Hip pain in adolescents with cerebral palsy: a population-based longitudinal study.

AIM: To investigate the prevalence, characteristics, and risk factors of hip pain in adolescents with cerebral palsy (CP) and compare the findings with those of the same individuals 5 years earlier. METHOD: Sixty-seven adolescents (28 females, 39 males; mean age 14y 7mo; SD 1y 5mo; range 12-17y) with bilateral CP, in Gross Motor Function Classification System (GMFCS) levels III to V enrolled in a CP surveillance programme were assessed for hip pain. Their caregivers responded to the questions on the intensity and frequency of hip pain from the Child Health Questionnaire (CHQ) (transformed to CHQ hip pain score; 100 indicates no pain). Interference of hip pain with daily activities and sleep was recorded on numeric rating scales. Hip displacement was measured radiographically by the migration percentage. RESULTS: Twenty-eight participants had 44 painful hips. Their mean CHQ hip pain score was 40 (SD 21.4; range 10-80). Independent risk factors for hip pain, low CHQ hip pain score, and interference with sleep were severe hip subluxation (migration percentage 50-89%) and GMFCS level V. A migration percentage of 50% to 89% was the only independent risk factor for interference with daily activities. Over 5 years, the number of participants with hip pain increased from 18 to 28, while the mean migration percentage of the most displaced hip was unchanged. INTERPRETATION: Our CP hip surveillance programme did not protect the participants against increasing prevalence of hip pain during adolescence. We suggest that surveillance programmes for CP should include guidelines on the characteristics and management of hip pain. WHAT THIS PAPER ADDS: Hip pain prevalence increased in adolescents over a 5-year period in a cerebral palsy surveillance programme. Risk factors for hip pain were Gross Motor Function Classification System level V and severe hip subluxation.

Does Patient-specific Functional Pelvic Tilt Affect Joint Contact Pressure in Hip Dysplasia? A Finite-element Analysis Study.

BACKGROUND: Although individual and postural variations in the physiologic pelvic tilt affect the acetabular orientation and coverage in patients with hip dysplasia, their effect on the mechanical environment in the hip has not been fully understood. Individual-specific, finite-element analyses that account for physiologic pelvic tilt may provide valuable insight into the contact mechanics of dysplastic hips, which can lead to further understanding of the pathogenesis and improved treatment of this patient population. QUESTION/PURPOSE: We used finite-element analysis to ask whether there are differences between patients with hip dysplasia and patients without dysplasia in terms of (1) physiologic pelvic tilt, (2) the pelvic position and joint contact pressure, and (3) the morphologic factors associated with joint contact pressure. METHODS: Between 2016 and 2019, 82 patients underwent pelvic osteotomy to treat hip dysplasia. Seventy patients with hip dysplasia (lateral center-edge angle ≥ 0° and < 20° on supine AP pelvic radiographs) were included. Patients with advanced osteoarthritis, femoral head deformity, prior hip or supine surgery, or poor-quality imaging were excluded. Thirty-two patients (32 hips) were eligible to this finite-element analysis study. For control groups, we reviewed 33 female volunteers without a history of hip disease. Individuals with frank or borderline hip dysplasia (lateral center-edge angle < 25°) or poor-quality imaging were excluded. Sixteen individuals (16 hips) were eligible as controls. Two board-certified orthopaedic surgeons measured sagittal pelvic tilt (the angle between the anterior pelvic plane and vertical axis: anterior pelvic plane [APP] angle) and acetabular version and coverage using pelvic radiographs and CT images. Intra- and interobserver reliabilities, evaluated using the kappa value and intraclass correlation coefficient, were good or excellent. We developed individual-specific, finite-element models using pelvic CT images, and performed nonlinear contact analysis to calculate the joint contact pressure on the acetabular cartilage during the single-leg stance with respect to three pelvic positions: standardized (anterior pelvic plane), supine, and standing. We compared physiologic pelvic tilt between patients with and without dysplasia using a t-test or the Wilcoxon rank sum test. A paired t-test or the Wilcoxon signed rank test with a Bonferroni correction was used to compare joint contact pressure between the three pelvic positions. We correlated joint contact pressure with morphologic parameters and pelvic tilt using the Pearson or the Spearman correlation coefficients. RESULTS: The APP angle in the supine and standing positions varied widely among individuals. It was greater in patients with hip dysplasia than in patients in the control group when in the standing position (3° ± 6° versus -2° ± 8°; mean difference 5° [95% CI 1° to 9°]; p = 0.02) but did not differ between the two groups when supine (8° ± 5° versus 5° ± 7°; mean difference 3° [95% CI 0° to 7°]; p = 0.06). The mean pelvic tilt was 6° ± 5° posteriorly when shifting from the supine to the standing position in patients with hip dysplasia. The median (range) maximum contact pressure was higher in dysplastic hips than in control individuals (in standing position; 7.3 megapascals [MPa] [4.1 to 14] versus 3.5 MPa [2.2 to 4.4]; difference of medians 3.8 MPa; p < 0.001). The median maximum contact pressure in the standing pelvic position was greater than that in the supine position in patients with hip dysplasia (7.3 MPa [4.1to 14] versus 5.8 MPa [3.5 to 12]; difference of medians 1.5 MPa; p < 0.001). Although the median maximum joint contact pressure in the standardized pelvic position did not differ from that in the standing position (7.4 MPa [4.3 to 15] versus 7.3 MPa [4.1 to 14]; difference of medians -0.1 MPa; p > 0.99), the difference in the maximum contact pressure varied from -3.3 MPa to 2.9 MPa, reflecting the wide range of APP angles (mean 3° ± 6° [-11° to 14°]) when standing. The maximum joint contact pressure in the standing position was negatively correlated with the standing APP angle (r = -0.46; p = 0.008) in patients with hip dysplasia. CONCLUSION: Based on our findings that individual and postural variations in the physiologic pelvic tilt affect joint contact pressure in the hip, future studies on the pathogenesis of hip dysplasia and joint preservation surgery should not only include the supine or standard pelvic position, but also they need to incorporate the effect of the patient-specific pelvic tilt in the standing position on the biomechanical environment of the hip. CLINICAL RELEVANCE: We recommend assessing postural change in sagittal pelvic tilt when diagnosing hip dysplasia and planning preservation hip surgery because assessment in a supine or standard pelvic position may overlook alterations in the hip's contact mechanics in the weightbearing positions. Further studies are needed to elucidate the effect of patient-specific functional pelvic tilt on the degeneration process of dysplastic hips, the acetabular reorientation maneuver, and the clinical result of joint preservation surgery.

