Hip morphology and its relationship with hip strength, mobility and lower limb biomechanics: a systematic review in adults

Relação da morfologia do quadril com força, mobilidade e biomecânica dos membros inferiores: uma revisão sistemática em adultos

Adriana Ferraz Heiliane de Brito Fontana Marcelo Peduzzi de Castro Caroline Ruschel Carlos Alberto Atherinos Pierri Helio Roesler About the authors

Abstract

This systematic review (PROSPERO registration n.43640) aimed to summarise and determine the quality of evidence relating hip bone morphology to (i) hip strength, (ii) mobility and (iii) lower limb biomechanics during functional activities. A standardized search on MEDLINE/PubMed, Web of Science, ScienceDirect and Scopus resulted in 17 papers that met inclusion criteria: i) original investigations with a minimal sample of n=10, ii) studies on humans and iii) presence of at least one quantitative hip morphological parameter and one hip functional (i.e. strength and mobility) and/or one lower limb biomechanical parameter. Risk of bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies tool with adaptations. Sixteen out of the 17 included studies showed high risk of bias. We observed that primary evidence pointed to the influence of hip morphology on hip mobility in the transverse plane. Specifically, positive correlations between femoral anteversion angle and range of internal hip rotation in physical examination were observed. Regarding biomechanical parameters, no clear evidence of association between hip morphology, and kinematic and kinetic parameters were found. Our results point to a field that is currently under explored and future studies with low risk of bias addressing these relationships are required.

Key words
Anatomy; Femur; Lower extremity; Movement; Pelvic bones

Resumo

Essa revisão sistemática (PROSPERO registro no 43640) tem por objetivo sintetizar e determinar a qualidade da evidência que relaciona morfologia do quadril à (i) força do quadril, (ii) mobilidade e (iii) biomecânica dos membros inferiores durante atividades funcionais. Uma busca padronizada no MEDLINE/PubMed, Web of Science, ScienceDirect e Scopus resultou em 17 artigos em acordo com os critérios de inclusão: i) estudos originais com amostra mínima de n=10; ii) estudos em humanos e iii) presença de no mínimo um parâmetro quantitativo da morfologia do quadril e um parâmetro funcional do quadril (ex.: mobilidade e força) e/ou um parâmetro biomecânico do membro inferior. A avaliação do risco de viés foi realizada através da ferramenta Quality Assessment of Diagnostic Accuracy Studies (QUADAS) com adaptações. Dezesseis dos 17 estudos incluídos apresentaram alto risco de viés. Observamos que a evidência primária aponta para influência da morfologia do quadril em sua mobilidade no plano transverso. Foram observadas, especificamente, correlações positivas entre o ângulo de anteversão femoral e a mobilidade de rotação interna do quadril durante o exame físico. Em relação aos parâmetros biomecânicos, não foram encontradas evidências claras sobre associação entre morfologia do quadril e parâmetros cinemáticos e cinéticos. Nossos resultados apontam para um campo atualmente subexplorado e investigações futuras com baixo risco de viés que avaliem essas relações são necessárias.

Palavras-chave
Anatomia; Extremidade inferior; Fêmur; Movimento; Ossos pélvicos

INTRODUCTION

Over the last two decades, great attention has been directed to the hip in the assessment and investigation of lower limb injuries and disorders1Hewett TE, Myer GD, Ford KR, Heidt RS, Colosimo AJ, McLean SG, et al. Biomechanical Measures of Neuromuscular Control and Valgus Loading of the Knee Predict Anterior Cruciate Ligament Injury Risk in Female Athletes: A Prospective Study. Am J Sports Med 2005;33(4):492-501.3Ireland ML, Willson JD, Ballantyne BT, Davis IM. Hip Strength in Females With and Without Patellofemoral Pain. J Orthop Sport Phys Ther 2003;33(11):671-676.. There has been an increasing body of literature suggesting that poor biomechanical performance within the hip joint, such as hip weakness and limited range of motion, is linked to the development of lower limb injuries, such as knee joint pain and osteoarthritis2Powers CM. The influence of abnormal hip mechanics on knee injury: a biomechanical perspective. J Orthop Sports Phys Ther 2010;40(2):42-51.5Magalhães E, Fukuda TY, Sacramento SN, Forgas A, Cohen M, Abdalla RJ. A Comparison of Hip Strength Between Sedentary Females With and Without Patellofemoral Pain Syndrome. J Orthop Sport Phys Ther 2010;40(10):641-647., and to traumatic injuries, such as knee and ankle sprains1Hewett TE, Myer GD, Ford KR, Heidt RS, Colosimo AJ, McLean SG, et al. Biomechanical Measures of Neuromuscular Control and Valgus Loading of the Knee Predict Anterior Cruciate Ligament Injury Risk in Female Athletes: A Prospective Study. Am J Sports Med 2005;33(4):492-501.6Friel K, McLean N, Myers C, Caceres M. Ipsilateral hip abductor weakness after inversion ankle sprain. J Athl Train 2006;41(1):74-78..

During weight bearing activities, increased hip internal rotation and adduction was shown to be a risk factor1Hewett TE, Myer GD, Ford KR, Heidt RS, Colosimo AJ, McLean SG, et al. Biomechanical Measures of Neuromuscular Control and Valgus Loading of the Knee Predict Anterior Cruciate Ligament Injury Risk in Female Athletes: A Prospective Study. Am J Sports Med 2005;33(4):492-501. and associated factor7Souza RB, Powers CM. Differences in Hip Kinematics, Muscle Strength, and Muscle Activation Between Subjects With and Without Patellofemoral Pain. J Orthop Sport Phys Ther 2009;39(1):12-19. for lower limb disorders. These findings have directed the focus of prevention and rehabilitation programs towards achieving control of hip internal rotation during functional gestures8Van Der Heijden RA, Lankhorst NE, Van Linschoten R, Bierma-Zeinstra SM, Van Middelkoop M. Exercise for treating patellofemoral pain syndrome: an abridged version of Cochrane systematic review. Eur J Phys Rehabil Med 2016;52(1):110-133.,9Thomson C, Krouwel O, Kuisma R, Hebron C. The outcome of hip exercise in patellofemoral pain: A systematic review. Man Ther 2016;26:1-30.. However, despite this fairly common practice, our understanding towards non-modifiable and modifiable factors related to abnormal hip biomechanics is incipient.

Among parameters that are not modifiable – not without surgery, the femur and hip bone morphology are likely strong determinants of the mechanical environment and behaviour of hip joints. Hip morphology varies depending on age, gender, ethnicity, activity level and developmental stage10Laborie LB, Engesæter IØ, Lehmann TG, Sera F, Dezateux C, Engesæter LB, et al. Radiographic measurements of hip dysplasia at skeletal maturity—new reference intervals based on 2,038 19-year-old Norwegians. Skeletal Radiol 2013;42(7):925-935.,11vanKlij P, Heerey J, Waarsing JH, Agricola R. The Prevalence of Cam and Pincer Morphology and Its Association With Development of Hip Osteoarthritis. J Orthop Sport Phys Ther 2018;48(4):230-238.. It is known that increased femoral anteversion influences lower extremity alignment during standing and also changes hip muscles’ moment arms and hip range of motion12Arnold AS, Komattu AV, Delp SL. Internal rotation gait: a compensatory mechanism to restore abduction capacity decreased by bone deformity. Dev Med Child Neurol 1997;39(1):40-44.,13Neumann DA. Kinesiology of the Hip: A Focus on Muscular Actions. J Orthop Sport Phys Ther 2010;40(2):82-94.. Modifiable factors are those related to muscle strength, joint mobility and motor control2Powers CM. The influence of abnormal hip mechanics on knee injury: a biomechanical perspective. J Orthop Sports Phys Ther 2010;40(2):42-51..

In some studies, deviations in hip morphology have been associated to the development of lower limb disorders14Gosvig KK, Jacobsen S, Sonne-Holm S, Palm H, Troelsen A. Prevalence of Malformations of the Hip Joint and Their Relationship to Sex, Groin Pain, and Risk of Osteoarthritis. J Bone Joint Surg Am 2010;92(5):1162-1169.,15Doherty M, Courtney P, Doherty S, Jenkins W, Maciewicz RA, Muir K, et al. Nonspherical femoral head shape (pistol grip deformity), neck shaft angle, and risk of hip osteoarthritis: A case-control study. Arthritis Rheum 2008;58(10):3172-3182.. However, this relationship is often non-specific, with many individuals presenting radiographic alterations and not evolving to lower limb injury or pain11vanKlij P, Heerey J, Waarsing JH, Agricola R. The Prevalence of Cam and Pincer Morphology and Its Association With Development of Hip Osteoarthritis. J Orthop Sport Phys Ther 2018;48(4):230-238.16Bardakos NV, Villar RN. Predictors of progression of osteoarthritis in femoroacetabular impingement. J Bone Joint Surg Br 2009;91-B(2):162-169.. While, for example, cam morphology seems to be associated with hip osteoarthritis, odds ratio varies between 2.2 and 20.614Gosvig KK, Jacobsen S, Sonne-Holm S, Palm H, Troelsen A. Prevalence of Malformations of the Hip Joint and Their Relationship to Sex, Groin Pain, and Risk of Osteoarthritis. J Bone Joint Surg Am 2010;92(5):1162-1169.,16Bardakos NV, Villar RN. Predictors of progression of osteoarthritis in femoroacetabular impingement. J Bone Joint Surg Br 2009;91-B(2):162-169., with most people with cam morphology not developing hip osteoarthritis11vanKlij P, Heerey J, Waarsing JH, Agricola R. The Prevalence of Cam and Pincer Morphology and Its Association With Development of Hip Osteoarthritis. J Orthop Sport Phys Ther 2018;48(4):230-238.. In the case of other morphological findings, such as pincer morphology, femoral and acetabular orientation, associations to injury and/or pain during functional daily activities seem to be even harder to draw from the literature11vanKlij P, Heerey J, Waarsing JH, Agricola R. The Prevalence of Cam and Pincer Morphology and Its Association With Development of Hip Osteoarthritis. J Orthop Sport Phys Ther 2018;48(4):230-238.,17Frank JM, Harris JD, Erickson BJ, Slikker W 3rd, Bush-Joseph CA, Salata MJ, et al. Prevalence of Femoroacetabular Impingement Imaging Findings in Asymptomatic Volunteers: A Systematic Review. Arthrosc J Arthrosc Relat Surg 2015;31(6):1199-1204.,18Mascarenhas VV, Rego P, Dantas P, Morais F, McWilliams J, Collado D, et al. Imaging prevalence of femoroacetabular impingement in symptomatic patients, athletes, and asymptomatic individuals: A systematic review. Eur J Radiol 2016;85(1):73-95..

