NORDIC HAMSTRING PROGRAM

Injury Prevention
Sport Med ‘18
January 26

Dave Wright CAT(c)

University of Guelph
Hamstring Injury Prevention
Injury Prevention: Evidence Based Literature
 Hamstring injuries are the most common soccer-related muscle injury
 Account for 37% of all soccer muscle injuries (Ekstrand J. et al, 2015)
 Using the Nordic Hamstring Exercise in regular training reduced hamstring
injury incidence rates by 65%-70% demonstrating preventative effect in reducing
recurrent injuries (Peterson J. et al, 2011)
 A random trial of using the Nordic Hamstring Exercise completed with
942 Danish soccer players resulted in:
 59% less new, acute hamstring injuries with the 10 week controlled group
 Re-injury rate was 86% lower in the same group (Peterson et al, 2008)
 The peak muscle-tendinous force and strain for the hamstring muscle group
occurs during the terminal swing phase, just before ground contact (Thorborg et
al, 2012)
 As a result, Thorborg et al recommended that eccentric muscle strength should be
performed at longer muscle-tendinous lengths representing movements and muscle
length occurring at both the knee and hip
What is the Nordic Hamstring Exercise?
 Nordic Hamstring Technique Cues
 Keep ankles firmly on ground or floor
 Suggest to place roll under ankles to reduce pressure
stress applied to joint
 Keep head, trunk, hips and thighs in a straight line
 Bend from knees NOT hip or spine (knee flexion
technique)
 Perform exercise slowly, under control, lowering body
as far as possible towards the ground or floor
Nordic Hamstring Exercise Benefits & Support
 Evidence and research based eccentric hamstring injury prevention
exercise
 Suitable for all patients and athletic abilities
 Easy instruction for effective technique
 No heavy equipment necessary only a soft surface
 Bodyweight and gravity acts as load
 Slow cadence with simple controlled movement
 May perform independently or with a partner
 Uses spine and hip extensors to stabilize trunk during exercise
 Posterior load stabilizer assisting in minimizing translation during an
ACL mechanism of injury
Why use the Nordic Hamstring Exercise?
 Well evidenced as hamstring injury prevention with
significant, supportive literature
 Formally introduced in 2001 finding hamstring injuries
caused by strength deficits, notably eccentric strength
towards end range (Mjolsnes et al, 2004)
 Englishtextbook from year 1880 demonstrating Swedish
exercise methods…yet to be named Nordic Hamstring
Exercise?
 “Old is new again” with Nordic Hamstring Curls seemingly
making a return…but did it really go away?
Recommended Frequency & Volume
 Systematic, minimal and progressive increase in volume, reps
and load

Week Sessions/Week Sets Reps

1 1 2 5
2 2 2 6
3 3 3 6-8
4 3 3 8-10
5-10 3 3 12, 10, 8

Source: Mjolsnes et al 2004

 Minimum Recommended Reps

 BEGINNER
 repetitions: 1 set (3 – 5 repetitions)
 INTERMEDIATE
 repetitions: 1 set (7 – 10 repetitions)
 ADVANCED
 repetitions: 1 set (minimum 12 – 15 repetitions)

Source: Mjolsnes et al 2004

 Injury Prevention Protocol
 Load increases as athlete can withstand the controlled,
forward fall
 Greatest eccentric benefit as hamstring muscle group
lengthens closer to ground
 When able to withstand the entire range of motion for
12 reps, increase load by adding speed to the starting
phase of the motion
 A partner may also increase loading further by pushing
at the back of shoulders
 Add the use of elastic cords to provide support and
control for proper technique to end range for beginners

