Are we squeezing the life out of adductor monitoring by Football Medicine & Performance Association

football medicine & performance The official magazine of the Football Medicine & Performance Association

Issue 26 Autumn 2018

Exclusive: Are we squeezing the life out of adductor monitoring

In this issue: Cardiac Screening Life After Football

Legal

Contents Welcome 4

Members’ News

Features 5

The Barcelona Way Damian Hughes

Research and Development What you should know about R&D

Cardiac Screening Saves Footballers’ Lives – But We Can Do More David Oxborough

Are we Squeezing the Life out of Adductor Monitoring Gary Silk

CHIEF EXECUTIVE OFFICER The launch of the FMPA Register is the culmination of much endeavour by the FMPA team and we are delighted with the response to date and the momentum that is starting to build. The Register was largely designed as an initiative to support members who leave the game often at a time of real need, giving them a platform to showcase their experience, helping them to maintain a presence in the game and supporting their private practice ventures. The needs of these members are clearly different to members in full time posts, hence why the register was set up as a separate entity and viewed as a potential bolt- on to membership, to be used as required. Continued support for colleagues, whether currently in the game or not, is what the FMPA is all about. Our membership is hugely diverse, covering more than a dozen disciplines, with a variety of specific needs. While this can be challenging at times, our profound belief is that ALL disciplines providing health care services to players and Clubs have an important role to play and individuals therein are an invaluable part of our membership. The change of title to FMPA underpins this belief. It is in working together that we have strength as an organisation and a significant voice in the professional game.

What do sports medicine professionals working in football need to know about sport psychology? Dr Caroline Heaney

The Supply of Medicines to Sports Teams Roni Lennon Bsc

The FMPA Register

Life After Football – Rob Swire

A Commonly Misdiagnosed injury – Lisfranc Fracture Dislocation in a Professional Soccer Player Ashley Jones MSc Rodger Wylde BSc Richard Moss MSc

One of our main aims has always been to improve standards but there are many questions still to be addressed; areas such as governance, indemnity, safeguarding, fitness to practise and the increasing `brain drain` of skilled practitioners from the game, to name but a few. We should be very concerned that, in some areas, standards are actually falling Some of this is centred around cost saving measures at clubs who seem to think that as long as they have the minimum requirements in place, then everything is ok. Let me give one example for all to consider. If healthcare insurers determined long ago that their members (the public) can only be treated by practitioners who have a minimum of 5 years post graduate experience, why is it that `football` is happy for new graduates to treat professional players the day after graduation?

The (Return to Play) Times, They are a Changin’ Markus Waldén Clare Ardern

While the foundations of the FMPA are firmly in place, all Medical and Performance practitioners working in professional football should recognise the role that the FMPA is playing and grasp the opportunity, not only to take the organisation forward, but to be an even louder voice in the game, raising standards to the world class level that you all deserve.

Eamonn Salmon CEO Football Medicine & Performance Association Football Medicine & Performance Association 6A Cromwell Terrace, Gisburn Road, Barrowford, Lancashire, BB9 8PT T: 0333 456 7897 E: info@fmpa.co.uk W: www.fmpa.co.uk

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Eamonn Salmon Eamonn.salmon@fmpa.co.uk

Executive Administrator Lindsay Butler Lindsay.butler@fmpa.co.uk

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ARE WE SQUEEZING THE LIFE OUT OF FEATURE/ GARY SILK, FIRST TEAM PHYSIOTHERAPIST, LEICESTER CITY FOOTBALL CLUB

A REVIEW OF OUR “GROIN BAR” EXPERIENCES AT LEICESTER CITY FC.

adductors muscles are often overshadowed by the increasing number of hamstring injuries in football (5).