Given the complex relationship between hip morphology and injury, investigations focusing on intermediate parameters may help on the identification of subgroups of higher risk of becoming symptomatic and/or developing lower limb injuries. Characteristics that are worth considering may include hip muscle strength, hip mobility, and lower limb biomechanical behaviour during functional activities such as gait, squatting, etc. Investigations on that matter may help to clarify the level of association between changes in hip morphology and the development of musculoskeletal disorders and to identify modifiable intermediate risk factors to prevent, stop, or slow down disease progression and/or to avoid overtreatment.

This systematic review was designed to summarise and investigate the quality of current available evidence relating hip bone morphology to hip strength, mobility and lower limb biomechanics in humans.

METHODS

We performed this systematic review according to the recommendations contained in Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)19Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JP, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. J Clin Epidemiol 2009;62(10):e1-34.,20Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. Ann Intern Med 2009;151(4):264-269.. The protocol was registered within the International prospective register of systematic reviews (PROPESRO) under the number 43640.

After a careful preliminary assessment of the literature related to hip morphology and clinical and biomechanical parameters, the three following sets of key words were elaborated: i) morphology set, ii) imaging findings set and iii) functional parameters set. For keywords within a set, the command OR was used in order to represent a given construct, while, between sets, the command “AND” was used to limit the search to the association between constructs (Box 1).

Box 1
Search strategy in MEDLINE (via Pubmed).

Prior to the official search, these key words were used to verify in the Cochrane and PROSPERO database whether a similar systematic review had been published or registered. No relevant results were found. For the official search, four databases were screened from the date they were concepted to July 2016: MEDLINE/PubMed, Web of Science, ScienceDirect e Scopus. Last search was performed in July 2016. According to each database, filters were used (Figure 1). Inclusion criteria were: i) original investigations with a minimal sample of 10 participants per group comparison, ii) studies on humans, iii) presence of quantitative hip morphological parameters and quantitative hip functional parameters and/or lower limb biomechanical parameters.

Figure 1
Systematic review diagram.

Articles that were not available in full format or articles that contained morphological findings that solely represent the progression of joint diseases were excluded from the analysis. No language restrictions were imposed.

Three independent reviewers conducted the selection process. First, Reviewer #1 excluded duplicates, editorials, case studies, incomplete articles and non-original investigations. Second, Reviewers #1 and #2 analysed all titles and excluded unrelated titles. After reading all selected abstracts, articles that could potentially fit to the inclusion/exclusion criteria were evaluated in their full format and a final independent decision was made by reviewers. The list of references cited in each article was screened for potential inclusion in the review. Third, in case of disagreement between reviewers #1 and #2 that persisted after discussion, reviewer #3 was consulted.

Bias and quality analysis of the selected papers was performed using a set of questions that were adapted from the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool21Whiting P, Rutjes AWS, Reitsma JB, Bossuyt PMM, Kleijnen J. The development of QUADAS: a tool for the quality assessment of studies of diagnostic accuracy included in systematic reviews. BMC Med Res Methodol 2003;3:25.. QUADAS contains 14 questions that are answered with “yes”, “no” or “unclear”. The instrument used in this systematic review was composed of 12 items (in contrast to 14 in the original QUADAS). Maximum score was 12 and meant that the paper met all requirements listed for a good quality. If the information was “unclear”, the item was scored with 0 points, similarly to answer “no”. As a cut point, articles that scored nine points or more, were considered of high quality, while articles that scored below nine were considered of poor methodological quality22Cook C, Mabry L, Reiman MP, Hegedus EJ. Best tests/clinical findings for screening and diagnosis of patellofemoral pain syndrome: a systematic review. Physiotherapy 2012;98(2):93-100..

For the analysis of associations between morphology and functional parameters the following interpretation of correlation scores was adopted: r values between 0 and 0.20 were considered indicative of a very poor correlation; r values between 0.21 and 0.40, a poor correlation; between 0.41 e 0.60, moderate; 0.61 and 0.80, high and r values greater than 0.80 were considered indicative of an excellent correlation23Williams R, Binkley J, Bloch R, Goldsmith CH, Minuk T. Reliability of the modified-modified Schöber and double inclinometer methods for measuring lumbar flexion and extension. Phys Ther 1993;73(1):33-44..

RESULTS

Up to the date this review was submitted (June, 2019), no systematic review addressing the relationship between hip morphological parameters and functional parameters of the lower limbs had been registered or published.

Our search returned 4425 titles, with 17 papers remaining eligible at the end of the selection process (Figure 1). Characteristics of individual studies are presented in Table II. The number of participants evaluated per study varied from 1024Bedi A, Dolan M, Hetsroni I, Magennis E, Lipman J, Buly R, et al. Surgical Treatment of Femoroacetabular Impingement Improves Hip Kinematics: a computer-assisted model. Am J Sports Med 2011;39(Supplement 1):43S-49S. to 22125Chadayammuri V, Garabekyan T, Bedi A, Pascual-Garrido C, Rhodes J, O'Hara J, et al. Passive Hip Range of Motion Predicts Femoral Torsion and Acetabular Version. J Bone Joint Surg Am 2016;98(2):127-134.. Morphological parameters of interest were evaluated primarily with radiographs25Chadayammuri V, Garabekyan T, Bedi A, Pascual-Garrido C, Rhodes J, O'Hara J, et al. Passive Hip Range of Motion Predicts Femoral Torsion and Acetabular Version. J Bone Joint Surg Am 2016;98(2):127-134.34Tannast M, Pfander G, Steppacher SD, Mast JW, Ganz R. Total acetabular retroversion following pelvic osteotomy: presentation, management, and outcome. Hip Int 2013;23 Suppl 9(Suppl 9):S14-26. followed by MRI27Botser IB, Ozoude GC, Martin DE, Siddiqi AJ, Kuppuswami S, Domb BG. Femoral Anteversion in the Hip: Comparison of Measurement by Computed Tomography, Magnetic Resonance Imaging, and Physical Examination. Arthrosc J Arthrosc Relat Surg 2012;28(5):619-627.30Lahner M, von Schulze Pellengahr C, Walter PA, Lukas C, Falarzik A, Daniilidis K, et al. Biomechanical and functional indicators in male semiprofessional soccer players with increased hip alpha angles vs. amateur soccer players. BMC Musculoskelet Disord 2014;15(1):88.,35Ejnisman L, Philippon MJ, Lertwanich P, Pennock AT, Herzog MM, Briggs KK, et al. Relationship Between Femoral Anteversion and Findings in Hips With Femoroacetabular Impingement. Orthopedics 2013;36(3):e293-e300.37Souza RB, Powers CM. Predictors of Hip Internal Rotation during Running. Am J Sports Med 2009;37(3):579-587. and computed tomography24Bedi A, Dolan M, Hetsroni I, Magennis E, Lipman J, Buly R, et al. Surgical Treatment of Femoroacetabular Impingement Improves Hip Kinematics: a computer-assisted model. Am J Sports Med 2011;39(Supplement 1):43S-49S.,25Chadayammuri V, Garabekyan T, Bedi A, Pascual-Garrido C, Rhodes J, O'Hara J, et al. Passive Hip Range of Motion Predicts Femoral Torsion and Acetabular Version. J Bone Joint Surg Am 2016;98(2):127-134.,27Botser IB, Ozoude GC, Martin DE, Siddiqi AJ, Kuppuswami S, Domb BG. Femoral Anteversion in the Hip: Comparison of Measurement by Computed Tomography, Magnetic Resonance Imaging, and Physical Examination. Arthrosc J Arthrosc Relat Surg 2012;28(5):619-627.,38Crawford EA, Whiteside D, Deneweth JM, Ross JR, Bedi A, Goulet GC. In Vivo Hip Morphology and Kinematics in Elite Baseball Pitchers. Arthroscopy 2016;32(5):798-805.. Only 1 study used bone densitometry39Baggaley M, Noehren B, Clasey JL, Shapiro R, Pohl MB. Frontal plane kinematics of the hip during running: Are they related to hip anatomy and strength? Gait Posture 2015;42(4):505-510..

