Original article
Br J Sports Med: first published as 10.1136/bjsm.2008.055749 on 11 March 2009. Downloaded from http://bjsm.bmj.com/ on December 20, 2021 at UCL Library Services. Protected by
1
Brunel University, Uxbridge,
UK; 2 SPORTSMED SA, Stepney,
South Australia, Australia;
3
Alphington Sports Medicine
Clinic, Melbourne, Victoria,
Australia; 4 Department of
Mechanical Engineering and
School of Physiotherapy,
University of Melbourne,
Victoria, Australia; 5 Department
of Mechanical Engineering,
University of Melbourne,
Victoria, Australia
Correspondence to:
Anthony Schache, Senior
Research Fellow, School of
Mechanical Engineering,
University of Melbourne,
Melbourne, Australia 3010;
anthonys@unimelb.edu.au
Accepted 6 February 2009
Published Online First
11 March 2009
Br J Sports Med 2009;43:739–744. doi:10.1136/bjsm.2008.055749
Hip flexibility and strength measures: reliability and
association with athletic groin pain
P Malliaras,1 A Hogan,2 A Nawrocki,3 K Crossley,4 A Schache5
ABSTRACT
Objective: Groin pain commonly affects football players
and can be associated with prolonged recovery periods.
Understanding the relationship between groin pain and
reliable measures of hip flexibility and strength may
facilitate the development of optimal rehabilitation and
prevention strategies. In this study, the reliability and
association with athletic groin pain of hip flexibility and
strength measures were investigated.
Methods: A cohort of 29 football players (15–21 years)
participating in junior elite competitions (Australian Rules
football and soccer) were recruited. The intra-rater reliability
(n = 13) and inter-rater reliability (n = 12) of various hip
flexibility (bent knee fall out test, hip internal rotation, hip
external rotation) and strength (hip abduction, hip internal
rotation, hip external rotation, hip adduction (squeeze test))
measures were investigated using intraclass correlation
coefficients (ICC). Reliable hip flexibility and strength
measures were compared between football players with
(n = 10) and without (n = 19) groin pain.
Results: The bent knee fall out test, hip internal rotation
flexibility and the squeeze test demonstrated acceptable
(ICC.0.75) intra-rater and inter-rater reliability, while hip
external rotation flexibility and hip abduction strength
demonstrated acceptable intra-rater but not inter-rater
reliability. Hip internal and external rotation strength tests
were not found to be reliable. Football players with groin
pain had significantly reduced force production on the
squeeze test (p.0.05).
Conclusion: Several hip flexibility and strength measures
were found to be reliable. Only the squeeze test discriminated
between football players with and without groin pain.
Groin pain commonly affects athletes participating
in football codes that require a combination of
running, rapid agility movements and repetitive
kicking.1–3 It has been reported that groin pain may
account for up to 13% of all football injuries.1 2 4
One of the main problems encountered with groin
pain is that it is often associated with longstanding
symptoms, limiting function and performance for
months or even years.5 Groin pain represents a
significant clinical challenge due to the difficulty
experienced in identifying the injured structure(s),
which is due in part to the complex anatomy of the
region. To assist in classifying groin pain and guide
management, Holmich et al6 proposed three groin
pain ‘‘clinical entities’’ (adductor-, iliopsoas- and
rectus abdominus-related). These clinical entities
were developed on the basis of a series of reliable
clinical measures that examined the reproduction
of groin pain via palpation, passive stretch and
active muscle contraction.7
In addition to the clinical measures evaluated by
Holmich et al,7 there are other measures frequently
used to quantify hip flexibility (eg, hip axial
rotation, combined hip flexion–abduction–external
rotation) and strength (eg, adductors, abductor,
internal/external rotators) among athletes. Little is
known about the reliability and discriminate
ability of these measures among football players
with and without groin pain. Reduced hip internal
and external rotation flexibility has been shown to
discriminate between Australian Rules football
players with and without longstanding groin pain8
and may indicate an increased risk of developing
longstanding groin pain.9 In these studies by
Verrall and co-workers,8 9 hip axial rotation flex-
ibility was recorded with the hip flexed to 90u,
whereas among football players, rotation closer to
neutral hip flexion–extension may better reflect
function. Combined hip flexion–abduction–exter-
nal rotation (bent knee fall out test) is likely to
reflect hip and/or adductor muscle flexibility. No
study has thus far investigated the relationship
between the bent knee fall out test and groin pain.
While hip muscle weakness has been suggested
copyright.
to be a risk factor for groin pain,10 11 and strength
exercises have been recommended as a suitable
intervention,12 as with hip flexibility, little is
actually known about the reliability and discrimi-
native ability of measures that quantify hip
strength among athletes with groin pain.
Holmich et al7 reported moderate reliability
(k = 0.65) in manually assessing the strength
(‘‘strong’’, ‘‘intermediate’’ or ‘‘weak’’) of a max-
imal bilateral hip adduction contraction (static)
among primarily young adult male soccer players.
Other methods, such as dynamometry, may offer
greater sensitivity in measuring hip strength;
however, their reliability and discriminative ability
among athletes with groin pain is yet to be
established. It is clear that further work is required
in evaluating the reliability and discriminate
validity of hip flexibility and strength measures
for examining athletes with groin pain.
The first aim of this study was to identify
reliable hip flexibility measures (bent knee fall out,
axial rotation) and strength measures (adductors,
abductor, internal/external rotators) among foot-
ball players with and without groin pain. The
second aim was to determine if hip flexibility and
strength measures, found to be reliable, were
capable of discriminating between football players
with and without groin pain.
METHODS
Participants
Elite junior (15–21 years old) male football players
(Australian Rules football and soccer) were invited
to participate in this study. Elite junior football
739
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Br J Sports Med: first published as 10.1136/bjsm.2008.055749 on 11 March 2009. Downloaded from http://bjsm.bmj.com/ on December 20, 2021 at UCL Library Services. Protected by
players were recruited as they suffer a high incidence of groin
pain.3 Football players with groin pain were included if they
reported groin pain while running or performing rapid agility
movements and had at least one of the following symptoms: (1)
groin pain standing on one leg, (2) groin pain or stiffness in the
morning, (3) groin pain at night or (4) groin pain when
coughing or sneezing. Asymptomatic football players did not
have any of these signs and symptoms. One of the investigators
(PM) assessed the inclusion and exclusion criteria for each
potential participant via direct interview. This study was
granted ethics approval by the ethics committee at La Trobe
University, Melbourne, Australia and participants provided
signed informed consent.

