hip strength when com- However, it is worth noting, that there is a lack of pared to healthy controls.120 Additionally, gluteus diagnostic accuracy/prediction of the use of the medius and maximus muscle weakness37,121,122 and Sport Test in relation to return to sport. atrophy121,123,124 have been correlated with hip joint osteoarthritis. Patient-reported outcome measures (PROs) Investigation of the most traditional hip PROs for hip Physical performance measures arthroscopy athletes suggest that the Non-arthritic Physical performance measures (PPMs) of the hip Hip Score (NAHS), the Hip Outcome Score (HOS), joint are applicable to the lumbar spine/pelvis and and the modified Harris Hip Score (mHHS) are lower extremities. A recent systematic review125 commonly used for patients who have undergone supports the use of the single-leg stance, single-leg hip arthroscopy.132,133 The NAHS was the only PRO squat, and the Star Excursion Balance Test (SEBT) with content validity, while the HOS scored best on

The International Journal of Sports Physical Therapy | Volume 9, Number 6 | November 2014 | Page 748 agreement, internal consistency, and responsive- changes in hip and groin pain and functional status, ness, of these three PROs.132,133 with the ability to discriminate between athletes with and without previous injury.140 Furthermore, However, recently newer and more promising PROs substantial disability is more often reported when have been developed for patients with hip and groin using iHOT and HAGOS due to the sports specific problems. The 33-item International Hip Outcome and patients-relevant questions asked in these ques- Tool (iHOT-33) has been developed for hip related tionnaires compared to the more traditional hip problems in younger patients. This questionnaire PROs (mHHS and NAHS) where content validity for uses a visual analog scale response format designed athletes has never been addressed sufficiently.136 for computer self-administration by young, active Taken together, this means that athletes often report athletes with hip pathology. The iHOT-33 has been very few problems in these older PROs due to lack shown to be reliable, has demonstrated face, con- of sports-specific and more functionally demanding tent, and construct validity, and is highly responsive questions. to clinical change.134 Furthermore, a short version of the International Hip Outcome Tool (iHOT-12) has The tools recommended for use in athletes who have been developed. It has very similar characteristics sustained a fracture is limited. The Short Musculo- to the original rigorously validated 33-item question- skeletal Function Assessment (SMFA) had good over- naire, losing very little information despite being all responsiveness in athletes with hip fractures and only one-third the length. It is valid, reliable, and has been recommended for use as one of the mea- responsive to change. It has been suggested to be sures to evaluate the outcome after a hip fracture.141 used for initial assessment and postoperative follow- up in routine clinical practice.135 SUMMARY This clinical commentary focuses on an evidence- The Copenhagen Hip and Groin Outcome Score based examination and physical assessment of hip (HAGOS) was also recently developed for the assess- joint-related pathology in athletes. Clinical exami- ment of symptoms, activity limitations, participation nation of the athlete with hip pain is a diagnostic restrictions and quality of life in physically active, challenge requiring a clearly defined approach with young to middle-aged athletes with long-standing sound clinical reasoning. Each component of this hip and/or groin pain.136 The HAGOS consists of approach contributes to the identification of the six separate subscales assessing pain, symptoms, potential existence/non-existence of a particular physical function in daily living, physical function pathology. Furthermore, the athlete’s functional abil- in sport and recreation, participation in physical ity in relation to important aspects of body functions activities and hip and/or groin-related quality of life. and structure (impairments), activities (activity limi- It is also a valid, reliable, and responsive to change tations) and participation (participation restrictions) measure.136 HAGOS includes a measure of the ath- is important to identify, in order to optimize and letes’ ability to perform at their usual and optimal structure and individualized rehabilitation program. pre-injury level, which is extremely relevant when The strengths and limitations of each component of dealing with athletes with longstanding problems, the proposed approach vary from athlete to athlete. as their ability to perform is often impaired, even This systematic, cogent, hip examination and assess- though they have returned to sporting activity.136 ment approach must therefore always be individualized to each particular athlete and situation. Both iHOT and HAGOS have shown to be reliable, valid and responsive measures for patients with hip and/or groin pain. Both of these measures have REFERENCES 1. Picavet HS, Schouten JS. Musculoskeletal pain in the recently been translated and validated in different Netherlands: prevalences, consequences and risk 135-138 languages and by different research groups, groups, the DMC(3)-study. Pain. 2003;102(1-2):167-178. and reference values has been provided in different 2. Fricker PA, Taunton JE, Ammann W. Osteitis pubis subgroups for these measures.139,140 So far data from in athletes. Infection, inﬂ ammation or injury? Sports HAGOS indicate that this measures is sensitive to Med. 1991;12(4):266-279.

