Journal of Sports Sciences

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Core stability training on lower limb balance

strength

Antonio Dello Iacono, Johnny Padulo & Moshe Ayalon

To cite this article: Antonio Dello Iacono, Johnny Padulo & Moshe Ayalon (2016) Core stability
training on lower limb balance strength, Journal of Sports Sciences, 34:7, 671-678, DOI:
10.1080/02640414.2015.1068437

To link to this article: http://dx.doi.org/10.1080/02640414.2015.1068437

Published online: 15 Jul 2015.

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JOURNAL OF SPORTS SCIENCES, 2016
VOL. 34, NO. 7, 671–678
http://dx.doi.org/10.1080/02640414.2015.1068437

Core stability training on lower limb balance strength

Antonio Dello Iacono1, Johnny Padulo2,3 and Moshe Ayalon1
1
Zinman College of Physical Education and Sport Sciences, Wingate Institute, Israel; 2University e-Campus, Novedrate, Italy; 3Tunisian Research
Laboratory “Sports Performance Optimization”, National Center of Medicine and Science in Sports, Tunis, Tunisia

ABSTRACT ARTICLE HISTORY

This study aimed to assess the effects of core stability training on lower limbs’ muscular asymmetries and Accepted 28 June 2015
imbalances in team sport. Twenty footballers were divided into two groups, either core stability or control
KEYWORDS
group. Before each daily practice, core stability group (n = 10) performed a core stability training pro- Ecological validity; injury;
gramme, while control group (n = 10) did a standard warm-up. The effects of the core stability training isokinetic test; jump perfor-
programme were assessed by performing isokinetic tests and single-leg countermovement jumps. mance; motor control; mus-
Significant improvement was found for knee extensors peak torque at 3.14 rad · s−1 (14%; P < 0.05), knee cle strength; team sport
flexors peak torque at 1.05 and 3.14 rad · s−1 (19% and 22% with P < 0.01 and P < 0.01, respectively) and peak
torque flexors/extensors ratios at 1.05 and 3.14 rad · s−1 (7.7% and 8.5% with P < 0.05 and P < 0.05,
respectively) only in the core stability group. The jump tests showed a significant reduction in the strength
asymmetries in core stability group (−71.4%; P = 0.02) while a concurrent increase was seen in the control
group (33.3%; P < 0.05). This study provides practical evidence in combining core exercises for optimal lower
limbs strength balance development in young soccer players.

Introduction extensors may decrease the incidence rate of football injuries

(Clark, Bryant, Culgan, & Hartley, 2005; Croisier et al., 2008;
Muscular asymmetries and muscular imbalances in the muscles
Daneshjoo, Mokhtar, Rahnama, & Yusof, 2012; Hewett,
of the lower limbs muscle have been the topic of numerous
Lindenfeld, Riccobene, & Noyes, 1999; Wong, 2005).
recent investigations aimed at clarifying their role as potential
Considering that the muscle strength symmetry and
risk factors in the occurrence of injuries as well as reinjuries in
balanced ratio seems related to core stability programmes,
different team sports (Fousekis, Τsepis, & Vagenas, 2010a; Jones &
as demonstrated in adults (Hewett et al., 2006), particularly
Bampouras, 2010). Muscular asymmetries refer to strength defi-
with respect to the reduction of the hamstrings muscle inju-
cits between the two lower limbs (Fousekis et al., 2010a) and
ries rate (Mjolsnes, Arnason, Osthagen, Raastad, & Bahr, 2004),
differ from muscular imbalances, which represent alterations of
core stability programmes could be useful in eliminating this
the normal strength agonist/antagonist ratios of muscle pairs
gap. Indeed, in younger male football players and in other
(Junge, Rösch, Peterson, Graf-Baumann, & Dvorak, 2002). These
team sports, the usefulness of core stability-based condition-
functional deficiencies are identified as intrinsic risk factors, and
ing programmes has been shown (Olsen, Myklebust,
their presence is commonly correlated with high risk of injury for
Engebretsen, Holme, & Bahr, 2005; Soligard et al., 2008).
athletes practising sport at the recreational or competitive level
Since the main purpose of core stability training is injury
(Croisier, Ganteaume, Binet, Genty, & Ferret, 2008).
prevention, the knowledge of training effects elicited by
However, when focusing on sport-specific epidemiology,
these programmes can help in identifying the potential
researchers showed that injury risk could potentially be mod-
mechanisms behind the reported reduction in injury inci-
ified through compensative training programmes (Hewett,
dence. Previous studies have described the training adapta-
Ford, & Myer, 2006; Soligard et al., 2008). Researchers
tions in lower limbs strength related to core stability training
(Soligard et al., 2008) highlight the importance of undertaking
programmes (Brito et al., 2010; Daneshjoo, Rahnama, Mokhtar,
specific preventive programmes aimed at limiting muscular
& Yusof, 2013). Daneshjoo et al. (2012) showed that the core
asymmetries and imbalances in order to avoid their negative
stability programme FIFA 11+ was effective in improving both
effects on the athletes’ health and performance. In the foot-
concentric and eccentric quadriceps and hamstring strength in
baller, strength deficiencies implicated injuries to the lower
young male professional football players. In addition, Brito
limbs, as muscle strength is crucial in injury prevention
et al. (2010) conducted the FIFA 11+ programme on a similar
(Croisier et al., 2008). In this scenario, since most soccer inju-
population and found the programme to be significantly
ries affect the knee joint and the surrounding muscles (Wong,
effective in increasing the conventional isokinetic strength
2005), the achievement of optimal muscle strength symmetry
ratio between knee flexors and extensors at 1.05 rad · s−1 by
and balanced ratio in the function of knee flexors and
14.8% and the dynamic conventional ratio by 13.8% in the

