Physical Therapy in Sport 52 (2021) 224e233

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Physical Therapy in Sport

journal homepage: www.elsevier.com/ptsp

Physical impairments in longstanding hip and groin pain: Cross-

sectional comparison of patients with hip-related pain or non-hip-
related groin pain and healthy controls
Anders Pålsson a, *, Ioannis Kostogiannis b, Eva Ageberg a
a
Department of Health Sciences, Lund University, Lund, Sweden
b
Department of Orthopaedics, Clinical Sciences, Lund University, Lund, Sweden

a r t i c l e i n f o a b s t r a c t

Article history: Objectives: To compare physical impairments between patients with hip-related pain and those with
Received 24 June 2021 non-hip-related groin pain, and to compare both patient groups with healthy controls.
Received in revised form Design: Cross-sectional.
14 September 2021
Participants: Eighty-one hip and groin pain patients were consecutively included and categorized into
Accepted 19 September 2021
having hip-related pain or non-hip-related groin pain. Twenty-eight healthy controls were recruited.
Settings: Tertiary care.
Keywords:
Main outcome measures: All participants performed physical impairment testing including hip ROM,
Hip
Groin
muscle function, and functional tasks. An analysis of covariates was used for analysis between patients
Pain groups and controls.
Physical performance Results: Patients with hip-related pain showed reduced hip ROM in internal rotation compared to pa-
tients with non-hip-related groin pain and controls (p
0.026, d 0.65; 0.97). No differences in muscle
function or performance in functional tasks were observed between patients with hip-related pain and
those with non-hip-related groin pain (p  0.136, d 0.00; 0.68). Both patient groups had worse muscle
function and worse performance in functional tasks compared to controls (p
0.048, d 0.67; 1.83).
Conclusions: Both patients with and without hip-related pain had worse muscle function and worse
performance in functional tasks compared to matched controls but no differences were observed be-
tween the patient groups. Only patients with hip-related pain had reduced ROM in internal rotation.
© 2021 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY license
(http://creativecommons.org/licenses/by/4.0/).

1. Introduction
Following patient history taking, clinical examination, and im-
aging, young to middle-aged patients presenting with longstanding
pain in the hip and groin can be categorized as having hip-related
pain, using a set of diagnostic criteria described in international
consensus statements (Griffin et al., 2016; Reiman et al., 2020). The
source of hip-related pain is thought to originate from intra-articular
structures, where FAI syndrome, acetabular dysplasia, and labral
and/or chondral conditions are the most common diagnoses
(Reiman et al., 2020). Hip and groin pain not categorized as hip-
related pain, i.e., non-hip-related groin pain, is thought to originate
* Corresponding author. Department of Health Sciences, Lund University, PO Box
157, 22100, Lund, Sweden.
E-mail addresses: anders.palsson@med.lu.se (A. Pålsson), ioannis.kostogiannis@
med.lu.se (I. Kostogiannis), eva.ageberg@med.lu.se (E. Ageberg).
from extra-articular structures such as the hip adductors, the hip
flexors, the inguinal region, or the pubic symphysis (Holmich, 2007;
Weir et al., 2015). First line treatment for patients with longstanding
hip and groin pain, with or without hip-related pain is suggested to
include education, modification of activity level, analgesics, and
exercise-based treatment (Casartelli et al., 2019; Griffin et al., 2016,
2018; Holmich et al., 1999, 2011). Additional hip surgery may be an
option for patients with hip-related pain who do not respond to first
line treatment (Griffin et al., 2016, 2018). Exercise-based treatment
has shown to improve hip related quality of life (Griffin et al., 2018;
Kemp et al., 2018) and should target the patient's physical impair-
ments (Kemp et al., 2019b). However, current exercise-based treat-
ment may not be based on best evidence (Kemp et al., 2019b).
Physical impairments such as reduced muscle function and
decreased performance in functional tasks has been reported in
patients with longstanding hip and groin pain (Diamond et al., 2015;
Freke et al., 2016). However, in previous studies, mainly patients with

