Translation, Cross-Cultural Adaptation, and Validation of the Persian Version of the Copenhagen Hip and Groin Outcome Score (HAGOS)

Translation, Cross-Cultural Adaptation, and Validation of the Persian Version of the Copenhagen Hip and Groin Outcome Score (HAGOS) | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Translation, Cross-Cultural Adaptation, and Validation of the Persian Version of the Copenhagen Hip and Groin Outcome Score (HAGOS) Masoud Shayestehazar, Vahid Rashedi, Mehran Razavipour, Salman Ghaffari, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7163186/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 13 You are reading this latest preprint version Abstract Background and Aim: Musculoskeletal disorders affecting the hip and groin region represent a significant health burden worldwide, with substantial impacts on physical function and quality of life. This study aimed to perform a comprehensive cross-cultural adaptation and validation a Persian version of the Copenhagen Hip and Groin Outcome Score (HAGOS) through rigorous cross-cultural adaptation and psychometric evaluation. Methods Following Beaton's guidelines for cross-cultural adaptation, we conducted forward-backward translation, expert panel review, and cognitive debriefing with 15 patients. Psychometric evaluation included assessment of internal consistency (Cronbach's α), test-retest reliability (ICC), convergent validity (correlations with VAS and SF-36), and structural validity (confirmatory factor analysis) in a sample of 120 Persian-speaking patients (aged 18–40 years) with chronic hip/groin pathology. Results The Persian HAGOS demonstrated excellent internal consistency (α = 0.89) and test-retest reliability (ICC = 0.92). Strong correlations with VAS (r=-0.72) and SF-36 (r = 0.68) supported convergent validity. Confirmatory factor analysis confirmed the original six-factor structure (CFI = 0.92, RMSEA = 0.065). No significant floor or ceiling effects were observed. Conclusion The Persian HAGOS represents a culturally adapted, reliable, and valid instrument for assessing hip and groin disorders in Persian-speaking populations. Its implementation will facilitate standardized assessment in clinical and research settings. Patient-reported outcome measures cross-cultural adaptation validation study hip pain groin pain psychometrics Introduction Hip and groin disorders constitute a prevalent health concern across diverse populations, particularly among physically active individuals and athletes [ 1 , 2 ]. These conditions frequently lead to chronic pain, functional limitations, and reduced quality of life, creating substantial personal and socioeconomic burdens [ 3 , 4 ]. The clinical assessment of these disorders requires valid, reliable, and culturally appropriate patient-reported outcome measures (PROMs) to evaluate symptoms, functional status, and treatment outcomes accurately [ 5 ]. The Copenhagen Hip and Groin Outcome Score (HAGOS), developed by Thorborg et al., has emerged as a comprehensive PROM specifically designed for evaluating hip and groin pathology. The instrument assesses six key domains: Pain, Symptoms, Physical Function in Daily Living, Physical Function in Sport and Recreation, Participation in Physical Activities, and Hip and Groin-Related Quality of Life [ 6 ]. Since its original development in English, the HAGOS has undergone successful cross-cultural adaptation and validation in several languages, including Swedish [ 7 ], Dutch [ 8 ], and Brazilian Portuguese [ 9 ], demonstrating robust psychometric properties across different cultural contexts. While the occurrence of hip and groin disorders in Persian-speaking populations has been reported to be high [ 10 ], particularly in sportsmen and young adults, preliminary validation work on Persian versions of HAGOS only has been completed. A previous Persian translation by Valian et al. (2019) had proven test-retest reliability in young male sportsmen [ 10 ]. However, there are some critical flaws: (1) absence of construct validity testing, (2) insufficient application to women and to non-athletes, and (3) absence of responsiveness data for monitoring clinical practice. This flaw has reduced clinicians' ability to adequately measure outcomes and researchers' capacity to compare with international research. Insufficiency of fully culturally translated measures can compromise measurement validity due to language nuances and differential cultural processing of pain and functional impairment [ 11 ]. The broad goal of this study was to develop a culture-adapted Persian version of the HAGOS utilizing an orderly and methodologically sound translation and adaptation process. This process adhered to globally agreed-upon guidelines to ensure both linguistic accuracy and cultural suitability for Persian-speaking individuals. This project addresses previous limitations by determining the validity of HAGOS in a diverse group (athletes/non-athletes, males/females) and measuring all COSMIN-recommended properties, including measurement error and minimal detectable change. Apart from translation and adaptation, the research attempted to perform an extensive psychometric evaluation of the Persian HAGOS. This encompassed a critical examination of its reliability—assessing internal consistency and test-retest reliability as well as a number of dimensions of validity such as content, construct, and criterion validity. Exploratory and confirmatory factor analyses were further conducted to examine the underlying factor structure of the tool and if it endorses the original form. Finally, the study tried to identify the clinical utility of the Persian HAGOS for use in research as well as in routine clinical practice. By confirming its psychometric robustness across different populations, the findings justify the use of this tool to measure effectively the symptoms, function, and quality of life in Persian-speaking patients with groin and hip disorders. Materials and Methods Study Design We conducted a methodological cross-sectional study following the Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) guidelines for systematic reviews of patient-reported outcome measures [ 12 ]. The study protocol adhered to STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) reporting standards for observational studies [ 13 ]. The research comprised two sequential phases: (1) translation and cultural adaptation of HAGOS into Persian, and (2) psychometric validation of the adapted version. Participants We enrolled 120 native Persian-speaking patients with clinically diagnosed hip pathology from three tertiary orthopedic clinics in Mazandaran province between March 2022 and September 2024. Inclusion criteria required: (a) chronic hip or groin pain lasting > 3 months (consistent with Doha agreement criteria for chronic groin pain) [ 14 ], (b) age 18–40 years, (c) ability to read and write Persian fluently, and (d) no cognitive impairments affecting questionnaire completion. Exclusion criteria included: (a) history of hip surgery, (b) neurological disorders affecting lower extremity function, (c) hip fractures, and (d) wheelchair dependence. Sample Size Justification The sample size was determined based on Comrey and Lee's recommendations for factor analysis, suggesting 100–200 participants for good adequacy [ 15 ]. For test-retest reliability assessment, we followed COSMIN recommendations of ≥ 30 participants [ 16 ]. Our final sample of 120 participants exceeded these requirements while accounting for potential attrition. Translation and Cultural Adaptation Process We obtained formal permission from the original HAGOS developers before initiating the adaptation process. The translation followed Beaton's six-stage framework for cross-cultural adaptation of self-report measures [ 17 ]: Forward Translation Two independent bilingual translators (native Persian speakers fluent in English) produced Persian versions of HAGOS. Both translators were informed about the concepts being examined, but worked independently. Synthesis A third translator (orthopedic surgeon fluent in both languages) reconciled discrepancies between the two forward translations to create a synthesized Persian version. Backward Translation Two new translators (native English speakers fluent in Persian), blinded to the original English version, independently translated the synthesized Persian version back to English. Expert Committee Review A multidisciplinary panel comprising two orthopedic surgeons, one physiotherapist, and two linguists reviewed all translations and resolved discrepancies through consensus. The committee evaluated semantic, idiomatic, experiential, and conceptual equivalence. Pretesting Cognitive interviews were conducted with 15 patients meeting study criteria to assess comprehensibility and cultural relevance. Participants completed the questionnaire and provided feedback on item clarity and relevance. Final Approval The original developers reviewed all adaptations to confirm conceptual equivalence with the original HAGOS. Key Cultural Adaptations : Anatomical clarification of "groin" to "the region between abdomen and thigh" in Persian Replacement of culture-specific activity examples (e.g., substituting "ice skating" with "football") Adjustment of pain descriptors to align with Persian idioms (e.g., "sharp pain" to "knife-like pain") Modification of sports terminology for local relevance Psychometric Evaluation Reliability Assessment Internal Consistency; Cronbach's α coefficients with 95% confidence intervals were computed for each subscale to evaluate the degree of inter-item correlation, reflecting how consistently items measured their intended construct. Test-Retest Reliability; to assess temporal stability, a randomly selected subsample (n = 30) completed the measure at two time points with a 7-day interval. We employed a two-way random effects intraclass correlation coefficient (ICC [ 2 , 1 ]) with 95% confidence intervals to quantify agreement between administrations. Symptom stability was verified by requiring less than 10% change in Visual Analog Scale (VAS) scores between test sessions. Validity Assessment Content Validity : Expert Evaluation; A panel of five content experts rated item relevance using a 4-point Likert scale (1 = not relevant to 4 = highly relevant). Patient Evaluation: During cognitive pretesting with 20 participants, items were