CONTACT Antonio Dello Iacono antdelloiacono@virgilio.it Life Science Departement, Zinman College of Physical Education and Sport Science, Wingate
Institute 42902, Israel.
© 2015 Taylor & Francis
672 A. DELLO IACONO ET AL.
non-dominant leg. However, both studies (Brito et al., 2010;
Daneshjoo et al., 2012) were not experimental (one-group,
pre-post design) and the power significance of their results
appears questionable. Moreover, to the best of our knowl-
edge, no well-designed and controlled studies have previously
examined the influences on football players’ strength asym-
metries and imbalances induced by core stability training
programmes. Therefore, the main aim of this randomised-
controlled study was to examine whether implementing a
short-term core stability training programme for 6 weeks as
a routine warm-up affect imbalances and asymmetries in the
muscles of the lower limbs in young football players.
Materials and methods
Participants
Twenty male football players, members of a young elite team
of the national Israeli league, volunteered to participate in the
study. All players had at least 10 years of football practice and
5 years of competitive experience at the national level.
Participants (Table I) were divided into two groups, either
the core stability training programme (CS, n = 10) or the
control (CG, n = 10) groups. Groups were matched according
to the normalised strength values, muscular imbalances and
asymmetries indexes, and years of practice of the players at
baseline time. This was effective for 14 players (2 × 7 for each
group) while the remaining 6 players were added to each
group by processing a blocked restricted randomisation,
where a block size of 6 and an allocation ratio of one-to-one
were selected (Hopkins, 2000; Schulz & Grimes, 2002). This
method, performed by a computer random number generator,
achieved a balanced randomisation while also assuring that
both groups displayed equivalent mean values for each para-
meter. All players were healthy, without history of major lower
limb injury, and were not taking any medication during their
participation in this study. Written informed consent was
obtained from each of the participants and guardians (i.e. for
underage players) after receiving a verbal explanation of the
potential risks and benefits resulting from this study participa-
tion. The study was conducted according to the Declaration of
Helsinki and approved by the Research Ethics Committee of
the local university (Harriss & Atkinson, 2013).
Design
A randomised-controlled study design was performed to
examine the effects of a core stability training programme
on the lower limbs muscles’ “imbalances and asymmetries”.
Table I. Anthropometric characteristics of the participants.
Variables CS CG
Age (years) 18.7 ± 0.67 19 ±
Height (m) 1.76 ± 0.1 1.8 ±
Body mass (kg) 73.22 ± 9.9 78.21 ±
Body fat (%) 12.6 ± 2.1 12.9 ±
Training experience (years) 9± 1.2 9±
Competitive experience (years) 5± 0.7 5±
Notes: Data shown as mean ± SD for core stability training programme (CS, n =
10) and control (CG, n = 10) groups. Between-groups differences were not
significant (P > 0.05).
This study involved over a period of 6 weeks young football
players, who were assigned either to the core stability group
or control group. In order to effectively compare the overall
effects of the core stability training and the standard warm-up,
the two conditioning approaches were matched with each
other in terms of training volume. Both of them took approxi-
mately 20 min to be completed with the core stability group
performing the core stability programme that replaced the
usual warm-up before each training session. The effect of the
training protocols was assessed using strength-relevant tests
such as isokinetic tests and single-leg vertical countermove-
ment jumps.
Methodology
Participants performed two similar batteries of tests at base-
line (a week before the first training week) and 1 week after
the end of the training, thus allowing a short tapering period
to maximise final performance (Mujika, 1998). All tests were
performed using the same procedures, and with the same
technicians, who were blind to the training group affiliation.
All participants were familiar with the testing procedures, as
they had performed them on previous occasions. All testing
sessions were performed at the same time of the day
(4:00 p.m. to 8:00 p.m.), temperature (19–22°C) and humidity
(45–50%). All players were asked to avoid intense exercise on
the day prior to the tests and to consume their usual meal at
least 3 h before the scheduled testing time.
Isokinetic tests
Bilateral isokinetic testing assessed maximal quadriceps and
hamstrings muscle performance (Croisier et al., 2003) using
an isokinetic dynamometer (Biodex “3” generation System,
New York, USA). Isokinetic strength tests were assessed after
following a standardised 10ʹ warm-up on a cycloergometer
(100 W) and 5ʹ dynamic stretching exercises of subsequently
involved muscles (Haddad et al., 2014; Padulo, Di Capua, &
Viggiano, 2012). The player was seated with the body stabi-
lised by several straps around the thigh, waist and chest in
order to avoid compensations (Di Vico, Ardigò, Salernitano,
Chamari, & Padulo, 2014). The range of knee motion was
fixed at 95° of flexion from the active maximum extension.
The gravitational factor of the dynamometer’s lever arm and
lower segment ensemble was calculated by the dynam-
ometer and automatically compensated during measure-
ments. An adequate familiarisation with the dynamometer
was provided in the form of further warm-up isokinetic repe-
titions at various angular speeds (1.05–3.14 rad · s−1). The
participant did not receive visual feedback during the test,
while verbal encouragement was given. The protocol
ANOVA included five maximal flexion/extension repetitions in con-
0.63 0.341 centric modality at both slow and fast speeds: 1.05 and 3.14
0.06 0.273
6 0.192 rad · s−1 with 90 s of passive recovery in-between (Zakas,
1.8 0.461 2006). Analysis of the results included the absolute peak
0.7 0.486 torques in Newton-metres normalised to body weight and
0.3 0.538
the bilateral comparison enabled the determination of asym-
metries expressed in percentage terms. A conventional
flexor/extensor peak torque ratio was established for the
 JOURNAL OF SPORTS SCIENCES 673