https://doi.org/10.1016/j.ptsp.2021.09.011
1466-853X/© 2021 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
A. Pålsson, I. Kostogiannis and E. Ageberg
hip-related pain, such as femoroacetabular impingement (FAI) syn-
drome, or patients with non-specific hip and groin pain have been
investigated (Diamond et al., 2015; Freke et al., 2016; Mosler et al.,
2015). Moreover, it is unknown whether there are differences in
physical impairments between patients with hip-related pain and
those categorized as having non-hip-related groin pain. If that would
be the case, exercise-based treatment should address any specific
needs of each patient group. Thus, to further improve exercise-based
treatment for patients with longstanding hip and groin pain, better
understanding of physical impairments in patients with and without
hip-related pain, and in comparison to asymptomatic individuals, is
needed. Therefore, the aims were to: 1) compare physical impair-
ments between patients with hip-related pain and those with non-
hip-related groin pain, and 2) Compare physical impairments be-
tween both patient groups and healthy controls.
2. Methods
Our reporting for this exploratory cross-sectional study adheres
to the STROBE statement (www.strobe-statement.org). The
Regional Ethical Review Board in Lund approved the study (Dnr
2014/12) and the participants signed an informed consent and the
rights of subjects were protected. This study is a part of a larger
project investigating patient characteristics, diagnosis, and physical
impairments in young to middle-aged patients with longstanding
hip and groin pain. Data on patient characteristics and patient-
reported outcomes from the present cohort have previously been
published (Pålsson et al., 2019).
3. Participants
From 2014 to 2017, all patients aged 18e55 years old who were
referred for non-arthritic hip and groin pain lasting >3 months
(n ¼ 148) to the Department of Orthopedics, Skåne University Hos-
pital, Sweden, were screened for eligibility. Patients with verified
moderate or severe osteoarthritis (To €nnis grade >1) or any other
musculoskeletal comorbidities overriding the hip and groin pain, or
limitations preventing testing of physical impairments, were
excluded. All exclusion criteria are described in full detail in a previous
study based on the same cohort (Pålsson et al., 2019). Ninety-five
patients were found eligible, of whom fourteen patients declined
participation. Eighty-one patients were finally included in the study.
The patients were categorized as having hip-related pain using
diagnostic criteria (Griffin et al., 2016; Reiman et al., 2020). For hip-
related pain, the following four criteria had to be met: 1) Passive
ROM decreased or end-range pain; 2) Pain provocation during hip
impingement tests; 3) Findings on radiological examination, MRI/
MRA, or during arthroscopic examination that are assumed to cause
hip-related pain and symptoms (Heerey et al., 2018) (cam
morphology (alpha angle 60 ), Pincer morphology (lateral center
edge angle) (LCEA) 40 ), hip dysplasia (LCEA
20 ), acetabular
labral tear or chondral conditions); and 4) Responder to diagnostic
intra-articular injection (50% decrease of pain registered on a visual
analog scale (VAS) 0e4 h after injection). If these four criteria for hip-
related pain were not met, the patient was categorized as having non-
hip-related groin pain. Further details on the methods used for the
categorization into hip-related pain and non-hip-related groin pain of
this cohort including description of symptoms, clinical tests, imaging,
and the intra-articular injection are described in a previous publica-
tion based on the same cohort (Pålsson et al., 2019).
Eleven patients declined block injection, or had missing data for
patient-reported response after block injection, and could therefore
not be categorized. Finally, 70 patients were categorized as either
having hip-related pain (n ¼ 33, 47%) or non-hip-related groin pain
(n ¼ 37, 53%). The prevalence of the different diagnoses related to
225
Physical Therapy in Sport 52 (2021) 224e233
hip-related pain are presented in Table 1.
Twenty-eight healthy controls matched for sex, age, and activity
level (physically active on recreational level) were recruited
through convenience sampling (students at the faculty of medicine,
circle of acquaintances, and collages) between 2016 and 2017. The
controls' activity level matched the patients’ Hip Sports Activity
Scale score as described (Pålsson et al., 2019). Patient and control
characteristics are described in Table 2.
4. Test procedure
All tests were performed by one tester (AP). Body mass, height,
and length of total leg (from the anterior superior iliac spine (ASIS) to
the medial malleolus), thigh (from the ASIS the medial joint line of
the knee) and lower leg (from the medial joint line of the knee to the
medial malleolus) were measured. All tests were performed first on
the right leg, except for isometric strength and hop performance in
which the starting leg was chosen in an alternating fashion.
5. Physical impairment testing
5.1. Hip ROM
Hip ROM was measured according to Pua et al. (2008) with a
digital inclinometer and a digital goniometer (Commander Echo
(JTECH Medical, Salt Lake City, Utah, USA). The mean value ( ) of
two measurements in each direction served as the outcome.
5.1.1. Flexion
Passive flexion was measured in a supine position. The digital
inclinometer was attached at the lateral aspect of the thigh 10 cm
proximal to the knee joint. The contralateral thigh was fixed with a
belt.
5.1.2. Internal/external rotation with 90 hip flexion
Passive internal and external rotation were measured with the
participant in a seated position at the edge of a table with 90 of
flexion in the hip and knee joints. The inclinometer was attached at
the anterior aspect of the lower leg 10 cm proximal to the medial
malleolus. For stabilization of the pelvis and trunk, the participant
was instructed to hold onto the edge of the table.
5.1.3. Internal rotation in neutral hip position
Passive internal rotation in neutral position was measured with
the participant in prone position with both knees at 90 flexion. The
pelvis was stabilized with a fixation belt. The inclinometer was
attached at the anterior aspect of the lower leg 10 cm proximal to
the medial malleolus.
5.1.4. Abduction
Passive abduction was measured with an extended digital
goniometer. The participant was in a supine position, with the
contralateral leg hanging down on the edge of the table to stabilize
the pelvis. The center of the goniometer was placed over the
