Abstract
Objectives
The study sought to evaluate possible relationships between dynamic postural balance and pain, core stability, and hip range of motion in soccer players who were experiencing groin pain (GP). Furthermore, the study aimed to compare these measurements in symptomatic and asymptomatic players.
Methods
The study included 42 male soccer players experiencing GP and an equal number of asymptomatic players. Dynamic postural balance, pain, hip range of motion and trunk endurance were measured.
Results
The GP group revealed reduced dynamic balance performance (p < 0.01–0.001) in injured and non-injured limbs compared to control group. Further, players experiencing GP demonstrated lower hip range of motion in internal (p < 0.05) and total rotations (p < 0.01) in the injured limb, and lower trunk endurance (p < 0.001) compared to their asymptomatic peers. In general, core stability was associated (r = 0.13–0.61, p < 0.05–0.001) with the poor dynamic balance performance in the GP group while standing on injured and non-injured limbs. No significant correlations between dynamic postural balance, pain and hip range of motion were observed.
Conclusion
Poor core endurance was found to be associated with dynamic balance disorders in soccer players experiencing GP. This information can aid in the development of targeted strategies to enhance dynamic postural balance in these players.
Keywords: Balance control, Groin injury, Trunk, Soccer
Highlights
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Players experiencing groin pain had dynamic postural balance disorders compared to controls.
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Core stability was associated with poor balance performance in these players.
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The study findings can provide a targeted approach to improve postural balance.
1. Introduction
Groin pain (GP) is frequently encountered in soccer.1 Studies found that soccer players experiencing GP displayed deficits in dynamic postural balance compared to asymptomatic ones.2,3 Deficiencies in this biomechanical parameter lead to lower extremity injuries.4 While they may continue to play,5 players experiencing GP may face a higher likelihood of sustaining further injuries owing to their compromised dynamic postural balance.3 To avoid further injuries, it is crucial to prioritize the maintenance of optimal dynamic postural balance in these players. However, a thorough understanding of its impairment is required in order to design successful rehabilitation interventions.
GP has been linked with poor core or trunk stability.6 In this regard, individuals experiencing GP have been found to have lower trunk muscular functions than those who are asymptomatic.7 Furthermore, previous studies have also shown that individuals with GP have restricted hip range of motion, specifically internal and total rotations, which distinguishe them from those without GP.7,8 Poor core stability,9 restricted hip range of motion, and pain10 all have a negative impact on dynamic postural balance. However, it's not yet clear how these factors relate to dynamic postural balance in soccer players with GP. Therefore, the main goal of this study was to explore the association between dynamic postural balance and pain, hip range of motion and core stability in these players. Furthermore, this study sought to compare all of these variables between symptomatic and asymptomatic players. Our hypothesis was that soccer players with GP would have poor dynamic postural balance when compared to their asymptomatic counterparts. Furthermore, we expected that pain, restricted hip range of motion, and inadequate core stability would adversely impact these players’ dynamic postural balance.
2. Methods
2.1. Study design and participants
A priori calculations were performed to establish the sample size required to identify significant results using correlation analysis, with a reference to a previous study.11 Utilizing a correlation coefficient (r = 0.38) derived from the association between the posteromedial direction of the Y-Balance test (Y-BT) and pain subscale of the Copenhagen Hip and Groin Outcome Score (HAGOS) in adolescent male soccer players with hip/GP considering an α = 0.05 and 1- β = 0.8, calculations indicated that a sample of 41 participants experiencing GP was needed.
This study, conducted between 2020 and 2022, followed the principles described in the Declaration of Helsinki and was approved by the local Ethics Committee. Before the study began, all participants had to provide written consent. This study involved the participation of 42 male soccer players who were experiencing GP (GP group), as well as an equal number of asymptomatic players (control group). Doctors specializing in sports medicine diagnosed12 and referred eligible cases. The inclusion criteria for these cases involved experiencing unilateral adductor-related GP for a minimum of 2 months without time-loss. Furthermore, cases with both adductor-related GP and inguinal symptoms were identified and included. The HAGOS, a validated clinical tool that examines athletes' groin function, was used to evaluate pain and other groin issues.13 Cases who presented with other diseases that possibly cause groin pain were excluded from the study. Additionally, players from both groups were excluded if they had any pathologies that could alter their postural balance.