Introduction: Hip and groin injuries are a common problem in Professional Football (1) due to the specific demands of match play and are typically difficult to both diagnose and manage. The most commonly injured being the Adductors, which have remained a constant burden over a 15 year period within elite level European football (2). Hip adductor strength is consistent throughout the literature as a strong risk factor for sustaining a new groin injury in football (3), while players with weak hip adductors have been found to have a 4 times higher risk of suffering a new groin injury compared to players without weak adductors (4). Consequently, athletic hip and groin research has received much attention over recent years, however specific injury prevention strategies for the

Following the 2016/17 season, we found the number of adductor related injuries to be high for our squad compared to previous years, equating 6 of our 15 (40%) muscle injuries and resulting in 45 days absence. Whilst these figures remained below average (6), we felt this was an area we needed to improve on moving forward. The start of the new season coincided with Vald Performance releasing the “Groin Bar”, an isometric strength testing device for the hip and groin musculature. Whilst there was no supporting research available on the Groin Bar, Vald Performance have essentially seen a clinical problem, and provided practitioners with a piece of equipment which allows us to objectify the process of adductor screening. We

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felt that given the increase in adductor injuries the previous season perhaps utilising the “Groin Bar” may help find an association between hip adductor strength and injury within our squad of Premier League Footballers. Vald Performance also manufacture the Nordbord an objective hamstring testing a device we have found helpful in the prevention of hamstring injuries. However, there are distinct differences when comparing the two devices, the Nordbord is a strengthening device and regular scores are gained from the players weekly strength program. Whereas the groin bar is solely a measuring/monitoring tool, this is due to the differences in both muscle range and contraction type. Squeeze Protocol: We initially experimented by testing the players in a variety of positions with both short and long levers, squeezing for 5 seconds as

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consistent throughout the literature. The short lever position with hips flexed to 45 degrees and knees flexed to 90 degrees has found to be the optimal thigh adductor squeeze test position, as it enables higher values and greater adductor muscle activation being observed (7). Towards the end of pre-season when committing to one position for comparison of longitudinal data, we chose the long lever position squeezing between the medial malleolus. Long-lever Adductor testing has been found to be precise and results in much higher levels of torque in comparison to short-lever test positions, maximizing stress to the Adductor musculature and the pubic complex, while being more reflective of most football kicking actions. Potentially alluding to subtler strength deficits which may indicate fatigue or future adductor injury (8), this position also targets the Adductor Longus most efficiently and therefore provokes the commonly injured structures (9). A pain rating score from 0 to 10 in line with the traffic light system from the Copenhagen five second squeeze was also recorded post squeeze. This has shown to be a valid indicator of sports related hip and groin function in football players and provided a quick assessment of current groin status (10). It’s important to note that the players also completed a progressive exposure to the Copenhagen Adduction Exercise (CHE) (11)

throughout preseason and a weekly exposure during the season as the fixture schedule would allow. Excel was used to record data and to identify a 15% drop off from the average of each players previous 3 peak scores. This is in line with the findings from Crow et al. (2010) (12) who found a 12 % drop off the week of injury onset, while Wollina et al. (2017) (13) found clinically meaningful deficits of 15% in adduction

through an App. The Scorebord gives real time feedback on how much force is being produced for both the right and left limbs, as well as the percent discrepancy between the two, this is something the players are familiar with and seem to like. The center unit becomes portable when removed from the main frame allowing for use in smaller areas or when travelling abroad, all reasons to give confidence in both its usability and gaining player buy in. Regarding our findings it should be noted that on no occasion did any player display a strength deficit of more than 15% (13) or even as much as 12% (12), furthermore no players reported symptoms over 5/10 NRS. This includes groin squeezes ranging from immediately post game, +24 hours, +48 hours and +72 hours postmatch.

Figure 1. The adductor squeeze protocol in long lying squeezing between the medial malleolus

strength during congested match periods. The protocol as seen in figure 1 was followed and individual adductor strength data was added to excel and analyzed. Summary of findings: The “Groin Bar” was quick and easy to use, and the fixed sensors improved standardization and repeatability compared to a hand held dynamometer or a pressure cuff. As with the Nordbord the software provided has two separate platforms, the “Scorebord” and the “Dashbord” which can be used wirelessly

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Pre-Season: On day one of pre-season each player was tested before and after our fitness test run with varied results. This was to be expected as it was the players first experience of using the Groin Bar and the running drill is only 18 minutes in duration, contains minimal turns, and at manageable speeds. However, this was a good opportunity for the players to get familiar with the squeeze test. During our week long pre-season camp in Austria, the players completed the squeeze protocol each morning before training. Whilst we predicted we may see signs of fatigue as

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Figure 2. The adductor strength increase of a player completing a graded exposure to training through preseason due to suffering from adductor and pubic related groin pain at the end of the previous season.

