Journal of Sports Sciences

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The effect of low back pain on trunk muscle size/

function and hip strength in elite football (soccer)
players

Julie A. Hides, Tim Oostenbroek, Melinda M. Franettovich Smith & M. Dilani

Mendis

To cite this article: Julie A. Hides, Tim Oostenbroek, Melinda M. Franettovich Smith &
M. Dilani Mendis (2016) The effect of low back pain on trunk muscle size/function and hip
strength in elite football (soccer) players, Journal of Sports Sciences, 34:24, 2303-2311, DOI:
10.1080/02640414.2016.1221526

To link to this article: https://doi.org/10.1080/02640414.2016.1221526

Published online: 19 Sep 2016.

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JOURNAL OF SPORTS SCIENCES, 2016
VOL. 34, NO. 24, 2303–2311
http://dx.doi.org/10.1080/02640414.2016.1221526

The effect of low back pain on trunk muscle size/function and hip strength in elite
football (soccer) players
a,b
Julie A. Hides , Tim Oostenbroekc,d, Melinda M. Franettovich Smith a
and M. Dilani Mendis a,e

a
Centre for Musculoskeletal Research, Mary MacKillop Institute for Health Research, Australian Catholic University, Woolloongabba, Australia;
b
Mater/ACU Back Stability Research Clinic, Mater Health Services, South Brisbane, Australia; cWesley Musculoskeletal Rehabilitation Unit, Brisbane,
Australia; dBrisbane Roar FC, Perry Park, Bowen Hills, Australia; ePhysiotherapy Department, Mater Health Services, South Brisbane, Australia

ABSTRACT ARTICLE HISTORY

Low back pain (LBP) is a common problem in football (soccer) players. The effect of LBP on the trunk and hip Accepted 27 July 2016
muscles in this group is unknown. The relationship between LBP and trunk muscle size and function in
KEYWORDS
football players across the preseason was examined. A secondary aim was to assess hip muscle strength. Multifidus muscle; hip
Twenty-five elite soccer players participated in the study, with assessments conducted on 23 players at both abductor muscle; hip
the start and end of the preseason. LBP was assessed with questionnaires and ultrasound imaging was used adductor muscle; ultrasound
to assess size and function of trunk muscles at the start and end of preseason. Dynamometry was used to imaging
assess hip muscle strength at the start of the preseason. At the start of the preseason, 28% of players
reported the presence of LBP and this was associated with reduced size of the multifidus, increased
contraction of the transversus abdominis and multifidus muscles. LBP decreased across the preseason,
and size of the multifidus muscle improved over the preseason. Ability to contract the abdominal and
multifidus muscles did not alter across the preseason. Asymmetry in hip adductor and abductor muscle
strength was found between players with and without LBP. Identifying modifiable factors in players with
LBP may allow development of more targeted preseason rehabilitation programmes.

Introduction lumborum muscle (Park, Tsao, Cresswell, & Hodges, 2013),

smaller size of the multifidus muscle (Danneels,
Low back pain (LBP) is common in football players. A recent
Vanderstraeten, Cambier, Witvrouw, & De Cuyper, 2000;
study of prevalence and risk factors for LBP showed that the
Hides, Stokes, Saide, Jull, & Cooper, 1994), decreased ability
overall 12-month prevalence of LBP for elite football players
to contract the multifidus muscles (Hides, Stanton, Mendis, &
was as high as 64% (van Hilst, Hilgersom, Kuilman, Kuijer, &
Sexton, 2011; Wallwork, Stanton, Freke, & Hides, 2009) and
Frings-Dresen, 2014). In addition, recurrence rates of up to
abdominal muscle overactivity and inability to draw in the
59% were reported in the 12-month period studied. LBP may
abdominal wall (Hides et al., 2011). Similar findings have
have negative consequences for performance in football as it
been demonstrated in elite cricketers (Hides et al., 2010) and
has been shown to affect trunk as well as lower limb kine-
elite Australian Football League players with LBP (Hides,
matics in walking and running (Muller, Ertelt, & Blickhan,
Boughen, Stanton, Strudwick, & Wilson, 2010; Hyde, Stanton,
2015). In addition, a recent systematic review and meta-ana-
& Hides, 2012). A recent study also demonstrated that male
lysis concluded that people with LBP have reduced range of
runners with LBP demonstrated deficits in their ability to con-
motion and proprioception and move more slowly than peo-
tract the lumbar multifidus muscles (Cai & Kong, 2015). It
ple without LBP (Laird, Gilbert, Kent, & Keating, 2014). Whilst
would therefore seem important in preseason screening to
the exact aetiology of LBP in athletes is unknown, it has been
identify trunk muscle deficits in those with LBP so that these
proposed that LBP can be a result of overuse as well as
may be addressed over the preseason period. To date, this has
traumatic injury (Ristolainen et al., 2010). It is therefore impor-
not been investigated in a football (soccer) population.
tant to identify modifiable factors to allow development of
Previous research has also reported changes in size of trunk
strategies to prevent and manage LBP in football players.
muscles across the season in Australian Football League
An important area of interest for spinal researchers is the
players (Hides & Stanton, 2012). An important aim of early
relationship between LBP and the size and function of trunk
preseason training is to counter the effects of the off season
muscles. Investigations of both athletic and non-athletic popu-
(detraining), which is known to negatively affect several phy-
lations with LBP have demonstrated deficits in trunk muscles
sical attributes (Silva, Nassis, & Rebelo, 2015). These include
including reduced endurance and strength of the lumbar
characteristics such as decreased strength and power on
extensor muscles (Grabiner & Jeziorowski, 1992; Holmstrom,
squatting (Izquierdo et al., 2007), endurance-related markers
Moritz, & Andersson, 1992), greater activation of the quadratus
(Koundourakis et al., 2014) and neuromuscular parameters,

