Low back pain or injury before collegiate athletics, a potential risk factor for non-contact athletic injuries.

CONTEXT: Majority of research surrounding the predictive value of clinical measurements and assessments for future athletic injury does not differentiate between contact and non-contact injuries. OBJECTIVE: We assessed the association between clinical measures and questionnaire data collected prior to sport participation and the incidence of non-contact lower extremity (LE) injuries among Division III collegiate athletes. DESIGN: Prospective cohort study. SETTING: University setting, NCAA Division III. PARTICIPANTS: 488 Division III freshmen athletes were recruited to participate in the study during their preseason physical examinations. PATIENTS OR OTHER PARTICIPANTS: 10,983 public schools. MAIN OUTCOME MEASURE: Prospective incidence of non-contact Lower extremity Injury. METHODS: Athletes completed questionnaires to collect demographics and musculoskeletal pain history. Clinical tests, performed by trained examiners, included hip provocative tests, visual appraisal of a single leg squat to identify dynamic knee valgus, and hip range of motion (ROM). Injury surveillance for each athlete's collegiate career was performed. The athletic training department documented each athlete-reported, new onset injury and documented the injury location, type, and outcome (days lost, surgery performed). Univariable Generalized Estimating Equations (GEE) models were used to analyze the relationship between each clinical measure and the first occurrence of non-contact LE injury. An exchangeable correlation structure was used to account for repeated measurements within athletes (right and left limbs). RESULTS: Of the 488 athletes, 369 athletes (75%) were included in the final analysis. 69 non-contact LE injuries were reported. Responding "Yes" to "Have you ever had pain or an injury to your low back" was associated with an increased risk of non-contact LE, odds ratio = 1.59 (95%CI 1.03- 2.45, p=.04). No other clinical measures were associated with increased injury risk. CONCLUSION: A history of prior low back pain or injury was associated with an increased risk of sustaining a non-contact LE injury while participating in NCAA Division III athletics.

Feasibility of an intensive interprofessional lifestyle medicine program for patients with musculoskeletal conditions in the setting of lifestyle-related chronic disease.

BACKGROUND: Lifestyle factors are associated with musculoskeletal pain and metabolic chronic diseases. To date, intensive lifestyle medicine programs have predominantly targeted metabolic rather than musculoskeletal conditions. OBJECTIVE: To assess the feasibility of an intensive interprofessional lifestyle medicine program for patients with musculoskeletal conditions. DESIGN: Prospective observational feasibility study. SETTING: Tertiary academic medical center. PATIENTS: Adults diagnosed with musculoskeletal condition(s) and lifestyle-related chronic disease(s) who previously completed standard-of-care musculoskeletal treatments, enrolled from 2018 to 2020. INTERVENTIONS: Patients enrolled in an intensive interprofessional lifestyle medicine program led by a physiatrist, with options to interface with an acupuncturist, dietician, massage therapist, psychologist, physical therapist, and smoking cessation specialist. The physiatrist engaged in shared decision making with patients to establish program goals related to function, overall health, and required lifestyle changes. Bimonthly interprofessional team conferences facilitated communication between treatment team and patients. MAIN OUTCOME MEASURES: Feasibility was measured by patient participation and goal attainment. Secondary outcomes included changes from program enrollment to discharge in patient anthropometric, metabolic lab, sleep apnea risk, and Patient-Reported Outcomes Measurement Information System (PROMIS) function, pain, and behavioral health measures. RESULTS: Twenty-six patients enrolled in the program (18 [69%] female, mean age 59 [SD 14.5] years, baseline hemoglobin A1c 6.0% [0.8%], high-sensitivity C-reactive protein 7.7 [12.1] mg/dL, 25-hydroxy vitamin D 32.0 [14.2] ng/mL). Of 21 (81%) patients who completed the program, 13/21 (62%) met their goal. On average, program completers presented for 26.2 (10.6) total visits over 191 (88) days. By discharge, program completers achieved clinically meaningful improvement in PROMIS Anxiety (mean difference -3.5 points, 95% confidence interval [-6.5 to 0.5], p = .035), whereas noncompleters did not (p > .05). CONCLUSIONS: An intensive interprofessional lifestyle medicine program for patients with musculoskeletal conditions is feasible. With training in lifestyle intervention, physiatrists are well suited to lead interprofessional teams aimed at assisting patients in making lifestyle changes to achieve personalized function- and health-related goals.

