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Hamstring Injury Prevention for Elite Soccer Players: A Real-World Prevention

Program Showing the Effect of Players' Compliance on the Outcome

Article  in  The Journal of Strength and Conditioning Research · February 2020

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 Original Research

Hamstring Injury Prevention for Elite Soccer

Players: A Real-World Prevention Program Showing
the Effect of Players’ Compliance on the Outcome
Souhail Chebbi,1 Karim Chamari,1 Nicol Van Dyk,1 Tim Gabbett,2,3 and Montassar Tabben1
1
Aspetar Orthopedic and Sports Medicine Hospital, Doha, Qatar; 2Gabbett Performance Solutions, Brisbane, Queensland, Australia;
and 3University of Southern Queensland, Institute for Resilient Regions, Ipswich, Queensland, Australia
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Abstract
Chebbi, S, Chamari, K, Van Dyk, N, Gabbett, T, and Tabben, M. Hamstring injury prevention for elite soccer players: A real-world
prevention program showing the effect of players’ compliance on the outcome. J Strength Cond Res XX(X): 000–000, 2020—The
aim of this study was to determine the effect of implementing the Nordic hamstring exercise (NHE) to prevent hamstring injuries in
soccer. A professional team was followed by the same medical team during 5 successive seasons (2012/2013 through 2016/
2017). During the first and last seasons (2012/2013 and 2016/2017), no hamstring preventive action was implemented. For the
seasons 2013/2014, 2014/2015, and 2015/2016, a noncompulsory (few players refusing to participate) NHE prevention program
was implemented with accurate recording of the players’ training and match exposure and attendance to the prevention sessions.
The first 10 weeks of the season were used to progressively increase the volume and intensity of the NHE exercises, and at the end
of the season, players were split in low-, moderate-, and high-attendance groups to the prevention sessions. Overall, 35 time-loss
hamstring strain injuries were accounted for. The injury incidence was 0.30 per player per season, and the injury rate was 0.95 injury/
1000 hour of exposure. A nonstatistically significant higher risk of hamstring injury was observed in the control, low, and moderate
attendance groups compared with the high-attendance group. The greatest risk of hamstring injury was observed in the low-
attendance group (odds ratio 1.77, confidence interval 0.57–5.47, p 5 0.32). Implementing a NHE prevention program has
a positive effect on the injury rate in a soccer team; however, the compliance of players with such interventions may be critical for its
success.
Key Words: hamstring injuries, injury prevention, eccentric strengthening, Nordic hamstring exercise, Nordic curl

Introduction noted in the literature within elite soccer teams, with only 16.7%
of clubs performing or partially performing the NHE program
The sports injuries’ literature has shown a high injury incidence in
(3,15). Reasons for the poor compliance have not been in-
elite teams (8). Specifically, hamstring injuries have been reported
vestigated. However, it could be explained by the difficulties faced
as the most common muscle injury in soccer (7), accounting for
in convincing players and/or coaches on the benefits of such ex-
37% of all soccer muscle injuries (8,11).
ercise prevention programs. A small minority believes it induces
The Nordic hamstring exercise (NHE), is a simple exercise, eliciting
muscle soreness, although this is unsubstantiated (3,14,15). From
high levels of recruitment within the hamstring muscle group (5). It
a practical point of view, the players’ motivation to take part in
has been shown to be an effective tool to reduce hamstring injuries in
prevention programs could also influence whether such pre-
soccer players, with previous studies on male professional soccer
vention measures are successful in an elite professional soccer
players reporting a reduction in hamstring injury incidence rates of
team (6,18).
approximately 70% (2,16,21). In these studies, the teams that used
To date, no studies have investigated the effect of a NHE
the intervention displayed significantly lower rates and severity of
preventive program on hamstring strain injuries within the same
hamstring injuries compared with previous seasons.
professional soccer team over multiple seasons. Thus, the first aim
A recent systematic review confirmed the results of these in-
of this study was to determine the effect of the implementation of
tervention studies, demonstrating a reduction in hamstring injuries
the NHE to prevent hamstring injuries over 5 professional soccer
where the NHE was implemented (1). Moreover, the follow-up pe-
seasons in the same team. Second, we investigated the effect of
riod for these studies is usually reported over 1 season and do not
compliance with the NHE program on injury outcome.
report whether the reduction in the number of hamstring injuries is
maintained when the intervention is terminated. In addition, the
effects of the intervention over multiple seasons are not known.
Despite the recognition of the NHE as being an effective pre- Methods
vention tool, poor compliance within elite soccer teams has been
Experimental Approach to the Problem
Address correspondence to Dr. Montassar Tabben, montassar.tabben@ A professional soccer team from Qatar was followed up during 5
aspetar.com. successive seasons (2012/2013 through 2016/2017 inclusive) by
Journal of Strength and Conditioning Research 00(00)/1–6 the same medical team (team doctor, head physiotherapist,
ª 2020 National Strength and Conditioning Association massage therapist, and physical coach).