2.2. Procedures
2.2.1. Dynamic postural balance
The dynamic postural balance was evaluated with the Y-BT in 3 directions: anterior, posteromedial, and posterolateral.14 Participants positioned themselves at the center of the grid on a single limb (injured/non-injured limbs for the GP group, dominant/non-dominant limbs for the control group) and they were told to extend the other limb in each direction to the utmost distance they could. Each participant had their normalized distances and composite scores calculated.14
2.2.2. Core stability
Trunk endurance tests were used to determine core stability. They included tests for trunk extension and flexion, as well as the side bridge.15 Experiments were carried out as demonstrated by McGill et al.15
2.2.3. Passive hip range of motion
The goniometer was used to measure the hip's internal and external rotations, as well as abduction, while each participant was lying supine, as previously described.16 The internal and external rotations were combined to determine the overall rotation score.
2.3. Statistical analyses
Analysis of statistics has been carried out using IBM SPSS®. Independent t-tests were applied to compare group differences in age, height, body mass, body mass index, and core stability (flexor and extensor endurance). Independent Mann-Whitney U tests were employed to evaluate the disparities in exposure, playing experience, and HAGOS outcomes between the groups. Data from the dominant limb among asymptomatic players were chosen for analysis as no significant differences in Y-BT, hip range of motion, or side bridge outcomes were observed. The independent t-tests were conducted to analyze the Y-BT and side bridge data, comparing GP and control groups. Additionally, paired t-tests were used to compare the limbs/sides within the GP group. Cohen's effect sizes (ESs) were computed when assessing the Y-BT and core stability results. To evaluate hip range of motion data, either the independent Mann-Whitney U tests were employed to assess differences between the GP and control groups, or the Wilcoxon signed rank tests were used to compare the limbs within the GP group. ESs were calculated as r2 or η2 = Z2/N.17 Intra-rater reliability of hip range of motion measures was evaluated in 12 asymptomatic soccer players using intraclass correlation coefficient (ICC). Additionally, the standard error of measurement (SEM) and the minimal detectable change (MDC) were computed.18 Pearson's correlations (r) were employed to examine the association between postural balance outcomes and core stability, whereas, Spearman's rho coefficients (rs) were used to calculate correlations between postural balance, HAGOS pain subscale, and hip range of motion. The variables that showed correlations with postural balance outcomes were then included in multivariate stepwise regression models. The percentage of explained variance was determined using R2. A significance level of p < 0.05 was established for all tests.
3. Results
3.1. Participants
Characteristics of the GP and control groups are detailed in Table 1. Validating accurate group assignments, all HAGOS subscale scores were significantly lower (p < 0.001) in the GP group compared to the control group. No significant differences were observed between the two groups for the other characteristic variables (Table 1).
Table 1.
Descriptive characteristics of participants.
| Control group (n = 42) | GP group (n = 42) | p | |
|---|---|---|---|
| Age (yrs) | 21.50 (2.55) | 21.23 (2.20) | 0.61 |
| Height (m) | 1.77 (0.05) | 1.76 (0.05) | 0.56 |
| Body mass (kg) | 72.64 (6.78) | 73.80 (7.35) | 0.45 |
| Body mass index (kg/m2) | 23.06 (2.00) | 23.62 (2.21) | 0.22 |
| Playing experience (yrs) | 6.10 (1.85) | 6.05 (1.34) | 0.60 |
| Weekly exposure | |||
| Trainings/week | 4.19 (0.77) | 4.40 (0.83) | 0.64 |
| Matches/week | 0.95 (0.22) | 0.93 (0.26) | 0.15 |
| Clinical entities (n, %) | |||
| Adductor-related GP | – | 33 (78.60%) | – |
| Adductor- in conjunction with inguinal-related GP | – | 9 (21.40%) | – |
| Injured limb (n, %) | |||
| Dominant | – | 16 (38.10%) | – |
| Non-dominant | – | 26 (61.90%) | – |
| Dominant limb (n, %) | |||
| Right | 40 (95.20%) | 37 (88.10%) | – |
| Left | 2 (4.80%) | 5 (11.90%) | – |
| HAGOS | |||
| Pain | 100.00 (100.00–100.00) | 70.00 (66.87–72.50) | <0.001 |
| Symptoms | 100.00 (100.00–100.00) | 67.86 (63.38–78.57) | <0.001 |
| ADL | 100.00 (100.00–100.00) | 75.00 (60–82.85.00) | <0.001 |
| Sports/Rec | 100.00 (100.00–100.00) | 57.81 (40.62–62.50) | <0.001 |
| PA | 100.00 (100.00–100.00) | 50.00 (34.37–63.50) | <0.001 |
| QOL | 100.00 (100.00–100.00) | 58.75 (45.00–75.00) | <0.001 |
GP: groin pain; HAGOS: Hip and Groin Outcome Score; ADL: activities in daily living; Sport/Rec: physical function in sport and recreation; PA: participation in physical activities; QOL: hip and/or groin-related quality of life.