Clinical Assessment and Treatment Options for Posterior Hip Pain.

BACKGROUND: Diagnosis and treatment of posterior hip pain has increased due to advancements in clinical, anatomical, biomechanical, and related pathological understandings of the hip. Due to its complexity and close anatomical relationship with many osseous, neurovascular, and musculotendinous structures, posterior hip pain must be appropriately categorized based on its origin. Therefore, it is crucial that clinicians are able to determine whether patient complaints are of extra-articular or intra-articular nature so that they can implement the optimal treatment plan. In the current review article, we discussed posterior hip pain with an emphasis on the main differential diagnoses of deep gluteal syndrome, ischiofemoral impingement, and hamstring tear/hamstring syndrome. For the appropriate diagnosis and etiology of posterior hip pain, a thorough and conclusive clinical history is imperative. Physicians should rule out the possibility of spinal involvement by physical examination and if necessary, by magnetic resonance imaging (MRI). Furthermore, because of the vicinity to other, non-orthopedic structures, an obstetric and gynecologic history, general surgery history, and urologic history should be obtained. Following the collection of patient history clinicians should adhere to an established and efficient order of evaluation starting with standing then to seated, supine, lateral, and prone testing. Imaging assessment of posterior hip pain begins with a standard anterior-posterior pelvic radiograph, in addition to frog-leg lateral. MRI is pivotal for assessing soft tissue-related extra-articular causes of hip in patients with posterior hip pain. Non-surgical treatment is preferred in most cases of deep gluteal syndrome, ischiofemoral impingement, pudendal nerve entrapment, and proximal hamstring pathologies. Surgical treatment is saved as a last resort option in cases of failed non-surgical treatment.

Clinical Hip Osteoarthritis in Current and Former Professional Footballers and Its Effect on Hip Function and Quality of Life.