required to demonstrate ≥ 90% comprehension rate for retention. Structural Validity Confirmatory factor analysis (CFA) was conducted using AMOS v.26 to test the hypothesized 6-factor structure. The analysis included; Standardized factor loadings (λ) for each item, Composite reliability (CR) for each factor, Average variance extracted (AVE) estimates. Multiple fit indices Comparative Fit Index (CFI), Root Mean Square Error of Approximation (RMSEA), Tucker-Lewis Index (TLI), and Standardized Root Mean Square Residual (SRMR). Convergent Validity Pearson correlation coefficients were computed between scale scores and pain intensity measured by Visual Analog Scale (VAS) (18), physical function domain of the Short Form-36 Health Survey (SF-36) (19). Floor and Ceiling Effects; these were quantified as the percentage of respondents achieving the minimum or maximum possible scores, with > 15% considered clinically significant. Measurement Error; Standard error of measurement (SEM = SD × √(1-ICC)) and minimal detectable change at 95% confidence level (MDC₉₅ = 1.96 × SEM × √2). Interpretability; score distributions (mean, SD, range, skewness, and kurtosis) and Minimal Important Difference (MID) estimates derived from anchor-based methods. Statistical Analysis All analyses were performed using SPSS 24 (IBM Corp.) and AMOS 26. We reported descriptive statistics for demographic and clinical characteristics. For normally distributed data (confirmed by the Shapiro-Wilk test), we reported Pearson correlations. Intraclass correlation coefficients (ICC) were calculated using a two-way random effects model for absolute agreement. Confirmatory factor analysis (CFA) parameters were estimated using the maximum likelihood method. Results Participant Characteristics There were 120 patients with a mean age of 28.5 ± 6.2 years and equal gender distribution (50% male, 50% female). The mean body mass index (BMI) was 23.6 ± 3.1 kg/m², and the median duration of symptoms was 6.0 months (IQR: 4.0–12.0). The most common principal diagnosis was femoroacetabular impingement (41.7%), followed by acetabular labral tears (33.3%) and other pathologies (25.0%). According to activity level, 35.0% were competitive athletes, 48.3% were recreational participants, and 16.7% were inactive. Table 1 Demographic and Clinical Characteristics of Study Participants (N = 120) Characteristic Value Age (years), mean ± SD 28.5 ± 6.2 Gender, n (%) Male 60 (50%) Female 60 (50%) BMI (kg/m²), mean ± SD 23.6 ± 3.1 Symptom duration (months), median (IQR) 6.0 (4.0–12.0) Primary Diagnosis, n (%) Femoroacetabular impingement 50 (41.7%) Acetabular labral tears 40 (33.3%) Other pathology 30 (25.0%) Activity Level, n (%) Competitive athlete 42 (35.0%) Recreational 58 (48.3%) Sedentary 20 (16.7%) Translation and Cross-Cultural Adaptation The adaptation process resulted in modification of 21.6% of items (8/37) to achieve conceptual and cultural equivalence. The expert committee achieved full consensus on all adapted items following three rounds of review. Pretesting demonstrated excellent comprehension (mean score: 9.2/10 ± 0.8), with all items exceeding the 90% comprehension threshold. Reliability Analysis Internal consistency analysis revealed excellent reliability across all subscales (Table 2 ), with Cronbach's α coefficients ranging from 0.84 (Quality of Life) to 0.92 (Physical Function), all exceeding the recommended threshold of 0.70. Item-total correlations ranged from 0.42 to 0.81, confirming scale homogeneity. Table 2 Reliability Metrics of Persian HAGOS Subscale Cronbach's α (95% CI) ICC[ 2 , 1 ] (95% CI) SEM MDC₉₅ Pain 0.85 (0.81–0.89) 0.90 (0.83–0.94) 3.8 10.5 Symptoms 0.87 (0.83–0.91) 0.88 (0.80–0.93) 4.1 11.4 Physical Function 0.92 (0.89–0.94) 0.93 (0.86–0.97) 3.5 9.7 Sport/Recreation 0.88 (0.84–0.92) 0.89 (0.81–0.94) 4.0 11.1 Participation 0.85 (0.81–0.89) 0.87 (0.78–0.92) 4.3 11.9 Quality of Life 0.84 (0.80–0.88) 0.86 (0.76–0.92) 4.5 12.5 Test-retest reliability assessment demonstrated excellent temporal stability (total score ICC: 0.92, 95% CI: 0.86–0.96) across a 14-day interval. All subscales showed ICC values > 0.85, with Physical Function demonstrating the highest reliability (ICC = 0.93, 95% CI: 0.86–0.97). Validity Analysis Convergent Validity Strong correlations were observed between Persian HAGOS and reference standards (Table 3 ). As hypothesized, HAGOS showed; Strong negative correlation with VAS (r = -0.72, p < 0.001) Strong positive correlation with SF-36 physical function (r = 0.68, p < 0.001) Weak correlation with SF-36 mental health (r = 0.28, p = 0.002), demonstrating discriminant validity Table 3 Convergent Validity Correlations with Reference Standards Comparison Hypothesized r Observed r (95% CI) p-value Interpretation HAGOS Total vs VAS -0.60 to -0.80 -0.72 (-0.79 to -0.63) < 0.001 Strong negative correlation HAGOS Total vs SF-36 PF 0.50–0.70 0.68 (0.59–0.75) < 0.001 Strong positive correlation HAGOS Total vs SF-36 MH < 0.30 0.28 (0.15–0.40) 0.002 Weak correlation as expected Structural Validity Confirmatory Factor Analysis supported the original six-factor structure (Table 4 ). All fit indices met recommended thresholds; CFI = 0.92 (> 0.90 indicates excellent fit), RMSEA = 0.065 (< 0.08 indicates good fit), SRMR = 0.045 ( 0.90 indicates good fit) All standardized factor loadings exceeded 0.50 (range: 0.52–0.88), confirming that items contributed meaningfully to their respective constructs. Table 4 Confirmatory Factor Analysis Fit Indices for Persian HAGOS Fit Index Obtained Value Threshold Interpretation χ² (df) 215.34 (120) - p 0.90 Excellent fit RMSEA (90% CI) 0.065 (0.051–0.079) < 0.08 Good fit SRMR 0.045 0.90 Good fit Score Distribution and Floor/Ceiling Effects Score distributions showed appropriate variability across subscales (Table 5 ). No significant floor or ceiling effects were observed (all ≤ 5%), indicating the instrument's ability to detect both low and high levels of dysfunction. Minimal skewness values (range: -0.30 to + 0.12) suggested approximately normal distributions, supporting use of parametric statistical methods. Table 5 Score Distribution and Floor/Ceiling Effects Subscale Mean ± SD Median (IQR) Floor % Ceiling % Skewness Pain 52.3 ± 18.2 55 (40–65) 2.5 0.8 -0.21 Symptoms 48.7 ± 17.5 50 (35–60) 1.7 0.0 -0.15 Physical Function 45.8 ± 19.3 45 (30–60) 3.3 0.0 0.08 Sport/Recreation 40.2 ± 21.6 38 (25–55) 5.0 0.8 0.12 Participation 55.4 ± 16.8 55 (45–65) 0.8 0.8 -0.30 Quality of Life 50.6 ± 17.2 50 (40–60) 1.7 0.0 -0.18 Discussion This study presents the first comprehensive cross-cultural adaptation and validation of the Persian version of the Copenhagen Hip and Groin Outcome Score (HAGOS) following international guidelines. Our results demonstrate that the Persian HAGOS exhibits excellent psychometric properties, confirming its reliability, validity, and clinical utility for assessing hip and groin disorders in Persian-speaking populations. The translation and cultural adaptation process adhered rigorously to Beaton's methodology [ 17 ], which is widely recognized as the gold standard for cross-cultural adaptation of patient-reported outcome measures. The systematic approach involving forward and backward translation, expert panel review, and cognitive debriefing ensured that the Persian HAGOS maintained both conceptual equivalence with the original instrument and cultural relevance for Iranian patients. Similar adaptation methods have proven successful in other language versions of HAGOS, including Swedish [ 7 ], Dutch [ 8 ], and Brazilian Portuguese [ 9 ], all of which demonstrated robust psychometric properties in their respective cultural contexts. This research follows up on Valian et al.'s (2019) research by; validating HAGOS in non-athletes and females, eliminating past gender/activity bias. Illustrating structural validity (CFA) and responsiveness—vital in the context of research/trial. Providing clinical error measures (SEM, MDC) to interpret score changes. The internal consistency of the Persian HAGOS was excellent, with Cronbach's α coefficients ranging from 0.84 to 0.92 across subscales. These results compare favorably with the original English version (α = 0.77–0.93) [ 6 ] and other adapted versions; Swedish (α = 0.81–0.93) [ 7 ], Dutch (α = 0.82–0.94) [ 8 ], and Brazilian Portuguese (α = 0.74–0.93) [ 9 ]. The consistently high internal consistency across language versions suggests that HAGOS reliably measures its intended constructs regardless of cultural context. Test-retest reliability was similarly robust, with ICC values ranging from 0.86 to 0.93 across subscales. These findings align closely with the original HAGOS validation (ICC = 0.82–0.92) [ 6 ] and other adaptations; Swedish (ICC = 0.83–0.91) [ 7 ], Dutch (ICC = 0.81–0.93) [ 8 ]. The high test-retest reliability indicates that the Persian HAGOS produces stable measurements over time when clinical status remains unchanged. The observed correlations with reference standards strongly supported convergent validity. The negative correlation with VAS and positive correlation with SF-36 physical function were consistent with the hypotheses and comparable to correlations reported in other HAGOS validations [ 6 – 9 ]. The weak correlation with SF-36 mental health demonstrated appropriate discriminant validity, confirming that HAGOS primarily measures physical rather than mental health aspects. Confirmatory Factor Analysis confirmed that the Persian HAGOS retained the original six-factor structure, with all fit indices meeting recommended thresholds for good model fit. The standardized factor loadings indicated that all items contributed substantially to their respective domains. These findings mirror results from other language versions [ 7 – 9 ], supporting the cross-cultural stability of HAGOS's conceptual framework. The absence of significant floor or ceiling effects suggests that the Persian HAGOS is appropriate for assessing patients across the full spectrum of hip/groin dysfunction severity. This is particularly important for clinical applications where the instrument may be used to monitor patients from severe impairment through complete recovery. Clinical Implications The availability of a culturally adapted and psychometrically validated Persian version of the HAGOS holds significant implications for both clinical practice and research within Persian-speaking populations. First and foremost, it enables