Procedures
Demographic and anthropometric data (age, weight, height,
years of football competition, hours of weekly football playing,
hours of training (before injury) and dominant kicking leg) were
Figure 1 Bent knee fall out test.
recorded via direct interview. The site of groin pain (pubic,
adductor, hip, abdominal) and the side of groin pain (left, right,
bilateral) was recorded for symptomatic football players. of the lower leg with the vertical axis. The inclinometer was
Clinical signs and symptoms were assessed by one of the used to measure the angle between the lateral aspect of the
authors (PM) and used to determine the primary and, when lower leg and the vertical axis (to the nearest degree).
applicable, secondary clinical entities using the classification
system described by Holmich et al.7 Supine hip external rotation
One examiner (PM) assessed the intra-rater reliability of hip The player was positioned in supine with their non-test hip
flexibility and strength measures (subset of 13 football players: flexed (and that foot resting on the end of the plinth) and their
5 soccer and 8 Australian Rules players). Measures were taken test leg hanging free over the end of the plinth. The
after a standardised warm-up (consisting of stretching and inclinometer was placed 10 cm proximal to the lateral aspect

stationary cycling) and a practice trial for familiarisation. The
examiner undertook an episodic memory distraction task during
the 30 min between the first and second measurements. Two
raters (PM and AN) assessed the inter-rater reliability of the
same measures (subset of 12 Australian Rules football players).
The order of testing was randomised for each footballer.
copyright.
of the lateral malleolus. The examiner passively moved the
lower leg into hip external rotation until he perceived the end of
range, and/or movement of the pelvis was observed (fig 3). No
overpressure was applied. The angle between the lateral aspect
of the lower leg and the vertical was measured using the
inclinometer (to the nearest degree).

