Hip and groin pain in physically active adults with a focus on terminology, clinical examination and imaging: A formal ESSKA-EHPA-ESMA Consensus

PURPOSE: This European Society of Sports Traumatology, Knee Surgery and Arthroscopy-European Hip Preservation Associates-European Sports Medicine Association (ESSKA-EHPA-ESMA) formal consensus aims to provide evidence- and expert opinion-based recommendations for the terminology, clinical examination and imaging concerning the assessment of athletes and physically active adults with hip and groin pain.

METHODS: The 'ESSKA Formal Consensus' methodology, involving a rigorous, iterative peer review process, was utilized. A multidisciplinary group of 57 experts from 22 countries formed a steering group (15 experts), rating group (20 experts) and reader group (22 experts). The steering group developed 13 questions, including four conclusive questions, across three domains: terminology, clinical examination and imaging. Statements were graded A (high-level scientific evidence) to D (expert opinion) and scored 1-9 according to the level of agreement by the rating group. The reader group assessed statements for clarity and geographic adaptability.

RESULTS: Median ratings for the 13 statements ranged from 8 to 9 out of 9. Strong agreement was recorded for five questions, relative agreement for five questions, and three questions remained uncertain. All statements were graded C. Recommended terminology includes adductor, iliopsoas, inguinal, pubic and hip joint-related groin pain. Clinical examination should include gait assessment, Trendelenburg's test, palpation and resistance testing of relevant muscle groups, hip range of motion and the flexion, adduction, internal rotation (FADIR) test. Imaging examinations are neither fully sensitive or specific and should always be used in conjunction with history and examination. Depending on the suspected pathology, plain radiographs or ultrasonography should be used as first-line investigations, with magnetic resonance imaging, computed tomography and diagnostic hip injections reserved as second-line investigations.

CONCLUSION: This consensus provides a structured reference frame for the terminology, examination and imaging for athletes and physically active adults with hip and groin pain. Different and combined aetiologies for hip and groin pain exist, and therefore consistent terminology and systematic clinical examination are essential. Red flags must not be ignored, and imaging must be interpreted alongside history and examination findings.

LEVEL OF EVIDENCE: Level I.