Hip adductor muscle strength is reduced preceding and during the onset of groin pain in elite junior Australian football players

Groin pain is a condition with a high prevalence in young Australian football players. It is considered that early identification of this condition allows for optimal management. Eighty-six players from two elite under-age Australian football sides were screened weekly for hip adductor muscle strength, using a hand-held dynamometer and for the onset of groin pain. The maximum variation in the average hip adductor muscle strength values of the sample was a 2.6% decrease from baseline in week 7 of the study. Twelve players (14% of the sample studied) reported groin pain for two consecutive weeks and were considered to have an onset of groin injury. The mean hip adductor muscle strength of these players was decreased significantly from baseline by an average of 11.75 ± 2.50% at the week of pain onset (F = 264.76 (1,11), p < 0.001), and 5.82 ± 5.16% in the week preceding the onset of pain (F = 14.03 (1,10), p = 0.004). These results confirm that hip adductor muscle strength is decreased both preceding and during the onset of groin injury in elite under-age Australian footballers.     

Description of pain provocation tests used for the diagnosis of sports-related chronic groin pain: relationship of tests to defined clinical (pain and tenderness) and MRI (pubic bone marrow oedema) criteria

The clinical assessment of groin pain in athletes is difficult, with the lack of specific clinical tests being in part responsible. Three pain provocation tests used in the diagnosis of chronic groin pain are described and their relationship to defined clinical and MRI criteria has been assessed. Eighty-nine Australian Rules football players with and without groin symptoms underwent clinical examination followed by history. Three pain provocation tests were performed (named as the Single Adductor, Squeeze and Bilateral Adductor tests). All athletes subsequently underwent MRI of their groin region for the presence of significant pubic bone marrow oedema (BMO). Of the 89, 47 were defined as having chronic groin pain, and 46 had significant BMO with 37 having both chronic groin pain and BMO. The three pain provocation tests demonstrated only moderate sensitivity (range 30-65%). Positive predictive values were moderate to high (67-93%) depending upon the individual test. The Bilateral Adductor test was the most sensitive test with the highest positive predictive values. The high specificity (88-93%) demonstrated should be treated with caution due to the study methodology. Three pain provocation tests of potential value in assessing chronic groin pain in athletes are described. If positive, all three pain provocation tests demonstrated a high likelihood for the athlete having MR-detected parasymphyseal pubic BMO. Further research is required on assessing the clinical usefulness of these tests.     

Exercise program for prevention of groin pain in football players: a cluster‐randomized trial

Groin injuries cause major problems in sports and particularly in football. Exercise is effective in treating adductor‐related groin pain, but no trials have been published regarding the specific prevention of groin pain or prevention specifically targeting overuse injuries in sport using exercise programs. We performed a cluster‐randomized trial including 55 football clubs representing 1211 players. The clubs were randomized to an exercise program aimed at preventing groin injuries (n=27) or to a control group training as usual (n=28). The intervention program consisted of six exercises including strengthening (concentric and eccentric), coordination, and core stability exercises for the muscles related to the pelvis. Physiotherapists assigned to each club registered all groin injuries. Twenty‐two clubs in each group completed the study, represented by 977 players. There was no significant effect of the intervention (HR=0.69, 95% CI 0.40–1.19). The risk of a groin injury was reduced by 31%, but this reduction was not significant. A univariate analysis showed that having had a previous groin injury almost doubles the risk of developing a new groin injury and playing at a higher level almost triples the risk of developing a groin injury.     

Running biomechanics in football players with and without hip and groin pain. A cross-sectional analysis of 116 sub-elite players

ObjectiveExamine whether football players with hip and/or groin (hip/groin) pain have impaired running biomechanics when compared to pain-free players, analysing men and women independently.DesignCross-sectional.SettingBiomechanics laboratory.ParticipantsSeventy-eight (62 men, 16 women) football players with >6months of hip/groin pain and a positive flexion-adduction-internal rotation test and 38 (25 men, 13 women) asymptomatic players.Main outcome measuresPelvis angles and hip, knee, and ankle joint angles and moments were analysed during the stance phase of overground running at 3–3.5 m⋅s⁻¹. Continuous joint angle and moment data were compared between symptomatic and asymptomatic football players of the same sex using statistical parametric mapping. Joint moment impulses (area under the curve) were compared between groups using linear regression models.ResultsSymptomatic football players did not display significant differences in pelvis angles or lower-limb joint angles, moments, or moment impulses during the stance phase of running, when compared to asymptomatic players of the same sex.ConclusionOur large sample of football players with hip/groin pain who were still participating in competitive sport displayed similar running biomechanics to asymptomatic players. Impaired running biomechanics might exist in people with worse hip/groin pain, warranting future investigation.     

