Delays in Diagnosis Are Common Among Hip Preservation Surgical Candidates: A Systematic Review

Abstract

Purpose

To systematically review the literature on delays in diagnosis or treatment of hip preservation patients.

Methods

A systematic review was performed by searching PubMed, the Cochrane Library, and Embase, from inception to November 2024, to identify any study reporting on delays in diagnosis or treatment of hip preservation patients, that is, patients with femoroacetabular impingement syndrome, hip dysplasia, or femoral torsion abnormalities. The search terms used were as follows: delay AND (diagnosis OR treatment) AND ("femoroacetabular impingement" OR "hip dysplasia" OR "hip arthroscopy" OR "periacetabular osteotomy"). Outcomes reported included demographic characteristics, preoperative duration of symptoms, and patient-reported outcomes.

Results

Twelve articles (1 Level II, 1 Level III, and 10 Level IV) met the inclusion criteria, with a total of 2,883 hips. The mean patient age ranged from 16.4 to 45.0 years, and the overall percentage of male patients ranged from 0% to 56.9%. The mean time from symptom onset to accurate diagnosis for hip preservation patients ranged from 17.2 to 61.5 months across studies. Prior health care providers consulted were largely other orthopaedic surgeons and primary care physicians; each patient consulted with an average of 1.9 to 4.2 providers and received a multitude of alternate diagnoses, imaging assessments, and treatment attempts before presentation to a hip preservation specialist. In studies comparing outcomes between patients with short and long durations of symptoms (i.e., <2 years and >2 years, respectively), significantly worse postoperative patient-reported outcomes were observed in the groups with a longer symptom duration.

Conclusions

Patients presenting with hip preservation pathologies commonly experience delays in diagnosis and/or treatment and consult with multiple health care providers across specialties before receiving an accurate diagnosis and appropriate treatment. In turn, this leads to poorer post-treatment outcomes compared with patients who receive appropriate treatment in a timely manner.

Level of Evidence

Level IV, systematic review of Level II to IV studies.

In young adults, hip pain often stems from 3 key factors central to hip joint preservation: femoroacetabular impingement syndrome (FAIS), hip dysplasia, and femoral torsion abnormalities.^1,2 Although not everyone with femoroacetabular impingement experiences pain, it remains a substantial concern affecting individuals of all ages, sexes, and activity levels.^3,4 Prior to surgery, a trial of nonoperative management of hip pain is recommended, including physical therapy and activity modification.² Hip preservation surgery for the treatment of prearthritic hip pathologies is an increasingly common intervention that has been shown to improve functional status and patient-reported outcomes (PROs) and to delay total hip arthroplasty.^2,5, 6, 7 However, several preoperative factors, such as high body mass index, older age, severe cam deformity, and pre-existing cartilage damage, have been shown to hinder postoperative improvement.8, 9, 10

Another factor found to have a negative impact on postoperative outcomes is the preoperative duration of symptoms. In a study of 624 hip arthroscopy patients by Basques et al.,¹¹ those with symptoms lasting more than 2 years showed improvement but reported worse outcomes and higher revision rates compared with those with symptoms lasting less than 2 years at 2-year follow-up. Other studies suggest similar results,^12,13 and a systematic review of 6 studies found that patients with a symptom duration greater than 2 years had worse postoperative outcomes than patients with a symptom duration less than 2 years.¹⁴ Despite advances in hip preservation techniques, diagnosing these conditions remains challenging, often delaying referrals to hip preservation specialists. The extent of the delay is highly variable across several studies assessing hip preservation patients, ranging from 3 months to as long as 15 years.^15,16 Diagnostic delays in hip preservation patients often result from nonspecific symptom presentation, lack of provider awareness, and health care system barriers such as specialist availability and wait times.¹⁵ Common misdiagnoses include lumbar radiculopathy, hip flexor strain, and early osteoarthritis, with patients frequently being referred to primary care physicians, physical therapists, or sports medicine specialists before seeing a hip preservation specialist.

