European Journal of Sport Science

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Eccentric knee flexor strength of professional

football players with and without hamstring injury
in the prior season

João Breno Ribeiro-Alvares, Gabriel Santos Oliveira, Felipe Xavier de Lima-e-

Silva & Bruno Manfredini Baroni

To cite this article: João Breno Ribeiro-Alvares, Gabriel Santos Oliveira, Felipe Xavier de Lima-
e-Silva & Bruno Manfredini Baroni (2020): Eccentric knee flexor strength of professional football
players with and without hamstring injury in the prior season, European Journal of Sport Science,
DOI: 10.1080/17461391.2020.1743766

To link to this article: https://doi.org/10.1080/17461391.2020.1743766

Accepted author version posted online: 17

Mar 2020.

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Publisher: Taylor & Francis & European College of Sport Science

Journal: European Journal of Sport Science

DOI: 10.1080/17461391.2020.1743766

Title:
Eccentric knee flexor strength of professional football players with and without
hamstring injury in the prior season

Running head:
Football players’ knee flexor eccentric strength

Submission Type
Original investigation

Authors:
João Breno Ribeiro-Alvares1, Gabriel Santos Oliveira1,
Felipe Xavier de Lima-e-Silva1, Bruno Manfredini Baroni1

Affiliations:
1
Federal University of Health Sciences of Porto Alegre, Brazil

Acknowledgments:
BMB thank CNPq-Brazil for the research productivity fellowship.

Conflict of interest:
Authors declared no conflict of interest.

Corresponding author:
Bruno Manfredini Baroni
Federal University of Health Sciences of Porto Alegre (UFCSPA)
Sarmento Leite St, 245 – zipcode 90050-170
Porto Alegre, Rio Grande do Sul, Brazil
Phone/fax +55 51 3303-8876

1
Email: bmbaroni@yahoo.com.br

Eccentric knee flexor strength of professional football players

with and without hamstring injury in the prior season

ABSTRACT

Both injury history and eccentric knee flexor strength have been associated with risk of

football players sustaining hamstring strain injury (HSI). However, it remains unclear

whether football players who sustained HSIs in the prior season present themselves for

the next season with persistent eccentric strength deficits. Therefore, the aim of the

present study was to verify the eccentric knee flexor strength of professional male

football players with and without history of HSI in the prior season. This case-control

study assessed 210 professional male football players from 10 Brazilian clubs: 182

included in the control group and 28 in the previously injured group. Players from the

injured group had suffered unilateral HSI in the prior season. We measured the peak

eccentric knee flexors force during the Nordic hamstring exercise and calculated the

between-limb asymmetry. Groups were similar for age, body mass and height (p>0.05).

Control group had similar strength values between left and right limbs (376.29±61.77 N

vs. 380.28±61.77 N; p=0.27; d=0.06), while the previously injured limb was weaker

than the contralateral uninjured limb in the injured group (350.87±60.79 N vs.

385.75±63.49 N; p<0.01; d=0.56). Thirty-seven percent of players in the control group

and 50% in the injured group presented between-limb asymmetry >10%. This study

demonstrates that players with history of HSI in the prior season present reduced

2
eccentric knee flexor strength in the injured limb, but half of them have between-limb

asymmetry within the most commonly adopted benchmark value of 10%.

KEY-WORDS: soccer; muscle injury; Nordic hamstring exercise; injury prevention.

3
INTRODUCTION

Hamstring strain injury (HSI) is a major concern in men’s professional football

(soccer) 1. Around 22% of players from elite teams suffer HSIs each season, and there is

an increasing HSI rate from the beginning of the century 2. Each HSI leads to an

average of 17 absence days 2, which impairs the team’s performance 3

with negative

impact over the club’s finances 4. Therefore, clubs have been making efforts to track
5,6
more vulnerable athletes in time to implement preventive strategies . The screening

tests are mainly performed at preseason and aim to identify potential risk factors for

HSI, such as previous injury and hamstring strength, among others 7.

Prospective studies have demonstrated the association between eccentric knee

8–11 12,13
flexor strength and HSI rate in football players and other athletic populations .
14
The link between eccentric strength and HSI is sometimes contradicted , which is

possibly related to the complex and multifactorial nature of sports injuries 15. However,

findings that football players with weak hamstrings at preseason have up to 4.4 times

greater risk of in-season HSI than stronger players 11 support the importance of strength
5,6
tests performed by most premier league football clubs . Although the isokinetic

dynamometry is considered the gold-standard method and has been largely used among
16
footballers , recent trials have assessed the eccentric knee flexor strength using the

device called Nordbord (Vald Performance, Queensland, Australia) 11,14,17. This portable
18
equipment was designed and validated by Australian researchers and measures knee

flexors force during the execution of the Nordic hamstring exercise (NHE), allowing a

quick and easy-to-perform assessment in a large group of athletes at their own facilities.

