INTRODUCTION
Soccer is a worldwide team sport that involves repetitive high-velocity activities including running, jumping, sprinting, ball-kicking, changing direction, acceleration, deceleration, and physical contact with the opponents. This imposes great technical, physical and physiological demands that increase the risk for injury.1,2 Most soccer injuries occur in the lower extremities (61-82%) especially at the ankle (28%) and knee (19%)3,4 with sprain and strain injuries constituting more than one-half of all collegiate injuries that require athletic trainer attention.5 That is why clubs invest in time and resources for reducing injury incidences.6
A theoretical framework of the association between core muscle dysfunction and musculoskeletal injury became popularized over the past decade with limited scientific evidence.7 Adequate core (lumbo-pelvic-hip) musculature neuromuscular control is required during lower limb dynamic activities to assure dynamic joint stability.8,9 Improper control predisposes lower limb joints to uncontrolled displacements, and excessive loading.9,10 Upon exceeding supporting soft tissue tensile threshold, these excessive stresses can cause mechanical failure.11
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Imbalance in core musculature strength that controls pelvic-femoral alignment in the transverse and frontal planes causes lower limb misalignment that may increase the risk for injury.12 Strong hip abductors and external rotators are necessary in unilateral limb support activities involved in soccer to avoid excessive hip adduction and internal rotation.13 The position of hip adduction and internal rotation that is associated with knee valgus and tibial external rotation is referred to as the “position of no return” being responsible for many injuries including anterior cruciate ligament injury.14 A negative correlation was previously reported between hip abductor peak torque (normalized to body mass) and dynamic knee valgus15 with every 1% increase in peak torque showing a decrease of 0.216 º in knee valgus.16 Similarly, a negative correlation was reported between hip external rotator strength and knee valgus.17 Athletes with weak hip abductors and/or external rotators have increased dynamic knee valgus.17-19 In the same context, hip muscle activity affects the force production ability of the quadriceps and hamstrings together with affecting their ability to resist forces experienced by the lower limb during jumping.20
Very few studies have examined the association between core stability measures and musculoskeletal injury10,21-23 and none of them dealt with soccer athletes. In addition, several limitations were identified in these studies. Leetun et al.,21 assessed hip muscles’ strength, however they examined isometric forces not isokinetic torques. Torque measurement takes in consideration height differences. For instance, if the injured players were systematically taller than the non-injured players, the difference between both groups in torques might have been less significant than force measurements.21 Their study used a hand-held dynamometer for strength (force) assessment not an isokinetic dynamometer (torque). Pre-season isokinetic strength testing has been identified as a useful tool for identifying soccer players that are potentially at risk for injury. Testing helped in detecting strength imbalances that increased the risk of hamstring injury.24 Specifically, impairment in eccentric hamstring action required in high velocity acceleration and deceleration activities of soccer is associated with elevated risk for joint and muscle injury.25
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In an attempt to identify the risk factors for injury, Wilkerson et al.10 and Wilkerson and Colston23 constructed a prediction model for core and lower extremity sprain and strain injury in football players. However, several limitations were identified that might have confounding effects on prediction power. They examined players with and without low back dysfunction. Low back dysfunction increases the susceptibility to lower extremity injury.21,22,26 In addition, they examined a combination of risk factors including core endurance, level of low back dysfunction, and game exposure to predict sprain and strain injuries of both the core and lower extremities. Thus, the recorded and analyzed injuries were neither specific to core stability measures nor specific to the lower extremities. The intention of the current study was to examine the isolated contribution of core endurance and strength to lower extremity injury only.
Since there are very limited data on the association between core stability and injury in the literature, it was of interest to compare core muscle endurance and hip muscle strength in injured players with those of non-injured players. Rapid core musculature fatigue is reflected in poor core stability.27,28 For instance, fatigue of hip and lumbar extensors, specifically, has been shown to contribute to forward trunk lean29 as well as reduced trunk proprioception28 and neural activation of lower limb muscles.26 The time a player is able to maintain static postures during core endurance tests that load the core musculature is valuable for quantifying the risk for injury.10 Thus, the purpose of this study was to compare core muscle endurance and hip muscle strength between soccer players who experienced non-contact lower extremity sprain and/or strain injury during their season and those who did not. Additionally, the frequency of injury was correlated with core muscle endurance and hip strength, and endurance was used for predicting the risk for injury.
Finally, core muscle endurance was used for predicting injury. Core endurance was the measure of interest as it is the most reliable measure of core stability followed by flexibility, strength, neuromuscular control and functional testing.30 It was hypothesized that injured players would present with low core muscle endurance and diminished hip muscle strength. In addition, it was anticipated that low endurance would be associated with increased frequency of injury.
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