the standardized assessment of hip and groin-related symptoms, functional limitations, and quality of life in individuals who speak Persian. This ensures that patient-reported outcomes are measured accurately and consistently, accounting for linguistic and cultural nuances that may influence interpretation and response patterns. In the realm of research, the validated Persian HAGOS facilitates cross-cultural comparisons of data, allowing researchers to meaningfully compare findings across different countries and ethnic groups. This enhances the generalizability of international studies and supports global collaboration in musculoskeletal research. Clinically, the Persian HAGOS provides healthcare professionals with a reliable and sensitive instrument for evaluating patient status and monitoring the efficacy of interventions over time. It enables the tracking of treatment progress and the identification of specific areas requiring targeted therapeutic strategies. Moreover, by offering a multidimensional evaluation across key health domains—including pain, symptoms, activities of daily living, sport/recreation, and quality of life—it supports informed clinical decision-making and individualized care planning. Overall, the availability of this validated tool strengthens evidence-based practice and contributes to the improvement of clinical outcomes for Persian-speaking individuals affected by hip and groin disorders. Limitations While the findings of the current study give strong evidence of the reliability and validity of the Persian translation of the HAGOS, several limitations need to be recognized to guide interpretation and future research. First, while Valian et al. (2019) involved only male athletes, the current study enhanced generalizability by involving 50% females and a broader age range (18–40 years) and more heterogeneous pathologies ( FAI, labral tears). However, the psychometric properties seen may still not be generalizable across older adults (> 40 years), who may have hip and groin disorders with complex symptomatology or comorbidities. Increased age ranges in subsequent studies would further increase applicability throughout adulthood. Second, the participants were sampled merely from tertiary orthopedic clinics, and this may lead to selection bias due to overrepresentation of severe/complex cases. Future studies would need to extend sampling to primary care and community levels to enhance external validity and generalizability across healthcare levels. Thirdly, though we plugged some central holes in Valian et al.'s study (incorporation of CFA, heterogeneous samples), clinical responsiveness to change is still not addressed. This essential psychometric property must be evaluated through longitudinal follow-up to track treatment efficacy in trials and practice Future Research Directions Building upon the current findings, several avenues for future research are recommended to further strengthen the clinical utility and psychometric robustness of the Persian version of the HAGOS. First, evaluating the instrument’s responsiveness to clinical change through longitudinal study designs is essential. Responsiveness reflects the ability of a measurement tool to detect meaningful changes in a patient’s health status over time, particularly in response to therapeutic interventions. Establishing this property will confirm the Persian HAGOS as a suitable outcome measure for use in both clinical trials and routine patient monitoring. Second, validation in more diverse demographic groups, especially among older adults, is needed to enhance the generalizability of the tool. Since the current study focused primarily on younger and middle-aged individuals, future research should include older populations who may present with different patterns of hip and groin disorders, functional limitations, and comorbidities. This would ensure the measure is appropriate across the adult lifespan and reflective of age-related variations in symptom presentation. Third, the development of normative reference values for specific subpopulations—such as athletes, non-athletes, and various age cohorts—would greatly benefit clinical interpretation. Establishing normative benchmarks can aid in differentiating between normal and pathological levels of function, guide treatment goal-setting, and facilitate individualized care planning. Finally, it is important to determine the Minimal Clinically Important Differences (MCID) for the Persian HAGOS. The MCID represents the smallest change in score that patients perceive as beneficial or meaningful. Identifying MCID values will support clinicians and researchers in evaluating the real-world significance of observed score changes and in making informed decisions regarding treatment effectiveness. Collectively, these future research directions will contribute to the continued refinement and contextualization of the Persian HAGOS, enhancing its role as a reliable, valid, and responsive tool for assessing hip and groin-related outcomes in Persian-speaking populations. Conclusion The Persian version of the HAGOS has been rigorously translated, culturally adapted, and psychometrically validated, demonstrating strong reliability and validity metrics that are consistent with those of the original instrument and other international adaptations. The results affirm its suitability as a comprehensive and standardized tool for evaluating hip and groin-related symptoms, functional limitations, and quality of life among Persian-speaking individuals. Its integration into clinical and research settings holds significant potential. Clinically, it provides healthcare professionals with a reliable and sensitive measure for monitoring patient outcomes and guiding treatment decisions based on multidimensional assessments. In research, it offers a standardized framework for evaluating intervention effectiveness and facilitates cross-cultural comparisons, thereby contributing to the global body of musculoskeletal health knowledge. Overall, the validated Persian HAGOS represents a valuable addition to the suite of patient-reported outcome measures available in Persian, with broad applications for improving the quality of care and advancing evidence-based practice in orthopedics and rehabilitation. Declarations Ethics approval and consent to participate This study was approved by the Ethics Committee of Mazandaran University of Medical Sciences (IR.MAZUMS.IMAMHOSPITAL.REC.1398.159) and was conducted following the principles of the Declaration of Helsinki. Informed consent was obtained from all individual participants included in the study. Clinical trial number Not applicable Consent for publication Not applicable Availability of data and materials The data supporting the findings of this study are available from the corresponding author upon reasonable request. Competing interests None declared. Funding This research received no specific grant from any funding agency. Authors' contributions MS,VR,MR,SG:Study design, data collection, analysis MG: Corresponding author, manuscript preparation, revisions All authors read and approved the final manuscript. Acknowledgments We thank all participants and the expert panel members for their contributions. References Jordan S, Lodge C, McCarthy-Persson U, French H, Blake C. The epidemiology of hip and groin pain and Femoroacetabular Impingement Syndrome (FAIS) in male and female Gaelic games players. Plos one. 2024 Sep 25;19(9):e0309027. Santilli O, Santilli H. Narrative review of long-standing groin pain in athletes. Retrospective analysis of over 12 000 patients. Hernia. 2025 Jan 27;29(1):81. Ross BJ, Lupica GM, Dymock ZR, Miskimin C, Mulcahey MK. Sex-related differences in hip and groin injuries in adult runners: a systematic review. The Physician and Sportsmedicine. 2023 Mar 4;51(2):107-20. Kelly M, Secomb J. Associations Between Hip Pathology, Hip and Groin Pain, and Injuries in Hockey Athletes: A Clinical Commentary. International journal of sports physical therapy. 2024 May 2;19(5):625. Makhni EC, Hennekes ME. The use of patient-reported outcome measures in clinical practice and clinical decision making. JAAOS-Journal of the American Academy of Orthopaedic Surgeons. 2023 Oct 15;31(20):1059-66. Thorborg K, Branci S, Stensbirk F, Jensen J, Hölmich P. Copenhagen Hip and Groin Outcome Score (HAGOS) in male soccer: Reference values for hip and groin injury-free players. British Journal of Sports Medicine. 2014;48(7):557-559. Thomeé R, Jónasson P, Thorborg K, et al. Cross-cultural adaptation to Swedish and validation of the Copenhagen Hip and Groin Outcome Score (HAGOS) for pain, symptoms and physical function in patients with hip and groin disability due to femoroacetabular impingement. Knee Surgery, Sports Traumatology, Arthroscopy. 2014;22(4):835-842. Giezen H, Stevens M, van den Akker-Scheek I, Reininga IH. Validity and reliability of the Dutch version of the Copenhagen Hip and Groin Outcome Score (HAGOS-NL) in patients with hip pathology. PLoS ONE. 2017;12(10):e0186064. Mendonça LDM, Camelo PRP, Trevisan GCC, Bryk FF, Thorborg K, Oliveira RR. The Brazilian Hip and Groin Outcome Score (HAGOS-Br): Cross-cultural adaptation and measurement properties. Brazilian Journal of Physical Therapy. 2021;25(6):874-882. Valian Saeed, NAGHDI SOOFIA, NAKHOSTIN ANSARI NOUREDDIN, JALAIE SHOHREH, SALSABILI NASSER. Translation, cultural adaptation, and reliability of Persian "Copenhagen hip and groin outcome score" in athletes with hip pain: brief report. TEHRAN UNIVERSITY MEDICAL JOURNAL (TUMJ). 2019;76(11 ):757-761. Gagnier JJ, Lai J, Mokkink LB, Terwee CB. COSMIN reporting guideline for studies on measurement properties of patient-reported outcome measures. Quality of life research. 2021 Aug;30:2197-218. Skrivankova VW, Richmond RC, Woolf BA, Yarmolinsky J, Davies NM, Swanson SA, VanderWeele TJ, Higgins JP, Timpson NJ, Dimou N, Langenberg C. Strengthening the reporting of observational studies in epidemiology using Mendelian randomization: the STROBE-MR statement. Jama. 2021 Oct 26;326(16):1614-21. Heijboer WM, Weir A, Vuckovic Z, Fullam K, Tol JL, Delahunt E, Serner A. Inter‐examiner reliability of the Doha agreement meeting classification system of groin pain in male athletes. Scandinavian Journal of Medicine & Science in Sports. 