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com
1
Arthroscopic Centre Amager,
Copenhagen University
Hospital, Hvidovre,
Copenhagen, Denmark
2
Physical Medicine and
Rehabilitation Research—
Copenhagen (PMR-C), and
Departments of Orthopaedic
Surgery and Physical Therapy,
Copenhagen University
Hospital, Copenhagen,
Denmark
Correspondence to
Dr Kristian Thorborg,
Arthroscopic Centre Amager,
Copenhagen University
Hospital, Hvidovre,
Copenhagen, Denmark,
Italiensvej 1, Copenhagen S
2300, Denmark,
kristianthorborg@hotmail.com
Received 6 May 2013
Accepted 17 June 2013
Published Online First
12 July 2013
To cite: Thorborg K,
Branci S, Stensbirk F, et al.
Br J Sports Med
2014;48:557–559.
Thorborg K, et al. Br J Sports Med 2014;48:557–559. doi:10.1136/bjsports-2013-092607
Copenhagen hip and groin outcome score (HAGOS)
in male soccer: reference values for hip and groin
injury-free players
Kristian Thorborg,1,2 Sonia Branci,1 Frederik Stensbirk,1 Jesper Jensen,1 Per Hölmich1
ABSTRACT
Background/aim Reference values are needed in
order to interpret the Copenhagen Hip and Groin
Outcome Score (HAGOS) in male soccer players with hip
and groin pain. The aim of this study was to establish
reference values for HAGOS in hip and groin injury-free
male soccer players.
Methods We included 444 groin injury-free soccer
players from 40 clubs (divisions 1–4) in Eastern
Denmark, mean age (SD) 23.6 (4.4), training soccer
3.4 (1) times per week. All players were hip and groin
injury-free at the time of inclusion (beginning of season,
2011).
Results Of the 444 hip and groin injury-free players,
301 reported no hip and/or groin pain in either the
present or the previous season, and 143 reported that
they had experienced hip and/or groin pain in the
previous season. Players (n=143) with hip and groin
pain in the previous season displayed lower scores than
players without (n=301), for all HAGOS subscales
( p<0.001). Age and playing level were not related to
HAGOS. The 95% reference ranges for HAGOS subscales
in hip and groin injury-free soccer players, with no pain
in the previous or present season (n=301), are: pain:
80.1–100, symptoms: 64.3–100, activities of daily
living: 80.3–100, sport and recreational activities: 71.9–
100, participation in physical activity: 75–100 and
quality of living: 75–100.
Conclusions Lower HAGOS subscales are seen in
soccer players who have experienced hip and/or groin
pain in the previous season, compared with those who
have not. Median HAGOS subscale scores in hip and
groin injury-free soccer players are in proximity to the
maximum score (100 points).
BACKGROUND
Hip and groin pain is one the most frequent com-
plaints in male soccer, affecting up to 70% of
players during a soccer season.1 2 The incidence
and severity of hip and groin injuries have primar-
ily been described in the past using time-loss defini-
tions, as suggested by consensus statements
concerning soccer-injury registration.3 However, as
many soccer-related hip and groin injuries present
as painful overuse conditions with an insidious
onset, and fluctuating long-standing symptoms,
defining the presence of these injuries using time-
loss definitions provides a very limited insight into
the true extent of hip and groin problems.1–6
In 2011, we published the Copenhagen Hip and
Groin Outcome Score (HAGOS), a self-reported
questionnaire evaluating hip and groin disability
status from 0 to 100, where 100 indicates no hip
Short report
and groin problems, and 0 indicates severe hip and
groin problems.7 This questionnaire was developed
to include items relevant not only for physically
active individuals in general, but also for athletes
such as soccer players. HAGOS showed promise as
a reliable, valid and responsive measure of hip and
groin disability outcome and injury status, revealing
that patients with long-standing hip and groin pain
had a low HAGOS (<50 points) in those subscales
that were related to participation in physical activ-
ity, sport and quality of life.7 A substantial propor-
tion of participants in this study were male soccer
players with hip and groin pain, indicating that
HAGOS may be a highly relevant measure for this
group of athletes.7 However, as HAGOS has never
been assessed exclusively in this group of athletes,
its performance in this population (healthy soccer
players) is unknown.
Therefore, the reference values of HAGOS based
on injury-free soccer players need to be established,
to enable future interpretation of HAGOS in male
soccer players with hip and groin pain. The aim of
this study was to establish reference values for
HAGOS in hip and groin injury-free male soccer
players.
METHODS
This study is based on data from a large cohort
study investigating hip and/or groin pain, self-
reported outcome, clinical characteristics, muscle
strength, range of motion and radiological findings
in male soccer players. All participants provided
written informed consent according to the Helsinki
Declaration. The project was approved by the
Danish National Committee on Health Research
Ethics (H-2-2010-127).
Forty teams including 725 players were invited
to join the study. Twenty-five participants failed to
meet the inclusion criteria of being at least 18 years
of age (n=10), or failed to answer the question-
naire correctly (n=15). Thus, a total of 700
players, representing 40 teams (divisions 1–4) in
Eastern Denmark, were eligible for the study. The
soccer players were all playing at a subelite level.
Four hundred and forty-four of the 700 players
were hip and groin injury-free at the time of initi-
ation of the study and therefore included. These
players were 23.6 (4.4) years of age, and were
training in soccer 3.4 (1) times/week.
All players answered HAGOS7 within the first
6 weeks of resuming the new season ( July/August
2011). Data collection was performed by observers
from the Arthroscopic Centre Amager. Data-
collection sessions were performed with each team
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Short report