The purpose of this study was to systematically review the literature on delays in diagnosis or treatment of hip preservation patients. We hypothesized that delays in diagnosis and treatment would be common within this population and that patients with longer diagnostic delays would experience worse postoperative outcomes.

Methods

This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines using a Preferred Reporting Items for Systematic Reviews and Meta-analyses checklist. Two independent reviewers (K.M., J.D.) searched PubMed, Embase, and the Cochrane Library from inception to November 5, 2024, and extracted all data. The electronic search strategy used was as follows: delay AND (diagnosis OR treatment) AND ("femoroacetabular impingement" OR "hip dysplasia" OR "hip arthroscopy" OR "periacetabular osteotomy"). A total of 678 studies were reviewed by title and/or abstract to determine study eligibility based on inclusion criteria. Furthermore, reference lists for studies that met the inclusion criteria were reviewed to see if any further studies were identified that met the inclusion criteria. In cases of disagreement, a third reviewer (M.J.K.) made the final decision (Fig 1). The inclusion criteria included any study with a primary focus on delays in diagnosis or operative treatment of hip preservation patients, that is, patients with FAIS, hip dysplasia, or femoral torsion abnormalities. Studies were excluded if they were unrelated to the hip joint, had patient populations of neonates or pediatric patients exclusively younger than 18 years, or were non-clinical studies. Overlapping studies were also excluded and were defined as studies conducted by the same principal investigator that assessed patients who (1) presented with the same condition and (2) were assessed during an overlapping period. In cases of overlapping studies, the study with the longest follow-up was selected. There was no need for funding or a third party to obtain any of the collected data.

Fig 1.

Preferred Reporting Items for Systematic Reviews and Meta-analyses diagram.

Reporting of Outcomes

When available, the following information was extracted from each study: first author, study type, study period, follow-up duration, demographic characteristics, duration from symptom onset to accurate diagnosis, and PROs. PROs included the modified Harris Hip Score (mHHS),¹⁷ Hip Outcome Score–Activities of Daily Living (HOS-ADL), Hip Outcome Score–Sport-Specific Subscale (HOS-SSS),¹⁸ visual analog scale for pain, International Hip Outcome Tool (iHOT-12) score,¹⁹ and Non-Arthritic Hip Score.²⁰ Rates of revision hip arthroscopy were also collected.

Study Methodology Assessment

Two authors (K.M., J.D.) used the Methodological Index for Non-randomized Studies criteria to score all included articles.²¹ Articles were individually graded. Article score discrepancies were resolved by article review and discussion until unanimous consensus was found. Level-of-evidence standards set by Hohmann et al.²² were used for the articles.

The Modified Coleman Methodology Score (MCMS) was used to evaluate study methodologic quality.²³ The MCMS has a scaled potential score ranging from 0 to 100. Scores ranging from 85 to 100 are excellent; 70 to 84, good; 55 to 69, fair; and less than 55, poor. The primary outcomes assessed by the MCMS are study size and type, follow-up time, attrition rate, number of interventions per group, and proper description of study methodology.

Statistical Analysis

Means and standard deviations were reported when available, and ranges were reported across studies for any continuous data. For comparative measures, P < .05 was considered statistically significant. Also reported were proportions of patients who previously experienced secondary characteristics of diagnostic latency, such as alternate diagnoses and/or interventions by other health care providers.

Postoperative PRO measures from multiple studies were synthesized using meta-analytic techniques. To facilitate comparisons across studies reporting different PRO metrics, raw postoperative scores were standardized as Z-scores, where each score was transformed relative to the overall mean and standard deviation of the data set. Standardized mean estimates and their corresponding confidence intervals were pooled using a random-effects model.

To compare postoperative outcomes between groups within each study, standardized mean differences were calculated using Hedges’ g, which adjusts for small sample bias. A random-effects meta-analysis was conducted to estimate the pooled standardized mean difference and assess variability across studies. Heterogeneity was quantified using the I² statistic, which describes the proportion of total variability attributable to between-study differences, and τ², which estimates between-study variance. All analyses and plots were performed in R version 4.4.1 using the meta²⁴ and metafor²⁵ packages.