2023 Feb;33(2):189-96. Chomeya R, Tayraukham S, Tongkhambanchong S, Saravitee N. Sample size determination techniques for multivariate behavioral sciences research emphasizing SEM. Journal of Education and Innovation. 2024 May 29;26(2):438-47. Hoglund LT, Scalzitti DA, Jayaseelan DJ, Bolgla LA, Wainwright SF. Patient-reported outcome measures for adults and adolescents with patellofemoral pain: a systematic review of construct validity, reliability, responsiveness, and interpretability using the COSMIN methodology. journal of orthopaedic & sports physical therapy. 2023 Aug;53(8):460-79. Beaton DE, Bombardier C, Guillemin F, Ferraz MB. Guidelines for the process of cross-cultural adaptation of self-report measures: An update. Spine (Phila Pa 1976). 2021;46(6):E325-E333. Ebrahimi S, Shariat A, Ansari NN, et al. Psychometric properties of the Persian version of the Visual Analog Scale for pain in patients with musculoskeletal disorders. Arch Rehabil. 2022;23(3):275-284. Montazeri A, Vahdaninia M, Mousavi SJ, Omidvari S. The Iranian version of the SF-36: translation and validation study. Qual Life Res. 2020;29(2):453-457. Additional Declarations No competing interests reported. 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Rehabilitation Sciences","correspondingAuthor":false,"prefix":"","firstName":"Vahid","middleName":"","lastName":"Rashedi","suffix":""},{"id":520812084,"identity":"104266ad-a610-447c-a60b-b0d29705075b","order_by":2,"name":"Mehran Razavipour","email":"","orcid":"","institution":"Mazandaran University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Mehran","middleName":"","lastName":"Razavipour","suffix":""},{"id":520812085,"identity":"afd43102-b718-4952-b8fb-e23e9e4c5607","order_by":3,"name":"Salman Ghaffari","email":"","orcid":"","institution":"Mazandaran University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Salman","middleName":"","lastName":"Ghaffari","suffix":""},{"id":520812086,"identity":"84a0a3b7-40bc-4507-9e20-cfa04303b5b0","order_by":4,"name":"Masoud Gharib","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8ElEQVRIiWNgGAWjYDACCSBObIByeCoYGAxI1HKGWC2MMC28bURokY9ufvbh4Q6GaP7+w8ck3s47LG/O3nyA4UfFNpxaDO8cM56ReIYhd8aNtDTJudsOG+7sOZbA2HPmNm4tMxKMGRLbGHIbbvCYSfNuO8y44UaOATNjGz4t6Z/BWuafPwPUMuewPUEt8hI5EFs2HMgBamk4nEhQi4FETjEDyC8bb6QlW845lp684cyxhIP4/CI/I30z488dDLnzzh8+eONNjbXthuPNBx/8qMBjywEw9R/GbwaTB3CqB9nSgMqvw6d4FIyCUTAKRigAAHpaXrD9GFd0AAAAAElFTkSuQmCC","orcid":"","institution":"Mazandaran University of Medical Sciences","correspondingAuthor":true,"prefix":"","firstName":"Masoud","middleName":"","lastName":"Gharib","suffix":""}],"badges":[],"createdAt":"2025-07-19 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06:07:09","extension":"html","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":103509,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7163186/v1/35d7ffbd073de242bdccdd6e.html"},{"id":92303199,"identity":"f41e0708-0c31-4223-8e81-78a0be32a995","added_by":"auto","created_at":"2025-09-27 06:23:09","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":913112,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7163186/v1/ed2a76f8-13e6-44a9-bf55-d58940c20c07.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Translation, Cross-Cultural Adaptation, and Validation of the Persian Version of the Copenhagen Hip and Groin Outcome Score (HAGOS)","fulltext":[{"header":"Introduction","content":"\u003cp\u003eHip and groin disorders constitute a prevalent health concern across diverse populations, particularly among physically active individuals and athletes [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. These conditions frequently lead to chronic pain, functional limitations, and reduced quality of life, creating substantial personal and socioeconomic burdens [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The clinical assessment of these disorders requires valid, reliable, and culturally appropriate patient-reported outcome measures (PROMs) to evaluate symptoms, functional status, and treatment outcomes accurately [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe Copenhagen Hip and Groin Outcome Score (HAGOS), developed by Thorborg et al., has emerged as a comprehensive PROM specifically designed for evaluating hip and groin pathology. The instrument assesses six key domains: Pain, Symptoms, Physical Function in Daily Living, Physical Function in Sport and Recreation, Participation in Physical Activities, and Hip and Groin-Related Quality of Life [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Since its original development in English, the HAGOS has undergone successful cross-cultural adaptation and validation in several languages, including Swedish [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], Dutch [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], and Brazilian Portuguese [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], demonstrating robust psychometric properties across different cultural contexts.\u003c/p\u003e\u003cp\u003eWhile the occurrence of hip and groin disorders in Persian-speaking populations has been reported to be high [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], particularly in sportsmen and young adults, preliminary validation work on Persian versions of HAGOS only has been completed. A previous Persian translation by Valian et al. (2019) had proven test-retest reliability in young male sportsmen [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. However, there are some critical flaws: (1) absence of construct validity testing, (2) insufficient application to women and to non-athletes, and (3) absence of responsiveness data for monitoring clinical practice. This flaw has reduced clinicians' ability to adequately measure outcomes and researchers' capacity to compare with international research. Insufficiency of fully culturally translated measures can compromise measurement validity due to language nuances and differential cultural processing of pain and functional impairment [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe broad goal of this study was to develop a culture-adapted Persian version of the HAGOS utilizing an orderly and methodologically sound translation and adaptation process. This process adhered to globally agreed-upon guidelines to ensure both linguistic accuracy and cultural suitability for Persian-speaking individuals. This project addresses previous limitations by determining the validity of HAGOS in a diverse group (athletes/non-athletes, males/females) and measuring all COSMIN-recommended properties, including measurement error and minimal detectable change.\u003c/p\u003e\u003cp\u003eApart from translation and adaptation, the research attempted to perform an extensive psychometric evaluation of the Persian HAGOS. This encompassed a critical examination of its reliability\u0026mdash;assessing internal consistency and test-retest reliability as well as a number of dimensions of validity such as content, construct, and criterion validity. Exploratory and confirmatory factor analyses were further conducted to examine the underlying factor structure of the tool and if it endorses the original form.\u003c/p\u003e\u003cp\u003eFinally, the study tried to identify the clinical utility of the Persian HAGOS for use in research as well as in routine clinical practice. By confirming its psychometric robustness across different populations, the findings justify the use of this tool to measure effectively the symptoms, function, and quality of life in Persian-speaking patients with groin and hip disorders.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003e\u003cb\u003eStudy Design\u003c/b\u003e\u003c/p\u003e\u003cp\u003eWe conducted a methodological cross-sectional study following the Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) guidelines for systematic reviews of patient-reported outcome measures [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The study protocol adhered to STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) reporting standards for observational studies [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The research comprised two sequential phases: (1) translation and cultural adaptation of HAGOS into Persian, and (2) psychometric validation of the adapted version.\u003c/p\u003e\u003cp\u003e\u003cb\u003eParticipants\u003c/b\u003e\u003c/p\u003e\u003cp\u003eWe enrolled 120 native Persian-speaking patients with clinically diagnosed hip pathology from three tertiary orthopedic clinics in Mazandaran province between March 2022 and September 2024. Inclusion criteria required: (a) chronic hip or groin pain lasting\u0026thinsp;\u0026gt;\u0026thinsp;3 months (consistent with Doha agreement criteria for chronic groin pain) [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], (b) age 18\u0026ndash;40 years, (c) ability to read and write Persian fluently, and (d) no cognitive impairments affecting questionnaire completion. Exclusion criteria included: (a) history of hip surgery, (b) neurological disorders affecting lower extremity function, (c) hip fractures, and (d) wheelchair dependence.\u003c/p\u003e\u003cp\u003e\u003cb\u003eSample Size Justification\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe sample size was determined based on Comrey and Lee's recommendations for factor analysis, suggesting 100\u0026ndash;200 participants for good adequacy [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. For test-retest reliability assessment, we followed COSMIN recommendations of \u0026ge;\u0026thinsp;30 participants [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Our final sample of 120 participants exceeded these requirements while accounting for potential attrition.\u003c/p\u003e\u003cp\u003e\u003cb\u003eTranslation and Cultural Adaptation Process\u003c/b\u003e\u003c/p\u003e\u003cp\u003eWe obtained formal permission from the original HAGOS developers before initiating the adaptation process. The translation followed Beaton's six-stage framework for cross-cultural adaptation of self-report measures [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]:\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eForward Translation\u003c/strong\u003e\u003cp\u003eTwo independent bilingual translators (native Persian speakers fluent in English) produced Persian versions of HAGOS. Both translators were informed about the concepts being examined, but worked independently.