Copyright © 2020 National Strength and Conditioning Association. Unauthorized reproduction of this article is prohibited.
 Hamstring Injury Prevention for Elite Soccer Players (2020) 00:00
Subjects
In total, 116 healthy players aged 18–41 years were included. The
number of subjects over the 5 seasons was 22, 29, 37, 29, and 40,
respectively (Figure 1). Owing to player turnover, 11 athletes
were carried over from 2012/13 to 2013/14, 11 athletes from
2013/14 to 2014/2015, 15 athletes from 2014/15 to 2015/16, and
17 athletes from 2015/16 to 2016/17. Ten athletes participated in
3 consecutive seasons, 8 in 4 consecutive seasons and 7 in 5
consecutive seasons. The study was reviewed and approved by the
Ethics Review Board: Anti-Doping Lab Qatar (Doha, Qatar).
Procedures
The data collection was part of a routine follow-up of the team by
the medical staff.
During the first (control) season (2012/2013), no NHE pre-
ventive action was implemented. During the next 3 consecutive
seasons (2013/14, 2014/15 and 2015/16), the medical team
implemented a NHE injury prevention program. In the final
season (2016/2017), the NHE program was discontinued (full
season without NHE prevention).
All players performed the same warm-up as planned by the
fitness coach. After finishing the warm-up, players were invited to
participate in the NHE training session, unless injured or unable
to perform the exercise. Before participation, the medical staff
explained the aim of the NHE exercise with respect to injury
prevention. Despite attempts to encourage compliance, atten-
dance in the prevention program varied, and on rare occasions,
some players refused to participate relating their reluctance to the
delayed onset muscle soreness (DOMS) induced by the NHE
exercise. Importantly, for the 2013/2014 to 2015/2016 seasons,
the prevention program was proposed and implemented exclu-
sively by the medical staff members of the team with the support
of the coaching staff.
The NHE sessions were completed in less than 5 minutes, after
which all the players continued with the regular training session.
During the first session, the subjects received standardized
instructions, attended a demonstration of the NHE, and per-
formed 3–4 repetitions for familiarization. The NHE was per-
formed with the player kneeling on a padded mat and their lower
Figure 1. Flowchart demonstrating the implementation of the Nordic hamstring exercise (NHE) program over 5 seasons.
*Partial implementation of the NHE program.
Copyright © 2020 National Strength and Conditioning Association. Unauthorized reproduction of this article is prohibited.
legs stabilized by either a member of the medical staff or a team-
mate. The player was instructed to progressively lean forward at
slow speed (;4 seconds per repetition) resisting the movement
with both limbs while keeping the trunk and hips in a neutral
position and arms flexed at the elbow with the hands facing
forward at the level of the shoulders. The players used their arms
in the final stages of the movement to buffer the fall. During the
return to the NHE starting position, subjects pushed-off the
ground with their upper limbs to avoid intensive concentric
actions of their hamstrings and return to the starting position. A
1-minute rest period was provided between sets.
The first 10 weeks of the season were used to progressively
increase the volume and intensity of the NHE, as described by
Petersen et al. (16). From the “11th week until the last week” of
the season, the NHE was performed once per week (comprising
3 sets of 8, 10, and 12 repetitions) as a maintenance period. The
progressive implementation of the program was not accom-
panied by any major concern related to exercise intensity and/
or DOMS, as no specific complaints were reported to the team
doctor.
The NHE program was performed over the entire season for
seasons 2 (2013/2014) and 4 (2015/2016). However, during
season 3 (2014/2015), a coaching staff change led to the NHE
program being stopped after 10 weeks. During this season, the
NHE program was performed during the first 10 weeks of the
season and stopped completely thereafter.
Injury data collection was performed daily by the team doctor
as part of the Aspetar/ASPREV Injury and Illness Surveillance
Programme (AIISP) (4). The AIISP includes prospective injury
and exposure (minutes of training and match play) recording
throughout the season, which follows international definitions
and methodology (9). Training exposure was defined as any
team-based or individual physical activities under the control or
guidance of the team’s coaching and/or fitness staff that aimed at
maintaining or improving players’ skills and/or physical
condition/recovery. Training exposure was quantified as the total
duration of the seasons from the start of the warming up until the
end. An injury was defined as any physical damage that occurred
during training or matches and resulted in the player being unable
to fully participate in one or more training or match-play sessions
(time-loss definition of injuries).
 Hamstring Injury Prevention for Elite Soccer Players (2020) 00:00 | www.nsca.com