before or after a training session. The players were asked to answer
two self-reported questionnaires: (1) HAGOS7 and (2) a self-
reported questionnaire concerning descriptive data and injury
status. HAGOS is a questionnaire evaluating hip and/or groin dis-
ability7 and consists of six subscales (Symptom, Pain, Activities of
Daily Living, Sports and Recreation, Participation in Physical
Activities and Quality of Life). Each subscale is scored as a percent-
age of the total possible score, ranging from 0 to100, where 0 indi-
cates severe problems and 100 indicates no problems. HAGOS has
proven to be valid, reliable and responsive for evaluating indivi-
duals with hip and/or groin pain, with the original study including
a large proportion of male soccer players.7
The questionnaire including self-reported descriptive data and
injury status covered general information (age, height, weight,
number of soccer training sessions per week and level of play)
and a self-reported history of hip and/or groin pain in the
current and previous seasons.
Statistical analyses
Descriptive variables were presented as mean±1 SD. As the
dependent variables (HAGOS) did not show a normal distribu-
tion, non-parametric statistics were used for all analyses. The
influence of age and playing level on HAGOS was analysed by
Spearman correlation. Median and IQRs were presented for all
results. An independent measures test (Mann-Whitney) was used
for comparison between groups. Reference intervals (95%) for
scores of each subscale from hip and groin injury-free players
are given,8 constituted by the 5th–100th centile.
RESULTS
HAGOS were obtained for all 444 included participants. One
subscale score could not be calculated for six different players
due to missing items. An initial analysis showed that of the 444
soccer players who were hip and groin injury-free at the begin-
ning of the season, 143 had experienced hip and/or groin pain
in the previous season. The initial analysis also showed that the
players who had experienced hip and/or groin pain in the previ-
ous season displayed lower scores than asymptomatic players for
all HAGOS subscales ( p<0.001; table 1). Therefore, only
values from the 301 soccer players who had no hip and groin
pain at the time of testing (in the beginning of the new season),
and no hip and groin pain in the previous season, were used for
calculating reference values for hip and groin injury-free soccer
players. Age and playing level were not correlated (Spearman
r<0.1) to HAGOS subscales in hip and groin injury-free soccer
players ( p>0.05).
The 5th–100th centiles, constituting the 95% reference range
for the hip and groin injury-free soccer players HAGOS subscale
scores, are: pain 80.1–100; symptoms: 64.3–100; activities of
daily living: 80.3–100; sport and recreational activities: 71.9–
100; participation in physical activity: 75–100 and quality of
living: 75–100 (figure 1).
DISCUSSION
The purpose of the present study was to establish reference data
for HAGOS in hip and groin injury-free male soccer players, in
order to provide a basis for future interpretation of HAGOS in
male soccer players with hip and groin pain. The present study
showed that the players who had experienced hip and/or groin
pain in the previous season displayed lower scores than the rest
of the players who did not, for all HAGOS subscales
(p<0.001). These players experienced more symptoms,
decreased function and decreased quality of life than the rest of
the players, and therefore only soccer players who had no hip
and groin pain in the beginning of the new season, and no hip
and groin pain in the previous season, were considered appro-
priate as hip and groin injury-free references.
Scores from self-reported questionnaires, such as the Knee
injury and Osteoarthritis Score (KOOS), have previously been
shown to be related to previous injury status in male and female
soccer players, with higher scores (close to 100 points) in injury-
free soccer players.9 10 As in the present study, a previous study
including KOOS suggests that the Symptoms subscale seems to
provide the lowest subscale score of the different subscales, indi-
cating that symptoms are being experienced in injury-free indivi-
duals. This may, however, be explained by the fact that some of
the questions in the Symptoms subscale of both HAGOS and
KOOS are not necessarily directly related to injury, such as ques-
tions related to joint clicking and joint stiffness. These symp-
toms reported by hip and groin injury-free players may,
especially when experienced in milder forms, be related to
sports activity in itself and thus be reflected in a lower HAGOS
Symptoms subscale, compared with the other HAGOS
subscales.
Interestingly, a previous study has shown that KOOS is able to
predict knee injuries when the total score is below 80 points.10
Whether total scores should be introduced in injury prediction

Table 1 HAGOS scores in asymptomatic soccer players with and

without hip and/or groin pain in the previous season
Asymptomatic soccer Asymptomatic soccer
players with NO pain in players with pain in the
the previous season previous season
(n=301) (n=143)
HAGOS Median (25th–75th) Median (25th–75th) p Value