same contraction modality and speed of 1.05 and 3.14 rad · s−1
(Croisier et al., 2008; Zakas, 2006).
Jumping tests
In a separate session, the players were assessed for jump
performances after a standard warm-up (8 min of jogging, 5ʹ
of dynamic stretching exercises, two 20 m sprints and jumping
drills). The players undertook countermovement jump with
one-leg tests to assess lower limb strength (Bosco, Luhtanen,
& Komi, 1983). Each participant performed three jumps with
bare feet to negate the effects of shoes, and the position of
the feet was standardised during all tests at shoulder width.
Starting position was stationary, erect, with knees fully
extended. The participant then squatted down to about ~90°
of knee flexion before starting the upward motion.
Participants were instructed to keep their hands on the hips
to prevent the influence of arm movements. Participants were
instructed to jump as high as possible and verbal encourage-
ment was provided before each trial. A rest period of at least 1
min was allocated between jumps to minimise muscular fati-
gue. The starting leg (left or right) was randomly selected to
avoid any order effect. The vertical ground reaction force data
were collected from a Kistler force plate (Type 9286A, Kistler
Biomechanics, Winterthur, Switzerland) mounted on a floor
apparatus. Sampling frequency was set at 500 Hz, and the
signal was electronically processed and amplified by a Kistler
amplifier (model no. 9681A). The force platform was regularly
checked for accuracy, linearity and consistency over time in
the loaded condition (5 min) using certified weights ranging
from 20 to 100 kg. For both legs, the peak vertical ground
reaction forces were calculated. For the ground reaction force
variables, asymmetry was quantified using the index of asym-
metry (IA) as previously described by Impellizzeri, Rampinini,
Maffiuletti, and Marcora (2007), where
stronger  weaker
IA ¼  100
stronger
This index expresses asymmetry as a value on a continuous
scale from 0 to +100. IAs from peak ground reaction forces
(GRFpeak) values were used in the data analysis.
The core stability training programme
All players were invited to a frontal instruction course 2 weeks
before the study which aimed at demonstrating the interven-
tion programme to them and explaining how to perform the
exercises correctly. During the study, both core stability group
and control group were involved in the same football training
programme five times per week for 6 weeks. In addition,
before each daily soccer practice, only core stability group
performed the core stability training programme consisting
of 11 exercises (Mjolsnes et al., 2004; Soligard et al., 2008) as
reported in Table II. The core stability training programme
consists of two parts, beginning with six exercises aimed at
improving balance and core stability (part I), followed by five
exercises to develop lower limb strength and neuromuscular
control (part II). The protocol was organised according to the
methodology of circuit training, thus, the 11 exercises were
consecutively repeated for three times with 20 s of rest
between them and 1 min inter-sets. At the same time, the
control group completed a regular warm-up including 8 min
of jogging, 6 min of dynamic stretching and 6 min of

