“Eccentric Exercises Reduce Hamstring Strains in Elite Adult Male Soccer Players: A Critically Appraised Topic”

by Shadle IB, Cacolice PA

Journal of Sport Rehabilitation
© 2016 Human Kinetics, Inc.

Note: This article will be published in a forthcoming issue of

the Journal of Sport Rehabilitation. The article appears here in
its accepted, peer-reviewed form, as it was provided by the
submitting author. It has not been copyedited, proofed, or
formatted by the publisher.

Section: Critically Appraised Topic

Article Title: Eccentric Exercises Reduce Hamstring Strains in Elite Adult Male Soccer Players:
A Critically Appraised Topic

Authors: Ian B. Shadle1 and Paul A. Cacolice2

Affiliations: 1Department of Athletic Training, Duquesne University, Pittsburgh, PA.

2
Department of Athletic Training, Westfield State University, Westfield, MA.

Running Head: Eccentric exercises reduce hamstring strains

Journal: Journal of Sport Rehabilitation

Acceptance Date: May 24, 2016

©2016 Human Kinetics, Inc.

DOI: http://dx.doi.org/10.1123/jsr.2015-0196
 “Eccentric Exercises Reduce Hamstring Strains in Elite Adult Male Soccer Players: A Critically Appraised Topic”
by Shadle IB, Cacolice PA
Journal of Sport Rehabilitation
© 2016 Human Kinetics, Inc.

CLINICAL SCENARIO:

Hamstring strains are a common sport-related injury, which may limit athletic performance for

an extended period of time. These injuries are common in the soccer setting.1 As such, it is

important to determine an appropriate prevention program to minimize the risk of such an injury

for these athletes. Hamstring strains occur when external loads exceed the strength of the tissue.

Development of eccentric muscle control has been shown to be an effective and inexpensive

intervention to improve strength. Eccentric hamstring training then, may provide an effective
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and practical hamstring strain prevention strategy.

FOCUSED CLINICAL QUESTION: What is the effect of eccentric exercises on hamstring

strain prevention in adult male soccer players?

 “Eccentric Exercises Reduce Hamstring Strains in Elite Adult Male Soccer Players: A Critically Appraised Topic”
by Shadle IB, Cacolice PA
Journal of Sport Rehabilitation
© 2016 Human Kinetics, Inc.

SUMMARY of Search, ‘Best’ Evidence’ appraised, and Key Findings:

 Current literature was searched for studies of level 2 evidence or higher that

investigated the effect of eccentric exercises in preventing hamstring strains in adult

male soccer players.

 Three articles returned from the literature search met the inclusion criteria. A fourth

article looked at differences in strength gains between eccentric and concentric

hamstring strengthening exercises, but did not record hamstring strain incidence. A
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fifth article, a systematic review, met all the criteria except for the correct population.

 Of the three studies, two were randomized control trails, and one was a cohort study.

Clinical Bottom Line: There is robust supportive evidence that eccentric hamstring

exercises can prevent a hamstring injury to an elite adult, male soccer player. Therefore, it

is recommended that athletic trainers and other sports medicine providers evaluate

current practices relating to reducing hamstring strains and consider implementing

eccentric exercise based prevention programs.

Strength of Recommendation: All evidence was attained from articles with a level of

evidence 2b or higher, based on the Center for Evidence-Based Medicine (CEBM) criteria,

stating that eccentric exercises can decrease hamstring strains.

SEARCH STRATEGY:

Terms used to guide Search Strategy:

Patient/Client Group: male and soccer

Intervention: eccentric exercise or strengthening or prevention

Comparison: none
 “Eccentric Exercises Reduce Hamstring Strains in Elite Adult Male Soccer Players: A Critically Appraised Topic”
by Shadle IB, Cacolice PA
Journal of Sport Rehabilitation
© 2016 Human Kinetics, Inc.

Outcomes: hamstring strain or hamstring injury

Sources of Evidence Searched:

 PubMed

 Medline

 Sport Discus

 Google Scholar

 ProQuest
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 PEDro database

 Additional resources were obtained via review of reference lists and hand searches

INCLUSION and EXCLUSION CRITERIA

Inclusion:

 Investigation of Level 2 evidence or higher

 Activities included eccentric strengthening exercises for prevention of hamstring strains

 Investigation must include reported incidence of hamstring injuries

 Limited to English language articles with human participants

 Sample of adult male soccer athletes at either the elite amateur or professional level of

play

Exclusion Criteria:

 Studies with mixed subject pool (male vs. female, adults and adolescent)

 Studies looking at hamstring biomechanics compared to strengthening

 Studies looking at a population under 18 years old

 “Eccentric Exercises Reduce Hamstring Strains in Elite Adult Male Soccer Players: A Critically Appraised Topic”
by Shadle IB, Cacolice PA
Journal of Sport Rehabilitation
© 2016 Human Kinetics, Inc.

