Copenhagen five-second squeeze: a valid indicator of sports-related hip and groin function

Inter- and intra-session variability of compression strain gauge for the adductor groin squeeze test on soccer athletes

The importance of hip adductor strength for injury prevention and performance benefits is well documented. The purpose of this study was to establish the intra- and inter-day variability of peak force (PF) of a groin squeeze protocol using a custom-designed compression strain gauge device. Sixteen semi-professional soccer players completed three trials over three separate testing occasions with at least 24-h rest between each session. The main findings were that the compression strain gauge was a reliable device for measuring PF within and between days. All intraclass correlations were higher than 0.80 and coefficients of variations were below 10% across the different sessions and trials. Due to the information gained through the compression strain gauge, the higher sampling frequency utilized, portability, and the relatively affordable price, this device offers an effective alternative for measuring maximal strength for hip adduction.

Effectiveness of a Preventative Program for Groin Pain Syndrome in Elite Youth Soccer Players: A Prospective, Randomized, Controlled, Single-Blind Study

Groin pain syndrome (GPS) is a prevalent issue in soccer. This study assessed the effectiveness of a new preventive protocol on GPS for youth soccer players. The protocol included targeted stretching and strengthening exercises for the adductor and core muscles from preseason to midseason. A questionnaire and two pain provocation tests were used for the evaluation. Mild GPS required positive results in at least two evaluations, while severe GPS was associated with pain incompatible with engagement in any activity confirmed by diagnostic ultrasound. Forty-two elite male athletes (aged 16.9 ± 0.7 years) participated in the study, with half of them assigned to the usual training (control group) and the remaining athletes undergoing the preventive protocol (treatment group) for 24 weeks. GPS rates were 14.3% (three diagnoses: two mild, one severe) in the treatment group and 28.6% (six diagnoses: three mild, three severe) in the control group. Toward the end of the season, three players, one from the treatment group and two from the control group had to stop playing due to severe GPS problems. In addition, one player in the control group stopped midseason. Even though the reduction in the risk of developing GPS was not significant (relative risk of 0.50 ([95%CI 0.14 to 1.74], p = 0.2759), the halved incidence of severe GPS and the increased muscle strength related to the treatment (p = 0.0277) are encouraging data for future studies.

Maximal and Explosive Muscle Strength During Hip Adduction Squeeze and Hip Abduction Press Test Using A Handheld Dynamometer: An Intra- and Inter-tester Reliability Study

Background

Hip adduction and abduction muscle function plays an important role for risk of groin pain in athletes. Maximal isometric strength can be obtained clinically using a handheld dynamometer. However, in very strong athletes this is challenging, as external fixation of the dynamometer is needed for reliable measures. An alternative to unilateral testing, is the long-lever hip adduction squeeze test and a novel bilateral hip abduction press test. While promising intra-tester reliability has been found for maximal strength during the long-lever hip adduction squeeze test, inter-tester reliability may be more challenging during both maximal and explosive strength measurements.

Hypothesis/purpose

The aim of the present study was to assess intra- and inter-tester reliability of maximal, and explosive strength during the long lever hip adduction squeeze test and the long lever hip abduction press test in healthy adults using a hand-held dynamometer.

Study design

Intra- and interrater reliability study.

Methods

Forty-nine healthy subjects were included for intra- (n=20) and inter-tester reliability (n=29). Subjects performed the hip adduction long lever squeeze test and the bilateral hip abduction press test in a randomized order. Maximal isometric strength and early (0-100 ms) and late (0-200 ms) phase rate of force development (explosive muscle strength) was obtained using a hand-held dynamometer. Relative reliability for all tests was assessed using ICC2,1 two-way mixed model with absolute agreement, thereby taking bias between testers into account.

Results

Maximal isometric strength showed good intra- and inter-tester reliability for adduction (ICC: 0.93-0.97) and abduction (ICC: 0.88-0.92). For 0-200 ms rate of force development, both the squeeze and press test showed good intra-tester reliability (ICC: 0.85-0.87), whereas inter-tester reliability was good for hip adduction squeeze (ICC: 0.75) and moderate for hip abduction press (ICC: 0.71). For 0-100 ms rate of force development, the hip abduction press test showed good intra-tester reliability (ICC: 0.78). Remaining tests for intra- and inter-tester reliability showed moderate reliability (ICC: 0.50-0.71).

Conclusion

Assessment of maximal isometric strength in hip adduction squeeze and abduction press test showed good intra- and inter-tester reliability, whereas only 0-200 ms rate of force development demonstrated good intra-tester reliability of both tests. Therefore, rate of force development should preferably be conducted by the same tester, while the long lever squeeze and press test can reliably be used within- and between testers to measure maximal isometric strength.

Level of Evidence

3©The Author(s).

Current Clinical Concepts: Exercise and Load Management of Adductor Strains, Adductor Ruptures, and Long-Standing Adductor-Related Groin Pain

Adductor-related groin pain is a common problem in sports. Evidence-based management of athletes with adductor strains, adductor ruptures, and long-standing adductor-related groin pain can be approached in a simple yet effective and individualized manner. In most cases, managing adductor-related pain in athletes should be based on specific exercises and loading strategies. In this article, I provide an overview of the different types of adductor injuries, from acute to overuse, including their underlying pathology, functional anatomy, diagnosis, prognosis, mechanisms, and risk factors. This information leads to optimal assessment and management of acute to long-standing adductor-related problems and includes primary, secondary, and tertiary prevention strategies that focus on exercise and load-based strategies. In addition, information on different options and contexts for exercise selection and execution for athletes, athletic trainers, and sports physical therapists in adductor injury rehabilitation is provided.