The femoral version angle24Bedi A, Dolan M, Hetsroni I, Magennis E, Lipman J, Buly R, et al. Surgical Treatment of Femoroacetabular Impingement Improves Hip Kinematics: a computer-assisted model. Am J Sports Med 2011;39(Supplement 1):43S-49S.,25Chadayammuri V, Garabekyan T, Bedi A, Pascual-Garrido C, Rhodes J, O'Hara J, et al. Passive Hip Range of Motion Predicts Femoral Torsion and Acetabular Version. J Bone Joint Surg Am 2016;98(2):127-134.,27Botser IB, Ozoude GC, Martin DE, Siddiqi AJ, Kuppuswami S, Domb BG. Femoral Anteversion in the Hip: Comparison of Measurement by Computed Tomography, Magnetic Resonance Imaging, and Physical Examination. Arthrosc J Arthrosc Relat Surg 2012;28(5):619-627.29Ferro FP, Ho CP, Briggs KK, Philippon MJ. Patient-centered outcomes after hip arthroscopy for femoroacetabular impingement and labral tears are not different in patients with normal, high, or low femoral version. Arthroscopy 2015;31(3):454-459.,31Romano C, Frigo C, Randelli G, Pedotti A. Analysis of the Gait of Adults Who Had Residua of Congenital Dysplasia of the Hip. J Bone Joint Surg Am 1996;78(10):1468-1479.,35Ejnisman L, Philippon MJ, Lertwanich P, Pennock AT, Herzog MM, Briggs KK, et al. Relationship Between Femoral Anteversion and Findings in Hips With Femoroacetabular Impingement. Orthopedics 2013;36(3):e293-e300.,37Souza RB, Powers CM. Predictors of Hip Internal Rotation during Running. Am J Sports Med 2009;37(3):579-587.,38Crawford EA, Whiteside D, Deneweth JM, Ross JR, Bedi A, Goulet GC. In Vivo Hip Morphology and Kinematics in Elite Baseball Pitchers. Arthroscopy 2016;32(5):798-805., the alpha angle24Bedi A, Dolan M, Hetsroni I, Magennis E, Lipman J, Buly R, et al. Surgical Treatment of Femoroacetabular Impingement Improves Hip Kinematics: a computer-assisted model. Am J Sports Med 2011;39(Supplement 1):43S-49S.,28Duthon VB, Charbonnier C, Kolo FC, Magnenat-Thalmann N, Becker CD, Bouvet C, et al. Correlation of Clinical and Magnetic Resonance Imaging Findings in Hips of Elite Female Ballet Dancers. Arthrosc J Arthrosc Relat Surg 2013;29(3):411-419.30Lahner M, von Schulze Pellengahr C, Walter PA, Lukas C, Falarzik A, Daniilidis K, et al. Biomechanical and functional indicators in male semiprofessional soccer players with increased hip alpha angles vs. amateur soccer players. BMC Musculoskelet Disord 2014;15(1):88.,35Ejnisman L, Philippon MJ, Lertwanich P, Pennock AT, Herzog MM, Briggs KK, et al. Relationship Between Femoral Anteversion and Findings in Hips With Femoroacetabular Impingement. Orthopedics 2013;36(3):e293-e300.,36Hagen M, Abraham C, Ficklscherer A, Lahner M. Biomechanical study of plantar pressures during walking in male soccer players with increased vs. normal hip alpha angles. Technol Heal Care 2015;23(1):93-100.,38Crawford EA, Whiteside D, Deneweth JM, Ross JR, Bedi A, Goulet GC. In Vivo Hip Morphology and Kinematics in Elite Baseball Pitchers. Arthroscopy 2016;32(5):798-805.,40Lahner M, Mußhoff D, Von Schulze Pellengahr C, Willburger R, Hagen M, Ficklscherer A, et al. Is the Kinect system suitable for evaluation of the hip joint range of motion and as a screening tool for femoroacetabular impingement (FAI)? Technol Heal Care 2015;23(1):75-82. and the lateral centre-edge angle25Chadayammuri V, Garabekyan T, Bedi A, Pascual-Garrido C, Rhodes J, O'Hara J, et al. Passive Hip Range of Motion Predicts Femoral Torsion and Acetabular Version. J Bone Joint Surg Am 2016;98(2):127-134.,29Ferro FP, Ho CP, Briggs KK, Philippon MJ. Patient-centered outcomes after hip arthroscopy for femoroacetabular impingement and labral tears are not different in patients with normal, high, or low femoral version. Arthroscopy 2015;31(3):454-459.,31Romano C, Frigo C, Randelli G, Pedotti A. Analysis of the Gait of Adults Who Had Residua of Congenital Dysplasia of the Hip. J Bone Joint Surg Am 1996;78(10):1468-1479.,32Siebenrock KA, Schaller C, Tannast M, Keel M, Büchler L. Anteverting Periacetabular Osteotomy for Symptomatic Acetabular Retroversion. J Bone Joint Surg Am 2014;96(21):1785-1792.,34Tannast M, Pfander G, Steppacher SD, Mast JW, Ganz R. Total acetabular retroversion following pelvic osteotomy: presentation, management, and outcome. Hip Int 2013;23 Suppl 9(Suppl 9):S14-26.,35Ejnisman L, Philippon MJ, Lertwanich P, Pennock AT, Herzog MM, Briggs KK, et al. Relationship Between Femoral Anteversion and Findings in Hips With Femoroacetabular Impingement. Orthopedics 2013;36(3):e293-e300.,38Crawford EA, Whiteside D, Deneweth JM, Ross JR, Bedi A, Goulet GC. In Vivo Hip Morphology and Kinematics in Elite Baseball Pitchers. Arthroscopy 2016;32(5):798-805. were the most commonly evaluated morphological parameters. The neck-shaft angle24Bedi A, Dolan M, Hetsroni I, Magennis E, Lipman J, Buly R, et al. Surgical Treatment of Femoroacetabular Impingement Improves Hip Kinematics: a computer-assisted model. Am J Sports Med 2011;39(Supplement 1):43S-49S.,28Duthon VB, Charbonnier C, Kolo FC, Magnenat-Thalmann N, Becker CD, Bouvet C, et al. Correlation of Clinical and Magnetic Resonance Imaging Findings in Hips of Elite Female Ballet Dancers. Arthrosc J Arthrosc Relat Surg 2013;29(3):411-419.,31Romano C, Frigo C, Randelli G, Pedotti A. Analysis of the Gait of Adults Who Had Residua of Congenital Dysplasia of the Hip. J Bone Joint Surg Am 1996;78(10):1468-1479.,37Souza RB, Powers CM. Predictors of Hip Internal Rotation during Running. Am J Sports Med 2009;37(3):579-587.39Baggaley M, Noehren B, Clasey JL, Shapiro R, Pohl MB. Frontal plane kinematics of the hip during running: Are they related to hip anatomy and strength? Gait Posture 2015;42(4):505-510., acetabular version angle25Chadayammuri V, Garabekyan T, Bedi A, Pascual-Garrido C, Rhodes J, O'Hara J, et al. Passive Hip Range of Motion Predicts Femoral Torsion and Acetabular Version. J Bone Joint Surg Am 2016;98(2):127-134.,28Duthon VB, Charbonnier C, Kolo FC, Magnenat-Thalmann N, Becker CD, Bouvet C, et al. Correlation of Clinical and Magnetic Resonance Imaging Findings in Hips of Elite Female Ballet Dancers. Arthrosc J Arthrosc Relat Surg 2013;29(3):411-419.,38Crawford EA, Whiteside D, Deneweth JM, Ross JR, Bedi A, Goulet GC. In Vivo Hip Morphology and Kinematics in Elite Baseball Pitchers. Arthroscopy 2016;32(5):798-805., acetabular index31Romano C, Frigo C, Randelli G, Pedotti A. Analysis of the Gait of Adults Who Had Residua of Congenital Dysplasia of the Hip. J Bone Joint Surg Am 1996;78(10):1468-1479.,33Siebenrock KA, Schoeniger R, Ganz R. Anterior femoro-acetabular impingement due to acetabular retroversion. Treatment with periacetabular osteotomy. J Bone Joint Surg Am 2003;85-A(2):278-286.,34Tannast M, Pfander G, Steppacher SD, Mast JW, Ganz R. Total acetabular retroversion following pelvic osteotomy: presentation, management, and outcome. Hip Int 2013;23 Suppl 9(Suppl 9):S14-26., anterior centre-edge angle31Romano C, Frigo C, Randelli G, Pedotti A. Analysis of the Gait of Adults Who Had Residua of Congenital Dysplasia of the Hip. J Bone Joint Surg Am 1996;78(10):1468-1479.,33Siebenrock KA, Schoeniger R, Ganz R. Anterior femoro-acetabular impingement due to acetabular retroversion. Treatment with periacetabular osteotomy. J Bone Joint Surg Am 2003;85-A(2):278-286., acetabular depth28Duthon VB, Charbonnier C, Kolo FC, Magnenat-Thalmann N, Becker CD, Bouvet C, et al. Correlation of Clinical and Magnetic Resonance Imaging Findings in Hips of Elite Female Ballet Dancers. Arthrosc J Arthrosc Relat Surg 2013;29(3):411-419., Idelberger and Frank angle33Siebenrock KA, Schoeniger R, Ganz R. Anterior femoro-acetabular impingement due to acetabular retroversion. Treatment with periacetabular osteotomy. J Bone Joint Surg Am 2003;85-A(2):278-286. and Sharp angle32Siebenrock KA, Schaller C, Tannast M, Keel M, Büchler L. Anteverting Periacetabular Osteotomy for Symptomatic Acetabular Retroversion. J Bone Joint Surg Am 2014;96(21):1785-1792. were also used. Some studies listed variables in the methods that were not presented in the results section27Botser IB, Ozoude GC, Martin DE, Siddiqi AJ, Kuppuswami S, Domb BG. Femoral Anteversion in the Hip: Comparison of Measurement by Computed Tomography, Magnetic Resonance Imaging, and Physical Examination. Arthrosc J Arthrosc Relat Surg 2012;28(5):619-627.,30Lahner M, von Schulze Pellengahr C, Walter PA, Lukas C, Falarzik A, Daniilidis K, et al. Biomechanical and functional indicators in male semiprofessional soccer players with increased hip alpha angles vs. amateur soccer players. BMC Musculoskelet Disord 2014;15(1):88.. An index relating the femoral and acetabular version angles was introduced by Chadayammuri et al.25Chadayammuri V, Garabekyan T, Bedi A, Pascual-Garrido C, Rhodes J, O'Hara J, et al. Passive Hip Range of Motion Predicts Femoral Torsion and Acetabular Version. J Bone Joint Surg Am 2016;98(2):127-134. (Box 2).