Table II. Core stability training programme.

Weeks
Exercises Guidelines 1–3 4–6
Part I
1 Seated torso + Seat on the floor, knee extended. Place hands crossed on the opposite shoulders. 3 sets of 10 3 sets of 10 reps for
eccentric phase** Extend the trunk trough an eccentric contraction of abdominal muscles until a reps each side, 30 s rec.
comfortable balance position is reached.
2 Kneeling “superman” Quadruped position, lift one arm and opposite leg keeping it straight. 3 sets of 10 3 sets of 10 reps
exercise** reps each side each side
3 Balancing seated twist Seat on the floor, lift knee keeping it flexed to 90° and raise feet few centimetres 3 sets of 10 3 sets of 10 reps
with arms extended** from the floor. Hands straight forward. Swing the trunk to the left and the right reps each side each side
laterally keeping a balance position.
4 Pendulum** Lie on supine position. Place hands on the side of the trunk. Lift knee and hips 3 sets of 10 3 sets of 10 reps
keeping it flexed at 90°. Twist and rotate the pelvis to the left and the right laterally reps each side each side
almost touching the floor with feet.
5 Static bench + hip Assume a bridge position supporting yourself on forearms and toes “Switch on your 3 sets of 20 s 3 sets of 20 s each
extension** core like a dimmer switch”. Stabilise, keep and hold while raising one leg into hip each side side
extension
6 Nordic hamstrings** Kneel on a soft surface. Ask to partner to hold the ankles down firmly. Keeping body 3 sets of 6 3 sets of 6 reps
completely straight from the shoulder to the knee, lean forward as far as, controlling reps
the movement with hamstrings and gluteal muscles.
Part II
7 Walking lunge** Stand with your feet at hip-width apart with hands on hips. Lunge forward slowly at 3 sets of 10 3 sets of 10 reps
an even pace, bending the leading leg until hip and knee are flexed to 90°. reps each leg
8 Frontal balance stance
9 Lateral balance Standing, hands on the iliac crests. Make a frontal/lateral leap landing on one foot 3 sets of 4 3 sets of 4 reps each
stance** with the knee flexed at 90°. Keep the balance position acquired for 3 s reps each leg leg
10 Shoulder contact Run forwards in pairs. Shuffle sideways by 90° to meet in the middle then jump 3 sets of 4 3 sets of 4 reps each
sideways towards each other to make shoulder-to-shoulder contact. reps each side side
11 Sprint and stop in Sprint maximally for 5 m and decelerate in a limited space of 1 m length. 3 sets of 4 3 sets of 4 sprints
delimitated space sprints
Note: **These exercises were performed with increased level of difficulty (closed eyes or unstable planes) during the fourth to sixth weeks.
674 A. DELLO IACONO ET AL.