Table 1
The prevalence (n and %) of the different diagnoses for patients with hip-related
pain.
Diagnosis n %
FAI syndrome 32 97
- Cam morphology 21 66
- Pincer morphology 9 28
- Mixed type morphology 2 6
- FAI syndrome with acetabular labral tear and/or chondral lesion 16 50
Isolated chondral lesion 1 3
A. Pålsson, I. Kostogiannis and E. Ageberg
Table 2
Participant characteristics. Data is expressed as mean (SD) unless otherwise stated.
Hip-related pain (n ¼ 33)Mean (SD)
Age, years 35 (10)
Women, n/% 10/30
Height, cm 176.4 (8.6)
BMI, kg/m2 25.96 (4.31)
Unilateral symptoms left/right, n 16/12
Bilateral symptoms, n 5 4
ipsilateral ASIS. The stationary arm of the goniometer was aligned
with the contralateral ASIS and the moveable arm was aligned
along the thigh to the center of the patella.
5.2. Muscle function
5.2.1. Isometric hip strength
Isometric strength was measured with a hand-held dynamom-
eter (Power Track II Commander (JTECH Medical, Salt Lake City,
Utah, USA)). A modified version of a test protocol by Thorborg et al.
(2010, 2013a, 2013b) was used. A submaximal test was performed
prior to the measurement to ensure correct technique. The partic-
ipant was instructed to push the leg as hard as possible against the
dynamometer for 5 s during strong verbal encouragement. The
dynamometer was fixed with a belt by the tester. Maximal value (N)
of three repetitions was recorded. Maximal torque was calculated
using total leg, thigh or lower leg length and was normalized to
bodyweight (Nm/kg bw).
5.2.2. Adduction/abduction
Tested in a supine position. The contralateral foot was placed on
the table. For stabilization, the subject was instructed to hold on to
the edges on the table during the test. The dynamometer was
placed 10 cm proximal to the medial malleolus on the medial
aspect for adduction and the lateral aspect for abduction.
5.2.3. Extension
Tested in a prone position with approximately half the length of
the lower leg off the edge of the table. The pelvis was stabilized by a
belt. The hands were placed above the head on the table during the
test. The dynamometer was placed on the posterior aspect of the
leg 10 cm proximal to the medial malleolus.
5.2.4. Internal/external rotation
Tested in prone position with the knee at 90 flexion. The pelvis
was stabilized with a fixation belt. The hands were placed above the
head on the table during the test. The dynamometer was placed
10 cm proximal to the medial malleolus on the lateral aspect for
internal rotation and on the medial aspect for external rotation.
5.2.5. Flexion
Tested in standing position with the back against a wall and the
hip at 90 flexion. The head and hands were placed against the wall
during the test. The dynamometer was placed on the anterior
aspect of the thigh 10 cm proximal to the knee joint.
5.2.6. Double leg lowering test
For trunk muscle function testing, double leg lowering test
(DLLT) was used. Trunk muscle function and pelvic control is
regarded as an important function for hip joint mechanics (Kemp
et al., 2019a). The DLLT aims to test the ability to maintain pelvic
control during eccentric contraction of the hip flexors. For this
study a modified DLLT was developed for direct measurement of
the pelvic tilt and the degree of maximal extension during the test.
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Physical Therapy in Sport 52 (2021) 224e233
Non-hip-related groin pain (n ¼ 37)Mean (SD) Controls (n ¼ 28)Mean (SD)
35 (8) 33 (9)
23/62 13 (46)
173.3 (10.3) 176.4 (10.1)
24.21 (3.51) 23.47 (2.36)
10/23 NA
NA
This was achieved with an iPod-based tilt sensor (Apple Inc.)
attached to the pelvis by a fixation belt and with a digital incli-
nometer (Commander Echo (JTECH Medical, Salt Lake City, Utah,
USA)) attached to the thigh. The test was performed in supine
position with the legs elevated to 70 hip flexion and the knee
joints in full extension. The hands were kept at waist level with the
palms facing the floor. The participant was instructed to lower the
legs while maintaining the lumbar spine against the floor. The hip
extension angle ( ) when the pelvis reached 10 anterior tilt was
recorded. The mean value of three trials served as the outcome.
5.3. Functional tasks
5.3.1. Standing active single leg raise
Pelvic control is required for normal hip function, especially for
patients with hip conditions (Kemp et al., 2019a). Pelvic control
during a single leg task was measured with standing active single
leg raise (SASLR) test. During the SASLR, the peak range of medial to
lateral and anterior to posterior pelvic tilt was measured. This test
was performed according to protocol by Chaudhari et al. (2011,
2014). An iPod-based tilt sensor (Apple Inc.) was attached to the
sacrum by a fixation belt. The participant stood with their feet
40 cm apart, their weight equally distributed across both feet, and
arms hanging relaxed along the body. The participant was
instructed to lift one foot over a platform (height: 10 cm) without
touching the top and then return to the starting position. The
procedure was repeated 3 times on each side. The mean range of
peak medial to lateral and anterior to posterior pelvic tilt ( ) during
the three repetitions served as the outcome.
5.3.2. Dynamic balance control
Dynamic balance control has previously been shown to be
reduced in patients with hip and groin pain (Freke et al., 2018) and
was assessed with the Y-balance test as described (Plisky et al.,
2009). The participant was instructed to stand on one leg and
reach the contralateral leg as far as possible in anterior, 45 posterior-
lateral, and 45 posterior-medial directions. Trunk and arm move-
ment as well as knee bending were allowed during test. Each di-
rection was tested three times and the maximal distance was
recorded. The test was invalid if weight bearing was taken on the
reaching leg, if balance was lost, if any part of the foot sole on the
standing leg left the floor, or if the participant did not manage to
return to the starting position. The maximal distance was normal-
ized to leg length, expressed as percent of total leg length (%LL).
5.3.3. 30-Second side-hop test
The participant performed as many one-leg side jumps as
possible across two tape-stripes, 40 cm apart, for 30 s. The test was
video recorded. The number of successful jumps (outside the
stripes, not touching the stripes) was counted in retrospect from
the video footage.
5.3.4. Single-leg hop for distance
The participant was instructed to jump as far as possible on one
A. Pålsson, I. Kostogiannis and E. Ageberg Physical Therapy in Sport 52 (2021) 224e233

