Congenital joint dislocations are present at birth and affect how one or more joints line up and move. People with congenital joint dislocations may have visible joint misalignment, limited movement, and pain with activity. Many living with congenital joint dislocations are diagnosed in infancy or early childhood, and features can range from mild to severe. Treatment often includes bracing, physical therapy, and surgery when needed, and outcomes vary by joint and severity. Not everyone will have the same experience, and most children with timely care grow and develop well.
Overview
Congenital joint dislocationsSymptoms
Congenital joint dislocations show up at birth or in early infancy. Early signs of congenital joint dislocations include a limb that looks out of place, limited motion, uneven leg lengths or skin folds, and joints that feel unstable or click.
Outlook and prognosis
Many people with congenital joint dislocations do well with early, tailored care. With timely reduction, bracing or casting, and selective surgery, joints often become stable, movement improves, and pain lessens. Outcomes vary by joint, severity, and associated conditions.
Causes and risk factors
Congenital joint dislocations start before birth from loose ligaments, abnormal joint growth, or limited womb space. Risks include breech position, first pregnancy, female sex, low amniotic fluid, tight postnatal swaddling, family history, and some genetic or neuromuscular disorders.
Genetic influences
Genetics play a major role in congenital joint dislocations, especially when connective tissue is naturally looser or shaped differently. Variants in genes affecting collagen or elastin can raise risk and severity. Family history increases likelihood, but expression varies widely.
Diagnosis
Doctors usually spot congenital joint dislocations on exam at birth or in early infancy, then confirm with X-rays or ultrasound. When several joints are involved or a syndrome is suspected, genetic diagnosis of congenital joint dislocations may be recommended.
Treatment and drugs
Treatment for congenital joint dislocations focuses on gently guiding the joint into a stable position and keeping it aligned as a child grows. Care plans often combine early bracing or casting, targeted physical therapy, and, when needed, corrective surgery. Ongoing follow-up helps protect joint function and comfort.
Symptoms
From the first days, families may notice a limb that sits at an unusual angle or a joint that seems too loose. Congenital joint dislocations are present from birth and can make movement or positioning harder as a child grows. Parents often notice early features of congenital joint dislocations such as a hip that rests differently or a knee that won’t fully straighten. The changes are often subtle at first, blending into daily life until they become more noticeable.
One limb may rest at an unusual angle, or a joint looks out of place. In newborn checks, this can be seen without obvious pain. With congenital joint dislocations, the difference is present from birth.
The joint may not fully bend or straighten. This can make diaper changes, dressing, or later sitting cross-legged harder.
The joint may feel wobbly or slip in and out. Clinicians call this instability, which means the tissues that support the joint are too loose. In congenital joint dislocations, this can happen during routine movements.
One leg may seem shorter or skin folds look uneven. When standing, one hip may sit higher. These differences are often tied to the hip but can happen with other joints too.
How people usually first notice Congenital joint dislocations?
Many families first notice congenital joint dislocations right after birth when a newborn’s hip, knee, or other joint looks out of place or moves in an unusual way, or when a routine newborn exam picks up a “click” or limited motion. Sometimes the first signs of congenital joint dislocations show up on prenatal ultrasound, such as an abnormal leg or foot position, and in milder cases they’re recognized later in infancy when a leg seems shorter, the hips feel unstable, or a baby favors one side. Doctors often confirm how congenital joint dislocations are first noticed with a physical exam and targeted imaging, like ultrasound for hips.
Types of Congenital joint dislocations
Congenital joint dislocations can look different from one child to another, and the pattern often depends on which joint is affected and whether a broader genetic syndrome is involved. Clinicians often describe them in these categories: hips, knees, elbows, shoulders, and generalized patterns tied to connective tissue or neuromuscular conditions. Early symptoms of congenital joint dislocations may include limited movement, an unusual joint position at rest, or differences in limb length or alignment. Not everyone will experience every type.
Hip dislocation
The ball-and-socket of the hip is not securely in place at birth. You may notice uneven thigh folds, a leg that looks shorter, or a hip that “clicks” during diaper changes. Some babies have no obvious pain but show limited outward hip movement.
Knee dislocation
The lower leg can rest too far forward relative to the thigh. Babies may hold the knee in a fixed bent or overly straight position and resist gentle flexing. This can make early kicking or straightening feel different from the other leg.