Table 1
Number of Nordic hamstring exercise (NHE) sessions by attendance groups over the 3 intervention seasons.*
Season: 2013/2014 (total no. of sessions: 36) Season: 2014/2015 (total no. of sessions: 20) Season: 2015/2016 (total no. of sessions: 53)
NHE subgroups Mean 6 SD Range Mean 6 SD Range Mean 6 SD Range
Low (,20%) 4.2 6 0.8 3–5 1.8 6 0.6 2–3 3.2 6 1.2 3–5
Moderate (20–70%) 18.3 6 5.5 8–24 7.9 6 2.9 4–12 15.1 6 4.5 7–21
High (.70%) 30.7 6 2.3 27–35 16.1 6 1.5 14–18 29.3 6 9.3 23–51
*The NHE prevention program was implemented for the whole seasons 2013/2014 and 2015/2016 but restricted to the first 10 weeks of the season for 2014/2015.

Hamstring injuries were filtered from all of the recorded injuries to
study the effect of the NHE program on injury risk. A hamstring
injury was defined as an acute (sudden onset injury) pain in the
posterior thigh that occurred during training or match play and
resulted in immediate termination of play and inability to participate
in the next training session or match (20). These injuries were con-
firmed through clinical examination (identifying pain on palpation,
pain with isometric contraction, and pain with muscle lengthening)
by the team medical doctor. If indicated, the clinical diagnosis was
supported by ultrasonography and magnetic resonance imaging at
the Aspetar Orthopedic and Sports Medicine Hospital, Doha, Qatar.
To ensure a training effect had taken place and to control for type I
error in the analysis, hamstring injuries that occurred in the first 6
weeks after the NHE program was started were excluded every
season.
Statistical Analyses
Data were analyzed in SPSS Version 22.0 (IBM Corporation,
New York, NY). Initial analysis of injury incidence was calcu-
lated by dividing the total number of injuries by exposure time
and reported as injury rates per 1,000 training- and match-hours.
Over the 5 seasons, the first and last seasons were considered
control seasons (no NHE performed, 2012/2013 and 2016/2017,
respectively), compared with the 3 seasons in-between (from
2013/2014 to 2015/2016) when the NHE program was per-
formed. In addition, players who did not participate in the NHE
training sessions were considered as the control group within each
season. Owing to the variation in NHE training attendance, the
NHE group was separated into 3 subgroups (low: ,20%, mod-
erate: 20–70%, and high: .70% with regard to the annual per-
centage of NHE sessions performed). Thus, data were divided
into 4 groups, with the control group being the reference group.
Odds ratios (OR) were calculated to determine the injury risk at
a given NHE attendance (low, moderate, and high).
Results
The attendance details of the NHE are presented in Table 1.
Over the 5 seasons, 40 time-loss hamstring strain injuries were
reported. Five injuries that occurred during the first 6 weeks of the
intervention period during each season were excluded from the
analysis. Across the full 5 years of the study, the incidence of
hamstring injury was 0.95 injury/1000 hour. Descriptive data are
presented in Table 2.
The highest risk of hamstring injury was reported in the low
attendance group but was not statistically significantly different
from the other groups (OR 1.77, confidence interval 0.57–5.47, p
5 0.32) (Table 3 and Figure 2).
During the intervention seasons, 8 players were added to the
control group, as they did not participate in any NHE sessions (3
players in season 2 (2013/2014), 3 players in season 3 (2014/
2015), and 2 players in season 4 (2015/2016).
Discussion
In this clinical observation of a single soccer team, despite the
statistically nonsignificant findings, there was a tendency toward
decreased hamstring injuries after the implementation of a NHE
prevention program. Surprisingly, the reduction in injuries was
maintained in the final season (2016/2017) when the program
was removed. This investigation also identified a statistically
nonsignificant association between increased compliance and
a decrease in the injury risk.