mobilisation exercises. During all the training sessions, one Results

researcher supervised the execution of the exercises aiming
to ensure the players’ compliance with the programme and
the quality of their movements. In addition, to isolate the
effect of the current intervention protocol, other fitness
training sessions were conducted in both groups identically
during the 6 weeks of the study. Specifically, the average
total training time for each group was 11.5 h per week,
including similar technical, tactical, strength and basic skills
drills. For both groups, strength training included one ses-
sion/week of upper and lower limb exercises (bench press,
shoulder press, pullover, half squat, deadlift, lunge), at a low
intensity of 50% of one repetition maximum (1-RM), three
sets for each exercise with 2 min of passive recovery in-
between (8–10 fast repetitions “<1 s”) and recovery
between reps (2 s); the work rest ratio = 1:3 (Padulo,
Laffaye, Chaouachi, & Chamari, 2014).
Statistical analysis
All data are presented as mean ± standard deviation (SD). For
intra-group comparisons (pre- vs. post-training test results for
both core stability group and control group), paired t-tests
were used. Two-way analysis of variance (ANOVA) was used to
examine the data of both groups together for the pre- and
post-training time points in order to determine the main and
interactive effects of training. The Shapiro–Wilk test was used
to ensure normal distribution of the results. Cohen’s effect size
coefficient with 95% confidence intervals was used to deter-
mine the practical significance of observations (Cohen, 1998).
Effect sizes (ES) of <0.09, 0.10–0.49, 0.50–0.79 and >0.80 were
considered trivial, small, moderate and large, respectively.
Differences between means were expressed as pre-to-post
intervention percentage and confidence interval of the corre-
sponding variation. The Bland–Altman method (Bland &
Altman, 1986), the intra-class correlation coefficient (ICC) and
typical error of measurement (Hopkins, 2000) were used to
determine the test–retest reliability of the measures.
Significance level was set at P < 0.05. Statistical analysis was
performed by using SigmaPlot 11.0 software (Systat Software,
Tulsa, OK, USA).
There were no differences between groups at baseline condi-
tions for age, body height, body mass, body fat or training
experience (Table I). The 95% of lower limits of agreement
between the test–retest measurements were from −1.32 to
1.75 for isokinetic tests and from −2.12 to 1.96 for jump
tests. These limits were narrow enough to indicate reasonably
agreement between trials. All the variables showed highly
reliable data, with ICC ranging from 0.925 to 0.978 for isoki-
netic and jump tests. The relative to body weight values of
isokinetic strength for flexors (1.05 and 3.14 rad · s−1) and
extensor muscles (1.05 and 3.14 rad · s−1), before and after
the 6-week intervention, are shown in Table III. At baseline, the
comparison of peak torque (flexion: 1.05 and 3.14 rad · s−1)
and (extension: 1.05 and 3.14 rad · s−1) values between core
stability group and control group showed no significant differ-
ences (F(1,18) = 1.311 with P = 0.373). A “training effect” was
observed for peak torque (flexion: 1.05 and 3.14 rad · s−1 with
P = 0.022 and P = 0.006 as shown in Table III). Two-way
ANOVA revealed differences (Figure 1) in peak torque (extension:
3.14 rad · s−1) (F(1,18) = 4.105 with P = 0.032), (flexion: 1.05 rad · s−1)
(F(1,18) = 7.124 with P = 0.002) and (flexion: 3.14 rad · s−1) (F
(1,18) = 8.014 with P = 0.001).
The conventional peak torque (flexion/extension) ratio
percentage changes before and after the 6-week interven-
tion are presented in Table IV. As for the core stability
group, paired t-test showed higher ratio values of 7.7%
(P = 0.042) and 9.5% (P = 0.038) in post-test compared to
baseline conditions in both legs at 1.05 and 3.14 rad · s−1,
respectively. In control group, there was no significant dif-
ference for the peak torque (flexion/extension) ratio with
respect to baseline conditions (P > 0.05). Two-way ANOVA
revealed a “training interaction” for the peak torque
(flexion/extension) ratio 1.05 rad · s−1 (F(1,18) = 3.745 with
P = 0.041) and the peak torque (flexion/extension) ratio 3.14
rad · s−1 (F(1,18) = 4.002 with P = 0.035). The effect size of the
relative changes for the peak torque (flexion/extension) ratios
ranged between moderate to large both for 1.05 rad · s−1
(ES = 0.61–0.75) and 3.14 rad · s−1 (ES = 0.71–0.95), respectively.
For the IA values, there was no significant difference when
comparing the baseline outcome measures of the core

Table III. Isokinetic peak torque in extensor and flexor muscles.