Surgical Reattachment of Rare Proximal Adductor Avulsion Injury in a Female Athlete: A Case Report

CASE

A 54-year-old female professional equestrian sustained a traumatic right groin injury with disabling groin pain. Magnetic resonance images indicated a proximal adductor avulsion injury with a 3.2-cm tendon retraction. Surgical reattachment of the fibrocartilage avulsion with suture anchor repair was subsequently performed.

CONCLUSION

Adductor avulsion injuries have been rarely reported in female athletes. Patient-reported outcomes demonstrate a successful return to preinjury levels of daily function and sports performance after surgery for a female athlete. Surgical reattachment should be considered for the management of proximal adductor avulsion injuries in elite female athletes.

Development and Predictive Validation of the Brazilian Adductor Performance Test for Estimating the Chance of Hip Adductor Injuries in Elite Soccer Athletes

PURPOSE

To develop and validate the Brazilian Adductor Performance Test (BAPT) for predicting hip adductor muscle injuries in elite soccer athletes.

METHODS

A total of 108 soccer athletes were assessed, followed up for 3 months, and evaluated for a history of adductor injury 6 months before BAPT evaluation. The Shapiro-Wilk test was used as the normality test. The Mann-Whitney U test was used to compare BAPT scores between injured and uninjured athletes. Binary logistic regression was performed to identify the athletes' chances of injury based on their BAPT scores. A receiver operating characteristic curve was used to determine the cutoff point for the number of repetitions in the BAPT and Spearman bivariate correlation and identify factors potentially related to the test score. Furthermore, the intraclass correlation coefficient was used to determine interexaminer agreement. The level of significance was set at 95%.

RESULTS

The BAPT scores for hip adductor injury history did not differ significantly (P = .08). A significant deficit was identified in the BAPT scores of the injured athletes at the 3-month follow-up (P = .001). The cutoff point identified was 33 repetitions. Low BAPT scores increased the chance of injury by 20% (odds ratio, 1.20%; P = .001). The interexaminer agreement was .96 (P = .001).

CONCLUSION

BAPT can be used to identify athletes most likely to sustain hip adductor muscle injuries, indirectly reducing the rate of this injury in soccer clubs.

Weekly screening of youth male football players: a 14-week longitudinal investigation of interactions between groin pain and long lever adductor squeeze strength

OBJECTIVES

To explore relationships between groin pain and adductor squeeze strength in male academy football players over a 14-week period.

DESIGN

Longitudinal cohort study.

METHODS

Weekly monitoring of youth male football players consisted of reporting groin pain and testing long lever adductor squeeze strength. Players who reported groin pain at any time during the study period were stratified into the "groin pain" group while players who did not report pain remained in the "no groin pain" group. Baseline squeeze strength was retrospectively compared between groups. Players that developed groin pain were examined via repeated measures ANOVA at four timepoints: baseline, last squeeze before pain, pain onset, and return to pain-free.

RESULTS

53 players were included (age 14.4 ± 1.6 years). Baseline squeeze strength was not different between players in the "groin pain" (n = 29, 4.35 ± 0.89 N/kg) versus "no groin pain" group (n = 24, 4.33 ± 0.90 N/kg, p = 0.83). At a group level, players with no groin pain maintained similar adductor squeeze strength throughout 14 weeks (p > 0.05). Compared to baseline (4.33 ± 0.90 N/kg), players with groin pain had decreased adductor squeeze strength at the last squeeze before pain (3.91 ± 0.85 N/kg, p = 0.003) and at pain onset (3.58 ± 0.78 N/kg, p < 0.001). Adductor squeeze strength at the point where pain subsided (4.06 ± 0.95 N/kg) was not different from baseline (p = 0.14).

CONCLUSIONS

Decreases in adductor squeeze strength manifest one-week prior to groin pain onset and further decrease at pain onset. Weekly adductor squeeze strength may be an early detector for groin pain in youth male football players.

Pain provocation tests and clinical entities in male football players with longstanding groin pain are associated with pain intensity and disability

BACKGROUND

Clinical examination of male football players with longstanding groin pain can be considered difficult. Pain provocation tests are used to examine and classify longstanding groin pain into clinical entities as adductor-, iliopsoas-, inguinal-, and pubic-related. It is unknown if pain provocation tests and clinical entities are associated with pain intensity and disability.

OBJECTIVES

To investigate if the number of positive pain provocation tests and clinical entities are associated with pain intensity and disability, measured by the Copenhagen 5-Second Squeeze Test (5SST) and the Copenhagen Hip and Groin Outcome Score (HAGOS), respectively.

DESIGN

Cross-sectional.

METHOD

Forty male football players (age: mean 24 years [SD: 3.2]; height: mean 182 cm [SD: 5.7]; weight: mean 78 Kg [SD: 6.6]) with longstanding groin pain for a median of 8.5 months (IQR: 4-36) were included. The players underwent a bilateral groin examination with 33 pain provocation tests and were classified with clinical entities (0-7) based on the test findings.

RESULTS

The number of positive pain provocation tests (median 10, range 2-23) correlated with pain intensity (5SST: rs = 0.70 [95% CI: 0.50, 0.83]) and disability (HAGOS subscales Sport: rs =-0.62 [95% CI: -0.81, -0.36], Pain: rs = -0.38 [95% CI: -0.69, -0.06], Symptoms: rs = 0.52 [95% CI: -0.73, -0.24], ADL: rs = -0.48 [95% CI: -0.71, -0.18]). The number of clinical entities (median 3, range: 1-7) showed similar but weaker correlations to pain intensity and disability.

CONCLUSIONS

In male football players with longstanding groin pain, the number of positive pain provocation tests and clinical entities shows weak to strong correlations with pain intensity and disability. Consequently, when pain intensity and disability are severe, a higher number of pain provocation tests may be positive, and more clinical entities may be present.

