THE ADDITION OF THE COPENHAGEN ADDUCTION EXERCISE TO THE FIFA 11+ INJURY PREVENTION PROGRAM TO PREVENT GROIN INJURIES IN FOOTBALL:

Injuries involving the groin are common in sports that require sudden acceleration and deceleration, sudden directional changes and kicking. Such sports include football (Eirale et al., 2014; Anderson et al., 2011) and Paajanen et al. (2011), and rugby as it includes the above actions (Hodgson et al., 2015). Also, research by Serner et al. (2015) has found hip adductor injuries to be the most frequent groin injuries in athletes. Within football specifically, hip adductor muscle injuries are the second most common muscle injury according to Elkstrand et al. (2011) and are thought to constitute to 64-69% of all groin injuries according to Werner et al. (2009) and 40% of experience absence from football for more than twenty-eight days (Hölmich et al., 2014). As well as having a high rate of first time occurrence, data provided by Hägglund et al. (2006) has found those who have suffered a groin strain are at a 2.4 times greater risk compared to those with no injury history, while work by Engebretsen et al. (2010) has identified previous injury as an intrinsic risk factor for groin injuries. This vicious cycle can therefore lead to not only a reduction in performance, but also missed training and/or competition time and more alarmingly, the potential end of an athlete’s career as well as potential future mobility impairment (Whittaker et al., 2015).

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Reduced hip abduction strength has been found to be an intrinsic risk factor for sustaining an adductor injury by Ryan et al. (2014) indicating that increasing Eccentric Hip Adductor Strength (EHAD) is a relevant intervention to look to prevent adductor-related injuries (Donaldson et al., 2015).

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The FIFA 11+ is an injury prevention program which was developed in partnership with both national and international experts under the guidance of the FIFA Medical and Research Centre (F-Marc), to decrease the incidence of football injuries (Barengo et al., 2014). The FIFA 11+ is a simple and easy to use sports injury prevention program that can be added into a warm-up that replaces the FIFA 11 (Krist et al., 2013; Verhagen, 2013). The program features exercises which focus on core stabilisation, eccentric thigh muscle training, proprioceptive training and plyometric drills; the only equipment it needs is a ball and once it is familiar to athletes, it can be completed in ten to fifteen minutes (Barengo et al., 2014).

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The FIFA 11+ has been shown to be widely effective in reducing injuries in football in a range of different settings. For example, Steffen et al. (2013) concluded that high rates of player adherence to the program resulted in significant improvements in both functional balance and injury risk in Canadian youth female football players. Secondly, Owoeye et al. (2014) concluded from their work that the FIFA 11+ programme is effective in reducing the rates of injuries in male youth football players. These findings are shared by Silvers-Granelli et al. (2015) who found that the FIFA 11+ significantly reduced injury rates by over 45% and time lost to injury by over 28% in competitive male collegiate soccer players. However, these effects are not seen in veteran players. In a randomised control trial Hammes et al. (2015) concluded that regularly completion (for example once a week) of the FIFA 11+ does not prevent injuries in veteran footballers under real training and competition circumstances. This lack of preventive effects is thought to be due to the too low overall frequency of training sessions.

The Copenhagen Adduction (CA) exercise is a dynamic, high-intensity pairs exercise performed to full range of motion. While side-lying, the lower forearm acts as support on the ground while the other arm is placed along the body. A partner holds the upper leg at hip height, with one hand supporting the ankle and the other supporting the knee. A repetition is perf­ormed as the player lifts the body in a three second concentric hip adduction movement until the body reaches a straight line, while simultaneously adducting the lower leg so that the feet touch each other. This is followed by a three second eccentric adduction where the body is lowered halfway to the ground while the foot of the lower leg is lowered until it just touches the ground without using it for support, as shown in Figure 2 (a) and (b); (Serner et al., 2014).

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The CA exercise has already been found to be a useful exercise to increase hip adductor strength. For example, Ishøi et al. (2016) found an increase of almost 36% in EHAD, an increase of just over 20% in eccentric hip abduction strength and an increase of just over 12% in eccentric hip adduction to abduction strength ratio. Secondly, it has been argued by Krommes et al. (2016) that the CA exercise appears to be one of the most relevant exercises to include within a groin injury prevention program as it causes muscle activity of greater that 80%, which is higher than other dynamic exercises. Also, research by Serner et al. (2014) argue that because the CA exercise features high Electromyographic activity of the Adductor Longus as well as eccentric contractions, it could therefore be recommended as one of the best exercises for the prevention of adductor-related injuries in footballers. These findings are further supported by a study by Jensen et al. (2014) who showed that an eight-week progressive strengthening programme which featured the CA exercise with a resistance band increased eccentric hip adduction strength by 13%. Lastly, and perhaps of the most significance Harøy et al. (2017) found a significantly greater increase in eccentric hip adduction strength of almost 9% in favour of the group performing the CA exercise when it replaced the Nordic Hamstring Curl in the FIFA 11+ whereas no within-group change was noted in the group that simply used the standard FIFA 11+ program. This study then concluded that including the CA exercise in the FIFA 11+ program increases eccentric hip adduction strength and therefore the CA exercise could be included in the FIFA 11+ to potentially increase the preventative effect of the program on groin injuries.

To conclude, given the high prevalence of adductor-related injuries in football, as well as the high risk of recurrence and the effects such injuries can have on athletes, there is a clear need to look to prevent such injuries. With the evident effectiveness of the FIFA 11+ already, plus the findings in the literature on the strength gains brought about by the implementation of the CA, is recommended to include this exercise in the FIFA 11+ to look to prevent future adductor-related injuries. 

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