Elbow dislocation
The elbow may not bend or straighten normally right after birth. Parents often notice difficulty dressing the arm or bringing the hand to the mouth. Doctors may see a limited arc of motion without clear pain.
Shoulder dislocation
The shoulder ball may sit shallow or slip out of place. You might see a rounded shoulder on one side and a flatter contour on the other. Lifting the arm overhead can be limited or uneven compared with the other side.
Generalized ligamentous type
Multiple joints are loose or unstable due to connective tissue differences. People may have dislocations or subluxations in several joints with soft, stretchy skin and easy bruising. Severity ranges from mild joint laxity to frequent dislocations.
Neuromuscular-associated type
Joint positions reflect muscle imbalance present from birth. Hips or knees may dislocate because tight or weak muscle groups pull joints out of alignment. This type often occurs alongside conditions that affect muscle tone.
Arthrogryposis-related type
Stiff joints and limited motion lead to fixed positions that favor dislocation. Elbows, knees, and hips can be involved, often on both sides. Early, gentle stretching and bracing are commonly part of care.
Syndromic connective tissue type
Dislocations accompany a known genetic syndrome with fragile connective tissues. People may have tall or small stature, flexible joints, or other features that signal a systemic pattern. Variants of congenital joint dislocations in this group can differ widely in severity.
What genetics can tell you about symptoms
Some genetic variants affecting collagen or connective tissue, like in Ehlers-Danlos or Larsen syndrome, can make ligaments too stretchy, leading to hip, knee, or elbow dislocations at birth. Others alter bone and joint shaping during fetal growth, causing unstable, easily dislocated joints.
Causes and risk factors
Congenital joint dislocations often stem from differences in how the joint develops before birth. Common risk factors for congenital joint dislocations include limited space in the uterus, low amniotic fluid, and breech position. Some babies have looser ligaments or connective tissue because of gene changes, which may be inherited or arise for the first time. Family history, being the first baby, and female sex can raise risk for certain joints, and tight swaddling with straight legs after birth can add to the problem. Doctors distinguish between risk factors you can change and those you can’t.
Environmental and biological risk factors
Understanding what raises the chance a baby is born with congenital joint dislocations can help families plan care early. Doctors often group risks into internal (biological) and external (environmental). Knowing the early symptoms of congenital joint dislocations is helpful, but it’s just as useful to understand the factors that can make them more likely before birth.
Being bottom-first or feet-first late in pregnancy places unusual pressure on hips and knees. This raises the chance of congenital joint dislocations, especially of the hips. Risk is highest when breech persists into the last weeks.
With less fluid, the baby has less cushioning and room to move. Joints can be held in tight positions for weeks, affecting how they form and align. This situation is linked with congenital joint dislocations at the hip or knee.
A small or unusually shaped uterus, or uterine fibroids, can limit available space. Crowding restricts fetal movement and can push joints into awkward angles. These mechanical pressures may contribute to joints being out of place at birth.
The uterus and abdominal wall are typically firmer with a first baby. This can make the womb feel tighter, limiting motion and increasing packaging pressures on joints.
Genetic risk factors
Congenital joint dislocations often run in families and can occur as part of certain genetic syndromes. Some risk factors are inherited through our genes. Changes that affect collagen, cartilage, or how joints form can make joints looser or shaped differently before birth. Here’s what we know about the genetic causes of congenital joint dislocations.
Family history: Having a close relative with congenital joint dislocations or developmental hip dysplasia raises your chance. The tendency can be passed through several genes acting together. Risk may be higher when multiple relatives are affected.
Ehlers-Danlos syndrome: Changes in connective tissue can leave ligaments looser, making congenital joint dislocations more likely. Several types, including classical and hypermobile forms, are linked to hip or knee instability at birth. Not everyone with Ehlers-Danlos will have a dislocation.
Larsen syndrome: This rare inherited condition is strongly associated with dislocations of the hips, knees, and elbows at birth. It results from gene changes that guide how the skeleton forms. Families often show an autosomal dominant pattern.
Stickler syndrome: Collagen changes that affect cartilage can cause loose joints and hip problems early in life. Babies may have hip dislocation present at birth as part of the syndrome. Eye or hearing findings in relatives can offer clues.