Results

Sixteen studies met the initial inclusion criteria^{3,4,11,12,15,16,}26, 27, 28, 29, 30, 31, 32, 33, 34, 35; 4 of these studies were excluded from our analysis because of overlapping patient populations (Fig 1).^11,12,26,27 Within the remaining 12 studies (1 Level II,³⁴ 1 Level III,³² and 10 Level IV^3,4,15,16,28, 29, 30, 31^,33,35), a total of 2,883 hips were included (Table 1). The mean patient age ranged from 16.4 years²⁸ to 45.0 years.²⁹ The mean post-treatment follow-up time ranged from 16.4 months³ to 60 months.³³ The average body mass index ranged from 24.5³⁴ to 25.3,³³ and the overall percentage of male patients ranged from 0%³² to 56.9%.¹⁶ Five studies assessed FAIS,^{15,16,28,33,34} 3 assessed patients with hip dysplasia,^4,30,32 2 focused on patients with acetabular labral tears,^3,31 1 assessed all hip arthroscopies performed by a single surgeon,³⁵ and 1 assessed all referrals to a hip preservation specialist.²⁹ Concerning methodologic quality assessment, the MCMS and Methodological Index for Non-randomized Studies scores from the 12 included studies are listed in Table 1. Five studies received a good score,^{4,30,32,34,35} and 7 studies received a fair score.^{3,15,16,28,29,31,33}

Table 1.

Study Information and Description of Patient Demographic Characteristics

Study	LOE	Pathology	Hips, n	Age, yr	Female-Male Ratio, n	BMI	Follow-Up, mo∗	MCMS	MINORS Score
Ruzbarsky et al.28	IV	FAIS	134	16.4 ± 1.1	87:47	NR	57.6 ± 26.4	67	12
Burnett et al.3	IV	Labral tears	66	38	47:19	NR	16.4	64	11
Nunley et al.4	IV	Hip dysplasia	65	24	47:18	NR	29.2	72	13
Petrera et al.29	IV	FAIS, labral tears, and osteoarthritis	96	45	49:47	NR	NA	62	11
Kennedy et al.30	IV	Hip dysplasia	51	37	46:5	NR	NA	70	12
Dierckman et al.31	IV	Labral tears	868	36.6 ± 14.2	553:315	25.0 ± 4.8	Minimum, 24	67	13
Luck et al.32	IV	Hip dysplasia	18	17.2 ± 1.9	18:0	NR	30.5 ± 10.5	72	12
Kunze et al.33	III	FAIS	310	34.1 ± 11.9	190:120	25.3 ± 5.1	Minimum, 60	63	15
Carreira et al.34	IV	FAIS and labral tears	620	36 ± 13	381:239	24.5 ± 3.9	Minimum, 24	62	11
Clohisy et al.16	II	FAIS	52	35	22:29	NR	NA	80	19
Kahlenberg et al.15	IV	FAIS and labral tears	78	34.9	49:29	NR	NA	60	9
Aprato et al.35	IV	FAIS, labral tears, and chondral lesions	525	39	284:241	NR	Minimum, 36	84	22

NOTE. Data are presented as mean or mean ± standard deviation unless otherwise indicated.

BMI, body mass index; FAIS, femoroacetabular impingement syndrome; LOE, level of evidence; MCMS, Modified Coleman Methodology Score; MINORS, Methodological Index for Non-randomized Studies; NA, not applicable; NR, not reported.

^∗Postoperative follow-up, when applicable.

Delays in Diagnosis

Twelve studies reported on symptom duration either before receiving an accurate diagnosis or before surgery (Table 2).^3,4,15,16,28, 29, 30, 31, 32, 33, 34, 35 The average delay ranged from 21 months³ to 61.5 months⁴ among studies reporting pre-diagnostic delays^{3,4,15,16,29,30} and from 17.2 months²⁸ to 27.4 months³¹ among studies reporting preoperative delays.^28,31, 32, 33, 34, 35 Three studies reported symptom duration as a categorical variable.^29,34,35 Within these studies, 42.7% of patients had a diagnostic delay of longer than 2 years²⁹ and 39.5% of patients³⁴ and 30.5% of patients³⁵ had preoperative delays of longer than 2 years and 3 years, respectively. Studies that focused on hip dysplasia reported longer average delays (54.4 to 61.5 months)^4,30 than those focused on FAIS and/or acetabular labral tears (17.2 to 37.2 months).^{3,15,16,28,31,33}

Table 2.