The rehabilitation programs for HSIs have evolved a lot in recent years, and

great attention has been recommended to the eccentric-biased strengthening exercises 19.

4
In a decision-based return to sport model, it is recommended that a previously injured

muscle restore its previous strength level or get close to the contralateral uninjured limb

strength level (a between-limb asymmetry <10% has been most commonly adopted by

researchers and clinicians) 20,21. However, two out of three professional football players

have residual strength deficits upon returning to sport following HSI (i.e., between-limb

asymmetry >10%) 20. In contrast to the isometric strength, which appears to be restored

within 20 to 50 days after an HSI, the time required to rebalance the between-limb
22
dynamic strength is inconclusive . Some studies including athletes from different

sports with history of unilateral HSI reported persistent eccentric strength deficits up to
18,23,24
18 months in previously injured limb compared to the contralateral limb . This

was contradicted by other investigations that have not observed any weakness in the
25–27
previously injured limb . Moreover, the conflicting results are also found in studies

that compared the previously injured limb strength values with athletes with no history
11,18
of HSI . Interestingly, only 16 football players with previous HSI were assessed in

those previous retrospective studies 23,24.

A previous HSI is usually considered a strong risk factor for this type of injury
28
. Therefore, it would be plausible to infer that a past HSI concurrent with a residual

eccentric strength deficit should increase the risk of a future HSI. However, the lack of

consensus in the literature and the few data available in footballers prevent us from

drawing a definitive conclusion as to whether players who sustained HSIs in the prior

season present themselves for the next season with persistent eccentric strength deficits.

Therefore, the aim of the present study was to verify the eccentric knee flexor strength

of professional male football players with and without history of HSI in the prior

season. Our hypothesis was that players with HSI in the prior season would be weaker

5
in the previously injured limb, leading this group of players to present a higher between-

limbs asymmetry compared to their peers without HSI in the prior season.

METHODS

Study design

This is a retrospective case-control study. Ten professional football clubs agreed

to include the knee flexor strength assessment during the NHE in their screening testing

routine. Assessments took place in the facilities of each club, during preseason or early

in-season of Brazilian professional football calendar, according to the coaching staff

preference. The club’s medical records and the own players' report were used to identify

those who had sustained HSI along the prior season. Then players were allocated to one

of the two groups: injured group and control group. The study was approved by the

institutional ethics committee. Approvals were obtained from each club in the course of

the study, as player’s assessment data were routinely collected over the season 29.

Participants

A total of 210 professional male football players participated in this study. They played

for clubs engaged in one of Brazil’s major state championships (7 in first division and 3

in second division during the season in which the study was carried out). Two clubs that

played the national premier league and the Libertadores de America Cup chose to

evaluate only their “B teams” due to schedule reasons. All players were free of any

current injury and were fully engaged in the team’s training routine at the time of

testing. Players with bilateral HSI in the prior season were not included in the current

6
study because our aim was to compare the previously injured limb with the uninjured

limb.

Procedures

Injury history

HSI was defined as a sudden pain in the posterior thigh that prevented the player

from continuing the activity and took him for at least one day out of practice or play 28.

Injuries were screened through the participants' report and club medical records. All

injuries were clinically diagnosed by the team’s clinician, and confirmed by imaging

examination. The affected limb (right or left), the injured muscle (semimembranosus,

semitendinosus or biceps femoris), the location of injury (proximal/distal, muscle

belly/muscle-tendon junction), the grade of injury, and the time-loss due to injury were

not considered as inclusion criteria.

Players allocated in the control group had no history of HSI in the prior season,

while those allocated in the injured group had sustained unilateral HSI in the prior

season (i.e., up to ~12 months before the testing). Considering a hypothetical situation

of a player having suffered the HSI on the last day of the prior season (i.e., in the eve of

the vacation period), at least 30 days would have elapsed between the injury and the

date of the strength assessment. Previously injured players had all returned to preinjury

levels of sport participation and were fully engaged in the team's training routine.

