Review Reports

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Dear Authors,

This narrative review addresses a clinically relevant topic and provides a broad overview of sports-related hip conditions in pediatric and adolescent athletes. Its condition-based organization and consistent coverage of clinical presentation, imaging, management, complications, and prevention are valuable. However, several issues should be addressed before publication. Most importantly, the review lacks a transparent methodology, the rationale for selecting the included conditions is unclear, and evidence from adult or mixed-age populations is occasionally extrapolated to pediatric athletes without sufficient qualification. Some treatment and prevention recommendations also appear more definitive than the underlying evidence permits.

Abstract

1. Lines 6–14: Please explicitly identify the article as a narrative review and briefly describe how the literature was identified and selected. At minimum, the databases, approximate search period, and general selection criteria should be reported.
2. Lines 7–14: The abstract does not sufficiently emphasize the “unique features” highlighted in the title. Please summarize the principal pediatric-specific considerations, such as open physes, apophyseal vulnerability, skeletal maturation, and growth-related changes in injury patterns.
3. Lines 10–14: The statement that all these conditions require “urgent diagnosis” is overly broad. Hip dislocations and high-risk femoral-neck stress injuries require urgent assessment and management, whereas other conditions require timely but not necessarily emergency evaluation. Please revise this wording accordingly.
4. Line 15: Please correct “orthpaedics” to “orthopaedics” or “orthopedics,” according to journal style.

Introduction

5. Lines 18–27: The Introduction is too brief to establish the need for this review. Please clarify what the present article adds to the existing reviews and consensus statements cited in references 2–4.
6. Lines 24–27: The included disorders are described as the “most common” pediatric sports-related hip injuries, but the rationale for selecting apophyseal injuries, hip dislocations, coxa saltans, FAIS, and stress fractures is unclear. Other relevant conditions, including muscle injuries and labral pathology, are not reviewed separately. Please justify the selection using epidemiological evidence or revise the wording to “selected sports-related hip conditions.”
7. Lines 18–27: Please define “pediatric,” “adolescent,” and “young athlete.” These terms are used interchangeably, although skeletal maturity may be more clinically relevant than chronological age for several of the conditions discussed.

Review Methodology

8. After line 27: A dedicated Methods section should be added. Even for a narrative review, the authors should report the databases and other sources searched, date of the final search, principal search concepts, language and publication-date restrictions, eligibility criteria, study-selection process, and rationale for selecting the five conditions.
9. After line 27: Please explain whether pediatric evidence was prioritized and how adult or mixed-age studies were handled when pediatric-specific evidence was unavailable. Where conclusions rely on indirect evidence, this should be stated explicitly.
10. Lines 779–783: The authors disclose the use of Open Evidence for the literature review and ChatGPT for language editing. Please confirm that all references, numerical findings, and clinical recommendations were independently checked against the original publications. The use of these tools does not replace a transparent literature-selection process.

Applied Anatomy of the Developing Hip

11. Lines 28–70: This section is detailed but disproportionately long relative to the clinical focus of the review. Please shorten the embryological and general anatomical material and focus more directly on pediatric sports-injury implications, including open physes, apophyseal maturation, traction vulnerability, and growth-related changes in hip morphology.
12. Lines 37–38: The description of the appearance and closure of the three acetabular ossification centers appears overly precise. Please verify the age ranges, identify the specific centers being described, and acknowledge sex-related and individual variability.
13. Lines 42–51: Please distinguish more clearly between cam or pincer morphology and clinically symptomatic FAIS. Morphological findings alone do not establish the syndrome.
14. Lines 64–70: The clinical relevance of the vascular-development paragraph should be made clearer, particularly in relation to avascular necrosis following hip dislocation. Otherwise, this material could be shortened.

Physical, Psychosocial, and Financial Impact

15. Lines 71–101: Most evidence in this section concerns pediatric sports injuries generally rather than hip injuries specifically. Please shorten the section or clearly identify these findings as indirect evidence.
16. Lines 92–101: The financial estimates are derived from general pediatric sports injuries and ACL reconstruction. These data should not be presented as direct evidence of the financial burden of pediatric hip injuries.

Epidemiology

17. Lines 102–109: Please distinguish incidence, prevalence, and injury burden more carefully. The statement that hip and groin injuries constitute 11% of all sports injuries and have a seasonal prevalence of 19% may combine estimates derived from different populations and methodological approaches. Please provide the relevant age groups, sports, denominators, and surveillance methods.
18. Lines 110–116: Please clarify whether the reported sex differences are based on pediatric-only, mixed-age, clinic-based, or exposure-based populations. A greater proportion of clinical presentations does not necessarily indicate a higher exposure-adjusted incidence.