Description of Diagnostic Delay Among Included Studies

Study	Pre-diagnostic Duration, mo	Preoperative Symptom Duration, mo	Range, mo	No. of HCPs
Ruzbarsky et al.28	NR	17.2 ± 15.2	1.4-72	NR
Burnett et al.3	21	NR	2-156	3.3
Nunley et al.4	61.5	NR	5-348	3.3
Petrera et al.29	>24: 42.7%∗	NR	NR	1.9
Kennedy et al.30	54.4	NR	4-194	NR
Dierckman et al.31	NR	27.4 ± 42	1-360	NR
Luck et al.32	NR	>24†	4-96	NR
Kunze et al.33	NR	27 ± 37.6	NR	NR
Carreira et al.34	NR	>24: 39.5%∗	NR	NR
Clohisy et al.16	37.2	NR	3-180	4.2
Kahlenberg et al.15	32	NR	0.3-360	4.0
Aprato et al.35	NR	>36: 30.5%∗	NR	NR

NOTE. Data are presented as mean or mean ± standard deviation unless otherwise indicated.

HCP, health care provider; NR, not reported.

^∗Proportion of patients within longest symptom duration subgroup for study.

^†Most patients experienced pain for greater than 2 years before surgery.

The average number of health care providers consulted before receiving an accurate diagnosis ranged from 1.9²⁹ to 4.2¹⁶ (Table 2).^3,4,15,16,29 One study reported that patients were referred to a hip specialist more often by primary care physicians, rather than by other orthopaedic surgeons.²⁹ However, 3 other studies reported that other orthopaedic surgeons were the most common referring physicians to a hip preservation specialist.^4,15,16 Five studies reported on prior imaging, alternate diagnoses, and treatment attempts before establishment of an accurate diagnosis (Table 3).^3,4,15,16,29

Table 3.

Description of Patient Experiences Prior to Presentation to Hip Specialist

Study	Imaging Performed, %					Common Diagnoses Offered, %		Treatments Performed, %					Surgery, %
	MRI	Radiography	CT	Ultrasound	MRA	Soft Tissue, Nonspecified	Osteoarthritis	Anti-inflammatory Medication	Physical Therapy	Intra-articular Corticosteroid Injection	Narcotic Medication	Chiropractic/Manual Therapy	Recommended (at Other Site Than Hip)	Performed, Without Resolution
Burnett et al.3	—	—	—	—	—	21	15	83	64	—	39	—	17	6
Nunley et al.4	—	—	—	—	—	17	11	57	43	—	8	—	—	18
Petrera et al.29	83	52	5	3	6	—	—	32	53	20	6	—	—	—
Clohisy et al.16	—	—	—	—	—	19	10	65	58	35	—	25	—	13
Kahlenberg et al.15	With contrast: 66.7 Without contrast: 34.6	With contrast: 26.9 Without contrast: 73.1	11.5	14.1	—	—	—	82.1	62.8	17.9	23.1	19.2	—	—

NOTE. Outcomes represent the proportion of patients who experienced the described intervention. Outcomes that were not reported in a study are represented with dashes.

CT, computed tomography; MRA, magnetic resonance arthrogram; MRI, magnetic resonance imaging.

Patient-Reported Outcomes

Preoperative and postoperative PROs among studies that directly compared symptoms of short versus long durations are outlined in Table 4.^28,31,33, 34, 35 Ruzbarsky et al.²⁸ assessed an adolescent population and contributed the highest value to each preoperative and postoperative measurement for the mHHS, HOS-ADL, and HOS-SSS across all studies; additionally, this was the only study to report no difference between patients with short and long symptom durations. The other studies reported statistically significant differences in all postoperative PROs between short– and long–symptom duration groups.^31,33, 34, 35 Fig 2, Fig 3 and Fig 2, Fig 3 show the forest plots with the various postoperative scores and symptom duration groups outlined in the applicable studies.