Short-term Clinical Outcomes of Hip Arthroscopy Versus Physical Therapy in Patients With Femoroacetabular Impingement: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

BACKGROUND: Both physical therapy (PT) and surgery are effective in treating femoroacetabular impingement (FAI), but their relative efficacy has not been well established until recently. Several randomized controlled trials (RCTs) comparing the early clinical outcomes of these treatments have been published, with contradictory results. PURPOSE/HYPOTHESIS: The purpose of this study was to perform a meta-analysis of RCTs that compared early patient-reported outcomes (PROs) of hip arthroscopy versus PT in patients with symptomatic FAI. The hypothesis was that surgical treatment of FAI leads to better short-term outcomes than PT. STUDY DESIGN: Systematic review; Level of evidence, 1. METHODS: In March 2019, a systematic review was performed to identify RCTs comparing hip arthroscopy and PT in patients with symptomatic FAI. A total of 819 studies were found among 6 databases; of these, 3 RCTs met eligibility (Griffin et al, 2018; Mansell et al, 2018; and Palmer et al, 2019). All 3 RCTs reported international Hip Outcome Tool--33 (iHOT-33) scores, and 2 reported Hip Outcome Score (HOS)-Activities of Daily Living (ADL) and HOS-Sport results. In a random-effects meta-analysis, between-group differences in postintervention scores were assessed according to intention-to-treat and as-treated approaches. Quality was assessed with CONSORT, CERT, TiDieR, and the Cochrane Collaboration tool. RESULTS: The 3 RCTs included 650 patients with FAI; the mean follow-up ranged from 8 to 24 months. All studies reported PRO improvement from baseline to follow-up for both PT and surgery. The quality of the Griffin and Palmer studies was good, with minimal bias. In the Mansell study, a 70% crossover rate from PT to surgery increased the risk of bias. The meta-analysis demonstrated improved iHOT-33 outcomes with surgery compared with PT for intention-to-treat (mean difference [MD], 11.3; P = .046) and as-treated (MD, 12.6; P = .007) analyses. The as-treated meta-analysis of HOS-ADL scores favored surgery (MD, 12.0; P < .001), whereas the intention-to-treat analysis demonstrated no significant difference between groups for HOS-ADL (MD, 3.9; P = .571). CONCLUSION: In patients with FAI, the combined results of 3 RCTs demonstrated superior short-term outcomes for surgery versus PT. However, PT did result in improved outcomes and did not appear to compromise the surgical outcomes of patients for whom therapy failed and who progressed to surgery.

Nonoperative Treatment Options for Patients With Sacroiliac Joint Pain.

Sacroiliac joint (SIJ) pain is thought to be a component of low back pain in 20% of people who suffer with it chronically. There is no consistent objective diagnostic testing that includes SIJ pain as the diagnosis and thereby it can become a diagnosis of exclusion. Treatment of SIJ pain is variable, and no set method or protocol of treatment has been found to be efficacious or reliable. Thus, the healthcare provider is often left to create an individual treatment plan based on their own experiences and expertise. The purpose of this narrative review is to describe and discuss nonoperative treatment options for patients with SIJ pain. Further, coordination of treatment options and progression of treatment will be offered.

Hip Radiograph Findings in Patients Aged 40 Years and Under with Posterior Pelvic Pain.