leg, taking off and landing on the same leg. The distance from toe at
push-off to the heel on landing was measured. The maximal dis-
tance of three repetitions was recorded.
5.3.5. Intra-tester reliability
Excellent intra-tester reliability (ICC >0.8) for the hop tests has
been reported in a systematic review (Kivlan & Martin, 2012). The
remaining tests were pre-assessed for intra-tester reliability in
15e20 healthy participants recruited by convenience sampling and
not included as controls in our cohort, showing ICC values above 0.8
for all tests except ROM abduction and isometric medial rotation
(Table 3). Passive ROM in extension was excluded due to poor test-
retest reliability (ICC <0.2).
the analysis in any variable (p > 0.086) except for anterior direction
in Y-balance test in favour for the excluded participants (p < 0.041).
6.2. Hip ROM
Patients with hip-related pain showed reduced hip ROM in in-
ternal rotation in both 90 flexion and in neutral position compared
to patients with non-hip-related groin pain (p
0.026) (d 0.97
to 0.65), and in neutral position compared to controls (p
0.026)
(d 0.70). Hip ROM did not differ between patients with non-hip-
related groin pain and controls (p  0.64) (d 0.30 to 0.28) (Table 4).
6.3. Muscle function

5.4. Statistical analysis
For patients with unilateral symptoms only data from the
symptomatic hip was used in the analysis. For patients with bilat-
eral symptoms, data from the hip that the patient perceived most
affected was used. No differences were found between legs in the
control group and, therefore, values from the right leg were used in
the analysis.
All variables were analyzed for skewness using Kolmogorov-
Smirnov test Values for all variables and all groups were dis-
played as mean and standard deviation (SD). For between group
analysis, an analysis of covariates (ANCOVA) was performed with
each variable combined with sex as covariate due to the uneven
distribution of male and female patients in the patient groups. The
mean differences between groups as well as the confidence in-
tervals were Bonferroni adjusted due to multiple comparisons. Ef-
fect sizes for all between group differences were calculated
according to Cohen's d, with thresholds of small (d < 0.50), medium
(d ¼ 0.50e0.80), and large (d > 0.80).
Due to the exploratory design of the study, no a priori power
calculation was conducted. However, based on previous cross-
sectional studies included in a systematic review on physical im-
pairments in patients with FAI-syndrome (Freke et al., 2016), the
number of participants in each group were estimated to be suffi-
cient to detect possible differences in the different variables.
6. Results
6.1. Dropout analysis
The eleven participants excluded from the analysis (patients
that could not be categorized as having hip-related pain or non-hip
related groin pain), did not differ from the participants included in
Muscle function did not differ between patients in the hip-related
pain group and the group with non-hip-related groin pain (p  0.96)
(d 0.00 to 0.26). Both patient groups had worse muscle function
compared to controls (p
0.048) (d 1.83 to 0.67). (Table 4).
6.4. Functional tasks
Dynamic balance control or hop performance did not differ
between the patient groups (p  0.136) (d 0.23 to 0.68). Both
patient groups had reduced dynamic balance and worse hop per-
formance compared to controls (p < 0.01) (d 1.49 to 0.77). No
differences in SASLR were noted between the patient groups or
between patients and controls (p  0.099) (d 0.00e0.56) (Table 4).
7. Discussion
The results showed reduced hip ROM in internal rotation in
patients with hip-related pain compared to those with non-hip-
related groin pain and controls. Both patient groups had impair-
ments in hip and trunk muscle function, dynamic balance control,
and hop performance compared to healthy controls, with no dif-
ferences between the patient groups.
Restricted hip internal rotation in a heterogenous patient group
of athletes with hip and groin pain compared to pain-free athletes
has been observed in a systematic review with meta-analysis
(Mosler et al., 2015). In the present study, including patients
referred to tertiary care due to longstanding hip and groin pain, we
only found restricted internal rotation in patients with hip-related
pain. A restricted internal rotation in patients with hip-related pain
is considered to be a consequence of the bony interaction between
the femur and the acetabulum in cam and/or Pincer morphology
(Byrd, 2014). However, two systematic reviews on hip ROM in pa-
tients with hip-related pain report contradictory results (Diamond

Table 3
Intra-tester reliability with Intraclass Correlation Coefficient (ICC3.1) values and 95% confidence interval (95%CI), standard error of measure-
ment in absolute values and per cent (%) for all tests.

TESTS ICC (95%CI) SEM (%)

ROM flexion 0.839 (0.643; 0.933) 4.1 (4.9)

ROM internal rotation with 90 hip flexion 0.868 (0.685; 0.947) 3.6 (1.2)
ROM external rotation with 90 hip flexion 0.842 (0.641; 0.934) 5.1 (2.0)
ROM internal rotation with neutral hip position 0.941 (0.859; 0.976) 2.6 (6.3)
ROM abduction 0.635 (0.193; 0.848) 3.1 (1.3)
Isometric strength flexion 0.942 (0.883; 0.971) 13.2N (7.8)
Isometric strength adduction 0.889 (0.697; 0.963) 19.0N (9.3)
Isometric strength abduction 0.865 (0.629; 0.955) 14.5N (7.5)
Isometric strength extension 0.921 (0.738; 0.975) 20.8N (8.1)
Isometric strength internal rotation 0.721 (0.347; 0.900) 17.5N (11.3)
Isometric strength external rotation 0.864 (0.625; 0.954) 15.1N (9.3)
Double leg lowering test 0.895 (0.730; 0.962) 3.7 (10.5)
SASLR frontal plane 0.972 (0.920; 0.990) 0.5 (6.0)
SASLR sagital plane 0.889 (0.691; 0.961) 0.4 (6.0)
Y-balance test (ant þ pos-med þ post-lat) 0.855 (0.359; 0.957) 0.08m (3.5)

Number of participants for each test (n). ROM n ¼ 20, Isometric strength and DLLT n ¼ 15, SASLR n ¼ 16, Y-balance test ¼ 20.
227
A. Pålsson, I. Kostogiannis and E. Ageberg Physical Therapy in Sport 52 (2021) 224e233

Table 4
Result for the physical impairment testing expressed in observed mean with standard deviation (SD), Bonferroni adjusted mean group differences with 95% confidence interval
(95%CI), and effect size (Cohen's d) with 95% confidence interval (95%CI) for patients in the hip-related pain group (n ¼ 33), the group with non-hip-related groin pain (n ¼ 37),
and controls (n ¼ 28). Bold numbers represent significant differences (p < 0.05).