Table 2
Number of injuries (exposure) and incidence data for NHE subgroups, together with team ranking over 5 seasons.*†
NHE subgroups
Control‡ Low Moderate High Total Incidence (per 1,000 hour)§ League ranking
2012/13
Hamstring injuries, n (exposure, hour) 11 (7,855) 11 (7,855) 1.4 3rd (2nd league)
2013/14
Hamstring injuries, n (exposure, hour) 0 (226) 2 (1,281) 1 (2,229) 2 (3,466) 5 (7,202) 0.7 1st (2nd league)
2014/15
Hamstring injuries, n (exposure, hour) 0 (625) 1 (740) 4 (2,136) 3 (3,783) 8 (7,285) 1.1 14th (1st league)
2015/16
Hamstring injuries, n (exposure, hour) 0 (105) 1 (758) 4 (3,827) 1 (2,489) 6 (7,179) 0.8 3rd (2nd league)
2016/17
Hamstring injuries, n (exposure, hour) 5 (7,119) 5 (7,119) 0.7 4th (2nd league)
*NHE, Nordic hamstring exercise; n, number of injuries.
†The NHE prevention program was implemented for the whole seasons 2013/2014 and 2015/2016 but restricted to the first 10 weeks of the season for 2014/2015.
‡Players who did not participate in the implementation program at all were considered as the control group for the intervention seasons (n , 2 per season).
§There were no significant differences in the incidence rate across the seasons.