CONTACT Julie A. Hides julie.hides@acu.edu.au Centre for Musculoskeletal Research, Mary MacKillop Institute for Health Research, ACU, Level 1, 631
Stanley Street, Woolloongabba, QLD 4102, Australia.
Institutional Review Board: Australian Catholic University Human Research Ethics Committee.
© 2016 Informa UK Limited, trading as Taylor & Francis Group
2304 J. A. HIDES ET AL.
such as jumping and sprinting (Izquierdo et al., 2007;
Koundourakis et al., 2014). As LBP has known negative effects
on trunk muscle size and function in other populations, it is
important to understand the relationship between these vari-
ables at the start of the preseason. Furthermore, it is important
to know whether variables, such as size and function of trunk
muscles, change over the preseason in response to preseason
training, and if the changes differ in those players with and
without LBP.
In addition to considering the trunk region in people with
LBP, it has been proposed that the spine should not be
considered in isolation from the lower limbs, especially the
hip joint (McGregor & Hukins, 2009). Several studies have
examined the relationship between LBP and hip muscle
strength in the general population (Cooper et al., 2015;
Kendall, Schmidt, & Ferber, 2010; Nourbakhsh & Arab, 2002;
Penney, Ploughman, Austin, Behm, & Byrne, 2014). These stu-
dies have shown that hip adductor and abductor muscle
strength was weaker in people with LBP compared with
those without LBP (Cooper et al., 2015; Kendall et al., 2010;
Nourbakhsh & Arab, 2002; Penney et al., 2014). Weakness of
the hip extensor and flexor muscles has also been demon-
strated in people with LBP (Lemaire, Ripamonti, Ritz, &
Rahmani, 2013; Nourbakhsh & Arab, 2002). However, only a
few studies have investigated hip muscle strength in athletes
with and without LBP (Cai & Kong, 2015; Nadler, Malanga,
DePrince, Stitik, & Feinberg, 2000; Tsai et al., 2010), and no
studies have investigated this relationship in football players. If
LBP affects hip muscle strength as suggested by previous
evidence, this could affect football players’ performance as
this sport requires hip muscle strength to allow repetitive
kicking, acceleration, deceleration and cutting manoeuvres
(Masuda, Kikuhara, Demura, Katsuta, & Yamanaka, 2005).
Therefore, it would be important to investigate if hip muscle
strength is altered in football (soccer) players with and with-
out LBP.
The primary aim of this study was to determine the rela-
tionship between LBP and trunk muscle size and function
among elite football (soccer) players at the start and end of
the preseason. A secondary aim was to assess hip muscle
strength in football (soccer) players with and without LBP at
the start of the preseason period. We hypothesised that
players with LBP would demonstrate reduced trunk muscle
size and function and reduced hip muscle strength at the start
and end of the preseason period.
Materials and methods
Participants
Football players from a professional football (soccer) club were
invited to participate in the study, resulting in an eligible
sample of 25 players. The mean (SD) age, height, mass and
years playing football for players were 24.4 (5.5) years, 178.1
(6.8) cm, 74.9 (7.4) kg and 6.4 (5.7) years, respectively. All 25
players (ranging in age from 18 to 34 years) were assessed at
the start of the 2014 preseason (June 2014) and 23 players
were available for assessment at the end of preseason
(September 2014). Despite acknowledged differing athletic
demands related to playing positions (e.g., the goalkeeper),
to maximise the sample size, all available players from the
team participated. This study was approved by the Australian
Catholic University Human Research Ethics Committee. Players
provided written informed consent and the rights of the par-
ticipants were protected.
Procedures
At the start of the preseason, self-report questionnaires were
used to collect information regarding player demographics,
such as age, height, and weight, and current history of LBP.
LBP was defined as pain localised between T12 and the gluteal
fold (Hides, Stanton, Mendis, Gildea, & Sexton, 2012). Players
were asked to answer “yes” or “no” to the presence of LBP in
the previous week and for those players who answered “yes”,
a Visual Analogue Scale (VAS) was used to assess average LBP
intensity for the previous week and the location of pain was
drawn on a body chart. In relation to the effect of LBP on
function, players were asked to nominate if the LBP was
“severe enough to interfere with current training”.
Ultrasound imaging was used to assess the size and function
of the trunk muscles. Handheld dynamometry was used to
assess hip muscle strength. The team physiotherapist docu-
mented preseason training. Increased player commitments in
the period prior to the commencement of the playing season
resulted in a decrease in the amount of time available for
testing. This unfortunately precluded the repeat performance
of hip strength measurements at the end of the preseason. At
the end of the preseason (September 2014), self-report ques-
tionnaires, LBP intensity (VAS) and ultrasound imaging of the
trunk muscles were repeated.
Ultrasound imaging procedure
Ultrasound imaging was conducted using LOGIQ e ultrasound
imaging apparatus equipped with a 5-MHz curvilinear trans-
ducer (GE Healthcare, Wuxi, China). Trunk muscle size was
assessed by imaging the cross-sectional area (CSA) of the
multifidus and quadratus lumborum muscles. This procedure
has been previously validated to magnetic resonance imaging
(Hides, Richardson, & Jull, 1995). To image the size of the
multifidus muscle, participants were positioned in prone
lying and instructed to relax the paraspinal musculature,
conductive gel was applied, and the transducer placed trans-
versely over the spinous process of the vertebral level being
measured (Hides et al., 1995). The multifidus muscles were
imaged bilaterally from L2 to L5. To image the size of the
quadratus lumborum muscle, the transducer was shifted lat-
erally, in line with the level of the L3–4 vertebral interspace on
each side.
Trunk muscle function was assessed by imaging the con-
traction of the multifidus, transversus abdominis and internal
oblique muscles. To capture contraction ability, muscles were
imaged at rest and on contraction. This procedure has been
previously validated to electromyographic activity (Hodges,
Pengel, Herbert, & Gandevia, 2003). The external oblique mus-
cle was not assessed, as previous ultrasound thickness mea-
surements of this muscle during contraction were reported to

