Hamstring Strain Injuries Incidence, Mechanisms,.5

Hamstring Strain Injuries:
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Incidence, Mechanisms,
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Risk Factors, and Training

Recommendations
Chris Wing, MSc1 and Chris Bishop, MSc2
1
South Fremantle Football Club and Peel Regional Academy of Sport, Perth, Australia; and 2London Sport Institute,
Middlesex University, Allianz Park, London, United Kingdom
ABSTRACT period) and chronic or recurrent (i.e., evaluating HSI prevention programs
the repeat injury of the same muscle site have centered solely around the
Hamstring strain injury (HSI) is one of the
due to a reduction in function and/or development of eccentric hamstring
most commonly reported sports injuries.
lack of appropriate healing and rehabili- strength. These have often included
This has led to a substantial amount of tation, which may also take the form of
research aimed at identifying factors that the use of the Nordic hamstring curl
an acute injury) (18). In some cases, HSI (2,90,107). In some cases, interven-
increase the risk of an athlete suffering can be severe in nature, which has been
a HSI. The identification of risk factors tions of this nature have reduced
previously defined as an injury that takes HSI by 65% (2), as well as significantly
allows practitioners to plan intervention greater than 28 days to recover (29). reducing the time lost to HSI (90).
programs with the aim of reducing the Often, HSI leads to a significant loss of
rate and severity of HSI. As a multitude athlete playing time, which may have Despite this ongoing research, and
of factors contribute to the risk of HSI, a detrimental effect upon team perfor- subsequent training recommenda-
interventions should be multifaceted in mance and subsequent financial losses tions, HSI have been reported to have
nature. This review outlines the inci- for sporting organizations (41,44). A increased annually within professional
dence, mechanisms, and risk factors for report in Australian football from the soccer (31), athletics (72), and in
HSI and provides evidence-based train- 2012 season estimated that HSI could cricket (77) since the introduction of
ing recommendations to reduce the rate cost clubs up to $245,842 per season the 20 over format (a faster paced
(44). This was seen as an increase of game played across 20 overs per
and severity of HSI.
71% in comparison with the figures re- team). Although challenging to fully
ported for the 2003 season (44). explain, this may be due to the lack
INTRODUCTION of emphasis placed upon the other
This has led to a substantial amount of modifiable risk factors within HSI pre-
amstring strain injuries (HSIs)
H are one of the most com-

monly reported lower limb inju-
ries, with high incidence and reinjury
research aimed at identifying risk factors
that predispose athletes to suffering
a HSI. These risk factors have been clas-
sified into 2 groups: modifiable and non-
vention programs. Furthermore, after
injury, the hamstrings not only seem
to suffer from a loss of strength
rates across a number of sports (25,50,54,64,73,74), but also flexibility
modifiable (56). The modifiable risk as well (50,64), which is believed to
(12,16,26,29,31,76,77,79,102,114). These
factors are those that can be altered contribute to the risk of reinjury.
injuries can be viewed as acute (i.e., as
through a training intervention and Therefore, it seems that additional fac-
a direct result of an impact or traumatic
include reduced eccentric strength, tors, and not just eccentric hamstring
event with sudden feelings of pain), over-
fatigue, flexibility, high-speed running
use (i.e., exposure to inappropriately high
loads, and insufficient or inadequate
training load/volume over an extended KEY WORDS:
warm-up. However, despite identifying eccentric strength; high-speed running;
Address correspondence to Chris Bishop, several risk factors that contribute to multifaceted approach; prevention
MSc, C.Bishop@mdx.ac.uk. HSI risk, a substantial amount of research
40 VOLUME 42 | NUMBER 3 | JUNE 2020 Copyright Ó National Strength and Conditioning Association
Copyright © National Strength and Conditioning Association. Unauthorized reproduction of this article is prohibited.
strength alone, warrant particular atten- the lateral aspect of the ischial tuber- the terminal swing phase, the biceps
tion within HSI prevention programs. osity and extends distally to attach at femoris long head, semitendinosus,
In order for these programs to be suc- the posterior aspect of the medial tibial and semimembranosus exhibit peak
cessful, practitioners should have a thor- condyle (18,108,113). The biceps fem- strain, produce peak force, and perform
ough understanding of the different oris short head arises from the femur greater negative energy absorption
types of HSI, the injury mechanisms, and inserts at the fibula head, making it (86). It is a common theory that the
and the potential risk factors associated a uniarticular muscle that crosses only additional work placed upon the ham-
with HSI. Thus, the purpose of this the knee joint (18,108,113). The iso- strings at this time point is responsible
review is to summarize the injury mech- lated function of the hamstring muscle for the high number of HSI (21,86,87).
anisms, injury rate, and risk factors on group is to shorten concentrically to Furthermore, the hamstrings seem to
HSI, with a focus on providing produce knee flexion and hip exten- play an important role in horizontal
evidence-based guidelines for multifac- sion. During more integrated or force production during acceleration
eted injury prevention programs. dynamic muscle actions (e.g., jumping, sprint mechanics (68). It has been pro-
Throughout this review, it is important sprinting, and changing direction), the posed that those athletes displaying
to have an appreciation for different hamstrings aid in the stabilization of higher levels of hip extensor torque
injury definitions used within the liter- the lumbopelvic hip complex and knee (eccentric hamstring strength) and
ature when comparing any research of joints (51,86). the highest hamstring electromyogra-
this nature. For example, Orchard et al. Of particular interest regarding HSI is phy (EMG) activation during the ter-
(76) define an injury as one that causes the intramuscular or central tendon, minal swing phase were able to
an athlete to miss only match-playing which descends down the length of generate greater horizontal ground
time. By contrast, Ekstrand et al. (29) the muscle belly (17,55). The intramus- reaction forces (68). The important
includes any injury that prevents cular (central) tendon acts as a support- role of the hamstrings during running
a player from taking part in training ing structure to which the muscle fibers performance is further supported by
and competition. These differences in attach (17). When this tendon is injured Kyrolainen et al. (53) who suggested
methodologies may have an influence or damaged, the injury is considered to that as running speed increases, so
over the prevalence and severity of re- be more severe with increased return to too does force production, which can
ported HSI. training and competition (17,22,55,82). be partly attributed to the action of the
This is highlighted in the study by Com- hamstrings (53). Therefore, as the
in et al. (22) who identified 45 biceps hamstrings seem to play a prominent
HAMSTRING ANATOMY
femoris injuries, of which 12 also role in speed development, it is essen-
Having an understanding of the basic involved the central tendon. It was re- tial for practitioners to have an under-
hamstring anatomy and function can ported that the recovery times for those standing of appropriate training
aid to improve the understanding of injuries involving the central tendon methods that optimize both their
HSI risk. The hamstring muscle group that did not require surgical intervention health and performance.
consists of 3 major muscles of the pos- (71 days) were significantly (p , 0.01)
terior thigh: semitendinosus, semi- longer than those not involving the cen-
membranosus, and biceps femoris tral tendon (21 days) (22). Therefore, HAMSTRING STRAIN INJURY
(long and short head) (18,108,113). the intramuscular tendon has important Hamstring strain injuries are one of the
The biceps femoris long head, semite- implications for injury prevention and most commonly reported sports injuries
ndinosus, and semimembranosus have rehabilitation. (12,16,18,26,29,31,76,77,79,102,114). A
a biarticular formation where they HSI is commonly classified as a grade
cross both the knee and hip joint. This FUNCTIONAL ROLE OF THE I–III strain depending on its level of
biarticular formation causes the ham- HAMSTRINGS IN ATHLETIC severity (18). A grade I strain typically
string to stretch at 2 points, a factor PERFORMANCE affects a small number of muscle fibers;
often hypothesized to contribute to The predominant role of the ham- grade II, a significant amount of muscle
the high rate of HSI (114). The biceps strings within sports performance is fibers; and grade III, a complete tear of
femoris long head originates from the often centered around their function the muscle (18). Using similar grade
medial facet of the ischial tuberosity during high-speed running. Their pri- classifications, Ekstrand et al. (30) re-
through its proximal tendon and dis- mary role during this is to decelerate ported return to play times to be 17 6
tally inserts to the lateral surface of the knee extension during the terminal 10 days (grade I), 22 6 11 days (grade
fibula head (18,108,113). The semite- swing phase (a point in the running II), and 73 6 60 days (grade III) within
ndinosus also originates at the ischial cycle where neither limb is in contact professional soccer. In more recent
tuberosity before extending and insert- with the ground), so that the foot can times, additional injury grading systems
ing distally at the medial surface of the make ground contact under the body’s have been proposed to increase their
tibia (18,108,113). The semimembra- center of mass, after which they act as specificity and provide clearer informa-
nosus proximal tendon arises from an active hip extensor (86,87). During tion on return to play times (20,69,81).
41
Strength and Conditioning Journal | www.nsca-scj.com
Hamstring Strain Injuries
Pollock et al. (81) suggest that along- femoris (long head) was the primary present in 2 different sports populations
side grading the injury severity on injury location in all 18 hamstring in- (type I: sprinters and type II: dancers),
a scale of 1–4 (small, moderate, exten- juries suffered by elite-level sprinters which may have influenced the differ-
sive, or complete tear), an additional within their study. A further 8 sprinters ence in recovery times.
suffix of (myofascial, musculotendi- (44%) suffered additional injury, with 7