Type II collagen disorders: Conditions such as spondyloepiphyseal dysplasia congenita affect collagen that builds cartilage and growth plates. This can lead to congenital joint dislocations and early joint instability. These conditions are usually inherited in an autosomal dominant way.
Down syndrome: Low muscle tone and joint laxity raise the chance of hip instability. While hip dislocation can appear later, some newborns have problems noted at birth. The underlying extra chromosome usually happens by chance rather than being inherited.
Neuromuscular syndromes: Inherited nerve or muscle conditions can reduce fetal movement, which may allow joints to form out of place. This can result in congenital knee or hip dislocation. Examples include some congenital myopathies.
Nail-patella syndrome: A gene change that guides limb development can cause small or absent kneecaps and unstable knees. People may be born with the kneecap out of place or develop dislocation early. Family history often shows autosomal dominant inheritance.
Polygenic susceptibility: For many families, no single gene explains congenital joint dislocations, but several small genetic influences can add up. This background can raise baseline risk across siblings. Genetic testing may not pinpoint one clear cause in these cases.
Lifestyle risk factors
Congenital joint dislocations are not caused by lifestyle, but daily habits can influence joint stability, pain, and long-term function. Understanding how lifestyle affects congenital joint dislocations can help reduce redislocation risk and support recovery after treatment. The elements below focus on lifestyle risk factors for congenital joint dislocations and how to modify them for better outcomes.
High-impact or contact sports can increase redislocation risk and joint wear. Low-impact activities like swimming or cycling help strengthen stabilizing muscles with less strain. Gradual progressions prevent flare-ups.
Repeated end-range positions and hyperextension can provoke instability or subluxations. Using joint-friendly techniques (neutral alignment, smaller ranges, controlled speed) protects vulnerable joints.
Excess body weight raises mechanical load on unstable joints and can increase pain. Modest, sustained weight loss lowers joint stress and may reduce subluxation episodes.
Regular, targeted exercises for strength, proprioception, and motor control improve joint stability. Skipping sessions or home programs can lead to stiffness and recurrent instability.
Risk prevention
Congenital joint dislocations start before birth, so true prevention isn’t always possible. Still, you can lower risks and catch problems early with good prenatal care, safe baby positioning, and targeted newborn screening. Even if you can’t remove all risks, prevention can reduce their impact. Learning the early symptoms of congenital joint dislocations and seeking prompt evaluation can lead to timely treatment and better outcomes.
Attend all pregnancy visits and manage conditions like diabetes or thyroid disease. Avoid tobacco, alcohol, and non-prescribed drugs to support healthy fetal growth.
If the baby is breech late in pregnancy, discuss options like turning the baby and delivery planning. Babies born breech need careful checks for congenital joint dislocations after birth.
If you or close relatives had congenital joint dislocations or connective tissue disorders, consider preconception counseling. Ask for targeted newborn screening, such as early hip ultrasound, after delivery.
Ensure hip and knee checks at every newborn and infant visit. For high‑risk babies, an ultrasound in the first 4–6 weeks can catch congenital joint dislocations early.
Transmission
Congenital joint dislocations are not infectious and can’t be spread between people. In many children, the joint dislocation develops before birth and isn’t inherited, though having a family history can raise the chance. When genetic transmission of congenital joint dislocations does occur, it’s typically because a parent passes down a gene change that affects how joints form or how loose they are; this can happen as part of certain syndromes, and the pattern may involve one parent or, less often, both. Some cases arise from a new genetic change in the child with no prior family history. How congenital joint dislocations are inherited varies with the underlying cause, so a genetics consult can help clarify personal and family risk.
When to test your genes
Consider genetic testing if you or close relatives were born with multiple joint dislocations, unusually loose joints, or features suggesting a connective tissue syndrome (like Ehlers-Danlos). Testing helps confirm the cause, guide surveillance for complications, and tailor therapies. It’s especially useful before surgery, during family planning, or in childhood.
Diagnosis
In the first days after birth, you might notice a hip that clicks during diaper changes, a knee that won’t bend easily, or an elbow that seems out of place. Doctors often suspect congenital joint dislocations based on how a joint looks, moves, and lines up, then confirm it with imaging and sometimes genetic tests. The goal is to identify which joints are involved, how severe the dislocation is, and whether it’s part of a broader condition. Early and accurate diagnosis can help you plan ahead with confidence.