Midseason Screening for Groin Pain, Severity, and Disability in 101 Elite American Youth Soccer Players: A Cross-Sectional Study

OBJECTIVE

To (1) systematically screen for groin pain and type in young elite soccer players and (2) assess whether hip and groin-related severity and disability differed between players with different levels of groin pain and tenderness.

DESIGN

Cross-sectional observational.

SETTING

Elite American soccer academy at midseason.

PARTICIPANTS

One hundred one academy soccer players (mean age 14.3 ± 1.8 years).

INTERVENTION

All players underwent clinical examinations to classify groin pain by the Doha agreement taxonomy.

MAIN OUTCOME MEASURES

Tests for groin-related severity and disability included the Copenhagen 5-second squeeze test, Copenhagen Hip and Groin Outcome Score (HAGOS), and Hip Outcome Score (HOS). Players were stratified into 3 groups: those with groin pain, those with tenderness, and those with no groin pain or tenderness.

RESULTS

Twenty-two players (22%) reported groin pain. Adductor-related groin pain was the most common (n = 14), followed by iliopsoas-related (n = 3), and pubic-related (n = 2). Multiple locations were present in 3 players. Thirty-nine players (39%) did not have groin pain but were tender to palpation in 1 or more structures related to the Doha agreement taxonomy. Copenhagen 5-second squeeze test differentiated between players with and without groin pain (groin pain vs tenderness group: P = 0.011; groin pain vs no groin pain group P < 0.001). Four HAGOS subscales (pain, symptoms, sport/recreation, and quality of life) differentiated between players with and without groin pain ( P < 0.05).

CONCLUSIONS

One in five academy soccer players experiences groin pain with adductor-related most common during a midseason screening. Both Copenhagen 5-second squeeze test and HAGOS subscales can differentiate between players with and without groin pain.

Effects of a Groin Pain Prevention Program in Male High School Soccer Players: A Cluster-Randomized Controlled Trial

Background

Groin pain is frequently reported by soccer players. A prevention program incorporating the Copenhagen adduction exercise (CAE) has been shown effective in decreasing adductor muscle injury in semi-professional soccer players. However, the effect of such programs on groin pain in high school soccer players is unknown. No reports have examined the effects of combining the CAE with other targeted exercises such as the Nordic hamstrings exercise (NHE).

Purpose

To evaluate the preventative effects of exercise on groin pain in high school soccer players in three groups comprising NHE alone, combined NHE and CAE, and a control group.

Design

Randomized Controlled Clinical Trial.

Methods

A cluster randomized controlled trial spanning 16 weeks was conducted on 202 high school soccer players from seven high schools in a Japanese under 18 Soccer League. Players were allocated to either group A (three schools, 66 players) receiving the CAE alone, or group B (two schools, 73 players) receiving the CAE and NHE, or control group C (two schools, 63 players) who performed their usual training. This study compared the number of injuries, injury rate, and severity of the injury of groin pain in these three groups.

Results

The number of players injured was less in group B (4 players) compared to C (18 players), and time-lost to soccer was less in groups A (6 players) and B (3 players) compared to group C (16 players). Injury rates were significantly lower in groups A and B, with the relative risk of injury compared to group C of 0.42 (95% CI 0.19% to 0.90%) in group A and 0.19 (95% CI 0.07 to 0.54) in group B.

Conclusion

A 16-week program incorporating the CAE in training sessions in high school soccer players reduced the incidence of groin pain and which may be related to injury severity according to time -lost to soccer, however the combination of both the CAE and NHE may be more effective than the CAE alone.

Level of Evidence

2b.

Soccer players show the highest seasonal groin pain prevalence and the longest time loss from sport among 500 athletes from major team sports

PURPOSE

Groin pain is a widely recognized medical issue among athletes. Groin pain can affect both player and team performance and sometimes can be a career-ending injury. The aim of this study was to assess seasonal groin pain prevalence and the average seasonal time loss from sport for each injury in different team sport athletes. The hip and groin functionality at the beginning of the following season was also investigated.

METHODS

A cross-sectional study was undertaken on 600 team sport athletes (soccer, futsal, basketball, volleyball, and water polo players). The seasonal prevalence of groin pain, level of competition (professional and non-professional), time loss, and concomitant injuries in addition to groin pain were reported and analyzed. The Copenhagen Hip and Groin Outcome Score (HAGOS) was used to assess hip and groin pain and function related to sport and activity.

RESULTS

Among the 506 (84%) players included, 123 players (24.3%) reported groin pain. Overall, soccer players reported the highest groin pain prevalence (32.5%) followed by futsal (25.5%), basketball (25.2%), water polo (17.6%) and volleyball players (13.6%). Professional soccer, futsal and basketball athletes showed higher groin pain prevalence in comparison with non-professional athletes (p = 0.02, p = 0.005 and p = 0.004, respectively). The mean time loss from sport due to groin pain was 60.3 ± 66 days in soccer, 41.1 ± 16.6 days in futsal, 31.5 ± 18 days in water polo, 37.2 ± 14.2 days in basketball and 50.8 ± 24.6 days in volleyball. Significantly lower HAGOS values were found in athletes with groin pain for all sports evaluated compared to athletes with no groin pain history (p =  0.0001). Longer time loss from sport was correlated with lower HAGOS values in soccer (p = 0.002) and futsal (p = 0.002) players with groin pain. Concomitant injuries were correlated with lower HAGOS values in water polo players (p = 0.03).

CONCLUSIONS

Seasonal groin pain occurs in as many as one in four team sport athletes. Soccer players show the highest groin pain prevalence and the longest time loss from sport. Professional athletes report higher prevalence of groin pain in comparison with non-professional athletes. HAGOS appears to be a valid outcome instrument to measure groin pain, correlating with both time loss from sport and concomitant injuries in athletes.

LEVEL OF EVIDENCE

Level IV.

