Exercise programmes for hip control to improve lower limb movement quality inyoung footballers: a proof of concept and feasibility trial

Abstract

Hip and groin pain are common, affecting 55% of male football players, and femoroacetabular Impingement (FAI) is a major cause of this pain and a precursor of hip osteoarthritis (OA). Approximately 72% of footballers have the morphological changes of FAI, which can start as early as 10-12 years and are not always associated with pain. There may be a link between altered movement and hip and groin pain, FAI (symptomatic or asymptomatic) and later life OA developing. However, no studies have investigated movement abnormalities of the hip that specifically inform exercise programmes for improving movement quality, possibly a modifiable factor. Therefore, the research presented in this thesis aimed to provide proof of concept (PoC) for retraining movement control of the hip and pelvis in young footballers using a motor control exercise intervention, and to examine the feasibility of conducting a future randomised controlled trial in a community football setting.

Initially, a Hip and Lower Limb Movement Screen (HLLMS) was used to assess 36 academy footballers at a Premiership Football Club (aged 9-18 years, mean 14), to identify altered movement patterns to inform the exercise intervention (Chapter 3). The HLLMS included seven tests: a small knee bend (SKB), SKB with trunk rotation, deep squat, standing and sitting hip flexion to 110° and side-lying hip abduction with the leg laterally and then medially rotated. The quality of movement was observed by the investigator and each test was rated against benchmark criteria. Reliability of ratings was acceptable, with overall intra-rater reliability having almost perfect agreement (AC1 0.91; PA 95%), and moderate inter-rater reliability (AC1 0.79; PA 87%) and within-subject variability (AC1 0.73; PA 83%) (Chapter 5). The main movement abnormality identified in academy footballers was the inability to control hip flexion and medial rotation during these tests and the results informed the development of the targeted exercise intervention programme (Chapter 3).

The feasibility and PoC study involved two recreational football clubs, including 59 players aged 16-19 years (mean 16; SD 0.81 years). Data were collected at baseline prior to a 12-week motor control exercise intervention, with immediate follow-up post-intervention (Chapter 6). Questionnaires included Copenhagen Hip and groin outcome score (HAGOS), International Hip Outcome Tool (iHOT-33), Paediatric Pain Screening Tool (PPST) and the health status generic measure (EQ-5D-5L). Clinical screening tests included passive hip internal rotation (IR) and hip flexion range, tests for hip impingement and the Star Excursion Balance Test (SEBT) to evaluate dynamic postural control, while, the HLLMS assessed movement control. The study demonstrated recruitment was feasible, with players and coaches accepting the exercise intervention when it formed part of routine football warm-up training although barriers were identified. The intervention was performed around three times per week, resulting in improved hip and pelvic movement quality (p=0.004), with 80% of players showing a difference above the 4.68 minimal detectable change. Movement quality improved during all seven HLLMS tests, showing changes in hip flexion and medial rotation control, providing PoC for retraining movement control in young footballers. The findings support the feasibility of a future RCT in a young football community setting. Public representation from coaches and players will be vital to successful research, implementation and long-term adherence, as highlighted by representatives in the present study, who advised that focus should be on performance rather than injury prevention to motivate players and clubs.

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Identifiers

ORCID for Nadine Carmella Licia Booysen: orcid.org/0000-0001-8798-2411

ORCID for Maria Stokes: orcid.org/0000-0002-4204-0890

ORCID for Martin Warner: orcid.org/0000-0002-1483-0561

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