Nordic Hamstring Exercises for Preventing Hamstring Strain Injuries

and Recurrence: A Critically Appraised Topic

Kyle Davis, SPT, The University of St. Augustine for Health Sciences

Background

A young male patient experienced a hamstring strain at the beginning of a new

football season. He rested the injured leg and returned to sport around 2 weeks later. Within a
few weeks, the young male athlete strained the same hamstring again. This time, his mom
signed him up for physical therapy. After taking over his case following an initial evaluation,
eccentric strengthening exercises were incorporated into his exercises. I had learned that a
form of eccentric hamstring strengthening called Nordic hamstring exercises (NHE) was
beneficial in decreasing the likelihood of recurring hamstring strains. The clinical question
developed for investigation was, “Are NHE’s an effective intervention for preventing
recurring hamstring strains? The search criteria I used for this critical appraisal are listed in
Table 1.

P: Hamstring strain patients

I: Nordic hamstring exercise
O: Hamstring strain recurrence

Table 1. Search criteria for literature pertaining to the clinical question being examined.
Databases Search Terms Limits Used

Pubmed Nordic exercise, eccentric hamstring, English

PEDro hamstring strain prevention, language,
EBSCO host hamstring strain recurrence, publication date
hamstring strain risk factors 2006-2021, peer-
reviewed,
clinical trial

Introduction

In the active population, hamstring strain injuries (HSI) are among the most common
injuries. HSI’s are also known for having high rates of re-aggravation.1,3,4 Many of the studies
performed have been on HSI’s and professional athletes in sports that require sprinting,
kicking, acceleration, and change of direction. In the NFL, HSI’s have been reported to
account for 12% of all reported injuries, with a recurrence rate at 32%.1 They are also the
most common injury reported in professional soccer. Additionally, they count for 29% of
track and field injuries in sprinters.1 Several authors have identified that one of the best
predictors for a hamstring injury is a prior hamstring injury.1,2,3,7,8 The risk for a recurring
injury is highest within the first two weeks after return to sport.1 The average amount of time
missed from sport is 18 days.1 This period of time doesn’t seem that detrimental, however,
this time frame can cost players hundreds of thousands of dollars. As physical therapists, we

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play an important role in the rehabilitation from an injury, but also in the implementation of a
strategy to prevent future related events. Resistance training has been found to be a safe and
effective intervention for reducing the rate of HIS’s and their recurrence. Recent literature
supports that eccentric strengthening of the hamstring muscles can reduce the risk of HSI’s.
HSI’s are most common to the biceps femoris muscle.1 Biomechanically, this is because the
biceps femoris is required to contract forcefully while lengthening to decelerate the extending
knee and flexing hip during terminal swing phase.1 Eccentric hamstring strength is
recognized as an important modifiable risk factor to HSI.2,3 This led to the development of
prevention exercises such as the NHE. The purpose of this critical appraisal is to specifically
review both the risk factors for HSI’s and experimental research pertaining to eccentric
training to prevent HSI’s and their recurrence.

Summary of Research

Table 2. Details of the methodology and results of each clinical trial included in this
appraisal.2-4 PEDro items listed exclude qualification sections met.
Study Design Sampl Intervention Outcome Main Results
e Measures

Gabbe & RCT n=220 Treatment Group: 5 The occurrence Overall

Branson session program of hamstring
2006)4 over a 12-week a hamstring injury
period focusing on injury including: rates were
eccentric training. sudden onset significantly
posterior thigh lower in the TG
Control Group: 5 pain, point when both
session program tenderness, with groups
over a 12-week or without pain completed at
period focusing on on stretch or least 2 sessions.
stretching. contraction of the (P=0.098).
hamstring
muscles.

PEDro Score: 4/10 [Concealed allocation: No; Blind subjects: No; Blind therapists: No;
Blind assessors: No; Adequate follow-up: No; Point estimates and variability: No.]

(Petersen Cluster n=942 Treatment Group: Number of Overall

& RCT 10-week overall, new, and hamstring
Thorborg progressive recurrent acute injury
2011)5 eccentric training hamstring rates were
program injuries during 1 significantly
full soccer lower in the TG
Control Group: season. (P< .001).
Usual training
program

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PEDro Score: 6/10 [Eligibility criteria: No; Random allocation: Blind subjects: No; Blind
therapists: No; Blind assessors: No; Intention-to-treat analysis: No]

(Horst & RCT n=579 Treatment Group: Hamstring injury 11 HSI’s (31%)
Smits 25 sessions of NHE incidence. were recorded
2015)6 in a 13-week in the TG and
period. Absolute 25 (69%) in the
numbers as well CG.
Control Group: as an injury
Regular soccer incidence rate for Risk for HSI’s
training number of was reduced in
injuries per 1000. the TG after
performing the
NHE protocol
(P =.005).