Doctors check joint position, stability, and range of motion and compare both sides. They also look for limb-length differences and skin-crease asymmetry that point to dislocation.
For infants under about 4–6 months, ultrasound shows how the hip socket and ball line up. It confirms hip dislocation without using radiation.
After 4–6 months, when bones have hardened more, X-rays reveal joint alignment and bone shape. Imaging findings help grade severity and guide treatment planning.
Late-pregnancy scans may show unusual limb positions or limited joint movement. These clues help plan delivery and immediate evaluation after birth.
Stages of Congenital joint dislocations
Congenital joint dislocations does not have defined progression stages. Because these dislocations are present from birth and vary by which joint is affected, clinicians judge severity by how stable the joint is and what imaging shows, not by a step-by-step decline. Early symptoms of congenital joint dislocations may include uneven leg movement, a limb that doesn’t bend as expected, or a joint that looks out of place, and newborn checks plus follow-up exams are key. Different tests may be suggested to help confirm the diagnosis and track growth, such as ultrasound in the first months and X-rays later in childhood.
Outlook and prognosis
Looking at everyday life, some people with congenital joint dislocations walk, play sports, and work with only minor adjustments, while others need ongoing bracing, tailored physical therapy, or periodic surgeries. The outlook is not the same for everyone, but it often improves when joints are guided into better alignment early and muscles are strengthened to support them. Early symptoms of congenital joint dislocations can include hips that feel unstable in infancy, shoulders that slip, or kneecaps that don’t track well; catching these signs early typically leads to better function later on.
Understanding the prognosis can guide planning and helps set realistic goals for mobility, pain control, and activity. Many people find that symptoms ease after corrective treatment in childhood, with steady function through school years and adulthood, though high-impact activities may still provoke pain or swelling. Others—especially those with broader connective tissue differences or multiple joints involved—may face repeated dislocations, cartilage wear, or early arthritis that require long-term follow-up. In medical terms, the long-term outlook is often shaped by both genetics and lifestyle, including muscle strength, healthy weight, and joint protection habits at work and in sports.
Serious complications are uncommon when care is consistent, but they can include persistent instability, chronic pain, and, in severe hip involvement, a higher chance of early hip replacement. Mortality is not increased for most people with congenital joint dislocations; risk rises mainly when dislocations occur as part of a rare syndromic condition that also affects the heart, lungs, or spine. With ongoing care, many people maintain good mobility and independence into later life. Talk with your doctor about what your personal outlook might look like, including activity goals, signs of recurrence, and when to consider new therapies or surgical options.
Long-term effects
For many, the long-term picture centers on how stable and comfortable the affected joints remain over the years. Long-term effects vary widely, shaped by which joints were involved and how early alignment was achieved. People who had early symptoms of congenital joint dislocations in infancy may notice different patterns across childhood, adolescence, and adulthood.
Persistent looseness can lead to giving-way sensations during routine tasks. In congenital joint dislocations, this may recur or fluctuate with growth.
Stiffness or tightness can restrict bending, straightening, or rotation. Limits may be most noticeable after growth spurts or previous immobilization.
Hip, knee, or ankle involvement can cause limping and uneven steps. Some develop compensatory patterns that tire muscles more quickly.
Misaligned or unstable joints can wear down cartilage sooner than expected. In congenital joint dislocations, this often appears earlier than average in weight-bearing joints.
How is it to live with Congenital joint dislocations?
Living with congenital joint dislocations often means planning your day around stability and energy. Many people build strong routines with supportive braces, targeted physical therapy, and smart movement strategies to reduce pain, prevent re-injury, and keep up with work, school, and play. There can be extra time and logistics for medical visits and adaptive equipment, and some days bring fatigue or flare-ups that change plans. Family, friends, and caregivers often become teammates—helping with transportation, home setup, and encouragement—while learning when to step in and when to support independence.
Treatment and drugs
Treatment for congenital joint dislocations focuses on guiding the joint into a healthy position early, then keeping it stable as a child grows. For many babies, this starts with gentle positioning devices like a soft brace or harness that holds the joint in place while tissues tighten and grow correctly; some may need a cast after the joint is put back in position. If these steps don’t fully correct the joint, surgery may be recommended to realign bones, tighten loose tissues, or deepen a shallow socket, followed by a period of casting and later physical therapy. Alongside medical treatment, lifestyle choices play a role, with ongoing physiotherapy to build strength, protect joint function, and support everyday movement as kids become active. It’s common to try more than one medication before finding the right pain control plan, but medicines mainly support comfort; the core treatment is mechanical correction and, when needed, surgery.