correlate poorly with measures of muscle activity (Hodges
et al., 2003). With the participant in prone lying, the multifidus
muscle was imaged from L2 to L5 in parasagittal section
allowing visualisation of the zygapophyseal joints, muscle
bulk and thoracolumbar fascia (Van, Hides, & Richardson,
2006). Each player was instructed to relax and an image was
obtained at rest. Participants were then instructed to try to
“swell” or contract the multifidus muscle without moving the
spine or pelvis (Wallwork et al., 2009). Ultrasound images of
the transversus abdominis and internal oblique muscles were
captured in a supine lying position. Each player was instructed
to relax the abdominal wall, and a transverse image was
obtained along a line midway between the inferior angle of
the rib cage and the iliac crest for the right and left sides
(Hides, Miokovic, Belavy, Stanton, & Richardson, 2007). The
transducer was aligned perpendicular to the fascia covering
the anterolateral abdominal muscles. In order to standardise
the location of the ultrasound transducer for each participant,
the anterior fascial insertion of the transversus abdominis
muscle was positioned approximately 2 cm from the medial
edge of the ultrasound image when the subject was relaxed
(Hides et al., 2007). Each player was instructed to relax and an
image was obtained at rest. For assessment of contraction of
the abdominal muscles, participants were asked to draw in the
lower abdomen without moving the spine (Hides et al., 2007).
Ultrasound images were stored and measured offline.
Image visualisation and measurements were conducted
using OsiriX medical imaging software (Geneva,
Switzerland). For trunk muscle size, CSA of the multifidus
and quadratus lumborum muscles were measured by tracing
the borders of the muscles (Figure 1(a,b)). For trunk muscle
function, the thickness of the transversus abdominis (Figure 2
(a,b)), internal oblique (Figure 2(a,b)) and multifidus muscles
(Figure(c,d)) was measured in the relaxed and contracted
conditions. Contraction ability was calculated by subtracting
the thickness in the relaxed condition from the thickness in
the contracted condition. Study data were de-identified prior
to measurement to ensure the researchers were blinded to
group allocation and presenting symptoms. All measure-
ments were conducted by physiotherapists with extensive
experience in ultrasound imaging and have previously
demonstrated fair to high reliability in measuring quadratus
lumborum size (intraclass correlation coefficient [ICC] = 0.98,
standard error of measurement [SEM] = 0.09 cm2) (Hides &
Stanton, 2016), multifidus muscle size (ICC = 0.83–0.99,
SEM = 0.12–0.27 cm2) (Hides, Lambrecht, Stanton, &
Figure 1. Ultrasound images of trunk muscles in transverse section with traced line indicating cross-sectional area. (a) Lumbar multifidus muscles at the L5 vertebral
level; (b) the quadratus lumborum muscle.
JOURNAL OF SPORTS SCIENCES 2305
Damann, in press; Hides et al., 1995), multifidus muscle thick-
ness (ICC = 0.94–0.95, SEM = 0.06–0.09 cm) (Wallwork, Hides,
& Stanton, 2007) and abdominal muscles thickness (transver-
sus abdominis: ICC = 0.84–0.85, SEM = 0.02 cm; Internal
oblique: ICC = 0.6–0.7, SEM = 0.04 cm) (Hides et al., 2007).
Hip strength measurement
Participants were tested for hip abduction, hip adduction,
hip external rotation and hip flexion strength using a
Commander Power Trak II handheld dynamometer (J-Tech
Medical, UT, USA). These particular directions were chosen
based on muscle activation patterns during kicking in soc-
cer (Brophy, Backus, Pansy, Lyman, & Williams, 2007), with
hip abductor and adductor muscles selected due to their
known roles in kicking and support of the stance leg. Hip
external rotator and abductor muscles were selected due to
the proposed link between hip adduction and internal rota-
tion with knee injury (Boden, Torg, Knowles, & Hewett,
2009), and the hip external rotator and abductor muscles
were selected as they oppose those movements. It is possi-
ble that less than optimal load transfer through the lower
limb to the lumbar spine could be associated with LBP, so
this was the basis for prioritising the muscles selected. For
hip abduction and adduction strength (Figure 3(a,b)), parti-
cipants were positioned in supine lying with the test leg
positioned so that the hip was in a neutral position and the
non-test leg bent with the foot flat on the examination
table (Thorborg, Petersen, Magnusson, & Holmich, 2010).
For hip external rotation (Figure 3(c)), participants were
positioned in supine lying with the test leg bent over the
edge of the plinth, the hip in neutral position and the non-
test leg flexed (Malliaras, Hogan, Nawrocki, Crossley, &
Schache, 2009). For hip flexion (Figure 3(d)), participants
were seated with the hips in 90° flexion (Thorborg et al.,