BACKGROUND: Several sacroiliac joint (SIJ) provocative tests used to assess posterior pelvic pain involve moving and stressing the hip. It is unknown if there is a subgroup of patients with posterior pelvic pain who have underlying hip deformity that could potentially influence performance and interpretation of these tests. OBJECTIVE: To describe the prevalence of radiographic hip deformity and hip osteoarthritis in a group of adults 40 years old and under who met the clinical diagnostic criteria for treatment of posterior pelvic pain with an image guided intra-articular SIJ injection. DESIGN: Retrospective cohort study. SETTING: Tertiary university orthopedic department PATIENTS (OR PARTICIPANTS): One hundred and forty-eight patients were evaluated (83% (123/148) female; mean age 31.3 ± 6.2 years). All had completed a trial of comprehensive noninvasive treatment for posterior pelvic pain and had a minimum of three positive SIJ provocative tests on physical examination. METHODS: Retrospective review identified patients undergoing SIJ injection for pain recommended and performed by seven physiatrists between 2011 and 2017. Hip radiographs were read by a physician with expertise in hip measurements with previously demonstrated excellent intrarater reliability. MAIN OUTCOME MEASUREMENTS: Percentage of patients with hip deformity findings. RESULTS: No patients meeting the inclusion criteria had significant radiographic hip osteoarthritis (Tonnis ≥2 indicating moderate or greater radiographic hip osteoarthritis) and 4/148 (3%) were found to have mild radiographic hip osteoarthritis. Prearthritic hip disorders were identified in 123 (83%, 95% CI: 76, 89%) patients. For those patients with prearthritic hip disorders, measurements consistent with femoroacetabular impingement (FAI) were seen in 61 (41%) patients, acetabular dysplasia in 49 (33%) patients, and acetabular retroversion in 85 (57%) patients. Acetabular retroversion was identified in 43% (crossover sign) and 39% (prominent ischial spine) of patients. CONCLUSIONS: Approximately 57% of adult patients under the age of 40 years with the clinical symptom complex of SIJ pain were found to have radiographic acetabular retroversion. This is a higher percentage than the 5%-15% found in asymptomatic people in the current literature. Further study is needed to assess links between hip structure, hip motion, and links to pelvic pain including peri and intra-articular SIJ pain. LEVEL OF EVIDENCE: III.

Anxiety and Insomnia in Young and Middle-Aged Adult Hip Pain Patients With and Without Femoroacetabular Impingement and Developmental Hip Dysplasia.

BACKGROUND: In young and middle-aged adults with and without hip deformity, hip pain receives treatment focused primarily related to hip structure. Because this hip pain may be chronic, these patients develop other coexisting, modifiable disorders related to pain that may go undiagnosed in this young and active population, including insomnia and anxiety. OBJECTIVE: The objective of this study was to compare assessments of insomnia and anxiety in young and middle-aged adults presenting with hip pain with no greater than minimal osteoarthritis (OA) compared to asymptomatic healthy controls. Comparisons between types of hip deformity and no hip deformity in hip pain patients were performed to assess whether patients with specific hip deformities were likely to have insomnia or anxiety as a cofounding disorder to their hip pain. DESIGN: Prospective case series with control comparison. SETTING: Two tertiary university physiatry outpatient clinics. PARTICIPANTS: A total of 50 hip pain patients aged 18-40 years and 50 gender- and age-matched healthy controls. METHODS: Patients were enrolled if 2 provocative hip tests were found on physical examination and hip radiographs had no or minimal OA. Radiographic hip deformity measurements were completed by an independent examiner. Comparisons of insomnia and anxiety were completed between 50 hip pain patients and 50 controls and between patients with different types of hip deformity. MAIN OUTCOME MEASURES: Insomnia Severity Index (ISI) and Pain Anxiety Symptoms Scale (PASS). RESULTS: A total of 50 hip pain patients (11 male and 39 female) with mean age of 31.2 ± 8.31 years enrolled. Hip pain patients slept significantly less (P = .001) per night than controls. Patients experienced significantly greater insomnia (P = .0001) and anxiety (P = .0001) compared to controls. No differences were found in insomnia and anxiety scores between hip pain patients with and without hip deformity or between different types of hip deformity. CONCLUSION: Hip pain patients with radiographs demonstrating minimal to no hip arthritis with and without hip deformity experience significant cofounding yet modifiable disorders of sleep and anxiety. If recognized early in presentation, treatment of insomnia and anxiety ultimately will improve outcomes for hip patients treated either conservatively or surgically for their hip disorder. LEVEL OF EVIDENCE: II.