Australian football players experiencing groin pain exhibit reduced subscale scores of Activities of Daily Living and Sport and Recreation on the HAGOS questionnaire: A case-control study

ObjectivesTo report normative responses to the HAGOS questionnaire for Australian football players and to determine whether any of the HAGOS questionnaire sub scales can differentiate players with and without groin pain.DesignCase-control.SettingClinical setting.ParticipantsProfessional (n = 66) and semi-professional (n = 9) Australian football (AF) players with current groin pain (n = 16) and controls (n = 57) without current groin pain.Main outcome measureThe HAGOS subscales were compared between players with and without groin pain using the Wilcoxon rank-sum test with effect sizes (ES) calculated. Floor and ceiling effects were examined. A post-hoc factor analysis was undertaken.ResultsParticipants with current groin pain showed lower Physical Function of Daily Living (PFDL) and Physical Function in Sport and Recreation (PFSR) subscale scores (p < 0.05, ES: 0.77 and 0.90 respectively). Any groin pain (current and/or historical) lowered the Pain and Quality of Life (QOL) subscale scores (p < 0.05, ES: 0.38 and 0.72 respectively). Factor analysis showed 8 significant factors with one main factor identified representing items describing forceful activities (Eigenvalue = 18.02, Proportion = 0.49).ConclusionsThe HAGOS can distinguish AF players with current groin pain in the PFDL and PFSR subscales but not in the other four subscales. Any current or historical groin pain lowers scores on the QOL and Pain sub scales.Level of evidenceAetiology, Individual Case-Control Study, Level 3b     

Depression and pain in retired professional football players

PURPOSE: To assess the prevalence of depressive symptoms and difficulty with pain in retired professional football players, difficulties with the transition from active athletic competition to retirement, perceptions of barriers to receiving assistance for those difficulties, and recommended programs to provide such assistance. METHODS: Survey sent to 3377 retired members of the National Football League Players Association (NFLPA), with usable responses received from 1617 members (functional response rate, 48.6%). RESULTS: Respondents were categorized as experiencing no to mild depression (N=1366; 84.5%) or moderate to severe depression (N=237; 14.7%). Respondents were also categorized according to whether they reported difficulty with pain as not or somewhat common (N=837; 51.8%) versus quite or very common (N=769; 47.6%). Respondents most frequently reported trouble sleeping, financial difficulties, marital or relationship problems, and problems with fitness, exercise, and aging, all of which were strongly correlated with the presence of moderate to severe depression and with quite or very common difficulty with pain. The same difficulties were even more commonly experienced by respondents who reported both moderate to severe depression and quite or very common difficulty with pain, compared with those who reported low scores in both domains. CONCLUSION: Retired professional football players experience levels of depressive symptoms similar to those of the general population, but the impact of these symptoms is compounded by high levels of difficulty with pain. The combination of depression and pain is strongly predictive of significant difficulties with sleep, social relationships, financial difficulties, and problems with exercise and fitness. A hypothesis explaining this association is that significant musculoskeletal disability and chronic pain interferes with physical activity and fitness during retirement and increases the risk of depression.     

Physical testing characteristics better explain draft outcome than in-game movement profile in junior elite Australian rules football players

ObjectivesThe aim of this study was to investigate the extent to which Australian Football League (AFL) draft outcome is associated with physical performance and/or in-game movement profile.DesignObservational cohort design.MethodsPhysical testing results and in-game global positioning system (GPS) data were collated from Victorian-based, draft-eligible participants in the under 18 boys NAB League competition (n = 450; age = 17.1 ± 0.3 y). Players were grouped by position as nomadic, fixed-position or fixed&ruck.ResultsIndividually, variables that best distinguish drafted and non-drafted players were: estimated V̇O₂ max (all-position, nomadic, fixed&ruck: d = 0.60, 0.64, 0.53), standing vertical jump (d = 0.57, 0.58, 0.53), running vertical jump (d = 0.52, 0.51, 0.56), AFL agility (d = 0.49, 0.44, 0.67) and 20-m speed (all-position, nomadic: d = 0.50, 0.61). Factor analysis prior to binary logistic regression assessed the probability of factors influencing position-specific draft outcome. AFL agility (all-position, fixed&ruck: OR = 4.58, 15.86), anthropometry (all-position, nomadic, fixed, fixed&ruck: OR = 2.55, 2.06, 11.41, 7.99), and jumping (all-position, nomadic, fixed&ruck: OR = 1.75, 1.69, 2.68) were the factors most associated with positive draft outcome. More game involvement (fixed&ruck: OR = 2.22), sprinting (all-position, fixed&ruck: OR = 1.45, 2.06) and less non-sprinting activities (all-position, nomadic: OR = 0.64, 0.61) were associated with positive draft outcome. The fixed&ruck model was the best performing (χ²(115) = 30.59, p < 0.001, AUC = 84.7%).ConclusionsPhysical testing-related factors were most likely to influence draft outcome, where larger and more agile players were desirable draft picks. In-game movement profile had some bearing on draft outcome in all positional groups with the exception of fixed.     