Differential Diagnosis

19. Lines 118–130: This section would be more clinically useful if organized around age-related diagnostic priorities and red flags. Consider adding a concise table summarizing typical age, presentation, key red flags, initial imaging, and urgency of referral.
20. Lines 121–128: Please highlight findings requiring urgent investigation, including fever or systemic symptoms, inability to bear weight, night or rest pain, neurological findings, and pain disproportionate to the reported mechanism.

Common Sports-Related Hip Conditions

21. Lines 131–753: The consistent organization of each condition is helpful. Nevertheless, the manuscript is lengthy and lacks a comparative clinical summary. Please consider adding a table containing the typical mechanism, age or sport, pain location, key examination findings, first-line imaging, urgent referral criteria, usual management, and return-to-sport considerations.

Apophyseal Injuries

22. Lines 146–154: The reported anatomical-distribution percentages overlap considerably. Please clarify whether they were obtained from different studies and provide information about the relevant denominators and populations.
23. Lines 163–169: The statement that early or aggressive range-of-motion treatment can lead to displacement, nonunion, and chronic pain implies causality. Please moderate this wording unless a direct causal relationship is supported by pediatric evidence.
24. Lines 196–209: Return to sport should not be discussed primarily in terms of elapsed time. Please include functional criteria such as pain-free range of motion, absence of local tenderness, restoration of strength, and successful completion of sport-specific tasks.
25. Lines 210–220: The manuscript appropriately acknowledges that no validated displacement threshold for surgery has been established. Please ensure that the historical 15–20-mm threshold is not interpreted as a definitive contemporary indication and emphasize individualized clinical decision-making.
26. Lines 246–254: Several preventive strategies are proposed despite the acknowledged lack of direct evidence. Please distinguish evidence-based recommendations from expert opinion or extrapolation from general lower-extremity injury-prevention research.

Hip Dislocations

27. Lines 296–329: The discussion of advanced imaging, the six-hour reduction target, and the appropriate setting for reduction is repetitive. Please consolidate these points into a clearer clinical pathway.
28. Lines 300 and 314–327: Please emphasize that reduction should be performed as soon as safely possible. The six-hour threshold should be presented as an upper clinical target derived predominantly from observational evidence, rather than as an acceptable period of delay.
29. Lines 315–329 and 410–419: Emergency-department reduction is described as safe in selected cases, whereas the later discussion highlights the risk of epiphysiolysis under conscious sedation. Please integrate these findings and provide a clearer age- and risk-based distinction between patients suitable for emergency-department reduction and those who should undergo reduction in the operating room.
30. Lines 330–345: The detailed descriptions of the Allis and Stimson maneuvers may be excessive for the scope of this review. Consider shortening this material and emphasizing that reduction should be performed by appropriately trained clinicians with adequate sedation or anesthesia and readiness to address associated injuries.
31. Lines 346–352: Please clarify whether the recommended post-reduction weight-bearing restrictions are supported by pediatric comparative evidence or primarily reflect expert opinion.
32. Lines 426–435: The cited neuromuscular-training evidence concerns general lower-extremity injury prevention rather than hip dislocation specifically. Please identify this as indirect evidence and avoid implying that these programs have been demonstrated to prevent pediatric hip dislocations.

Coxa Saltans

33. Lines 436–454: Please distinguish among asymptomatic snapping, symptomatic snapping hip, and snapping hip syndrome. The reported prevalence of up to 91% in elite ballet dancers may reflect snapping rather than clinically significant painful pathology.
34. Lines 469–477: Please clarify when dynamic ultrasonography is preferable to MRI and whether imaging is required when the clinical diagnosis is clear.
35. Lines 486–490: The warning regarding corticosteroid injection, adverse effects on the growing physis, and rapidly destructive hip disease is strong. Please verify that references 119 and 120 directly support these risks in skeletally immature patients. If the evidence is adult-derived or limited to case reports, the wording should be moderated.
36. Lines 496–500: The claim that arthroscopic iliopsoas release produces superior outcomes to open procedures should be contextualized by reporting the study population, design, and follow-up. Adult-derived evidence should not be generalized directly to pediatric athletes.
37. Lines 512–520: Eccentric weakness and reduced flexibility observed in symptomatic patients should not automatically be interpreted as causal or modifiable risk factors. Please avoid implying preventive efficacy in the absence of prospective evidence.