nous, or intratendinous) should also at the semitendinosus and one at the HAMSTRING STRAIN INJURY
be included to indicate the location biceps femoris short head (5). INCIDENCE, TIME LOSS, TIME OF
of the injury. Similarly, Chan et al. INJURY INCIDENCE, AND TYPICAL

Type II hamstring strains are com- SEVERITY
(20) proposed a new classification sys- monly seen as stretch-related injuries
tem, which included lesion site (prox- The incidence and time loss of HSI
(18). These injuries most commonly across several sports is summarized in
imal musculotendinous junction, occur during combined excessive
muscle, or distal musculotendinous Table 1. Within professional soccer,
stretching into hip flexion and knee HSI incidence has been widely re-
junction), with muscle injuries having extension (6). Askling et al. (6) report
2 additional suffixes including location ported. Petersen et al. (79) reported
that these types of injury can occur in an average of 3.4 (range 5 1–5) HSI
(proximal, middle, or distal) and ana-
several sports (soccer, dance, judo, per club per season, Woods et al. (114)
tomical site (intramuscular, myofascial,
gymnastics, and sprint running) and reported a higher average of 5.0 (range
myofascial/perifascial, myotendinous,
during different athletic actions (high 5 0–16) per club, and Ekstrand et al.
or combined). Including such informa-
kicking, stretching, and sagittal and (29) claimed that clubs could expect
tion within injury classifications has
side splits). However, this is most com- around 7 HSIs per season. This is sim-
been proposed to aid practitioners with
monly seen among dancers, with As- ilar to those reported for Australian
both injury prevention and rehabilita-
kling et al. (3) reporting that 66% of football, where Orchard et al. (76) re-
tion practices (20,69,81).
acute HSI occurred during a sagittal ported 6 injuries during the 1995 sea-
plane split and 12% during a side split. son. Hamstring strain injury incidence
HAMSTRING STRAIN INJURY TYPE
These injuries commonly affect the also highlighted in the more recent
A type I strain is commonly referred to
semimembranosus, with Askling et al. 2018 Australian Football League
as a sprinting-related strain and is typ-
(6) reporting this occurrence in 83% of (AFL) injury report, with 6.35 new
ically reported in sports such as rugby,
type II strains, with all semimembrano- HSIs per club per season (1). The sim-
athletics, and the various football co-
sus strains also involving its proximal ilar number of HSI per club per season
des (5,16,26,29,76,79,114). These often
free tendon. It is important for practi- reported within these 2 studies pro-
occur when the hamstring muscle
tioners to understand which type of vides some evidence that HSI occur-
group are required to work eccentri-
HSI is most likely to occur in their rence within AFL has remained
cally (produce force while lengthening)
athletic population, enabling more spe- consistent across 23 seasons (1,76).
to decelerate the limb and control knee
cific rehabilitation protocols to be Furthermore, the AFL injury report
extension during the terminal swing
applied. also demonstrated a HSI reinjury rate
phase of high-speed running
(21,42,57,88). This mechanism of Although athletes suffering a type I of 20%, defined as the same injury type,
injury has been supported by the work strain often initially present with on the same side in the same season
of Heiderscheit et al. (42) and Schache greater functional deficits compared (1). Injury incidence rates have also
et al. (88) who studied the time frame with type II strains, their recovery time been reported for rugby union (5.6
of hamstring injury during running and has been reported to be quicker (4). per 1,000 player hours) (16), cricket
concluded that injury occurred during The study by Askling et al. (4) demon- (22.5 per 1,000 team days) (77), and
the late swing phase. Schache et al. (88) strated that athletes who suffered from a range of National Collegiate Athletic
further reported that during the injury both type I and II strains could perform Association (NCAA) sports (3.05 per
phase, the biceps femoris reached strength and flexibility assessments at 10,000 athlete exposures) (26). Finally,
a peak length estimated to be 12% .90% of the uninjured leg 6 weeks after within a cohort of student dancers,
greater than that seen during upright injury. However, their self-reported a retrospective analysis found that
posture and exceed the normalized time to return to preinjury levels of per- 51% of athletes reported suffering pos-
peak length of the medial hamstrings. formance were markedly different terior thigh pain at some point in their
Furthermore, Higashihara et al. (45) (type I: average of 16 weeks [range 5 careers (3). Thus, the prevalence of
reported significant increases in ham- 6–50 weeks] and type II: average of 50 HSI seems common across a multitude
string activation when running speeds weeks [range 5 30–76 weeks]), identi- of sporting populations.
were increased from 85 to 95% of an fying the need for both subjective and Time loss due to hamstring injury can
individual’s maximum velocity. Often- objective information during the reha- be seen as a more important factor
times, the biceps femoris is the main bilitation period (4). It should be noted than injury incidence because ulti-
site of damage in type I strains, with that in the work of Askling et al. (4), mately, the amount of time missed by
Askling et al. (5) stating that the biceps these 2 different types of HSI were an athlete may have a direct effect on
42 VOLUME 42 | NUMBER 3 | JUNE 2020

Table 1
Hamstring injury incidence and time lost across a number of sports
Author(s) Subjects Study Length Hamstring Injury Definition Injury Incidence Time Lost
Brooks 546 professional 2 seasons Any injury that prevents a player from taking full part in all 5.6 per 1,000 player Total of 1,176 days.
et al. rugby union training or match-play activities for a period .24 hours. hours.
151 days per 1,000 player
(16) athletes
hours.
Ekstrand 23 UEFA soccer 7 seasons Any injury that prevents a player being able to fully participate 7 in 25 players suffer 12% of severe injuries (.28
et al. clubs in training or match-play. a hamstring strain. days lost) were
(29) hamstring strains.
Orchard 37 professional 1 season Clinically diagnosed and caused a player to miss match-playing 6 injuries. Average 2.5 matches
et al. Australian time. Minor injuries where only practice time missed.
(76) footballers was missed were not included. Range 1–6.
Orchard Elite cricketers 20 years Diagnosis by medical personnel. Match injury incidence Not reported.
et al. 22.5 per 1,000 team
(77) days.
Ekstrand 36 soccer clubs 13 seasons Any injury that prevents a player being able to fully participate 1,614 total injuries. 1.2 Mean time lost: 17 days
et al. in training or match-play. injuries per 1,000
(31) player hours.
Dalton 25 NCAA sports 5 academic An injury identified by an athletic trainer that occurred during 1,142 total injuries. 3.05 37.7% time loss ,24 hours.
et al. teams years NCAA-sanctioned practice or match. per 10,000 hours. 6.3% time loss .3 weeks.
(26)
Woods 91 professional 2 seasons An injury sustained in normal competition or training that 796 total hamstring Average 18 days and 3
et al. soccer clubs prevented a player from taking part in normal training injuries (749 were matches per injury.
(114) and competition for .48 hours. strains); 12% of total Clubs can expect 90 days
injury occurrence. and 15 matches missed
Average of 5 hamstring per season.
strains per club per
season.
Petersen 374 elite soccer 12 months Any self-reported posterior thigh pain from training or 3.4 hamstring injuries Average 21.5 days per
et al. players competition. per team per season. injury.
(79)
(continued)
43
team performance and results (41). hamstring injuries, with 10% reported
Range from 2 weeks to 80
This is highlighted in the 2018 AFL as minimal, 21% mild, 54% moderate,
injury report, which noted that during and 15% severe in nature (31). The
a 22 game season, clubs could expect to findings within these studies would
lose 25.19 matches to HSI, which may suggest that most hamstring injuries
ultimately have a detrimental effect within soccer athletes are minimal to
14% sustained an injury. Not reported.
Incident causing acute pain to posterior thigh, which resulted 118 injuries. 24.1% of all Not reported. upon team selection (1). The reporting moderate in nature and/or classified as
months.
of time loss in professional soccer grades 0 to 2.