The objective of the study was to establish the prevalence of clinical hip osteoarthritis in current and former professional footballers and to explore its consequences on hip function and health-related quality of life (HRQoL). A cross-sectional study by means of questionnaire was conducted among current and former professional footballers fulfilling the following inclusion criteria: (1) male (2) active or retired professional footballer (3) member of FIFPRO (Football Players Worldwide) (4) between 18 and 50 years old (5) could read and understand texts in French, Spanish, or English. Controls (matched for: gender, age, body weight and height) were also recruited. The main outcome measures were clinical hip osteoarthritis, hip function and HRQoL. Questionnaires were sent to 2,500 members of which 1,401 participated (1,000 current and 401 former professional footballers). Fifty-two controls were recruited. Prevalence of hip osteoarthritis was 2% among current and 8% among former professional footballers. Hip function was significantly (p ≤ 0.001) lower in both types of footballers with hip osteoarthritis than in footballers without hip osteoarthritis and controls. Current and former professional footballers with hip osteoarthritis reported significantly lower physical health scores (p = 0.032, p = 0.002) than those without. Hip osteoarthritis led to a significantly lower score in the physical (p = 0.004) and mental (p = 0.014) component of HRQoL in former footballers compared to the controls, while in current footballers only the physical component was significantly (p = 0.012) lower compared to the controls. Hip osteoarthritis has a higher prevalence in former than in current professional footballers and impacts hip function and HRQoL negatively.

Eldecalcitol is superior to alfacalcidol in maintaining bone mineral density in glucocorticoid-induced osteoporosis patients (e-GLORIA).

INTRODUCTION: Eldecalcitol increases bone mineral density (BMD) and reduces vertebral fracture in patients with primary osteoporosis. However, the effect of eldecalcitol on BMD and fracture in glucocorticoid-induced osteoporosis (GIO) patients is unknown. This study was undertaken to compare the effect of eldecalcitol on BMD and fracture with that of alfacalcidol in GIO patients. MATERIALS AND METHODS: A randomized, open-label, parallel group study was conducted to identify the effectiveness and safety of monotherapy with 0.75 µg eldecalcitol compared with 1.0 µg alfacalcidol in GIO patients. RESULTS: Lumbar spine BMD increased with eldecalcitol, but decreased with alfacalcidol at 12 and 24 months (between group difference 1.29%, p < 0.01, and 1.10%, p < 0.05, respectively). Total hip and femoral neck BMD were maintained until 24 months by eldecalcitol, but decreased by alfacalcidol (between group difference 0.97%, p < 0.05 and 1.22%, p < 0.05, respectively). Both bone formation and resorption markers were more strongly suppressed by eldecalcitol than by alfacalcidol. Eldecalcitol showed better effect on BMD than alfacalcidol in patients with no prevalent fracture and BMD > 70% of the young adult mean, and with ≤ 3 months of previous glucocorticoid treatment. No significant difference in the incidence of vertebral fracture was found, and the incidence of adverse events was similar between the two groups. CONCLUSIONS: Eldecalcitol was more effective than alfacalcidol in maintaining BMD in GIO patients. Because eldecalcitol was effective in patients with no or short-term previous glucocorticoid treatment, as well as those without prevalent fracture or low BMD, eldecalcitol can be a good candidate for primary prevention of GIO. CLINICAL TRIAL REGISTRATION NUMBER: UMIN000011700.

Hip and Shoulder Involvement and Their Management in Axial Spondyloarthritis: a Current Review.

PURPOSE OF REVIEW: Hip and shoulder disease can occur in patients with spondyloarthritis (SpA). While hip involvement has been widely assessed in axial SpA patients, studies in the overall SpA population as well as studies focused on shoulder involvement are scarce. Here, we review the most recent studies on the epidemiology, evaluation, and treatment of root joint involvement in SpA patients. RECENT FINDINGS: Radiological hip involvement can affect up to 25% of patients with SpA, reflecting more severe disease and associated with functional impairment. Shoulder involvement in SpA patients is characterized by cuff tendinitis and enthesitis, while primary glenohumeral joint involvement is rare. Anti-tumor necrosis factor (anti-TNF) treatment in SpA patients seems to have an effect on hip arthritis, showing a change in trend in the frequency of hip replacement in this population. The majority of studies evaluating hip involvement have focused on axial SpA patients, but further studies evaluating root joint involvement in the overall SpA population are needed. Anti-TNF therapy should be considered in patients with hip involvement, and root joint involvement should be assessed routinely in clinical practice.

Changes in Parkinsonian gait kinematics with self-generated and externally-generated cues: a comparison of responders and non-responders.