Non-drug treatment
Living with congenital joint dislocations often means focusing on comfort, safe movement, and protecting growing joints during everyday life. Non-drug treatments often lay the foundation for recovery by guiding alignment, building strength, and supporting development. Spotting early symptoms of congenital joint dislocations can allow earlier bracing or harness use, which may guide growth in a safer position. Care plans are tailored by age, joint involved, and how the joint responds over time.
Custom braces or soft splints hold a joint in a safe position while tissues grow and strengthen. They are adjusted as your child grows and as alignment improves. Wearing time is set by the care team to balance support and comfort.
A soft harness can keep hips in a protected position in early infancy. Parents learn skin care, diapering, and safe handling while the harness is on. Regular check-ins ensure the hips stay well-positioned.
Stepwise casts gently guide a joint toward better alignment without surgery. Casts are changed regularly to follow progress and avoid skin problems. This can reduce stiffness and improve function over time.
Gentle stretches and strengthening help protect flexible joints and prevent stiffness. Therapists also work on rolling, sitting, standing, and walking skills. Home exercises reinforce gains between visits.
Your genes may have an impact on how drugs work for you
Medicines used for pain, muscle relaxation, or anesthesia can work differently in people with congenital joint dislocations because gene differences affect how fast the body absorbs, breaks down, and responds to drugs. Genetic variation may change ideal doses or side‑effect risk, so clinicians often individualize treatment.
Pharmacological treatments
Medicines for congenital joint dislocations mainly support comfort and recovery alongside bracing, casting, and surgery. They help ease pain, swelling, and muscle tightness that can follow diagnosis or early symptoms of congenital joint dislocations. Medication is often just one chapter in care, with physical therapy, splints, and procedures doing the alignment work.
Acetaminophen (paracetamol) can reduce mild to moderate pain without increasing bleeding risk. It is often used after casting, bracing, or surgery.
Ibuprofen or naproxen can ease pain and swelling from irritated joints or soft tissues. Celecoxib may be used in older teens or adults when stomach side effects are a concern.
Diclofenac gel and lidocaine patches can target a sore area with lower whole‑body exposure. These can be helpful for localized pain around surgical sites or tight soft tissues.
Baclofen or diazepam may reduce muscle spasms that pull on a joint. Tizanidine is another option your team may consider for short periods.
Genetic influences
Genetics can play a role in why some babies are born with joints out of place, by influencing how the connective tissues and bones form before birth. In some families, small inherited differences that affect ligament looseness or the shape of the hip, knee, or elbow can raise the chance of congenital joint dislocations. Family history is one of the strongest clues to a genetic influence. Sometimes a single gene condition leads to several joints dislocating, while in many others the risk comes from a mix of genes together with non-genetic factors such as breech position during pregnancy. A genetic tendency increases risk but does not guarantee a dislocation, and relatives with the same tendency may have mild laxity, one joint involved, or no problems at all. If several relatives are affected or more than one joint is involved, talking with a genetics professional can help clarify your family’s pattern and guide early checks for early symptoms of congenital joint dislocations.
Is Congenital joint dislocations genetic?
Genetics play a major role in congenital joint dislocations, especially when connective tissue is naturally looser or shaped differently. Variants in genes affecting collagen or elastin can raise risk and severity. Family history increases likelihood, but expression varies widely.
Pharmacogenetics—how genetics influence drug effects
For people needing treatment or surgery for congenital joint dislocations, genes can shape which medicines work best and which to avoid. Genetic testing can sometimes identify how your body processes certain pain relievers or anesthetics. For example, some people break down codeine or tramadol very slowly or very quickly, which can mean poor pain control or a higher chance of side effects; in those cases, doctors choose different pain medicines. Differences in drug‑processing enzymes can also affect anti‑inflammatory drugs used after surgery for congenital joint dislocations, changing how much you might need and your risk of stomach or bleeding problems. Before anesthesia, inherited conditions like malignant hyperthermia or pseudocholinesterase deficiency may change which muscle relaxants and anesthetic gases are safe, so the anesthesia team may use alternative drugs and extra monitoring. If a blood thinner such as warfarin is prescribed after orthopedic procedures, known gene–drug interactions can guide the starting dose to lower the risk of bleeding or clotting; talk with your care team about anesthesia safety in congenital joint dislocations and whether pharmacogenetic results could be helpful.