Figure 3. Longitudinal data of the one player that sustained a right sided grade 2 adductor longus strain. Highlighted is the week of injury, the player produced a PB groin squeeze pain free.

Figure 4. The combined peak adductor strength for each player of the LCFC first team squad.

the week progressed, in particular for players with previous injury history, the results were again mixed and didn’t show any meaningful correlations. Although the players are heavily loading the adductors through change of direction, the low levels of sprint distance at this stage of the season may protect the adductors and provide the reason for not identifying any meaningful drop in strength scores across the week. One player completed a graded exposure to training through pre-season due to suffering from both adductor and pubic related groin pain at the end of the previous season. Initially posting low scores, he showed the most consistent increases in adductor squeeze strength (figure 2) and we were able to use the Groin Bar to identify load tolerance. While there may be an element of familiarization, psychologically it was good to be able to show the player the objective data, improving his confidence in training and achieving buy in for strength work. In Season: As we entered the season we tended to test pre training on Mondays for non-starters and pre training on Tuesdays for starters as they generally stayed in doors to complete a post 48-hour recovery session. It is suggested that adductor strength takes 4 days to fully

recover post-match (14) however, this wasn’t evident in our players scores and wouldn’t be a realistic indicator for readiness to train in our environment. During the first half of the season we sustained one adductor injury, a right sided grade 2 Adductor Longus strain. This player was the third strongest in the squad and posted a personal best groin squeeze the week of injury with no symptoms. (figure 3). On reflection this was a new signing who was trying to impress and was perhaps not ready for the demands of the premier league, rather than an adductor strength deficit. When considering the squad peak strength scores, only the player with the 3rd highest score suffered an injury. Most of the players produced strength scores well below the injured player yet didn’t suffer an adductor strain (figure 4). Relying on player motivation to give a maximal squeeze on every occasion can be difficult, particular as the season progressed and the groin squeeze became more routine. This was evident when one player increased his PB by 30% as a result of showing him he was in the bottom half of the squad for adductor strength scores, bringing his previous maximal efforts into question.

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Two players with a previous history of lumbar disc protrusion reported back pain during the groin squeeze due to the increase in abdominal pressure, this was easily resolved by asking the players to exhale during each squeeze. There was no association between the scores produced on the Groin Bar and the progressive exposure to the CHE. This could be due to testing players on the days post-match when they were potentially in a fatigued state. Discussion: The adductor muscle group’s main action is described to be adduction of the thigh in the open kinetic chain and stabilization of the lower extremity in the closed kinetic chain. The variability of play stresses the adductor muscle group in different situations with high intensity turns, cutting maneuvers, sprinting and the repetitive action of kicking all being stressful components (15). The adductor longus appears to be at greatest risk of injury between 30% and 45% of the swing phase. At this point in the kicking cycle, the adductor longus is both eccentrically most active and stretching most rapidly. The coincident timing of maximum activation, maximum rate of lengthening and maximum hip extension angle explains the adductor longus high risk of injury (16). With this mechanism of injury in mind it seems

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unlikely that an inner range isometric test in supine would be able to identify players at risk of adductor injury. It’s been found that weekly monitoring of adductor strength within a squad could identify those at risk of breakdown and allow early modification of activity (12). However, we know injuries result from a complex interaction of multiple factors, a player’s injury risk is dynamic and subject to frequent change when exposed to external loads (17), meaning screening tests to predict injury often fail to demonstrate significant effects and establishing thresholds to determine whether athletes are considered as high or low risk can be problematic (18). Despite the emergence of new monitoring tools each season, we are still faced with the same injuries and rates of occurrence as previous years (19). Like most other injuries a previous history of groin pain is linked to an increase risk of its reoccurrence and this can be used to identify who is at need of further intervention (20). Due to the difficulty of completing research in senior professional football, the majority of adductor literature is completed in junior and