Purpose: Rhythmic auditory stimulation such as listening to music can alleviate gait bradykinesia in people with Parkinson disease (PD) by increasing spatiotemporal gait features. However, evidence about what specific kinematic alterations lead to these improvements is limited, and differences in responsiveness to cueing likely affect individual motor strategies. Self-generated cueing techniques, such as singing or mental singing, provide similar benefits but no evidence exists about how these techniques affect lower limb joint movement. In this study, we assessed immediate effects of external and self-generated cueing on lower limb movement trajectories during gait.Methods: Using 3D motion capture, we assessed sagittal plane joint angles at the hip, knee, and ankle across 35 participants with PD, divided into responders (n = 23) and non-responders (n = 12) based on a clinically meaningful change in gait speed. Joint motion was assessed as overall range of motion as well as at two key time points during the gait cycle: initial contact and toe-off.Results: Responders used both cue types to increase gait speed and induce increases in overall joint ROM at the hip while only self-generated cues also increased ROM at the ankle. Increased joint excursions for responders were also evident at initial contact and toe-off.Conclusions: Our results indicate that self-generated rhythmic cues can induce similar increases in joint excursions as externally-generated cues and that some people may respond more positively than others. These results provide important insight into how self-generated cueing techniques may be tailored to meet the varied individual needs of people with PD.

Bone Health Following Bariatric Surgery: An Update.

Obesity rates are increasing rapidly, and bariatric surgery is currently the most effective tool for weight loss. Recently, bariatric surgery induced bone loss has gained attention. Such detrimental effect on bone is multifactorial and causes may include nutrient deficiencies, gut and gonadal hormonal changes, mechanical unloading, loss of lean mass, increased bone marrow fat, and increased risk of fall. This review describes the available evidence on bone loss and fracture risk following bariatric surgery and summarizes the guidelines on the topic. Increased bone resorption starts early postsurgery, and bone markers peak at 1-2 yr. Across studies, the drop in areal bone mineral density is inconsistent at the lumbar spine, while a 2%-5% drop at 6 mo and a 6%-10.5% at 9-12 mo are observed at the total hip. Conversely, studies using quantitative CT showed a 6%-7% decrease in volumetric bone mineral density at the lumbar spine at 6-12 mo postsurgery. These studies also report significant bone loss at the radius and tibia, in addition to alteration in bone microarchitecture. Fracture risk increases 2 yr after surgery, more so following malabsorptive procedures. Fractures were reported at axial, weight bearing sites and at appendicular sites. The available evidence is very heterogeneous, and mostly derived from studies on Roux-en-y gastric bypass in premenopausal women. Data on restrictive procedures is scarce. Our findings suggest that the early postoperative phase represents the "golden window" to intervene and promote bone health. More research is needed to determine the effect of different bariatric procedures on bone, to identify optimal interventions to prevent bone loss and to characterize high risk individuals who should be targeted.

Patellofemoral pain: One year results of a randomized trial comparing hip exercise, knee exercise, or free activity.

OBJECTIVE: Extended follow-up of a randomized trial comparing hip-focused exercise, knee-focused exercise, and free physical activity in patellofemoral pain (PFP). METHODS: A single-blind randomized controlled trial included 112 patients aged 16-40 years (mean 27.6 years) with a clinical diagnosis of PFP ≥3 months (mean 39 months) and pain ≥3/10 on a Visual Analog Scale. Patients were randomized to a 6-week exercise-based intervention consisting of either isolated hip-focused exercises (n = 39), traditional knee-focused exercise (n = 37), or free physical activity (n = 36). All patients received the same patient education. The primary outcome measure was the Anterior Knee Pain Scale (AKPS, 0-100). Secondary outcomes were usual and worst pain, Tampa Scale of Kinesiophobia, Knee Self-Efficacy Score, Euro-Qol (EQ-5D-5L), step-down test, and isometric strength. Blinded observers assessed outcomes at baseline, 3, and 12 months. The study was designed to detect a difference in AKPS >10 at 12 months. RESULTS: After 1 year, there were no significant between-group differences in any primary or secondary outcomes. Between-group differences for AKPS were as follows: knee versus free physical activity -4.3 (95% CI -12.3 to 3.7); hip versus free physical activity -1.1 (95% CI -8.9 to 6.7); and hip versus Knee 3.2 (95% CI -4.6 to 11.0). The cohort as a whole improved significantly at 3 and 12 months compared to baseline for all measures except for knee extension strength. CONCLUSION: After 1 year, there was no difference in effectiveness of knee exercise, hip exercise, or free physical activity, when combined with patient education in PFP.

