How Should Hip Instability Be Clinically Diagnosed? Consensus Statements From a Scoping Review and an International...

Although several clinical signs have been proposed for diagnosing atraumatic hip instability, the condition remains poorly defined because of the absence of standardized diagnostic criteria. To address this gap, a Delphi consensus study with an international panel of experts to establish standardized clinical statements for the diagnostic criteria of hip instability was conducted.

The objective was to reach consensus on the following questions: (1) What are typical presenting symptoms of hip instability? (2) What physical examination should be used to assess hip instability in patients presenting with symptoms of hip instability? (3) What risk factors are associated with patients presenting with symptomatic hip instability?

A consensus study using the modified Delphi technique was conducted in accordance with the Accurate Consensus Reporting Document (ACCORD) guideline. The consensus meeting was held during the 15th Symposium on Joint Preserving and Minimally Invasive Surgery of the Hip, which took place in Québec City, Québec, Canada, in June 2025. The process involved a multidisciplinary steering committee and a diverse panel of 100 international participants representing 13 countries. Following a rapid scoping review, statements were developed and sent to participants 1 week prior to the meeting. These statements were voted across two Delphi rounds during the meeting, with consensus defined as ≥ 75% agreement.

Clinically, three physical examination tests, the abduction-hyperextension-external rotation (AB-HEER), prone instability, and anterior apprehension (HEER) tests, achieved consensus as clinically useful to assess hip instability. The flexion-abduction-external rotation (FABER) test and hip flexion + rotation arc of 200° did not reach consensus. Symptomatically, consensus was reached on patients reporting anterior hip pain during daily activities such as sitting, squatting, or participating in sports; mechanical symptoms such as popping, clicking, or grinding; and subjective sensations of looseness or instability. Female sex and hip dysplasia were agreed upon as key risk factors associated with atraumatic hip instability. Younger age as a potential risk factor did not reach consensus.

Individual physical examination tests assess different components of hip instability. As such, the use of a combination of tests alongside consideration of symptoms and relevant risk factors has been suggested to enhance diagnostic specificity and produce higher assessment accuracy. Also, further research is warranted to assess other psychometric properties of these tests to develop a comprehensive diagnostic framework for atraumatic hip instability.

By outlining key symptoms, recommended physical examination maneuvers, and associated risk factors, this study supports a more standardized and reproducible approach to evaluate hip instability in clinical practice. These findings can inform clinical algorithms, enhance diagnostic accuracy, and reduce variability in both research protocols and clinical practice.