AFL players. Junior players have an increased risk of developing groin injury compared with their senior counterparts with over 50 injuries per ten thousand player hours (21). Potential reasons for strength drop off in this population may be due to lower levels of strength, a less developed pelvis, less training load monitoring, competing in a tournament scenario and able to achieve higher distances in the sprint zones due to the larger AFL pitch. Therefore, the research and strength drop off identified may be more relevant to academy players and staff where data collection for the Elite Players Performance Plan is needed. On reflection, at first team level we may have benefited from identifying coefficient variations rather than a 15% drop off, to produce more individualized results that were more sensitive to change. The small sample size and low number of injuries across the season may limit the value of our findings from the Groin Bar, however it did increase buy in for adductor strength work. A progressive exposure to the CHE for all players seemed to reduce adductor injuries across the squad, while also considering we had fewer matches and less travelling this season due to

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not being in the Champions League, increasing recovery time and allowing for more windows of opportunity for strength sessions. Whilst the CHE doesn’t hold all the answers, it does target the longer adductors and abdominals and has been found to produce large increases in eccentric adduction strength (11), that we can assume causes beneficial structural changes within the tissue resulting in a protective effect against injury. Perhaps a device to gain objective strength scores during the eccentric phase of the CHE could potentially provide more clinically useful information to guide practice. That said, the Groin Bar has potential early in preseason by promoting additional contact with each player and creating ‘buy in’ for adductor strengthening during a period when the adductor muscles are at an increased risk of injury due to unloading through the off season (22). Similarly, during rehab it could be used to objectively guide progression and return to play through comparison to baseline scores and provide a measure for the onset of pain as a percentage of peak strength, enabling us to identify load tolerance in a safe, non-provocative position (23). However, if it’s believed that strength is a causative factor during injury, we may need to superseded the baseline score.

football medicine & performance Using the Groin Bar to monitor for adductor strength deficits seems a simple and logical approach, however in reality it is fraught with complexity. We know injuries are multifactorial in nature and analytical strategies must reflect this reality or ‘screening’ will appear useless (24). Furthermore, a good relationship with the coaches is required to be able to act on your findings to manage the player accordingly. Recently it has been suggested that injuries are in fact being better prevented and managed in clubs than it may appear (25), however we can further improve by sharing our clinical experiences and I would welcome your views on adductor monitoring.

1)Werner, J., Hägglund, M., Waldén, M. & Ekstrand, J. (2009). UEFA injury study: a prospective study of hip and groin injuries in professional football over seven consecutive seasons. British Journal of Sports Medicine.

9) Drew, M., Palsson, T., Izumi, M., Hirata, R., Lovell, G., Chiarelli, P., Osmotherly, P. & Graven-Nielsen, T. (2016). Resisted adduction in hip neutral is a superior provocation test to assess adductor longus pain. Scandinavian Journal of Medicine & Science in Sports.

2) Werner, J., Hägglund, M., Waldén, M. & Ekstrand, J. (2018). Hip and groin time-loss injuries decreased slightly but injury burden remained constant in men’s professional football: the 15-year prospective UEFA Elite Club Injury Study. British Journal of Sports Medicine.

10) Thorborg, K., Branci, S., Nielsen, M., Langelund, M. & Holmich, P. (2016). Copenhagen five-second squeeze: A valid indicator of sports-related hip and groin function. British Journal of Sports Medicine.

3) Ryan, J., DeBurca, N. & McCreesh, K.(2014). Risk factors for groin/hip injuries in field-based sports: a systematic review. British Journal of Sports Medicine.

11) Ishøi, L., Sørensen, C.N., Kaae, N.M., Jørgensen, L.B., Hölmich, P. & Serner, A. (2016). Large eccentric strength increase using the Copenhagen Adduction exercise in football: A randomised controlled trial. Scandinavian Journal of Medicine and Sports Science.