3.2. Dynamic postural balance
The control group demonstrated no significant differences between the dominant and non-dominant limbs in terms of anterior (d = 0.06), posteromedial (d = 0.17), posterolateral (d = −0.11) distances, and composite scores (d = 0.02). However, the anterior (d = 1.16), posteromedial (d = 0.95), and posterolateral (d = 1.18) reach distances, and the composite score (d = 1.69), were all significantly lower (p < 0.001) in the injured limb compared to the non-injured one among the GP group (Table 2).
Table 2.
Y-Balance test (Y-BT) and hip range of motion outcomes in groin pain (GP) and control groups.
| Control group (n = 42) |
GP group (n = 42) |
|||
|---|---|---|---|---|
| Dominant limb | Non-dominant limb | Injured limb | Non-injured limb | |
| Y-BT (%) | ||||
| Anterior | 82.96 (5.18) | 82.87 (4.91) | 74.03 (4.46)a,d | 79.55 (7.17)h |
| Posteromedial | 97.61 (7.53) | 97.27 (7.77) | 82.03 (8.89)a,d | 88.74 (8.12)g |
| Posterolateral | 96.53 (9.34) | 96.85 (9.90) | 80.07 (8.23)a,d | 88.71 (8.81)g |
| Composite score | 92.37 (6.06) | 92.33 (6.28) | 78.71 (5.96)a,d | 85.67 (6.06)g |
| Hip range of motion (°) | ||||
| Abduction | 45.80 (3.28) | 45.09 (3.34) | 45.11 (4.48) | 45.47 (3.95) |
| Internal rotation | 30.80 (2.37) | 30.85 (2.68) | 30.23 (2.62)c,f | 30.88 (2.39) |
| External rotation | 39.95 (2.55) | 40.19 (2.10) | 40.02 (2.64) | 40.53 (2.16) |
| Total rotation | 70.76 (3.01) | 71.04 (3.70) | 70.26 (4.68)b,e | 71.40 (3.62) |
a Significant differences between the injured and non-injured limbs at p < 0.001.
b Significant differences between the injured and non-injured limbs at p < 0.01.
c Significant differences between the injured and non-injured limbs at p < 0.05.
d Significant differences between the injured and dominant limbs at p < 0.001.
e Significant differences between the injured and dominant limbs at p < 0.01.
f Significant differences between the injured and dominant limbs at p < 0.05.
g Significant differences between the non-injured and dominant limbs at p < 0.001.
h Significant differences between the non-injured and dominant limbs at p < 0.01.
Examining differences between GP and control groups, anterior (injured limb vs. dominant limb: p < 0.001, d = 1.84; non-injured limb vs. dominant limb: p < 0.01; d = 0.54), posteromedial (injured limb vs. dominant limb: p < 0.001; d = 1.89; non-injured limb vs. dominant limb: p < 0.001; d = 1.13), and posterolateral (injured limb vs. dominant limb: p < 0.001; d = 1.86; non-injured limb vs. dominant limb: p < 0.001; d = 0.86) reach distances, and composite scores (injured limb vs. dominant limb: p < 0.001; d = 2.27; non-injured limb vs. dominant limb: p < 0.001; d = 1.10) were all significantly lower in both injured and non-injured limbs of the GP group compared to the dominant limb of the control group (Table 2).
3.3. Core stability
Controls' side bridge measures on dominant and non-dominant limbs did not differ significantly (d = 0.02). Similarly, there were no significant differences in side bridge endurance times within the GP group between injured and non-injured limbs (d = 0.16). However, comparison between the GP group and controls illustrated significantly lower (p < 0.001) endurance times for the side bridge on both injured (d = 1.89) and non-injured limbs (d = 1.76), as well as for trunk flexor (d = 3.21) and extensor (d = 3.21) tests, compared to the controls’ dominant limb outcomes (Table 3).