Abnormal hip physical examination findings in asymptomatic female soccer athletes.

PURPOSE: Examination of the hip provides information regarding risk for pre-arthritic hip disorders, knee injuries, and low back pain. The purpose of this study was to report a hip screening examination of asymptomatic female soccer athletes and to test the hypothesis that these findings vary by competition experience. METHODS: Asymptomatic females from a youth soccer club, a college, and a professional team were evaluated. Passive hip range of motion, hip abduction strength, and hip provocative tests were assessed. Data were compared for the grade/middle school, high school, college, and professional athletes. RESULTS: One hundred and seventy-two athletes with a mean age of 16.7 ± 5 years (range 10-30) participated. Professional athletes had less flexion (HF) for both hips (p < 0.0001) and less internal rotation (IR) for the preferred kicking leg (p < 0.05) compared to all other groups. Grade/middle school athletes had more external rotation in both hips as compared to all other groups (p < 0.0001). For the preferred kicking leg, collegiate athletes had less hip abduction strength as compared to other groups (p < 0.01). Positive provocative hip tests were found in 22 % of all players and 36 % of the professionals. In professionals, a positive provocative test was associated with ipsilateral decreased HF (p = 0.04). CONCLUSION: Asymptomatic elite female soccer athletes with the most competition experience had less bilateral hip flexion and preferred kicking leg IR than less-experienced athletes. Positive provocative hip tests were found in 22 % of athletes. Future studies are needed to show whether these findings link to risk for intra-articular hip or lumbar spine and knee disorders. LEVEL OF EVIDENCE: III.

Activity Tolerance After Periacetabular Osteotomy.

BACKGROUND: Periacetabular osteotomy is a well-described surgical intervention for symptomatic acetabular deformities in skeletally mature patients. Data regarding return to athletic activity or sport after this procedure are still limited. PURPOSE: To evaluate the ability of patients to return to preoperative levels of activity after periacetabular osteotomy. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: This is a retrospective review of active patients treated with periacetabular osteotomy for acetabular deformity correction. Patients were identified as those with preoperative University of California-Los Angeles activity levels ≥7. Patient demographics, operative data, radiographic measures, and clinical outcomes were documented prospectively. The University of California-Los Angeles activity score, Harris Hip Score, Hip Dysfunction and Osteoarthritis Outcome Score, and Western Ontario and McMaster Universities Osteoarthritis Index were used to measure clinical outcomes, and details regarding activity and satisfaction were analyzed. RESULTS: This study included 36 patients (39 hips; 15 males and 21 females) whose average age was 25 years (range, 15-45 years) and whose average body mass index was 24 ± 3.5 kg/m(2). Mean follow-up was 33 months (range, 18-59 months). Preoperatively, the average lateral center edge angle, anterior center edge angle, and acetabular index were 10°, 14°, and 21°, respectively; 92% of patients had a Tönnis osteoarthritis grade of 0 or 1. One patient failed hip preservation surgery and went on to total hip arthroplasty 27 months after periacetabular osteotomy. Of the remaining patients, 71% reported an increase or no change in activity level postoperatively. The University of California-Los Angeles score was also unchanged (9.2 vs 8.8, P = .157), and the Harris Hip Score (63 vs 87, P < .001), Hip Dysfunction and Osteoarthritis Outcome Score-Quality of Life (38 vs 71, P < .001), and Western Ontario and McMaster Universities Osteoarthritis Index (71 vs 92, P < .001) results improved from preoperative levels. There was a 97% rate of satisfaction with the surgery. Four patients (11%) reported hip pain as the primary factor limiting postoperative activity. CONCLUSION: The majority (71%) of active patients with hip dysplasia return to presurgical or higher activity levels after open hip preservation surgery with the periacetabular osteotomy.