Interactions with other conditions
Congenital joint dislocations often occur alongside other health issues that affect tissues, nerves, or muscle tone, which can change how joints move and heal. Shared genetic variants may explain why certain conditions cluster together. For example, people with Ehlers-Danlos syndrome or Marfan syndrome may have looser connective tissue, making dislocations more likely and recovery slower, while neuromuscular conditions present at birth, such as arthrogryposis, can limit joint motion and make bracing or casting less effective. Some find related features like clubfoot or torticollis appear at the same time, and in Down syndrome the neck joints can be more unstable, so teams watch the spine closely during sports or anesthesia. When another condition is present, early symptoms of congenital joint dislocations may be harder to spot because pain or stiffness can be attributed to the other diagnosis. Coordinated care among orthopedics, genetics, physical therapy, and—when needed—cardiology or neurology helps tailor treatment plans and reduce the risk that one condition complicates the other.
How genes can cause diseases
Humans have more than 20,000 genes, each carrying out one or a few specific functions in the body. One gene instructs the body to digest lactose from milk, another tells the body how to build strong bones and another prevents the body's cells from beginning to multiply uncontrollably and developing into cancer. As all of these genes combined are the building instructions for our body, a defect in one of these genes can have severe health consequences.
Through decades of genetic research, we know the genetic code of any healthy/functional human gene. We have also identified that in certain positions on a gene, some individuals may have a different genetic letter from the one you have. We call these hotspots "Genetic Variations" or "Variants" in short. In many cases, studies have been able to show that having the genetic letter "G" in the position makes you healthy, but having the letter "A" in the same position disrupts the gene function and causes a disease. Genopedia allows you to view these variants in genes and summarizes all that we know from scientific research, which genetic letters (Genotype) have good or bad consequences on your health or on your traits.
History
Throughout history, people have described babies born with joints that didn’t sit in place—hips that slipped, knees that bent backward, or elbows that wouldn’t move as expected. Midwives and surgeons noted that some infants’ joints “popped” or felt loose, and that careful wrapping, splints, or position changes sometimes helped. Families and communities once noticed patterns: a grandparent who walked with a sway, an aunt who wore a brace as a child, a cousin who needed surgery early in life.
First described in the medical literature as various “congenital dislocations,” these conditions were once grouped together based on how a joint looked or felt at birth. Over time, descriptions became more precise as clinicians realized that not all congenital joint dislocations share the same cause. Some involve a single joint like the hip; others affect multiple joints and come with very flexible skin or a limited range of motion. With each decade, better physical exams, X‑rays, and later ultrasound showed that a joint could be shallow, misaligned, or held tight by surrounding tissues even before birth.
From early theories to modern research, the story of congenital joint dislocations has moved from observation to mechanism. In the mid‑20th century, routine newborn hip screening made early symptoms of congenital joint dislocations easier to catch, and harnesses and casts reduced the need for invasive surgery. Advances in genetics helped explain why some families see several members with similar findings, while others have an isolated, one‑time event. DNA research now explains that differences in collagen or other connective‑tissue proteins can make ligaments looser—like a dimmer switch set too low—while other conditions make tissues stiffer, limiting motion and fixing joints out of place.
As medical science evolved, naming also changed. Hips once called “congenitally dislocated” are now described more accurately as developmental dysplasia of the hip, reflecting that some changes develop over late pregnancy and early infancy. Clinicians also learned that position in the womb, breech birth, and cultural swaddling practices can influence risk, which explains why certain forms appeared more often in some regions and time periods.
In recent decades, knowledge has built on a long tradition of observation. Ultrasound screening in early infancy, wider access to pediatric orthopedics, and genetic testing have all improved timing and choice of treatment. Despite evolving definitions, the goal has stayed steady: find congenital joint dislocations early, guide the joint into a healthy position, and support families with clear information and practical care. Knowing the condition’s history helps explain today’s mix of approaches—bracing when it works, surgery when needed, and, increasingly, personalized plans when a genetic diagnosis is involved.