Tests Hip-related Non-hip- Controls Hip-related pain vs non-hip- Hip-related pain vs Controls Non-hip-related groin pain vs
pain related groin related groin pain controls
pain

n Mean N Mean n Mean Mean diff. Effect size Mean diff. Effect size Mean diff. Effect size
(SD) (SD) (SD) (95%CI) d (95%CI) (95%CI) d (95%CI) (95%CI) d (95%CI)

Hip ROM ( )
a
Flexion 33 95.4 34 102.1 28 102.9 5.3 (12.2; 0.47 (0.95; 6.8 (13.9; 0.60 1.5 (8.5; 0.14 (0.64;
(9.7) (12.0) (12.3) 1.6) 0.01) 0.3) (1.11; 0.34) 5.5) 0.37)

Internal rotation with 90 hip 33 23.8 34 30.9 28 28.6 ¡4.5 (-8.6; 0.65 3.5 (7.8; 0.51 1.0 (3.2; 5.2) 0.14 (0.36;
a
flexion (7.3) (8.1) (7.7) -0.4) (1.14; 0.16) 0.7) (1.02; 0.24) 0.64
External rotation with 90 hip 33 37.3 34 39.3 28 40.9 0.9 (5.1; 0.14 (0,62; 3.1 (7.4; 0.45 2.2 (6.4; 0.30 (0.81;
a
flexion (8.8) (6.6) (4.3) 3.3) 0.3) 1.2) (0.95; 0.19) 2.1) 0.20)
Internal rotation with neutral 33 33.1 34 44.2 28 40.3 ¡7.3 (-11.9; 0.97 ¡5.3 (-10.0; 0.70 (1.23; 2.0 (2.7; 6.7) 0.28 (0.22;
a
hip position (10.4) (8.2) (9.7) -2.6) (1.47; 0.47 -0.5) 0.43) 0.78)
Abduction 33 24.7 37 27.1 28 25.8 1.8 (5.2; 0.34 (0.81; 0.8 (4.3; 0.14 (0.65; 1.0 (2.5; 4.5) 0.20 (0.29;
a
(5.9) (6.1) (4.9) 1.6) 0.13) 2.8) 0.11) 0.70)

Muscle function

Isom. adduction (Nm/kg bw) 33 1.70 37 1.50 27a 2.18 0.04 (0.29; 0.00 (0.47; ¡0.61 (-0.88; 1.57 ¡0.57 (-0.83; 1.52
(0.58) (0.55) (0.51) 0.21) 0.47) -0.34) (2.08; 1.31) -0.31) (2.08; 0.96)
Isom. abduction (Nm/kg bw) 33 1.61 37 1.54 27a 2.13 0.08 (0.29; 0.28 (0.75; ¡0.60 (-0.82; 1.69 ¡0.52 (-0.74; 1.37
(0.45) (0.44) (0.29) 0.14) 0.19) -0.34) (2.21; 1.43) -0.31) 1.92; 0.82)
Isom. extension (Nm/kg bw) 33 2.18 37 2.05 27a 2.61 0.08 (0.41; 0.00 (0.47; ¡0.55 (-0.90; 0.91 ¡0.47 (-0.81; 0.94
(0.69) (0.60) (0.59) 0.25) 0.47) -0.20) (1.42; 0.65) -0.13) (1.46; 0.42)
Isom. external rotation (Nm/kg 33 0.48 37 0.43 27a 0.62 0.001 (0.06; 0.00 (0.47; ¡0.17 (-0.23; 0.91 ¡0.17 (-0.23; 0.89
bw) (0.12) (0.11) (0.14) 0.06) 0.47) -0.10) (1.42; 0.65) -0.10) (1.41; 0.37)
Isom. internal rotation (Nm/kg 33 0.43 37 0.42 27a 0.56 0.02 (0.09; 0.00 (0.47; ¡0.14 (-0.22; 1.83 ¡0.12 (-0.20; 1.77
bw) (0.15) (0.13) (0.10) 0.06) 0.47) -0.07) (2.34; 1.57) -0.05) (2.36; 1.19)
Isom. flexion (Nm/kg bw) 33 0.91 37 0.84 25a 1.12 0.03 (0.19; 0.00 (0.47; ¡0.28 (-0.46; 0.73 ¡0.25 (-0.42; 0.71
(0.34) (0.31) (0.24) 0.13) 0.47) -0.10) (1.24; 0.47 -0.08) (1.22; 0.20
Double leg lowering test ( ) 29a 37.3 32a 33.8 25a 46.7 3.7 (5.3; 0.26 (0.24; ¡9.3 (-18.6; 0.67 ¡13.0 (-22.0; 0.93
(14.7) (13.2) (12.9) 12.6) 0.77) -0.07) (1.20; 0.40) -3.9) (1.48; 0.39)