Copyright © 2020 National Strength and Conditioning Association. Unauthorized reproduction of this article is prohibited.
 Hamstring Injury Prevention for Elite Soccer Players (2020) 00:00
Table 3
Nordic hamstring exercise (NHE) attendance groups’ risk factors
for hamstring strain injuries.*†
NHE subgroups Odds ratio (injuries per 1000 hour) 95% CIs
Control group‡ 1.00
Low (,20%) 1.77 0.57–5.47
Moderate (20–70%) 1.20 0.49–2.9
High (.70%) 0.75 0.29–1.99
*CI, confidence intervals.
†Data presented as OR with 95% CIs.
‡Reference group for odds ratio calculations.
This five-season observational study tracked the effects of
a NHE program in a specific team. The results of this study show
a tendency toward reduced hamstring injuries after the in-
troduction of a NHE program. The strongest effect was found in
the second season (2013/2014), after the introduction of the
Nordic hamstring program for the first time, after which the
hamstring injury rate remained relatively stable and the ham-
string injury incidence was effectively halved. The relative in-
crease in the injury rate in season 2014/2015 compared with
season 2013/2014 could be due to the fact that the NHE pre-
vention was only performed during the first 10 weeks of season
2013/2014. To support this assumption, the injury rate of the
next season (i.e., 2015/2016), during which the prevention pro-
gram was conducted over the whole season, decreased again,
demonstrating injury rates similar to season 2013/2014. These
results, although statistically nonsignificant, confirm previous
findings in the literature and demonstrate the potential protective
effect of introducing a NHE program in the practical setting.
Interestingly, there were no injuries in the control group during
the intervention seasons (2013/2014–2015/2016). However, this
represents only 1–2 players each season, with very low exposure
(226 hours compared with 7,250 hours on average). Although the
introduction of an eccentric training program might result in
DOMS, as well as potential microdamage to the muscle, no
injuries were reported during the training sessions. However, we
Figure 2. Hamstring injury rate/1000 hour for each of the Nordic hamstring exercise (NHE)
subgroups according to attendance.
Copyright © 2020 National Strength and Conditioning Association. Unauthorized reproduction of this article is prohibited.
did exclude 2 hamstring injuries in season 2 (occurred in the high-
attendance group) and season 4 (occurred in the low-attendance
group), as well as 1 hamstring injury in season 3 (occurred in the
p moderate attendance group) during the initial 6 weeks of the in-
tervention. Although unlikely, it is not known whether the in-
0.32
troduction of an eccentric program may have contributed to the
0.69 occurrence of these hamstring injuries.
0.57 The minimum effective dose of any NHE-based program is
currently unknown. Only a 10-week program with maintenance
as suggested in a previous reported trial has been shown to be
effective (8). However, anecdotal evidence suggests that struc-
tural tissue adaptation similar to what is seen in a 10-week pro-
gram might be possible in 4 weeks performing only 2 sets of 4
NHE exercises weekly (17).
Interestingly, a slight increase in hamstring injury incidence
was observed in the third season (2014/2015, Table 1), when the
NHE program was only partially performed. The club was also
promoted to the premier league of the competition in that season.
Although speculative, the increased match demands in a higher-
level competition coupled with less regular practice of the injury
prevention program (Table 3) may have influenced the injury
incidence during this season. More importantly, this observation
highlights what is now widely accepted—the multifactorial na-
ture of hamstring injuries (19). Indeed, because of the multifac-
torial nature of hamstring injuries, a combination of different
variables might influence risk, including age, previous injury,
strength, fatigue, flexibility, neuromuscular control, and psy-
chological factors. In addition, workload has also been high-
lighted as a potential risk or protective factor for injuries (10). It is
unlikely that 1 strategy aiming at increasing eccentric strength will
address all of the potential risk factors. Equally, it is unclear
whether a combination of these risk factors might interact and
influence the risk of hamstring injuries.
Interestingly, the injury rate remained comparatively low in the
final season (2016/2017), when the NHE program was ceased for
reasons that were independent from the medical staff (Table 1).
This could reflect normal variation in injury incidence observed
over different seasons in 1 team. However, it has been shown that
 Hamstring Injury Prevention for Elite Soccer Players (2020) 00:00
eccentric strengthening has an effect on structural adaptations
within the muscle, particularly the fascicle length (19). Specula-
tively, it is possible that changes to muscle architecture would
continue to provide a protective effect even after the prevention
program ceased, resulting in a low hamstring injury incidence in
the final (control) season. This potential long-term protective ef-
fect of the NHE exercise warrants further investigation.
Despite the nonsignificant statistical results, there was a ten-
dency toward a reduced injury incidence in the more compliant
group (Figure 2). In this regard, the low compliance of some
players in this study has also been observed elsewhere. Indeed, the
poor compliance reported within elite soccer teams is curious,