RESULTS OF SEARCH

Three relevant studies were located and categorized as shown in Table 1(based on Levels

of Evidence, CEBM, 2011).2

BEST EVIDENCE

The studies in table 2 were identified as the “best” evidence and selected for inclusion in

the critically appraised topic (CAT). Reasons for selecting these studies were

 Studies met the inclusion and exclusion criteria

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 Each study was graded level 2 evidence or higher

 Each study examined the effects of eccentric exercises on hamstring injury prevention

and/or strengthening

Implications for Practice, Education, and Future Research: Eccentric strengthening

of the hamstrings was utilized in each of these articles. While all three articles showed that

implementing an eccentric strength training program lowered the incidence rates of hamstring

strains, each article varied on the definition of a hamstring strain. 3,4,5 Arnason et al. recorded a

hamstring strain based on clinical assessment of the team medical staff. A player was defined as

injured if he was unable to participate in a match or a training session due to a hamstring strain

that occurred in a soccer match or soccer training.3 The player remained injured until he was able

to play in a match or fully comply with full training instructions.3 Askling et al. also had all

hamstring strains diagnosed by a clinical examination, defining injury as pain in connection with

palpation as well as with isometric contraction and stretching.4 The injury had to occur during

scheduled matches or practices, resulting in the player to miss at least the next practice session or

game.4 Petersen et al. defined a hamstring injury as any acute-occurring physical complaint in
 “Eccentric Exercises Reduce Hamstring Strains in Elite Adult Male Soccer Players: A Critically Appraised Topic”
by Shadle IB, Cacolice PA
Journal of Sport Rehabilitation
© 2016 Human Kinetics, Inc.

the region of the posterior thigh sustained during a soccer match or training, irrespective of the

need for medical attention or time loss from soccer activities.5 A player remained injured until

they returned to full participation in team training and was available for match selection.5

A fourth article, which could not be included because it did not look at hamstring injury

incidence, demonstrated a positive correlation between eccentric strength training of the

hamstring muscle group and increased hamstring strength.6 The authors suggested that eccentric

training can be used as a prevention tool, as well as an efficient strengthening technique.

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However, further research should continue to look at eccentric strength gains versus concentric

strength gains for the hamstring muscle group for confirmation of these author’s conclusions.

The Nordic hamstring exercise was most commonly used activity for eccentric

strengthening in the investigations. In contrast, Askling et al utilized the YoYo fly wheel, which

consisted of both a concentric and eccentric motion. The fly wheel was set at an angle to create

an eccentric overload, maximizing eccentric gains.4 Use of this method also caused a decrease in

the incidence of hamstring strains in adult male soccer players.4 The use of an eccentric training

method is not only appropriate, but necessary for all clinicians to consider when dealing with

elite adult male soccer players.

Future research should investigate which eccentric exercises are the best for preventing

hamstring injuries. The Nordic Hamstring exercise was the most commonly used in these

studies, but other eccentric hamstring strengthening exercises are used in practice. Further

research should also compare the Nordic to other eccentric hamstring exercises. Additional

research comparing different concentric exercises verses eccentric exercise may also help

determine which exercise provide the greatest prevention.

 “Eccentric Exercises Reduce Hamstring Strains in Elite Adult Male Soccer Players: A Critically Appraised Topic”
by Shadle IB, Cacolice PA
Journal of Sport Rehabilitation
© 2016 Human Kinetics, Inc.

Delayed Onset Muscle Soreness (DOMS) was the only complaint of the athletes in the

studies. Further research should be conducted to examine if DOMS can be avoided by altering

the training volume, intensity, or selection of activity. Future research should also look at the

most effective ways to recover from DOMS due DOMS prevalence in eccentric exercises.6 New

studies should replicate current studies, but with other at risk populations to confirm that

eccentric hamstring exercises can help reduce hamstring injuries in all populations. The

populations examined in these studies were all involved in quick acceleration due to the
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requirements of their sport. Other at risk population are those involved in sports requiring quick

acceleration, such as track, football, and lacrosse.7 It is important that new studies focus on these

populations in particular, due to the high risk factor.