Table 3.
Core stability measures in the groin pain (GP) and control groups.
| Control group (n = 42) | GP group (n = 42) | P | Mean difference (95 % confidence interval) | Cohen's d | |
|---|---|---|---|---|---|
| Flexor | 133.52 (27.24) | 62.33 (15.54) | <0.001 | 71.19 (61.52–80.85) | 3.21 |
| Extensor | 149.90 (31.46) | 70.00 (15.57) | <0.001 | 79.90 (69.06–90.74) | 3.21 |
| Side bridge on dominant/injured limbs | 85.16 (19.47) | 53.19 (13.84) | <0.001a | 31.97 (24.64–39.31) | 1.89 |
| Side bridge on non-dominant/non-injured limbs | 85.69 (25.20) | 55.28 (13.86) | <0.001b | 29.88 (22.54–37.21) | 1.76 |
a Significant difference between the side bridge while lying on dominant limb and injured limb.
b Significant difference between the side bridge while lying on dominant and non-injured limb.
3.4. Passive hip range of motion
Results demonstrated excellent test-retest reliability for range of motion measures, with ICC values of single measures of 0.88–0.94, and SEM values of 0.62–0.78 with an MDC of 1.72–2.16. The ICC value of total rotation was 0.92 and SEM and MDC were 1.00 and 2.76, respectively.
There were no significant differences in the range of motion between the dominant and non-dominant limbs in abduction (η2 = 0.04), internal (η2 = 0.004), external (η2 = 0.002), and total (η2 = 0.003) rotation within the control group. However, within the GP group, the injured limb showed significantly lower internal (p < 0.05; η2 = 0.13) and total (p < 0.01; η2 = 0.18) rotation compared to the non-injured one. It is worth noting that these observed differences did not exceed MDC. Additionally, injured and non-injured limbs displayed no significant differences in abduction (η2 = 0.03) and external rotation (η2 = 0.08). Comparing the GP group to the control group, GP group injured limbs showed decreased internal (p < 0.05; η2 = 0.06) and total (p < 0.01; η2 = 0.08) rotations compared to controls’ dominant one, but observed differences did not exceed the MDC. These limbs demonstrated no significant difference in in abduction (η2 = 0.01) and external rotation (η2 = 0.03). Similarly, no significant differences were observed between non-injured limb and dominant limb in abduction (η2 = 0.001), internal (η2 = 0.001), external (η2 = 0.01) and total (η2 = 0.007) rotations (Table 2).
3.5. Correlation and regression
In the GP group, no significant correlation was observed between dynamic postural balance and pain subscale of the HAGOS and hip range of motion. However, in both limbs, all dynamic postural balance showed a positive correlation (r = 0.13–0.61, p < 0.05–0.001) with core stability measures, except for anterior and posterolateral reaches in the non-injured limb. These reaches were not found to be significantly correlated with the side bridge endurance time on the non-injured limb (Table 4–A).
Table 4-A.
Correlation outcomes between dynamic postural balance, core stability, hip range of motions, and pain subscale of the Copenhagen Hip and Groin Outcome Score (HAGOS) among the groin pain (GP) group.