Incidence of cervical spinal stenosis in professional and rookie football players

Sagittal canal/vertebral body ratios were measured on cervical spine lateral radiographs of 124 professional football players and 100 rookie football players. A total of 894 levels were measured in 224 players. Thirty-two percent (40) of the 124 professional football players, and 34% of the 100 rookies had a ratio of less than 0.80 at one or more levels from C3 to C6. The 0.80 ratio has been considered indicative of cervical spinal stenosis. This is the first time that the incidence of spinal stenosis, as determined by Torg's ratio, has been demonstrated in a population of professional and rookie football players. Because one-third of this population has cervical spinal stenosis as determined by the Torg ratio, other factors should be considered in the evaluation of a player with a transient quadriplegic episode when making continued play decisions.     

The effect of neoprene shorts on leg proprioception in Australian football players

Our purpose was to assess the effect of wearing close-fitting neoprene shorts on swinging leg movement discrimination (MD) scores in elite level Australian Football players. Twenty players had their swinging leg MD assessed using the active movement extent discrimination apparatus (AMEDA), once wearing close-fitting neoprene and once wearing loose-fitting running shorts. Subjects were randomly allocated to one of the shorts conditions prior to repeating the test in the other condition. The AMEDA was used to assess the accuracy at which subjects judge the extent of a standing backward swinging leg movement corresponding to the late swing early stance phase of running. Each subject performed 40 movements made to one of five randomly set physical limits, and without the aid of vision made a judgment as to the perceived limit position. From the accuracy of these judgments, a movement discrimination (MD) score was calculated for each subject under each condition. Subjects were grouped as having low or high neuromuscular control, or ability to use proprioception when controlling active movements without vision, based on their loose-shorts MD score. Analysis was performed on the MD scores obtained for each limb from subjects in the two groups, under the two shorts-wearing conditions. There was no main effect of wearing close-fitting shorts when the cohort was treated as a whole. A significant interaction effect was obtained (F = 17.027, p = 0.0006) whereby the mean MD score of the low neuromuscular control ability group was improved when wearing neoprene shorts but was reduced for the high ability group. Wearing close-fitting neoprene shorts has a beneficial effect on leg swing judgment accuracy in subjects with low neuromuscular control ability. Conversely, leg swing judgment accuracy for subjects with high ability was reduced by wearing neoprene shorts.     

Acute effect of exercise on kicking accuracy in elite Australian football players

Kicking accuracy (KA) is an important skill in Australian football but the potential influence of exercise on this skill has not been previously investigated. The purpose of this study was to determine if a 2× 2 min time trial running protocol influenced short KA in elite Australian football. Another aim was to identify if endurance, playing experience and position were related to any exercise-induced KA changes. Twenty-seven professional footballers performed a KA test by kicking at a bullseye on a target projected onto a screen. The mean error from the centre of the target was the KA score. The players were assessed on the KA test, and then performed a 2× 2 min time trial with a 3-min recovery between runs. The total distance covered was used as a measure of endurance fitness, and the test also served as an exercise bout designed to impose some physiological stress. Immediately following this test, the players walked into the laboratory and performed the KA test again. A paired t-test revealed that the whole group achieved a non-significant 2.7% improvement in KA. Players were divided into two distinct groups based on endurance (2× 2 min results), playing experience and position (midfielders and forwards/backs). Analysis of covariance showed that after the exercise bout, the fitter group had significantly better KA (p = 0.010) than the less fit group, and the more experienced players were 16% more accurate than the less experienced group (p = 0.055). The midfielders were 8.2% better than the forwards/backs in KA (p = 0.32). It was suggested that greater endurance and playing experience may facilitate KA under moderate physiological stress.     

