Physical Therapist Resource Hub

Clinical Decision Support in Hip Preservation

Physical therapists are often the first clinicians to evaluate young athletes with hip pain. Determining when to continue structured rehabilitation, when advanced imaging is appropriate, and when referral for hip preservation evaluation is indicated can be complex — particularly in cases involving femoroacetabular impingement (FAI), labral pathology, dysplasia, or hip microinstability.

This resource hub is designed as a clinical decision support framework. It provides practical algorithms, differentiation tables, imaging interpretation guidance, and referral indicators grounded in an indications-first philosophy.

The goal is not to accelerate surgical referral.

The goal is to support appropriate decision-making based on patient trajectory, functional response, and structural stability.

Core Principle:
Imaging supports clinical decision-making — it does not replace it.

Morphology alone does not determine intervention.
Functional limitation, symptom reproducibility, mechanical instability, and failure of structured rehabilitation remain the primary drivers of referral consideration.

Stepwise Clinical Algorithm

Clinical decision algorithm for physical therapists managing young athletes with hip pain.

Clinical Interpretation: Understanding the Gray Zone

Most young athletes with hip pain do not fall cleanly into “rehab success” or “surgical candidate” categories. The majority exist in a diagnostic gray zone characterized by partial strength improvement, persistent activity-related pain, and imaging findings that may or may not correlate with symptoms.

Clinical trajectory — not isolated morphology — determines progression toward referral.

Clinical decision matrix outlining when to continue rehabilitation, monitor, or refer for hip preservation evaluation based on symptom duration, strength progression, range of motion, mechanical symptoms, instability signs, and injection response.

The majority of patients fall within the “Monitor / Reassess” column. Referral becomes progressively weighted when symptoms persist beyond 12 weeks despite structured rehabilitation, mechanical symptoms increase in frequency, or instability indicators accumulate. Escalation decisions should reflect a pattern of failed trajectory rather than a single exam finding.

Escalation is driven by failure of progression — not the presence of morphology alone.

Comparison table differentiating femoroacetabular impingement from hip instability based on patient demographics, range of motion patterns, pain arc, capsular tone, apprehension signs, and expected arthroscopy outcomes.

Misclassification between impingement-dominant and instability-dominant pathology is one of the most common contributors to persistent postoperative pain and failed conservative management. While cam morphology is common in asymptomatic athletes, instability — particularly borderline dysplasia and capsular laxity — is frequently under-recognized.

Careful attention to rotational patterns, apprehension signs, and symptom reproduction arc improves diagnostic accuracy.

Clinical Takeaway: Instability is often under-recognized in the young athletic population.

Imaging Interpretation: Context Over Morphology

Imaging findings are common in asymptomatic athletic populations. Labral tears, cam morphology, and even mild dysplasia may be present in patients without functional limitation. For this reason, imaging must support clinical findings — not dictate escalation independently.

The relevance of imaging is determined by symptom reproduction, mechanical instability, and failure of structured rehabilitation.

Labral Tears on MRI

Labral tears are frequently identified on MRI in athletes without symptoms. The presence of a tear alone does not establish surgical indication. Mechanical locking, reproducible catching, and persistent activity limitation are stronger clinical drivers than imaging alone.

Sagittal cross-sectional medical illustration of the human hip joint showing the femoral head seated congruently within the acetabulum.

Medical illustration of the femoral head and neck in an oblique view demonstrating alpha angle measurement.

Cam Morphology and Alpha Angle

Cam morphology is prevalent in high-level athletes, particularly males participating in cutting and pivoting sports. Increased alpha angle does not inherently require intervention. Clinical correlation with flexion-based pain and functional limitation is required before escalation.

Dysplasia and the Limits of LCEA Alone

Borderline dysplasia cannot be diagnosed by lateral center-edge angle in isolation. Assessment must include anterior coverage, acetabular version, Tönnis angle, and clinical instability signs. Under-recognition of instability is a common contributor to failed arthroscopy.

Side-by-side coronal medical illustrations comparing acetabular coverage of the hip joint.

Imaging supports clinical decision-making.
It does not replace functional assessment and trajectory analysis.

Diagnostic Injection: What the Response Actually Tells You

Image-guided intra-articular hip injections are frequently used in the evaluation of persistent hip pain. However, interpretation of injection response requires nuance. Relief of pain does not automatically imply surgical indication, and lack of response does not definitively exclude intra-articular pathology.

Injection results must be interpreted in the context of mechanical symptoms, instability signs, and functional limitation.

Table explaining clinical interpretation of diagnostic intra-articular hip injection responses, including complete relief, partial relief, and no relief, with corresponding referral implications.

Complete symptom relief confirms an intra-articular pain source but does not determine the optimal treatment pathway. Persistent mechanical symptoms or functional shutdown after adequate rehabilitation increase referral weight. Conversely, absent relief should prompt reconsideration of extra-articular contributors, lumbopelvic mechanics, or subtle instability patterns.

Injection response clarifies pain origin — it does not independently determine intervention.

