The hip adductors don’t get much love from most bilateral multi-joint lower body exercises. With unilateral lower body exercises, demands of the adductors increase, but relying on indirect stimulation through inclusion of a few unilateral multi-joint exercises focused in the sagittal plane is not enough to optimize hip adductor strength and function.

In Case You Missed It…

In case you’re late to the party and missed Part 1-6 of this comprehensive article series, you can view them here, here, here, here, here, and here.

Part 1: How non-contact injuries occur in sport and why well-functioning hips are necessary for elite ice hockey performance.

Part 2: Prevalence of hip injures in ice hockey, how and to whom they occur, with a special focus on groin strains.

Part 3: Review of where groin pain may actually be coming from (spoiler alert: it may not be from the groin muscles)

Part 4: The financial cost of injury for NHL players, and the potential costs to sustained high-level performance and long-term health.

Part 5: Key considerations to make when designing a hip screening/monitoring program to identify athletes that may be at increased risk for injury.

Part 6: How to treat different types of hip pain and a rant on how early specialization in youth ice hockey can screw up the hips, for life.

I strongly advise taking the time to go through each of these articles, at some point. I intentionally broke up this article series into many parts to make the content of each article more easily digestible.

Without further ado, the final chapter of the The Hip in Ice Hockey article series awaits you…

Why Strengthening Your Groin is a Great Idea

Collecting and evaluating pertinent hip data is crucial for optimizing athletic performance and health in most athletes, including those that play ice hockey. The value of hip testing in this population becomes clear when considering the disproportionately large incidence of non-contact injury to the hip complex in ice hockey, in addition to the heavy involvement of the hip musculature during the unique locomotion of skating.

What hip-centric properties warrant in-depth evaluation?

Hip adductors appear to have a special importance relative to the rest of the hip musculature, in ice hockey athletes. Although all hip muscles become more active with increased skating velocity, hip adductor activity appears to increase both in peak activation amplitude, and in activation duration, to disproportionately greater extents than the other hip muscles [1]. Focusing on hip adductor strength is of primary importance, not only because of its involvement with performance at high speeds, but also because of its impact on injury risk. Lack of absolute hip adduction strength and/or lack of hip adduction relative to hip abduction strength, may increase risk for groin strains [2-9]. Activities such as powerful forward or crossover skating require strong eccentric contraction of the adductors, making the groin an area particularly susceptible to injury in ice hockey players [10].

Simple Exercise for Improving Groin Strength and Function

There are simple ways to strengthen the hip adductors, using little or no equipment [11]. As you will soon see, using no equipment, an elastic band, or a ball or pad of any kind, can provide sufficient stimulus for improving hip adduction strength. Here are 7 simple hip adduction exercises that can easily be incorporated into an athlete’s warm up or strength and conditioning program to improve hip adductor function and strength.

1. Isometric Squeeze with ball or pad between the ankles (IBA)
2. Isometric Squeeze with ball or pad between the knees (IBK)
3. Side-lying hip adduction (SLA)
4. Sliding hip adduction/abduction (SLIDE)
5. Standing hip adduction with elastic band (EB)
6. Copenhagen Adduction (CA)
7. Supine bilateral hip adduction (SBA)

Comparison of Hip Adductor Muscle Activity Among Different Exercises

Serner et al. (2013) compared the muscle activity of the adductor longus (via EMG), during 8 different hip adduction strengthening exercises, including the 7 listed above, in 40 elite male soccer players [11]. The other exercise included in their analysis involved the hip adduction machine (AM) [11]. Images and descriptions of all exercises included in this study are provided below.

Exercise Images and Descriptions [11]:

Isometric adduction—with a ball between the ankles (IBA): Isometric hip adduction against a football placed between the feet inferior to the medial malleoli when lying supine. The knees are kept straight and feet vertical. The feet are pressed against the ball as hard as possible.

Isometric adduction—with a ball between the knees (IBK): Isometric hip adduction against a football placed between the knees when lying supine with hips and knees flexed, and feet flat on the surface. The first toe is pointed straight forward and the knees are pressed against the ball as hard as possible.Side-lying hip adduction (SLA): The player is lying on the side of the dominant leg with the dominant leg straight and the non-dominant leg flexed 90° in the hip and knee. Maximal hip adduction of the dominant leg is performed keeping the knee straight and foot horizontal.

Sliding hip abduction/adduction (SLIDE): Standing with the dominant leg on a wash cloth with hips and knees straight and hands placed laterally on the trunk. The dominant leg is abducted, so the centre of gravity moves laterally as much as control as possible. The dominant leg is then adducted, sliding back to the starting position.

Hip adduction with an elastic band (EB): Stand with the hip of the dominant leg positioned in maximal abduction. An elastic band (Thera-Band) is attached to a fixation point and around the ankle of the dominant leg keeping a slight tension in the elastic band from the beginning. The upper body is kept straight and the player holds on to a stable support. The dominant leg is adducted until there is a foot width between the feet and the dominant leg is approximately half a foot length behind the foot of the non-dominant leg.