Eccentric knee flexor strength test

Evaluations were scheduled according to the club’s availability and preference,

in order not to interfere nor be influenced by the practices and matches. The following

recommendations were given: (1) no high-intensity physical activities 24 hours prior to

7
the tests; (2) no intake of analgesic and/or anti-inflammatory drugs 48 hours prior to the

tests; and (3) no consumption of stimulants (e.g., caffeine) on the day of the test.

Following the evaluation, comprehensive and accessible reports were delivered to each

team’s coaching staff.

All players had experience with the NHE, sparing them from holding any

familiarization session. After a general warm-up structured and guided by the team’s

strength and conditioning coach, the player was positioned on a custom-made device

built by our research group to measure the eccentric knee flexor strength during the

NHE execution (Figure 1). This device was based on the prototype validated by Opar et
18 14,17,30
al. , and increasingly used in previous studies focused on HSI . The player

started the test in kneeling position over a padded board (with the hip neutral and the

torso upright) and progressively moved the torso forward using only the knee joint (i.e.,

maintaining the hips and spine neutral). One of the researchers was responsible for

supervising the correct execution of the NHE, controlling the execution time and

verbally encouraging the player to continue eccentrically contracting the hamstrings

until the end of the exercise. The player should use his upper limbs to absorb the fall

and to return to the initial position.

Players performed at least 3 valid repetitions of the NHE, with a minimum 10-

second interval between them. During the testing, the left and right ankles were

individually secured by ankle braces placed superior to the lateral malleolus and fixed to

two independent commercially-available load cells (E-lastic, E-sporte Soluções

Esportivas, Brasilia, Brazil) perpendicularly attached to the board. Force data of each

load cell were simultaneously transferred via Bluetooth to a mobile cellphone (sample

rate = 10 Hz). Force values were registered in every repetition, and the peak value

obtained in each limb was used for statistical analysis. Test-retest reliability with 95%

8
confidence intervals of our device was assessed through data from 20 healthy active

men obtained in our laboratory: Intraclass Correlation Coefficient, 0.94 (0.85-0.98);

Typical Error, 1.89 N (1.42 – 2.79 N); Coefficient of Variation, 5% (3.2 – 6.7%).

<< FIGURE 1 >>

Statistical analysis

The characteristics of subjects (age, body mass, and height) allocated to control

and injured groups were compared through independent-sample t-tests.

No difference was found for hamstring peak force produced by left and right

limbs in the control group, then a between-limb average value of these players was used

for comparison with each limb of the injured group. This analysis was performed with a

one-way ANOVA, followed by an LSD post-hoc test.

Absolute between-limb asymmetry was calculated as the player’s stronger limb

minus the weaker limb. The between-limb asymmetry also used the stronger limb as the

reference value (i.e., 100%). The between-limb asymmetry of control and injured

groups was compared through independent-sample t-test.

Statistical significance was set at 5% (p<0.05) for all comparisons. Practical

significances were assessed using Cohen’s d with the effect sizes being deemed trivial

(d<0.20), small (d>0.20), medium (d>0.50), or large (d>0.80).

RESULTS

This study included 210 professional male football players: 24 goalkeepers, 70

defenders, 63 midfielders, and 53 forwards. Twenty-eight players (i.e., 13.33%) had

sustained unilateral HSI during the prior season limb (goalkeepers, 4%; defenders, 36%;

9
midfielders, 32%, forwards, 28%). Sixteen players of the injured group had sustained

HSI on the left limb and 12 on the right. The players allocated to control and injured

groups presented similar age, body mass and height (p>0.05 for all comparisons; Table

1).

<< TABLE 1 >>

In the control group, peak force values of 33 players with at least one HSI

episode throughout their careers (without HSI in the prior season) were similar to those

found in 149 players free of HSI history; thus, they were analyzed as a single group

(n=182). The control group showed no statistically significant difference between the

left (376.29±61.77 N) and right limb (380.28±61.77 N) in knee flexor peak force during

the NHE [p=0.27; trivial effect size, d=0.06 (-0.14-0.27)]. In contrast, the previously

injured limb (350.87±60.79 N) was weaker than the contralateral uninjured limb

(385.75±63.49 N) in the injured group [p<0.01; medium effect size, d=0.56 (0.02-1.09);

Figure 2]. The previously injured limb also had lower hamstring peak force compared to

the control group [378.28±56.72 N; p=0.03; small effect size, d=0.48 (0.08-0.88);

Figure 2].