Femoroacetabular Impingement Syndrome

38. Lines 523–535: Please maintain a consistent distinction between radiographic cam or pincer morphology and symptomatic FAIS. Morphology alone, particularly in asymptomatic athletes, does not establish the syndrome.
39. Lines 544–546: The use of the Warwick Agreement is appropriate. Please indicate whether pediatric-specific diagnostic considerations or limitations apply.
40. Lines 554–556: Please identify the population from which the reported three-year diagnostic delay and assessment by approximately four healthcare providers were derived. These findings should not be presented as pediatric-specific if the source included adults.
41. Lines 568–588: Alpha-angle thresholds vary according to imaging modality, measurement plane, and population. The >55° threshold should therefore not be presented as universally diagnostic.
42. Lines 590–604: The adolescent-specific non-operative outcome data are valuable. Please describe the main components and duration of the rehabilitation program more clearly so that the findings are clinically interpretable.
43. Lines 614–622: The RCTs comparing arthroscopy with conservative care and the long-term osteoarthritis data appear to derive mainly from adult populations. Please label these findings clearly as adult-derived and avoid presenting them as direct evidence of surgical superiority in pediatric athletes.
44. Lines 623–641: This subsection combines the natural consequences of FAIS, surgical complications, osteoarthritis progression, and long-term postoperative outcomes. Please separate these concepts into natural history, treatment-related complications, and long-term outcomes.
45. Lines 642–653: The recommendation to increase training load by 10–20% per week is generic and has not been established as a specific strategy for preventing cam morphology or FAIS. Please moderate or remove this recommendation.

Stress Fractures

46. Lines 654–672: Please distinguish consistently among bone stress injury, stress reaction, and stress fracture because these terms have different imaging and management implications.
47. Lines 665–668 and 742–750: Please use the current term “Relative Energy Deficiency in Sport (REDs)” consistently. The discussion should also acknowledge that REDs may affect athletes of all sexes.
48. Lines 682–688: The statement that point tenderness is the most consistent finding should be qualified by anatomical site, because femoral-neck and sacral injuries may not produce readily accessible focal tenderness.
49. Lines 695–699: The reported 99% sensitivity of MRI should be contextualized by describing the study population, anatomical site, reference standard, and relevant limitations rather than presenting it as a universal estimate.
50. Lines 700–731: The non-operative and operative sections partly duplicate the same decision pathway. Consider presenting the management algorithm in a table or figure stratified by tension- versus compression-sided location, fracture-line width, displacement, and joint effusion.
51. Lines 706–718: Please clarify whether the proposed MRI-based treatment algorithm has been validated in pediatric athletes or is derived mainly from adult or military populations.
52. Lines 724–725: The statement that three cannulated screws in an inverted-triangle configuration represent the construct of choice should be qualified according to skeletal maturity, patient size, fracture pattern, and surgeon preference.
53. Lines 732–741: Please distinguish complications arising from the injury itself from complications associated with surgical treatment.
54. Lines 742–753: The prevention section moves from observed associations to presumed intervention effects. Please distinguish established risk factors and reasonable clinical considerations from interventions prospectively shown to reduce injury incidence.

Key Takeaway Points

55. Lines 754–767: The key points are broad and partially repetitive. They would be more clinically valuable if they identified condition-specific red flags and urgent actions, particularly for hip dislocation, femoral-neck stress injury, and apophyseal avulsion.
56. Lines 764–767: The phrase “should be incorporated” is repeated and should be revised.

Summary

57. Lines 768–778: The Summary largely repeats the Abstract and Key Takeaway Points. Please reduce this redundancy and use the section to emphasize major evidence gaps, including the limited number of pediatric comparative studies, inconsistent return-to-sport criteria, and reliance on adult-derived evidence.
58. Lines 773–778: Please distinguish conditions associated with emergency complications from those more commonly associated with delayed recovery or chronic symptoms.

Author Declarations and References

59. Line 3: Please correct “Joshua Abzug and MD” to “Joshua Abzug, MD.”
60. Lines 779–783: Please ensure that the declaration concerning generative AI and AI-assisted technologies conforms to the journal’s required wording.
61. Lines 784–786: Author initials and punctuation should be standardized, for example, “L.H., J.A.” and “Y.Y.”
62. References beginning at line 789: Please standardize the reference list according to journal style. Journal titles alternate between abbreviated and full forms, capitalization is inconsistent, and online-first references should be updated where final bibliographic details are available.
63. Throughout the manuscript: Please standardize “non-operative/nonoperative,” “post-operative/postoperative,” “intra-articular/intraarticular,” subsection capitalization, and the formatting of age ranges.

