Nordic fails & hamstring injury prevention

We were attempting to demonstrate my poor hamstring eccentric strength and showcase Alan’s excellent control however, that didn’t exactly go to plan! A bit extra weight my side and I just about managed to hold on! Kudos on those hammers Alan!

Today’s incident reminded me of another Nordic fail I had with a patient when I first qualified. The patient presented with an annually recurrent hamstring injury and he was looking for anything he could do to get through a football season without injury. I did my research and discovered the holy grail for hamstring injuries…Nordic hamstring curls! I explained to him that this was a 12-week eccentric strengthening program and that DOMS (delayed onset muscle soreness) was to be expected but nothing to worry about. He was sold on the word preventative and was looking forward to an injury free season. I prescribed one session of 2 sets of 5 reps for the first week and two sessions of 2 sets of 6 reps for the second week. We booked a follow-up session for two weeks later. He arrived back with a story and a half. The first week had gone well, a little bit sorer than expected. However, the second week…his housemate wasn’t available to assist him and with necessity being the mother of all invention, he jammed his heels underneath the radiator of his rented apartment and started to slowly lower himself to the floor, when suddenly the screws holding the radiator to the wall, could no longer withstand the strength of his hamstrings and he yanked the whole thing clean off the wall and burst the connecting pipe!

So nearly 10 years later, I’m not sure if his hamstrings or radiators are still intact but I am still flying the Nordic flag for hamstring injury prevention. There is strong evidence that Nordic hamstring exercise programs decrease the risk of hamstring injury by 50-65% (Al Attar et al., 2016, Goode et al., 2015). So why are the rates of hamstring injuries increasing in both soccer (Ekstrand et al., 2016) and Gaelic football (Roe et al., 2016)?

Why are hamstring injuries still increasing?
There is anecdotal arguments that training has intensified in recent years, and there is evidence that sudden increased volume of high speed running is associated with risk of hamstring injury (Duhig et al., 2016) however continuous “hard” training has been shown to have a protective effect against injury (Gabbett, 2016). There is also some evidence that less days between matches, limiting recovery time increases the overall risk of injury (Murray et al., 2014) but we don’t have any evidence on whether this directly increases the risk of hamstring injury.

Hamstring risk factors
There has been an amount of research into the risk factors for hamstring muscle injury, with previous history of hamstring injury and increasing age identified as strong risk factors (Freckleton and Pizzari, 2013). Although there is strong evidence for eccentric strengthening to prevent hamstring injury (Petersen et al., 2011), the role of decreased strength of hamstring muscles is only a weak risk factor for future injury (van Dyk et al., 2016). We know hamstring strength is important in rehabilitation and prevention but research into its role as a risk factor is ongoing. Flexibility of hamstring muscles is not considered a strong risk factor for hamstring injury (Freckleton and Pizzari, 2013) but new research by the Aussie hamstring group have shown that shorter biceps femoris long head fascicle length as measured by ultrasound increases the risk of future hamstring injury (Timmins et al., 2016).

How can we improve uptake of hamstring prevention programs?
Eccentric hamstring exercises decrease the risk of hamstring injury but the problem, is that compliance with the program is low (Goode et al., 2015). One of the main reasons cited for noncompliance is the soreness after the exercises and the volume of exercises prescribed to be completed. This is understandable, particularly when working with an athlete who has a history of hamstring injury and may be hypervigilant to any soreness or tightness in their hamstrings. Education, reassurance and possibly supervised sessions for a the first few weeks can be helpful in this situation. When working with a big squad of players it can be challenging to fit in the hamstring prevention program around other S&C programs, busy match fixtures and for players who compete on multiple teams.

What do hamstring prevention programs look like?
The traditional Nordic protocol is a 10-12wk program
Week ||  No of sessions/week  || Reps and sets
1                           1                                2 X 5
2                           2                                2 X 6
3                           3                               3 X 6-8
4                           3                               3 X 8-10
5-10                      3                              3 X (12,10,8)

As discussed, some of the issues with compliance is the number of sessions per week and trying to fit these sessions into a busy training schedule. New research coming out from Presland et al, provides evidence that the benefits of Nordic exercises can be maintained at a lower volume and frequency (Table 2) Check out Hamstring King David Opar here where he presents this research.