Functional tasks

SASLR frontal plane ( ) 32a 8.5 (2.0) 35a 8.1 (2.0) 26a 7.2 (2.0) 0.3 (0.9; 0.15 (0.33; 1.2 (0.1; 2.5) 0.56 (0.04: 0.9 (0.4; 2.1) 0.47 (0.04;
1.5) 0.63 0.82) 0.99)
SASLR sagittal plane ( ) 32a 7.1 (3.9) 35a 5.7 (2.1) 26a 5.7 (2.3) 1.4 (0.3; 0.48 0.00; 0.97) 1.4 (0.5; 3.3) 0.48 (0.05; 0.03 (1.9; 0.00 (0.52:
3.2) 0.74) 1.8) 0.51)
Y-balance test anterior (%LL) 30a 65.7 29a 65.6 26a 72.0 0.9 (3.3; 0.15 (0.36; ¡5.7 (-10.0; 0.91 ¡6.6 (-10.9; 1.07
(5.4) (6.1) (7.9) 5.1) 0.66) -1.5) (1.42; 0.64) -2.4) (1.64; 0.50)
Y-balance test postero-lateral 30a 101.9 29a 101.0 26a 116.6 1.7 (7.3; 0.23 (0.74; ¡12.9 (-18.6; 1.49 ¡11.2 (-16.9; 1.27
(%LL) (14.9) 11.6) (11.2) 3.9) 0.28) -7.2) (2.02; 1.22) -5.5) (1.85; 0.69)
a a a
Y-balance test postero-medial 30 108.3 29 109.7 26 121.0 0.4 (8.0; 0.08 (0.43; ¡15.1 (-23.6; 1.16 ¡15.5 (-24.0; 1.25
(%LL) (9.9) (9.4) (5.1) 8.8) 0.58) -6.6) (1.68; 0.89) -7.0) (1.82; 0.67)
30 s side-hop test (n) 22b 38.8 18b 28.2 24c 45.3 7.7 (1.6; 0.68 (0.04; ¡8.6 (-17.2; 0.77 (1.36: ¡16.4 (-25.4; 1.44
(15.4) (11.9) (11.3) 17.1) 1.31) -0.006) 0.46) -7.4) (2.12; 0.75)
Single-leg hop for distance 25b 153.1 22b 136.9 26c 165.5 6.1 (9.4; 0.28 (0.29; ¡19.1 (-33.9; 0.89 ¡25.3 (-40.4; 1.16
(cm) (28.2) (29.3) (26.5) 21.7) 0.85) -4.4) (1.44; 0.60) -10.2) (1.78; 0.55)

a ¼ Missing data due to technical issues, b ¼ Missing data due to pain, c ¼ Missing data due to reasons unknown. %LL ¼ percentage of leg length, Isom. ¼ isometric.

et al., 2015; Freke et al., 2016). In one systematic review, Diamond
et al. (2015) reported decreased hip ROM in patients compared to
controls. In the included studies, advanced equipment (simulated
ROM using a CT model, 3D-motion analysis, electromagnetic
tracking system) was used. Such measurements may be sensitive to
detect small ROM restrictions, but they are not feasible for use in a
clinical setting. In the other systematic review, the included studies
had used clinically feasible methods such as goniometer and
inclinometer, and no evidence of reduced hip ROM was found in
patients compared to controls (Freke et al., 2016). Also, different
imaging methods, cut-off values of the alpha angle, as well as un-
clear diagnostic criteria were used in the different studies in the
two systematic reviews (Diamond et al., 2015; Freke et al., 2016),
which may also explain the contradictory results. In our study, we
used well-defined diagnostic criteria based on current best evi-
dence (Reiman et al., 2020) in an effort to improve the selection of
patients with confirmed hip-related pain. All patients but one in the
hip-related pain group had radiological findings of cam and/or
Pincer morphology, which could explain our findings of reduced
internal rotation with 90 hip flexion compared to those with non-
hip-related groin pain. However, the observed restriction of ROM in
internal rotation in neutral hip position might not be caused by
bony interaction but rather by soft tissue restriction such as
capsular thickness (Zhang et al., 2018) and/or involuntary muscle
contraction (Carvalhais et al., 2011).
In accordance with previous studies (Freke et al., 2016, 2018;
Mosler et al., 2020), we observed reduced strength for all hip muscle
groups in patients with hip-related pain compared to controls. In a
systematic review, Freke et al. (2016) reported hip strength de-
ficiencies in all hip muscle groups, except extensors, in patients with
hip-related pain compared to controls, and in a cross-sectional study,
patients scheduled for arthroscopic hip surgery had reduced hip
strength in all muscle groups compared to controls (Freke et al., 2018).
We also found reduced hip muscle strength in patients with non-hip-

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A. Pålsson, I. Kostogiannis and E. Ageberg Physical Therapy in Sport 52 (2021) 224e233

