EP7.13 Diagnosis of iliopsoas-related groin pain and interrater reliability of the Hip Externoflexion Ceiling (HEC) test: a combined systematic review and reliability study

Abstract

Abstract Background Iliopsoas-related groin pain is a clinically relevant but diagnostically challenging condition due to symptom overlap with other hip pathologies and limited utility of imaging. Reliable and accurate clinical tests are essential for clinical decision-making. The Hip Externoflexion Ceiling (HEC) test has recently been proposed as a promising diagnostic tool, but evidence on its interrater reliability remains limited. Objectives This combined systematic review and reliability study aims to evaluate (1) the diagnostic accuracy of clinical tests for iliopsoas-related groin pain, and (2) the interrater reliability of the HEC test within a standardized clinical examination protocol. Methods A systematic review was conducted according to PRISMA 2020 guidelines (PROSPERO registered). Studies assessing diagnostic accuracy of clinical tests for iliopsoas-related groin pain were included. Risk of bias was assessed using QUADAS-3, and a narrative synthesis was performed. Additionally, a cross-sectional interrater reliability study was conducted in individuals following total hip arthroplasty. Two independent raters assessed patients using a standardized clinical test protocol. Interrater reliability of the HEC test was evaluated using weighted Cohen’s kappa. Results Three diagnostic accuracy studies were included. Overall, evidence for clinical tests was limited. The HEC test demonstrated the highest diagnostic accuracy, with reported sensitivity of 94% and specificity of 88% when compared to diagnostic injection. Other commonly used tests (e.g. resisted hip flexion, straight leg raise in external rotation) showed high sensitivity but poor specificity, limiting their standalone diagnostic value. In the reliability study (n = 90; 95 hips), the HEC test demonstrated substantial interrater reliability (κ = 0.72), outperforming many other extra-articular hip tests. In contrast, adductor- and rectus femoris-related tests showed only fair to moderate agreement (κ = 0.20–0.41), and hamstring tests were inconsistent (κ = 0.17–0.62), likely influenced by skewed distributions with predominantly low scores. Conclusion The HEC test appears to be a promising clinical tool for the assessment of iliopsoas-related groin pain, combining high diagnostic accuracy with substantial interrater reliability. However, current evidence remains limited and heterogeneous. Clinical assessment should not rely on a single test, and further high-quality diagnostic studies are needed to support evidence-based diagnostic pathways.