Incidence, Prevalence, and Severity of and Risk Factors for Hip and Groin Problems in Swedish Male Ice Hockey Players: A 1-Season Prospective Cohort Study

CONTEXT

The epidemiologic focus on time loss may underestimate the true magnitude of hip and groin problems in male ice hockey players.

OBJECTIVE

To describe the prevalence, incidence, and severity of hip and groin problems (time loss and non-time loss) in Swedish ice hockey players over the course of a season and explore potential preseason risk factors for these conditions.

DESIGN

Prospective 1-season cohort study.

SETTING

Professional and semiprofessional Swedish ice hockey players.

PATIENTS OR OTHER PARTICIPANTS

A total of 12 professional and semiprofessional male ice hockey teams were invited to participate. Of those, 9 teams agreed, and 163 players were included in the analyses.

MAIN OUTCOME MEASURE(S)

Hip and groin problems in the previous season (time loss, non-time loss), isometric adduction and abduction strength, and 5-second squeeze test results were recorded before the season and served as independent variables in the risk factor analysis. Main outcome measures were cumulative incidence of hip and groin problems, average prevalence, and odds ratios (ORs) for groin problems in season.

RESULTS

Cumulative incidence was 45.4% (95% CI = 37.6%, 53.4%) for all problems and 19% (95% CI = 13.3%, 25.9%) for substantial problems. Average prevalence was 14.1% (95% CI = 10.8%, 17.5%) for all and 5.7% (95% CI = 4.3%, 7.2%) for substantial problems. Among reported problems, 69.2% had a gradual onset, and only 17% led to time loss. Players with non-time-loss problems in the previous season had higher odds for new problems (all: OR = 3.3 [95% CI = 1.7, 6.3]; substantial: OR = 3.6 [95% CI = 1.8, 8.4]). Preseason strength was not significantly associated with the odds for subsequent problems.

CONCLUSION

Hip and groin problems are common in ice hockey players and may lead to substantial impairments in performance. Only 1 in 5 problems led to time loss, and 7 in 10 had a gradual onset. Non-time-loss problems in the previous season were a significant risk factor for new problems, whereas decreased preseason hip-adduction and -abduction strength was not.

Factors Associated with Hip and Groin Pain in Elite Youth Football Players: A Cohort Study

BACKGROUND

Despite hip and groin pain being commonly reported in elite youth football players, little evidence on risk factors exists. Risk factors in adult football players include reduced hip adductor strength and hip adductor/abductor strength ratios, and lower Copenhagen Hip and Groin Outcome Score (HAGOS) subscale scores. It is unknown if these factors are also predictive of pain development in youth football players.

OBJECTIVE

To identify whether preseason hip adductor and abductor strength and HAGOS subscale scores of male and female elite youth football players are associated with in-season or historical (lifetime) hip and groin pain.

METHODS

Preseason hip adductor and abductor strength testing and the HAGOS were undertaken by 105 elite male (n = 58) and female (n = 47) football players aged 11-15 years. Medical staff documented both players' self-reported historical and in-season hip and groin pain. Univariate and multivariate logistic regression models were undertaken with main outcome measures in-season hip and groin pain and historical hip and groin pain and independent variables of hip muscle strength, hip muscle torque and HAGOS subscale scores.

RESULTS

Twenty-three players (21.9%) self-reported in-season hip and groin pain, while 19 players (18.1%) self-reported historical hip and groin pain. Pre-season hip adductor and abductor variables and HAGOS subscale scores failed to predict in-season hip and groin pain. However, a higher body mass index (odds ratio [OR] = 1.32; 95% CI 1.01, 1.73, p = .043) and being male (OR 5.71; 95% CI 1.65, 19.7) were associated with having in-season hip and groin pain (R2 = 0.211). There was also an association between historical hip and groin pain (R2 = 0.579) and both HAGOS subscale Quality of Life (odds ratio [OR] = 0.84; 95% CI 0.77, 0.91, p < .001) and mean abductor torque (OR = 11.85; 95% CI 1.52, 91.97; p = .018).

CONCLUSION

Pre-season hip adductor and abductor strength and HAGOS subscale scores did not predict subsequent in-season hip and groin pain in elite youth football players. However, pre-season higher hip abductor strength and lower HAGOS scores were retrospectively associated with historical hip and groin pain.

Validation of the Copenhagen Hip and Groin Outcome Score (HAGOS) using modern test theory across different cultures and languages: a cross-sectional study of 452 male athletes with groin pain

BKGROUND

No studies have tested the validity of the Copenhagen Hip and Groin Outcome Score (HAGOS) using modern test theory, across different cultures and languages.

OBJECTIVE

To validate the Danish, English and Norwegian versions of HAGOS and its six subscales (Symptoms (S, Item 1-7), Pain (P, Item 1-10), activities of daily living (Item 1-5), Sport and recreation (Sport/rec, Item 1-8), Participation in physical activity (item 1-2) and quality of life (item 1-5)) by evaluating differential item functioning (DIF) and measurement invariance across the three language versions in male multidirectional team athletes with groin pain. Second, to modify subscales depending on goodness-of-fit to the item response theory models and calculate conversion tables if language DIF was observed.

METHODS

We included individual responses to the Danish (n=157), English (n=146) and Norwegian (n=149) language versions of HAGOS from 452 athletes (median age 24 years old, range 20-28) with groin pain. Overall fit, model fit, individual item fit, local response dependence and measurement invariance was examined using confirmatory factor analysis and graphical Rasch models.

RESULTS

The removal of seven misfitting items (S2, P1, P2, A4, SP1, SP5, Q3) resulted in 6 HAGOS subscales with acceptable psychometric properties. For the Symptoms, Pain and Sports subscales evidence of DIF was disclosed between the three different language-versions of HAGOS and conversion tables were created.

CONCLUSIONS

A revised HAGOS derived using modern test theory provides valid measurements for male multidirectional athletes with groin pain across different cultures and languages. Conversion tables must be applied to compare HAGOS scores from Danish, Norwegian and English language versions.