seems to be fairly consistent across
the literature, with Woods et al. (114)
MECHANISMS OF INJURY
(18 days), Ekstrand et al. (31) (17 days),
51% reported suffering
and Petersen et al. (79) (21.5 days) all Among the literature presented in
Table 1, running and sprinting was
reporting similar average time-loss val-
shown to be the primary mechanism
ues per injury. Woods et al. (114) fur-
for hamstring injury (16,26,30,36,114).
ther report that during this 18-day
Ekstrand et al. (30) highlight that
injuries.
time-loss period, athletes are likely to

injury.
sprinting and high-speed running were

miss 3 competitive soccer matches.
responsible for 70% of hamstring inju-
Within NCAA athletes, 37.7% of HSIs
ries among soccer players. Similarly,
incurred a time loss of ,24 hours, with
Gabbe et al. (36) found that 73% of
in cessation from competition. Positive clinical examination
6.3% reported to miss .3 weeks (26).

hamstring injuries among elite Austra-
The severity of hamstring injuries was
lian footballers (AF) could be attrib-
An injury causing an athlete to miss at least one game.
further displayed by Ekstrand et al. (29)

uted to running or sprinting. These
who stated that 12% of injuries classed
figures are much higher than those re-
as severe (time loss .28 days) were
ported by Woods et al. (114) who
seen to be hamstring injuries.
claimed running was responsible for
Hamstring strain injury incidence
(continued )
57% of hamstring injuries. The percent-

Self-reported pain to the posterior thigh.
Table 1
(31,79,114) and rate (26) is reported age of HSI attributed to running and
to be more prevalent during competi- sprinting has also been reported for
tion than in training. This may indicate other team sports including American
the increased intensity of match-play football (48.4%), lacrosse (men 35.6%;
but also suggests that training may women 48.5%), basketball (men 25%;
not sufficiently prepare athletes for women 35.1%), and individual sports
the demands of competition (29). This such as outdoor track and field (men
upon follow-up.
notion is further supported by Ek- 58.3%; women 46.9%) in a study of

strand et al. (29) who states that ham- NCAA athletes (26). Furthermore,
string strains are more prevalent in- within rugby union athletes, the “back”
season compared with preseason, playing positions have been shown to
highlighting the importance of contin- suffer a greater incidence of hamstring
ually training the hamstring group all injury, possibly because of the greater
year round within athlete development demand of high-speed running upon
programs. Furthermore, it has been re- this playing group (16).
Retrospective
unlimited
ported that 47% of hamstring strains in

Other hamstring injury mechanisms
length
1 season
professional soccer occur in the final

study:
reported within the literature include

48,473 track and 3 years
third of the first and second halves, stretching (6,30,114), sliding (30), turn-
suggesting that fatigue may be a con- ing (30,114), twisting (30,114), kicking
tributing factor (114). (6,30,114), overuse (26,30), jumping
field athletes
A magnetic resonance imaging (MRI) (30,114), and during escape/sparring/

footballers
Australian
98 student
study of hamstring injuries within pro- take-down maneuvers in sports such as

dancers
222 elite
fessional soccer highlighted 207 inju- wrestling (26). Collectively, although

ries, of which 13% were classified as these actions are not as common as
grade 0 (negative MRI with no visible sprint-related injuries for team sport
pathology), 57% grade 1, 27% grade 2, athletes, however, their importance
et al.
et al.
et al.
Askling
Gabbe
and 3% grade 3 (30). Similar findings should not be understated. The action
(36)
(72)
(3)
Opar
could be seen within a second study in of kicking, either a ball or an opponent,