Peak torque
Right leg Left Leg
Group Pre (Nm/kg) Post (Nm/kg) Δ% (95% CI) Pre (Nm/kg) Post (Nm/kg) Δ% (95% CI)
CS
EXT (1.05 rad · s−1) 3.2 ± 0.4 3.6 ± 0.2 11.2 (5.4 to 17) 3.1 ± 0.1 3.5 ± 0.1 11.5 (6.4 to 16.6)
EXT (3.14 rad · s−1) 1.9 ± 0.3 2.2 ± 0.1 13.7 (3.4 to 24) 1.8 ± 0.6 2.1 ± 0.3 14.3 (6.2 to 22.4)
FL (1.05 rad · s−1) 1.73 ± 0.02 2.12 ± 0.08*† 18.4 (1.8 to 35.1) 1.68 ± 0.04 2.09 ± 0.06*† 19.7 (14.3 to 25.1)
FL (3.14 rad · s−1) 1.2 ± 0.2 1.5 ± 0.07*† 20 (12.3 to 27.7) 1.1 ± 0.4 1.45 ± 0.1*† 24.2 (18.4 to 30)
CG
EXT (1.05 rad · s−1) 3.1 ± 0.3 3.2 ± 0.1 3.2 (−7.4 to 13.8) 3 ± 0.2 3.1 ± 0.3 2.6 (−5.4 to 10.6)
EXT (3.14 rad · s−1) 2 ± 0.2 2.1 ± 0.1 4.8 (−12.1 to 21.7) 1.9 ± 0.3 2 ± 0.2 5 (−1.4 to 11.4)
FL (1.05 rad · s−1) 1.65 ± 0.04 1.62 ± 0.08 −1.9 (−3.4 to −0.4) 1.71 ± 0.03 1.69 ± 0.04 −1.2 (−1.5 to −0.9)
FL (3.14 rad · s−1) 1.3 ± 0.12 1.3 ± 0.2 −0.2 (−1.4 to 1) 1.2 ± 0.09 1.2 ± 0.04 −0.1 (−1.4 to 1.2)
Notes: Data shown as mean ± SD and percentage change (δ) (values are mean (95% CI)) between pre- to post-training time for core stability training programme
(CS, n = 10) and control (CG, n = 10) groups.
*Significant differences from pre- to post-time (P < 0.05).
†
Significant differences between groups from pre- to post-time (P < 0.05).
EXT, extensor muscles; FL, flexor muscles Nm/kg = Newton meter per kg of body weight; pre, pre-test; post, post-test; CI, confidence interval; EF, effect size.
 JOURNAL OF SPORTS SCIENCES 675

Figure 1. Muscular imbalance and asymmetries between pre- to post-training time. Values are means ± SE. Notes: *significant differences from pre- to post-time
(P < 0.05); †significant differences between groups from pre- to post-time (P < 0.05). CS, core stability training group; CG, control group; PT, peak torque;
EXT, extensor muscles; FL, flexor muscles; IA, index of asymmetry; GRFpeak, peak ground reaction forces; %, percentage difference.

Table IV. Peak torque ratio between isokinetic knee flexors/extensors.

Peak torque ratio
Right leg Left leg
Group Pre Post Δ% (95% CI) Pre Post Δ% (95% CI) ES
CS
FL/EXT (1.05 rad · s−1) 0.54 ± 0.12 0.58 ± 0.1*† 7 (6.2 to 7.9) 0.54 ± 0.12 0.59 ± 0.06*† 8.5 (5.3 to 11.7) 0.61–0.75
FL/EXT (3.14 rad · s−1) 0.63 ± 0.03 0.68 ± 0.02*† 7.4 (6.9 to 7.9) 0.61 ± 0.02 0.69 ± 0.01*† 11.6 (9.8 to 13.4) 0.71–0.95
CG
FL/EXT (1.05 rad · s−1) 0.53 ± 0.09 0.51 ± 0.08 −3.8 (−8 to 0.4) 0.57 ± 0.12 0.55 ± 0.08 −3.6 (−8.2 to 1) 0.06–0.08
FL/EXT (3.14 rad · s−1) 0.65 ± 0.04 0.62 ± 0.05 −4.7 (−11.2 to 1.8) 0.63 ± 0.06 0.6 ± 0.08 −4.8 (−9.1 to −0.5) 0.08–0.09
Notes: Data shown as means ± SD and percentage change (δ) (values are mean (95% CI)) between pre- to post-time for core stability training programme (CS, n =
10) and control (CG, n = 10) groups.
*Significant differences from pre- to post-time (P < 0.05).
†
Significant differences between groups from pre- to post-time (P < 0.05).
FL/EXT, conventional isokinetic knee flexors/extensors ratio; pre, pre-test; post, post-test; CI, confidence interval; ES, effect size.