related groin pain compared to controls. This patient group is poorly study being underpowered when comparing the patient groups.
investigated and therefore any comparison to previously reported However, the mean differences in muscle function and functional
finding is not easy to make. In a systematic review with meta-analysis tasks between the two patient groups were small and may not be
investigating differences in physical function between athletes with clinically relevant. Finally, the patient group with non-hip-related
non-specific hip and groin pain compared to pain-free athletes, only groin pain was not further classified and may therefore include
reduced hip adductor strength was found (Mosler et al., 2015). several different entities. Further classification of this patient group
However, the athletic population with non-specific hip and groin pain and investigation of physical impairment for the different entities
included in that analysis (Mosler et al., 2015) may not be comparable may be a subject for further study.
to our cohort with physically active, but mainly non-athletic patients, Exercise-based treatment is one important component in the
referred to tertiary care. In addition to reduced hip muscle strength, treatment of patients with longstanding hip and groin pain. Based on
we found impaired trunk muscle function tested with DLLT in both our results, when designing exercise-based treatment for patients
patient groups compared to controls. In line with our result, impaired with hip and groin pain, the individual's physical impairments
trunk muscle function compared to controls tested with side-plank should be considered rather than the diagnosis, i.e., hip-related pain
has previously been reported in both patients with hip-related pain or non-hip-related groin pain. In our cohort, only patients with hip-
post hip surgery (Kemp et al., 2016). Altered trunk muscle function has related pain appeared to have reduced hip ROM in internal rotation.
also been observed in athletes with non-specific groin pain compared Exploration of treatment options in order to improve hip ROM in
to pain-free athletes (Mosler et al., 2015). Trunk muscle function patients with hip-related pain may be a subject in further studies.
training is suggested to be included in exercise-based treatment for
patients with longstanding hip and groin pain since impaired trunk
8. Conclusions
muscle function is believed to reduced pelvic control and may also
reduce acetabular retroversion, which in turn may affect hip
Both patients with hip-related pain and those with non-hip-
impingement (Kemp et al., 2019a). A possible explanation of the
related groin pain had worse muscle function and worse perfor-
observed poor muscle function in both patient groups regardless of
mance in functional tasks compared to matched controls but no
the origin of pain, may be due to physical deconditioning and/or
differences were observed between the patient groups. Only pa-
altered movement strategies due to longstanding pain (King et al.,
tients with hip-related pain had reduced ROM in internal rotation.
2018). Muscle function is an important modifiable factor and based
The medium to large effect sizes indicate that the observed differ-
on the results from our study and previous studies (Freke et al., 2016,
ences are clinically relevant.
2018; Kemp et al., 2016), exercise-based treatment should include
strength training for all hip muscle groups and trunk for both patients
with hip-related pain and those with non-hip-related groin pain. Key points
We found worse performance in functional tasks in both patient
groups compared to controls, while no differences were noted Findings
between the patient groups. In line with our study, previous studies
have shown impaired dynamic balance control in patients with hip Patients with hip-related pain and those with non-hip-related
related pain (Freke et al., 2018; Mosler et al., 2020). Kemp et al. groin pain have worse muscle function and worse performance in
(2016) reported bilateral impaired performance compared to con- functional tasks compared to healthy controls. However, only pa-
trols in the single-leg hop for distance 12e24 months after tients with hip-related pain have reduced hip ROM.
arthroscopic surgery due to chondrolabral pathology. Similarly,
Kivlan et al. (2016) found worse performance during medial and
Implications
lateral hop triple tests in dancers with FAI syndrome as compared
to healthy dancers. However, due to the large amount of missing
Exercise-based treatment should include hip muscle strength
data in our cohort due to pain in the hop performance tests (43% for
training, trunk strength/control training as well as training to
30s side-hop test and 33% for the single-leg hop for distance), the
improve performance in functional tasks for all patients with
results of these tests should be interpreted with caution. In the
longstanding hip and groin pain, despite diagnosis.
SASLR test, no differences were found between the patient groups
or between patients and controls. The SASLR is novel and has not
been validated for these patient groups, and the test may not be Caution
sufficiently demanding for evaluating ability to maintain pelvic
control during single-leg stance in these patients. Based on the The findings of the present study are limited to young to middle-
results from the present study, patients referred to tertiary care due aged patients with longstanding hip and groin pain referred to
to longstanding hip and groin pain appear to have reduced function tertiary care.
in functional tasks, regardless of whether they have hip-related
pain or non-hip-related groin pain.
Ethical approval
The present study has some limitations that need to be
addressed. First, although the tester was blinded to whether or not
The Regional Ethical Review Board in Lund approved the study
patients had hip-related pain, the tester was not blinded as to
(Dnr 2014/12) and the participants signed an informed consent and
whether participants were patients or controls. Second, the con-
the rights of subjects were protected.
trols were not assessed with radiographs due to ethical reasons and
any possible hip morphology was, therefore, unknown. Due to the
previously reported high prevalence of cam morphology in Funding
asymptomatic populations (Frank et al., 2015), we cannot rule out
any hip morphology in the control group which may have influ- Grant support: This study was funded by the Swedish Rheu-
enced hip ROM especially in internal rotation in 90 hip flexion. matism Association, the Kocks Foundation, and the Governmental
Third, due to the exploratory nature of our study, no sample size funding of clinical research within the National Health Services
calculation was made prior to the recruitment with the risk of the (NHS).
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A. Pålsson, I. Kostogiannis and E. Ageberg Physical Therapy in Sport 52 (2021) 224e233

Declaration of competing interest Muscle function

The authors declare that they have no competing interests.

Appendix

Physical impairment testing

Passive hip ROM

Table 5
Overview of the position of the participant's position, equipment, procedure, and outome of passive hip ROM.