| Anterior |
Posteromedial |
Posterolateral |
Composite score |
|||||
|---|---|---|---|---|---|---|---|---|
| Injured limb | Non-injured limb | Injured limb | Non-injured limb | Injured limb | Non-injured limb | Injured limb | Non-injured limb | |
| Core stability | ||||||||
| Flexor | r = 0.34* | r = 0.41** | r = 0.40** | r = 0.33* | r = 0.36* | r = 0.31* | r = 0.45** | r = 0.46** |
| p < 0.05 | p < 0.01 | p < 0.01 | p < 0.05 | p < 0.05 | p < 0.05 | p < 0.01 | p < 0.01 | |
| Extensor | r = 0.43** | r = 0.41** | r = 0.68*** | r = 0.49** | r = 0.60*** | r = 0.43** | r = 0.73*** | r = 0.59*** |
| p < 0.01 | p < 0.01 | p < 0.001 | p < 0.01 | p < 0.001 | p < 0.01 | p < 0.001 | p < 0.001 | |
| Side bridge on injured limb | r = 0.54*** | r = 0.52*** | r = 0.43** | r = 0.35* | r = 0.54*** | r = 0.37* | r = 0.61*** | r = 0.55*** |
| p < 0.001 | p < 0.001 | p < 0.01 | p < 0.05 | p < 0.001 | p < 0.05 | p < 0.001 | p < 0.001 | |
| Side bridge on non-injured limb | r = 0.38* | r = 0.13 | r = 0.41** | r = 0.32* | r = 0.41** | r = 0.28 | r = 0.50** | r = 0.33* |
| p < 0.05 | p = 0.38 | p < 0.01 | p < 0.05 | p < 0.01 | p = 0.07 | p < 0.01 | p < 0.05 | |
| Hip range of motion | ||||||||
| Abduction injured limb | rs = −0.01 | rs = 0.005 | rs = 0.10 | rs = 0.07 | rs = −0.4 | rs = 0.11 | rs = 0.05 | rs = 0.12 |
| p = 0.95 | p = 0.97 | p = 0.51 | p = 0.64 | p = 0.77 | p = 0.48 | p = 0.71 | p = 0.43 | |
| Abduction non-injured limb | rs = −0.004 | rs = −0.01 | rs = 0.07 | rs = 0.02 | rs = −0.13 | rs = 0.04 | rs = 0.01 | rs = 0.07 |
| p = 0.98 | p = 0.92 | p = 0.62 | p = 0.87 | p = 0.40 | p = 0.77 | p = 0.94 | p = 0.64 | |
| Internal rotation injured limb | rs = −0.01 | rs = 0.07 | rs = −0.02 | rs = −0.09 | rs = −0.22 | rs = −0.05 | rs = −0.13 | rs = −0.06 |
| p = 0.93 | p = 0.64 | p = 0.86 | p = 0.54 | p = 0.14 | p = 0.72 | p = 0.39 | p = 0.69 | |
| Internal rotation non-injured limb | rs = −0.08 | rs = 0.03 | rs = 0.14 | rs = 0.09 | rs = −0.10 | rs = 0.10 | rs = −0.01 | rs = 0.15 |
| p = 0.60 | p = 0.81 | p = 0.37 | p = 0.56 | p = 0.50 | p = 0.51 | p = 0.93 | p = 0.32 | |
| External rotation injured limb | rs = 0.002 | rs = 0.007 | rs = −0.005 | rs = 0.22 | rs = −0.06 | rs = 0.05 | rs = −0.02 | rs = 0.11 |
| p = 0.98 | p = 0.96 | p = 0.97 | p = 0.16 | p = 0.68 | p = 0.72 | p = 0.88 | p = 0.45 | |
| External rotation non-injured limb | rs = −0.12 | rs = −0.03 | rs = −0.24 | rs = −0.09 | rs = −0.12 | rs = −0.07 | rs = −0.24 | rs = −0.04 |
| p = 0.42 | p = 0.84 | p = 0.12 | p = 0.54 | p = 0.43 | p = 0.62 | p = 0.12 | p = 0.78 | |
| Total rotation injured limb | rs = 0.01 | rs = 0.03 | rs = −0.034 | rs = 0.09 | rs = −0.20 | rs = 0.03 | rs = −0.11 | rs = 0.04 |
| p = 0.90 | p = 0.83 | p = 0.83 | p = 0.54 | p = 0.19 | p = 0.83 | p = 0.48 | p = 0.75 | |
| Total rotation non-injured limb | rs = −0.09 | rs = −0.008 | rs = −0.01 | rs = 0.04 | rs = −0.17 | rs = 0.01 | rs = −0.14 | rs = 0.08 |
| p = 0.55 | p = 0.96 | p = 0.93 | p = 0.77 | p = 0.27 | p = 0.92 | p = 0.35 | p = 0.58 | |
| HAGOS pain | rs = −0.10 | rs = 0.006 | rs = 0.11 | rs = 0.12 | rs = 0.18 | rs = 0.03 | rs = 0.16 | rs = 0.10 |
| p = 0.52 | p = 0.97 | p = 0.48 | p = 0.41 | p = 0.23 | p = 0.82 | p = 0.30 | p = 0.51 | |
*p < 0.05, **p < 0.01, ***p < 0.001.