Patterns of Failed Arthroscopy

Why Some Scopes Do Not Fully Resolve Symptoms

Hip arthroscopy can be highly effective in appropriately selected patients. However, persistent or recurrent symptoms following arthroscopy are not uncommon, particularly when underlying structural instability or version abnormalities were not fully recognized preoperatively.

Understanding the common patterns associated with suboptimal outcomes helps physical therapists identify patients who may benefit from further structural evaluation rather than repeated rehabilitation alone.

Unrecognized Structural Instability

One of the most frequent contributors to persistent postoperative pain is under-recognized instability. Borderline dysplasia, capsular laxity, and version abnormalities may not be fully appreciated on initial evaluation.

Patients may initially improve, only to experience recurrent pain with return to sport.

Clinical Clues:

Female athlete
Persistent apprehension
Excess external rotation
Pain with extension-based activity

Instability misclassified as isolated impingement can limit arthroscopic success.

Capsular Insufficiency

Excessive capsulotomy or inadequate capsular repair may contribute to persistent microinstability. These patients often describe vague discomfort, fatigue pain, or loss of confidence in dynamic activities.

Clinical Pattern:

Deep ache rather than sharp mechanical pain
Difficulty with pivoting sports
Apprehension without true locking

Version Abnormalities

Femoral or acetabular version abnormalities can alter joint biomechanics and may not be fully corrected during arthroscopy. Persistent rotational discomfort or asymmetrical motion may remain.

Clinical Clues:

Persistent rotational pain
Asymmetry not explained by strength deficits
Limited improvement despite good rehab adherence

Incomplete Cam Resection

In some cases, residual impingement morphology may persist.

Clinical Pattern:

Flexion-based pain remains primary complaint
FADIR remains strongly positive
Mechanical symptoms continue

This is less common in experienced centers but remains a recognized contributor.

Non-Intra-Articular Contributors

Not all persistent pain after arthroscopy is structural. Extra-articular sources such as:

Iliopsoas irritation
Core weakness
Abductor insufficiency
Lumbopelvic dysfunction

must also be considered.

Rehabilitation remains critical in these cases.

Clinical Perspective

Persistent symptoms following hip arthroscopy are rarely the result of a single variable. Careful reassessment of structural stability, version alignment, and rehabilitation progression is essential before assuming surgical failure. Collaborative discussion can help determine whether continued rehabilitation, imaging reassessment, or structural evaluation is most appropriate.

Not all persistent pain after arthroscopy indicates surgical error.
Many cases reflect unrecognized instability, version complexity, or multifactorial contributors.

Return-to-Sport Risk Stratification Framework

Clinical Markers of Readiness vs Risk

Return to sport following hip rehabilitation or hip arthroscopy requires more than strength symmetry alone. Persistent instability patterns, fatigue pain, and mechanical symptoms may increase reinjury risk even when objective metrics appear adequate.

A structured risk stratification model helps guide progression decisions and identify patients who may benefit from further evaluation.

Low Risk Return to Sport

Green traffic light icon indicating low risk for return to sport.

Symmetric hip strength (within 10%)
Pain-free sport-specific drills
No apprehension with extension/rotation
No mechanical locking or catching
Full tolerance to progressive loading

Patients meeting these criteria typically progress safely with structured return-to-play protocols.

Yellow traffic light icon indicating caution during return to sport progression.

Caution Zone

Mild fatigue-related groin pain
Slight asymmetry in internal rotation
Apprehension with high-speed pivoting
Inconsistent tolerance to volume increases
Fear avoidance behaviors

These athletes may require load modification, neuromuscular retraining, and closer monitoring before full clearance.

Elevated Risk

Recurrent mechanical locking
Extension-based instability pain
Persistent apprehension sign
Progressive loss of ROM
Shutdown during sport participation

Recurrent shutdown or mechanical symptoms warrant structural reassessment prior to unrestricted return.

Clinical Integration

Return-to-sport decisions should integrate mechanical stability, symptom reproducibility, and fatigue response — not strength testing alone. In cases of repeated sport intolerance despite adequate rehabilitation, structural evaluation may be appropriate.

Recurrent shutdown is not deconditioning. It is a diagnostic signal.

Collegial Case Collaboration & Educational Resources

Collaborative Case Discussion

Hip preservation decision-making often requires integration of rehabilitation trajectory, imaging findings, and structural stability assessment. In cases that fall within the clinical gray zone, direct discussion can help clarify whether continued rehabilitation, further imaging, or structural evaluation is most appropriate.

Collegial case review is welcomed for complex or uncertain presentations.

What to Include in a Case Summary

Patient age and activity level
Duration of symptoms
Rehabilitation timeline and response
Mechanical symptoms (if present)
Imaging summary (if available)
Injection response (if performed)

For case discussion:

Contact

Case discussions are intended to support collaborative care and are not a substitute for formal medical consultation.

Educational Resource for Physical Therapists

For physical therapists interested in a broader framework of hip preservation principles — including early diagnosis, conservative management, surgical indications, and post-operative rehabilitation collaboration — the following presentation may be helpful.