given that most European soccer clubs recognize the NHE as an
effective prevention tool (13). It therefore seems that raising
awareness and education around the value of NHE is warranted
in elite soccer clubs.
McCall et al. highlighted the challenges faced in obtaining
players’ adherence and coaches’ compliance to the NHE pre-
vention program (22). This includes players being concerned
about muscle soreness, not convinced that the exercises will
prevent injuries, and also concerned that some exercises may in-
crease the risk of injury (probably due the NHE intensity and/or
DOMS on the following implementation). In the studied team,
these issues were unlikely to be an influencing factor, as no spe-
cific complaints were reported to the team doctor. The results of
this study indicate that not only compliance within a specific team
is variable but also compliance with the exercise could boost the
preventive effects.
Challenges to coach compliance include the desire from the
coach for the player to train as much as possible with the team
(instead of performing exercises) (12). In this study, the imple-
mentation or absence of the NHE program was not within the
control of the medical team, and, at times, heavily influenced by
the perception of the coaching staff. The success of any injury
intervention program relies heavily on coach support and player
compliance. Therefore, one of the next challenges of sports
medicine practitioners will be to improve their communication
and to demonstrate the benefit of intelligently implemented pre-
vention actions that match the environment in which they
work (22).
This study highlights the outcomes for a specific soccer team
after the introduction of a NHE program over consecutive sea-
sons, which has not been reported previously. Importantly, this
investigation was performed with data collected during clinical
care, including the implementation of the NHE program. A
standardized injury surveillance system was followed during each
season, including exposure to match play and training, and im-
portantly, these data collection was performed by the same team
doctor. To ensure that the effect of the intervention was accu-
rately assessed, injuries occurring during the first 6 weeks were
excluded. Given the small cohort size, the possibility of this
influencing our results cannot be ruled out.
It is important to acknowledge that this is a clinical observa-
tional study and that a number of confounding factors were not
accounted for in the analysis. Although compliance was mea-
sured, the players were not randomized into a specific group, and
we cannot exclude possible selection bias in these results. How-
ever, this reflects the true clinical setting and players’ adherence to
any specific exercise. Moreover, the turnover of players, although
relatively low, and the promotion of the team from the second to
the first league for the 2014/2015 season, might have resulted in
a change in general characteristics of the roster with regard to
hamstrings injury history, and this was not taken into account in
Copyright © 2020 National Strength and Conditioning Association. Unauthorized reproduction of this article is prohibited.
| www.nsca.com
this study. The introduction and cessation of the NHE program
was also not decided by the study group. Indeed, the medical staff
proposed the NHE program to the different coaches, and the
compliance or not of this latter was decisive in the success of the
injury prevention programs. Although data from 5 seasons were
presented, the baseline injury scores were based on only 1 season.
This is a limitation that the authors were unable to address, as the
only data available started from season 2012/2013. During one of
the control seasons (last season, 2016/2017), it is possible that
some players may have continued with a NHE program in-
dependently, which may have influenced the results.
Certain practical difficulties also prohibited the strict regimen
of the prescribed program, such as matches played within a few
days or additional unplanned training sessions. Therefore, the
program was adapted to suit the conditions of the match and
training schedule. However, this is representative of a clinical
soccer environment and is inevitable with professional soccer
teams.
Despite the statistically nonsignificant findings of the current
study, the implementation of a NHE prevention program was
associated with a reduction in the hamstrings injury rate. In ad-
dition, the compliance of players with such interventions seems to
influence its efficiency.
Practical Applications
The initial reduction in hamstring injury incidence confirms
the previous findings in large intervention studies and high-
lights the effectiveness of NHE programs at the level of the
studied team. Increased compliance seems to be an important
factor to create successful injury prevention programs. Every
effort should be made to improve players’ adherence. We
encourage clinicians to perform similar investigations in their
own practice or team environment and perform appropriate
data analysis to better interpret the clinical observations. This
type of analysis might provide insights into the potential im-
mediate and long-term success of specific prevention exercises
such as the NHE program. By measuring outcomes, we im-
prove our ability to interpret the effectiveness of how we
manage our players. Thus, we can consider practical evidence
to support clinical decision-making that ultimately may lead
to improved health and performance of the players.
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