Proposed new Nordic protocol….
Week  ||  No of sessions/week   ||  Reps and sets
1                      2                                   4 X 6
2                      2                                   4 X 6
3                      1                                   2 X 4
4                      1                                   2 X 4
5                      1                                   2 X 4
6                      1                                   2 X 4

Interestingly, after a 2-week detraining period the beneficial effect of eccentrics decreased to near baseline, which means this is a program that should be maintained on a continuous basis (1 session per week 2 X 4 reps). It may also be important to take this into consideration, when your athlete is returning to play after another injury i.e. knee injury, and has possibly discontinued hamstring prevention exercises.

Take home message
For GAA teams and athletes, this time of year is ideal to start your hamstring prevention program. Try the new proposed Nordic protocol above and continue it once per week to maintain. Stretching your hamstrings does not decrease your risk of future hamstring injury.

In conclusion, Nordic programs decrease your risk of hamstring injury, but as with life, you need to choose your partner wisely!

In the meantime, I will be wishing for a Nordboard for Christmas!

Any questions, find me on snapchat @michellebiggs or Instagram @proactivephysio

AL ATTAR, W. S. A., SOOMRO, N., SINCLAIR, P. J., PAPPAS, E. & SANDERS, R. H. 2016. Effect of Injury Prevention Programs that Include the Nordic Hamstring Exercise on Hamstring Injury Rates in Soccer Players: A Systematic Review and Meta-Analysis. Sports Medicine, 1-10.
DUHIG, S., SHIELD, A. J., OPAR, D., GABBETT, T. J., FERGUSON, C. & WILLIAMS, M. 2016. Effect of high-speed running on hamstring strain injury risk. British Journal of Sports Medicine, 50, 1536-1540.
EKSTRAND, J., WALDÉN, M. & HÄGGLUND, M. 2016. Hamstring injuries have increased by 4% annually in men’s professional football, since 2001: a 13-year longitudinal analysis of the UEFA Elite Club injury study. British journal of sports medicine, 50, 731-737.
FRECKLETON, G. & PIZZARI, T. 2013. Risk factors for hamstring muscle strain injury in sport: a systematic review and meta-analysis. Br J Sports Med, 47, 351-8.
GABBETT, T. J. 2016. The training—injury prevention paradox: should athletes be training smarter and harder? British journal of sports medicine, 50, 273-280.
GOODE, A. P., REIMAN, M. P., HARRIS, L., DELISA, L., KAUFFMAN, A., BELTRAMO, D., POOLE, C., LEDBETTER, L. & TAYLOR, A. B. 2015. Eccentric training for prevention of hamstring injuries may depend on intervention compliance: a systematic review and meta-analysis. British journal of sports medicine, 49, 349-356.
MURRAY, N. B., GABBETT, T. J. & CHAMARI, K. 2014. Effect of different between-match recovery times on the activity profiles and injury rates of national rugby league players. The Journal of Strength & Conditioning Research, 28, 3476-3483.
PETERSEN, J., THORBORG, K., NIELSEN, M. B., BUDTZ-JØRGENSEN, E. & HÖLMICH, P. 2011. Preventive effect of eccentric training on acute hamstring injuries in men’s soccer a cluster-randomized controlled trial. The American journal of sports medicine, 39, 2296-2303.
ROE, M., MURPHY, J. C., GISSANE, C. & BLAKE, C. 2016. Hamstring injuries in elite Gaelic football: an 8-year investigation to identify injury rates, time-loss patterns and players at increased risk. British Journal of Sports Medicine, bjsports-2016-096401.
TIMMINS, R. G., BOURNE, M. N., SHIELD, A. J., WILLIAMS, M. D., LORENZEN, C. & OPAR, D. A. 2016. Short biceps femoris fascicles and eccentric knee flexor weakness increase the risk of hamstring injury in elite football (soccer): a prospective cohort study. British Journal of Sports Medicine, 50, 1524-1535.
VAN DYK, N., BAHR, R., WHITELEY, R., TOL, J. L., KUMAR, B. D., HAMILTON, B., FAROOQ, A. & WITVROUW, E. 2016. Hamstring and Quadriceps Isokinetic Strength Deficits Are Weak Risk Factors for Hamstring Strain Injuries: A 4-Year Cohort Study. The American Journal of Sports Medicine.

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