In the case of studies that focused on movement biomechanics26Asayama I, Naito M, Fujisawa M, Kambe T. Relationship between radiographic measurements of reconstructed hip joint position and the Trendelenburg sign. J Arthroplasty 2002;17(6):747-751.,30Lahner M, von Schulze Pellengahr C, Walter PA, Lukas C, Falarzik A, Daniilidis K, et al. Biomechanical and functional indicators in male semiprofessional soccer players with increased hip alpha angles vs. amateur soccer players. BMC Musculoskelet Disord 2014;15(1):88.,31Romano C, Frigo C, Randelli G, Pedotti A. Analysis of the Gait of Adults Who Had Residua of Congenital Dysplasia of the Hip. J Bone Joint Surg Am 1996;78(10):1468-1479.,34Tannast M, Pfander G, Steppacher SD, Mast JW, Ganz R. Total acetabular retroversion following pelvic osteotomy: presentation, management, and outcome. Hip Int 2013;23 Suppl 9(Suppl 9):S14-26.,37Souza RB, Powers CM. Predictors of Hip Internal Rotation during Running. Am J Sports Med 2009;37(3):579-587.39Baggaley M, Noehren B, Clasey JL, Shapiro R, Pohl MB. Frontal plane kinematics of the hip during running: Are they related to hip anatomy and strength? Gait Posture 2015;42(4):505-510., kinematic parameters were most often evaluated using infrared cameras31Romano C, Frigo C, Randelli G, Pedotti A. Analysis of the Gait of Adults Who Had Residua of Congenital Dysplasia of the Hip. J Bone Joint Surg Am 1996;78(10):1468-1479.,34Tannast M, Pfander G, Steppacher SD, Mast JW, Ganz R. Total acetabular retroversion following pelvic osteotomy: presentation, management, and outcome. Hip Int 2013;23 Suppl 9(Suppl 9):S14-26.,37Souza RB, Powers CM. Predictors of Hip Internal Rotation during Running. Am J Sports Med 2009;37(3):579-587.,39Baggaley M, Noehren B, Clasey JL, Shapiro R, Pohl MB. Frontal plane kinematics of the hip during running: Are they related to hip anatomy and strength? Gait Posture 2015;42(4):505-510., electromagnetic tracking26Asayama I, Naito M, Fujisawa M, Kambe T. Relationship between radiographic measurements of reconstructed hip joint position and the Trendelenburg sign. J Arthroplasty 2002;17(6):747-751. and inertial systems30Lahner M, von Schulze Pellengahr C, Walter PA, Lukas C, Falarzik A, Daniilidis K, et al. Biomechanical and functional indicators in male semiprofessional soccer players with increased hip alpha angles vs. amateur soccer players. BMC Musculoskelet Disord 2014;15(1):88.,38Crawford EA, Whiteside D, Deneweth JM, Ross JR, Bedi A, Goulet GC. In Vivo Hip Morphology and Kinematics in Elite Baseball Pitchers. Arthroscopy 2016;32(5):798-805.. Ground reaction forces were assessed with force platforms30Lahner M, von Schulze Pellengahr C, Walter PA, Lukas C, Falarzik A, Daniilidis K, et al. Biomechanical and functional indicators in male semiprofessional soccer players with increased hip alpha angles vs. amateur soccer players. BMC Musculoskelet Disord 2014;15(1):88.,31Romano C, Frigo C, Randelli G, Pedotti A. Analysis of the Gait of Adults Who Had Residua of Congenital Dysplasia of the Hip. J Bone Joint Surg Am 1996;78(10):1468-1479.,37Souza RB, Powers CM. Predictors of Hip Internal Rotation during Running. Am J Sports Med 2009;37(3):579-587., and plantar pressure distribution with insole systems and pressure platforms30Lahner M, von Schulze Pellengahr C, Walter PA, Lukas C, Falarzik A, Daniilidis K, et al. Biomechanical and functional indicators in male semiprofessional soccer players with increased hip alpha angles vs. amateur soccer players. BMC Musculoskelet Disord 2014;15(1):88.,36Hagen M, Abraham C, Ficklscherer A, Lahner M. Biomechanical study of plantar pressures during walking in male soccer players with increased vs. normal hip alpha angles. Technol Heal Care 2015;23(1):93-100..

Muscle strength was assessed based on torque capacity or force against resistance. All contractions were isometric and the peak force achieved was the parameter estimated34Tannast M, Pfander G, Steppacher SD, Mast JW, Ganz R. Total acetabular retroversion following pelvic osteotomy: presentation, management, and outcome. Hip Int 2013;23 Suppl 9(Suppl 9):S14-26.,37Souza RB, Powers CM. Predictors of Hip Internal Rotation during Running. Am J Sports Med 2009;37(3):579-587.,39Baggaley M, Noehren B, Clasey JL, Shapiro R, Pohl MB. Frontal plane kinematics of the hip during running: Are they related to hip anatomy and strength? Gait Posture 2015;42(4):505-510..