4) Engebretsen, A.H., Myklebust, G., Holme, I., Engebretsen, L. & Bahr R. (2010). Intrinsic risk factors for groin injuries among male soccer players: a prospective cohort study. American Journal of Sports Medicine. 5) Ekstrand, J., Waldén, M. & Hägglund, M. (2016). Hamstring injuries have increased by 4% annually in men’s professional football, since 2001: a 13year longitudinal analysis of the UEFA Elite Club injury study. British Journal of Sports Medicine. 6) Mosler, A.B., Weir, A., Eirale, C., Farooq, A., Thorborg, K., Whiteley, R.J., H lmich, P. & Crossley, K. (2017). Epidemiology of time loss groin injuries in a men’s professional football league: a 2-year prospective study of 17 clubs and 606 players. British Journal of Sports Medicine. 7) Delahunt, E., Kennelly, C., McEntee, B.L., Coughlan, G.F. & Green, B.S. (2016). The thigh adductor squeeze test: 45 of hip flexion as the optimal test position for eliciting adductor muscle activity and maximum pressure values. Journal of Manual Therapy. 8) Light, N. & Thorborg, K. (2016). The precision and torque production of common hip adductor squeeze tests used in elite football. Journal of Science and Medicine in Sport.

12) Crow, J.F., Pearce, A.J., Veale, J.P., Vander Westhuizen, D., Coburn, P.T. & Pizzari, T. (2010). Hip adductor muscle strength is reduced preceding and during the onset of groin pain in elite junior Australian football players. Journal of Sciences and Medicine in Sport. 13) Wollina, M., Pizzari, T., Spagnolo, K., Welvaert, M. & Thorborgd, K. (2017). The effects of football match congestion in an international tournament on hip adductor squeeze strength and pain in elite youth players. Journal of Sports Science. 14) Buchheit, M., Morgan, W., Wallace, J., Bode, M. & Poulos, N. (2017). Monitoring post-match lowerlimb recovery in elite Australian rules football using a groin squeeze strength test. Sports Performance and Science Reports. 15) Serner, A., Due Jakobsen, M., Andersen, L., Hölmich, P., Sundstrup, E. & Thorborg, K. (2014). EMG evaluation of hip adduction exercises for soccer players: implications for exercise selection in prevention and treatment of groin injuries. British Journal of Sports Medicine. 16) Charnock, B., Lewis, C., Garrett, W., Queen, R., Krzyzewski, M. (2009). Adductor longus mechanics during the maximal effort soccer kick. Journal of Sports Biomechanics.

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17) Meeuwisse, W.H. (1994). Assessing causation in sport injury: a multifactorial model. Clinical Journal of Sport Medicine. 18) Bahr, R. (2016). Why screening tests to predict injury do not work-and probably never will...: a critical review. British Journal of Sports Medicine. 19) Ekstrand, J. (2017). UEFA Elite Club Injury Study Report 2016/17. Produced on behalf of the UEFA Medical Committee. 20) Glasgow, P. & McNicholl, C. (2011). Prevention and Management of Chronic Groin Pain in Gaelic football. Sports Institute of Northern Ireland. 21) Orchard, J., Wood, T., Seward, H. & Broad, A. (1998). Comparison of injuries in elite senior and junior Australian football. Journal of Science and medicine in sport. 22) Esteve, E., Rathleff, M., Vicens-Bordas, J., Clausen,, M., Holmich, P., Sala, L. & Thorborg, K. (2018). Preseason Adductor Squeeze Strength in 303 Spanish Male Soccer Athletes: A Crosssectional Study. Orthopaedic Journal of sports Medicine. 23) Hogan, A. (2012). So Doc…..when will I be ready to run? An important rehab decision for athletic groin pain. Aspetar sports medicine journal. 24) Hughes, T., Sergeant, J., van der Windt, D., Riley, R. & Callaghan, M. (2018). Periodic Health Examination and Injury Prediction in Professional Football (Soccer): Theoretically, the Prognosis is Good. Sports Med. 25) Buchheit, M., Eirale, C., Simpson, B.M. & Lacome, M. (2018). Injury rate and prevention in elite football: let’s first search within our own hearts. British journal of sports medicine.

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