Hip flexibility Hip strength measures

Bent knee fall out test Hip abduction
Hip abduction strength was assessed in supine with an
The player was positioned in a crook lying position with their
electronic dynamometer (Lafayette Instrument Company,
knees flexed to 90u (established using a template) and their feet
Lafayette, Indiana, USA) placed 5 cm proximal to the lateral
together. They were instructed to allow their knees to fall
joint line of the knee. The players were instructed to push into
outward while keeping their feet together, and the examiner
abduction as hard as they could for 3 s, with the same degree of
used gentle overpressure to check that the player had relaxed at
the limit of movement. The distance between the most distal
point on the head of the fibula and the surface of the plinth was
measured using an inflexible tape measure (to the nearest
0.5 cm) and recorded (fig 1).

Prone hip internal rotation

The player was positioned in a prone position with their knees
flexed to 90u. They were instructed to allow both feet to fall
outwards (ie, hip internal rotation) while keeping their knees
together. A spirit level, placed across the greatest convexity of
both gluteus maximus muscles, was used to monitor for
unwanted rotation of the pelvis during the hip internal rotation.
The examiner used gentle overpressure to check that the player
had relaxed at the limit of movement. A fluid-filled gravity
inclinometer with a 360u dial (Plurimeter CE, Dr Rippstein, La
Conversion, Switzerland) was placed 10 cm proximal to the
inferior tip of each lateral malleolus. The angle between the
lateral border of the lower leg and the vertical was measured
using the inclinometer (to the nearest degree) and recorded
(fig 2). In addition, a set-square was used to align the long axis Figure 2 Prone hip internal rotation.