professional soccer that reported 1,614 has also been highlighted within the

literature as a HSI mechanism wrestling athletes, with actions such that eccentric peak hamstring torque
(6,15,37). Previously, Askling et al. (6) as sparring, takedown maneuvers, and and the functional hamstring:quadri-
has identified HSI during high kicking performing escapes all reported to be cep (H:Q) ratio (eccentric hamstrings
actions in ballet, taekwondo, and soc- responsible for 15.4% (each) of all HSI versus concentric quadriceps) were sig-
cer. Within rugby union athletes, (26). Although running and sprinting nificantly reduced during the fatigue
Brooks et al. (15) explained that kick- are reported as the most common inducing protocol (95). Furthermore,
ing was responsible for approximately causes for HSI, identifying other pos- the authors found no significant
10% of HSI, and that these were seen sible mechanisms is important infor- changes in concentric peak torque of
as the most severe in terms of time lost mation that can enable practitioners both the hamstrings and quadriceps
(36 days lost). Furthermore, Gabbe to understand the risk of HSI and (95). Greig (39) also found no signifi-
et al. (37) reported that in community develop appropriate injury prevention cant changes in concentric knee flexor
level Australian football, 19.2% of HSI plans for their given sport. and extensor peak torque at all con-
were attributed to kicking the ball. In traction speeds tested but were able
INJURY RISK FACTORS
addition, within professional soccer, up to demonstrate significant reductions
to 55% of HSI have been reported in Several risk factors relating to ham- in peak eccentric hamstring torque,
the preferred kicking leg (30). Further- string injury and reinjury have been which were more evident at the faster
more, Lord et al. (59) reported that reported within the literature. These contraction speeds. This indicates that
100% (n 5 20) of the injured subjects can be categorized into 2 distinct the hamstrings are more greatly
within their study suffered the HSI groups: modifiable and nonmodifiable. affected when having to produce force
Risk factors classified as modifiable are
within the preferred kicking leg. quickly when fatigued, which may be
often seen as factors where the risk can
Although the reason for this has not particularly relevant when considering
be reduced through a targeted training
been well established, Rahnama et al. the relationship between high-speed
intervention (e.g., increasing an ath-
(83) found the knee flexors of the pre- running and HSI (39).
lete’s strength). Nonmodifiable risk fac-
ferred kicking leg to be significantly The reduced ability of the hamstrings
tors are those which are out of the
weaker (p , 0.05) than the nonkicking to produce force when under fatigue is
control of the athlete and practitioner
leg when measured at 2.09 rad/s, and also supported by Lord et al. (58,59).
(e.g., age of the athlete). Oftentimes,
that 68% of athletes tested had Their first study highlighted signifi-
these risk factors can be specific for
between-limb differences in strength cantly reduced mean horizontal force
each sport. For example, high-speed
.10%. Therefore, as strength deficits production in limbs previously suffer-
running loads are likely a risk factor
have been highlighted as a risk factor ing a HSI during a 10 3 6-s repeated
in soccer as opposed to wrestling,
for HSI, it is reasonable to assume that sprint test on a nonmotorized treadmill
whereas some may be global to all ath-
the reduction in strength of the pre- (58). The second study measured peak
letes, such as poor levels of strength.
ferred kicking leg plays a role in its These risk factors and their implica- concentric knee flexor and extensor
increased susceptibility to injury, espe- tions for training are discussed in the torque during isokinetic testing mea-
cially when this is coupled with the following section. sured at 1808/s, after the completion
possibility that this limb is overloaded of the same 10 3 6-s repeated sprint
during performance (83). MODIFIABLE RISK FACTORS protocol (59). They found significant
Stretching and performing side and FATIGUE reductions in isokinetic knee flexor tor-
sagittal splits have been reported as As previously mentioned, hamstring que and the concentric H:Q ratio only
a mechanism of injury in a variety of injuries often occur toward the end of in limbs that had previously suffered
sports including ballet, dance, rock match-play, presumably with fatigue a hamstring injury (59). Furthermore,
climbing, tennis, soccer, judo, ice being a contributing factor. Several au- the decline in knee flexor torque was
hockey, and gymnastics (6). This type thors have investigated the role fatigue also able to correctly identify the pre-
of injury is commonly reported within may have upon other established risk viously injured limb with 100% accu-
dancers. In fact, Askling et al. (3) stated factors, such as eccentric knee flexor racy (59). Therefore, it seems that
that within a cohort of student dancers, strength and, therefore, the ability of fatigue may also play a prominent role
88% of acute HSIs were suffered during the hamstrings to generate and toler- in hamstring reinjury rates as the pre-
slow activities such as performing ate force. Small et al. (95) and Greig viously injured limb seems to suffer
splits. In other sports, such as profes- (39) both used a soccer-specific fatigu- greater loss of function when in
sional soccer, stretching- and sliding- ing protocol to measure the impact of a fatigued state (58,59). Coratella et al.
related HSI have been reported with fatigue upon measures of torque ob- (23) also found significant increases in
less regularity, with Ekstrand et al. tained through isokinetic dynamome- peak joint torque angle, both during
(30) stating that they account for 5% try at contraction speeds of 60, 120, concentric and eccentric contractions,
of all HSI. Finally, 13 HSI were re- 180, and 3008/s, respectively. It was after a fatigue-inducing protocol,
ported in a population of NCAA found in the work by Small et al. (95) which consisted of the Loughborough
45
Intermittent Shuttle Test (a 20-m shut- BICEPS FEMORIS FASCICLE bouts at a significantly higher risk of
tle run that involves sprinting, walking, LENGTH injury (63). They further explained that
and running at 55 and 95% of an in- The contribution of the biceps femoris those athletes who were exposed to
dividual’s maximal aerobic speed fascicle length in HSI occurrence and events over 95% of their maximal
[MAS]). The authors hypothesized reoccurrence has been discussed velocity benefitted from a protective
that these fatigue-induced changes within the literature (9,34,101,102). effect of training (63). A secondary
(where the hamstring exerts greater The prospective research by Timmins study by Malone et al. (61) reported
force at shorter muscle lengths) may et al. (102) in elite soccer players re- that large weekly changes of 351–
highlight their impaired ability to act ported that short biceps femoris fasci- 455 m in high-speed running (.14.4
against the quadriceps during near cle lengths of ,10.56 cm increased the km/h) and 75–105 m of sprint speed
maximal knee extension when the risk of HSI by 4.1-fold. Furthermore, (.19.8 km/h) increased the risk of
hamstring is in a lengthened position a retrospective study by Timmins et al. injury. Furthermore, athletes who
(23). However, it should be noted (101) found that after injury, both fas- completed a moderate distance (high
that these measurements were made cicle length and fascicle length relative speed: 701–750 m; sprint speed: 201–
in a seated position and therefore are to muscle thickness was significantly (p 350 m) were at reduced risk compared
not indicative of sprint running , 0.001) reduced compared with the with those who completed relatively
gait (23). uninjured contralateral limb. low amounts (high speed: ,674 m;
The reduced ability of the hamstrings It has been hypothesized that the con- sprint speed: ,165 m) (61).
to produce force at longer muscle tributing mechanism to the increased This is somewhat supported by Duhig
lengths, and maybe more importantly risk of injury to shorter fascicles may et al. (28) who reported that athletes
absorb opposing force, may help to be owed to a reduced number of in- completing higher than typical mean
enhance the understanding of fatigue series sarcomeres, which may be (calculated from each athlete’s 2 yearly
as a risk factor for injury. During excessively lengthened during eccen- session average) high-speed running
sprint running, the hamstrings work tric contractions (9,102). This may be (.24 km/h) distances in the 4 weeks
both eccentrically to decelerate knee exacerbated further after injury with before injury were at greater likelihood
extension to counteract inertia of the the presence and formation of scar tis- of suffering a hamstring injury. Further-
sue, which may increase the burden
leg swing during the terminal swing more, the study by Ruddy et al. (85)
placed upon the fascicles during exces-
phase and concentrically as an active involving 220 elite Australian footbal-
sive lengthening (34,52,93). Therefore,
hip extensor (57,78). It is at this time lers supports the monitoring of running
it can be seen that short biceps femoris
(terminal swing) that the biceps fem- distances completed above 24 km/h in
fascicle lengths may play a role in both
oris, semitendinosus, and semimem- relation to HSI. They reported that
first-time HSI and injury reoccurrence
branosus are subjected to peak absolute weekly distance covered
and should be a factor that is consid-
strain, force, and energy absorption above 24 km/h (.653 m, relative risk
ered in both injury prevention and
(86). The reduced ability of the ham- [RR] 5 3.4), absolute week to week
rehabilitation programs.
strings to both absorb energy and pro- change in distance covered above 24
duce force once fatigued is likely to km/h (.218 m, RR 5 3.3), relative
impair their ability to perform subse- HIGH-SPEED RUNNING LOADS week to week change in distance cov-
quent tasks, and when accompanied Running at high speed or sprinting has ered . 24 km/h (.2.00, RR 5 3.6),
by increased quadriceps dominance already been identified as a mechanism and distance covered above 24 km/h
(as indicated by the reduced H:Q for hamstring injury. It has been pre- expressed as a percentage of that cov-
ratio), this may predispose the ham- viously well reported that spikes in ered above 10 km/h (.2.5%, RR 5
strings to heightened injury risk athlete load increase the risk for soft- 6.3) provided the largest significant risk
(21,23,57,86,95). Furthermore, altered tissue injury, and that appropriately factors of suffering a HSI in the sub-
hamstring muscle activation patterns planned vigorous training may sequent week (85). However, despite
(once fatigued), have been proposed decrease the risk of injury (38,48). Ma- the significant RR values, the authors
as a possible cause of injury (80,110). lone et al. (63) studied exposure to report a substantial overlap in running
Pinniger et al. (80) explain that under high-velocity running events in 37 elite distances between those subsequently
fatigue, there is a significant increase Gaelic football athletes and found that injured and those uninjured (85).
in the duration of hamstring EMG both underexposure and overexposure Therefore, although providing an asso-
activity due to the earlier onset of to these events increased the risk of ciation between distances covered
muscle activation. It has been sug- injury. Specifically, those performing above 24 km/h and HSI, it was not
gested that this may be a mechanism 6–10 maximal velocity efforts per week possible to predict HSI at the individ-
to overcome the reduced force gener- were at reduced risk of injury com- ual athlete level, which is further high-
ation capabilities of the hamstring pared with those completing ,5 ef- lighted by none of the absolute running
muscle group (80,110). forts, and those completing .10 variables reporting both sensitivity and

specificity values above 0.6 (85). the value of the H:Q in relation to HSI isokinetic testing of both the eccentric
Although not all the aforementioned prediction could be questioned. hamstrings and concentric hip exten-
studies are specific to hamstring injury, Because of the previously mentioned sors (which include but are not limited
it seems that inappropriate high-speed to the hamstrings). Furthermore,
primary role of the hamstring muscles