2010). Belts were used to stabilise pelvic position for all
tests except hip flexion and participants were allowed to
self-stabilise by holding on to the plinth. For all tests, an
isometric “make” test was performed. Participants were
given standard instructions to push against the dynam-
ometer at a maximal effort for 5 s and the examiner
matched the resistance produced by the subject.
Participants completed one practice trial followed by three
trials with a 15-s rest between each trial. Pen marks were
placed on their legs to standardise placement of the
dynamometer and for measurement of lever arm length
2306 J. A. HIDES ET AL.
Figure 2. Transverse ultrasound image of the muscles of the right anterolateral
abdominal wall, showing transversus abdominis (TrA), internal oblique (IO) and
external oblique (EO) muscles (a) at rest (left side of screen) and (b) during
contraction (right side of screen). Note on the (right) contracted image, the
increase in thickness of the TrA and IO muscles. Transverse ultrasound image of
the multifidus muscle (and linear measurements thereof) (c) at rest (left side of
screen) and (d) during a voluntary isometric contraction (right side of screen) at
the levels of the L4/5 and L5/S1 zygapophyseal joints. S = Sacrum;
ST = subcutaneous tissue.
(Thorborg et al., 2010). Force output was recorded in
Newtons. For each person, the average of three trials was
multiplied by the lever arm length to calculate torque (N ·
m). A male physiotherapist performed all strength measures
and was blinded to presenting symptoms (Thorborg,
Bandholm, Schick, Jensen, & Holmich, 2013). To establish
reliability within our research team, intra-rater reliability
was assessed in 15 randomly selected participants.
Reliability was good to high (hip abduction ICC = 0.91,
SEM = 11.6 N · m; hip adduction ICC = 0.8, SEM 15.1 N ·
m; hip external rotation ICC = 0.75, SEM = 12.4 N · m and
hip flexion ICC = 0.78, SEM = 19.7 N · m) and comparable to
previous research (Thorborg et al., 2010).
Figure 3. Strength testing of hip muscles using a hand-held dynamometer for (a) hip adduction; (b) hip abduction; (c) hip external rotation and (d) hip flexion.
Preseason training programme
In addition to the club’s standard preseason soccer training
programme, players also participated in a programme aimed
at injury prevention over the preseason, which was designed
and conducted by the team physiotherapist/medical staff,
independent of the current study. Training was conducted
twice per week over a period of 12 weeks in a gym, closely
supervised by both a qualified Exercise Physiologist and a
qualified Sports Physiotherapist. A cardiovascular warm-up at
low–moderate intensity was performed for 5–10-min duration
either on a stationary bike or treadmill. Players then partici-
pated in two 30 min exercise sessions, with half the team in
each group, swapping sessions after 30 min. Players in the
“gym resistance session” performed a maximum of six exer-
cises against low–moderate resistance. Exercises included
open squat, walking lunge, Romanian Hamstring lift and dead-
lift and generic upper limb exercises including chin-up, push-
up and bench press (Figure 4). Quality performance of the
exercises and “good technique” was emphasised. Players were
asked to perform three sets of six to eight repetitions working
short of failure, to ensure technique was not compromised.
Players in the “core, agility and proprioception session” per-
formed a series of prescribed floor-based activities using only
their body weight as resistance (minimal equipment required).
Emphasis was placed on maintaining correct posture and
movement control. Exercises included front and side plank,
single leg bridging, adductor squeeze, low-level plyometric
work, ladder work and mini-trampoline drills to improve pro-
prioception of the foot and ankle. Small groups were used to
encourage player compliance with the programme and to
assist the supervisors to make technical corrections of the
prescribed exercises. At the conclusion of the training, players
were required to complete a series of lower limb stretches
over 10–15 min.
Statistical analysis
IBM SPSS Statistics (version 22, IBM Corp, Armonk, NY) was
used for statistical analysis with a significance level set at
P < 0.05. A preliminary analysis of variance (ANOVA) was
conducted to examine between group differences in baseline
characteristics. Multivariate repeated measures analysis of cov-
ariance (MANCOVA) was used to examine between group
differences for trunk muscle size and function across the pre-
season and between group differences for hip muscle strength
at the start of preseason. Based on the data capture design for
the muscles (size, function and time points), separate models
were run for (1) muscle size of the trunk (multifidus CSA L2–L5
 JOURNAL OF SPORTS SCIENCES 2307