The 45-second anterior knee pain provocation test: A quick test of knee pain and sporting function in 10-14-year-old adolescents with patellofemoral pain

OBJECTIVE

To test 1) if the 45-second Anterior Knee Pain Provocation Test (AKPP-test) could differentiate between adolescents with patellofemoral pain (PFP) and pain-free controls and; 2) whether improvements in the AKPP-test over 12 weeks were associated with improvements in self-reported knee function and pain.

DESIGN

Prospective cohort.

PATIENTS

151 with PFP and 50 pain-free controls (age 10-14 years).

OUTCOMES

The AKPP-test was performed at baseline, 4- and 12-week follow-up. Pain and function were collected using Knee Injury and Osteoarthritis Outcome Score (KOOS).

RESULTS

At baseline, the AKPP-test provoked pain to a median of 5 points (IQR: 3-7) on the 0-10 Numeric Pain Rating Scale in adolescents with PFP, compared to 0 (IQR 0-0) in controls. Higher pain during the AKPP-test was associated with worse KOOS-Sport/Rec (r = -0.33, P < 0.001), worse KOOS-Pain (r = -0.47, P < 0.001), and pain intensity (worst pain last 24 hours) (r = -0.39, P < 0.001) at baseline. Improvements in the AKPP-test over 12 weeks were associated with improvements in KOOS Pain (r = 0.48, P < 0.001) and KOOS Sport/Rec (r = 0.40, P < 0.001).

CONCLUSIONS

Improvements in the AKPP-test were associated with improvements in self-report knee pain and limitations in sports, suggesting the AKPP-test may be a clinically responsive test of knee pain and sporting function in adolescents with PFP.

Hip and groin function and strength in male ice hockey players with and without hip and groin problems in the previous season- a prospective cohort study

OBJECTIVE

To describe and compare hip and groin strength and function of male ice hockey players over one season in players with and without hip and groin problems in the previous season.

DESIGN

Prospective cohort study.

SETTING

Swedish male ice hockey.

PARTICIPANTS

We followed 193 players from 10 teams during the 2017/2018 season.

MAIN OUTCOME MEASURES

Hip adduction and abduction strength, 5 s squeeze test (5SST), and self-reported hip and groin function (Hip and Groin Outcome Score). Changes over the season and differences between players with and without problems in the previous season were analyzed by linear mixed models.

RESULTS

Adduction strength decreased slightly from pre-to mid-season and abduction strength increased slightly over the full season. However, self-reported function or pain did not change. Players with hip and groin problems in the previous season had significantly worse self-reported function, and more groin pain during the 5SST compared to players without. Strength measurments did not differ between groups.

CONCLUSIONS

Hip muscle strength, groin pain, and self-reported function appear to remain stable throughout the season in male ice hockey players. Remaining impairments in players with problems in the previous season suggest that function does not recover by ice hockey participation alone.

Maximal hip muscle strength and rate of torque development 6-30 months after hip arthroscopy for femoroacetabular impingement syndrome: A cross-sectional study

OBJECTIVES

Reduced sports function is often observed after hip arthroscopy for femoroacetabular impingement syndrome (FAIS). Impaired muscle strength could be reasons for this. We aimed to investigate hip muscle strength after hip arthroscopy for FAIS and its association with sports function and participation.

DESIGN

Cross-sectional study.

METHODS

We included 45 patients (34 males; mean age: 30.6 ± 5.9 years) after unilateral hip arthroscopy for FAIS (mean follow-up [range]: 19.3 [9.8-28.4] months). Maximal isometric hip muscle strength (Nm/kg) including early- (0-100 ms) and late-phase (0-200 ms) rate of torque development (Nm∗kg^-1∗s^-1) for adduction, abduction, flexion, and extension was measured with an externally fixated handheld dynamometer and compared between operated and non-operated hip. Associations between muscle strength and self-reported sports function and return to sport were investigated.

RESULTS

For maximal hip muscle strength, no between-hip differences were observed for adduction, abduction, flexion, and extension (p ≥ 0.102). For rate of torque development, significantly lower values were observed for the operated hip in flexion at both 0-100 ms (mean difference: 1.58 Nm∗kg^-1∗s^-1, 95% CI [0.39; 2.77], p = 0.01) and 0-200 ms (mean difference: 0.72 Nm∗kg^-1∗s^-1, 95% CI [0.09; 1.35], p = 0.027). Higher maximal hip extension strength was significantly associated with greater ability to participate fully in preinjury sport at preinjury level (odds ratio: 17.71 95% CI [1.77; 177.60]).

CONCLUSIONS

After hip arthroscopy for FAIS subjects show limited impairments in maximal and explosive hip muscle strength between operated and non-operated hip. Higher muscle strength was positively associated with higher sports function and ability to participate in sport.

Do hip and groin muscle strength and symptoms change throughout a football season in professional male football players? A prospective cohort study with repeated measures

OBJECTIVES

Groin injuries are common in professional male football and result in significant complaints, time-loss and cost. We aimed to study: 1. Normal values of hip muscle strength and self-reported hip and groin function (Hip And Groin Outcome Score (HAGOS)). 2. Changes in these values throughout the season. 3. If previous (groin) injuries, leg dominance or league were associated with these outcome measures.

DESIGN

Prospective cohort study.

METHODS

313 professional male football players (11 clubs) participated. Player characteristics and previous injuries were registered. Hip muscle strength (hand-held dynamometer) and HAGOS measurements were done at the start, middle and end of the season.