and sprint running loads may lead to an (to function eccentrically to decelerate Orchard et al. (76) found that a signifi-
increase in soft-tissue injury. Therefore, knee extension during the late swing cantly increased risk of injury was pres-
as high-speed running and sprinting phase), it may be argued that a more ent if an individual displayed
have been reported mechanisms for functional assessment of the H:Q ratio a hamstring to opposite hamstring
hamstring injury, exposure to these would be to assess the eccentric action ratio of ,0.92. Despite this being a use-
types of events warrants particular of the hamstrings versus the concen- ful finding, this value reported as a per-
attention as a risk factor for HSI. tric action of the quadriceps (23,24). centage difference between limbs may
This method was retrospectively used be of more practical use and better
STRENGTH AND INTRALIMB AND by Croisier et al. (24) who discovered understood by practitioners in the field.
INTERLIMB ASYMMETRY This is further supported by the study
significant imbalances in the functional
Hamstring strength and asymmetry of Croisier et al. (25) involving 462 soc-
ratio between the injured (0.73 6 0.24)
have been widely proposed as modifi- cer players. They found that those with
and uninjured limb (0.90 6 0.16; p ,
able risk factors (12,19,25,75,76,100, significant imbalances (.15% bilateral
0.01) within subjects with previous
102,116). Asymmetry may present in difference in concentric or eccentric
hamstring injury. However, a prospec-
2 forms: interlimb (the difference hamstring strength) had a 4–5 times
tive study by Bennell et al. (11) found
between 2 limbs) (12,25) and intralimb increased risk of injury (25). The au-
no predictive benefit of isokinetic test-
(the difference between the quadri- thors reported that reducing these im-
ing, including the comparison of func-
ceps and the hamstrings within the balances to ,5% significantly reduced
tional H:Q ratio. Similarly, Van Dyk
same limb) (116). Intralimb differen- the risk of injury from a RR ratio of
et al. (109) found no significant differ-
ces are often reported as a ratio 4.66–1.43 (25).
ences between injured and uninjured
(116), whereas interlimb differences
limbs when studying the functional Strength imbalances were further
are typically displayed as a percentage
H:Q ratio. However, it should be noted highlighted as a risk factor when tested
(12,25). Oftentimes, the concentric
that eccentric hamstrings torque was during the Nordic hamstring exercise
H:Q has been investigated to high-
measured at 608/s and concentric (12). In a prospective study, it was
light strength discrepancies between
quadriceps torque at 3008/s. Further- found that the subsequently injured
the hamstrings and quadriceps. The
more, the hamstrings were not tested limb was significantly weaker than
literature highlights that a significant
eccentrically at faster contraction the uninjured contralateral limb, and
reduction in the H:Q ratio was evident
speeds (like the quadriceps), which that differences of $15% and $20%
in subsequently injured limbs in com-
may be more indicative of high-speed increased the risk by 2.4- and 3.4-
parison with uninjured athletes and/
running (109). As previously men- fold, respectively (12). Further meas-
or the uninjured limb (19,76,116). In-
tioned, Small et al. (95) found signifi- urements made during the perfor-
fact, Yeung et al. (116) explain that
cant reductions in the functional H:Q mance of the Nordic hamstring
when measuring concentric strength
ratio during a multidirectional soccer- exercise provide additional support
at an angular velocity of 1808/s, a ratio
specific fatigue-inducing protocol, for strength as a risk factor. Both Opar
lower than 0.6 led to a 17 times
which may suggest that performing et al. (75) and Timmins et al. (102)
increased risk of injury. However, in
these ratios within a fatigued state report that weaker limbs and athletes
a study of 614 elite soccer players
may be more sensitive to injury pre- were at an increased risk of injury. In
across 4 competitive seasons, the
diction. However, it should be noted a population of 210 elite Australian
H:Q was not supported as a potential
risk factor for future HSI, with the that Small et al. (95) did not report footballers eccentric strength below
authors reporting no relationship upon any relationships with injury, 256 Newtons (N) at the start of pre-
between H:Q measurements and sub- and therefore, further prospective season and 279 N at the end of pre-
sequent HSI (109). No significant dif- research within this area is warranted. season were said to increase risk by 2.7-
ferences were noted between the It has been reported across several and 4.3-fold, respectively (75). This is
injured and uninjured limbs (n 5 studies that hamstring injury often oc- further corroborated by Timmins et al.
167) in the concentric H:Q measured curs within the weaker limb, indicating (102) who found that for every 10 N
at 60 and 3008/s (109). Furthermore, that between-limb strength differences increase in eccentric knee flexor
after multiple logistic regression anal- may be a factor for consideration with strength, the risk of injury fell by
ysis, odds ratios were also reported to HSI (25,76,100). The work of Sugiura 8.9%. Finally, a reduction in hamstring
be nonsignificant (n 5 563) at both 60 et al. (100) explains that significant in- strength, in comparison with uninjured
and 3008/s (109). Thus, given the sam- terlimb asymmetries existed between limbs/subjects, after a hamstring injury
ple size and time course of the study, injured and noninjured limbs in has been widely reported among the
47
literature (50,54,73,74). Although this with the control group (n 5 837) suf- injury is inconsistent across the litera-
does not add any prospective predic- fering 8 injuries (97). However, the ture. Bennell et al. (10) studied 67 Aus-
tive value per se, as it is unknown incidence per 1,000 playing hours tralian football players and concluded
whether the reduction in strength can was 0.1 in the intervention group and that there were no significant differen-
be attributed to previous injury or if the 0.2 in the control group, which was not ces in hamstring flexibility between
weakness is the result of previous significantly different (97). It should be those who subsequently sustained an
injury; thus, testing previously injured noted that hamstring injury rates injury and those who remained unin-
athletes may provide some value. As before intervention were not reported, jured. Similarly, Orchard et al. (76)
strength deficits and previous injury which would have allowed for better found no correlation between injury
have been identified as risk factors, comparisons to be made as to the effec- and hamstring flexibility as measured
coupled with the role that the normal- tiveness of the intervention. through the sit and reach test in a pop-
ization of strength imbalances can play The reports by Silvers-Granelli et al. (94) ulation of Australian footballers. How-
on reducing risk (25), identifying those and Grooms et al. (40) both support the ever, it should be noted that the sit and
individuals still at risk after previous value of the FIFA 11+ program within reach test is not specific to hamstring
injury may help in the planning of tar- athletic training after discovering signifi- flexibility, and often results can be
geted training interventions. cant reductions in hamstring injuries impaired by an athlete’s hip mobility
compared with a control group and a ref- and their ability to flex the spine (76).
INSUFFICIENT/INADEQUATE It is also worth noting that the test is
WARM-UP erence group, respectively, across one
entire season. It was reported that 55 unable to differentiate between limbs,
Oftentimes, an appropriately planned
and 16 HSIs were experienced by the potentially masking any imbalances that
warm-up that adequately prepares an
control and intervention group, respec- may be present (76). These findings are
athlete for training and match-play has
tively, resulting in the intervention reduc- further supported by both Hennessy
been recommended to reduce injuries
ing the likelihood of injury 2.74-fold (p , and Watson (43) and Yeung et al.
(32,70,97,99), although there is a lack of
0.001) (94). However, a better under- (116) who also found no correlation
empirical evidence to support this the-
standing of the intervention’s success between hamstring flexibility and injury.
ory for HSI. A systematic review by
Fradkin et al. (32) found insufficient evi- could have been gained if these HSI oc- By contrast, Witvrouw et al. (112), pro-
dence to both promote or discourage currences had been compared with spectively studied the relationship
pre-exercise warm-up for the reduction those experienced during the preinter- between hamstring flexibility and ham-
of injury occurrence. Of the 5 studies vention period. In the study by Grooms string injury among 146 professional
included within the review, 3 found that et al. (40) the intervention group, who soccer players. They reported that, in
the inclusion of the warm-up signifi- performed the FIFA 11+ program 5–6 comparison with their uninjured coun-
cantly reduced injury, whereas 2 found times per week, reported only one ham- terparts, those injured displayed signif-
no significant effect upon injury occur- string injury compared with the 5 re- icantly reduced levels of flexibility
rence (32). The authors conclude that ported by the control group. However, (,908 during passive straight leg raise;
although there is insufficient evidence to it should be noted that the FIFA 11+ p 5 0.02) (112). The differences in the
support or discourage the implementa- program includes the Nordic curl exer- results presented here may be partly
tion of a warm-up to prevent injuries, cise, which has been widely reported to attributed to the different methods
the weight of evidence is in favor of reduce hamstring injuries (2,90,107). used to ascertain hamstring flexibility.
implementing a warm-up strategy (32). Therefore, it could be suggested that in- However, both Witvrouw et al. (112)
creases in strength, derived through the and Yeung et al. (116) measured flexi-
Recently, structured warm-up proto-
inclusion of the Nordic curl, are the larg- bility through a passive straight leg
cols, such as the Fédération Internatio-
est factor in reducing HSIs within the raise and reported opposing results.
nale de Football Association (FIFA)
FIFA 11+ program, and not the overall With such discrepancies existing
11+ (also referred to as the FIFA Med-
ical Assessment and Research Centre process of performing a warm-up. within the literature, the role of flexi-
11+), have been implemented with the Although the potential benefit of the bility in hamstring injury should be
aim of reducing lower limb injury warm-up is not fully supported by the viewed with caution, especially when
occurrence (40,94,97). Soligard et al. research provided here, there is some a multitude of factors may contribute
(97) reported that although statistical evidence to suggest that an appropriately to hamstring injury.
significance had not been reached, planned warm-up may aid the reduction It should be noted that in a retrospective
a reduction in overall lower limb injury of injuries. study performed by Jonhagen et al. (50),
could be seen due to the implementa- Oftentimes, flexibility/dynamic stretch- previously injured sprinters showed sig-
tion of the structured warm-up inter- ing exercises are included as part of nificantly reduced hamstring flexibility
vention. When looking at the a warm-up routine (49). However, the during a passive hamstring raise com-
hamstring specifically, the intervention evidence to suggest that altered levels of pared with a group of uninjured sprinters
group (n 5 1,055) suffered 5 injuries, flexibility are a risk factor for hamstring (average RoM 5 67.28 versus 74.18;