Clinical outcomes analysis of conservative and surgical treatment of patients with clinical indications of prearthritic, intra-articular hip disorders.

OBJECTIVE: To describe outcomes of the conservative treatment of patients who had the clinical presentation of a prearthritic, intra-articular hip disorder, including acetabular labral tears, developmental hip dysplasia, and femoroacetabular impingement. DESIGN: Prospective observational clinical outcomes study. SETTING: Outpatient orthopedic clinic at a tertiary university hospital. PATIENTS: Patients presenting with prearthritic, intra-articular hip disorders were recruited. Fifty-eight consecutive patients were enrolled; 6 were lost to follow-up, and 52 subjects completed the study. METHODS: Patients were recruited on the basis of symptoms, distribution of pain, and the findings of a physical examination. Radiographic measurements of the hip were obtained for all subjects to describe the presence or absence and extent of deformity and/or osteoarthritis. All subjects completed a directed course of conservative treatment. After 3 months of conservative care, subjects with continued limitations, reduction of symptoms with a diagnostic intra-articular hip injection, and a surgically amenable lesion found on a magnetic resonance arthrogram proceeded to surgery. MAIN OUTCOME MEASUREMENTS: Numeric Pain Score (0-10), Short Form-12, Modified Harris Hip Score, Western Ontario and McMaster Universities Osteoarthritis Index, Nonarthritic Hip Score, Baecke Questionnaire of Habitual Activity, and patient choice to have surgery. RESULTS: Fifty-eight patients (9 men and 49 women) with a mean age of 35 ± 11 years (range, 18-50 years) enrolled in the study. Fifty-two subjects completed the study. Twenty-three subjects (44%) reported satisfaction with conservative care. Twenty-nine subjects (56%) chose to have surgery. Both groups demonstrated equally significant improvement (P value ranges: P = .03 to P = .0001) in all outcome measures from baseline to 1-year follow-up. Subjects who chose surgery had higher baseline activity scores compared with the conservative treatment group (P = .02). CONCLUSION: All subjects with signs and symptoms of prearthritic, intra-articular hip disorders who were treated with conservative treatment alone and with conservative treatment followed by surgery demonstrated significant improvement in pain and functioning from baseline to 1 year. Forty-four percent of patients improved with conservative care alone, and 56% chose to have surgery after receiving conservative care. Persons with more active lifestyles were more likely to choose surgery. These data suggest that a trial of conservative management for persons with prearthritic, intra-articular hip disorders should be considered before engaging in surgical intervention.

Reliability of various observers in determining common radiographic parameters of adult hip structural anatomy.

BACKGROUND: Radiographic evaluation of the hip is extremely important in the diagnosis and treatment decisionmaking process for pre-arthritic hip disease. Many different radiographic measurements have been described as indicators of underlying structural hip deformity. The purpose of this study was to determine the interobserver and intraobserver reliability of various musculoskeletal physicians in performing selected measurements of adult structural hip anatomy. METHODS: A blinded review of 45 sets of radiographs from patients with developmental dysplasia, femoro-acetabular impingement, and normal anatomy was performed. Data points included the lateral center-edge angle (LCEA), vertical-center-anterior angle (VCA), head-neck offset ratio (UNO), alpha angle, Tönnis angle, Tönnis osteoarthritis grade and a radiographic diagnosis. One orthopaedic fellow, two orthopaedic residents, and two attending musculoskeletal physiatrists analyzed radiographs on two separate occasions. One sports medicine orthopaedic attending physician completed a single analysis of the image sets. Intraobserver and interobserver reliability was established using intra-class correlation coefficients (ICC) for continuous variables. Agreement regarding categorical variables was performed using the kappa coefficient RESULTS: Excellent intraobserver reliability was found for the following: LCEA (ICC = 0.88), VCA (0.88), Tönnis angle (0.83), HNO on the frog lateral (0.78), alpha angle on the frog lateral (0.76), HNO on the cross-table lateral (0.75), and angle alpha on the cross-table lateral (0.76). Intraobserver reliability for osteoarthritis grade was poor (weighted kappa = 0.57). For all data points, interobserver reliability was considerably worse, with 95% confidence intervals spanning below 0.55. CONCLUSIONS: While the described measurements of adult structural hip anatomy provide excellent reliability for a given reader, these measurements are less reliable across readers. Taken in isolation, these measurements, as performed by observers with varied clinical experience and clinical backgrounds, are limited in determining a consistent radiographic diagnosis.

