Development and Internal Validation of a Field-Based Triage Tool for Lumbopelvic-Hip Dysfunction in Collegiate Athletes

This study developed and internally validated a 14-factor clinical triage scoring system (CTSS) designed to help sports medicine professionals quickly identify collegiate athletes requiring priority intervention for lumbopelvic-hip dysfunction during field-based assessments.

The Gist

The "Traffic Light" for Athlete Health: A Simple Guide to the CTSS

Imagine you are a coach or a trainer standing on the sidelines of a high-stakes college football or basketball game. Suddenly, an athlete clutches their lower back or hip. In that split second, you have a massive decision to make:

• Green Light: "You’re okay; just keep an eye on it and keep training."
• Yellow Light: "We need to get you to a specialist or a physical therapist right away."
• Red Light: "Stop everything! This looks like a serious medical emergency."

The problem is that in the heat of the moment, making that call is hard. If you send everyone to the doctor, you waste precious time and money. If you send the wrong person home, you might cause a permanent injury.

This research paper introduces a new tool called the CTSS (Clinical Triage Scoring System)—essentially a "smart traffic light" designed to help sports professionals make that decision quickly and accurately.

---

The Problem: The "Invisible" Injury

Most people think that if you aren't in pain, you aren't injured. But athletes are different. They are like high-performance race cars. A race car might sound fine and drive straight, but if the suspension is slightly misaligned, it’s going to crash eventually.

The researchers found that many athletes have "functional deficits"—meaning their muscles aren't firing correctly or their joints aren't moving right—even if they don't feel pain right then. If you only look for pain, you miss the "misaligned suspension."

The Solution: The CTSS "Scorecard"

Instead of relying on a "gut feeling," the researchers studied over 800 athletes to create a mathematical scorecard. They looked at 53 different things, including:

• The History: Have you had back pain in the last 6 months?
• The Body: What is your BMI?
• The Movement: How flexible are your hips? How strong are your glutes?
• The "Stress Tests": When we move your leg in a certain way, does it trigger a specific sensation?

They boiled all of this down into 14 key factors. Think of it like a credit score for your physical health. You get points for certain "red flags" (like muscle weakness or specific pain locations) and even lose points for others (like having very tight hamstrings, which in this specific context, actually pointed toward a different type of issue).

How It Works: The Magic Number 9

The researchers found that the "sweet spot" for this scorecard is the number 9.

• Score 0–8: You’re likely in the "Self-Management" zone. You can keep training, but stay mindful.
• Score 9 or higher: You’ve hit the "Priority Intervention" zone. You need to see a professional (like a physical therapist or chiropractor) to fix the "alignment" before it turns into a breakdown.

Why This Matters (The "Safety Net" Analogy)

Think of the CTSS as a safety net under a tightrope walker.

The goal isn't to perform surgery on every athlete; the goal is to catch the ones who are "wobbling" before they fall. Because the tool looks at how the body moves (the mechanics) and not just how it feels (the pain), it can catch athletes who think they are fine but are actually at high risk of a major injury.

The Bottom Line

This isn't a tool that replaces a doctor, but it is a powerful "first responder" tool. It helps sports trainers move away from "I think he's fine" and toward "The data shows he needs help." It’s about being proactive rather than reactive—fixing the car in the pit stop so it doesn't break down on the final lap.

Technical Summary

Technical Summary: Development and Internal Validation of a Field-Based Triage Tool for Lumbopelvic-Hip Dysfunction in Collegiate Athletes

1. Problem Statement

In multidisciplinary sports medicine, practitioners (athletic trainers, physiotherapists, etc.) often face time-constrained environments where they must rapidly decide whether an athlete requires priority clinical intervention or can be managed through self-management. Current assessment methods frequently rely on imaging or clinic-based specialist evaluations, which are impractical for sideline or field-based triage. Furthermore, existing clinical prediction rules for low back pain (LBP) are often designed for general populations and may not capture the dynamic, functional, and neuromuscular impairments specific to high-load collegiate athletes. There is a lack of standardized, field-applicable tools to assist in the rapid stratification of lumbopelvic-hip (LPH) dysfunction.

2. Methodology

This was a cross-sectional derivation and internal validation study involving 864 collegiate athletes (mean age 21.3; 80.8% male) from 10 universities in Taiwan.

• Reference Standard: Since no single "gold standard" exists for LPH dysfunction, the researchers established a clinical reference standard through a two-phase expert consensus process. A multidisciplinary panel of seven senior clinicians defined triage grades (0–3). For the model, Grade 2 (priority intervention) was compared against Grades 0 and 1 (self-management). Inter-rater reliability was high ($\kappa = 0.977$).
• Data Collection: 53 candidate predictor variables were collected across four domains: demographics/training, injury history, self-reported pain/function, and objective physical examination (including manual muscle testing, range of motion, and 14 orthopedic provocation tests).
• Model Development: A forward stepwise multivariable logistic regression was used to derive a weighted Clinical Triage Scoring System (CTSS). To ensure clinical utility, regression coefficients were rescaled into an integer-based scoring system.
• Statistical Validation:
  • Internal Validation: Performed using 1,000 bootstrap resamples to assess optimism and coefficient stability.
  • Performance Metrics: Discrimination was evaluated via Area Under the Receiver Operating Characteristic curve (AUROC); calibration was assessed via the Hosmer-Lemeshow test and calibration plots; and clinical utility was evaluated using Decision Curve Analysis (DCA).

3. Key Contributions

• The CTSS Tool: The study developed a pragmatic, 14-factor weighted scoring system (ranging from 0 to 26 points) that integrates subjective history with objective functional markers.
• Integration of Functional Markers: Unlike symptom-only tools, the CTSS incorporates neuromuscular (muscle weakness) and mechanical (mobility/provocation) indicators.
• Decision Support Framework: The tool provides both a dichotomous threshold for rapid triage and a continuous probability scale for individualized risk estimation.

4. Results

• Model Performance: The CTSS demonstrated strong discriminative ability with an AUROC of 0.851 (95% CI: 0.824–0.876). After bootstrap correction, the AUROC remained high at 0.842, indicating minimal optimism.
• Predictors:
  • Positive-weight predictors (increase score): LBP in the last 6 months, current LBP, localized pain (L1–L5, right paraspinal, or left gluteal), positive Bonnet’s, Thomas, hyperextension, and internal/external hip rotation tests, gluteus medius/piriformis weakness, and higher BMI.
  • Negative-weight predictors (decrease score): Positive Lasegue’s sign and hamstring weakness (acting as safety-related modifiers).
• Optimal Threshold: An operational threshold of $\ge$9 points was identified (via Youden Index), yielding a sensitivity of 84.4% and a specificity of 71.8%.
• Clinical Utility: DCA confirmed that the CTSS provides a higher net benefit than "treat-all" or "treat-none" strategies across clinically relevant threshold probabilities (20%–50%).

5. Significance

The CTSS represents a significant advancement for field-based sports medicine. Its primary value lies in its ability to identify clinically relevant impairments in asymptomatic athletes (19.5% of the priority group reported no current symptoms), thereby preventing potential injury progression through early identification. By providing a structured, evidence-based framework, the tool helps optimize resource allocation—ensuring that athletes with high-priority mechanical or neuromuscular deficits receive timely professional care while reducing unnecessary referrals for those suitable for self-management.

Note: The authors emphasize that while the tool is highly effective for triage, it is intended to complement, not replace, comprehensive clinical diagnosis and medical evaluation.