p , 0.05). The reduction in flexibility NONMODIFIABLE RISK FACTORS et al. (37) found that athletes $23 years
after hamstring injury is further sup- PREVIOUS INJURY old were at a greater risk of hamstring
ported by Maniar et al. (64) whose injury. It has also been reported that for
A previous HSI has often been identi-
meta-analysis showed reduced ham- every 1 year increase in age, the risk of
fied as a risk factor for future HSI

string flexibility up to 40 days after injury. hamstring injury increases by 1.3-fold
(12,26,31,36,77,79,102,114). Reinjury
Therefore, it may be more important to when assessed independently of previ-
rates have typically been reported at
consider flexibility as a risk factor in ous injury (110). It was also reported
12–13% (26,31,114), with Petersen
those previously suffering from a HSI among a large cohort of track and field
et al. (79) reporting greater values of
to reduce the risk of a subsequent injury. athletes that masters athletes (.40
25%. However, it is important to note
years of age) were significantly more
the significantly different methodolog-
likely to suffer a HSI than high school
LUMBO-PELVIC HIP CONTROL ical approaches in the work of Petersen
and collegiate athletes (72). It has been
Despite only a relatively small amount et al. (79), who define a HSI as any self-
hypothesized that the role of age in
of current evidence, lumbo-pelvic hip reported posterior thigh pain, irrespec-
increased injury risk may be attributed
control should be considered as tive of time loss, which may account
to increased body weight, decreased
a potential risk factor for HSI. An for the reported increased reinjury rate.
hip flexor flexibility (35), reduced
increased anterior pelvic tilt during Gabbe et al. (36) found that among
eccentric hamstring strength, and short
sprint running is believed to place the Australian footballers, a HSI sustained
biceps femoris fascicle length (102).
hamstrings into an elongated position, within the previous 12 months, to be
Therefore, maintaining optimal body
thus increasing the strain placed upon the strongest independent predictor of
composition, flexibility of the ham-
them (47,96). This may be particularly future injury (odds ratio 5 4.3; p 5
string and hip musculature, and eccen-
critical during the terminal swing 0.003). It has also been reported among
tric hamstring strength may be
phase, when the biceps femoris long international cricketers that after
beneficial to hamstring injury preven-
head is already placed under increased a HSI, an athlete is at 3.7 times higher
tion among older athletes.
stretch, which may be further exacer- risk of suffering a further injury within
bated by the presence of an anteriorly the same season and at 2.7 times higher
PRACTICAL APPLICATIONS:
tilted pelvis (21,47,96). This may result risk in subsequent seasons (77). This
INJURY PREVENTION PROGRAM
in an increased chance of suffering risk factor is slightly lower than those
As the literature highlights several
a HSI; however, further research is reported for both rugby union athletes
contributing factors to HSI and rein-
required in this regard to fully corrob- (4.1 times higher) (12) and Australian
jury rates, injury prevention programs
orate such a theory. footballers (4.9 times higher) (110).
should be multifaceted in nature and
Previous knee (p 5 0.039) and groin
Furthermore, restricted sagittal plane address all the potential modifiable risk
(p 5 0.015) injuries were also reported
motion at the hip, as measured using factors. The program outlined (Fig-
as significant risk factors for future
the modified Thomas test, has been ure 1) is aimed at team sport athletes,
HSI (110).
shown to reduce gluteal activation who are at greatest risk of suffering
(67). This may be important to HSI Although previous injury is seen as a type I strain (sprint-related). The pro-
risk, as the work by Schuermans et al. a nonmodifiable risk factor, it has been gram is divided into 4 stages, with
(89) highlights proximal neuromuscu- highlighted that those with previous stages 1–3 representing a preseason
lar control as another risk factor for injury had reduced eccentric ham- period and stage 4, an in-season phase,
HSI. They studied muscle activation string strength (102) and interlimb which may be implemented for main-
(through surface EMG) during sprint asymmetries (12) when performing taining performance levels. The pro-
running in a population of 60 amateur the Nordic hamstring exercise. Fur- gram outlined in Figure 2 is aimed at
soccer players (89). During the 1.5 sea- thermore, short biceps femoris fascicle athletes who are at greater risk of suf-
son follow-up period, they reported length was also reported as a contribu- fering a type II strain (such as dancers
that those athletes not suffering tor to multiple hamstring injuries (102). and combat athletes) and is divided
a HSI had significantly (p 5 0.027) Therefore, it could be speculated that into 3 progressive stages, which can
greater gluteal muscle activity during improving these physical attributes be implemented in the lead up to
the front swing phase and greater trunk may aid in the prevention of repeat a competition. It is intended that both
muscle activity (p 5 0.042) during the HSI (12,102). injury prevention programs should not
back swing (89). Therefore, it may be stand alone and instead should be inte-
hypothesized that restricted motion at AGE grated into the wider athlete perfor-
the hip has the potential to inhibit glu- A study by Gabbe et al. (35) identified mance plan.
teal activation, and subsequently prox- that athletes $25 years of age had
imal neuromuscular control, which a higher hamstring injury incidence WARM-UP
could lead to an increased risk of suf- (19.2%) than those #20 years of age Although there is not overwhelming
fering a HSI (67,89). (6.9%). A separate study by Gabbe evidence to suggest that a structured
49
Figure 1. Potential evidence-based HSI prevention program focusing on type I strains. HSI 5 hamstring strain injury.
warm-up is beneficial to the reduction training protocols, which cannot only motion for 450 seconds 5 times per
of HSI, warm-ups are common place aid athletic movement competencies week, on biceps femoris muscle archi-
in sports performance to prepare the (49), but also injury prevention tecture, as measured through ultra-
athlete both mentally and physically (40,94,97). The FIFA 11+ recommends sound sonography. They reported
for activity (49). During this prepara- the integration of the Nordic curl as significant increases (+12.3 mm, p 5
tion phase, team sport athletes should part of a structured warm-up to pre- 0.04) in biceps femoris fascicle lengths
be gradually exposed to maximal vent HSI (40,94,97). Furthermore, as well as significant improvements in
velocity efforts (i.e., 40-m sprints at other exercises, including those that passive knee extension range of motion
65, 75, 85, 95, and 100% of perceived may play a role in increases in flexibil- (+14.28, p 5 0.04) (33). As short biceps
maximal velocity), as well as gradually ity, may also be included within a struc- femoris fascicle lengths have been high-
increasing kicking (for appropriate tured warm-up to improve the overall lighted as a potential risk factor for HSI
sports) distances (i.e., 10-, 20-, 30-, time efficiency of the athlete perfor- (102), it would appear prudent to
40-m kicks), particularly as these mance program. include elements of flexibility training
events have been highlighted as injury Although there is limited evidence to within a HSI prevention program. To
mechanisms within these populations suggest that reduced levels of flexibility increase time efficiency, such exercises
(6,15,16,26,30,36,37,114). Similarly, in play a significant role in increasing the can be incorporated into a structured
sports where type II HSI is more likely, risk of HSI (10,43,76,112,116), it has warm-up routine.
performing sport-specific movements been demonstrated that flexibility train-
(i.e., high kicks, sagittal, and side splits) ing can have a positive effect on biceps ECCENTRIC STRENGTH
at gradually increasing intensity and femoris fascicle lengths (33). The study Strength, and more specifically eccen-
range can be incorporated into the by Freitas et al. (33) described the effects tric strength, has been previously high-
preparation phase of the warm-up. of an 8-week high-volume stretching lighted as a contributing risk factor for
The warm-up also affords practitioners intervention, which involved stretching HSI, demonstrating the need for the
with a period in which to deliver the hamstring at maximum range of inclusion of eccentric strength exercises