Figure 4. Gym resistance session against low–moderate resistance included (a) deadlift, (b) walking lunge and (c) open squat.

vertebral levels, quadratus lumborum CSA), (2) the contraction
(change in thickness) of the multifidus muscle at L2–L5, and
abdominal muscles (transversus abdominis, internal oblique)
and (3) hip strength (hip abduction, hip adduction, hip exter-
nal rotation and hip flexion; Time 1 only). The between subject
factor was LBP (coded as “LBP” or “no LBP”) and where appro-
priate the within subject factors were “time”, “side” of body
and “contraction” (relaxed and contracted condition).
Covariates of height, weight and number of years playing
football were included in the model. Significant multivariate
results were followed up with post-hoc univariate analysis,
forming the basis of the reported results.
Results
Participant characteristics
start of the preseason had decreased to 0/10 by the end of the
preseason.
Size of trunk muscles
There was a significant interaction effect for “time” and LBP for
CSA of the multifidus muscles at vertebral levels L4 (F = 8.12,
P = 0.01) and L5 (F = 8.56, P = 0.009) (see means in Table 1).
The largest increases in CSA across the preseason were seen in
those with LBP (players with LBP at L4: increase 1.24 cm2, L5:
increase 1.93 cm2; players without LBP at L4: decrease
0.37 cm2, L5: increase 0.52 cm2). Results for CSA of the quad-
ratus lumborum muscle were not significant (P > 0.05).
Function of trunk muscles