Source: Mjolsnes et al 2004

Assisted Nordic Hamstring Curl
 Nordbord
 Designed at University of Queensland, Australia
 Youth Soccer Initiatives
 FIFA 11+ injury preventative program
 Developed by International experts from FIFA’s Medical
Assessment and Research Centre (F-MARC), the Oslo Sports
Trauma Research Center and the Santa Monica Orthopaedic
and Sports Medicine Research Foundation
 When incorporated into team warm-up, resulted in 11.5%
fewer game injuries and 25.3% less injuries during training or
practice (Bizzini, M., Junge, A., Dvorak, J., 2013)
 Study: Barengo, N., Francisco Meneses-Echávez, J.,
Ramírez-Vélez, R., Cohen, D., The Impact of the FIFA 11+
Training Program on Injury Prevention in Football Players: A
Systematic Review; Int. J. Environ. Res. Public
Health 2014, 11(11), 11986-12000
 International Professional Soccer
 FCBarcelona “Muscle Injuries Clinical Guide 3.0” (January 2015)
 First edition published in 2009
 FCBarcelona and Aspetar Medical Staff
 Why Not More Widely Used?
 Concern for Delayed Onset Muscle Soreness (DOMS)
 Mjolsnes protocol progressively designed to minimize effects
 Compliance
 Program design recommends 6-10 week training periods
 Current industry exercise approach is “functional” vs “isolation”
 Players fail to maintain proper technique and load during full active range
of motion
 Cramping, dehydration a possibility?
 Differentials: fatigue, sciatic nerve (Slump Test), lumbar spine, anterior
pelvic tilt, poor gluteal muscle activation…
 Open chain exercise
 Inhibition: hamstring injury rehabilitation protocols too conservative?
 Bilateral exercise rather than independent or single side exercise for
muscle balance
 Does not increase concentric hamstring strength during technique
 Nordic Hamstring as Rehab Exercise

 “If you think hamstring exercises must be

‘functional’, be aware that data shows
structure matters.”
 “Examine the athlete, not the image of the
injured hamstring.”
 Kristian Thorborg PhD, Sports Orthopedic Research Centre -
Copenhagen
 Lengthening Protocol

Source: Askling et al, 2014

Preventative Muscle Activations &
Stabilizers
 Opposite arm/leg raise (50% gluteus maximus
activation prior to each leg lift):

 Bridging/table top with leg lift:

(progress by extending leg on floor)
 Implementation Techniques
Team or Group Applications:
 Complete during dedicated gym sessions
 Team or group circuit training combined with agility skills
development or conditioning drills
 Off-day training post warm up, mobility, flexibility and fascial
release/foam roller techniques
 Team or Individual off-season or LTD training programs
 Incorporate FIFA 11+ as group warm up
 Begin with only 1 session/week to a program maximum of 3
sessions/week as recommended by Mjolsnes chart
 Perform in conjunction with spine and gluteal muscle patterns
for global trunk stabilization and intrinsic muscle balance
.

References
 Ekstrand J, Hagglund M, Walden M. Epidemiology of Muscle Injuries in Professional Football (Soccer). Am J
Sports Med. 2011;39(6):1226-1232
 Peterson J, Thorborg K, Bachmann Nielsen M, Budt-Jorgensen E, Holmich P. Preventative Effect of Eccentric
Training on Acute Hamstring Injuries in men’s soccer; A Cluster-Randomized Controllecd Trial. Am J Sports Med.
2011;39(11):2296-2303
 van der Horst N, Smits D-W, Petersen J, Goedhart E A, Backx F J.G. The Preventive Effect of the Nordic
Hamstring Exercise on Hamstring Injuries in Amateur Soccer Players: A Randomized Controlled Trial. Am J Sports
Med. 2015;43(6):7
 Mjølsnes R, Arnason A, Osthagen T, et al. A 10-week randomized trial comparing eccentric vs. concentric
hamstring strength training in well-trained soccer players. Scand J Med Sci Sports 2004;14:311–17.
 Petersen J, Thorborg K, Nielsen MB, et al. Preventive effect of eccentric training on acute hamstring injuries in
men's soccer: a cluster-randomized controlled trial. Am J Sports Med 2011;39:2296–303
 FCBarcelona Muscle Injuries Clinical Guide 3.0; January 2015 in collaboration with Aspetar Medical Staff
 Bizzini, M., Junge, A., Dvorak, J., (2013.) Implementation of he FIFA 11+ football warm up program: How to
approach and convince the Football associations to invest in prevention. British journal of sports medicine,
bjsports-2012-092124
 Arnason A., Anderson TE, Holme I, et al. Prevention of hamstring strains in elite soccer: an intervention study.
Scand J Med Sci Spors 2008; 18:40-8
 Askling CM, Tengvar M, Thorstensson A. Acute hamstring injuries in Swedish elite football: a perspective
randomized controlled clinical trial comparing two rehabilitation protocols. Br J Sports Med 2013;47;953-9
 Ditroilo M, De Vito G, Delahunt E. Kinematic and electromyographic analysis of the Nordic Hamstring Exercise.
2013 Oct;23(5):1111-8
 Timmins R, Porter K, Williams M, et al. Biceps femoris muscle architecture—the influence of previous injury. Br J
Sports Med 2014;48:665–6
 Sherry MA, Best TM. A comparison of 2 rehabilitation programs in the treatment of acute hamstring strains. J
Orthop Sports Phys Ther2004;34:116–25
Thank you