Thirteen studies verified hip mobility24Bedi A, Dolan M, Hetsroni I, Magennis E, Lipman J, Buly R, et al. Surgical Treatment of Femoroacetabular Impingement Improves Hip Kinematics: a computer-assisted model. Am J Sports Med 2011;39(Supplement 1):43S-49S.,27Botser IB, Ozoude GC, Martin DE, Siddiqi AJ, Kuppuswami S, Domb BG. Femoral Anteversion in the Hip: Comparison of Measurement by Computed Tomography, Magnetic Resonance Imaging, and Physical Examination. Arthrosc J Arthrosc Relat Surg 2012;28(5):619-627.35Ejnisman L, Philippon MJ, Lertwanich P, Pennock AT, Herzog MM, Briggs KK, et al. Relationship Between Femoral Anteversion and Findings in Hips With Femoroacetabular Impingement. Orthopedics 2013;36(3):e293-e300.,38Crawford EA, Whiteside D, Deneweth JM, Ross JR, Bedi A, Goulet GC. In Vivo Hip Morphology and Kinematics in Elite Baseball Pitchers. Arthroscopy 2016;32(5):798-805.,40Lahner M, Mußhoff D, Von Schulze Pellengahr C, Willburger R, Hagen M, Ficklscherer A, et al. Is the Kinect system suitable for evaluation of the hip joint range of motion and as a screening tool for femoroacetabular impingement (FAI)? Technol Heal Care 2015;23(1):75-82.. Functional questionnaires containing qualitative assessment of hip mobility were used in some studies31Romano C, Frigo C, Randelli G, Pedotti A. Analysis of the Gait of Adults Who Had Residua of Congenital Dysplasia of the Hip. J Bone Joint Surg Am 1996;78(10):1468-1479.34Tannast M, Pfander G, Steppacher SD, Mast JW, Ganz R. Total acetabular retroversion following pelvic osteotomy: presentation, management, and outcome. Hip Int 2013;23 Suppl 9(Suppl 9):S14-26.. Hip passive range of motion in the transverse plane was evaluated for hip internal and/or external rotation24Bedi A, Dolan M, Hetsroni I, Magennis E, Lipman J, Buly R, et al. Surgical Treatment of Femoroacetabular Impingement Improves Hip Kinematics: a computer-assisted model. Am J Sports Med 2011;39(Supplement 1):43S-49S.,27Botser IB, Ozoude GC, Martin DE, Siddiqi AJ, Kuppuswami S, Domb BG. Femoral Anteversion in the Hip: Comparison of Measurement by Computed Tomography, Magnetic Resonance Imaging, and Physical Examination. Arthrosc J Arthrosc Relat Surg 2012;28(5):619-627.30Lahner M, von Schulze Pellengahr C, Walter PA, Lukas C, Falarzik A, Daniilidis K, et al. Biomechanical and functional indicators in male semiprofessional soccer players with increased hip alpha angles vs. amateur soccer players. BMC Musculoskelet Disord 2014;15(1):88.,32Siebenrock KA, Schaller C, Tannast M, Keel M, Büchler L. Anteverting Periacetabular Osteotomy for Symptomatic Acetabular Retroversion. J Bone Joint Surg Am 2014;96(21):1785-1792.35Ejnisman L, Philippon MJ, Lertwanich P, Pennock AT, Herzog MM, Briggs KK, et al. Relationship Between Femoral Anteversion and Findings in Hips With Femoroacetabular Impingement. Orthopedics 2013;36(3):e293-e300.,38Crawford EA, Whiteside D, Deneweth JM, Ross JR, Bedi A, Goulet GC. In Vivo Hip Morphology and Kinematics in Elite Baseball Pitchers. Arthroscopy 2016;32(5):798-805.40Lahner M, Mußhoff D, Von Schulze Pellengahr C, Willburger R, Hagen M, Ficklscherer A, et al. Is the Kinect system suitable for evaluation of the hip joint range of motion and as a screening tool for femoroacetabular impingement (FAI)? Technol Heal Care 2015;23(1):75-82.. Positions for testing were supine with hip flexion24Bedi A, Dolan M, Hetsroni I, Magennis E, Lipman J, Buly R, et al. Surgical Treatment of Femoroacetabular Impingement Improves Hip Kinematics: a computer-assisted model. Am J Sports Med 2011;39(Supplement 1):43S-49S. supine with hip extension38Crawford EA, Whiteside D, Deneweth JM, Ross JR, Bedi A, Goulet GC. In Vivo Hip Morphology and Kinematics in Elite Baseball Pitchers. Arthroscopy 2016;32(5):798-805. and prone25Chadayammuri V, Garabekyan T, Bedi A, Pascual-Garrido C, Rhodes J, O'Hara J, et al. Passive Hip Range of Motion Predicts Femoral Torsion and Acetabular Version. J Bone Joint Surg Am 2016;98(2):127-134.. Sagittal plane hip range of motion was evaluated for hip flexion25Chadayammuri V, Garabekyan T, Bedi A, Pascual-Garrido C, Rhodes J, O'Hara J, et al. Passive Hip Range of Motion Predicts Femoral Torsion and Acetabular Version. J Bone Joint Surg Am 2016;98(2):127-134.,27Botser IB, Ozoude GC, Martin DE, Siddiqi AJ, Kuppuswami S, Domb BG. Femoral Anteversion in the Hip: Comparison of Measurement by Computed Tomography, Magnetic Resonance Imaging, and Physical Examination. Arthrosc J Arthrosc Relat Surg 2012;28(5):619-627.,28Duthon VB, Charbonnier C, Kolo FC, Magnenat-Thalmann N, Becker CD, Bouvet C, et al. Correlation of Clinical and Magnetic Resonance Imaging Findings in Hips of Elite Female Ballet Dancers. Arthrosc J Arthrosc Relat Surg 2013;29(3):411-419.,32Siebenrock KA, Schaller C, Tannast M, Keel M, Büchler L. Anteverting Periacetabular Osteotomy for Symptomatic Acetabular Retroversion. J Bone Joint Surg Am 2014;96(21):1785-1792.35Ejnisman L, Philippon MJ, Lertwanich P, Pennock AT, Herzog MM, Briggs KK, et al. Relationship Between Femoral Anteversion and Findings in Hips With Femoroacetabular Impingement. Orthopedics 2013;36(3):e293-e300.,38Crawford EA, Whiteside D, Deneweth JM, Ross JR, Bedi A, Goulet GC. In Vivo Hip Morphology and Kinematics in Elite Baseball Pitchers. Arthroscopy 2016;32(5):798-805. and extension28Duthon VB, Charbonnier C, Kolo FC, Magnenat-Thalmann N, Becker CD, Bouvet C, et al. Correlation of Clinical and Magnetic Resonance Imaging Findings in Hips of Elite Female Ballet Dancers. Arthrosc J Arthrosc Relat Surg 2013;29(3):411-419.,33Siebenrock KA, Schoeniger R, Ganz R. Anterior femoro-acetabular impingement due to acetabular retroversion. Treatment with periacetabular osteotomy. J Bone Joint Surg Am 2003;85-A(2):278-286., and frontal plane hip range of motion was evaluated for abduction and adduction25Chadayammuri V, Garabekyan T, Bedi A, Pascual-Garrido C, Rhodes J, O'Hara J, et al. Passive Hip Range of Motion Predicts Femoral Torsion and Acetabular Version. J Bone Joint Surg Am 2016;98(2):127-134.,27Botser IB, Ozoude GC, Martin DE, Siddiqi AJ, Kuppuswami S, Domb BG. Femoral Anteversion in the Hip: Comparison of Measurement by Computed Tomography, Magnetic Resonance Imaging, and Physical Examination. Arthrosc J Arthrosc Relat Surg 2012;28(5):619-627.,28Duthon VB, Charbonnier C, Kolo FC, Magnenat-Thalmann N, Becker CD, Bouvet C, et al. Correlation of Clinical and Magnetic Resonance Imaging Findings in Hips of Elite Female Ballet Dancers. Arthrosc J Arthrosc Relat Surg 2013;29(3):411-419.,32Siebenrock KA, Schaller C, Tannast M, Keel M, Büchler L. Anteverting Periacetabular Osteotomy for Symptomatic Acetabular Retroversion. J Bone Joint Surg Am 2014;96(21):1785-1792.,33Siebenrock KA, Schoeniger R, Ganz R. Anterior femoro-acetabular impingement due to acetabular retroversion. Treatment with periacetabular osteotomy. J Bone Joint Surg Am 2003;85-A(2):278-286.,35Ejnisman L, Philippon MJ, Lertwanich P, Pennock AT, Herzog MM, Briggs KK, et al. Relationship Between Femoral Anteversion and Findings in Hips With Femoroacetabular Impingement. Orthopedics 2013;36(3):e293-e300..

Concerning the quality assessment of studies, raters independently agreed in 61.8% of the items (126) scored in the risk of bias scale, while, for the remaining 38.2%, agreement was met after discussion (Table 1). The study with the lowest score40Lahner M, Mußhoff D, Von Schulze Pellengahr C, Willburger R, Hagen M, Ficklscherer A, et al. Is the Kinect system suitable for evaluation of the hip joint range of motion and as a screening tool for femoroacetabular impingement (FAI)? Technol Heal Care 2015;23(1):75-82. received 4/12 points and the one with the highest score37Souza RB, Powers CM. Predictors of Hip Internal Rotation during Running. Am J Sports Med 2009;37(3):579-587. received 10/12 points. A representative sample of the population of interest was present in only seven studies28Duthon VB, Charbonnier C, Kolo FC, Magnenat-Thalmann N, Becker CD, Bouvet C, et al. Correlation of Clinical and Magnetic Resonance Imaging Findings in Hips of Elite Female Ballet Dancers. Arthrosc J Arthrosc Relat Surg 2013;29(3):411-419.,30Lahner M, von Schulze Pellengahr C, Walter PA, Lukas C, Falarzik A, Daniilidis K, et al. Biomechanical and functional indicators in male semiprofessional soccer players with increased hip alpha angles vs. amateur soccer players. BMC Musculoskelet Disord 2014;15(1):88.,36Hagen M, Abraham C, Ficklscherer A, Lahner M. Biomechanical study of plantar pressures during walking in male soccer players with increased vs. normal hip alpha angles. Technol Heal Care 2015;23(1):93-100.,38Crawford EA, Whiteside D, Deneweth JM, Ross JR, Bedi A, Goulet GC. In Vivo Hip Morphology and Kinematics in Elite Baseball Pitchers. Arthroscopy 2016;32(5):798-805.40Lahner M, Mußhoff D, Von Schulze Pellengahr C, Willburger R, Hagen M, Ficklscherer A, et al. Is the Kinect system suitable for evaluation of the hip joint range of motion and as a screening tool for femoroacetabular impingement (FAI)? Technol Heal Care 2015;23(1):75-82., with most studies based on samples that were not randomly selected. In addition, in most studies (9 out of 17), the selection criteria were not clear (Item 2)25Chadayammuri V, Garabekyan T, Bedi A, Pascual-Garrido C, Rhodes J, O'Hara J, et al. Passive Hip Range of Motion Predicts Femoral Torsion and Acetabular Version. J Bone Joint Surg Am 2016;98(2):127-134.,28Duthon VB, Charbonnier C, Kolo FC, Magnenat-Thalmann N, Becker CD, Bouvet C, et al. Correlation of Clinical and Magnetic Resonance Imaging Findings in Hips of Elite Female Ballet Dancers. Arthrosc J Arthrosc Relat Surg 2013;29(3):411-419.,30Lahner M, von Schulze Pellengahr C, Walter PA, Lukas C, Falarzik A, Daniilidis K, et al. Biomechanical and functional indicators in male semiprofessional soccer players with increased hip alpha angles vs. amateur soccer players. BMC Musculoskelet Disord 2014;15(1):88.,31Romano C, Frigo C, Randelli G, Pedotti A. Analysis of the Gait of Adults Who Had Residua of Congenital Dysplasia of the Hip. J Bone Joint Surg Am 1996;78(10):1468-1479.,33Siebenrock KA, Schoeniger R, Ganz R. Anterior femoro-acetabular impingement due to acetabular retroversion. Treatment with periacetabular osteotomy. J Bone Joint Surg Am 2003;85-A(2):278-286.,36Hagen M, Abraham C, Ficklscherer A, Lahner M. Biomechanical study of plantar pressures during walking in male soccer players with increased vs. normal hip alpha angles. Technol Heal Care 2015;23(1):93-100.,38Crawford EA, Whiteside D, Deneweth JM, Ross JR, Bedi A, Goulet GC. In Vivo Hip Morphology and Kinematics in Elite Baseball Pitchers. Arthroscopy 2016;32(5):798-805.40Lahner M, Mußhoff D, Von Schulze Pellengahr C, Willburger R, Hagen M, Ficklscherer A, et al. Is the Kinect system suitable for evaluation of the hip joint range of motion and as a screening tool for femoroacetabular impingement (FAI)? Technol Heal Care 2015;23(1):75-82..