When considering the strength of recommendation associated with this topic, our

assessment revealed support for a level ‘A’ recommendation that eccentric hamstring exercises

can prevent hamstring injuries in elite adult, male soccer players.8 Therefore, it is recommended

that athletic trainers and other sports medicine providers evaluate current practices as it relates to

hamstring injury prevention and consider implementing eccentric exercise based prevention

programs. This CAT should be reviewed in 2 years to determine whether additional best-research

evidence has been published that could aid in answering the focused clinical question.

Acknowledgments

We would like to acknowledge Dr. Sarah Manspeaker and Dr. Jason Scibek for their

contributions.
 “Eccentric Exercises Reduce Hamstring Strains in Elite Adult Male Soccer Players: A Critically Appraised Topic”
by Shadle IB, Cacolice PA
Journal of Sport Rehabilitation
© 2016 Human Kinetics, Inc.

References

1. Ekstrand J, Hagglund M, Walden M. Injury incidence and injury patterns in professional

football: the UEFA injury study. Br J Sports Med. 2011;45(7):553-558.
2. Howick J, Chalmers I, Glasziou P, et al. The Oxford 2011 Levels of Evidence. Centre for
Evidence-Based Medicine Web site. http://www.cebm.net/index.aspx?o=5653. Accessed
November 18, 2015
3. Arnason A, Andersen T, Holme I, Engebretsen L, Bahr R. Prevention of hamstring strains in
elite soccer: an intervention study: Prevention of hamstring strains in soccer. Scand J
Med Sci Sports. 2007;18(1):40–48.
4. Askling C, Karlsson J, Thorstensson A. Hamstring Injury Occurrence in Elite Soccer Players
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After Preseason Strength Training with Eccentric Overload. Scand J Med Sci Sports.
2003;13(4):244–250.
5. Petersen J, Thorborg K, Nielsen MB, Budtz-Jorgensen E, Holmich P. Preventive Effect of
Eccentric Training on Acute Hamstring Injuries in Men’s Soccer: A Cluster-Randomized
Controlled Trial. Am J Sports Med. 2011;39(11):2296–2303.
6. Mjolsnes R, Arnason A, Osthagen T, Raastad T, Bahr R. A 10-week randomized trail
comparing eccentric vs. concentric hamstring strength training in well-trained soccer
players. Scand J Med Sci Sports. 2004;14:311–317.
7. Sherry MA, Johnston TS, Heiderscheit BC. Rehabilitation of Acute Hamstring Strain Injuries.
Clin Sports Med. 2015;34(2):263-284.
8. Ebell MH, Siwek J, Weiss BD, Woolf SH, Susman J, Ewigman B, Bowman M. Strength of
Recommendation Taxonomy (SORT): A Patient-Centered Approach to Grading
Evidence in the Medical Literature, J Am Board Fam Med. 2004 17(1):59-67.
 “Eccentric Exercises Reduce Hamstring Strains in Elite Adult Male Soccer Players: A Critically Appraised Topic”
by Shadle IB, Cacolice PA
Journal of Sport Rehabilitation
© 2016 Human Kinetics, Inc.

Table 1: Summary of Study Designs of Articles Retrieved

Level of Evidence Study Design/Methodology Number Author (Year)

of Articles Retrieved Located

1b Randomized Controlled Study 1 Askling (2003)

1b Cluster Randomized 1 Petersen (2011)