Table V. Inter-limb muscular asymmetries.

stability group and control group (F(1,18) = 0.956 with
Index of asymmetry (%)
P = 0.193). Paired t-test showed a large decrease of inter-
limb asymmetries values in the core stability group Group Pre (%) Post (%) Δ% (95% CI) ES
(P = 0.016), while a concurrent significant increase was CS 5.4 ± 0.11 1.6 ± 0.2*† −71.4 (−56.4 to −86.4) 2.01
CG 4.8 ± 0.3 7.2 ± 0.1* 33.3 (29.4 to 37.2) 1.28
reported in the control group for the same variables
Notes: Data shown as mean ± SD of percentage difference (%) (values are mean
(P = 0.026) (Figure 1). Two-way ANOVA showed significant (95% CI)) of inter-limb differences at pre- and post-training time for core
main effect on IAs between the core stability group and con- stability training programme (CS, n = 10) and control (CG, n = 10) groups.
trol group (F(1,18) = 9.152 with P = 0.001) (Table V), while a *Significant differences from pre- to post-time (P < 0.05).
†
Significant differences between groups from pre- to post-time (P < 0.05).
large effect size was found (ES = 1.28–2.01). Pre, pre-test; post, post-test; CI, confidence interval; ES, effect size.

Discussion to affect lower limb muscle imbalances and asymmetries in

The aim of this study was to verify whether a core stability young football players. The values of strength imbalances and
training programme represents an effective programme able asymmetries assessed using isokinetic and jumps tests were
676 A. DELLO IACONO ET AL.
significantly decreased in core stability compared with the
control group after the 6-week intervention. These findings
led us to provide an insight about the core stability training
effectiveness in reducing the athletes’ functional deficiencies
and improving the lower limbs’ neuromuscular control.
The pre- and post-training results demonstrate that the
changes in the values of muscle imbalances and asymmetries
are similar to those that have been reported by previous
researchers (Brito et al., 2010; Daneshjoo et al., 2012, 2013).
In the present study, the core stability training programme
significantly increased the peak torque (flexion/extension)
ratios between pre- and post-intervention in both legs at
1.05 and 3.14 rad · s−1 by 7.7% and 9.5%, respectively. These
results confirm a previous proposal, formulated by Daneshjoo
et al. (2013), that an 8-week FIFA 11+ programme is efficacious
in improving knee flexors/extensors strength ratios. The
authors investigated the FIFA 11+ programme on young
male football players, who showed significant increases in
strength ratio at 1.05, 3.14 and 5.23 rad · s−1 by 9.7%, 9.1%
and 1.2%, respectively. Similarly, our results reported augmen-
ted values of peak torque (flexion/extension) ratios as a con-
sequence of greater significant increases in the concentric
strength of the hamstring muscles in a within-group analysis
(Table III). Specifically, the core stability training programme
includes several special strength exercises for hamstring mus-
cles, such as “Nordic hamstring”, frontal and lateral balance
stance, and repeated short sprint and stops, which may have a
direct influence on hamstring strength values.
For example, the “Nordic hamstring” exercise has been shown
to be effective in improving concentric and eccentric hamstring
strength among adult male football players, thus providing a
protective effect against injury mechanisms involving anterior
cruciate ligaments (ACLs) and hamstring muscles themselves
(Mjolsnes et al., 2004). In addition, Padulo et al. (2013) have
proved that landing skills such as those similarly proposed in
some exercises of the core stability training programme in our
study are associated with significantly greater hamstring muscle
activation and involvement. Indeed, the short period of time
during which a landing-based task is completed requires higher
peak hamstring muscular forces, aiming to provide a dynamic
support for a better knee stabilisation. Hence, it can be postulated
that these mechanisms played a key role in generating the
observed improvements in hamstring strength and the conse-
quent increase in the peak torque (flexion/extension) ratio values.
Another finding of the present study was the significantly
greater reduction of the inter-limbs strength asymmetries in
the core stability compared to the control group after 6 weeks
of training. Our outcomes reveal the core stability training
programme to significantly reduce the bilateral flexors’ and
extensors’ peak torque differences between pre- and post-test
in the core stability group from 2.9% to 1.5% and from 3.2% to
2.8% and at 1.05 rad · s−1, respectively, according to
Daneshjoo et al. (2012, 2013). They reported a significant
reduction of the dominant and non-dominant leg asymme-
tries, from 4% to 2.4% at 1.05 rad · s−1, from 1.9% to 0.9% at
3.14 rad · s−1 for the extensor muscles and from 2.8% to 2.1%
at 1.05 rad · s−1, and from 4.1% to 3.4% at 3.14 rad · s−1 for the
flexor muscles, respectively (Daneshjoo et al., 2013). Although
we found a “training effect” between the core stability group
and control group on muscle strength asymmetries assessed
by isokinetic tests, the magnitude of these differences was
quite variable, from small to very large (ES = 0.41–1.75) and
their practical significance has to be further verified. On the
other hand, from an injury prevention perspective, we cannot
exclude that this difference was meaningful, but unfortunately
there is no literature supporting how even such a limited
amount of training effect is necessary for reducing injury in
football players.
Additionally, the comparison between groups showed a
significant main effect on inter-limbs peak ground reaction
force asymmetries assessed by single leg countermovement
jump, only in the core stability group after the 6-week inter-
vention. Impellizzeri et al. reported that a between-limbs com-
parison of single-leg countermovement jump performances
could enable bilateral functional strength and power imbal-
ances to be determined (Impellizzeri et al., 2007). The values
obtained by the core stability group in single-leg counter-
movement jump tests highlighted a significant reduction in
post-training functional asymmetry compared to pre-training
results (Table V). This trend was not observed in the control
group; in addition, a higher mean level of limb peak ground
reaction force asymmetry was observed in the post-training
single-leg countermovement jump test compared to pre-train-
ing levels. A possible explanation for these results is that,
when practising or playing football, players are forced to use
their lower limbs unilaterally in almost all skills (kicking, jump-
ing, cutting) (Reilly, 1996) and this alters the strength balance
between the two extremities or between agonist/antagonist
muscle groups (Fousekis, Tsepis, & Vagenas, 2010b). Thus,
consistent asymmetrical workloads and functional adaptations
gradually induce asymmetries in the myodynamic character-
istics of the player. In turn, soccer-specific kinetic adaptations
and strength asymmetries are suspected to influence the
degree of pre-existing anatomic and functional asymmetries,
thus leading to football injuries (Fousekis et al., 2010a). The
results of the ANOVA (Figure 1) clearly indicate a significant
“training group” interaction highlighting the core stability
training benefits in leading to a significant reduction in the
observed values of limb peak ground reaction force asymme-
tries. Nevertheless, more data and/or studies are required
before we can infer a clear outcome for these variables.
Given the fact that several investigators (Croisier et al.,
2008; Devan, Pescatello, Faghri, & Anderson, 2004;
Kuszewski, Gnat, & Saulicz, 2009; Soligard et al., 2008) iden-
tified a relation between strength imbalance and injuries,
training interventions aimed to reduce strength deficiencies
in young athletes are likely to correlate with lower risk of
football injuries. In this respect, Andrade Mdos et al. (2012)
suggested that muscle imbalances in the thigh can lead to
muscle injuries and increased knee laxity. In addition, sig-
nificant etiological factors for football injury include
strength deficits in knee extensors and knee joint instability
(Wong, 2005), muscle imbalances between extensors and
flexors of the knee (Devan et al., 2004) and large eccentric
strength asymmetry (≥15%) between the lower extremities
(Croisier et al., 2008). Certainly, a proportionate relation in
quadriceps strength against that of the hamstring will
reduce the anterior tibia shearing of ACL, playing a