Passive hip ROM Participant's position Equipment and procedure Outcome

Flexion Supine. The contralateral thigh was fixed with a belt. The digital inclinometer was attached to the lateral side of Mean ( ) of two repetitions
the thigh, 10 cm proximal of the knee joint. at end range.
Internal rotation Sitting. For stabilization of the pelvis and trunk, the The digital inclinometer was attached on the anterior Mean ( ) of two repetitions
with 90 hip participant was instructed to hold on to the edge of the aspect of the leg, 10 cm proximal to the medial malleolus at visual pelvic movement.
flexion table.
External rotation Sitting. For stabilization of the pelvis and trunk, the The digital inclinometer was attached on the anterior Mean ( ) of two repetitions
with 90 hip participant was instructed to hold on to the edge of the aspect of the leg, 10 cm proximal to the medial malleolus at visual pelvic movement.
flexion table.
Internal rotation in Prone. The pelvis was stabilized with a belt. The digital inclinometer was attached on the posterior Mean ( ) of two repetitions
neutral hip aspect of the leg, 10 cm proximal to the medial malleolus at end range.
position
Abduction Supine. Contralateral leg hanging down on the edge of the The digital goniometer was placed along the femur and a Mean ( ) of two repetitions
table to stabilize the pelvis. line drawn between the anterior superior iliac spines. at end range.

Fig. 1. A-E Measurement of passive hip ROM in A: Flexion, B: Internal rotation with 90 hip flexion, C: External rotation with 90 hip flexion, D: Internal rotation in neutral hip
position, E: Abduction.

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A. Pålsson, I. Kostogiannis and E. Ageberg Physical Therapy in Sport 52 (2021) 224e233

Table 6
Overview of the position of the participant's position, equipment, procedure, and outome of muscle function testing.

Muscle function Position Equipment and method Outcome

Isometric Supine. Opposite foot was placed on the table. The handheld digital dynamometer was placed Maximum torque of three trials normalized by
adduction Participant held on to the edges of the table for on the medial aspect of the leg, 10 cm proximal bodyweight (Nm/kg)
stabilization. to the medial malleolus. The dynamometer was
fixed with a belt around the assessor.
Isometric Supine. Opposite foot was placed on the table. The handheld digital dynamometer was placed Maximum torque of three trials normalized by
abduction Participant held on to the edges of the table for on the lateral aspect of the leg, 10 cm proximal bodyweight (Nm/kg)
stabilization. to the medial malleolus. The dynamometer was
fixed with a belt around the assessor.
Isometric extension Prone. Fixation belt over the pelvis. Palms The handheld digital dynamometer was placed Maximum torque of three trials normalized by
placed on the table. on the dorsal aspect of the leg, 10 cm proximal bodyweight (Nm/kg)
to the medial malleolus. The dynamometer was
fixed with a belt anchored to the floor by the
assessor's foot.
Isometric internal Prone. Fixation belt over the pelvis. Palms The handheld digital dynamometer was placed Maximum torque of three trials normalized by
rotation placed on the table. on the lateral aspect of the leg, 10 cm proximal bodyweight (Nm/kg)
to the medial malleolus. The dynamometer was
fixed with a belt around the assessor.
Isometric external Prone. Fixation belt over the pelvis. Palms The handheld digital dynamometer was placed Maximum torque of three trials normalized by
rotation placed on the table. on the medial aspect of the leg, 10 cm proximal bodyweight (Nm/kg)
to the medial malleolus. The dynamometer was
fixed with a belt around the assessor.
Isometric flexion Standing with the hip in 90 flexion. Fixation The handheld digital dynamometer placed on Maximum torque of three trials normalized by
belt over the thigh. Head, pelvis and palms the thigh, 10 cm proximal to the knee joint. The bodyweight (Nm/kg)
against a wall. The opposite heel placed 10 cm dynamometer was fixed with a belt anchored to
from the wall. the floor by the assessor's foot.
Double leg Supine. Both legs straight and elevated into 70 The tilt sensor was attached between the iliac The hip extension was measured when the tilt
lowering test hip flexion. crest and the greater trochanter by a fixation sensor registered 10 posterior pelvic tilt. Mean
belt. ( ) of three trials served as outcome.
The digital inclinometer was attached to the
lateral side of the thigh 10 cm proximal to the
knee joint. The subject was instructed to keep
the lumbar spine flat on the floor while the
assessor let go of the legs and lowered under
control by the participant.

Fig. 2. A-F Measurement of isometric hip strength in A: Adduction, B: Abduction, C: Extension, D: Internal rotation, E: External rotation, and F: Flexion.

231
A. Pålsson, I. Kostogiannis and E. Ageberg Physical Therapy in Sport 52 (2021) 224e233

Fig. 3. Double leg lowering test.

Functional tasks
Fig. 5. Y-balance test.

Table 7
Overview of the position of the participant's position, equipment, procedure, and outome of functional tasks.

Functional Position Equipment and method Outcome

tasks

Standing active The participant was An iPod tilt sensor was placed on the sacrum with a fixation belt. The The range in degrees ( ), medial to lateral pelvic tilt, was
single leg standing with the feet participant was instructed to lift his/hers foot above a 10 cm box measured. The mean range of three trials served as
raise (Fig. 4) 40 cm apart. without touching it and return to the starting position. outcome.
Y-balance test Standing on one leg. The participant was instructed to reach with the foot forward, 45 The maximum distance (cm), of three trials in every
(Fig. 5) posterior/laterally and 45 posterior/medially as far as he/she can direction was measured. The percentage of total leg
without losing balance. A lightweight plastic box was pushed along a length (%LL) served as outcome.
bar by the participant in all three directions.
Side-hop 30 s Standing on one leg. A distance of 40 cm was marked by tape on the floor. The subject was The test was filmed and the number of jumps during 30 s
instructed to jump across the distance without touching the tape as was counted and served as outcome.
many times as possible during 30 s. The test was performed one time
on each side.
Singe-leg hop Standing on one leg at The participant stands on one leg and was instructed to jump as far as Maximum distance (cm) of three jumps (starting point to
for distance starting point he/she can and land on the same leg. posterior margin of the heel served as outcome.

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