Clinical presentation of symptomatic acetabular dysplasia in skeletally mature patients.

BACKGROUND: Acetabular dysplasia is recognized as a cause of early degenerative hip osteoarthritis. The purpose of this study was to prospectively determine the early clinical presentation of symptomatic acetabular dysplasia in skeletally mature patients. METHODS: Fifty-seven consecutive skeletally mature patients with a total of sixty-five symptomatic hips were diagnosed with symptomatic acetabular dysplasia on the basis of the history, physical examination, and radiographs. These fifty-seven patients were enrolled in this study and were followed prospectively for a minimum of twenty-four months postoperatively. RESULTS: The study group included forty-one female patients (72%) and sixteen male patients (28%) with a mean age of twenty-four years. All were treated with a periacetabular osteotomy and were followed for a minimum of twenty-four months. The initial presentation was insidious in 97% of the hips, and the majority (77%) of the hips were associated with moderate-to-severe pain on a daily basis. Pain was most commonly localized to the groin (72%) and/or the lateral aspect of the hip (66%). Activity-related hip pain was common (88%), and activity restriction frequently diminished hip pain (in 75% of the cases). On examination, thirty-one hips (48%) were associated with a limp; twenty-five (38%), with a positive Trendelenburg sign; and sixty-three (97%), with a positive impingement sign. The mean time from the onset of symptoms to the diagnosis of hip dysplasia was 61.5 months. The mean number of health-care providers seen prior to the definitive diagnosis was 3.3. The mean Harris hip score improved from 66.4 points preoperatively to 91.7 points at a mean of 29.2 months after the periacetabular osteotomy. CONCLUSIONS: The diagnosis of symptomatic acetabular dysplasia is commonly delayed, and procedures other than a pelvic reconstructive osteotomy are frequently recommended. The diagnosis of developmental dysplasia of the hip should be suspected and investigated when a skeletally mature, young, active patient has a predominant complaint of insidious activity-related groin pain and/or lateral hip pain. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions to Authors for a complete description of levels of evidence.

Reliability and agreement of hip range of motion and provocative physical examination tests in asymptomatic volunteers.

OBJECTIVE: To: (1) report passive hip range of motion (ROM) in asymptomatic young adults, (2) report the intratester and intertester reliability of hip ROM measurements among testers of multiple disciplines, and (3) report the results of provocative hip tests and tester agreement. DESIGN: Descriptive epidemiology study. SETTING: Tertiary university. PARTICIPANTS: Twenty-eight young adult volunteers without musculoskeletal symptoms, history of disorder, or surgery involving the lumbar spine or lower extremities were enrolled and completed the study. METHODS: Asymptomatic young adult volunteers completed questionnaires and were examined by 2 blinded examiners during a single session. The testers were physical therapists and physicians. Hip ROM and provocative tests were completed by both examiners on each hip. MAIN OUTCOME MEASUREMENTS: Inter-rater and intrarater reliability for ROM and agreement for provocative tests were determined. RESULTS: Twenty-eight asymptomatic adults, mean age 31 years (range, 18-51 years), with a mean modified Harris Hip Score of 99.5 ± 1.5 and UCLA activity score of 8.8 ± 1.2 completed the study. Intrarater agreement was excellent for all hip ROM measurements, with intraclass correlation coefficients (ICCs) ranging from 0.76 to 0.97, with similar agreement if the examiner was a physical therapist or a physician. Excellent inter-rater reliability was found for hip flexion ICC 0.87 (95% confidence interval [95% CI] 0.78-0.92), supine internal rotation ICC 0.75 (95% CI 0.60-0.84), and prone internal rotation ICC 0.79 (95% CI 0.66-0.87). The least reliable measurements were supine hip abduction (ICC 0.34) and supine external rotation (ICC 0.18). Agreement between examiners ranged from 96% to 100% for provocative hip tests, which included the hip impingement, resisted straight leg raise, Flexion Abduction External Rotation/Patrick, and log roll tests. CONCLUSIONS: Specific hip ROM measures show excellent inter-rater reliability, and provocative hip tests show good agreement among multiple examiners and medical disciplines. Further studies are needed to assess the use of these measurements and tests as a part of a hip screening examination to assess for young adults at risk for intra-articular hip disorders before the onset of degenerative changes.