Table 4.

PROs in Studies That Compared Short Versus Long Duration of Symptoms

Study	PRO	Symptom Duration Groups		P Value
		<12 mo	>12 mo
Ruzbarsky et al.28
Pathology: FAIS	Preoperative
Follow-up	mHHS	56.0 ± 14.0	63.0 ± 15.0	.01
<12 mo: 4.7 ± 2.1 yr	HOS-ADL	67.0 ± 17.0	70.0 ± 15.0	.38
>12 mo: 4.9 ± 2.3 yr	HOS-SSS	48.0 ± 21.0	52.0 ± 20.0	.48
	SF-PCS	40.9 ± 9.1	42.7 ± 8.5	.25
	SF-MCS	55.0 ± 9.3	53.8 ± 8.6	.52
	Postoperative
	mHHS	91.0 ± 14.0	89.0 ± 13.0	.29
	HOS-ADL	94.0 ± 10.0	93.0 ± 9.0	.37
	HOS-SSS	90.0 ± 16.0	86.0 ± 19.0	.12
	SF-PCS	55.3 ± 5.9	54.4 ± 6.0	.36
	SF-MCS	54.4 ± 5.4	51.4 ± 10.2	.34
	Satisfaction	8.8	8.3	.11
		<24 mo	>24 mo
Kunze et al.33
Pathology: FAIS
Follow-up: minimum 5 yr for all groups
	Preoperative
	mHHS	58.2 ± 14.3	55.8 ± 16.7	.24
	HOS-ADL	68.9 ± 18.4	65.0 ± 20.7	.11
	HOS-SSS	46.0 ± 23.6	43.4 ± 25.7	.42
	VAS	75.2 ± 15.7	71.9 ± 21.0	.21
	Postoperative
	mHHS	81.3 ± 21.5	72.0 ± 24.7	.005
	HOS-ADL	88.1 ± 16.5	79.6 ± 21.9	.001
	HOS-SSS	79.1 ± 25.9	65.0 ± 32.2	<.001
	VAS	24.8 ± 25.6	34.7 ± 31.1	.012
	Satisfaction	75.3 ± 31.3	69.7 ± 34.9	.2
		<24 mo	>24 mo
Carreira et al.34
Pathology: FAIS and labral tears
Follow-up: minimum 2 yr for all groups
	iHOT-12
	Preoperative	36.0 ± 18.0	37.0 ± 19.0	<.001
	Postoperative	77.0 ± 23.0	69.0 ± 26.0	<.001
		Group A	Group B
Aprato et al.35
Pathology: FAIS, labral tears, and chondral lesions
Follow-up: 3 yr for all
Symptom duration groups
Group A: <6 mo
Group B: 6-36 mo
Group C: >36 mo
	mHHS
	Preoperative	59.0	58.0	.844
	Postoperative	79.0	75.0	.041
		Group B	Group C
	mHHS
	Preoperative	58.0	55.0	.056
	Postoperative	75.0	69.0	.001
		Group A	Group C
	mHHS
	Preoperative	59.0	55.0	.652
	Postoperative	79.0	69.0	.001
Dierckman et al.31		Univariate regression analysis per Log(10) months of symptoms
Pathology: labral tears
Follow-up: minimum 2 yr for all groups		Rate	SE
	mHHS	–5.15	1.55	.0009
	NAHS	–5.65	1.51	.0002
	HOS-ADL	–5.1	1.75	.0035
	HOS-SSS	–7.59	2.64	.004
	VAS	0.852	0.195	<.0001
	Satisfaction	–0.683	0.15	<.0001

NOTE. Data are presented as mean or mean ± standard deviation unless otherwise indicated.