The side bridge endurance time for the injured limb accounted for 29.5% and 27.5% (p < 0.001) of the variance in the anterior reach, while standing on the injured and non-injured limbs, respectively. On the other hand, the trunk extensor endurance time explained 46.6% and 24.6% (p < 0.001) of the posteromedial reach, 36.4% (p < 0.001) and 18.5% (p < 0.01) of the posterolateral reach, and 53.6% and 53.2% (p < 0.001) of the composite score, while standing on the injured and non-injured limbs, respectively.
In control group, no significant correlations were observed between dynamic postural balance and hip range of motion and core stability measures (Table 4–B).
Table 4-B.
Correlation outcomes between dynamic postural balance, core stability and hip range of motion among the control group.
| Anterior |
Posteromedial |
Posterolateral |
Composite score |
|||||
|---|---|---|---|---|---|---|---|---|
| Dominant limb | Non-dominant limb | Dominant limb | Non-dominant limb | Dominant limb | Non-dominant limb | Dominant limb | Non-dominant limb | |
| Core stability | ||||||||
| Flexor | r = 0.07 | r = 0.03 | r = −0.02 | r = 0.008 | r = 0.03 | r = 0.06 | r = 0.03 | r = 0.04 |
| p = 0.63 | p = 0.82 | p = 0.89 | p = 0.95 | p = 0.81 | p = 0.66 | p = 0.84 | p = 0.75 | |
| Extensor | r = −0.20 | r = −0.13 | r = −0.09 | r = −0.12 | r = −0.20 | r = −0.17 | r = −0.20 | r = −0.18 |
| p = 0.19 | p = 0.38 | p = 0.54 | p = 0.41 | p = 0.19 | p = 0.26 | p = 0.19 | p = 0.25 | |
| Side bridge on dominant limb | r = −0.10 | r = −0.07 | r = −0.16 | r = −0.09 | r = −0.06 | r = −0.03 | r = −0.13 | r = −0.07 |
| p = 0.49 | p = 0.64 | p = 0.29 | p = 0.55 | p = 0.68 | p = 0.84 | p = 0.40 | p = 0.64 | |
| Side bridge on non-dominant limb | r = −0.15 | r = −0.16 | r = −0.08 | r = −0.09 | r = 0.01 | r = 0.04 | r = −0.07 | r = −0.06 |
| p = 0.31 | p = 0.29 | p = 0.60 | p = 0.54 | p = 0.90 | p = 0.79 | p = 0.66 | p = 0.69 | |
| Hip range of motion | ||||||||
| Abduction dominant limb | rs = 0.18 | rs = 0.20 | rs = 0.02 | rs = 0.04 | rs = 0.05 | rs = 0.05 | rs = 0.09 | rs = 0.06 |
| p = 0.23 | p = 0.20 | p = 0.89 | p = 0.80 | p = 0.72 | p = 0.72 | p = 0.54 | p = 0.68 | |
| Abduction non-dominant limb | rs = −0.02 | rs = −0.08 | rs = −0.07 | rs = 0.003 | rs = −0.002 | rs = −0.004 | rs = 0.002 | rs = −0.02 |
| p = 0.89 | p = 0.58 | p = 0.65 | p = 0.98 | p = 0.98 | p = 0.98 | p = 0.99 | p = 0.90 | |
| Internal rotation dominant limb | rs = 0.07 | rs = −0.03 | rs = −0.02 | rs = −0.04 | rs = 0.02 | rs = 0.06 | rs = 0.007 | rs = −0.008 |
| p = 0.64 | p = 0.84 | p = 0.85 | p = 0.78 | p = 0.86 | p = 0.70 | p = 0.96 | p = 0.96 | |
| Internal rotation non-dominant limb | rs = 0.20 | rs = 0.05 | rs = −0.17 | rs = −0.21 | rs = −0.05 | rs = −0.01 | rs = −0.03 | rs = −0.08 |
| p = 0.18 | p = 0.74 | p = 0.26 | p = 0.17 | p = 0.73 | p = 0.90 | p = 0.84 | p = 0.58 | |
| External rotation dominant limb | rs = −0.02 | rs = 0.007 | rs = 0.08 | rs = 0.06 | rs = −0.02 | rs = 0.01 | rs = 0.02 | rs = 0.04 |
| p = 0.90 | p = 0.96 | p = 0.57 | p = 0.68 | p = 0.86 | p = 0.92 | p = 0.88 | p = 0.80 | |
| External rotation non-dominant limb | rs = −0.02 | rs = 0.08 | rs = −0.17 | rs = −0.19 | rs = 0.001 | rs = −0.01 | rs = −0.10 | rs = −0.07 |
| p = 0.89 | p = 0.57 | p = 0.27 | p = 0.21 | p = 0.99 | p = 0.95 | p = 0.49 | p = 0.62 | |
| Total rotation dominant limb | rs = 0.02 | rs = −0.04 | rs = 0.02 | rs = −0.02 | rs = 0.01 | rs = 0.06 | rs = 0.01 | rs = −0.006 |
| p = 0.85 | p = 0.76 | p = 0.86 | p = 0.89 | p = 0.93 | p = 0.66 | p = 0.90 | p = 0.97 | |
| Total rotation non-dominant limb | rs = 0.18 | rs = 0.07 | rs = −0.18 | rs = −0.21 | rs = −0.009 | rs = 0.007 | rs = −0.02 | rs = −0.063 |
| p = 0.25 | p = 0.64 | p = 0.23 | p = 0.17 | p = 0.95 | p = 0.96 | p = 0.86 | p = 0.69 | |
4. Discussion
Findings indicated that soccer players experiencing GP displayed compromised dynamic postural balance in both limbs compared to dominant limb of asymptomatic players. Additionally, those experiencing GP demonstrated reduced internal and total rotations in the injured limb and weaker core stability compared to their asymptomatic counterparts. However, the differences observed in hip range of motion did not exceed the MDC. Overall, in soccer players experiencing GP, poor dynamic balance performance was associated with lower core stability while standing on both limbs. However, there were no notable connections found between the players' dynamic postural balance, pain, and hip range of motion. Additionally, asymptomatic soccer players did not reveal any significant correlations between their dynamic postural balance results, core stability, or hip range of motion.