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The International Journal of Sports Physical Therapy | Volume 9, Number 6 | November 2014 | Page 753 108. Thorborg K, Branci S, Nielsen MP, Tang L, Nielsen 121. Loureiro A, Mills PM, Barrett RS. Muscle weakness MB, Holmich P. Eccentric and isometric hip- in hip osteoarthritis: A systematic review. Arthritis adduction strength in soccer players with and Care Res (Hoboken). 2012. without adductor-related groin pain. An assessor- 122. Grimaldi A. Assessing lateral stability of the hip and blinded comparison. Orthopedic Journal of pelvis. Man Ther. 2011;16(1):26-32. Sportsmedicine 2014. 123. Grimaldi A, Richardson C, Durbridge G, Donnelly 109. Beasley WC. Infl uence of method on estimates of W, Darnell R, Hides J. The association between normal knee extensor force among normal and degenerative hip joint pathology and size of the postpolio children. Phys Ther Rev. 1956;36(1):21-41. gluteus maximus and tensor fascia lata muscles. 110. Thorborg K, Petersen J, Magnusson SP, Holmich P. Man Ther. 2009;14(6):611-617. Clinical assessment of hip strength using a hand- 124. Grimaldi A, Richardson C, Stanton W, Durbridge G, held dynamometer is reliable. Scand. J. Med. Sci. Donnelly W, Hides J. The association between Sports. 2010;20(3):493-501. degenerative hip joint pathology and size of the 111. Stratford PW, Balsor BE. A comparison of make and gluteus medius, gluteus minimus and piriformis break tests using a hand-held dynamometer and muscles. Man Ther. 2009;14(6):605-610. the Kin-Com. J. Orthop. Sports Phys. Ther. 125. Kivlan BR, Martin RL. Functional performance 1994;19(1):28-32. testing of the hip in athletes. A systematic review 112. Bohannon RW. Make tests and break tests of elbow for reliability and validity. Int J Sports Phys Ther. fl exor muscle strength. Phys. Ther. 1988;68(2): 2012;7(4):402-412. 193-194. 126. Plisky PJ, Rauh MJ, Kaminski TW, Underwood FB. 113. Bohannon RW. Hand-held compared with isokinetic Star Excursion Balance Test as a predictor of lower dynamometry for measurement of static knee extremity injury in high school basketball players. extension torque (parallel reliability of J. Orthop. Sports Phys. Ther. 2006;36(12):911-919. dynamometers). Clin. Phys. Physiol. Meas. 127. Hubbard TJ, Kramer LC, Denegar CR, Hertel J. 1990;11(3):217-222. Correlations among multiple measures of 114. Friden J, Sjostrom M, Ekblom B. Myofi brillar functional and mechanical instability in subjects damage following intense eccentric exercise in with chronic ankle instability. J Athl Train. Jul- man. Int. J. Sports Med. 1983;4(3):170-176. 2007;42(3):361-366. 115. Friden J, Sfakianos PN, Hargens AR. Muscle 128. Norris B, Trudelle-Jackson E. Hip- and thigh-muscle soreness and intramuscular fl uid pressure: activation during the star excursion balance test. J comparison between eccentric and concentric load. Sport Rehabil. 2011;20(4):428-441. J Appl Physiol (1985). 1986;61(6):2175-2179. 129. Crossley KM, Zhang WJ, Schache AG, Bryant A, 116. Ramskov D, Pedersen MB, Kastrup K, et al. Cowan SM. Performance on the single-leg squat Normative values of eccentric hip abduction task indicates hip abductor muscle function. Am. J. strength in novice runners: an equation adjusting Sports Med. 2011;39(4):866-873. for age and gender. Int J Sports Phys Ther. 130. Reiman MP, Manske RC. Functional Testing in 2014;9(1):68-75. Human Performance. Champaign, IL.: Human 117. Augustsson J, Thomee R, Karlsson J. Ability of a Kinetics; 2009. new hop test to determine functional defi cits after 131. Wahoff M, Ryan M. Rehabilitation after hip anterior cruciate ligament reconstruction. Knee femoroacetabular impingement arthroscopy. Clin. Surg. Sports Traumatol. Arthrosc. 