Twenty-five players were assessed at the start of preseason Mean (SE) values of the multifidus, transversus abdominis and
and 23 players assessed at the end of preseason. Two players internal oblique muscles in the relaxed and contracted states
were unavailable at the end of preseason due to transfer to are shown in Table 2. Results for contraction of the multifidus
other clubs. There were no baseline differences in demo- muscle at vertebral levels L3–L5 were not significant for
graphic variables (age, height and weight) between groups players with and without LBP (P > 0.05). At the L2 level, players
for players with and without LBP (P > 0.05). with LBP contracted the muscle more than players without
LBP (0.29 cm compared to 0.21 cm; F = 4.73, P = 0.04). Results
for the internal oblique muscle were not significant (P > 0.05).
LBP Results for the transversus abdominis muscle showed that
Seven players (28%) reported having LBP at the start of the players with and without LBP contracted the muscle differ-
preseason. Of these, four were backs, and there was one
midfielder, one forward and the goalkeeper. Results for pain Table 1. Cross-sectional areas of trunk muscles (mean (SE)) in cm2 across the
intensity, obtained from the VAS (for pain over the last week), preseason (averaged across side).
showed that the mean (SD) VAS score for the players with LBP No low back pain Low back pain
at the start of the preseason was 2.2 (2.5) cm. The location of Muscle Time 1 Time 2 Time 1 Time 2
the LBP was central in five cases, left sided in one case and Multifidus L2 2.63 (0.14) 2.63 (0.12) 2.52 (0.23) 2.67 (0.20)
right sided in one case. None of the players reported that the Multifidus L3 4.49 (0.21) 4.24 (0.22) 3.87 (0.34) 4.36 (0.36)
Multifidus L4* 6.74 (0.31) 6.37 (0.31) 5.77 (0.51) 7.01 (0.65)
pain was severe enough to interfere with current training. Multifidus L5* 7.84 (0.29) 8.36 (0.47) 6.68 (0.47) 8.61 (0.60)
Results for the VAS at the end of the preseason showed that Quadratus lumborum 8.12 (0.21) 8.53 (0.24) 7.92 (0.34) 8.18 (0.39)
the intensity of LBP for all players who reported LBP at the *P < 0.05.
2308 J. A. HIDES ET AL.

Table 2. Trunk muscle contraction size (mean (SE)) in cm for players with and without LBP (averaged across side).
No low back pain Low back pain
Muscle Relax Contract Percentage increase (%) Relax Contract Percentage increase (%)
Multifidus L2* 2.20 (0.06) 2.41 (0.05) 9.5 2.17 (0.10) 2.46 (0.09) 13.4
Multifidus L3 2.61 (0.09) 2.80 (0.09) 7.3 2.51 (0.14) 2.74 (0.14) 9.2
Multifidus L4 2.96 (0.08) 3.26 (0.09) 10.1 3.03 (0.13) 3.31 (0.14) 9.2
Multifidus L5 3.17 (0.07) 3.44 (0.08) 8.5 3.29 (0.12) 3.57 (0.14) 8.5
Transversus abdominis* 0.42 (0.03) 0.54 (0.03) 28.6 0.41 (0.04) 0.65 (0.05) 58.5
Internal oblique 1.23 (0.05) 1.35 (0.06) 10.1 1.38 (0.08) 1.54 (0.09) 11.0
*P < 0.05.