RESULTS

Data from 217 players were analysed. Adduction strength (mean±standard deviation, Nm/Kg) was 3.40±0.72 (start), 3.30±0.65 (mid) and 3.39±0.74 (end) (p=0.186). Abduction strength was 3.45±0.67, 3.14±0.57 and 3.28±0.61 (p<0.001). Adduction/abduction ratio was 1.00±0.21, 1.07±0.22 and 1.05±0.23 (p<0.001). Statistically, the HAGOS-subscale 'Pain' (median [interquartile range]) deteriorated slightly during the season (p=0.005), especially from mid-season (97.5 [90.6-100.0]) to end-of-season (95.0 [87.5-100.0]) (p=0.003). Other subscale scores remained unchanged between time points; 85.7 (symptoms), 100.0 (daily living), 96.9 (sports and recreation) 100.0, (physical activities) and 90.0 (quality of life). Previous injuries were associated with lower HAGOS-scores. Dominant legs had higher abduction strength (p<0.001) and lower adduction/abduction ratio (p<0.001). No differences between leagues were found for hip muscle strength and HAGOS-scores.

CONCLUSIONS

In Dutch male professional football players, hip muscle strength and HAGOS-scores remained relatively stable throughout the season. Pain increased slightly, which while statistically significant, was not clinically relevant.

Screening to Detect Hip and Groin Problems in Elite Adolescent Football (Soccer) Players - Friend or Foe?

Injury prevention strategies in team settings should not overlook early detection and secondary prevention. Monitoring systems may be an effective approach to detect common and troublesome injuries, such as hip and groin pain in football (soccer) players. The purpose of this International Perspective is to share our experiences with monitoring hip and groin pain in youth academy football and discuss challenges that surfaced. We consider why players may not accurately report pain, their perceptions of groin pain, and whether all groin pain is clinically meaningful.

LEVEL OF EVIDENCE

5.

Markers of muscle damage and strength performance in professional football (soccer) players during the competitive period

Background

The present study investigated the impact of competitive soccer on the short-term changes in isometric strength of the adductor muscle group during the competitive season.

Methods

In this cohort study we evaluated the association between a serum marker of muscle damage [creatine phosphokinase (CPK)] and isometric strength of the adductor muscles of the hip in 30 professional football players (age: 26.7±2.9 years) during two seasons of the national top-level championship. Serum CPK level was determined the day before the match, 12–20, 36–48, 60–72 h after the match. The maximum voluntary isometric contraction force of the adductor muscles complex was determined immediately after having taken blood samples.

Results

There was evidence of a statistically significant positive association between age, body mass index (BMI), percentage of body fat, and muscle strength, and between weight and muscle strength. There was evidence of a statistically significant negative association between the level of CPK and the maximum isometric strength of the adductors of soccer players. Changes in CPK levels were associated with the muscle strength recovery trend (P<0.001). The strength/CPK ratio at different time points had a U-shaped curve.

Conclusions

Exercise induced muscle damage significantly affects the strength of the adductor muscle group of professional soccer players during the competitive period. The lower the CPK level, the greater the athletes' strength at a given time point. Also, the greater the decrease in CPK level, the greater the rate of strength restoration.

Groin problems from pre- to in-season: a prospective study on 386 male Spanish footballers

This study investigated the weekly prevalence of groin problems over a 3-week football pre-season, compared to a 39-week competitive in-season. We registered time-loss groin injuries, and self-reported weekly groin-pain in 17 amateur male football teams (386 players). The average weekly prevalence of groin problems (prevalence ratio (PR)) was 1.8 times higher (95% CI 1.6 to 2.0) during pre-season (21%) compared to in-season (12%). We found a higher weekly prevalence (PR 1.8; 95% CI 1.6 to 2.1) of groin problems without time loss, during the pre-season (19%) compared to the in-season (10%), but no significant difference in the weekly prevalence of groin problems with time loss (PR 1.5; 95% CI 1.0 to 2.4). Attention should be given to optimal load progression, and early implementation of preventive measures during the football pre-season to reduce the prevalence of groin problems in both pre- and in-season.

Myositis Ossificans of the Adductor Longus in a Soccer Player

A 20-year-old male collegiate soccer goalkeeper presented to an athletic trainer during the season complaining of right (dominant kicking leg) groin pain. The athletic trainer identified a mass and hematoma and suspected myositis ossificans. The patient was referred to the team physician, who ordered radiographs and magnetic resonance imaging to confirm the diagnosis and rule out other injuries. Imaging demonstrated an adductor longus muscle strain with myositis ossificans. J Orthop Sports Phys Ther 2020;50(10):586. doi:10.2519/jospt.2020.9573.

Risk Factors in Elite, Adolescent Male Soccer Players: Prospective Study

Purpose. To find risk factors for soccer-related musculoskeletal injuries among elite, adolescent male soccer players. Methods. Prior to the season, various physical, clinical, and functional measurements were taken. One season was used as an injury surveillance period. Then, after the season, measures of potential risk factors were compared between (1) those players who sustained musculoskeletal injuries and (2) those who remained injury free. Results. Among 61 players, 37.7% (23/61) sustained soccer-related musculoskeletal injuries. After adjusting for covariates in a logistic regression model, presence of previous hip and low back injury (adjusted odds ratio [aOR] = 8.93, P = .046) and Functional Movement Screen (FMS) scores (aOR = 1.92, P = .022) were independently associated with musculoskeletal injures. Conclusion. Elite, adolescent male soccer players with a history of hip and back injury are at greater risk of sustaining a soccer-related musculoskeletal injury. In addition, our study indicated greater risk of sustaining a future soccer-related injury as FMS scores increase.

High prevalence of hip and groin problems in professional ice hockey players, regardless of playing position

PURPOSE

The prevalence of hip and groin problems in professional male ice hockey is unknown and suspected to differ between playing positions. The purpose of this study was to explore potential differences in the seasonal prevalence of hip and groin problems between playing positions in male elite ice hockey players and to explore the relationship between symptom duration and hip and groin function at the beginning of the new season.