Altered hip control during a standing knee-lift test is associated with increased risk of knee injuries.

A few prospective studies have investigated hip and pelvic control as a risk factor for lower extremity (LE) injuries. The purpose of this study was to investigate whether deficits in hip and lumbopelvic control during standing knee-lift test are associated with increased risk of acute knee and LE injuries in youth team sports. At baseline, 258 basketball and floorball players (aged 12-21 years) participated in a standing knee-lift test using 3-dimensional motion analysis. Two trials per leg were recorded from each participant. Peak sagittal plane pelvic tilt and frontal plane pelvic drop/hike were measured. Both continuous and categorical variables were analyzed. New non-contact LE injuries, and match and training exposure, were recorded for 12 months. Seventy acute LE injuries were registered. Of these, 17 were knee injuries (eight ACL ruptures) and 35 ankle injuries. Risk factor analyses showed that increased contralateral pelvic hike was significantly associated with knee injury risk when using categorical variable (HR for high vs low group 4.07; 95% CI 1.32-12.6). Furthermore, significant association was found between high lateral pelvic hike angles and ACL injury risk in female players (HR for high vs low group 9.10; 95% CI 1.10-75.2). Poor combined sensitivity and specificity of the test was observed. In conclusion, increased contralateral pelvic hike is associated with non-contact knee injury risk among young team sport players and non-contact ACL injuries among female players. More research to determine the role of pelvic control as a risk factor for knee injuries is needed.

Protocol for a multicenter prospective cohort study evaluating sport activity and development of femoroacetabular impingement in the adolescent hip.

BACKGROUND: Femoroacetabular impingement (FAI) is an important cause of hip pain in young and active individuals and occurs as a result of size and shape mismatch between the femoral head and acetabulum. Open physes in children can make hips more susceptible to injury, and high impact forces have been suggested to affect the developing femur. The diagnosis of FAI has recently risen, especially within adolescent populations, and there is an increasing trend towards year-round participation in sports with early specialization. The PREVIEW study is an international longitudinal study designed to determine the association between sport specialization in adolescence and the development of hip impingement. METHODS: This is a multicentre prospective cohort study evaluating 200 participants between the ages of 12-14 that include sport specialists at the moderate to vigorous physical activity (MVPA) level and non-sport specialists at any activity level. We will monitor physical activity levels of all participants using an activity log and a wrist-mounted activity tracker, with synced data collected every 3 months during the study period. In addition, participants will be evaluated clinically at 6, 12, and 18 months and radiographically at the time of enrolment and 24 months. The primary outcome is the incidence of FAI between groups at 2 years, determined via MRI. Secondary outcomes include hip function and health-related quality of life between subjects diagnosed with FAI versus no FAI at 2 years, as determined by the Hip Outcome Score (HOS) and Pediatric Quality of Life (PedsQL) questionnaires. DISCUSSION: It is important to mitigate the risk of developing hip deformities at a young age. Our proposed prospective evaluation of the impact of sport activity and hip development is relevant in this era of early sport specialization in youth. Improving the understanding between sport specialization and the development of pre-arthritic hip disease such as FAI can lead to the development of training protocols that protect the millions of adolescents involved in sports annually. TRIAL REGISTRATION: PREVIEW is registered with clinicaltrials.gov (NCT03891563).

Return to play after hip arthroscopy among tennis players: outcomes with minimum five-year follow-up.