2004;12(5):350-356. Sports Med. 2011;30(2):463-482. 118. Orchard J, Best TM, Verrall GM. Return to play 132. Tijssen M, van Cingel R, van Melick N, de Visser E. following muscle strains. Clin. J. Sport Med. Patient-Reported Outcome questionnaires for hip 2005;15(6):436-441. arthroscopy: a systematic review of the psychometric 119. Thorborg K, Couppe C, Petersen J, Magnusson SP, evidence. BMC Musculoskelet Disord. 2011;12:117. Holmich P. Eccentric hip adduction and abduction 133. Thorborg K, Roos EM, Bartels EM, Petersen J, strength in elite soccer players and matched Holmich P. Validity, reliability and responsiveness controls: a cross-sectional study. Br. J. Sports Med. of patient-reported outcome questionnaires when 2011;45(1):10-13. assessing hip and groin disability: a systematic 120. Casartelli NC, Maffi uletti NA, Item-Glatthorn JF, et review. Br. J. Sports Med. 2010;44(16):1186-1196. al. Hip muscle weakness in patients with 134. Mohtadi NG, Griffi n DR, Pedersen ME, et al. The symptomatic femoroacetabular impingement. Development and validation of a self-administered Osteoarthritis Cartilage. 2011;19(7):816-821. quality-of-life outcome measure for young, active

The International Journal of Sports Physical Therapy | Volume 9, Number 6 | November 2014 | Page 754 patients with symptomatic hip disease: the and physical function in patients with hip and groin International Hip Outcome Tool (iHOT-33). disability due to femoro-acetabular impingement: Arthroscopy. 2012;28(5):595-605; quiz 606-510 e591. cross-cultural adaptation and validation of the 135. Grifﬁ n DR, Parsons N, Mohtadi NG, Safran MR. A international Hip Outcome Tool (iHOT12) in short version of the International Hip Outcome Swedish. Knee Surg. Sports Traumatol. Arthrosc. Tool (iHOT-12) for use in routine clinical practice. 2014;22(4):826-834. Arthroscopy. 2012;28(5):611-616; quiz 616-618. 139. Sansone M, Ahlden M, Jonasson P, et al. A Swedish 136. Thorborg K, Holmich P, Christensen R, Petersen J, hip arthroscopy registry: demographics and Roos EM. The Copenhagen Hip and Groin Outcome development. Knee Surg. Sports Traumatol. Arthrosc. Score (HAGOS): development and validation 2014;22(4):774-780. according to the COSMIN checklist. Br. J. Sports Med. 2011;45(6):478-491. 140. Thorborg K, Branci S, Stensbirk F, Jensen J, 137. Thomee R, Jonasson P, Thorborg K, et al. Cross- Holmich P. Copenhagen hip and groin outcome cultural adaptation to Swedish and validation of the score (HAGOS) in male soccer: reference values for Copenhagen Hip and Groin Outcome Score hip and groin injury-free players. Br. J. Sports Med. (HAGOS) for pain, symptoms and physical function 2014;48(7):557-559. in patients with hip and groin disability due to 141. Hedbeck CJ, Tidermark J, Ponzer S, Blomfeldt R, femoro-acetabular impingement. Knee Surg. Sports Bergstrom G. Responsiveness of the Short Traumatol. Arthrosc. 2014;22(4):835-842. Musculoskeletal Function Assessment (SMFA) in 138. Jonasson P, Baranto A, Karlsson J, et al. A patients with femoral neck fractures. Qual. Life Res. standardised outcome measure of pain, symptoms 2011;20(4):513-521.

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