Table 3. Hip muscle strength (mean (SE)) in N · m, for players with and without
low back pain.
No low back pain Low back pain
Stance leg Kicking leg Stance leg
Hip abduction* 161.5 (6.6) 143.9 (7.8) 154.1 (10.0)
Hip adduction* 160.2 (5.8) 175.8 (7.8) 175.5 (8.8)
Hip external rotation 63.7 (2.9) 63.9 (3.1) 67.0 (4.4)
Hip flexion 117.6 (4.2) 111.6 (4.9) 126.7 (6.4)
*P < 0.05.
ently (F = 6.87, P = 0.02). Players with LBP contracted the
muscle more when they drew in the abdominal wall
(0.24 cm compared to 0.12 cm). There was no significant
interaction effect for time (P > 0.05).
Hip muscle strength at the start of the preseason
For the hip strength measures of abduction and adduction, a
significant interaction effect was found between “side” (kicking
or stance leg) and presence of “LBP” (F = 5.07, P = 0.04; F = 12.78,
P = 0.002, respectively), indicating that difference between the
stance and kicking leg was dependent upon whether or not
participants had LBP. The hip abductor muscles were stronger
on the stance leg compared with the kicking leg in players
without LBP (side difference: 17.6 N · m) but weaker on the
stance leg compared with the kicking leg in players with LBP
(side difference: 11.0 N · m) (see means in Table 3). The hip
adductor muscles were stronger on the kicking leg compared
with the stance leg in players without LBP (side difference:
15.6 N · m) but weaker on the kicking leg compared with the
stance leg in players with LBP (side difference: 20.9 N · m) (see
means in Table 3). Differences observed exceed the SEMs pre-
viously reported. There were no significant between group
differences for hip external rotator (F = 0.41, P = 0.53) or flexor
(F = 3.59, P = 0.07) strength.
Discussion
Multifidus and quadratus lumborum muscles
The results of the current investigation showed that the CSA
of the multifidus muscles at the L4 and L5 vertebral levels
increased across the preseason. The largest increases in size
were seen in the players who reported LBP at the start of the
preseason, and changes in muscle size were commensurate
with decreases in the players’ reported intensity of LBP. Even
though the mean VAS scores reported at the start of the
playing season were low, a mean improvement of 2.2
exceeded the minimum clinically significant difference in VAS
pain scores reported in clinical studies (Kelly, 1998). As can be
Kicking leg seen from the means in Table 1, players with LBP at the start
165.1 (11.8) of the preseason had smaller multifidus muscles than those
154.6 (11.8) without LBP and perhaps therefore had the greatest capacity
69.7 (4.6)
134.0 (7.4) to change. The features of the training programme adopted
may help to explain the changes seen in muscle size, as
exercise programmes which have targeted the multifidus mus-
cle in footballers (Hides et al., 2012) and cricketers (Hides,
Stanton, McMahon, Sims, & Richardson, 2008) have shown
similar increases in multifidus size, commensurate with
decreases in LBP. Common elements of these exercise pro-
grammes include precision of exercise performance, dissocia-
tion of the trunk from the hips in sagittal plane movements,
maintenance of the lumbar lordosis and thoracic kyphosis and
increased endurance (Hides et al., 2008, 2012). In support of
these results, optimal recruitment of the multifidus muscle has
been demonstrated during free weight exercises such as
squats and deadlifts (Martuscello et al., 2013). However, as
players were also participating in preseason soccer training
(in addition to the injury prevention programme), we are
unable to confirm that the changes seen in the size of the
multifidus muscle were due to the injury prevention pro-
gramme described in this study.
Results for contraction of the multifidus muscle showed
that in general, players with and without LBP were equally
able to voluntarily contract the muscle. There was a significant
difference at the L2 vertebral level, in that players with LBP
showed an increased amount of contraction. This may be
related to imaging of the upper lumbar levels in parasagittal
section, as in this plane, the lower segments of the thoracic
erector spinae muscles are also captured in the image. As a
previous study has shown that people with LBP showed
increased recruitment of the erector spinae muscles
(Lariviere, Gagnon, & Loisel, 2000), this could possibly explain
this result.
Abdominal muscles
Results for the transversus abdominis muscle showed that
overall, players with LBP had larger contractions of this mus-
cle, and this did not change over time. A similar result
(increased contraction) has been reported previously in crick-
eters with LBP for the transversus abdominis and internal
oblique muscles (Hides et al., 2010), and in Australian football
league players with LBP for the internal oblique muscle (Hyde
et al., 2012). This result was thought to represent a strategy to