The control and injured groups displayed similar between-limb asymmetry

values: 35.63±33.64 N vs. 48.89±46.76 N [p=0.16; small effect size, d=0.37 (-0.03 -

0.77)]; 8.77±7.92% vs. 11.91±10.16% [p=0.13; small effect size, d=0.38 (-0.02 – 0.78)].

Thirty-seven percent of players in the control group and 50% in the injured group

presented between-limb asymmetry >10% (Figure 3). Among the 67 players with

between-limb asymmetry >10% in the control group, 41 players (i.e., 61%) presented

deficit in the left limb and 26 (i.e., 39%) in the right limb. Among those with between-

10
limb asymmetry >10% in the injured group, 13 players (i.e., 93%) had strength deficit

in the previously injured limb.

<< FIGURE 2 >>

<< FIGURE 3 >>

DISCUSSION

This study aimed to verify the eccentric knee flexor strength of professional

male football players with and without history of HSI in the prior season. Our main

finding was those previously injured players presented significant strength deficit in

relation both to their contralateral limb and to the uninjured players, but half of them

had between-limb asymmetry within the most commonly adopted benchmark value of

10%20,21.

The athletes assessed in our study presented quite similar force values during
12
NHE than those reported for other football codes, such as rugby union (~368 N) ,
31 17
Gaelic football (~361 N) and Australian football (~371 N) . Studies with

professional football (soccer) players have reported distinct levels of eccentric knee
11
flexor strength, ranging from ~260 N to ~411 N 17. The reason for the discrepancy

observed among footballers may be related to their competitive level, as already

32
evidenced by previous findings using isokinetic evaluation . Moreover, the

familiarization with the testing task plays a crucial role. The NHE is largely used into

the injury prevention routine of Brazilian professional football clubs 6, and all players in

the present study had previous experience with NHE. These facts might explain the

11
force values assessed being closer to footballers playing in France 17 than in Australia 11

or Qatar 14.

It may be argued that it would be appropriate to normalize the force by the

player’s body mass. However, body mass seems to be weakly associated with peak
31
force during NHE in adult athletes (r=0.159) . According to the developers of this
18
assessment method , normalization by body mass is unnecessary because of the

nature of the NHE. For instance, when assessing two players with the same knee flexor

strength capacity, but different body masses; the heavier player will reach the critical

point earlier (i.e., smaller range of movement) than the lighter one, but both players will

require maximal force generation of the knee flexors during testing. Moreover, greater

predictability for future HSI in football players has been found with absolute than
11
normalized force values , which supports the absolute peak force as the primary

outcome of the current study. Ultimately, injured and control groups had the same body

mass, which eliminates the influence of this possible confounding factor from our

analysis.
11
The prospective cohort study by Timmins et al. demonstrated that Australian

premier league football players with eccentric knee flexor strength <337 N at preseason

had 4.4 times greater risk of a subsequent HSI than stronger players. Taking this cut-off

point into account, the majority of players in both groups of the current study would be

away from the zone of greatest threat for HSI 11. However, we should be aware that the

previously injured limb was 35 N weaker than the contralateral limb, and multivariate

logistic regression models suggest the risk of sustaining an HSI decreases ~9% at every
11
10 N increase in eccentric knee flexor strength . It means that even if the previously

injured limb is above the cut-off point previously suggested by the literature, the

12
hamstring strengthening to match the contralateral limb strength tends to further reduce

its risk of injury.

Previous studies have already reported that muscles suffering an HSI remain
18,23,24
weaker than the contralateral limb for several months after return to sport . The
18,24
between-limb strength asymmetry previously reported is ~15% on the NHE testing
23
and ~22-24% on the isokinetic dynamometry . Interestingly, our study adds to the

literature that 50% of players from the injured group would be classified within the

criterion of normality usually adopted for between-limb strength symmetry (i.e., <10%)
20,21
. This reduced level of between-limb asymmetry in half of our sample can be

partially explained by three different but not self-excluding hypotheses: (1) the HSI
19
rehabilitation has been focused on the eccentric strengthening of the injured muscle ;

(2) the return to sport following a HSI have been based on more stringent criteria in

relation to muscle strength recovery 33; and (3) the prevention programs using eccentric-
5,6
biased exercises adopted by clubs have contributed to strengthening of previously

injured muscles when players return to the team routines. However, when we looked

only at cases of between-limb strength asymmetry >10%, call us attention that almost

all athletes (i.e., 93%) had strength deficit in the previously injured limb, suggesting a

residual effect due to the previous HSI.

