Sports Medicine Research: In the Lab & In the Field: Hurts So Good: Eccentric Hamstrings to Prevent Strains (Sports Med Res)


Wednesday, April 15, 2015

Hurts So Good: Eccentric Hamstrings to Prevent Strains

The preventative effect of the Nordic hamstring exercise on hamstring injuries in amateur soccer players: a randomized controlled trial

Van der Horst N, Smits DW, Petersen J, Goedhart EA, & Backx FJG. The American Journal of Sports Medicine. Online ahead of print, March 20, 2015.

Take Home Message: A program focused on eccentric hamstring strengthening may prevent hamstring injuries.

Hamstring strains are common, especially in soccer, and can result in significant recovery times. Eccentric hamstring strengthening may be a modifiable risk factor of hamstring strains but it remains unknown if eccentric strengthening will prevent hamstring injuries.  Therefore, Van der Horst and colleagues conducted a randomized controlled trial to evaluate the effectiveness of an eccentric hamstring strengthening program (Nordic Hamstring Exercise [NHE]) in comparison to no intervention on hamstring injury incidence rates, severity, and time loss among a male amateur soccer population.  A total of 579 male soccer players from 32 teams completed the study. The authors randomized teams to the NHE or control group for the 13 week intervention program.  The NHE group completed 25 sessions of NHE exercises at the end of practices during the 13 weeks, and adjustments to the protocol were made for injury.  The training sessions were supervised by the coach or medical staff. For one year, the medical staff for each team reported any hamstring injury that required medical attention or time loss from soccer. Thirty-six hamstring injuries occurred with an incidence rate of 0.7 per 1000 exposure hours, with a greater occurrence in matches when compared with practices.  There were no group differences for hamstring injury incidence during the 13 week intervention; however, the chance of a hamstring injury was 72% lower in the NHE group during the remainder of the year.  There were no differences in injury severity between the NHE and control groups. 
Eccentric hamstring strengthening exercises, such as NHE, may have a positive effect in preventing hamstring injuries for up to 39 weeks after the program.  The authors of this study noted that a few teams withdrew or did not have full compliance due to the soreness affiliated with the NHE protocol.  It would be interesting to investigate the effectiveness of an NHE program prior to the soccer season. This would prevent soreness from impeding sport-specific training and lead to the effects of the training program to peak as the athletes are starting their competitive season.  The overall hamstring incidence rates seem relatively low within this current study.  Future research could work on replicating this study to determine if it has a similar effect in other levels of soccer athletes (e.g., college, high school) as well as to determine its treatment benefit among athletes with previous hamstring injuries.  Further objective measures of pre- and post-season hamstring strength would also add value to the effects of this training program as well as possibly identifying “at risk” athletes who have suffered repetitive hamstring strains and prescribing this type of program to them. Despite the need for more evidence, sports medicine clinicians may want to consider advocating for off-season and pre-season eccentric hamstring exercises as a possible strategy to reduce the number of hamstring injuries on their team(s). After all, these exercises can be easily done on the field at practice with minimal chance of harm and the potential to improve strength and reduce the rate of hamstring strains.
Questions for Discussion:  Will you use eccentric hamstring exercises to prevent hamstring injuries with any of your athletes/patients?   Will eccentric hamstring exercises decrease the risk of injury in other groups of athletes? 

Written by: Nicole Cattano
Reviewed by: Jeffrey Driban

Related Posts:

van der Horst, N., Smits, D., Petersen, J., Goedhart, E., & Backx, F. (2015). The Preventive Effect of the Nordic Hamstring Exercise on Hamstring Injuries in Amateur Soccer Players: A Randomized Controlled Trial The American Journal of Sports Medicine DOI: 10.1177/0363546515574057


Sandra Koen,ATC said...

Eccentric exercises for the hamstrings is an interesting but powerful idea, due to the common mechanism of injury for hamstring strains. It is also important because of the lengthy rehab that it can take and the recurrence rates. Although there have been other studies with beneficial outcomes in decrease number of injuries, I think one of the reasons there was no significant difference in the groups could be due to the elite status of the athletes. It would be interesting to use the same exercise protocols on Collegiate or even high school athletes to determine if it is beneficial. I think looking at the recovery from hamstring strains between groups would also be interesting, to see if there were any differences in doing those exercises pre injury; Other areas of interest could also include the type of activity during injury, and fitness levels, since they can both have an effect on injury and recovery time.

Nicole Cattano said...

Sandra - I agree that it would be interesting to see the external generalizability of these results in other groups of people/athletes. Thanks for your comment!

What are your thoughts regarding how activity during injury or fitness levels may affect injury or recovery time?

Kaitlyn Grossman ATC said...

I agree with Sandra. It would be interesting to see the generalizability of the NHE exercise program. I think it would be an easy thing to incorporate in pre/post practice stretching that would help prevent a very common injury. I have used Nortic Fall exercises in many rehabilitation programs, but I never thought of using them as a preventative exercise. I love the gear towards injury prevention the medical field is taking. It would be interesting to see results in other sports and populations.

Interesting article!

Nicole Cattano said...

Kaitlyn - Prevention is key! My only question would be timing of the exercises given the muscle soreness affiliated with these exercises...

When do people think would be a good time to implement these exercises clinically as a prevention program?

Rahul Katbamna said...

Rahul Katbamna:
This article provided a great intervention study utilizing an eccentric training program for the hamstrings. It would be interesting to see a future study on comparing the effects of NHE between gender-differences and see if the results would be the same or different. Also, it would be great to see if including an eccentric strengthening program for the hamstrings within the warm-ups would also have a positive effect in decreasing the incidence of hamstring strains.

Jeffrey Driban said...

Hi Rahul: Great comments. Adding these exercises to the warm-ups would likely be beneficial but your right that this should probably be tested since this study did the exercises after training. I agree that it would also be interesting to test this intervention in female athletes. Great research ideas for future studies.

Mark Colapietro said...

Another aspect it would be interesting to look into is the history of hamstring strains with the athletes that completed the study, along with seeing if eccentric exercises would aid those who have a history of hamstring pathologies. I feel one area that should be looked into is the availability and power production of the gluteus maximus, for I have seen working with field hockey players that some of them relied on using their hamstrings too much and were not using the gluteus maximus to provide more power. By strengthening the gluteus maximus and teaching athletes to fire the muscle more, it may prevent overuse to the hamstrings and decrease hamstring strain occurrence.

Nicole Cattano said...

Mark-I think that is a great point that is overlooked. What types of gluteus maximus training do you like to utilize?

Mark Foley said...

It's interesting to see how the exercise program didn't initially decrease the likelihood for a hamstring injury, but after the 13 week period, a significant decrease in injury likelihood was observed. I believe this is due to the fact that preseason often takes a toll on athletes' bodies, causing overuse injuries like hamstring strains. Simply put, a strength program takes weeks to have a lasting effect on the body, but the body is forced into heavy demand as soon as preseason begins. Therefore I believe these results do suggest that eccentric exercises do in fact decrease hamstring injuries and should be implanted in off-season workouts if possible. Soccer players can be prone to overly strong quadriceps, so I think it was beneficial that this study was performed on soccer players to truly see if the eccentric exercises could make a difference in likelihood of a hamstring strain.

Mark Foley said...
This comment has been removed by the author.
Nicole Cattano said...

Mark - great point about soccer players and the tendency for quadriceps dominance. The problem that we run into is that there isn't really a true "off-season" with sports anymore, as many athletes are playing and training year round.

Does anyone have any suggestions as to how to deal with the year-round athlete and when might be the best time to implement something like this?

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