METHODS

Male ice hockey players [n = 329 (92 goalkeepers, 93 defensemen, 144 forwards), Mean age (SD): 24 (5)] from the professional leagues in Sweden responded to an online survey. The survey assessed presence of hip and groin problems (time loss and non-time loss) and symptom duration (categorized into 0, 1-6, or > 6 weeks) in the previous season, and current self-reported hip and groin function (Copenhagen Hip and Groin Outcome Score).

RESULTS

During the previous season, 175 players (53.2%) had experienced hip and groin problems. Non time loss problems were experienced by 158 (48%) and time loss problems were experienced by 97 (29.5%) players. No significant differences between playing positions were found. Self-reported function differed significantly between players with different symptom duration and more disability was reported among players with longer symptom duration (p ≤ 0.002).

CONCLUSION

Regardless of playing position, hip and groin problems were prevalent in male ice hockey players. Players with hip and groin problems during the previous season had significantly worse hip and groin function in the beginning of the new season, and longer symptom duration was associated with more disability.

LEVEL OF EVIDENCE

III.

Impact of a modified progressive Copenhagen adduction exercise programme on hip adduction strength and postexercise muscle soreness in professional footballers

Background

Reduced hip adduction strength has been identified as a key predisposing factor in developing hip and groin injuries. The Copenhagen adduction programme has been shown to increase hip adduction strength in semiprofessional footballers but can cause muscle soreness. Therefore, a modified progressive Copenhagen adduction (MPCA) programme has been designed to increase hip adduction strength while limiting muscle soreness.

Objective

To investigate the effect of an 8-week MPCA exercise on eccentric hip adduction and abduction strength in senior professional footballers.

Methods

25 senior professional footballers completed an 8-week MPCA strengthening programme. Eccentric hip adduction (EHAD) and eccentric hip abduction (EHAB) strengths were measured. Changes in preintervention and postintervention strengths and EHAD:EHAB ratios were calculated. The statistical significance between strength changes was assessed with dependent t-tests and Wilcoxon signed-rank tests due to the distribution of the data (p<0.05). Delayed onset of muscle soreness (DOMS) and rate of perceived exertion were measured throughout the programme.

Results

There were statistically significant increases in EHAD strength (24% and 25%, left and right), EHAB strength (10% and 13%, left and right) and the EHAD:EHAB ratio (12% and 10%, left and right) (p<0.01).

Professional footballers were able to complete the MPCA exercise with low levels of DOMS.

Conclusion

An 8-week MPCA exercise elicited significant EHAD and EHAB strength increases with reduced levels of muscle soreness in senior professional footballers.

Concurrent validity of a patient self-administered examination and a clinical examination for femoroacetabular impingement syndrome

Objective

Telehealth has been established as a viable option for improved access and timeliness of care. Physician-guided patient self-evaluation may improve the viability of telehealth evaluation; however, there are little data evaluating the efficacy of self-administered examination (SAE). This study aims to compare the diagnostic accuracy of a patient SAE to a traditional standardised clinical examination (SCE) for evaluation of femoroacetabular impingement syndrome (FAIS).

Methods

75 patients seeking care for hip-related pain were included for participation. All patients underwent both SAE and SCE and were randomised to the order of the examinations. Diagnostic accuracy statistics were calculated for both examination group for a final diagnosis of FAIS. Mean diagnostic accuracy results for each group were then compared using Mann-Whitney U non-parametric tests.

Results

The diagnostic accuracy of individual SAE and SCE manoeuvres varied widely. Both SAE and SCE demonstrated no to moderate change in post-test probability for the diagnosis of FAIS. Although low, SAE demonstrated a statistically greater mean diagnostic accuracy compared with the SCE (53.6% vs 45.5%, p=0.02).

Conclusion

Diagnostic accuracy was statistically significantly higher for the self-exam than for the traditional clinical exam although the difference may not be clinically relevant. Although the mean accuracy remains relatively low for both exams, these values are consistent with hip exam for FAIS reported in the literature. Having established the validity of an SAE, future investigations will need to evaluate implementation in a telehealth setting.

Lower limb musculoskeletal screening in elite female Australian football players

OBJECTIVE

To report physical characteristics of lower-limb strength, endurance, range of motion, balance, and pain during adductor squeeze in elite female Australian Football (AF) players, and to examine the effect of limb dominance, previous AF experience, age, and previous level of sports participation on these characteristics.

DESIGN

Cross-sectional study.

SETTING

Three elite AF clubs.

PARTICIPANTS

Eighty-five female players. All were aged ≥18, contracted for the 2018 season, and participated in pre-season training.

MAIN OUTCOME MEASURES

The physical characteristic assessments included; pain on adductor squeeze, weight-bearing lunge, side bridge, isometric hip abduction and adduction strength, and the modified star excursion balance test.

RESULTS

The adductor squeeze had low pain scores, with 93% of players scoring ≤2 on the numerical rating scale. Other assessment results were (mean ± SD): 10.8 ± 2.7 cm for weight-bearing lunge, 95 ± 39s for side bridge, 1.85 ± 0.23 and 1.85 ± 0.36Nm/kg for hip abduction and adduction strength respectively, and 92 ± 8% for the modified star excursion balance test. There was no clinically relevant effect of limb dominance, previous AF experience, age, or previous level of sports on physical characteristics.

CONCLUSIONS

Physical characteristics for five assessments are reported. These data can be used for comparison purposes in the screening and clinical management of elite female AF players.

The effect of compression shorts on pain and performance in male football players with groin pain - A double blinded randomized controlled trial

OBJECTIVE

To investigate the effects of compression shorts on pain and performance in football players with groin pain.

STUDY DESIGN

Double blinded randomized controlled trial.

SETTING

Soccer pitch.

PARTICIPANTS

Thirty-four male football players with groin pain.