BACKGROUND: Playing tennis is associated with various movements that can lead to labral injuries and may require arthroscopic surgery. While hip arthroscopies have demonstrated good outcomes in athletes, there is limited literature reporting patient reported outcomes (PROs) and return to sport (RTS) in competitive or recreational tennis players after arthroscopic hip surgery. Therefore, the purpose of the present study was to (1) report minimum five-year PROs and RTS in tennis players who underwent arthroscopic hip surgery and (2) compare outcomes between recreational and competitive tennis players. METHODS: Data for patients who underwent hip arthroscopy surgery in the setting of femoroacetabular impingement and labral tears between March 2009 and January 2014 and who played tennis within one-year of surgery were retrospectively reviewed. Patients with preoperative and minimum five-year postoperative scores for the following PROs were included: modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), Hip Outcome Score-Sport Specific Subscale (HOS-SSS), and visual analog scale (VAS) for pain. Patient Acceptable Symptomatic State (PASS) and Minimal Clinically Important Difference (MCID) for mHHS and HOS-SSS were calculated. RESULTS: Of 28 patients, 31 hips met all inclusion and exclusion criteria of which 28 (90.3%) had minimum 5-year follow-up (mean: 72.8 ± 13.9 months). There were 3 professional, 3 collegiate, 2 high school, 2 organized amateur, and 18 recreational level tennis players. All PROs significantly improved at latest follow-up: mHHS from 67.0 to 86.7 (P <  0.001), NAHS from 65.9 to 87.2 (P <  0.001), HOS-SSS from 50.0 to 77.9 (P = 0.009), and VAS from 5.4 to 1.8 (P <  0.001). There was a 75.0% RTS rate. Additionally, 66.7% of patients achieved MCID and 83.3% achieved PASS for mHHS, and 63.6% achieved MCID and 58.3% achieved PASS for HOS-SSS. CONCLUSION: Regardless of the level of participation, tennis players who underwent arthroscopic hip surgery reported statistically significant PRO improvements. A favorable rate of RTS was also achieved by players with a continued interest in playing. The data here may be useful in counseling tennis players of various levels who are considering arthroscopic treatment of a hip injury. LEVEL OF EVIDENCE: IV.

Is chronic ankle instability associated with impaired muscle strength? Ankle, knee and hip muscle strength in individuals with chronic ankle instability: a systematic review with meta-analysis.

OBJECTIVE: Determine whether impairments in lower limb muscle strength exist in individuals with chronic ankle instability (CAI) compared with uninjured controls. DESIGN: Systematic review with meta-analysis. DATA SOURCE: A comprehensive search of PubMed, Cochrane, CINAHL, Web of Science and EMBASE electronic databases from inception to 10 February 2019. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Cross-sectional and case-control studies were included if they objectively measured lower limb muscle strength in individuals with CAI compared with controls. Risk of bias and quality of included studies were assessed. Data of included studies were extracted, and meta-analysis was conducted where appropriate. RESULTS: 12 397 unique studies were identified, of which 20 were included and 16 were eligible for meta-analysis. Reviewed studies clearly described the aim/hypothesis and main outcome measure, but most lacked sample size calculation and assessor blinding. Meta-analyses showed individuals with CAI had lower eccentric and concentric evertor strength (30 and 120°/s; Nm; standardised mean difference (SMD) between -0.73 and -0.95), eccentric invertor strength (60 and 120°/s; both Nm and Nm/kg; SMD between -0.61 and -1.37), concentric invertor strength (60 and 120°/s; Nm; SMD=-0.7) and concentric knee extensor strength (SMD=-0.64) compared with control participants. Ankle eccentric dorsiflexor strength was not different between groups. Although pooling was not possible, data from three separate studies indicated that hip flexor, abductor and external rotator strength, but not hip adductor and extensor strength, was lower in individuals with CAI than in control participants. CONCLUSION: Individuals with CAI have ankle inversion and eversion strength deficits. Our data also point to differences between individuals with CAI and controls in hip and knee strength. These elements of the kinetic chain should be evaluated by clinicians who rehabilitate individuals with CAI. PROSPERO REGISTRATION NUMBER: CRD42016037759.

Patient-reported outcome measures for hip-related pain: a review of the available evidence and a consensus statement from the International Hip-related Pain Research Network, Zurich 2018.