When compared to their asymptomatic peers, soccer players with GP had poorer trunk endurance time measures, indicating decreased core stability. These findings connect with earlier studies examining various aspects of trunk muscle function, all of which provide insight at alterations in patients with GP when compared to asymptomatic players.7,12 Some authors argue that decreased function of trunk muscles could result from physical deconditioning caused by chronic pain.19 Nevertheless, a recent study demonstrated no significant differences in side bridge endurance time between soccer players experiencing hip or GP and their asymptomatic peers.20 This inconsistency could be due to differences in the category of GP included in the study (hip-related GP) compared to ours (adductor-related GP, and adductor-combined with inguinal-related GP).
The core is critical to sports performance, offering proximal stability to facilitate distal mobility21 as illustrated by greater core endurance corresponding with better dynamic postural balance during Y-BT.22,23 Our correlation analyses verified the connection between Y-BT performance and core endurance in soccer players experiencing GP. However, there was no significant link between the anterior and posterolateral reaches of the non-injured limb and the side bridge endurance time of that limb. Despite the lack of significant findings, our players with GP showed a general pattern indicating a link between core endurance and dynamic postural balance. Correlation data suggests that decreased core endurance alters dynamic postural balance in players with GP.
Regression results showed, in both injured and non-injured limbs, that the trunk extensor endurance time was associated with the posteromedial (injured limb: 46.6%, non-injured limb: 24.6%) and posterolateral (injured limb: 36.4%, non-injured limb: 18.5%) reaches and the composite score (injured limb: 53.6%, non-injured limb: 53.2%). In addition, the side bridge endurance time, on injured limb, was associated with the anterior reach (injured limb: 29.5%, non-injured limb: 27.5%). The data indicate that, apart from the muscles engaged in the side bridge on the injured limb, the extensor muscles contribute further to dynamic postural balance in our soccer players experiencing GP. Postural balance is highly reliant on the extensor muscles located in the trunk and lower extremity.24 It is worth noting that reduced motor output in the extensor muscles has a higher impact on postural balance than the flexors.24 The horizontal trunk extension challenge the multifidus and erector spinae muscles.25 The multifidus plays an imperative role in stabilizing the lumbar spine and adjusting its position during movement.26 Indeed, the multifidus fascicles establish connections with individual vertebrae and have the ability to adjust each one during extension, mainly to counteract the undesired flexion caused by the abdominal muscles.27 This muscle is engaged before movement of the lower limbs to give postural support.21,28 Additionally, side bridge challenge the activation of the transversus abdominis, internal oblique29 and the quadratus lumborum30 muscles. The gluteus medius is more activated during the side bridge compared to other ones involving core muscles.31 Before starting a movement, the transversus abdominis muscle and obliques activate to stabilize the spine, aiming to create a stable base for functional movements.28 Furthermore, it was observed that hip abduction strength was a determinant of Y-BT performance in the three directions, and of composite score.32 Based on the information presented above, it appears that the muscles engaged during core endurance tests have a role in maintaining postural balance when performing lower limb motions. It is likely that deficits in these muscles contribute to the altered dynamic postural balance seen in our soccer players experiencing GP. Nonetheless, the exact role of these muscles in these impairments is not well understood.