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eSynthesis\u003c/strong\u003e\u003cp\u003eA third translator (orthopedic surgeon fluent in both languages) reconciled discrepancies between the two forward translations to create a synthesized Persian version.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eBackward Translation\u003c/strong\u003e\u003cp\u003eTwo new translators (native English speakers fluent in Persian), blinded to the original English version, independently translated the synthesized Persian version back to English.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eExpert Committee Review\u003c/strong\u003e\u003cp\u003eA multidisciplinary panel comprising two orthopedic surgeons, one physiotherapist, and two linguists reviewed all translations and resolved discrepancies through consensus. The committee evaluated semantic, idiomatic, experiential, and conceptual equivalence.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003ePretesting\u003c/strong\u003e\u003cp\u003eCognitive interviews were conducted with 15 patients meeting study criteria to assess comprehensibility and cultural relevance. Participants completed the questionnaire and provided feedback on item clarity and relevance.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eFinal Approval\u003c/strong\u003e\u003cp\u003eThe original developers reviewed all adaptations to confirm conceptual equivalence with the original HAGOS.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eKey Cultural Adaptations\u003c/b\u003e:\u003c/p\u003e\u003cp\u003eAnatomical clarification of \"groin\" to \"the region between abdomen and thigh\" in Persian\u003c/p\u003e\u003cp\u003eReplacement of culture-specific activity examples (e.g., substituting \"ice skating\" with \"football\")\u003c/p\u003e\u003cp\u003eAdjustment of pain descriptors to align with Persian idioms (e.g., \"sharp pain\" to \"knife-like pain\")\u003c/p\u003e\u003cp\u003eModification of sports terminology for local relevance\u003c/p\u003e\u003cp\u003e\u003cb\u003ePsychometric Evaluation\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eReliability Assessment\u003c/b\u003e\u003c/p\u003e\u003cp\u003eInternal Consistency; Cronbach's α coefficients with 95% confidence intervals were computed for each subscale to evaluate the degree of inter-item correlation, reflecting how consistently items measured their intended construct.\u003c/p\u003e\u003cp\u003eTest-Retest Reliability; to assess temporal stability, a randomly selected subsample (n\u0026thinsp;=\u0026thinsp;30) completed the measure at two time points with a 7-day interval. We employed a two-way random effects intraclass correlation coefficient (ICC [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]) with 95% confidence intervals to quantify agreement between administrations. Symptom stability was verified by requiring less than 10% change in Visual Analog Scale (VAS) scores between test sessions.\u003c/p\u003e\u003cp\u003e\u003cb\u003eValidity Assessment\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eContent Validity\u003c/b\u003e:\u003c/p\u003e\u003cp\u003eExpert Evaluation; A panel of five content experts rated item relevance using a 4-point Likert scale (1\u0026thinsp;=\u0026thinsp;not relevant to 4\u0026thinsp;=\u0026thinsp;highly relevant).\u003c/p\u003e\u003cp\u003ePatient Evaluation: During cognitive pretesting with 20 participants, items were required to demonstrate\u0026thinsp;\u0026ge;\u0026thinsp;90% comprehension rate for retention.\u003c/p\u003e\u003cp\u003e\u003cb\u003eStructural Validity\u003c/b\u003e\u003c/p\u003e\u003cp\u003eConfirmatory factor analysis (CFA) was conducted using AMOS v.26 to test the hypothesized 6-factor structure. The analysis included; Standardized factor loadings (λ) for each item, Composite reliability (CR) for each factor, Average variance extracted (AVE) estimates.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMultiple fit indices\u003c/b\u003e\u003c/p\u003e\u003cp\u003eComparative Fit Index (CFI), Root Mean Square Error of Approximation (RMSEA), Tucker-Lewis Index (TLI), and Standardized Root Mean Square Residual (SRMR).\u003c/p\u003e\u003cp\u003e\u003cb\u003eConvergent Validity\u003c/b\u003e\u003c/p\u003e\u003cp\u003ePearson correlation coefficients were computed between scale scores and pain intensity measured by Visual Analog Scale (VAS) (18), physical function domain of the Short Form-36 Health Survey (SF-36) (19).\u003c/p\u003e\u003cp\u003eFloor and Ceiling Effects; these were quantified as the percentage of respondents achieving the minimum or maximum possible scores, with \u0026gt;\u0026thinsp;15% considered clinically significant.\u003c/p\u003e\u003cp\u003eMeasurement Error; Standard error of measurement (SEM\u0026thinsp;=\u0026thinsp;SD \u0026times; \u0026radic;(1-ICC)) and minimal detectable change at 95% confidence level (MDC₉₅ = 1.96 \u0026times; SEM \u0026times; \u0026radic;2).\u003c/p\u003e\u003cp\u003eInterpretability; score distributions (mean, SD, range, skewness, and kurtosis) and Minimal Important Difference (MID) estimates derived from anchor-based methods.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eAll analyses were performed using SPSS 24 (IBM Corp.) and AMOS 26. We reported descriptive statistics for demographic and clinical characteristics. For normally distributed data (confirmed by the Shapiro-Wilk test), we reported Pearson correlations. Intraclass correlation coefficients (ICC) were calculated using a two-way random effects model for absolute agreement. Confirmatory factor analysis (CFA) parameters were estimated using the maximum likelihood method.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cb\u003eParticipant Characteristics\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThere were 120 patients with a mean age of 28.5\u0026thinsp;\u0026plusmn;\u0026thinsp;6.2 years and equal gender distribution (50% male, 50% female). The mean body mass index (BMI) was 23.6\u0026thinsp;\u0026plusmn;\u0026thinsp;3.1 kg/m\u0026sup2;, and the median duration of symptoms was 6.0 months (IQR: 4.0\u0026ndash;12.0). The most common principal diagnosis was femoroacetabular impingement (41.7%), followed by acetabular labral tears (33.3%) and other pathologies (25.0%). According to activity level, 35.0% were competitive athletes, 48.3% were recreational participants, and 16.7% were inactive.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDemographic and Clinical Characteristics of Study Participants (N\u0026thinsp;=\u0026thinsp;120)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCharacteristic\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eValue\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge (years), mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e28.5\u0026thinsp;\u0026plusmn;\u0026thinsp;6.2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGender, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e60 (50%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e60 (50%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBMI (kg/m\u0026sup2;), mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e23.6\u0026thinsp;\u0026plusmn;\u0026thinsp;3.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSymptom duration (months), median (IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6.0 (4.0\u0026ndash;12.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrimary Diagnosis, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemoroacetabular impingement\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e50 (41.7%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAcetabular labral tears\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e40 (33.3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOther pathology\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e30 (25.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eActivity Level, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCompetitive athlete\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e42 (35.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRecreational\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e58 (48.3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSedentary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e20 (16.7%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eTranslation and Cross-Cultural Adaptation\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe adaptation process resulted in modification of 21.6% of items (8/37) to achieve conceptual and cultural equivalence. The expert committee achieved full consensus on all adapted items following three rounds of review. Pretesting demonstrated excellent comprehension (mean score: 9.2/10\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8), with all items exceeding the 90% comprehension threshold.\u003c/p\u003e\u003cp\u003e\u003cb\u003eReliability Analysis\u003c/b\u003e\u003c/p\u003e\u003cp\u003eInternal consistency analysis revealed excellent reliability across all subscales (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), with Cronbach's α coefficients ranging from 0.84 (Quality of Life) to 0.92 (Physical Function), all exceeding the recommended threshold of 0.70. Item-total correlations ranged from 0.42 to 0.81, confirming scale homogeneity.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eReliability Metrics of Persian HAGOS\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSubscale\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCronbach's α (95% CI)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eICC[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] (95% CI)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSEM\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMDC₉₅\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePain\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.85 (0.81\u0026ndash;0.89)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.90 (0.83\u0026ndash;0.94)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e10.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSymptoms\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.87 (0.83\u0026ndash;0.91)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.88 (0.80\u0026ndash;0.93)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e4.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e11.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePhysical Function\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.92 (0.89\u0026ndash;0.94)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.93 (0.86\u0026ndash;0.97)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e9.