protective role for the stabilisation of the knee joint (Hewett
et al., 2006, 1999). Moreover, improvements in the level of
hamstring strength produce favourable neuromuscular
adaptation for the possible prevention of hamstring muscle
strain risks in football players (Andrade Mdos et al., 2012;
Clark et al., 2005).
Practitioners can expect that implementing core stability
training programme as a routine warm-up will be a useful
option for increasing knee flexors’ and extensors’ strength
and peak torque (flexion/extension) ratios in well-trained
young footballers over a 6-week period of time. In addition,
the meaningful effects found in lower limbs’ muscle asymme-
tries and imbalances measures suggest that the core stability
training programme can be proposed as a training strategy for
improving lower limbs strength balance. Indeed, the core
stability training programme can be considered both as an
appropriate alternative warm-up and an effective training pro-
tocol aimed at strength development. Consequently, during
the in-season competitive phases, coaches of team sports
should favour the use of core stability training programme
instead of the standard warm-up.
Conclusion
In conclusion, the current study implies that using a 6-week
core stability training programme is an effective method for
improving the lower limbs strength balance of young footbal-
lers. While previous research has focused on the long-term
effects of core stability training in terms of injury prevention,
this study reveals the effectiveness of core exercises in redu-
cing inter- and intra-limbs’ strength imbalances and asymme-
tries. For the development and the implementation of injury
prevention programmes addressed to young athletic popula-
tion, coaches and players are strongly encouraged to include
such interventions as a part of their regular training
programme.
Acknowledgement
The authors wish to thank all the footballers who volunteered for this
study.
Disclosure statement
No potential conflict of interest was reported by the authors.
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