Early intra-articular hip disease presenting with posterior pelvic and groin pain.

OBJECTIVE: To determine whether posterior pelvic pain is associated with intra-articular hip abnormalities (labral tears and early degenerative changes) in patients with minimal-to-no radiographic abnormalities. DESIGN: A retrospective observational study of prospectively collected data collected from patients with an arthroscopy-confirmed diagnosis of acetabular labral tear or femoral and/or acetabular chondrosis, without severe deformity. SETTING: An academic orthopedic clinic at a tertiary hospital. PATIENTS: All patients, having failed to respond to conservative treatment, required surgical intervention for definitive structural diagnosis and treatment because of pain and dysfunction. Within this group, patients with posterior pelvic pain were included. One hundred thirty consecutive patients, 93 women and 37 men with mean age 31.16 years (range, 10-65.5 years), entered the study, and observational findings were reported. INTERVENTIONS: University instructional review board approval was obtained before conducting the study. Patients completed medical information questionnaires, pain diagrams, severity of pain, and validated hip questionnaires that focused on symptoms and function. Postoperatively, patients who had posterior pelvic pain before surgery completed a phone interview regarding their clinical progress. MAIN OUTCOMES MEASUREMENT: A numeric pain scale, description of location of continued pain, Modified Harris Hip Score, and satisfaction with the procedure were recorded. RESULTS: Twenty-six (20%) of the 130 patients complained of posterior pelvic pain as a component of their clinical presentation. Of these patients, the mean duration of symptoms was 29.5 months. A total of 92% related that their pain was moderate or marked. The preoperative mean modified Harris Hip Score was 61.6 (range, 27-85) and showed postoperative improvement with a mean of 84.5 (range, 45-100; P < .001). The Modified Harris Hip Score was completed a mean 15.9 months postoperatively. Pain diagrams and questionnaires revealed that of the 26 patients with posterior pelvic pain, 92.3% (24/26) also had associated groin pain (P < .001), 57.7% (15/26) had lateral thigh pain, and 7.7% (2/26) had anterior thigh pain (P < .001). A total of 12 of 26 patients with an initial presentation including posterior pelvic pain agreed to a phone interview. The mean time after surgery in this group of patients was 56.9 months (range, 39-65 months). Five of 12 patients reported no pain and no activity limitations. The Visual Analog Scale representing their self-reported average daily pain was 1.4 (range, 0-3). The mean Modified Harris Hip Score was 10.4 (range, 8-13). All 7 patients with continued pain described the pain in more than one location. Ten of 12 patients were very satisfied with hip arthroscopy, 1 of 12 was somewhat satisfied, and 1 of 12 was dissatisfied. This latter patient went on to have total hip arthroplasty and was very satisfied with that procedure. All 12 patients would recommend the procedure to a friend. CONCLUSIONS: Twenty percent of patients at the authors' institution who required surgical intervention to treat their pain after not responding to conservative management had posterior pelvic pain in addition to groin or lateral and anterior hip pain. Of those respondents, 33% had complete resolution of symptoms at 4.75 years after surgery, and all had reduction in pain as compared with completion of conservative care. Patients with early intra-articular hip pathology, such as acetabular labral tears with no or mild hip deformity, and patients with arthrosis and mild hip deformity may experience groin and posterior pelvic pain as part of their clinical presentation.