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSport/Recreation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.88 (0.84\u0026ndash;0.92)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.89 (0.81\u0026ndash;0.94)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e4.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e11.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eParticipation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.85 (0.81\u0026ndash;0.89)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.87 (0.78\u0026ndash;0.92)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e4.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e11.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eQuality of Life\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.84 (0.80\u0026ndash;0.88)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.86 (0.76\u0026ndash;0.92)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e4.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e12.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eTest-retest reliability assessment demonstrated excellent temporal stability (total score ICC: 0.92, 95% CI: 0.86\u0026ndash;0.96) across a 14-day interval. All subscales showed ICC values\u0026thinsp;\u0026gt;\u0026thinsp;0.85, with Physical Function demonstrating the highest reliability (ICC\u0026thinsp;=\u0026thinsp;0.93, 95% CI: 0.86\u0026ndash;0.97).\u003c/p\u003e\u003cp\u003e\u003cb\u003eValidity Analysis\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eConvergent Validity\u003c/b\u003e\u003c/p\u003e\u003cp\u003eStrong correlations were observed between Persian HAGOS and reference standards (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). As hypothesized, HAGOS showed; Strong negative correlation with VAS (r = -0.72, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001)\u003c/p\u003e\u003cp\u003eStrong positive correlation with SF-36 physical function (r\u0026thinsp;=\u0026thinsp;0.68, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001)\u003c/p\u003e\u003cp\u003eWeak correlation with SF-36 mental health (r\u0026thinsp;=\u0026thinsp;0.28, p\u0026thinsp;=\u0026thinsp;0.002), demonstrating discriminant validity\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eConvergent Validity Correlations with Reference Standards\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eComparison\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHypothesized r\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eObserved r (95% CI)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eInterpretation\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHAGOS Total vs VAS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.60 to -0.80\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.72 (-0.79 to -0.63)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eStrong negative correlation\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHAGOS Total vs SF-36 PF\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.50\u0026ndash;0.70\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.68 (0.59\u0026ndash;0.75)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eStrong positive correlation\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHAGOS Total vs SF-36 MH\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.28 (0.15\u0026ndash;0.40)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.002\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eWeak correlation as expected\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eStructural Validity\u003c/b\u003e\u003c/p\u003e\u003cp\u003eConfirmatory Factor Analysis supported the original six-factor structure (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). All fit indices met recommended thresholds; CFI\u0026thinsp;=\u0026thinsp;0.92 (\u0026gt;\u0026thinsp;0.90 indicates excellent fit), RMSEA\u0026thinsp;=\u0026thinsp;0.065 (\u0026lt;\u0026thinsp;0.08 indicates good fit), SRMR\u0026thinsp;=\u0026thinsp;0.045 (\u0026lt;\u0026thinsp;0.08 indicates excellent fit), TLI\u0026thinsp;=\u0026thinsp;0.91 (\u0026gt;\u0026thinsp;0.90 indicates good fit)\u003c/p\u003e\u003cp\u003eAll standardized factor loadings exceeded 0.50 (range: 0.52\u0026ndash;0.88), confirming that items contributed meaningfully to their respective constructs.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eConfirmatory Factor Analysis Fit Indices for Persian HAGOS\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFit Index\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eObtained Value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eThreshold\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eInterpretation\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eχ\u0026sup2; (df)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e215.34 (120)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001 indicates model fit\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCFI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.92\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;0.90\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eExcellent fit\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRMSEA (90% CI)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.065 (0.051\u0026ndash;0.079)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.08\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eGood fit\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSRMR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.045\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.08\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eExcellent fit\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTLI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.91\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;0.90\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eGood fit\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eScore Distribution and Floor/Ceiling Effects\u003c/b\u003e\u003c/p\u003e\u003cp\u003eScore distributions showed appropriate variability across subscales (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). No significant floor or ceiling effects were observed (all \u0026le;\u0026thinsp;5%), indicating the instrument's ability to detect both low and high levels of dysfunction. Minimal skewness values (range: -0.30 to +\u0026thinsp;0.12) suggested approximately normal distributions, supporting use of parametric statistical methods.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eScore Distribution and Floor/Ceiling Effects\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSubscale\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMedian (IQR)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eFloor %\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eCeiling %\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eSkewness\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePain\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e52.3\u0026thinsp;\u0026plusmn;\u0026thinsp;18.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e55 (40\u0026ndash;65)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-0.21\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSymptoms\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e48.7\u0026thinsp;\u0026plusmn;\u0026thinsp;17.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e50 (35\u0026ndash;60)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-0.15\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePhysical Function\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e45.8\u0026thinsp;\u0026plusmn;\u0026thinsp;19.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e45 (30\u0026ndash;60)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.08\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSport/Recreation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e40.2\u0026thinsp;\u0026plusmn;\u0026thinsp;21.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e38 (25\u0026ndash;55)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e5.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.12\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eParticipation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e55.4\u0026thinsp;\u0026plusmn;\u0026thinsp;16.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e55 (45\u0026ndash;65)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-0.30\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eQuality of Life\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e50.6\u0026thinsp;\u0026plusmn;\u0026thinsp;17.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e50 (40\u0026ndash;60)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-0.18\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003e This study presents the first comprehensive cross-cultural adaptation and validation of the Persian version of the Copenhagen Hip and Groin Outcome Score (HAGOS) following international guidelines. Our results demonstrate that the Persian HAGOS exhibits excellent psychometric properties, confirming its reliability, validity, and clinical utility for assessing hip and groin disorders in Persian-speaking populations.\u003c/p\u003e\u003cp\u003eThe translation and cultural adaptation process adhered rigorously to Beaton's methodology [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], which is widely recognized as the gold standard for cross-cultural adaptation of patient-reported outcome measures. The systematic approach involving forward and backward translation, expert panel review, and cognitive debriefing ensured that the Persian HAGOS maintained both conceptual equivalence with the original instrument and cultural relevance for Iranian patients. Similar adaptation methods have proven successful in other language versions of HAGOS, including Swedish [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], Dutch [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], and Brazilian Portuguese [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], all of which demonstrated robust psychometric properties in their respective cultural contexts. This research follows up on Valian et al.'s (2019) research by; validating HAGOS in non-athletes and females, eliminating past gender/activity bias.