Figure 2. Potential evidence-based HSI prevention program focusing on type II strains. HSI 5 hamstring strain injury.
within HSI prevention programs. related strain) but may also experience control group (2). These findings are
When selecting strength-based exer- type II strains in actions such as kicking further corroborated by Van der Horst
cises, it is important to note which type (5,6). Within these populations, the et al. (107), who found that the inclu-
of HSI the athlete is likely to suffer and, inclusion of the Nordic curl exercise sion of Nordic hamstring curls within
therefore, which muscle group is likely in injury prevention programs has been a 13-week training program signifi-
to be the site of damage (type I: biceps well reported within the literature cantly reduced the incidence of ham-
femoris and type II: semimembranosus) (2,90,107). Arnason et al. (2) imple- string injuries compared with a control
(5,6,14). This enables practitioners to mented a flexibility and hamstring group (intervention group 5 0.25 per
program exercises with a focus toward strength training intervention among 1,000 player hours; control group 5 0.8
elite soccer players from Iceland and per 1,000 player hours; p 5 0.005)
a particular hamstring muscle (14). The
Norway. They found no effect upon within a large population of amateur
work by Bourne et al. (14) provides
injury reduction amongs those players soccer players. Furthermore, in the
a framework for selecting the most
performing flexibility training alone (p year before the intervention, 24 and
appropriate strength training exercises 5 0.22) (2). However, when Nordic 20 HSIs were reported in the interven-
within HSI prevention programs. hamstring curls were included as part tion and control group, respectively
Team sport athletes (Figure 1) are most of the program, hamstring injury was (107). This was reduced to 11 in the
likely to suffer a type I HSI (sprint reduced by 65% compared with the intervention group but increased to 25
51
in the control group during the Figure 2 highlights a HSI prevention This may suggest that additional uni-
52-week surveillance period (which program aimed at reducing the inci- lateral strength training exercises
included 13 weeks of the intervention) dence and severity of type II strains. should be included within HSI preven-
(107). A successful Nordic hamstring Within this population of athletes, tion programs aiming to address intra-
intervention was also seen within the site of injury is most commonly limb strength imbalances.
a group of baseball athletes imple- the semimembranosus, and therefore, Alongside the primary “lifts” (e.g., Nor-
mented across the entire 2012 season exercises should be selected accord- dic curl and stiff leg deadlift), supple-
(90). It was demonstrated that zero ingly (6,14). This should include the mentary unilateral exercises have been
hamstring injuries were reported among “Romanian” or “stiff leg” deadlift, included within both programs, out-
the intervention group, compared with which has been reported to show sig- lined in Figures 1 and 2, including
the 10 suffered by the control and non- nificantly (p , 0.01) higher levels of single-leg stiff leg deadlift, single-leg
compliant group (performing ,3.5 semimembranosus activation than slider curl, and both the Askling diver
Nordic curls per week) (90). Further- both the biceps femoris and semitendi- and glider exercises. The aim of these
more, upon the implementation of the nosus (71). The research by Ono et al. exercises is to both correct muscular
Nordic curl intervention, the time loss (71) further explained that following
imbalances (intralimb and interlimb)
because of HSI was reduced to 136 the performance of stiff leg deadlifts,
and to promote joint stability. Previous
days, compared with 273 and 309 days a significant increase in both MRI
research has suggested that interlimb
in previous seasons (90). transverse relaxation time (T2) value
strength imbalances should be reduced
and cross-sectional area of the semi-
The success of the Nordic curl exer- to ,5% to significantly reduce the risk
membranosus were observed.
cises within these studies may be of HSI (25). To achieve this, the single
attributed to its positive affect upon leg stiff leg deadlift is included within
STRENGTH IMBALANCES
biceps femoris long head muscle vol- Figure 1 and has been previously rec-
Additional to the development of
ume, size, and strength. Seymore et al. ommended within hamstring training
eccentric hamstring strength, there is
(92) studied the effect of the Nordic programs (60,66), despite Tsaklis
also a need to address both intralimb
curl exercise combined with stretching et al. (103) stating that hamstring
(differences between the quadriceps
compared with a control group who EMG was relatively low for this exer-
and the hamstrings in the same leg)
only performed stretching exercises. cise. However, it should be noted that
and interlimb (differences between
The intervention consisted of a 6- this exercise was performed without
hamstrings bilaterally) strength imbal-
week Nordic curl program where fre- external load (i.e., body weight only)
ances within HSI prevention pro-
quency (1–3) and volume (2 3 5 reps, during this study, which may have
grams. Previous research by Ruas
increasing to 3 3 8–12 reps) were pro- influenced the results (103). The
et al. (84) has demonstrated that eccen-
gressively increased (92). The group single-leg slider curl has also been
tric strength training significantly (p #
that performed Nordic hamstring exer- investigated by Tsaklis et al. (103)
0.05) increased the functional H:Q
cises in addition to stretching saw sig- who measured EMG outputs of 10
ratio after a 6-week intervention (H:Q
nificant increases (p , 0.05) in biceps hamstring-based exercises and found
pre 5 0.73 6 0.092; H:Q post 5 0.87 6
femoris long head physiological cross- the slider curl to have the highest mean
0.098). Furthermore, Holcomb et al.
sectional area (16.08 6 6.43 cm2 versus EMG activation of the biceps femoris
(46) reported that a 6-week hamstring
18.05 6 7.33 cm2) and muscle volume and semitendinosus muscles. However,
emphasized strength program was able
(131.46 6 43.32 cm3 versus 145.2 6 their results should be viewed with
to significantly (p , 0.05) increase the
46.42 cm3) compared with baseline caution as the 20 participants per-
functional H:Q ratio from 0.96 6 0.09
(92). Furthermore, Bourne et al. (13) formed all exercises in the same order,
to 1.08 6 0.11. The inclusion of the
found that Nordic curl training pro- albeit with a 5-minute rest period
Nordic hamstring curl in strength pro-
moted longer biceps femoris long head grams aimed at optimizing the func- between each, with no randomization
fascicle lengths and greater biceps fem- tional H:Q ratio is somewhat (103). Furthermore, their study did not
oris long head, short head, and semite- supported by Delextrat et al. (27). They differentiate between contraction types
ndinosus muscle volume when training reported that significant (p , 0.05) in- (concentric and eccentric) and only
sessions were performed twice a week creases of 27.8% in the functional H:Q provided results for combined contrac-
for 10 weeks. However, it should be ratio were seen after a 6-week training tion outputs, both of these methodo-
noted that within the same study, the program (27). However, it should also logical factors may have affected the
hip extension exercise promoted be noted that in comparison, the results of the study (103).
greater changes in biceps femoris long eccentric leg curl promoted greater im- The Askling diver and glider form part
head and semimembranosus (where provements (38.3%) than the Nordic of the Askling L-protocol (lengthening
the Nordic curl promoted no signifi- hamstring curl, and that for both exer- exercises), which has been shown to be
cant differences to the control group) cises, these results were only evident successful within hamstring rehabilita-
muscle volume (13). within the nondominant limb (27). tion programs (7). During the study,