Copenhagen Adduction (CA): A partner exercise where the player is lying on the side of his or her non-dominant leg, with one forearm used as support on the floor, and the other arm placed along the body. The dominant leg is held at approximately the height of the hip of the partner, who is holding the leg with one hand supporting the ankle and the other supporting the knee. The player then raises the body from the floor with the non-dominant leg adducted so that the feet touch each other and the body is in a straight line. The body is then lowered halfway to the ground, while the foot of the non-dominant leg is lowered so that it just touches the floor, without the player using it for support. New suggested high-intensity exercise by authors.

Hip adductor machine (AM): This exercise is not shown. Sitting in a hip adduction machine (TechnoGym, Bologna, Italy), with a slight knee flexion holding on to the handles, the legs are moved into maximal hip abduction and back.

Supine bilateral hip adduction (SBA): Lying supine with the hips in 90° flexion and the knees in 45° flexion, the legs are moved into maximal hip abduction and back, keeping the flexion in the hips and knees constant. New suggested low-intensity exercise by authors.

Muscle Activity & Symmetry Comparison:

Here’s a quick breakdown of the exercises (1) peak hip adductor longus activity, (2) symmetry between dominant and non-dominant limbs, and (3) required equipment:The IBK promotes high levels of hip adductor longus activity and symmetry, and its equipment needs are minimal. The CA and EB also promote high levels of dominant limb muscle activity, and have minimal equipment demands, but there’s a more significant degree of asymmetry between limbs with these exercises. When integrating these exercises into a strength and conditioning program, it’s important to recognize this potential asymmetrical stimulus so that increased or reduced volume/frequency/intensity can be applied, when appropriate. SLIDE falls in the middle of all categories; it induces moderate peak muscle activity, moderate symmetry between limbs, and has moderate equipment demands. While SA and SBA require literally no equipment, the stimulus may be insufficient for healthy, strong athletes aiming to improve hip adductor strength.

More Research on the Most Effective Exercises

Standing Hip Adduction with Elastic Band (EB)

The EB is an effective exercise for improving hip adduction strength, and it’s super simple to execute. Performing 3 sets of the EB exercise 2-3 times/week for 8 weeks improved hip adduction strength by 30% in sub-elite soccer players [12]. Although not a statistically significant difference, EB had greater peak adductor longus activity, compared with AM in the study by Serner and colleagues [11]. These results are supported by another group of researchers, who found greater recruitment of hip adductor muscles using an elastic band, compared with a seated hip adduction machine [13].

Copenhagen Adduction (CA)

Like the EB, the Copenhagen Adductor (CA) exercise requires little equipment (only an elevated surface or a partner). In the study by Serner et al. (2013), the CA was tied with IBK for the highest hip adductor longus EMG activity [11]. When performed for 8 weeks, the Copenhagen Adductor exercise increased eccentric hip adduction and abduction strength by 35.7% and 20.3%, respectively, in two U-19 sub-elite soccer teams [14]. Additionally, a 12.3% increase in hip adduction/abduction muscle strength ratio was observed [14].

Since 2004, FIFA has developed exercise programs designed to improve strength, balance and jumping/landing ability, in effort to reduce injury rates in soccer. One of these programs, termed FIFA 11+, includes specific strengthening, balancing and jumping/ landing exercises as part of a structured warm-up session [15]. In a recent systematic review, it was reported that the FIFA 11+ program has a substantial injury-preventing effect, reducing soccer injuries by 39% [15]. One of the exercises included in the FIFA 11+ warm up program is the Nordic hamstring curl, while the Copenhagen Adductor exercise is not included [15]. A group of researchers investigated how replacing the single set of the Nordic hamstring curl exercise with the Copenhagen Adductor exercise in the FIFA 11+ program affected hamstring and adductor strength [16]. Replacing the Nordic hamstring curl with the Copenhagen Adductor exercise resulted in an 8.9% increase in hip adduction strength in U19 elite male soccer players, while the standard FIFA 11+ program with the Nordic hamstring curl had no effect on eccentric hip adduction strength [16].  With this exercise exchange, one would expect a decrement in knee flexor strength, but there was no significant difference observed [16]. When professional male soccer players performed two hip adductor strengthening exercises as part of their pre-season training (2x/week for 4 weeks), increased groin strength was observed [17]. These exercises were  (1) a side-lying isometric version of the CA (3 sets of 6×10 second holds), and (2) a bridge with an isometric adductor squeeze (3 sets of 8), [17].

Unlike the other exercises mentioned, the base version of the CA exercise is difficult to perform as it requires high levels of hip adductor strength. Carl Valle from SimpliFaster does a great job discussing regressions and modifications for the CA in his recent article.