PEDro Score: 5/10 [Concealed allocation: No; Blind subjects: No; Blind therapists: No;
Blind assessors: No; Adequate follow-up: No]

(Alvares RCT n=20 Treatment Group: 4 Knee flexor and Isometric,

& week NHE extensor strength eccentric, and
Marques program, 2 using functional
2018)7 sessions/week, 3 dynamometry. hamstring:
sets of 6-10 reps. quadriceps
Biceps femoris torque ratios
Control Group: No muscle were higher in
exercise architecture the TG vs the
intervention using ultrasound. CG. (P>.05)

Increased
fascicle length,
and reduced
pinnation angle
in the long head
of the biceps
femoris, which
are both
reductions in
risk factors for
HSI’s, were
found in the TG
vs the CG.
(P<.05)

PEDro Score: n/a

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Results

Hamstring Strain Injury Rate

All four studies included in this appraisal examined at least one outcome measure
related to hamstring strain injuries and/or their recurrence. The Gabbe, Peterson, and Horst
studies all had treatment groups that focused on eccentric hamstring exercises similar to the
Nordic curl as an intervention for hamstring injuries. Every study included found that NHE’s
were beneficial to the reduction of HSI’s, whether it be new or recurring. The Peterson and
Thornborg’s trial aimed to include 1000 players on 50 teams. They were still able to achieve
a power of 80% with a significance level of 5% to detect a relative risk reduction of 50%.
They were able to do this by having a sample size of 428 players in each group was needed.
Analysis revealed reduction of hamstring strain injuries by at least 1 MCID was significantly
greater in the treatment groups that received eccentric focused training vs normal to no
training at all (23% vs 77%, P< .001). The same study found similar trends with recurrent
injuries as well (7.1% vs 45%). The 2015 study by Horst et al further confirmed the reduction
of hamstring strain injury rates with the use of eccentric exercise vs traditional training (31%
vs 69%, P=.005). This critical appraisal was further verified by a systematic review and meta-
analysis of 8459 athletes receiving Nordic hamstring exercises for injury prevention. Their
research found a reduction in the overall injury risk ratio of 0.49 (95% CI 0.32 to 0.74,
P=0.0008) in favour of programmes including the NHE.8 Further analysis showed that when
8 studies with a high risk of bias were removed, there was an increased risk ratio to 0.55
favouring NHE programs (95% CI 0.34 to 0.89, p=0.006).8

Improvement of Modifiable Risk Factors

In 2018, Alvares et al found that Nordic hamstring exercises had positive effects on
improving modifiable risk factors that had effects on hamstring strain injury rates.7
The treatment group that received 4 weeks of eccentric training found greater isometric,
eccentric, and functional hamstring: quadricep torque ratios vs the control group who
received no training at all (P>.05) The same study also found the treatment group participants
had increased fascicle length, and reduced pinnation angle in the long head of the biceps
femoris, which are both improvements in risk factors for HSI’s.

Discussion

Critical appraisal of the research on eccentric training using Nordic curls for
participants involved in activities requiring sprinting, kicking, acceleration, and change of
direction revealed limitations using comparable methodology. While the four studies selected
for this appraisal were the most recent clinical trials of athletes involved in activities with
increased risk of HIS’s. The variability of the activities involved and differences in eccentric
training programming leads to difficulty attributing any significant improvements to the
actual eccentric nature of the exercise vs random occurrence.

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 Difficulty with compliance was also found in the Gabbe study, although the ratio risk
of active participants did show promising data. The level of sport varied across the different
studies ranging from professional soccer and football players to amateur athletes. This
variance in skill also brings a variance in age of participants involved.
The studies included in this appraisal all had deficiencies with establishing internal
validity specific to blinding patients and therapists made evident by their PEDro results
(Table 2). Future research on this intervention should establish more explicit blinding,
inclusion criteria based on past medical history related to hamstring injury, and sport specific
limitations of participants. The direct nature of the outcome “did a participant experience a
HIS” makes interpreting outcomes easy. However, having control groups consisting of more
universal intervention types, whether that be concentric training or no added training at all
would be beneficial in the future.
For over a decade, many studies have looked at the effects of eccentric training in the
form of NHE’s on the rate of HSI’s. However, not many have conducted experimental trials
to assess their impact when compared to traditional or no hamstring exercise. Overall, the
research currently available on the effectiveness of eccentric training for reducing the rate of
either new or recurring hamstring strains in participants involved in activities requiring
sprinting, kicking, acceleration, and change of direction is promising even though there is still
a need for better designed control trials.

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biceps femoris fascicles and eccentric knee flexor weakness increase the risk of
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