the L-protocol reported significantly reduced aerobic fitness (as measured produce hamstring muscle actions at
shorter (mean 28 days, range 8–58 days) through a 1-km time trial) were at an high velocities throughout the stretch-
return to play time, compared with increased chance of injury (odds ratio shortening cycle (105). Therefore, they
a conventional hamstring training pro- 5 1.5–2.5) compared to those with supe- have the potential to stimulate muscle
gram (mean 51 days, range 12–94 days) rior aerobic fitness (62). With this evi- actions that are similar to those reported
(7). EMG studies of these 2 exercises dence in mind, appropriately planned during the mechanism of injury associ-
have shown the hamstrings to be eccen- conditioning should be included within ated with high-speed running (105).
trically contracted at similar working the injury prevention plan to improve Tsang and DiPasquale (104), imple-
points to that of the swing phase during overall fitness levels and reduce the bur- mented a 6-week plyometric training
high-speed running (91), further sup- den of fatigue upon the hamstrings. For program where subjects performed the
porting their use within prevention team-sport athletes, this can include MAS intervention 3 times per week. Their
and rehabilitation programs. training (8). This can be prescribed at findings highlighted increases in ham-
The strength training component increased percentages of an individual’s string strength alongside maintaining
should be included as part of the wider MAS across stages 1–3 (outlined in Fig- quadriceps strength, thus improving
strength training program (i.e., athletes ure 1) (8), after which sport-specific con- the Q:H ratio (104). In addition, Vissing
should also be performing other exer- ditioning (i.e., small-sided games in et al. (111) demonstrated significant (p
cises to develop all round athletic per- soccer) can be implemented during the , 0.001) increases in hamstring cross-
formance). It may be prudent for in-season period. In nonrunning-based sectional area (6.7 6 1.8%) after a 12-
practitioners to also consider the rear sports, fitness can be developed through week plyometric training intervention.
foot elevated split squat (RFESS) sport-specific conditioning. For example, However, their results should be viewed
within the overall athletic develop- it has been recommended that dancers with an element of caution, as the sub-
ment plan. The work by McCurdy can build cardiorespiratory fitness by jects were classified as “untrained,” and
et al. (65), who compared EMG meas- using dance movements with appropriate therefore, it could be hypothesized that
urements of the RFESS and the tradi- work:rest periods (115). any training stimulus would have pro-
tional back squat exercise, at 85% of moted a positive effect.
HIGH-SPEED RUNNING
a subject’s 3 repetition maximum for The plyometric exercises included in
each exercise, supports its inclusion The monitoring of running loads and,
more importantly in the case of HSI stage 1, as well as the drop land in
within athletic training programs that stage 2, of both prevention programs
have an emphasis on HSI prevention. prevention, high-speed running loads
is common within sports performance are aimed at developing optimal land-
Their research showed that the RFESS ing mechanics, which should be estab-
recorded significantly (p , 0.01) (28,38,48,61,63,85). All running-based
training, and particularly that covered lished before progressing to exercises
greater mean and mean peak ham- of greater intensity and complexity
string activation, whereas the tradi- above 24 km/h, should be carefully
monitored to prevent spikes in training (106). The additional exercises within
tional back squat showed significantly Figure 1 are programmed with a bias
greater recruitment of the mean quad- load and to ensure that the athlete has
been exposed to appropriate training toward horizontal force production, to
riceps (p , 0.05), mean peak quadri- replicate similar movement vectors to
ceps, and mean Q:H (p , 0.01) (65). As doses that may provide a preventative
effect upon HSI occurrence that during high-speed running. The
the RFESS seems to provide a greater additional exercises within Figure 2
demand on the hamstrings, com- (28,38,48,61,63,85). The inclusion of
conditioning-based drills and supple- are focused on developing overall plyo-
pared with the back squat (which pla- metric ability but may be adapted to
ces a greater emphasis on the mental maximal velocity training
should be informed by the data col- suit each individual sport.
quadriceps), it may be seen as a viable
alternative to the traditional back- lected from this monitoring process.
CONCLUSION
squat exercise in athletic programs
PLYOMETRICS Within sports performance, HSIs are
when an emphasis on hamstring con-
ditioning is required (65). Plyometrics are often included within highly prevalent and incur high rein-
athletic training programs; however, jury rates. Consequently, this leads to
their potential role in HSI prevention is athletes missing extended periods of
FATIGUE AND FITNESS often overlooked. Previously, plyometric- the competitive season, which can
Fatigue has been previously linked to based exercises, including unilateral and have a detrimental effect on both the
HSI occurrence due to injuries being re- bilateral sagittal plane hurdle hops, fron- performance and finances of sporting
ported to occur toward the end of games, tal plane hurdle hops, 1808 hops, and organizations. Although HSIs com-
possibly because of the effect of fatigue split-squat jumps, have been shown to monly occur during high-speed run-
on the reduction of eccentric knee flexor recruit the hamstring musculature (98). ning activities, practitioners should be
strength. Furthermore, it has been previ- Furthermore, because of the nature of aware that a variety of injury mecha-
ously demonstrated that those with plyometric exercises, they are likely to nisms exist. Furthermore, a multitude
53
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57

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Risk Factors, and Training

H are one of the most com-

suffix of (myofascial, musculotendi- (44%) suffered additional injury, with 7

of the injury. Similarly, Chan et al. INJURY INCIDENCE, AND TYPICAL

42 VOLUME 42 | NUMBER 3 | JUNE 2020

of time loss in professional soccer grades 0 to 2.

time-loss period, athletes are likely to

sprinting and high-speed running were

6.3% reported to miss .3 weeks (26).

further displayed by Ekstrand et al. (29)

57% of hamstring injuries. The percent-

notion is further supported by Ek- 58.3%; women 46.9%) in a study of

ported that 47% of hamstring strains in

professional soccer occur in the final

reported within the literature include

A magnetic resonance imaging (MRI) (30,114), and during escape/sparring/

study of hamstring injuries within pro- take-down maneuvers in sports such as

fessional soccer highlighted 207 inju- wrestling (26). Collectively, although

could be seen within a second study in of kicking, either a ball or an opponent,

44 VOLUME 42 | NUMBER 3 | JUNE 2020

46 VOLUME 42 | NUMBER 3 | JUNE 2020

primary role of the hamstring muscles

48 VOLUME 42 | NUMBER 3 | JUNE 2020

fied as a risk factor for future HSI

50 VOLUME 42 | NUMBER 3 | JUNE 2020

52 VOLUME 42 | NUMBER 3 | JUNE 2020

Leader for the 11. Bennell K, Wajswelner H, Lew P, et al.

ements of the injury prevention plan Sport Institute, 309–314, 1998.

54 VOLUME 42 | NUMBER 3 | JUNE 2020

35. Gabbe BJ, Bennell KL, Finch CF. Why are

60. Malliaropoulos N, Mendiguchia J,

56 VOLUME 42 | NUMBER 3 | JUNE 2020

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