Isometric Squeeze with ball between knees (IBK) or ankles (IBA)

Perhaps the simplest exercise to perform for hip adductor strengthening is the supine isometric squeeze of a ball between the knees (IBK). The IBK was tied with CA for having the highest peak hip adductor activation in the study by Serner and colleagues [11]. This position resulted in greater hip adductor activation than the same exercise performed with the ball placed between the ankles with leg straight (IBA), [11]. These findings were replicated in another study involving 24 healthy male soccer and rugby players [18]. The IBK has an advantage over the CA and EB exercises when it comes to symmetry. Although the muscle activity among exercises was similar, the IBK had far less between-limb difference between dominant and non-dominant limbs [11]. In my opinion, the IBK exercise gives you the best bang-for-your-buck, compared with other hip adduction exercises; it’s simple to perform, requires little to no equipment, performance can be objectively quantified with ease (more on this below), peak muscle activation is quite high and symmetrical between limbs, relative to other exercise options.

Although EMG was used to collect data in the Serner et al. (2013) study, applying EMG to monitor hip strength is not practical in many settings. Fortunately, hand-held dynamometry [19] and a relatively new device called the GroinBar (a product of Vald Performance) have been shown to be reliable for measuring isometric hip strength in athletes [20]. To learn more about Vald Performance, go here. I also mention Vald Performance when I talk about how to develop and implement an appropriate protocol for testing and monitoring the hips for identification of athletes who may be from suffering hip-related pathology or are at increased risk for injury. It’s important to note that I’m not affiliated with Vald Performance in any way; I’m simply a fan of their product and believe they provide a great, standardized solution for objective muscle strength testing/monitoring.

Sliding Hip Adduction/Abduction (SLIDE)

Another effective exercise is the sliding hip abduction/adduction (SLIDE), [11]. This exercise entails standing with the dominant leg on a wash cloth or towel with hips and knees straight and hands placed laterally on the trunk. The dominant leg is abducted, so the centre of gravity moves laterally as much as controllably possible. The dominant leg is then adducted, sliding back to the starting position [11]. Similar to the IBK, there were no significant differences observed in peak hip adductor longus activation between the dominant and non-dominant limbs [11]. Although there were minor peak hip adductor activation differences among the 4 exercises mentioned thus far (EB, CA, IBK, SLIDE), these differences were not statistically significant [11]. Any of these exercises would make fine choices for hip adductor strengthening, with IBK and SLIDE exercises potentially being less prone to inter-limb strength differences.

Side-lying Hip Adduction (SLA)

The muscle activity in the side-lying hip adduction (SLA) exercise was very low, compared with the other exercises performed in the Serner et al. (2013) study [11]. In contrast, a study in healthy college-aged males found very high levels of muscle activity relative to maximal voluntary isometric contraction (MVIC) when SLA was performed with a 5lb weight attached at the ankle [21]. There was also a drastic difference in muscle activity between dominant and non-dominant limbs [11]. Given the asymmetry and muscle activity variance with minor resistance adjustments, the SLA may be a valuable exercise for beginning to regain muscle strength in an injured (or previously injured) limb.

Supine Bilateral Hip Adduction (SBA)

The muscle activity in the supine bilateral hip adduction (SBA) exercise was by far the lowest of all exercises performed in the Serner et al. (2013) study [11]. Unlike with SLA, the levels of peak hip adductor between dominant and non-dominant limbs were very similar with SBA. The combination of lower levels of hip adductor muscle activity and symmetry between limbs makes this exercise valuable as an introductory exercise to groin strengthening or for athletes on the road to recovery from bilateral groin pathology. To my knowledge, there is no other research on this exercise.

Strong Groin Equals Lower Injury Risk and Faster Return-to-Play

Rehabilitation protocols including these hip adduction exercises have been shown to be effective at promoting faster full return to sport [22-25]. In general, adding a hip adduction strength program seems to be a preventative measure for reducing injury risk, as well.

A systematic review noted that adding a hip adductor strengthening program reduced groin injuries in male soccer players by 22% [26]. An adductor strengthening program consisting of a single exercise, the Copenhagen Adductor (CA) exercise, has been shown to be an effective implementation for reducing the risk of sustaining groin problems during the competitive soccer season [27]. When performed 3 times per week during the pre-season, and once per week during the competitive season, there was a 41% reduction in groin problem prevalence in a cohort of 35 semi-professional Norwegian senior football teams [27].

Although data is limited in ice hockey athletes, it would be advisable to include routine performance of one or more simple and effective hip adductor strengthening exercises into strength programs for ice hockey athletes. It’s my recommendation to include one or more of the exercises mentioned in the article (EB, IBA, IBK, CA, SLA, SLID, or SBA), or similar exercises aimed at improving hip adductor strength, into strength training programs for ice hockey athletes in effort to enhance on-ice performance and reduce injury risk for hip/groin-related pathology. It’s important that exercise selection and manipulation of all other programming variables are individualized for each athlete.

Congratulations and Thank You

This concludes the final chapter of the comprehensive article series investigating the hip in ice hockey. If you’ve read all 7 parts, congratulations! You’ve gained a ridiculous amount of knowledge and are well-versed in research surrounding the hip musculature. Thank you so much for taking the time and putting forth the effort to come along with me on this journey. As a reward for your extraordinary commitment and effort, Shakira and I would like to leave you with this:

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Reference

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