Inter-rater reliability of three musculoskeletal physical examination techniques used to assess motion in three planes while standing.

OBJECTIVE: The objective of the study was to measure the reliability between examiners of 3 basic maneuvers of the Total Body Functional Profile physical examination test. The hypothesis was musculoskeletal health care providers of different disciplines could reliably use the 3 basic maneuvers as part of the musculoskeletal physical examination. DESIGN: A prospective observational study was conducted. Twenty-eight adult volunteers were measured on both the left and right side by 2 independent raters on a single occasion. SETTING: The subjects were recruited through advertisements placed by the orthopedic department at a tertiary university. PARTICIPANTS: Twenty-eight volunteers were recruited and completed the study. The volunteers were between the ages of 18 and 51 years of age, had no symptoms in the lower extremity or spine, had no previous history of surgery or tumor involving the lower extremity, and no medical conditions that would preclude participation. METHODS: On a single occasion, 2 examiners per 1 volunteer were blinded to their own and each others' measurements. Each examiner assessed the distance of frontal and sagittal plane lunge and angle of motion for transverse plane testing. MAIN OUTCOME MEASUREMENTS: Inter-rater agreement is expressed with intraclass correlation coefficients (ICCs) and corresponding 95% confidence intervals (CIs). The difference between raters is reported with 95% CIs. Baseline demographics, University of California Los Angeles (UCLA), and Harris hip questionnaires were completed by all participants. RESULTS: The UCLA and Harris hip scores showed no significant activity restrictions or pain limitations in all participants. The inter-rater reliability for sagittal, frontal, and transverse plane matrix testing was good with ICCs of 0.86 (95% CI 0.77-0.91), 0.90 (95% CI 0.84-0.94), and 0.85 (95% CI 0.75-0.91), respectively. The rater reliability between disciplines for transverse, sagittal, and frontal plane matrix testing was good with ICCs of 0.89 (95% CI 0.80-0.94), 0.88 (95% CI 0.79-0.94), and 0.90 (95% CI 0.81-0.95), respectively. CONCLUSIONS: The inter-rater reliability for 3 basic maneuvers of the Total Body Functional Profile is good among musculoskeletal health care providers of different disciplines. These 3 maneuvers may be used consistently as part of the musculoskeletal physical examination.

Clinical presentation of patients with symptomatic anterior hip impingement.

Femoroacetabular impingement (FAI) is considered a cause of labrochondral disease and secondary osteoarthritis. Nevertheless, the clinical syndrome associated with FAI is not fully characterized. We determined the clinical history, functional status, activity status, and physical examination findings that characterize FAI. We prospectively evaluated 51 patients (52 hips) with symptomatic FAI. Evaluation of the clinical history, physical exam, and previous treatments was performed. Patients completed demographic and validated hip questionnaires (Baecke et al., SF-12, Modified Harris hip, and UCLA activity score). The average patient age was 35 years and 57% were male. Symptom onset was commonly insidious (65%) and activity-related. Pain occurred predominantly in the groin (83%). The mean time from symptom onset to definitive diagnosis was 3.1 years. Patients were evaluated by an average 4.2 healthcare providers prior to diagnosis and inaccurate diagnoses were common. Thirteen percent had unsuccessful surgery at another anatomic site. On exam, 88% of the hips were painful with the anterior impingement test. Hip flexion and internal rotation in flexion were limited to an average 97 degrees and 9 degrees, respectively. The patients were relatively active, yet demonstrated restrictions of function and overall health. These data may facilitate diagnosis of this disorder.