NORMATIVE VALUE OF ADDUCTOR SQUEEZE TEST IN NEPALI MALE PROFESSIONAL FOOTBALL PLAYERS: A CROSS-SECTIONAL STUDY

of hip ﬂexion posion was 120.57 ± 21.88. 45⁰of hip ﬂexion has the highest value of the adductor squeeze test. This study established reference ranges for adductor squeeze tests for normave pre-season data in Nepali male A-division professional football players.


INTRODUCTION
Groin pain is one of the common overuse injuries in a soccer 1,2 game and accounts for 10-18% of all soccer injuries. The evalua on and treatment of groin pain in the athletes are challenging, and these injuries are prone to recurrence that 3,4 can lead to chronic disability. The adductor muscle group has a poor blood supply and a rich nerve supply, making it 5 slow to heal and very sensi ve to any interven on. Football is one of the most popular sports with the greatest 1 par cipa on globally. There are 204 million people from 203 na ons are members of the Federa on of Interna onal 6 Football Associa ons (FIFA). Regular par cipa on and training have several benefits related to physical and mental 7 health, cardiovascular and musculoskeletal variables. Various methods of assessing adductor muscle strength [8][9][10] have been purported including hand-held dynamometer, [11][12][13] manual muscle tes ng devices and isokine c dynamometry. The adductor squeeze test is an important objec ve outcome for both rehabilita on and preven on of groin injuries at it has been shown that decreased hip adductor 8 strength precedes groin injuries in some popula ons. The objec ves of this study were to establish norma ve value for adductor strength in Nepali professional football players and from different playing posi on. These values may assist the sports medicine clinician and physiotherapist in the determina on of the physical status of a player and facilitate the design of groin injury preven on and management programs in a clinical se ng. In Nepal, so far there are no any studies done to establish norma ve adductor strength in soccer players.

METHODOLOGY
Ethical approval was granted by Ins tu onal Review Commi ee (IRC). Wri en permission was taken from five different clubs and players had their consent forms signed before conduc ng the study. Convenient sampling method was used and Subjects were recruited from five top clubs of A-division. They were Army football club, Nepal police football club, Armed police force football club, Friends football club and Jawalakhel youth football club. The total number of players who had par cipated in the current study was 161. Poten al subjects based on the inclusion criteria were t-s with no history of surgery, no self-reported history of groin or pelvic pain in either limb, no other lower limb injury and no pain reported during the tes ng procedure ( Figure No

Outcome Measure
The adductor squeeze test (AST) protocol undertaken was the same as that previously described. All par cipants wore shorts and were barefooted. The test was performed in three submaximal efforts in each of the test posi on that is 0°, 45° and 90°of hip flexion. For the tes ng session, par cipants were again informed of the test procedure.
They were then posi oned supine with their head flat on the bed and arms across the chest. Each par cipant was required to perform 3 maximal squeezes in 0°, 45°, and 90° of hip flexion. The sphygmomanometer was used for all subjects. It was pre-inflated to 10 mmHg and place between the player's knees such that the middle third of the cuff was located at the most prominent point of the medial femoral condyles. For formal tes ng the player was instructed to squeeze the cuff as hard as he could. The highest-pressure value displayed on the sphygmomanometer dial was recorded during each maximal adductor squeeze test. Trials were considered invalid and repeated if any of the following occurred: the par cipants head li ed off the bed, hands were removed from chest, the pressure cuffed slipped, or the par cipant pushed through heels/feet. Par cipants were allowed a 15-second rest between maximal squeeze 14 and 45-second rest between each test posi on. Par cipants were unable to see the sphygmomanometer and were unaware of test scores for the dura on of the tes ng session.

Sta s cal analysis
Mean strength for all test posi ons were calculated to determine the reference range. Mean and standard devia on was calculated from each tes ng posi on and also a number of variables, namely, height (m), weight (kg), age (categorized as 5 years intervali.e., 18-22; 23-27; 28-32; 33-37) and playing posi on (goalkeeper, defense, mid fielder, winger and striker) Sta s cal analysis was undertaken using SPSS sta s cs version 21.