Interestingly, a study found that individuals with GP had less activity in the transversus abdominis/internal oblique, gluteus medius, and multifidus muscles when turning than their peers.33 Furthermore, investigations on people with GP found that they had slower transversus abdominis muscle activation during functional activities34 and lower gluteus medius muscle activity during unilateral stance35 than their peers.
Contrary to our initial hypothesis, we did not observe any significant associations between pain and dynamic postural balance results among our soccer players experiencing GP. This could possibly be attributed to the fact that the HAGOS pain items took into account the functionality of the hip and groin throughout the previous week,13 prior to postural balance testing. Our soccer players experiencing GP did not reveal any significant associations between Y-BT measures and hip range of motion. Whilst these players showed lower internal and total hip rotations in the injured limb than asymptomatic players, these differences did not extend beyond the MDC. As a result, these differences are not clinically significant.
Our results pointed out the contribution of poor core stability for dynamic postural balance disorders in injured and non-injured limbs of soccer players experiencing GP. This information can assist set up strategies to offer a targeted approach to enhance postural balance in those players. This suggests that scientific trials designed to enhance core stability may have the potential to enhance dynamic postural balance for soccer players experiencing GP.
The current study encountered some limitations. Despite conducting numerous tests to evaluate core stability, there is a lack of agreement regarding the definition and evaluation of this measure. In our study, we applied trunk endurance tests to evaluate core stability owing to their simplicity and cost-effectiveness. Additionally, incorporating electromyography to measure core muscle activation during Y-BT among soccer players experiencing GP could potentially enhance our comprehension of their impact on dynamic balance performance.
5. Conclusion
According to the study, soccer players with non-time loss GP performed worse in dynamic balance in both injured and non-injured limbs as compared to the dominant limb of asymptomatic players. Poor dynamic balance performance correlated with lower core endurance in players experiencing GP when standing on both limbs.
Guardian/patient's consent
o I confirm that I have read and understood the subject information sheet for the study and have had the opportunity to ask questions which have been answered fully.
o I understand that participation is voluntary and I am free to withdraw at any time, without giving any reason, without medical care or legal rights being affected.
o The compensation arrangements have been discussed with me.
o I understand that I will be given a copy of this consent form.
Ethical approval
This work has been approved by the local Ethics Committee (Protection Committee for sud Persons, approval number CPP/SUD: 0206/2019), and participants gave informed consent to the work.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Patient consent statement
Prior to enrollment, all participants gave their written informed consent.
Data availability statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.
CRediT authorship contribution statement
Fatma Chaari: Conceptualization, Investigation, Formal analysis, Writing – original draft, Writing – review & editing. Abderrahmane Rahmani: Supervision, Writing – review & editing, Writing – original draft. Haithem Rebai: Conceptualization, Supervision. Thouraya Fendri: Investigation. Sonia Sahli: Supervision, Writing – review & editing, Writing – original draft. Sébastien Boyas: Supervision, Writing – review & editing, Writing – original draft.
Declaration of competing interest
There are no relevant financial or non-financial competing interests to report.
Acknowledgments
The authors thank the participants for their voluntary participation, patience and availability.
Contributor Information
Fatma Chaari, Email: chaarifatma94@gmail.com.
Abderrahmane Rahmani, Email: Abdel.Rahmani@univ-lemans.fr.
Haithem Rebai, Email: haithem.rebai@isseps.usf.tn.
Thouraya Fendri, Email: thouraya.fendri.1@gmail.com.
Sonia Sahli, Email: sonia.sahli@isseps.usf.tn.
Sébastien Boyas, Email: Sebastien.Boyas@univ-lemans.fr.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.