740 Br J Sports Med 2009;43:739–744. doi:10.1136/bjsm.2008.055749


Figure 3 Supine hip external rotation.
verbal encouragement provided for each effort (fig 4). The
maximum force displayed on the dynamometer (to the nearest
0.1 kg) was recorded, and the distance between the greater
trochanter and the dynamometer (ie, the moment arm) was
measured using a flexible tape measure (to the nearest 0.5 cm).
Hip internal and external rotation strength
Hip internal and external rotation strength was assessed in the
same position as that used for the supine hip external rotation
test. The dynamometer was placed 10 cm proximal to the
medial malleolus to measure external rotation and 10 cm
proximal to the lateral malleolus to measure internal rotation.
Each player was instructed to push into internal or external
rotation as hard as he could for 5 s, with the same degree of
verbal encouragement provided for each effort (fig 5). The
maximum force displayed on the dynamometer (to the nearest
0.1 kg) was recorded, and the distance between the medial or
lateral knee joint line and the dynamometer (ie, the moment
arm) was measured using a flexible tape measure (nearest
0.5 cm).
Figure 4 Hip abduction strength.
Br J Sports Med 2009;43:739–744. doi:10.1136/bjsm.2008.055749
Original article
Br J Sports Med: first published as 10.1136/bjsm.2008.055749 on 11 March 2009. Downloaded from http://bjsm.bmj.com/ on December 20, 2021 at UCL Library Services. Protected by
Figure 5 Hip internal and external rotation strength.
Hip adduction strength (squeeze test)
With the player lying in supine, templates were used to position
the leg in 0u, 30u and 45u of hip flexion. The squeeze test was
quantified using a sphygmomanometer (Welch Allyn Disytest,
Skaneateles, New York, USA) that was pre-inflated to
10 mm Hg. The cuff of the sphygmomanometer was placed
between the knees, and the player was instructed to squeeze the
copyright.
cuff as hard as he could. The highest pressure displayed on the
sphygmomanometer dial (to the nearest 5 mm Hg) and the site
and side of any groin pain experienced during the test was
recorded (fig 6).
Statistical methods
An average of the two measurements recorded for each test was
used in the statistical analyses. The angle between the distal
tibia and the long axis of the lower leg was subtracted from the
external rotation range and added to the internal rotation range.
Torque (t) was calculated (t = moment arm (m) 6 force (kg))
Figure 6 The squeeze test.
741
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Br J Sports Med: first published as 10.1136/bjsm.2008.055749 on 11 March 2009. Downloaded from http://bjsm.bmj.com/ on December 20, 2021 at UCL Library Services. Protected by
Table 1 Demographic data for players in the control and groin pain alpha level was set at 0.05 for all analyses. Post hoc power was
groups calculated for non-significant findings.15
Control* Groin pain*
Descriptive measures (n = 19) (n = 10)
RESULTS
Age (years) 17.1 (1.6) 17.3 (0.8) Nineteen asymptomatic players and 10 players with groin pain
Height (cm) 183.9 (7.8) 184.4 (6.7) were recruited. The groups were homogeneous with regards to
Weight (kg) 77.1 (5.4) 78.5 (7.0) all demographic and anthropometic characteristics (table 1).
Training (hrs/week) 6.2 (2.1) 5.5 (3.5) Eight players with groin pain had an insidious onset of pain, and
Years of football 8.6 (2.1) 8.2 (2.2)
two players had an acute onset. Five players with groin pain had
Favoured kicking leg, R:L 8:2 16:3
been showing symptoms for between 4 and 5 weeks, while five
Position (back:midfield:forward) 5:11:3 3:6:1
players with groin pain had been showing symptoms for
*Values are mean (SD). 6 weeks or longer (median = 5.5 weeks, IQR = 4–11 weeks).
L, left; R, right.
Nine players had symptoms consistent with the adductor-
related clinical entity (pubic bone tenderness, pain with resisted
for each dynamometry measure. Group differences in demo- adduction) and six of these players had secondary iliopsoas-
graphic data were investigated using independent t tests (age, related symptoms (tenderness lower lateral abdomen and/or
height, weight, training, years of football) or the x2 test distal to inguinal ligament, pain with Thomas test extension
(favoured kicking leg, playing position). Intraclass correlation stretching).6 One player had symptoms consistent with the
coefficients (ICC) and 95% CIs were calculated to determine abdominal-related clinical entity (tenderness of the distal rectus
intra-rater reliability (model 2,1) and inter-rater reliability abdominis tendon or insertion into pubic bone, pain with
(model 3,1).13 Reliability was judged based on established resisted rectus abdominis contraction).6 Eight players had
criteria: good reliability >0.75, moderate reliability ,0.75 and bilateral symptoms and two had left-sided pain.
>0.50, and poor reliability ,0.50.15 To express measurement
error in the original units of measurement, the SEM and 95% CI Reliability of hip flexibility and strength measures
were calculated (SEM = SDav(!12ICC), where SDav = average The bent knee fall out test, prone hip internal rotation and the
standard deviation). For hip flexibility and strength measures squeeze test demonstrated good intra-rater and inter-rater
with acceptable intra-rater reliability (ICC.0.75), group differ- reliability (table 2). Supine hip external rotation and hip
ences were assessed using independent t tests. In addition, total abduction strength demonstrated good intra-rater reliability

copyright.
flexibility (sum of left and right measures) for prone hip internal only (table 2). Measures of hip internal and external rotation
rotation and supine hip external rotation was investigated. The strength demonstrated poor to moderate reliability (table 2).

Table 2 Test–retest and inter-rater reliability for each hip flexibility and strength measure
Test–retest (n = 13) Inter-rater (n = 12)
ICC 95% CI ICC 95% CI
Measures Test* Retest* (3,1) SEM SEM Rater A* Rater B* (2,1) SEM SEM