Box 2
Summary of studies included in this systematic review.
Table 1
Methodological quality of the included studies.

In 15 out of 17 studies, the imaging exam used was considered appropriate for the morphological parameter of interest (Item 3). However, in 1 study39Baggaley M, Noehren B, Clasey JL, Shapiro R, Pohl MB. Frontal plane kinematics of the hip during running: Are they related to hip anatomy and strength? Gait Posture 2015;42(4):505-510. the measurement of the neck-shaft angle was performed using densitometry; in another study40Lahner M, Mußhoff D, Von Schulze Pellengahr C, Willburger R, Hagen M, Ficklscherer A, et al. Is the Kinect system suitable for evaluation of the hip joint range of motion and as a screening tool for femoroacetabular impingement (FAI)? Technol Heal Care 2015;23(1):75-82., the alpha angle was measured using an anteroposterior incidence. Both imaging procedures may be considered inappropriate for the measurement of interest. In relation to the time between exams and the possibility of change in the parameters of interest, both reviewers agreed that the time was often irrelevant given the time required to modify a morphological measurement (Item 4). However, there were studies that involved participants with degenerative alterations, in which the time between exams could potentially influence results but was not mentioned34Tannast M, Pfander G, Steppacher SD, Mast JW, Ganz R. Total acetabular retroversion following pelvic osteotomy: presentation, management, and outcome. Hip Int 2013;23 Suppl 9(Suppl 9):S14-26.. In three studies31Romano C, Frigo C, Randelli G, Pedotti A. Analysis of the Gait of Adults Who Had Residua of Congenital Dysplasia of the Hip. J Bone Joint Surg Am 1996;78(10):1468-1479.,32Siebenrock KA, Schaller C, Tannast M, Keel M, Büchler L. Anteverting Periacetabular Osteotomy for Symptomatic Acetabular Retroversion. J Bone Joint Surg Am 2014;96(21):1785-1792.,38Crawford EA, Whiteside D, Deneweth JM, Ross JR, Bedi A, Goulet GC. In Vivo Hip Morphology and Kinematics in Elite Baseball Pitchers. Arthroscopy 2016;32(5):798-805., the exam of interest was not applied to the entire sample and the choice of which participants would or would not take the exam was not random (Item 5).

In relation to the biomechanical measurements, nine studies24Bedi A, Dolan M, Hetsroni I, Magennis E, Lipman J, Buly R, et al. Surgical Treatment of Femoroacetabular Impingement Improves Hip Kinematics: a computer-assisted model. Am J Sports Med 2011;39(Supplement 1):43S-49S.,26Asayama I, Naito M, Fujisawa M, Kambe T. Relationship between radiographic measurements of reconstructed hip joint position and the Trendelenburg sign. J Arthroplasty 2002;17(6):747-751.,30Lahner M, von Schulze Pellengahr C, Walter PA, Lukas C, Falarzik A, Daniilidis K, et al. Biomechanical and functional indicators in male semiprofessional soccer players with increased hip alpha angles vs. amateur soccer players. BMC Musculoskelet Disord 2014;15(1):88.,31Romano C, Frigo C, Randelli G, Pedotti A. Analysis of the Gait of Adults Who Had Residua of Congenital Dysplasia of the Hip. J Bone Joint Surg Am 1996;78(10):1468-1479.,35Ejnisman L, Philippon MJ, Lertwanich P, Pennock AT, Herzog MM, Briggs KK, et al. Relationship Between Femoral Anteversion and Findings in Hips With Femoroacetabular Impingement. Orthopedics 2013;36(3):e293-e300.39Baggaley M, Noehren B, Clasey JL, Shapiro R, Pohl MB. Frontal plane kinematics of the hip during running: Are they related to hip anatomy and strength? Gait Posture 2015;42(4):505-510. described the procedures with enough detail to allow for replication (Item 6). The most commonly missing information in studies seemed to be the description of instruments25Chadayammuri V, Garabekyan T, Bedi A, Pascual-Garrido C, Rhodes J, O'Hara J, et al. Passive Hip Range of Motion Predicts Femoral Torsion and Acetabular Version. J Bone Joint Surg Am 2016;98(2):127-134.,27Botser IB, Ozoude GC, Martin DE, Siddiqi AJ, Kuppuswami S, Domb BG. Femoral Anteversion in the Hip: Comparison of Measurement by Computed Tomography, Magnetic Resonance Imaging, and Physical Examination. Arthrosc J Arthrosc Relat Surg 2012;28(5):619-627.,29Ferro FP, Ho CP, Briggs KK, Philippon MJ. Patient-centered outcomes after hip arthroscopy for femoroacetabular impingement and labral tears are not different in patients with normal, high, or low femoral version. Arthroscopy 2015;31(3):454-459. and patient positioning29Ferro FP, Ho CP, Briggs KK, Philippon MJ. Patient-centered outcomes after hip arthroscopy for femoroacetabular impingement and labral tears are not different in patients with normal, high, or low femoral version. Arthroscopy 2015;31(3):454-459.,33Siebenrock KA, Schoeniger R, Ganz R. Anterior femoro-acetabular impingement due to acetabular retroversion. Treatment with periacetabular osteotomy. J Bone Joint Surg Am 2003;85-A(2):278-286.,39Baggaley M, Noehren B, Clasey JL, Shapiro R, Pohl MB. Frontal plane kinematics of the hip during running: Are they related to hip anatomy and strength? Gait Posture 2015;42(4):505-510.,40Lahner M, Mußhoff D, Von Schulze Pellengahr C, Willburger R, Hagen M, Ficklscherer A, et al. Is the Kinect system suitable for evaluation of the hip joint range of motion and as a screening tool for femoroacetabular impingement (FAI)? Technol Heal Care 2015;23(1):75-82. used in the assessment of hip range of motion. With regards to the imaging exam procedure (Item 7), five studies did not seem to provide enough detail to allow for replication. Only one study clearly stated that measurements were blinded between the morphological and biomechanical tests (items 8 and 9)25Chadayammuri V, Garabekyan T, Bedi A, Pascual-Garrido C, Rhodes J, O'Hara J, et al. Passive Hip Range of Motion Predicts Femoral Torsion and Acetabular Version. J Bone Joint Surg Am 2016;98(2):127-134..

Considering the sample participation, one study did not clearly describe what happened to all participants that were initially included in the study (item 10)34Tannast M, Pfander G, Steppacher SD, Mast JW, Ganz R. Total acetabular retroversion following pelvic osteotomy: presentation, management, and outcome. Hip Int 2013;23 Suppl 9(Suppl 9):S14-26.. Five studies27Botser IB, Ozoude GC, Martin DE, Siddiqi AJ, Kuppuswami S, Domb BG. Femoral Anteversion in the Hip: Comparison of Measurement by Computed Tomography, Magnetic Resonance Imaging, and Physical Examination. Arthrosc J Arthrosc Relat Surg 2012;28(5):619-627.,33Siebenrock KA, Schoeniger R, Ganz R. Anterior femoro-acetabular impingement due to acetabular retroversion. Treatment with periacetabular osteotomy. J Bone Joint Surg Am 2003;85-A(2):278-286.,34Tannast M, Pfander G, Steppacher SD, Mast JW, Ganz R. Total acetabular retroversion following pelvic osteotomy: presentation, management, and outcome. Hip Int 2013;23 Suppl 9(Suppl 9):S14-26.,36Hagen M, Abraham C, Ficklscherer A, Lahner M. Biomechanical study of plantar pressures during walking in male soccer players with increased vs. normal hip alpha angles. Technol Heal Care 2015;23(1):93-100.,37Souza RB, Powers CM. Predictors of Hip Internal Rotation during Running. Am J Sports Med 2009;37(3):579-587. presented a clear descriptive analysis of data, with mean/median and dispersion statistics (Item 11). With regards to the inferential statistics (Item 12), seven studies25Chadayammuri V, Garabekyan T, Bedi A, Pascual-Garrido C, Rhodes J, O'Hara J, et al. Passive Hip Range of Motion Predicts Femoral Torsion and Acetabular Version. J Bone Joint Surg Am 2016;98(2):127-134.,27Botser IB, Ozoude GC, Martin DE, Siddiqi AJ, Kuppuswami S, Domb BG. Femoral Anteversion in the Hip: Comparison of Measurement by Computed Tomography, Magnetic Resonance Imaging, and Physical Examination. Arthrosc J Arthrosc Relat Surg 2012;28(5):619-627.,29Ferro FP, Ho CP, Briggs KK, Philippon MJ. Patient-centered outcomes after hip arthroscopy for femoroacetabular impingement and labral tears are not different in patients with normal, high, or low femoral version. Arthroscopy 2015;31(3):454-459.,32Siebenrock KA, Schaller C, Tannast M, Keel M, Büchler L. Anteverting Periacetabular Osteotomy for Symptomatic Acetabular Retroversion. J Bone Joint Surg Am 2014;96(21):1785-1792.34Tannast M, Pfander G, Steppacher SD, Mast JW, Ganz R. Total acetabular retroversion following pelvic osteotomy: presentation, management, and outcome. Hip Int 2013;23 Suppl 9(Suppl 9):S14-26.,37Souza RB, Powers CM. Predictors of Hip Internal Rotation during Running. Am J Sports Med 2009;37(3):579-587. introduced a correlation analysis.