Hip-related pain is a well-recognised complaint among active young and middle-aged active adults. People experiencing hip-related disorders commonly report pain and reduced functional capacity, including difficulties in executing activities of daily living. Patient-reported outcome measures (PROMs) are essential to accurately examine and compare the effects of different treatments on disability in those with hip pain. In November 2018, 38 researchers and clinicians working in the field of hip-related pain met in Zurich, Switzerland for the first International Hip-related Pain Research Network meeting. Prior to the meeting, evidence summaries were developed relating to four prioritised themes. This paper discusses the available evidence and consensus process from which recommendations were made regarding the appropriate use of PROMs to assess disability in young and middle-aged active adults with hip-related pain. Our process to gain consensus had five steps: (1) systematic review of systematic reviews; (2) preliminary discussion within the working group; (3) update of the more recent high-quality systematic review and examination of the psychometric properties of PROMs according to established guidelines; (4) formulation of the recommendations considering the limitations of the PROMs derived from the examination of their quality; and (5) voting and consensus. Out of 102 articles retrieved, 6 systematic reviews were selected and assessed for quality according to AMSTAR 2 (A MeaSurement Tool to Assess systematic Reviews). Two showed moderate quality. We then updated the most recent review. The updated literature search resulted in 10 additional studies that were included in the qualitative synthesis. The recommendations based on evidence summary and PROMs limitations were presented at the consensus meeting. The group makes the following recommendations: (1) the Hip and Groin Outcome Score (HAGOS) and the International Hip Outcome Tool (iHOT) instruments (long and reduced versions) are the most appropriate PROMs to use in young and middle-aged active adults with hip-related pain; (2) more research is needed into the utility of the HAGOS and the iHOT instruments in a non-surgical treatment context; and (3) generic quality of life measures such as the EuroQoL-5 Dimension Questionnaire and the Short Form Health Survey-36 may add value for researchers and clinicians in this field. We conclude that as none of the instruments shows acceptable quality across various psychometric properties, more methods studies are needed to further evaluate the validity of these PROMS-the HAGOS and iHOT-as well as the other (currently not recommended) PROMS.

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.

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.

'My hip is damaged': a qualitative investigation of people seeking care for persistent hip pain.

OBJECTIVES: Clinicians who use the biopsychosocial approach to manage musculoskeletal pain disorders aim to understand how patients make sense of their symptoms. Treatment includes targeting the negative beliefs and coping responses that can lead to progressive pain and disability. We aimed to explore how people seeking care for persistent hip pain and disability make sense of their symptoms. METHODS: Cross-sectional qualitative study. People were eligible if they were aged ≥18 years, were consulting an orthopaedic surgeon for persistent hip pain and offered a non-surgical intervention. Data were collected through interviews that explored patients' beliefs about the identity (diagnosis), causes, consequences, timeline and controllability of their symptoms, their strategies to cope with pain and their experiences in seeking healthcare. Transcribed interview data were analysed thematically using a framework approach. RESULTS: Sixteen people (median age=51, range=33-73 years; median duration hip pain=3 years, range=3 months-20 years) participated. Most participants (10/16) believed their pain was caused by an exercise-related injury. Because of the results of imaging and interactions with healthcare professionals, all participants believed they had damaged hip structures. All described ineffective strategies to manage their pain and multiple failed treatments. For many (7/16), a lack of control over symptoms threatened their physical and mental health. CONCLUSIONS: The way participants with persistent hip pain and disability made sense of their symptoms contributed to them avoiding physical activity, and it impaired their sleep, emotional well-being and physical health.

Wearable hip-assist robot modulates cortical activation during gait in stroke patients: a functional near-infrared spectroscopy study.

BACKGROUND: Gait dysfunction is common in post-stroke patients as a result of impairment in cerebral gait mechanism. Powered robotic exoskeletons are promising tools to maximize neural recovery by delivering repetitive walking practice. OBJECTIVES: The purpose of this study was to investigate the modulating effect of the Gait Enhancing and Motivating System-Hip (GEMS-H) on cortical activation during gait in patients with chronic stroke. METHODS: Twenty chronic stroke patients performed treadmill walking at a self-selected speed either with assistance of GEMS-H (GEMS-H) or without assistance of GEMS-H (NoGEMS-H). Changes in oxygenated hemoglobin (oxyHb) concentration in the bilateral primary sensorimotor cortex (SMC), premotor cortices (PMC), supplemental motor areas (SMA), and prefrontal cortices (PFC) were recorded using functional near infrared spectroscopy. RESULTS: Walking with the GEMS-H promoted symmetrical SMC activation, with more activation in the affected hemisphere than in NoGEMS-H conditions. GEMS-H also decreased oxyHb concentration in the late phase over the ipsilesional SMC and bilateral SMA (P < 0.05). CONCLUSIONS: The results of the present study reveal that the GEMS-H promoted more SMC activation and a balanced activation pattern that helped to restore gait function. Less activation in the late phase over SMC and SMA during gait with GEMS-H indicates that GEMS-H reduces the cortical participation of stroke gait by producing rhythmic hip flexion and extension movement and allows a more coordinate and efficient gait patterns. Trial registration NCT03048968. Registered 06 Feb 2017.