FAIS, femoroacetabular impingement syndrome; HOS-ADL, Hip Outcome Score–Activities of Daily Living Subscale; HOS-SSS, Hip Outcome Score–Sport-Specific Subscale; iHOT-12, International Hip Outcome Tool 12; mHHS, modified Harris Hip Score; NAHS, Non-Arthritic Hip Score; PRO, patient-reported outcome; SE, standard error; SF-MCS, 12-Item Short Form Health Survey Mental Component Summary; SF-PCS, 12-Item Short Form Health Survey Physical Component Summary; VAS, visual analog scale.

Fig 2.

Forest plot comparing Z-score–adjusted patient-reported outcomes (PROs) for applicable studies. (CI, confidence interval; HOS-ADL, Hip Outcome Score–Activities of Daily Living Subscale; HOS-SSS, Hip Outcome Score–Sport-Specific Subscale; iHOT-12, International Hip Outcome Tool 12; IV, instrumental variables; mHHS, modified Harris Hip Score; SD, standard deviation; SF-MCS, 12-Item Short Form Health Survey Mental Component Summary; SF-PCS, 12-Item Short Form Health Survey Physical Component Summary; VAS, visual analog scale.)

Fig 3.

Forest plot comparing differences in patient-reported outcomes (PROs) between symptom duration groups in applicable studies. (CI, confidence interval; HOS-ADL, Hip Outcome Score–Activities of Daily Living Subscale; HOS-SSS, Hip Outcome Score–Sport-Specific Subscale; iHOT-12, International Hip Outcome Tool 12; mHHS, modified Harris Hip Score; Post-Op, postoperative; SE, standard error; SF-MCS, 12-Item Short Form Health Survey Mental Component Summary; SF-PCS, 12-Item Short Form Health Survey Physical Component Summary; TE, treatment effect; VAS, visual analog scale.)

Three studies produced further statistical analyses, which all found a negative association between symptom duration and postoperative outcomes independent of confounding variables.^31,33,34 Dierckman et al.³¹ suggested a decrease of 5 to 7 points in postoperative mHHS, Non-Arthritic Hip Score, HOS-ADL, and HOS-SSS for every unit of increased symptom duration (each unit was an additional 13 months) (Table 4). Multivariate regression analyses were performed by 3 studies, which showed a strong independent association between symptom duration and poorer outcomes.^31,33,34

The achievement of clinical benefit was reported by 3 studies.^28,33,34 Rates of achievement of the minimal clinically important difference (MCID) ranged from 72.5%³³ to 100%²⁸ for the mHHS, from 66.7%³³ to 91.7%²⁸ for the HOS-ADL, from 70.0%³³ to 95.8%²⁸ for the HOS-SSS, and from 74.0%³⁴ to 86.0%³⁴ for the iHOT-12 score. Rates of achievement of the patient acceptable symptomatic state (PASS) ranged from 54.2%³³ to 100%²⁸ for the mHHS, from 67.5%³³ to 91.7%²⁸ for the HOS-ADL, from 62.5%³³ to 91.7%²⁸ for the HOS-SSS, and from 64.0%³⁴ to 77.0%³⁴ for the iHOT-12 score. Ruzbarsky et al.²⁸ again reported no significant differences in attaining the MCID or PASS between patients with short and long durations of symptoms. The other 2 studies reported greater achievement of the MCID, PASS, and substantial clinical benefit among patients with a shorter duration of preoperative symptoms.^33,34

Revision Hip Arthroscopy

Differences in revision rates between symptom duration groups were reported by 3 studies.^28,33,35 Two of these studies suggested no significant difference in revision rates, including those of Ruzbarsky et al.²⁸ (<12 months, 9.3%; >12 months, 7.1%; P = .64) and Kunze et al.³³ (<24 months, 1.2%; >24 months, 1.9%; P = .64), on multivariate regression. However, 1 study did note a stepwise increase in revision rates of 4%, 11%, and 13% in the <6-month, 6- to 36-month, and >36-month symptom duration groups, respectively.³⁵