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Comments on the Quality of English Language

The English could be improved to more clearly express the research.

Author Response

Please see attached word document with responses.

Author Response File: Author Response.docx

Reviewer 2 Report

Comments and Suggestions for Authors

This is a comprehensive and clinically relevant a review article  of sports-related hip injuries in pediatric and adolescent athletes. The manuscript is well organized, follows a logical structure, and provides useful information regarding clinical presentation, imaging, treatment, complications, and prevention. The inclusion of quantitative data and references throughout strengthens the manuscript. The sections on hip dislocation, snapping hip, femoroacetabular impingement syndrome (FAIS), and femoral neck stress fractures are particularly useful for clinicians managing young athletes.However, several areas would benefit from clarification, greater consistency, and refinement before publication. In particular, some recommendations appear stronger than the evidence presented, terminology should be standardized, and several statements would benefit from additional qualification regarding the pediatric population.

The manuscript's principal strengths are its broad clinical scope, practical organization, emphasis on early diagnosis, and incorporation of both conservative and operative treatment strategies. The authors appropriately emphasize the unique vulnerability of the immature skeleton and the importance of multidisciplinary care. The inclusion of prevention, return-to-sport considerations, and long-term complications makes the review clinically useful rather than purely descriptive.The manuscript has substantial value and is potentially suitable for publication after minor revision. The principal priorities should be strengthening the distinction between pediatric and adult evidence, moderating recommendations where evidence is limited, verifying quantitative claims and citations, and improving terminology and consistency. Addressing these issues would substantially improve the scientific rigor and clinical usefulness of the review. Minor revision considers: to clarify the pediatric evidence base.
Much of the discussion appropriately addresses children and adolescents, but some of the cited evidence appears to derive from adult populations or mixed-age cohorts. The manuscript should clearly distinguish pediatric/adolescent evidence from adult evidence, particularly when discussing FAIS surgery, osteoarthritis progression, and hip arthroscopy outcomes. Article needs to  reconsider wording regarding general anesthesia and reduction.
The statement that operating-room reduction "offers the advantages" of general anesthesia, muscle relaxation, and fluoroscopy is reasonable, but it could be framed more cautiously. The risk of epiphyseal injury during reduction is important, but the available evidence appears to be based on small case series. The manuscript should avoid implying that general anesthesia definitively prevents this complication. The manuscript appropriately emphasizes sports-related pathology, but pediatric hip pain has a broad differential, including infection, inflammatory disease, malignancy, SCFE, Perthes disease, and referred pain. The manuscript states that FAIS "arises from abnormal morphology" leading to symptoms and tissue damage. Current terminology distinguishes morphological findings from the clinical syndrome. Because cam and pincer morphology can be present in asymptomatic individuals, the manuscript should emphasize that morphology alone does not constitute FAIS especially in population under 18 years of age. The subsequent reference to the Warwick Agreement appropriately supports this distinction, but the concept should be maintained consistently throughout the section.  Paper needs also clarification considers  the role of corticosteroid injections in skeletally immature patients.
The warning regarding injections is appropriate, but the statement concerning potential damage to the physis and rapidly destructive hip disease is significant and should be supported by particularly strong evidence. In pediatric patients injections should generally be avoided or used only in highly selected circumstances.The manuscript alternates between terms such as "pediatric," "adolescent," "young athlete," and "skeletally immature patient." These terms are not interchangeable. Defining the population at the beginning of the review and using terminology co

Author Response

Please see the attachment.

Author Response File: Author Response.docx

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Dear Authors,

Thank you for your careful and comprehensive revision of the manuscript and for addressing my previous comments in detail.

I have reviewed your responses and the revisions made to the manuscript. The major concerns raised during the previous round of review, particularly those related to methodological transparency, the distinction between pediatric-specific and adult-derived evidence, clinical interpretation, terminology, and the strength of treatment and prevention recommendations, have been adequately addressed.

Overall, I believe that the revisions have substantially improved the clarity, clinical relevance, and scientific rigor of the manuscript. I have no further substantive comments and consider the manuscript suitable for publication in its current form.

Best wishes,

Reviewer 2 Report

Comments and Suggestions for Authors

I have carefully reviewed the revised version of the manuscript and the authors’ responses to the comments raised during the initial review. I appreciate the effort made by the authors to address all  issues I pointed out. It improved the value of the article which  now is ready for  presentation and have potential clinical value.