Characterising groin pain in rink hockey: Function and five-second squeeze in Spanish players

ObjectivesTo assess the relationship between history of past season groin pain and current pain during the five-second squeeze test (5SST) with groin function and adductor strength in rink hockey players.DesignCross-sectional.SettingFirst (Ok Liga), Second (Plata) and third division (Bronce) clubs. Participants: Sixty-eight female and 183 male hockey players.Main outcome measuresSeasonal prevalence of groin pain (time/non-time-loss). Adductor strength and pain during the 5SST. Function was evaluated with the Hip and Groin Outcome Score (HAGOS).ResultsSeasonal time-loss groin pain prevalence was 21%. Male players had 3.5 higher odds of having had an episode of time-loss groin pain during the previous season compared to female players. The adductor relative strength was no different between players with and without previous season groin injury (p = 0.53-0.55), while the HAGOS results differed between groups, with past season groin injury players obtaining lower values in all subscales. HAGOS scores differed between the 5SST pain intensity groups (p < 0.01).ConclusionsMale players had higher odds of having had a groin injury in the previous season compared to female players. Players with pain during 5SST and previous season groin injury reported functional deficits, while strength remains identical to their healthy counterparts.     

Considerations in interpreting neuromuscular state in elite level Australian Rules football players

ObjectivesExamine the influence of test modality, season stage, match load and physical qualities on the interpretation of neuromuscular function (NF) post Australian Rules Football (ARF) matches.DesignRepeated measures design.MethodsThirty-two elite ARF players’ NF was assessed 72 h following competitive matches (7 ± 2) via the counter movement jump (CMJ) and isometric mid-thigh pull (IMTP). Influence of season stage, external load parameters (GPS; 10 Hz) and moderating influences of lower body strength (LBS), lower body power (LBP) and intermittent exercise capacity upon NF recovery were assessed using linear mixed effects models.ResultsModerate negative seasonal trends were evident for both rate of force development (RFD) 0?100 ms (d = ?0.86, 95%, CI: ±0.57) and 0?200 ms (d = ?0.76, CI: ±0.64). Significant but trivial effects of match load were observed between one standardised unit increase in high speed running (HSR) versus CMJ: Force at zero velocity (d = 0.12, CI: ±0.12), and sum of high intensity accelerations and CMJ: Eccentric deceleration RFD (d = ?0.18, CI: ±0.14). Accounting for baseline LBS better explained (weight of evidence: W = 87%) seasonal trends observed in IMTP: peak force, with lower LBS showing greater capacity for improvement. Positive moderating influences were observed with baseline LBS and LBP (W = 91 & 75%) on CMJ: eccentric mean power responses to HSR, and CMJ: jump height responses to very-HSR, respectively.ConclusionsInterpretation of athlete NF responses is complicated by the inconsistent and interacting influence of contextual factors (assessment modality, stage of season, load), in-particular higher baseline LBS and LBP may improve acute load related responses of NF.     

Drug doping in senior Australian rules football: a survey for frequency.

OBJECTIVES: To determine by survey whether the frequency of use of performance enhancing drugs (drug doping) is significant in elite players of Australian Rules football, and to compare this frequency with that in other competitions. METHODS: Randomised unannounced prospective urine testing during the period 1990-95 of players from the Australian Football League out of competition, in competition matches, and in finals matches; testing was performed according to Olympic International Committee protocols and standards. The players' identities and clubs were unknown during testing. RESULTS: Of 900 random urine tests, no positive results were obtained for anabolic steroids, diuretics, caffeine, or peptide hormones. Five positive results (0.6%) were obtained-for pseudoephedrine in two instances, and for probenecid, methoxyphenamine, and dextropropoxyphene in one instance each. Each were inadvertent medical doping and declared before testing. CONCLUSIONS: Drug doping is not a problem in the Australian Football League. This is probably because no doping method is considered to be of value to Australian Rules football, because an educational programme is run by football authorities, and because random during season and out of season testing for drugs occurs.     