Significant correlations between morphological and biomechanical parameters were found in some studies25Chadayammuri V, Garabekyan T, Bedi A, Pascual-Garrido C, Rhodes J, O'Hara J, et al. Passive Hip Range of Motion Predicts Femoral Torsion and Acetabular Version. J Bone Joint Surg Am 2016;98(2):127-134.,27Botser IB, Ozoude GC, Martin DE, Siddiqi AJ, Kuppuswami S, Domb BG. Femoral Anteversion in the Hip: Comparison of Measurement by Computed Tomography, Magnetic Resonance Imaging, and Physical Examination. Arthrosc J Arthrosc Relat Surg 2012;28(5):619-627.,29Ferro FP, Ho CP, Briggs KK, Philippon MJ. Patient-centered outcomes after hip arthroscopy for femoroacetabular impingement and labral tears are not different in patients with normal, high, or low femoral version. Arthroscopy 2015;31(3):454-459.,30Lahner M, von Schulze Pellengahr C, Walter PA, Lukas C, Falarzik A, Daniilidis K, et al. Biomechanical and functional indicators in male semiprofessional soccer players with increased hip alpha angles vs. amateur soccer players. BMC Musculoskelet Disord 2014;15(1):88.,35Ejnisman L, Philippon MJ, Lertwanich P, Pennock AT, Herzog MM, Briggs KK, et al. Relationship Between Femoral Anteversion and Findings in Hips With Femoroacetabular Impingement. Orthopedics 2013;36(3):e293-e300.,36Hagen M, Abraham C, Ficklscherer A, Lahner M. Biomechanical study of plantar pressures during walking in male soccer players with increased vs. normal hip alpha angles. Technol Heal Care 2015;23(1):93-100.,37Souza RB, Powers CM. Predictors of Hip Internal Rotation during Running. Am J Sports Med 2009;37(3):579-587., while in some others descriptive statistics allowed for the exploration of possible associations between morphology and the parameters of interest in this review 24Bedi A, Dolan M, Hetsroni I, Magennis E, Lipman J, Buly R, et al. Surgical Treatment of Femoroacetabular Impingement Improves Hip Kinematics: a computer-assisted model. Am J Sports Med 2011;39(Supplement 1):43S-49S.,25Chadayammuri V, Garabekyan T, Bedi A, Pascual-Garrido C, Rhodes J, O'Hara J, et al. Passive Hip Range of Motion Predicts Femoral Torsion and Acetabular Version. J Bone Joint Surg Am 2016;98(2):127-134.,29Ferro FP, Ho CP, Briggs KK, Philippon MJ. Patient-centered outcomes after hip arthroscopy for femoroacetabular impingement and labral tears are not different in patients with normal, high, or low femoral version. Arthroscopy 2015;31(3):454-459.,30Lahner M, von Schulze Pellengahr C, Walter PA, Lukas C, Falarzik A, Daniilidis K, et al. Biomechanical and functional indicators in male semiprofessional soccer players with increased hip alpha angles vs. amateur soccer players. BMC Musculoskelet Disord 2014;15(1):88.,35Ejnisman L, Philippon MJ, Lertwanich P, Pennock AT, Herzog MM, Briggs KK, et al. Relationship Between Femoral Anteversion and Findings in Hips With Femoroacetabular Impingement. Orthopedics 2013;36(3):e293-e300.,36Hagen M, Abraham C, Ficklscherer A, Lahner M. Biomechanical study of plantar pressures during walking in male soccer players with increased vs. normal hip alpha angles. Technol Heal Care 2015;23(1):93-100.,38Crawford EA, Whiteside D, Deneweth JM, Ross JR, Bedi A, Goulet GC. In Vivo Hip Morphology and Kinematics in Elite Baseball Pitchers. Arthroscopy 2016;32(5):798-805.,40Lahner M, Mußhoff D, Von Schulze Pellengahr C, Willburger R, Hagen M, Ficklscherer A, et al. Is the Kinect system suitable for evaluation of the hip joint range of motion and as a screening tool for femoroacetabular impingement (FAI)? Technol Heal Care 2015;23(1):75-82.. The significance, context and interpretation of these relationships are specified in the discussion section.

DISCUSSION

Based on the parameters evaluated, 16 out of the 17 studies performed poorly in the risk of bias and quality assessment with only one study reaching a score equal or above 9 in the scale and being considered of high quality37Souza RB, Powers CM. Predictors of Hip Internal Rotation during Running. Am J Sports Med 2009;37(3):579-587.. We speculate the high risk of bias present in the literature regarding the relationship between morphological and biomechanical parameters is likely related to the difficulty in inspecting hip morphology in healthy control individuals and to the cost and ethical issues related to imaging tests. The results of our analysis emphasize the need of interpreting available evidence with caution.

Significant correlations between morphological and biomechanical parameters were found in some studies25Chadayammuri V, Garabekyan T, Bedi A, Pascual-Garrido C, Rhodes J, O'Hara J, et al. Passive Hip Range of Motion Predicts Femoral Torsion and Acetabular Version. J Bone Joint Surg Am 2016;98(2):127-134.,29Ferro FP, Ho CP, Briggs KK, Philippon MJ. Patient-centered outcomes after hip arthroscopy for femoroacetabular impingement and labral tears are not different in patients with normal, high, or low femoral version. Arthroscopy 2015;31(3):454-459.,30Lahner M, von Schulze Pellengahr C, Walter PA, Lukas C, Falarzik A, Daniilidis K, et al. Biomechanical and functional indicators in male semiprofessional soccer players with increased hip alpha angles vs. amateur soccer players. BMC Musculoskelet Disord 2014;15(1):88.,36Hagen M, Abraham C, Ficklscherer A, Lahner M. Biomechanical study of plantar pressures during walking in male soccer players with increased vs. normal hip alpha angles. Technol Heal Care 2015;23(1):93-100.. Patients with small femoral offset were associated to a greater pelvic drop in the Trendelenburg test (r=0.416; p=0.0137)26Asayama I, Naito M, Fujisawa M, Kambe T. Relationship between radiographic measurements of reconstructed hip joint position and the Trendelenburg sign. J Arthroplasty 2002;17(6):747-751.. In a study with female runners39Baggaley M, Noehren B, Clasey JL, Shapiro R, Pohl MB. Frontal plane kinematics of the hip during running: Are they related to hip anatomy and strength? Gait Posture 2015;42(4):505-510., a moderate correlation between neck-shaft angle and the strength of hip abductor muscles was found (r=-0.47; p=0.02) but not between neck-shaft angle and gait kinematic parameters.

Significant correlations were also observed in studies that focused in patients that had undergone hip video arthroscopy. In a study with 123 patients27Botser IB, Ozoude GC, Martin DE, Siddiqi AJ, Kuppuswami S, Domb BG. Femoral Anteversion in the Hip: Comparison of Measurement by Computed Tomography, Magnetic Resonance Imaging, and Physical Examination. Arthrosc J Arthrosc Relat Surg 2012;28(5):619-627., the femoral anteversion angle was found to be related to the range of internal rotation in physical examination (r=0.36; p<0.001). Ejnisman et al.35Ejnisman L, Philippon MJ, Lertwanich P, Pennock AT, Herzog MM, Briggs KK, et al. Relationship Between Femoral Anteversion and Findings in Hips With Femoroacetabular Impingement. Orthopedics 2013;36(3):e293-e300. evaluated 188 patients and also found a similar correlation (r=0.231; p=0.002) accompanied with a negative correlation between femoral anteversion and external rotation (r=-0.208; p=0.027). It is important to note however that despite reaching statistical significance, all observed correlations are poor, indicating that other parameters may contribute largely. Finally, Souza and Powers37Souza RB, Powers CM. Predictors of Hip Internal Rotation during Running. Am J Sports Med 2009;37(3):579-587. investigated biomechanical and morphological factors related to hip internal rotation angle at the first 50% of stance phase during running in female runners with patellofemoral pain syndrome. No significant relationship was found between hip internal rotation and femoral version or neck-shaft angle (p=0.11 and p=0.10; respectively).