Flexibility
Right BKFO 10.1 (2.4) 9.8 (2.4) 0.90 1 2 14.6 (5.7) 14.1 (5.8) 0.93 2 3
(cm)
Left BKFO (cm) 9.6 (3.1) 9.4 (2.9) 0.89 1 2 14.2 (5.2) 14.0 (4.8) 0.91 2 3
Right hip ER (u) 41.5 (7.1) 40.3 (7.5) 0.82 4 7 42.5 (6.8) 41.8 (8.6) 0.64 5 9
Left hip ER (u) 50.9 (8.8) 48.7 (8.6) 0.80 4 7 48.7 (10.8) 45.8 (10.1) 0.77 6 10
Right hip IR (u) 30.6 (10.2) 29.6 (9.4) 0.97 2 4 37.9 (9.1) 37.5 (9.4) 0.89 3 6
Left hip IR (u) 28.5 (11.0) 27.0 (9.6) 0.96 2 4 38.1 (12.7) 38.1 (11.8) 0.93 4 7
Strength
Right hip ABD 14.0 (1.9) 14.6 (1.9) 0.81 0.9 1.7 13.1 (2.2) 12.0 (2.6) 0.73 1.3 2.5
(Nm)
Left hip ABD 13.9 (2.4) 13.7 (2.1) 0.84 0.9 1.8 13.2 (2.4) 12.4 (2.5) 0.58 1.6 3.1
(Nm)
Right hip ER 3.8 (1.2) 4.1 (0.9) 0.55 0.8 1.4 4.5 (1.6) 4.3 (1.0) 0.60 0.8 1.6
(Nm)
Left hip ER 3.6 (0.9) 4.0 (1.2) 0.64 0.7 1.3 3.9 (1.3) 4.1 (0.9) 0.63 0.7 1.3
(Nm)
Right hip IR 3.1 (0.8) 3.4 (1.0) 0.67 0.6 1.0 3.3 (0.8) 3.0 (0.6) 0.40 0.5 1
(Nm)
Left hip IR 3.0 (0.9) 3.1 (0.7) 0.57 0.5 1.0 3.4 (0.7) 3.1 (0.7) 0.54 0.5 1
(Nm)
Squeeze 0u 204 (48) 216 (37) 0.81 20 35 202 (34) 203 (43) 0.80 20 35
(mm Hg)
Squeeze 30u 206 (52) 215 (49) 0.91 20 30 218 (40) 213 (40) 0.82 20 35
(mm Hg)
Squeeze 45u 208 (48) 205 (46) 0.94 15 30 206 (37) 209 (41) 0.83 20 35
(mm Hg)
ABD, abduction; BKFO, bent knee fall out; ER, external rotation; IR, internal rotation.
*Values are mean (SD).

742 Br J Sports Med 2009;43:739–744. doi:10.1136/bjsm.2008.055749

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Br J Sports Med: first published as 10.1136/bjsm.2008.055749 on 11 March 2009. Downloaded from http://bjsm.bmj.com/ on December 20, 2021 at UCL Library Services. Protected by
Table 3 Hip flexibility and strength among players in the control and groin pain groups
Post hoc
Measures Control* (n = 19) Groin pain*(n = 10) p Value power

Flexibility
Right BKFO (cm) 12.9 (5.1) 16.4 (4.8) 0.09 0.4
Left BKFO (cm) 12.5 (4.7) 14.4 (3.8) 0.28 0.2
Right hip ER (u) 40.8 (7.1) 39.4 (8.7) 0.66 0.1
Left hip ER (u) 48.3 (9.6) 46.2 (13.4) 0.63 0.1
Right hip IR (u) 34.2 (11.6) 34.4 (8.1) 0.96 0.1
Left hip IR (u) 33.3 (13.6) 32.7 (10.7) 0.91 0.1
Total hip external rotation (u) 89.1 (14.9) 85.6 (21.0) 0.61 0.1
Total hip internal rotation (u) 67.4 (24.2) 67.1 (16.7) 0.96 0.1
Strength
Right hip ABD (Nm) 13.3 (2.0) 13.1 (2.5) 0.84 0.1
Left hip ABD (Nm) 13.5 (2.4) 13.2 (2.3) 0.71 0.1
Squeeze 0u (mm Hg) 210.8 (39.3) 172.3 (28.2) 0.01
Squeeze 30u (mm Hg) 217.1 (43.2) 182.0 (36.3) 0.03
Squeeze 45u (mm Hg) 209.6 (42.3) 180.5 (30.2) 0.07 0.6
*Values are mean (SD).