Influence of training years on upper-body strength and power changes during the competitive season for professional Australian rules football players

ObjectivesTo determine if upper-body strength or power changes during the competitive season for elite Australian rules footballers and what influence the number of training years has on any changes.DesignRepeated measures.MethodsTwenty elite Australian rules footballers were assessed at preseason, in-season and postseason. Strength was assessed by the 1 Repetition Maximum bench press and power was assessed by bench press throws. Athletes’ results were analysed as a whole group as well as being divided into two groups according to training years: less than 3 years training and greater than 3 years training. All athletes performed the same resistance training program.ResultsThere were no significant differences in height, body mass, or skinfold measurements between the two age groups. As a whole group, there was no significant change in 1RM bench press. There was a small but significant decrease in mean bench throw power in-season (525 W) compared to preseason (542 W) and it then increased at postseason (541 W). Within group analysis revealed the in-season decrease in upper-body power was largely pertaining to the younger athletes. The older group maintained their upper body power levels while the younger group decreased power in-season (4%) before regaining it at season's end.ConclusionOlder footballers were able to maintain their upper body power while the younger footballers had a small but significant decrease in-season before regaining it by season's end. The overall volume of training and playing appears to have affected the younger athletes’ power more than older athletes. Both age groups maintained upper body strength.     

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

ObjectivesTo explore relationships between groin pain and adductor squeeze strength in male academy football players over a 14-week period.DesignLongitudinal cohort study.MethodsWeekly 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.Results53 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).ConclusionsDecreases 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.     

When physiology becomes pathology: the role of magnetic resonance imaging in evaluating bone marrow oedema in the humerus in elite tennis players with an upper limb pain syndrome

Upper limb stresses are well recognised in tennis, and the normal physiological responses of the humerus to externally applied forces are well defined. Changes to both the microscopic and macroscopic bony architecture are often not apparent on plain radiographs in the early stages of a stress reaction. Bone scintigraphy is more sensitive, but not very specific to subtle changes, as is computer aided tomography. Magnetic resonance imaging (MRI) scans are now used to assess many musculoskeletal injuries, and may allow earlier recognition of changes. This study reports on eight high level tennis players (seven professionals, one highly ranked amateur), who all presented during the course of the 2002 Australian Open and its lead up events. All had an upper limb pain syndrome centred around the elbow. Each underwent an MRI scan. A group of asymptomatic players also had scans of the same area to serve as controls. All symptomatic patients had various levels of bone marrow oedema in their distal humerus, some with periosteal reactions, although most without. No scans revealed a cortical breach. The management of these reactions is problematic in players on an international circuit, as review is sporadic and not always coordinated. The timetabling of international tournaments means it is difficult for top players to obtain adequate rest to avoid injury. Awareness of this early overuse reaction needs to be raised to allow preventive and therapeutic options to be considered to reduce the incidence of this humeral stress response producing an upper limb pain syndrome.     

Evaluating bone marrow oedema patterns in musculoskeletal injury

MRI is a common tool in the evaluation of musculoskeletal injury that allows the clinician to pinpoint specific pathologies. The patient's history and physical exam play a critical role in the diagnosis of sports injuries, however, complementary imaging can play an important role in determining the nature and extent of injury. With the widespread use of MRI, attention has focused on the signals generated following injury. In particular, bone marrow oedema (BME) patterns can be used to aid in the diagnosis of musculoskeletal injury. In this pictorial essay, the authors will demonstrate common patterns of BME that accompany a wide range of musculoskeletal injuries. It is expected that by the end of this article, the reader will be able to (1) recognise BME is a phenomenon observed on MRI following sports injury; (2) recognise typical patterns of BME; (3) understand the relationship of oedema to the type of injury and (4) in the presence of oedema, understand other co-existing injuries that ultimately may have an impact on management.     

Prevalence and severity of hip and groin pain in sub‐elite male football: a cross‐sectional cohort study of 695 players

The purpose of this study was twofold: (a) to investigate the prevalence of hip and groin pain in sub‐elite male adult football in Denmark and (b) to explore the association between prevalence and duration of hip and groin pain in the previous season with the Copenhagen Hip and Groin Outcome Score (HAGOS) in the beginning of the new season. In total 695 respondents from 40 teams (Division 1–4) were included. Players completed in the beginning of the new season (July–Sept 2011) a self‐reported paper questionnaire on hip and/or groin pain during the previous season and HAGOS. In total 49% (95% CI: 45–52%) reported hip and/or groin pain during the previous season. Of these, 31% (95% CI: 26–36%) reported pain for >6 weeks. Players with the longest duration of pain during the previous season had the lowest HAGOS scores, when assessed at the beginning of the new season, P < 0.001. This study documents that half of sub‐elite male adult football players report pain in the hip and/or groin during a football season. The football players with the longest duration of pain in previous season displayed the lowest HAGOS scores in the beginning of the new season.