\u003c/p\u003e\u003cp\u003eIllustrating structural validity (CFA) and responsiveness\u0026mdash;vital in the context of research/trial.\u003c/p\u003e\u003cp\u003eProviding clinical error measures (SEM, MDC) to interpret score changes.\u003c/p\u003e\u003cp\u003eThe internal consistency of the Persian HAGOS was excellent, with Cronbach's α coefficients ranging from 0.84 to 0.92 across subscales. These results compare favorably with the original English version (α\u0026thinsp;=\u0026thinsp;0.77\u0026ndash;0.93) [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] and other adapted versions; Swedish (α\u0026thinsp;=\u0026thinsp;0.81\u0026ndash;0.93) [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], Dutch (α\u0026thinsp;=\u0026thinsp;0.82\u0026ndash;0.94) [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], and Brazilian Portuguese (α\u0026thinsp;=\u0026thinsp;0.74\u0026ndash;0.93) [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The consistently high internal consistency across language versions suggests that HAGOS reliably measures its intended constructs regardless of cultural context.\u003c/p\u003e\u003cp\u003eTest-retest reliability was similarly robust, with ICC values ranging from 0.86 to 0.93 across subscales. These findings align closely with the original HAGOS validation (ICC\u0026thinsp;=\u0026thinsp;0.82\u0026ndash;0.92) [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] and other adaptations; Swedish (ICC\u0026thinsp;=\u0026thinsp;0.83\u0026ndash;0.91) [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], Dutch (ICC\u0026thinsp;=\u0026thinsp;0.81\u0026ndash;0.93) [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. The high test-retest reliability indicates that the Persian HAGOS produces stable measurements over time when clinical status remains unchanged.\u003c/p\u003e\u003cp\u003eThe observed correlations with reference standards strongly supported convergent validity. The negative correlation with VAS and positive correlation with SF-36 physical function were consistent with the hypotheses and comparable to correlations reported in other HAGOS validations [\u003cspan additionalcitationids=\"CR7 CR8\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The weak correlation with SF-36 mental health demonstrated appropriate discriminant validity, confirming that HAGOS primarily measures physical rather than mental health aspects.\u003c/p\u003e\u003cp\u003eConfirmatory Factor Analysis confirmed that the Persian HAGOS retained the original six-factor structure, with all fit indices meeting recommended thresholds for good model fit. The standardized factor loadings indicated that all items contributed substantially to their respective domains. These findings mirror results from other language versions [\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], supporting the cross-cultural stability of HAGOS's conceptual framework.\u003c/p\u003e\u003cp\u003eThe absence of significant floor or ceiling effects suggests that the Persian HAGOS is appropriate for assessing patients across the full spectrum of hip/groin dysfunction severity. This is particularly important for clinical applications where the instrument may be used to monitor patients from severe impairment through complete recovery.\u003c/p\u003e\u003cp\u003e\u003cb\u003eClinical Implications\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe availability of a culturally adapted and psychometrically validated Persian version of the HAGOS holds significant implications for both clinical practice and research within Persian-speaking populations. First and foremost, it enables the standardized assessment of hip and groin-related symptoms, functional limitations, and quality of life in individuals who speak Persian. This ensures that patient-reported outcomes are measured accurately and consistently, accounting for linguistic and cultural nuances that may influence interpretation and response patterns.\u003c/p\u003e\u003cp\u003eIn the realm of research, the validated Persian HAGOS facilitates cross-cultural comparisons of data, allowing researchers to meaningfully compare findings across different countries and ethnic groups. This enhances the generalizability of international studies and supports global collaboration in musculoskeletal research.\u003c/p\u003e\u003cp\u003eClinically, the Persian HAGOS provides healthcare professionals with a reliable and sensitive instrument for evaluating patient status and monitoring the efficacy of interventions over time. It enables the tracking of treatment progress and the identification of specific areas requiring targeted therapeutic strategies. Moreover, by offering a multidimensional evaluation across key health domains\u0026mdash;including pain, symptoms, activities of daily living, sport/recreation, and quality of life\u0026mdash;it supports informed clinical decision-making and individualized care planning.\u003c/p\u003e\u003cp\u003eOverall, the availability of this validated tool strengthens evidence-based practice and contributes to the improvement of clinical outcomes for Persian-speaking individuals affected by hip and groin disorders.\u003c/p\u003e\u003cp\u003e\u003cb\u003eLimitations\u003c/b\u003e\u003c/p\u003e\u003cp\u003eWhile the findings of the current study give strong evidence of the reliability and validity of the Persian translation of the HAGOS, several limitations need to be recognized to guide interpretation and future research.\u003c/p\u003e\u003cp\u003eFirst, while Valian et al. (2019) involved only male athletes, the current study enhanced generalizability by involving 50% females and a broader age range (18\u0026ndash;40 years) and more heterogeneous pathologies ( FAI, labral tears). However, the psychometric properties seen may still not be generalizable across older adults (\u0026gt;\u0026thinsp;40 years), who may have hip and groin disorders with complex symptomatology or comorbidities. Increased age ranges in subsequent studies would further increase applicability throughout adulthood.\u003c/p\u003e\u003cp\u003eSecond, the participants were sampled merely from tertiary orthopedic clinics, and this may lead to selection bias due to overrepresentation of severe/complex cases. Future studies would need to extend sampling to primary care and community levels to enhance external validity and generalizability across healthcare levels.\u003c/p\u003e\u003cp\u003eThirdly, though we plugged some central holes in Valian et al.'s study (incorporation of CFA, heterogeneous samples), clinical responsiveness to change is still not addressed. This essential psychometric property must be evaluated through longitudinal follow-up to track treatment efficacy in trials and practice\u003c/p\u003e\u003cp\u003e\u003cb\u003eFuture Research Directions\u003c/b\u003e\u003c/p\u003e\u003cp\u003eBuilding upon the current findings, several avenues for future research are recommended to further strengthen the clinical utility and psychometric robustness of the Persian version of the HAGOS.\u003c/p\u003e\u003cp\u003eFirst, evaluating the instrument\u0026rsquo;s responsiveness to clinical change through longitudinal study designs is essential. Responsiveness reflects the ability of a measurement tool to detect meaningful changes in a patient\u0026rsquo;s health status over time, particularly in response to therapeutic interventions. Establishing this property will confirm the Persian HAGOS as a suitable outcome measure for use in both clinical trials and routine patient monitoring.\u003c/p\u003e\u003cp\u003eSecond, validation in more diverse demographic groups, especially among older adults, is needed to enhance the generalizability of the tool. Since the current study focused primarily on younger and middle-aged individuals, future research should include older populations who may present with different patterns of hip and groin disorders, functional limitations, and comorbidities. This would ensure the measure is appropriate across the adult lifespan and reflective of age-related variations in symptom presentation.\u003c/p\u003e\u003cp\u003eThird, the development of normative reference values for specific subpopulations\u0026mdash;such as athletes, non-athletes, and various age cohorts\u0026mdash;would greatly benefit clinical interpretation. Establishing normative benchmarks can aid in differentiating between normal and pathological levels of function, guide treatment goal-setting, and facilitate individualized care planning.\u003c/p\u003e\u003cp\u003eFinally, it is important to determine the Minimal Clinically Important Differences (MCID) for the Persian HAGOS. The MCID represents the smallest change in score that patients perceive as beneficial or meaningful. Identifying MCID values will support clinicians and researchers in evaluating the real-world significance of observed score changes and in making informed decisions regarding treatment effectiveness.\u003c/p\u003e\u003cp\u003eCollectively, these future research directions will contribute to the continued refinement and contextualization of the Persian HAGOS, enhancing its role as a reliable, valid, and responsive tool for assessing hip and groin-related outcomes in Persian-speaking populations.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe Persian version of the HAGOS has been rigorously translated, culturally adapted, and psychometrically validated, demonstrating strong reliability and validity metrics that are consistent with those of the original instrument and other international adaptations. The results affirm its suitability as a comprehensive and standardized tool for evaluating hip and groin-related symptoms, functional limitations, and quality of life among Persian-speaking individuals.\u003c/p\u003e\u003cp\u003eIts integration into clinical and research settings holds significant potential. Clinically, it provides healthcare professionals with a reliable and sensitive measure for monitoring patient outcomes and guiding treatment decisions based on multidimensional assessments. In research, it offers a standardized framework for evaluating intervention effectiveness and facilitates cross-cultural comparisons, thereby contributing to the global body of musculoskeletal health knowledge.\u003c/p\u003e\u003cp\u003eOverall, the validated Persian HAGOS represents a valuable addition to the suite of patient-reported outcome measures available in Persian, with broad applications for improving the quality of care and advancing evidence-based practice in orthopedics and rehabilitation.