Some studies presented descriptive analysis that allow for the exploration of possible associations between morphology and the parameters of interest in this review. Chadayammuri et al.25Chadayammuri V, Garabekyan T, Bedi A, Pascual-Garrido C, Rhodes J, O'Hara J, et al. Passive Hip Range of Motion Predicts Femoral Torsion and Acetabular Version. J Bone Joint Surg Am 2016;98(2):127-134. grouped 221 patients in I) femoral version <10o; II) femoral version between 10 and 20o and III) femoral version >20o and found that internal rotation range of movement was significantly greater at group III, followed by II and I (40.7±14.8o, 30.9±11.8o and 24.8±12.5o respectively; p<0.001). An opposite effect was found for external rotation (28.6±11.7o; 26.4±10.4o; 22.7±11.8o for group I, II and III respectively; p<0.001). Ejnisman et al.35Ejnisman L, Philippon MJ, Lertwanich P, Pennock AT, Herzog MM, Briggs KK, et al. Relationship Between Femoral Anteversion and Findings in Hips With Femoroacetabular Impingement. Orthopedics 2013;36(3):e293-e300. grouped patients in I) femoral version <5°; II) femoral version between 5 and 15°; and III) femoral version > 15°. Group I presented significantly greater range of movement towards external rotation (45±14°, 38±12° and 36±13° for group I II and III, respectively). No significant differences between groups were observed for internal rotation. Ferro et al,29Ferro FP, Ho CP, Briggs KK, Philippon MJ. Patient-centered outcomes after hip arthroscopy for femoroacetabular impingement and labral tears are not different in patients with normal, high, or low femoral version. Arthroscopy 2015;31(3):454-459. using the same grouping criteria, also found that internal rotation increased, and external rotation decreased from group I to II and from group II to III.

We found only one study that focused on the potential effect of acetabular version angle on hip mobility. Chadayammuri et al.25Chadayammuri V, Garabekyan T, Bedi A, Pascual-Garrido C, Rhodes J, O'Hara J, et al. Passive Hip Range of Motion Predicts Femoral Torsion and Acetabular Version. J Bone Joint Surg Am 2016;98(2):127-134. grouped individuals in I) acetabular version >20o; II) acetabular version between 15 and 20o and III) acetabular <15o and identified that individuals in group I presented greater range of movement towards internal rotation than others. External rotation, however, did not seem to be affected by acetabular version. Besides the differences in the transverse plane, authors also found that hip flexion range of movement was significantly smaller for hips with the acetabulum retroverted – group III (104.6±17.6o) compared to normal hips or increased acetabular version (110.6±12.3o and 112.1±12.3o respectively) (p<0.001).

Chadayammuri et al.25Chadayammuri V, Garabekyan T, Bedi A, Pascual-Garrido C, Rhodes J, O'Hara J, et al. Passive Hip Range of Motion Predicts Femoral Torsion and Acetabular Version. J Bone Joint Surg Am 2016;98(2):127-134. also analysed the combination of acetabular (normal, anteversion and retroversion) and femoral version (normal, anteversion and retroversion), resulting in nine different groups. Overall, hips with femoral anteversion and acetabular anteversion exhibited the greatest internal rotation range of motion at a neutral hip position (44.2o), whereas hips with femoral retroversion and acetabular retroversion demonstrated the lowest corresponding value (20.1o; p<0.001). A combined femoral-acetabular version (COTAV) index was calculated as the sum of femoral and acetabular version angles. The COTAV was considered excessive if >45o, normal if between 20o and 45o, or reduced if <20o. A multiple linear regression analysis indicated that the COTAV index increased approximately 0.5o per degree increase in internal rotation range of movement and 0.26o per one year increase in age (R2Powers CM. The influence of abnormal hip mechanics on knee injury: a biomechanical perspective. J Orthop Sports Phys Ther 2010;40(2):42-51.=0.384, p<0.001).

Bedi et al.24Bedi A, Dolan M, Hetsroni I, Magennis E, Lipman J, Buly R, et al. Surgical Treatment of Femoroacetabular Impingement Improves Hip Kinematics: a computer-assisted model. Am J Sports Med 2011;39(Supplement 1):43S-49S. found that after an arthroscopic resection of cam deformity in patients with femoroacetabular impingement syndrome, the reduction in the alpha angle (59.8o to 36.4o; p<0.001) was accompanied by a significant increase in hip internal rotation range (17.5 ±11.4o to 31 ±8.43o). Lahner et al.40Lahner M, Mußhoff D, Von Schulze Pellengahr C, Willburger R, Hagen M, Ficklscherer A, et al. Is the Kinect system suitable for evaluation of the hip joint range of motion and as a screening tool for femoroacetabular impingement (FAI)? Technol Heal Care 2015;23(1):75-82. also found that individuals with hip alpha angles ≤55o presented a slightly greater range of hip internal rotation when compared to hip alpha angles >55o (27.6±5.1o versus 24.2±8.5o, respectively).

Investigations regarding morphological and biomechanical parameters in the sport context were found30Lahner M, von Schulze Pellengahr C, Walter PA, Lukas C, Falarzik A, Daniilidis K, et al. Biomechanical and functional indicators in male semiprofessional soccer players with increased hip alpha angles vs. amateur soccer players. BMC Musculoskelet Disord 2014;15(1):88.,36Hagen M, Abraham C, Ficklscherer A, Lahner M. Biomechanical study of plantar pressures during walking in male soccer players with increased vs. normal hip alpha angles. Technol Heal Care 2015;23(1):93-100.,38Crawford EA, Whiteside D, Deneweth JM, Ross JR, Bedi A, Goulet GC. In Vivo Hip Morphology and Kinematics in Elite Baseball Pitchers. Arthroscopy 2016;32(5):798-805.. Hagen et al.36Hagen M, Abraham C, Ficklscherer A, Lahner M. Biomechanical study of plantar pressures during walking in male soccer players with increased vs. normal hip alpha angles. Technol Heal Care 2015;23(1):93-100. investigated differences in plantar pressure distribution during walking between male soccer players with alpha angle >55o or <50o and found that a greater alpha angle was accompanied with a smaller hallux contact area, smaller force and pressure integral on the rearfoot region and greater force integral on the medio-lateral region of the foot. Lahner et al.30Lahner M, von Schulze Pellengahr C, Walter PA, Lukas C, Falarzik A, Daniilidis K, et al. Biomechanical and functional indicators in male semiprofessional soccer players with increased hip alpha angles vs. amateur soccer players. BMC Musculoskelet Disord 2014;15(1):88. compared amateur to professional soccer players with regards to hip alpha angle and plantar pressure distribution and rearfoot motion during running. Although plantar pressure parameters differed between them, no significant differences in alpha angle were observed. Crawford et al.38Crawford EA, Whiteside D, Deneweth JM, Ross JR, Bedi A, Goulet GC. In Vivo Hip Morphology and Kinematics in Elite Baseball Pitchers. Arthroscopy 2016;32(5):798-805. compared the alpha angle between the front and rear leg in baseball players and, despite the exposure to different kinematics during the throwing motion, no differences in hip morphology were found.

In general, there seems to be a significant relationship between femoral and acetabular version angles and hip mobility in the transverse plane. Most of the evidence available points to a small effect on range of motion with little being known about possible effects of morphology on movement biomechanics. Although there is a theoretical expectation of hip morphology to affect strength at a certain degree due to changes in moment arms, only one study was found supporting experimental evidence towards this hypothesis39Baggaley M, Noehren B, Clasey JL, Shapiro R, Pohl MB. Frontal plane kinematics of the hip during running: Are they related to hip anatomy and strength? Gait Posture 2015;42(4):505-510..

Some limitations should be considered in this systematic review. Although no restrictions in language were imposed to the search, the fact that only English keywords were entered may have restricted access to some non-English papers. With regards to the instrument used to access quality and risk of bias, although the original QUADAS scale from which the instrument was created has been extensively used, the adaptations made for the purpose of this review have not been validated. Finally, we used a cut point of 70% of affirmative responses to define a study of high quality22Cook C, Mabry L, Reiman MP, Hegedus EJ. Best tests/clinical findings for screening and diagnosis of patellofemoral pain syndrome: a systematic review. Physiotherapy 2012;98(2):93-100., while there has been criticism on the use of scores to classify studies on quality21Whiting P, Rutjes AWS, Reitsma JB, Bossuyt PMM, Kleijnen J. The development of QUADAS: a tool for the quality assessment of studies of diagnostic accuracy included in systematic reviews. BMC Med Res Methodol 2003;3:25..

CONCLUSION

This study assessed the quality and summarized the evidence available on the role of hip morphology in determining hip strength, mobility and the biomechanics of lower limb movement during functional and sport activities. Literature in the area is limited and the studies available are mostly accompanied by a high risk of bias. Primary evidence seems to be focused on the influence of hip morphology on the hip mobility in the transverse plane, primarily on changes in range of motion. With regards to biomechanical parameters that could provide insights into the association between hip morphology and kinematic and kinetic characteristics of movement, we were not able to draw a clear conclusion based on the available findings. Our results point to a field that is currently under explored and future studies addressing these relationships will be beneficial to our understanding of modifiable and non-modifiable parameters related to lower limb disorders.

How to cite this article

  • Ferraz A, Fontana HB, Castro MP, Ruschel C, Pierri CAA, Roesler H. Hip morphology and its relationship with hip strength, mobility and lower limb biomechanics: a systematic review in adults. Rev Bras Cineantropom Desempenho Hum2020, 22:e67085. DOI: http://dx.doi.org/10.1590/1980-0037.2020v22e67085

COMPLIANCE WITH ETHICAL STANDARDS

  • Funding

    This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - Brasil (CAPES) - Finance Code 001.
  • Ethical approval

    This research is in accordance with the standards set by the Declaration of Helsinki.

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Publication Dates

  • Publication in this collection
    23 Oct 2020
  • Date of issue
    2020

History

  • Received
    02 Sept 2019
  • Accepted
    25 Feb 2020
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