Step descent strategy is altered bilaterally despite unilateral muscle strength impairment after total knee arthroplasty.

PURPOSE: Muscle weakness and difficulty descending stairs are common after unilateral total knee arthroplasty (TKA), but the relationship between each is unclear. The purpose of this study was to compare lower extremity muscle strength, lower extremity support moments during step descent, and assess relationships between each. METHODS: The study included 40 subjects (20 post-TKA, 20 control). Knee extensor, hip abductor, and hip external rotator strength were measured and biomechanical analyses of step descent performed. Patients with TKA were assessed 3 and 6 months post-surgery. RESULTS: At 3 and 6 months post-TKA, operated limb hip external rotator and knee extensor strength were impaired compared to the non-operated limb (p < 0.01); however, no between-limb differences were observed during step descent. Compared to the control group, hip external rotator and knee extensor strength, total lower extremity support moment, and knee support moment during step descent were impaired post-TKA (p < 0.05). At 6 months post-TKA, knee extensor and hip external rotator strength correlated with total support moment during step descent (rs = 0.40, 0.41, p < 0.02). Hip abductor and external rotator strength negatively correlated with knee support moment during step descent (rs = - 0.35, - 0.39, p < 0.03). CONCLUSIONS: Persistent operative limb knee extensor and hip external rotator muscle weakness are noted following unilateral TKA. Despite unilateral weakness, bilateral alterations in step descent strategy occur following TKA. Patients with TKA utilize hip musculature to reduce knee muscle demand during step descent, possibly contributing to limitations in long-term step descent performance.

Muscle Size and Quality of the Gluteal Muscles and Tensor Fasciae Latae in Women with Greater Trochanteric Pain Syndrome.

Greater trochanteric pain syndrome (GTPS) is prevalent in women and severely impacts quality of life. A key muscle group demonstrating reduced strength are the hip abductors. An understanding of specific muscles affected will help guide targeted rehabilitation. Objectives of this case-control study were to compare gluteal and tensor fasciae latae (TFL) muscle size and quality (fatty infiltration) in women with symptomatic GTPS to asymptomatic age-matched female controls. Magnetic resonance imaging of 16 women with GTPS (mean age 55.75 years, range 23-69) and 15 asymptomatic controls (mean age 55.60 years, range 31-66) was undertaken. Muscle volumes of the gluteus maximus, gluteus medius, gluteus minimus, and TFL were calculated. Fatty infiltration was rated using the Goutallier classification system for all muscles in their entirety, as well as anterior and posterior segments of gluteus medius and minimus. Muscle volumes and fatty infiltration were compared between groups. Significantly smaller muscle volumes were identified in the symptomatic group for the upper (P = 0.01) and lower (P = 0.04) portions of gluteus maximus, gluteus medius (P = 0.03), and gluteus minimus (P = 0.02). There was no difference in TFL (P = 0.18). Symptomatic participants displayed significantly greater fatty infiltration in gluteus maximus upper (P = 0.021) and lower (P = 0.049) when adjusted for BMI, and gluteus minimus (P = 0.018), particularly in the posterior portion (P = 0.04). Anterior gluteus minimus demonstrated high amounts of fatty infiltration in both groups. Gluteal muscle atrophy and fatty infiltration in women with GTPS suggests gluteus maximus and minimus may be an important target for rehabilitation. Clin. Anat., 33:1082-1090, 2020. © 2019 Wiley Periodicals, Inc.

Photo-Based Range-of-Motion Measurement: Reliability and Concurrent Validity in Children With Cerebral Palsy.

PURPOSE: To investigate intrarater and interrater reliability, agreement, and concurrent validity of a smartphone photography-based application compared with a universal goniometer in children with cerebral palsy. METHODS: Range of motion of hip abduction, popliteal angle, and ankle dorsiflexion was measured with a universal goniometer and a photography-based application in children with cerebral palsy, Gross Motor Function Classification System levels I to V.A 2-way random-effects intraclass correlation coefficients and Bland-Altman plots, standard error of measurement, and smallest detectable change were used for analyses. RESULTS: The application had good to excellent reliability and concurrent validity compared with a universal goniometer, while the large measurement error of both methods suggests that changes of 10° to 23° are needed to be certain that changes over time are not results of measurement error. CONCLUSIONS: A photography-based goniometer can be a reliable and valid tool when measuring range of motion in children with cerebral palsy.