splint or stiffen the spine (Silfies, Squillante, Maurer, Westcott,
& Karduna, 2005). Cricketers with LBP who (over) contracted
the transversus abdominis and internal oblique muscles were
shown to be less able to effectively draw in the abdominal
wall (Hides et al., 2010). A motor control training programme
restored this ability and decreased amounts of contraction of
the transversus abdominis and internal oblique muscles were
observed (Hides et al., 2010). It is possible that the (increased)
contraction of the transversus abdominis observed in the
players with LBP in the current study did not alter over time
as their preseason training did not focus on targeted motor
control training of the abdominal muscles, but rather overall/
global resistance exercises.
Hip muscle strength
For skilled football players, kicking performance (ball velocity)
has been shown to be positively correlated with hip adduc-
tion strength (Masuda et al., 2005). Isometric hip adductor
strength has previously been shown to be increased in the
kicking leg compared with the stance leg in elite football
players (Thorborg et al., 2011). In support of this finding,
electromyography studies have demonstrated greater activa-
tion of the hip adductor muscles for the kicking leg than the
stance leg for both the side foot kick and the instep football
kick (Brophy et al., 2007). These findings are in agreement
with the pattern seen in the current investigation for players
without LBP, where the abductor muscles were stronger than
the adductor muscles for the stance leg, and the adductor
muscles were stronger than the abductor muscles on the
kicking leg. However, this pattern was reversed in the current
investigation for people with LBP. For the hip abductor mus-
cles, it has been proposed that hip abduction strength of the
supporting leg is correlated to ball velocity, as the stance leg
has a stabilising role (Masuda et al., 2005). In the current
investigation, the abductor muscles were stronger than the
adductor muscles for the stance leg for players without LBP,
but for those with LBP, the pattern was reversed and the
adductor muscles were found to be stronger than the abduc-
tor muscles for the stance leg. If increased hip adduction
strength on the kicking leg and increased hip abduction
strength on the stance leg represent the optimal profile for
kicking performance, the results of the current investigation
would suggest that players with LBP did not demonstrate the
optimal profile.
Whilst we are unable to determine from the current
investigation why the strength of hip abductor and adductor
muscles was reversed in those with LBP, biomechanical and
imaging studies may provide some insights. LBP has been
shown to be associated with modifications in both trunk
and lower limb movements in walking and running (Muller
et al., 2015). People with LBP have been shown to demon-
strate less pelvic rotation (Muller et al., 2015) and increased
stiffness of the trunk with decreased variability of trunk
movement (van den Hoorn, Bruijn, Meijer, Hodges, & van
Dieen, 2012). In addition, when compared with healthy con-
trols, people with LBP adopted a trunk-flexed posture and
walked with more extended knees (Muller et al., 2015),
which has been shown to increase vertical force in healthy
JOURNAL OF SPORTS SCIENCES 2309
participants (Podraza & White, 2010). This could potentially
increase the risk of injury, and recent LBP has previously
been shown to increase the odds of lower limb injury in
Australian Football League players (Hides, Stanton, Mendis,
Franettovich Smith, & Sexton, 2014). Since the lower limbs
and the trunk are linked by the hip, it is therefore important
to consider the strength of muscles which have a key role in
transferring forces to the hip joint. Given that both partici-
pating in kicking sports and the presence of LBP are already
known to be associated with between side differences of
lumbopelvic muscles (Hides et al., 2010; Hides et al., 2014;
Hides et al., 1994), altered trunk and lower limb movement,
in combination with altered force transfer, may be respon-
sible for the changes seen in soccer players with LBP this
study. Based on the findings of biomechanical investiga-
tions, it would be important for future studies to also
include investigations of the hamstring and gluteus maxi-
mus muscles.
A limitation of the current investigation was the small
sample size from one football club. However, our results
appear clinically meaningful as significant results observed in
this small sample exceeded the measurement error reported
for these. Future research could investigate more clubs at the
elite level to establish the generalisability of our results.
Regarding assessment of hip muscle strength, this was only
assessed at the start of the preseason, and lack of assessment
at the end of the preseason period is a limitation of the
current investigation. As results showed changes in strength
of opposing (agonist/antagonistic) hip muscles in players with
LBP, future studies could examine opposing hip muscle
groups in all planes of movement (sagittal, frontal and trans-
verse) across the preseason and playing season.
Conclusion
LBP was related to changes in size of the multifidus muscles
and alterations in contraction and size of the anterolateral
abdominal muscles. Although size of the multifidus muscles
increased in response to preseason training, and pain levels
decreased, motor control (ability to voluntarily contract the
abdominal and multifidus muscles) did not alter across time.
Whilst it is has been proposed that LBP in athletes can result
from overuse and traumatic injury, the players in this study
reported LBP at the start of the preseason period, after the
off season. This may reflect the importance of others factors
in the off season, such as lifestyle and posture which are
thought to be of importance in non-athletic populations.
Hip abductor and adductor muscle strength in the stance
and kicking limbs differed in players with LBP compared
with those without LBP. Previous studies have suggested
that size and ability to contract trunk muscles are modifiable
with motor control training and have been associated with
increased player availability for games. Future studies could
incorporate the modifiable factors identified in the current
study in an intervention trial and assess the effects of pro-
grammes targeting LBP. Inclusion of a control group would
allow the effects specific to the injury prevention pro-
gramme to be established.
2310 J. A. HIDES ET AL.
Acknowledgments
The authors would like to thank the players for participating in the study,
Andrew Cooper and Warren Stanton for assistance with statistical analysis
and, Margot Sexton and Tanja Miokovic for assistance with preparation of
this manuscript.
Disclosure statement
No potential conflict of interest was reported by the authors.
Funding
This work was supported by an Australian Catholic University Research
Funding/CRN grant. We affirm that we have no financial affiliation (includ-
ing research funding) or involvement with any commercial organisation
that has a direct financial interest in any matter included in this manu-
script, except as cited in the manuscript. No other conflict of interest (i.e.,
personal associations or involvement as a director, officer, or expert wit-
ness) exists.
ORCID
Julie A. Hides http://orcid.org/0000-0002-1830-8121
Melinda M. Franettovich Smith http://orcid.org/0000-0002-0098-7656
M. Dilani Mendis http://orcid.org/0000-0002-0533-2587
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