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

Abstract

There is no agreement on how to classify, define or diagnose hip-related pain—a common cause of hip and groin pain in young and middle-aged active adults. This complicates the work of clinicians and researchers. The International Hip-related Pain Research Network consensus group met in November 2018 in Zurich aiming to make recommendations on how to classify, define and diagnose hip disease in young and middle-aged active adults with hip-related pain as the main symptom. Prior to the meeting we performed a scoping review of electronic databases in June 2018 to determine the definition, epidemiology and diagnosis of hip conditions in young and middle-aged active adults presenting with hip-related pain. We developed and presented evidence-based statements for these to a panel of 37 experts for discussion and consensus agreement. Both non-musculoskeletal and serious hip pathological conditions (eg, tumours, infections, stress fractures, slipped capital femoral epiphysis), as well as competing musculoskeletal conditions (eg, lumbar spine) should be excluded when diagnosing hip-related pain in young and middle-aged active adults. The most common hip conditions in young and middle-aged active adults presenting with hip-related pain are: (1) femoroacetabular impingement (FAI) syndrome, (2) acetabular dysplasia and/or hip instability and (3) other conditions without a distinct osseous morphology (labral, chondral and/or ligamentum teres conditions), and that these terms are used in research and clinical practice. Clinical examination and diagnostic imaging have limited diagnostic utility; a comprehensive approach is therefore essential. A negative flexion–adduction–internal rotation test helps rule out hip-related pain although its clinical utility is limited. Anteroposterior pelvis and lateral femoral head–neck radiographs are the initial diagnostic imaging of choice—advanced imaging should be performed only when requiring additional detail of bony or soft-tissue morphology (eg, for definitive diagnosis, research setting or when planning surgery). We recommend clear, detailed and consistent methodology of bony morphology outcome measures (definition, measurement and statistical reporting) in research. Future research on conditions with hip-related pain as the main symptom should include high-quality prospective studies on aetiology and prognosis. The most common hip conditions in active adults presenting with hip-related pain are: (1) FAI syndrome, (2) acetabular dysplasia and/or hip instability and (3) other conditions without distinct osseous morphology including labral, chondral and/or ligamentum teres conditions. The last category should not be confused with the incidental imaging findings of labral, chondral and/or ligamentum teres pathology in asymptomatic people. Future research should refine our current recommendations by determining the clinical utility of clinical examination and diagnostic imaging in prospective studies.

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

“…Key points to discuss with patients to facilitate realistic expectations regarding treatment outcomes may include (i) the associated risks of surgical and non-surgical options; (ii) the likely magnitude of improvement and (iii) the likely duration and cost. In addition, the relationship between pain and hip joint structure (including the prevalence of morphological and intra-articular findings in asymptomatic people)7 should be discussed with the patient.…”

“…The diagnosis of FAI syndrome currently includes bony morphological changes in the hip which may cause aberrant joint forces during hip movements and possible damage to the intra-articular structures of the joint 1. Other causes of hip-related pain can include acetabular dysplasia and intra-articular soft-tissue features such as labral, chondral or ligamentum teres lesions 7…”

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

“…To understand how movement-related parameters, including biomechanics and muscle function, may contribute to or result from symptoms, function, quality of life, imaging and intra-articular findings, future research should include measures of each of these parameters to identify the inter-relationships. The method of obtaining and grading imaging and intra-articular findings should be reported in future research on hip-related pain (Reiman et al , 2019) 5…”

“…It is frequently seen in young and middle-aged active adults, with the psychological and physical impact occurring at a time when major work and life responsibilities are experienced 1–4. The most common causes of hip-related pain in young and middle-aged active adults are: femoroacetabular impingement (FAI) syndrome, dysplasia and intra-articular pathology (labral tears, chondral damage and ligamentum teres tears) without bony morphological variant (Reiman et al , 2019) 5. High economic burden can result from hip-related pain,6 emphasising the need for early detection and effective management of this musculoskeletal condition.…”

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

“…[1][2][3][4] In 2017, the International Hip Pain Research Network (IHiPRN) was established to facilitate collaboration across research groups and disciplines and to improve knowledge dissemination of hip-related pain to clinicians. In this paper, 5 published in the British Journal of Sports Medicine, we first describe the general consensus process applied to all topics in this series. We then make recommendations on the first topic on how to classify, define and diagnose hip disease in young and middle-aged active adults, with hip-related pain as the main symptom.…”