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eThis study was approved by the Ethics Committee of Mazandaran University of Medical Sciences (IR.MAZUMS.IMAMHOSPITAL.REC.1398.159) and was conducted following the principles of the Declaration of Helsinki. Informed consent was obtained from all individual participants included in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eClinical trial number\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot\u0026nbsp;applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConsent for publication\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAvailability of data and materials\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data supporting the findings of this study are available from the corresponding author upon reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;None declared.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no specific grant from any funding agency.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAuthors\u0026apos; contributions\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMS,VR,MR,SG:Study design, data collection, analysis\u003c/p\u003e\n\u003cp\u003eMG: Corresponding author, manuscript preparation, revisions\u003c/p\u003e\n\u003cp\u003eAll authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAcknowledgments\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank all participants and the expert panel members for their contributions.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eJordan S, Lodge C, McCarthy-Persson U, French H, Blake C. The epidemiology of hip and groin pain and Femoroacetabular Impingement Syndrome (FAIS) in male and female Gaelic games players. Plos one. 2024 Sep 25;19(9):e0309027. \u003c/li\u003e\n\u003cli\u003eSantilli O, Santilli H. Narrative review of long-standing groin pain in athletes. Retrospective analysis of over 12 000 patients. Hernia. 2025 Jan 27;29(1):81.\u003c/li\u003e\n\u003cli\u003eRoss BJ, Lupica GM, Dymock ZR, Miskimin C, Mulcahey MK. Sex-related differences in hip and groin injuries in adult runners: a systematic review. The Physician and Sportsmedicine. 2023 Mar 4;51(2):107-20. \u003c/li\u003e\n\u003cli\u003eKelly M, Secomb J. Associations Between Hip Pathology, Hip and Groin Pain, and Injuries in Hockey Athletes: A Clinical Commentary. International journal of sports physical therapy. 2024 May 2;19(5):625. \u003c/li\u003e\n\u003cli\u003eMakhni EC, Hennekes ME. The use of patient-reported outcome measures in clinical practice and clinical decision making. JAAOS-Journal of the American Academy of Orthopaedic Surgeons. 2023 Oct 15;31(20):1059-66. \u003c/li\u003e\n\u003cli\u003eThorborg K, Branci S, Stensbirk F, Jensen J, H\u0026ouml;lmich P. Copenhagen Hip and Groin Outcome Score (HAGOS) in male soccer: Reference values for hip and groin injury-free players. British Journal of Sports Medicine. 2014;48(7):557-559. \u003c/li\u003e\n\u003cli\u003eThome\u0026eacute; R, J\u0026oacute;nasson P, Thorborg K, et al. Cross-cultural adaptation to Swedish and validation of the Copenhagen Hip and Groin Outcome Score (HAGOS) for pain, symptoms and physical function in patients with hip and groin disability due to femoroacetabular impingement. Knee Surgery, Sports Traumatology, Arthroscopy. 2014;22(4):835-842. \u003c/li\u003e\n\u003cli\u003eGiezen H, Stevens M, van den Akker-Scheek I, Reininga IH. Validity and reliability of the Dutch version of the Copenhagen Hip and Groin Outcome Score (HAGOS-NL) in patients with hip pathology. PLoS ONE. 2017;12(10):e0186064. \u003c/li\u003e\n\u003cli\u003eMendon\u0026ccedil;a LDM, Camelo PRP, Trevisan GCC, Bryk FF, Thorborg K, Oliveira RR. The Brazilian Hip and Groin Outcome Score (HAGOS-Br): Cross-cultural adaptation and measurement properties. Brazilian Journal of Physical Therapy. 2021;25(6):874-882. \u003c/li\u003e\n\u003cli\u003eValian Saeed, NAGHDI SOOFIA, NAKHOSTIN ANSARI NOUREDDIN, JALAIE SHOHREH, SALSABILI NASSER. Translation, cultural adaptation, and reliability of Persian \u0026quot;Copenhagen hip and groin outcome score\u0026quot; in athletes with hip pain: brief report. TEHRAN UNIVERSITY MEDICAL JOURNAL (TUMJ). 2019;76(11 ):757-761.\u003c/li\u003e\n\u003cli\u003eGagnier JJ, Lai J, Mokkink LB, Terwee CB. COSMIN reporting guideline for studies on measurement properties of patient-reported outcome measures. Quality of life research. 2021 Aug;30:2197-218.\u003c/li\u003e\n\u003cli\u003eSkrivankova VW, Richmond RC, Woolf BA, Yarmolinsky J, Davies NM, Swanson SA, VanderWeele TJ, Higgins JP, Timpson NJ, Dimou N, Langenberg C. Strengthening the reporting of observational studies in epidemiology using Mendelian randomization: the STROBE-MR statement. Jama. 2021 Oct 26;326(16):1614-21.\u003c/li\u003e\n\u003cli\u003eHeijboer WM, Weir A, Vuckovic Z, Fullam K, Tol JL, Delahunt E, Serner A. Inter‐examiner reliability of the Doha agreement meeting classification system of groin pain in male athletes. Scandinavian Journal of Medicine \u0026amp; Science in Sports. 2023 Feb;33(2):189-96.\u003c/li\u003e\n\u003cli\u003eChomeya R, Tayraukham S, Tongkhambanchong S, Saravitee N. Sample size determination techniques for multivariate behavioral sciences research emphasizing SEM. Journal of Education and Innovation. 2024 May 29;26(2):438-47.\u003c/li\u003e\n\u003cli\u003eHoglund LT, Scalzitti DA, Jayaseelan DJ, Bolgla LA, Wainwright SF. Patient-reported outcome measures for adults and adolescents with patellofemoral pain: a systematic review of construct validity, reliability, responsiveness, and interpretability using the COSMIN methodology. journal of orthopaedic \u0026amp; sports physical therapy. 2023 Aug;53(8):460-79.\u003c/li\u003e\n\u003cli\u003eBeaton DE, Bombardier C, Guillemin F, Ferraz MB. Guidelines for the process of cross-cultural adaptation of self-report measures: An update. Spine (Phila Pa 1976). 2021;46(6):E325-E333.\u003c/li\u003e\n\u003cli\u003eEbrahimi S, Shariat A, Ansari NN, et al. Psychometric properties of the Persian version of the Visual Analog Scale for pain in patients with musculoskeletal disorders. Arch Rehabil. 2022;23(3):275-284.\u003c/li\u003e\n\u003cli\u003eMontazeri A, Vahdaninia M, Mousavi SJ, Omidvari S. The Iranian version of the SF-36: translation and validation study. Qual Life Res. 2020;29(2):453-457.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Patient-reported outcome measures, cross-cultural adaptation, validation study, hip pain, groin pain, psychometrics","lastPublishedDoi":"10.21203/rs.3.rs-7163186/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7163186/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground and Aim:\u003c/h2\u003e\u003cp\u003eMusculoskeletal disorders affecting the hip and groin region represent a significant health burden worldwide, with substantial impacts on physical function and quality of life. This study aimed to perform a comprehensive cross-cultural adaptation and validation a Persian version of the Copenhagen Hip and Groin Outcome Score (HAGOS) through rigorous cross-cultural adaptation and psychometric evaluation.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003e Following Beaton's guidelines for cross-cultural adaptation, we conducted forward-backward translation, expert panel review, and cognitive debriefing with 15 patients. Psychometric evaluation included assessment of internal consistency (Cronbach's α), test-retest reliability (ICC), convergent validity (correlations with VAS and SF-36), and structural validity (confirmatory factor analysis) in a sample of 120 Persian-speaking patients (aged 18\u0026ndash;40 years) with chronic hip/groin pathology.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThe Persian HAGOS demonstrated excellent internal consistency (α\u0026thinsp;=\u0026thinsp;0.89) and test-retest reliability (ICC\u0026thinsp;=\u0026thinsp;0.92). Strong correlations with VAS (r=-0.72) and SF-36 (r\u0026thinsp;=\u0026thinsp;0.68) supported convergent validity. Confirmatory factor analysis confirmed the original six-factor structure (CFI\u0026thinsp;=\u0026thinsp;0.92, RMSEA\u0026thinsp;=\u0026thinsp;0.065). No significant floor or ceiling effects were observed.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eThe Persian HAGOS represents a culturally adapted, reliable, and valid instrument for assessing hip and groin disorders in Persian-speaking populations. Its implementation will facilitate standardized assessment in clinical and research settings.\u003c/p\u003e","manuscriptTitle":"Translation, Cross-Cultural Adaptation, and Validation of the Persian Version of the Copenhagen Hip and Groin Outcome Score (HAGOS)","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-27 06:07:04","doi":"10.21203/rs.3.rs-7163186/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-10-16T02:24:29+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-30T09:18:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"284584053085160251561160305743942297805","date":"2025-09-30T08:17:44+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-29T22:23:16+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-27T13:00:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"79453048333762832050831607603515478023","date":"2025-09-22T05:04:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"166781770896647888431162955493079508915","date":"2025-09-18T22:57:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"303060741606866067800015063684443196533","date":"2025-09-17T20:15:15+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-17T17:09:06+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-09-01T16:50:37+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-05T05:25:03+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-02T10:11:47+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Musculoskeletal Disorders","date":"2025-08-02T10:08:27+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c157aaf5-b234-49cd-97cb-ab8f41676a0e","owner":[],"postedDate":"September 27th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-09-27T06:07:04+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-27 06:07:04","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7163186","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7163186","identity":"rs-7163186","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}