Discriminate validity of reliable hip flexibility and strength
measures
Players with groin pain had a significantly lower measure on the
squeeze test compared with their asymptomatic counterparts
when tested at 0u and 30u of hip flexion (table 3). There was no
significant difference evident between the groups for any of the
other tests (p.0.05) (table 3).
DISCUSSION
not found to display high torques. Hence, for these two
measures, the magnitude of the measurement error was large in
relation the size of the measure.
Discriminative validity
An important finding of this study was that football players
with groin pain produced significantly less force on the squeeze
test (0u and 30u of hip flexion) when compared with
asymptomatic players. This result is consistent with the

This study investigated the reliability and discriminant validity
of selected hip flexibility and strength measures among junior
football players with and without groin pain. While this study
investigated a small cohort of symptomatic players (n = 10),
all football players in the study were young (15–21 years) and
had a similar training load (table 1). The diagnosis of players
with groin pain was not known and included players with
symptoms for 4–5 weeks (50%) and >6 weeks (50%). However,
9 of the 10 symptomatic players had adductor-related pain, and
6 of these players also had secondary iliopsoas-related pain.
Reliability
The bent knee fall out test, prone hip internal rotation and
squeeze tests demonstrated acceptable intra-rater and inter-
rater reliability. The findings for the Prone hip internal rotation
test are consistent with previous reliability studies.16 17 To our
knowledge, this is the first study to report the reliability of the
bent knee fall out test. The squeeze test has previously been
shown to be reliable in measuring the presence of pain7 and
strength using a handheld dynamometer.18 This study intro-
duces the traditional sphygmomanometer as a cost-effective
alternative to the handheld dynamometer.
The supine hip external rotation flexibility and the hip
abduction strength tests demonstrated acceptable intra-rater
reliability, but not inter-rater reliability. This indicates that
these measures are suited to clinical and research situations that
rely on repeat measures by the same examiner. Given the
difficulty in determining the end range of motion, it is possible
that the supine hip external rotation test may be more reliable if
performed as an active movement.16 The strength measures of
hip IR and hip ER using a handheld dynamometer did not
demonstrate acceptable reliability in the current cohort. This
may be partly related to the small cohort in this study.
Additionally, the hip internal and external rotator muscles were
copyright.
difference (ie, athletes with symptoms compared with asymp-
tomatic athletes with adductor-related groin pain for .4 weeks)
evident in the descriptive statistics provided by Mens et al.19 It
cannot be determined whether the significantly reduced
maximal force production on the squeeze test is because of
muscle weakness or pain inhibition (or both). Likewise, the
cause or effect relationship between reduced strength on the
squeeze test and the presence of longstanding groin pain cannot
be determined. A previous study investigating Australian Rules
football players reported that assessing the presence or absence
of pain on the squeeze test is specific (88%) in identifying
longstanding groin pain (tenderness at the pubic symphysis and
What is already known on this topic
c Measures that quantify hip flexibility and strength are often
used to examine athletes with longstanding groin pain.
c Little is known about the reliability of some of these measures
and whether they discriminate between athletes with and
without longstanding groin pain.
What this study adds
c Reliable measures of hip flexibility (bent knee fall out, hip
internal and external rotation) and strength (squeeze test, hip
abduction) were identified among junior football players.
c Force production on the squeeze test may discriminate
between junior football players with and without longstanding
groin pain.

Br J Sports Med 2009;43:739–744. doi:10.1136/bjsm.2008.055749 743

 Original article

superior pubic rami for .6 weeks) and therefore may be useful Funding: The Australian Physiotherapy Association funded this study.
in diagnosis, although the sensitivity of this test was low Competing interests: None.
(40%).20 Taken together with the findings from the current
Provenance and peer review: Not commissioned; externally peer reviewed.
study, the squeeze test would appear to be capable of
discriminating between athletes with and without groin pain.
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