The distribution of players according to their between-limb strength asymmetry

(see figure 3) highlights the importance of looking at the individual scores rather than

evaluate all athletes based on group behavior. Surprisingly, even in the absence of

significant between-limb strength asymmetry in the control group, 37% of those athletes

are outside the normality range. This prevalence of strength asymmetry may be related

to the asymmetrical demands of football and/or other previous injuries (not assessed in

this study), as well as other unknown factors. In a practical standpoint, regardless of

13
HSI history, a considerable portion of professional football players start the season with

knee flexor strength asymmetry, thus they should be engaged in some hamstring-

specific strengthening program to restore their between-limb symmetry and minimize

chances of HSI along the season. Interestingly, only ~1% of players from the control

group presented between-limb strength asymmetries >30%, while 11% of the injured

group had that exacerbated strength imbalance level. These findings suggest that

worrying between-limb strength asymmetries, although not exclusive, are much more

prevalent in those players who suffered HSIs in the prior season. Therefore, special

attention for athletes with HSI history in the prior season is recommendable.

Regular football training seems to be unable to increase the eccentric knee flexor
34
strength , thus it is recommended that specific training be implemented to strengthen

this muscle group eccentrically. NHE is a field-based exercise able to produce

35,36
significant eccentric knee flexor strength gains . Other exercise types also can be
37
used to strengthening the hamstrings eccentrically, such as hip extension and

exercises performed in flywheel ergometer 34 or isokinetic dynamometer 8. However, as

NHE currently presents the best evidence in preventing HSI in football and other team
38
sports , it can be recommended as the first choice for preventative programs. As a

bilateral exercise, it is difficult to ensure whether there is a side predominance or

whether the strength is equally distributed between limbs during NHE execution.

Therefore, including the NHE (or other eccentric-focused exercises) is as important as

the quantifying players’ eccentric knee flexor strength to assess each limb training

responses in order to enhance the effectiveness of the injury prevention program.

The authors acknowledge that the current study has limitations. The

retrospective nature limits any determination if the reported differences in eccentric

knee flexor strength are the cause or the result of previous HSIs. Clubs did not provide

14
detailed information regarding the HSIs (i.e., injured muscle, grade of injury, time-loss,

etc.), which would allow us further analysis. The lack of characterization of injury

severity is an important limitation of the present study, also observed in previous studies

with similar purpose 23,24. We also did not have the opportunity to monitor the hours of

exposure (training and matches) and the HSI incidence throughout the season in which

the data collections were performed, which would allow us to verify the injury rate in

control and injured groups. Despite these limitations, this is one of the few studies with

a large sample of professional football players and our results showing a persistent

deficit of eccentric knee flexor strength in the injured limb during NHE execution serve

as alert to coaching staffs regarding the importance of systematically monitoring the

eccentric knee flexor strength in their team’s players.

In conclusion, professional male football players with history of HSI in the prior

season present a persistent deficit of eccentric knee flexor strength in the injured limb

during NHE execution. Half of them present between-limb strength asymmetry >10%,

and the previously injured limb is the weakest in 93% of cases, suggesting that strength

deficit may be related with the HSI in the prior season. However, 37% of the uninjured

players also have between-limb strength asymmetry being >10%. It means that

eccentric strength deficit is not consistent among players with history of HSI, and many

uninjured players also have worrisome between-limb strength asymmetry. Therefore,

coaching staffs should focus on individual scores to identify those players with

hamstring weakness regardless of their history of HSI in order to develop individualized

prevention program.

15
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FIGURE LEGENDS

Figure 1. Assessment of eccentric knee flexors strength during the NHE execution. The

white arrows highlight the two load cells used for data acquisition.

Figure 2. Knee flexor peak force (mean and 95% confidence interval) produced by

players in the control group (average between left and right limb – black bar) and by the

uninjured (grey bar) and injured (white bar) limbs of players in the injured group. * the

asterisk denotes significant difference (p<0.05).

Figure 3. Individual analysis of between-limb asymmetry: the black dots are players

allocated in the control (top) and injured (bottom) groups; the grey zone highlights the

cases classified as players with “strength imbalance” (i.e., between-limb strength

asymmetry >10%); the right column presents the gross number and percentage of

players in each sub-group.

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TABLE

Table 1. Characteristics of players (mean ± SD).

Control group (n=182) Injured group (n=28)

Age (years) 24.15 ± 5.31 24.29 ± 5.60

Body mass (kg) 78.19 ± 8.53 76.64 ± 7.39

Height (m) 1.81 ± 0.07 1.79 ± 0.06

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