Critical Review Twenty-Year Systematic Review of the Hip Pathology, Risk Factors, Treatment, and Clinical Outcomes in Artistic Athletes—Dancers, Figure Skaters, and Gymnasts Ioanna Bolia, MD, MSc,* Hajime Utsunomiya, MD, PhD,* Renato Locks, MD,* Karen Briggs, MPH, MBA,* and Marc J. Philippon, MD*† Abstract Objective: To identify (1) the predominant level of evidence of the clinical studies regarding the hip pathology, risk factors, treatment, and clinical outcomes in artistic athletes (dancers, figure skaters, and gymnasts) (2) the most commonly reported hip pathology, risk factors, treatments, and clinical outcomes in dancers, figure skaters, and gymnasts. Methods: To conduct this systematic review PubMed, EMBASE, and Scopus databases were searched for relevant studies and pertinent data were collected from the eligible articles. Included were studies which reported hip injuries in artistic athletes, the risk factors, treatment, and/or the clinical outcomes. We excluded case reports or irrelevant studies. No meta-analysis was performed because of study heteroge- neity. The methodical index for nonrandomized studies (MINORS) criteria were used for quality control. Main Results: Thirty-eight studies were included in the analysis. The mean MINORS score was 13.6 6 4.6 points indicating fair quality of evidence of the included articles. The predominant level of evidence was level IV. Chondrolabral pathology and muscle injuries were the most commonly reported pathologies. We found only 2 risk factor analysis studies; however, many studies reported risk correlation between artistic sports or imaging findings and hip pathology. Treatment strategies were reported in only 7 studies, clinical outcomes are significantly underreported. Conclusion: Chondrolabral pathology was the most commonly reported hip pathology in artistic athletes, however, prospective cohort studies are necessary to really understand these injuries and their associated risk factors. The lack of clinical outcomes is significant and future data collection is required to assess the effectiveness of the various treatments. Key Words: hip labrum, ligamentum teres, ballet, ice skating, gymnastics, muscle (Clin J Sport Med 2018;28:82–90) INTRODUCTION The presence of hip pathology in athletes may be the result of an acute injury or an overuse syndrome. Labral tears, acetabular and/or femoral head chondral defects, tearing of the ligamentum teres, or joint instability are common. 1 Avascular necrosis of the femoral head in athletes, although less common, can occur because of prolonged anabolic steroid administration. 2 Diagnosis of hip pathology in athletes can be challenging, partially because of the complex anatomy of the joint which makes it difficult for the patient to localize the pain. 3 Especially for labral tears, a study revealed that the mean time from symptom manifestation to the definitive diagnosis was 21 months, whereas these patients were seen by 3.3 healthcare providers on average before the establishment of this diagnosis which was arthroscopically confirmed. 4 In addition, pathology from the surrounding areas (sacroiliac joint, abdomen, and groin) may manifest with hip pain. 3 Artistic sports, like dance, figure skating, and gymnastics, may predispose the athletes to hip injuries because of repetitive extreme range of motion in the hip joint during performance. Although these 3 sports share some similar movements (arabesque, attitude etc.) in terms of hip biomechanics, the manifestation of hip pathology is sport-specific; the combi- nation of joint hyperelasticity and acetabular dysplasia (lateral center edge (CE) angle ,25 degrees) in dancers is an example. 5,6 During gymnastics, the athlete often lands on his feet after a high-jump movement which further increases the load on the hip joint (hip flexion under stress). 7 Acceleration phase in figure skating requires a “push off” motion of the hip joint (push leg) in abduction and external rotation, similar to the Peewee ice hockey sprint start. 8 The last has been shown be an “at risk” hip maneuver. Based on the above, detailed biomechanical analysis of each sport is necessary to deeply understand the mechanisms that lead to hip injury. However, it is important for the hip sports health profes- sionals to be provided with appropriate clinical information to be able to develop injury prevention strategies and improve the clinical care of hip injuries in artistic athletes. For the purposes of Submitted for publication December 30, 2016; accepted March 16, 2017. From the *Steadman Philippon Research Institute, Vail, Colorado; and † The Steadman Clinic, Vail, Colorado. M. J. Philippon receives research support from National Institute of Health, National Institute of Arthritis and Musculoskeletal ans Skin Diseases, National Institute of Aging, Smith and Nephew Endoscopy, Ossur, Arthrex, Siemens and Royalties from Bledsoe, ConMed Linvatec, DonJoy, SLACK Iinc., Elsevier. M. J. Philippon is stockholder of Arthrosurface, MJP Innovations, LLC, MIS, Vail Valley Medical Center-Governing. The remaining authors report no conflicts of interest. Corresponding Author: Marc J. Philippon, MD, Steadman Philippon Research Institute, The Stedman Clinic, 181 West Meadow Drive, Suite 400, Vail, CO 81657 (karen.briggs@sprivail.org). Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. http://dx.doi.org/10.1097/JSM.0000000000000440 I. Bolia et al. (2018) Clin J Sport Med Copyright Ó 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.