RESULTS
One hundred and sixty one Nepali male professional players from five football clubs were invited to par cipate in this study. All invited players agreed to par cipate (100%). Analysis was done to find the mean values and standard

DISCUSSION
This study assessed the adductor strength of Nepali male professional football players. We established norma ve ranges of strength for hip muscle groups in tes ng posi on that is commonly used in the assessment of adductor related groin pain. The value of AST in three tes ng posi on has not so many differences. However, the mean value of AST at 45⁰ found higher. This is the first study to report this value in professional football players. We also observed test values in different playing posi on. The results of this study may assist the sports physiotherapist in making key decision regarding the management and rehabilita on of both symptoma c and asymptoma c players. This informa on can be used to assess the degree of player's weakness at presenta on rela ve to predic ve normal. Hence, this study also suggests that for groin injury preven on, iden fica on of risk of injury and for be er rehabilita on, the groin has to assess properly and func onally keeping all the aspects of groin injury including the other causa ve factors and associated injuries such as iliopsoas-related groin injury and pain, especially more focused adductor muscle for any group of athletes.

Original Research Ar cle
The adductor muscles play an important role in motor control and stability of lower kinema c chain during the gait cycle. The main func on of adductor group muscle is to bring foot together and cross leg ac vi es such as kicking which is frequently used in football game. Ancillary to their ac on as hip adductors in the frontal plane, they also act as an accessory hip flexor up to 90° of hip flexion and an accessory hip extensor at angle greater than in the sagi al 15,16 plane. Lovell  whereas we included only asymptoma c individuals who experienced no pain during the test procedure. The values were observed lower due to various other factors such as lack of proper physical training, discon nua on of seasonal game, lack of proper rehabilita on and also due to lack physiotherapist in every football club. We observed lower adductor squeeze value in both the 0 and 90 degree of hip flexion in this study. The 0 degree of hip flexion posi on corresponds closely with maximal hip extension at the terminal stance phase of the gait cycle, and the 90 degree of hip flexion posi on is similar to the range of mo on achieved by sprinters towards terminal swing phase 20 of the gait cycle. Varying physical capaci es and anthropometric profiles are required for different playing posi on in football. We observed no sta s cally significant difference between the posi on units and categoriza on in squeeze test values; however, further data with a larger sample size may lead to significant findings. This suggest that players size in this A division football players does not influence these values. The higher squeeze values were observed among goalkeepers (n=16) in 45° of hip flexion (158.75±23.43 mm of Hg) and in 90° of hip flexion (127.18±17.60 mm of Hg). Whereas, other players in different playing posi on had low test values. This may result in overuse of the adductor muscle group and therefore poten ally result in higher risk of injury in this group. The poten al weakness is that these data related to the start of the season (pre-season screening program) and do not provide informa on on how these scores may vary during the season. However, it was important to take all the values at the same me point to enable a norma ve range for that me to be determined, than to try and amalgamate a range of season me points, and as such the start of the season, when the players are being assessed for their training needs going forward, seemed logical and most useful for players, coaches and team physiotherapist. Another weakness of this study is that the data were recorded only from five A division clubs. The result of the study will be more relevant if more clubs were included.

CONCLUSION
With the increasing demand of football as a professional game, preven on of injuries and rehabilita on for player performance and to maximize player training are important. The adductor squeeze test values can be helpful in the reduc on of injuries by early detec on and management of injuries, giving a en on to the techniques and monitoring the efforts of interven on over me. Though the players were healthy, the test values were lower than other studies; it might me due to various other. So, to get higher squeeze value, the players should train regularly, con nue their game and should get proper rehabilita on a er injury. The results in this study represent the norma ve strength values for professional football players only and cannot be considered to be norma ve values for other athle c popula ons. Further recommenda on from this study shows, the research can be done to find out the associa on between BMI.

RECOMMENDATIONS
The current study findings, norma ve value of adductor muscle strength can be used as a baseline finding for prognos c as well as rehabilita on phase of an athlete. The study shows difference in strength of hip adductor muscle among different player's posi on. Hence, the reference value can be useful for different playing posi on of the players. Groin pain among the football players should be taken into considera on preseason as well as post season as it is beneficial for the football players to perform be er during the main event. Furthermore, Pre and post season measurement of adductor strength should be taken and can be compared with the players with groin injuries.

LIMITATIONS OF THE STUDY
The football players for the current study were assessed only preseason. Post season evalua on of the adductor strength was not done due to player's engagement. The current study didn't consider the players with the groin injuries or groin pain. The players adductor strength can be also be measured with groin pain and injuries. Hence, players adductor strength pre-season and post season was not compared and also players with groin injuries strength were not compared.