Hip Outcome Score (HOS)

May 19, 2016


Hip Outcome Survey (HOS)

There are many different hip outcome reporting measures in use today and many of them are tailored towards an older age group, which by definition is a less mobile and less active demographic.

Because of this, many of these reporting measures fall victim to the ‘ceiling effect’ – a statistical term for the phenomenon that occurs when the highest score on a rating tool is unable to properly assess a patient’s level of ability. For instance, younger patients tend to be significantly more active than elderly patients and as such, rating tools that have a median age of 60 may fail to account for the activities carried out by individuals in the 20s or 30s age bracket.

In 2006, the Hip Outcome Survey (HOS) was developed to help address this issue. As younger patients have different goals, expectations and quality of life benchmarks post-treatment, it was believed that a reporting measure with these concerns in mind would be more representative than many of the pre-existing surveys. The HOS is a self-administered questionnaire with a scoring system composed of two subscales:

  • The Activities of Daily Living (ADL) subscale made of seventeen scored items and the Sports subscale composed of nine items. The ADL subscale focuses on a wide range of functions from small activities such as putting on socks, standing, and sitting, to more demanding activities like squatting, twisting, and pivoting on the affected leg.
  • The Sports subscale looks at the ability of an individual to perform specific tasks such as running one mile or swinging items like a golf club. This scale asks respondents about activities they carry out using their normal technique and includes movements like starting, stopping quickly, lateral and cutting motions.

Both subscales are marked separately with both scales responses being scored from zero to four, with zero being “unable to do” and four being “no difficulty.” Patients are also able to leave a “Not applicable” response. Those responses are not counted when scoring. The total score is then multiplied by four to get the highest potential score, for the ADL scale the score can be no greater than 68 while the Sports scale can be no greater than 36. For both scales, a higher score represents a greater level of function.

Unlike many reporting measures the HOS scoring system focuses on a younger, more active patient population – which is evidenced by the questions seen in the survey and helps to remove the ceiling effect present in other reporting measures.


As mentioned, the primary strength of the HOS survey is its applicability to those individuals with a very high level of physical functioning, such as athletes. Currently, there are few other reporting measures with this key feature in mind – The Harris Hip Score (HHS), the Nonarthritic Hip Score (NHS) and the MAHORN (Multicenter Arthroscopy of the Hip Outcomes Research Network).

Additionally, other traditional hip scoring systems make it difficult to determine whether activities are limited by hip pain or if the pain felt is related to other pre-existing causes such as knee or back pain. To solve this problem, the HOS reporting measure allows respondents to address this by specifically answering ‘Not applicable’ if any pain felt is related to another cause. The ‘Not applicable’ responses are removed from the overall score and have no effect on the final outcome.

Another strength of the HOS instrument is its robustness as a reporting measure. This was demonstrated by a study carried out in 2011 that found that the HOS has the greatest amount of clinimetric evidence (rigor of rating scales and indexes for the description of clinical phenomena) as compared to other similar alternatives.


The effectiveness of the HOS survey is based on the total number of questions that a respondent is able to answer. It has been suggested that for a valid outcome, a minimum of fourteen of the ADL questions must be answered. However, because the nature of the survey assumes a relatively moderate level of activity, some physicians may find that this measure isn’t always appropriate for their older, more sedentary patients, thereby making it ineffective for some individuals in this demographic.

Additionally, very little literature exists with regards to the correlation between HOS and other hip reporting measures.

Overall, the Hip Outcome Score which was designed to assess higher level activities (eg. those required in athletics) appears to be a reliable reporting tool for healthcare providers with a younger patient demographic.

Licensing and Cost

The Hip Outcome Score does not require a license. To view the tool, please visit: https://orthotoolkit.com/hos/.


Patient Reported Outcome questionnaires for hip arthroscopy: a systematic review of the psychometric evidence. | Hip Arthroscopy Assessment Tools and Outcomes | A Physical Therapy Program Versus Surgery for Femoroacetabular Impingement: Randomized Clinical Trial | Patient-reported outcome instruments for femoroacetabular impingement and hip labral pathology: a systematic review of the clinimetric evidence


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