MAIN OUTCOME MEASURES

The effect of wearing zoned high compression shorts (ZHC-shorts), non-zoned low compression shorts (NZLC-shorts), and normal sports clothes on pain measured with the Numeric Pain Rating Scale (NPRS) and performance during the Copenhagen 5-s squeeze test (CS), the Illinois Agility test (IAT), and maximum shooting (ST). The effects of wearing ZHC versus NZLC shorts on symptoms were measured using the Hip and groin outcome score (HAGOS) during actual football activities.

RESULTS

Wearing ZHC-shorts reduced pain during the IAT (1.4, ES = 0.58, p= <0.01) and ST (1.2, ES = 0.47, p= <0.01) compared to wearing normal sports clothes, but did not negatively affect performance. Compared to the baseline HAGOS scores a clinically significant improvement in the symptoms (9.7, ES = 0.63, p= <0.01) and sport/recreation (13.2, ES = 0.68, p = 0.01) subscales was found when wearing the ZHC-short during football activities.

CONCLUSION

Wearing zoned high compression shorts could be useful in reducing groin pain in football players during their football activities.

Five-Second Squeeze Testing in 333 Professional and Semiprofessional Male Ice Hockey Players: How Are Hip and Groin Symptoms, Strength, and Sporting Function Related?

Background

Hip and groin problems are just as common in ice hockey as they are in soccer. The 5-second squeeze test (5SST) is a valid indicator of hip- and groin-related sporting function (self-reported function) in soccer and is suggested to be interpreted according to a "traffic light" approach in guiding the early identification and management of affected players. It is currently unknown how the 5SST relates to self-reported function and muscle strength in ice hockey players.

Purpose

To investigate correlations between the 5SST result, self-reported function, and hip muscle strength in ice hockey players. A further aim was to investigate the discriminative ability of the "traffic light" approach (numeric rating scale [NRS] score: 0-2 = green, 3-5 = yellow, 6-10 = red) regarding levels of self-reported function and strength.

Study Design

Cross-sectional study; Level of evidence, 3.

Methods

Professional and semiprofessional male ice hockey players (N = 333) performed the 5SST and completed the Sport subscale of the Copenhagen Hip and Groin Outcome Score (HAGOS). Bilateral adduction and abduction strength was measured using handheld dynamometry. Associations were estimated using Spearman rank-order correlations, and groups were compared using the Kruskal-Wallis test or analysis of variance. Standardized effect sizes (ESs) for differences in strength (Hedges g) and self-reported function (r) were provided.

Results

The 5SST result was significantly correlated with self-reported function (rho, -0.319; P < .01) and hip muscle strength (rho, -0.157 to -0.305; P < .01). The HAGOS Sport scores differed significantly between all 3 traffic light groups (ES, 0.23-0.33; P ≤ .005). Players with an NRS score >2 (yellow or red light) had lower adduction (ES ≥ 0.75; P < .001) and abduction strength (yellow: ES, 0.30; P = .031) (red: ES, 0.51; P = .058) than players with a green light.

Conclusion

The 5SST result was significantly correlated with self-reported function as well as hip muscle strength and was able to discriminate between the traffic light levels in ice hockey players. Players with a yellow or red light had reduced adduction and abduction strength compared with players with a green light (NRS score ≤2). Routine 5SSTs may allow the early identification of affected ice hockey players and indicate yellow and red light situations, in which players may benefit from load management and appropriate hip muscle strengthening.

The Adductor Strengthening Programme prevents groin problems among male football players: a cluster-randomised controlled trial

Background

Groin injuries represent a considerable problem in male football. Previous groin-specific prevention programmes have not shown a significant reduction in groin injury rates. An exercise programme using the Copenhagen Adduction exercise increases hip adduction strength, a key risk factor for groin injuries. However, its preventive effect is yet to be tested.

Aim

To evaluate the effect of a single-exercise approach, based on the Copenhagen Adduction exercise, on the prevalence of groin problems in male football players.

Methods

35 semiprofessional Norwegian football teams were cluster-randomised into an intervention group (18 teams, 339 players) and a control group (17 teams, 313 players). The intervention group performed an Adductor Strengthening Programme using one exercise, with three progression levels, three times per week during the preseason (6–8 weeks), and once per week during the competitive season (28 weeks). The control group were instructed to train as normal. The prevalence of groin problems was measured weekly in both groups during the competitive season using the Oslo Sports Trauma Research Center Overuse Injury Questionnaire.

Results

The average prevalence of groin problems during the season was 13.5% (95% CI 12.3% to 14.7%) in the intervention group and 21.3% (95% CI 20.0% to 22.6%) in the control group. The risk of reporting groin problems was 41% lower in the intervention group (OR 0.59, 95% CI 0.40 to 0.86, p=0.008).

Conclusion

The simple Adductor Strengthening Programme substantially reduced the self-reported prevalence and risk of groin problems in male football players.

Trial registration number

ISRCTN98514933.

Clinical Examination, Diagnostic Imaging, and Testing of Athletes With Groin Pain: An Evidence-Based Approach to Effective Management

Synopsis Groin pain is common in athletes who participate in multidirectional sports and has traditionally been considered a difficult problem to understand, diagnose, and manage. This may be due to sparse historical focus on this complex region in sports medicine. Until recently, there has been little agreement regarding terminology, definitions, and classification of groin pain in athletes. This has made clear communication between clinicians difficult, and the results of research difficult to interpret and implement into practice. However, during the past decade, the field has evolved rapidly, and an evidence-based understanding is now emerging. This clinical commentary discusses the clinical examination (subjective history, screening, physical examination); imaging; testing of impairments, function, and performance; and management of athletes with groin pain in an evidence-based framework. J Orthop Sports Phys Ther 2018;48(4):239-249. Epub 6 Mar 2018. doi:10.2519/jospt.2018.7850.