Controlled study
2b Cohort Study 1 Arnason (2007)
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 “Eccentric Exercises Reduce Hamstring Strains in Elite Adult Male Soccer Players: A Critically Appraised Topic”
by Shadle IB, Cacolice PA
Journal of Sport Rehabilitation
© 2016 Human Kinetics, Inc.
Table 2: Characteristics of Included Studies
Arnason et al (2007)3
Study Design Cohort
Participants Male soccer teams from the Icelandic
and Norwegian top leagues with 18 to
24 players per team. Seventeen teams
agreed to participate during 1999, 15
during 2000, 16 during 2001, and 10
during 2002. Participant recruitment
was based upon both the coach and
league administrators. No other
inclusion or exclusion criteria were
described.
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Intervention There were three groups: warm up
Investigated stretching (control), flexibility
training, and eccentric strength
training. The flexibility training
program was based on a partner
contract relax stretching exercise done
three times per week during preseason
and one to two times per week during
the season. The eccentric training
program was based on the Nordic
hamstring exercise and done after
training the same amount as the
flexibility program. The intervention
group teams must have used the
program at least twice weekly during
the preseason and at least once per
week during the competitive season.
Outcome Overall Injury Incidence, hamstring
Measure(s) injury incidence, hamstring injury
incidence with each program type.
Askling et al. (2003)4
Randomized Controlled Study
Thirty male soccer players from two
premier league division teams in
Sweden were recruited to
participate. Players with chronic
hamstring problems were excluded
as were goalkeepers and injured
players. Participating players from
each team were randomly assigned
to training and control groups.
Before the study period started there
were no significant prior differences
between groups with respect to
muscle strength, maximal running
speed, hip flexibility, or
anthropometric measures.
Sixteen sessions of specific
hamstring strength training were
performed, every fifth day for the
first four weeks and every fourth
day during the last six weeks.
Training was performed in a non-
fatigued state after a standardized
warm up. Training consisted of both
concentric and eccentric actions
performed on a YoYo flywheel
ergometer.
Answers to the assessment of
soreness questionnaire. Change to
isokinetic muscle strength, running
speed, injury occurrence.
Petersen et al. (2011)5
Cluster Randomized Controlled
Study
50 soccer teams from the top five
Danish soccer divisions participated.
Teams were ineligible if they already
had an eccentric hamstring exercise
program in place. Players who did
not complete an entire season with
the same team did not participate.
Teams were clustered by level of
skill and then randomized to
intervention.
A 10-week program was
implemented during the mid-season
break. All teams in the intervention
and control groups followed their
usual training program. The
intervention group utilized the
Nordic hamstring exercise and
increased frequency and reps over 27
sessions.
Injured hamstring incidence and
duration, drop-out rate, session
compliance frequency.
 “Eccentric Exercises Reduce Hamstring Strains in Elite Adult Male Soccer Players: A Critically Appraised Topic”
by Shadle IB, Cacolice PA
Journal of Sport Rehabilitation
© 2016 Human Kinetics, Inc.
Arnason et al (2007)3
Study Design Cohort
Main Findings There was no significance difference
in the incidence of hamstring strains
between teams that followed the
flexibility training, and those that did
not. [0.54±0.12 vs 0.35 ± 0.10,
relative risk (RR): 1.53, 95%CI 0.76-
3.08, P=0.22]. With eccentric
strength training the overall incidence
of hamstring strains was 65% lower
among teams that used the eccentric
strength training program, compared
with teams that did not use the
program (0.22±0.06 vs 0.62±0.05,
RR: 0.35, 95%CI 0.19-0.62, P<0.001).
During matches, the rate of hamstring
strains among the intervention teams
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was lower than among the control
teams (P=0.03) and there was a
similar trend during training (P=0.07).
Level of 2b
Evidence
Validity Score N/A
Conclusion Results from this study indicate that
an eccentric strength training program
with Nordic hamstring lowers could
reduce the incidence of hamstring
strains in elite soccer players. It is
important to start a Nordic hamstring
program slowly with few repetitions
and sets with a gradual increase in
load and the number of repetitions.
Askling et al. (2003)4
Randomized Controlled Study
Significant increases after the
training period in both eccentric and
concentric knee flexor strength was
recorded (P< .05). No significant
changes occurred in the control
group. Thirty meter maximal speed
running was significantly faster post
intervention in the training group
(P< .05) but remained unchanged in
the control group. Thirteen
hamstring injuries were reported
among the 30 players (43% of
subjects), all occurring during the
competition season; 3/15 were in
the intervention group compared to
10/15 in the control group. Eleven
of the fifteen players considered the
extra hamstring training meaningful
and were positive towards a
continuation.
1b
PEDro 5/10
The training group showed
improvements both in isolated
strength of the hamstrings and in a
coordinated activity - that is, short-
term maximal speed running. The
ordinary training performed by the
control group did not cause any
such changes.
Petersen et al. (2011)5
Cluster Randomized Controlled
Study
The total number of drop outs was
79 (8%) players with similar
numbers from both the intervention
and control groups. A total of 67
acute hamstring injuries (44 new and
23 reoccurring injuries) occurred.
There were 15 injuries in the
intervention group, and 52 injuries in
the control group. Nine of the 15
(60%) injuries in the intervention
group occurred before the training
period was completed. Overall
hamstring injury rates were
significantly lower in the
intervention group. (RR, 0.293; 95%
CI 0.150-0.572; P<.001). The
numbers needed to treat (NNT) to
prevent one overall hamstring injury,
be it a new or reoccurring injury,
was 13 (95% CI 9-23) players.
Delayed onset muscle soreness was
reported by the intervention group
during the first weeks of the training
program.
1b
PEDro 6/10
It is possible to reduce the incidence
of hamstring injuries in professional
and amateur soccer significantly by
completing a training program that
focuses on increasing eccentric
hamstring muscle strength.