Pain 100.0 (97.5–100) 95.0 (90–100) (<0.001)

Symptoms 89.3 (82.1–96.4) 82.1 (75–89.3) (<0.001)
ADL 100.0 (100–100) 100.0 (90–100) (<0.001)
Sport/Rec 100.0 (90.6–100) 90.6 (78.9–100) (<0.001)
PA 100.0 (100–100) 100.0 (84.4–100) (<0.001)
QOL 100.0 (95–100) 90.0 (80–95) (<0.001)
25th–75th; 25th–75th centiles, ADL, activities of daily living; HAGOS, Hip And Groin
Outcome Score; PA, participation in physical activity; QOL, quality of living; Sport/Rec,
sport and recreational activities.
Figure 1 Reference-interval including 95% of values from hip and
groin injury-free players.

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is questionable as composite scoring should be avoided.11
However, the lower HAGOS reference limits provide cut-points
for abnormal scores of the different HAGOS subscales, and
these lower limits may therefore be helpful in identifying
players at risk of future hip and groin injury. However, the pre-
dictive validity of HAGOS subscales remains to be investigated
in future studies.
CONCLUSION
Lower HAGOS subscales are seen in soccer players who
have experienced hip and/or groin pain in the previous season,
compared with those who have not. Median HAGOS subscale
scores in hip and groin injury-free soccer players are in proxim-
ity to the maximum score (100 points), and scores of 64–80
provide the lower limit for the six subscale 95% reference range
in soccer players.
Acknowledgements The authors would like to thank the participating clubs and
Martin Nielsen, Michael Madsen, Mads Langelund and Lasse Lundquist for assisting
with the data collection.
Contributors KT, SB, FS, JJ and PH all contributed to the design, statistical
analyses and drafting and writing of the manuscript.
Funding This work was funded by the Arthroscopic Centre Amager, Copenhagen
University Hospital, Hvidovre, Copenhagen.
Competing interests None.
Patient consent Obtained.
Ethics approval The Danish National Committee on Health Research Ethics.
Provenance and peer review Not commissioned; externally peer reviewed.
Thorborg K, et al. Br J Sports Med 2014;48:557–559. doi:10.1136/bjsports-2013-092607
Short report
REFERENCES
1 Hanna CM, Fulcher ML, Elley CR, et al. Normative values of hip strength in adult
male association football players assessed by handheld dynamometry. J Sci Med
Sport 2010;13:299–303.
2 Thorborg K, Serner A, Petersen J, et al. Hip adduction and abduction strength
profiles in elite soccer players: implications for clinical evaluation of hip adductor
muscle recovery after injury. Am J Sports Med 2011;39:121–6.
3 Fuller CW, Ekstrand J, Junge A, et al. Consensus statement on injury definitions and
data collection procedures in studies of football (soccer) injuries. Scand J Med Sci
Sports 2006;16:83–92.
4 Hölmich P. Long-standing groin pain in sportspeople falls into three primary
patterns, a “clinical entity” approach: a prospective study of 207 patients. Br J
Sports Med 2007;41:247–52.
5 Werner J, Hägglund M, Waldén M, et al. UEFA injury study: a prospective study of
hip and groin injuries in professional football over seven consecutive seasons. Br J
Sports Med 2009;43:1036–40.
6 Clarsen B, Myklebust G, Bahr R. Development and validation of a new method for
the registration of overuse injuries in sports injury epidemiology: the Oslo Sports
Trauma Research Centre (OSTRC) Overuse Injury Questionnaire. Br J Sports Med
2013;47:495–502.
7 Thorborg K, Hölmich P, Christensen R, et al. The Copenhagen Hip and Groin
Outcome Score (HAGOS): development and validation according to the COSMIN
checklist. Br J Sports Med 2011;45:478–91.
8 Campbell MJ, Gardner MJ. Calculating confidence intervals for some non-parametric
analyses. BMJ 1988;296:1454–6.
9 Frobell RB, Svensson E, Göthrick M, et al. Self-reported activity level and knee
function in amateur football players: the influence of age, gender, history of knee
injury and level of competition. Knee Surg Sports Traumatol Arthrosc
2008;16:713–19.
10 Steffen K, Myklebust G, Andersen TE, et al. Self-reported injury history and lower
limb function as risk factors for injuries in female youth soccer. Am J Sports Med
2008;36:700–8.
11 Thorborg K, Roos EM, Bartels EM, et al. Validity, reliability and responsiveness of
patient-reported outcome questionnaires when assessing hip and groin disability:
a systematic review. Br J Sports Med 2010;44:1186–96.
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 Downloaded from http://bjsm.bmj.com/ on November 29, 2014 - Published by group.bmj.com

Copenhagen hip and groin outcome score

(HAGOS) in male soccer: reference values for
hip and groin injury-free players
Kristian Thorborg, Sonia Branci, Frederik Stensbirk, Jesper Jensen and
Per Hölmich

Br J Sports Med 2014 48: 557-559 originally published online July 12,
2013
doi: 10.1136/bjsports-2013-092607

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