Discussion

The major findings of this study were that patients presenting with FAIS, labral tears, or hip dysplasia often experience delays from symptom onset to receiving an accurate diagnosis and/or definitive treatment. Additionally, these patients are commonly evaluated by multiple medical providers, sometimes from multiple subspecialties within medicine, before being referred to a hip preservation specialist. The most common subspecialists consulted included primary care physicians, other orthopaedists, and physical therapists, although not necessarily in that order.^4,15,16,29 Finally, significantly lower postoperative PROs are common among patients with a longer duration of symptoms.^31,33, 34, 35

Reducing diagnostic latency is key to optimizing postoperative outcomes in patients with hip preservation pathologies. A systematic review published in 2023 concluded that postoperative outcomes are better in patients with symptoms of hip pain lasting less than 2 years before hip arthroscopy compared with patients with a longer duration of symptoms.¹⁴ These results are consistent with the findings of several studies included in this review.^31,33, 34, 35 In light of these results, it is important that appropriate treatment regimens are started quickly once patients initially present with hip symptoms. Nonsurgical intervention, such as physical therapy and/or activity modification with the use of nonsteroidal anti-inflammatory medication, is recommended as a short-term management strategy.^3,36,37 Hip dysfunction refractory to nonsurgical intervention, in combination with a clinically and radiographically confirmed diagnosis of FAIS or dysplasia, should warrant operative treatment. At this stage, the duration of symptoms should be discussed with the patient because postoperative outcomes may be below average in patients with a longer preoperative duration of symptoms.

Because general orthopaedic surgeons are consulted at a high rate, these physicians should be able to recognize when a patient’s hip pain may be due to a primary anatomic deformity such as FAIS or dysplasia. This should include screening for common clinical presentations in young hip preservation candidates, such as insidious-onset pain and/or pain with specific motions located in the anterior groin or lateral hip.^16,38 However, because a significant proportion of health care providers performing the initial assessment of these patients are either primary care physicians or physical therapists,^4,15,16,29 these individuals can also play a major role in the timely management of patients with hip preservation pathologies.

This timely management begins with increased awareness of conditions such as FAIS and hip dysplasia. It is important to integrate hip preservation discussions at conferences targeting primary care physicians and physical therapists to improve the care of this patient population. Additionally, with the increased utilization of midlevel providers in the primary care setting,³⁹ inclusion of educational opportunities for these health care providers would be of benefit. Ultimately, improved hip preservation awareness should begin at the level of medical school education. Considering the increased prevalence of these pathologies alongside the potential for early development of osteoarthritis,^40,41 it is crucial for medical providers to have baseline exposure and the ability to recognize when referral to a hip specialist is warranted. We believe that a greater emphasis on pathologies such as FAIS and adult hip dysplasia in medical school would improve the time to treatment for these patients.

Limitations

The limitations of this study should be mentioned. Most of the studies included were of a low level of evidence (Level III or IV), which introduces selection and confounding bias. Additionally, there is a risk of publication bias because the studies included in this systematic review specifically focused on the long duration of symptoms among hip preservation candidates. It is possible that some studies were not included in this review if they did not focus on delayed diagnosis of hip preservation pathologies. There was also heterogeneity in the reported outcomes and pathologies assessed, which was not of adequate quality to allow for meta-analysis pooling. Additionally, variations in surgical indications between studies may have influenced the outcomes. Furthermore, differentiation between preoperative and pre-diagnostic symptom duration must be acknowledged; because some patients may have an extended period between receiving an accurate diagnosis and undergoing surgery, an extended “preoperative” symptom duration may not always equate to a diagnostic delay.

Conclusions

Patients presenting with hip preservation pathologies commonly experience delays in diagnosis and/or treatment and consult with multiple health care providers across specialties before receiving an accurate diagnosis and appropriate treatment. In turn, this leads to poorer post-treatment outcomes compared with patients who receive appropriate treatment in a timely manner.

Disclosures

The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: M.J.K. reports a consulting or advisory relationship with Smith & Nephew and is on the Arthroscopy Editorial Board. All other authors (K.M., J.D., C.K.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.