Clin J Sport Med  Volume 23, Number 1, January 2013
COMMENTARY of weeks. A more severe grade II or III
The review by van den Bekerom
et al investigated the clinical effects of
therapeutic US applied in the acute stage
of an ankle sprain. The rationale for high-
frequency mechanical vibrations induced
through US—for an ankle sprain usually
about 3 MHz—is to increase fluid move-
ment in the damaged area, increase the
synthesis of proteins, and improve blood
flow.1 These effects are thought to reduce
pain and swelling and to improve tissue
healing, which were precisely the out-
comes that van den Bekerom et al re-
ported on in their review. Overall, no
therapeutic effect of US was found for
any of the outcomes, and the use of US
in the treatment of acute ankle sprains
was therefore not supported by the accu-
mulated evidence.
This will not come as a surprise to
many, as the rationale behind US and its
effects is questionable. Reports of the
physiologic effects vary, and outcomes
seem to be dependent on dosage (ie, the
frequency and rate of repetition) and
anatomical location and anatomical struc-
ture (ie, muscle or tendon). In the absence
of any clearly defined physiologic effects,
a clinical effect would be unexpected.
Although van den Bekerom et al have
produced a robust and well-written review
and have reached reasonable conclusions,
there are some important issues that
should be considered.
For example, they did point out
some of the weaknesses in their methods
and in the included reports. Amongst
these, the small number of relevant
studies (n = 6) was mentioned as well
as the variation in the quality and report-
ing of the data. Because of these flaws,
we should be careful in interpreting the
results. There was no strong indication
that US was clinically effective, yet the
opposite holds true as well. The evi-
dence does not rule out the absence of
an effect.
More important, it should be noted
that van den Bekerom et al were only
able to review the short-term clinical
effects in the acute and rehabilitation
phases of ankle sprain. To my knowl-
edge, there are no studies looking at the
long-term effects, but this may be where
US could be beneficial. Ankle sprains
are generally considered to be minor
injuries that easily resolve within a matter
Ó 2013 Lippincott Williams & Wilkins
were invited to participate. The exclu-
sprain (ligament tear) may require pro-
longed care, but the overall prognosis is
usually considered relatively favorable.
Some reports, however, indicate that
even minor sprains may lead to severe
and disabling long-term pain and insta-
bility, as well as the risk of recurrent
sprains.2
Evert A.L.M. Verhagen, PhD
Department of Public and Occupational
Health, EMGO+ Institute
VU University Medical Center
Amsterdam, Netherlands
REFERENCES
1. Maxwell L. Therapeutic ultrasound: its effects
on the cellular and molecular mechanisms of
inflammation and repair. Physiotherapy. 1992;
78:421–426.
2. Braun BL. Effects of ankle sprain in a gen-
eral clinic population 6 to 18 months after
medical evaluation. Arch Fam Med. 1999;8:
143–148.
Does Eccentric Training of
Hamstring Muscles Reduce
Acute Injuries in Soccer?
Petersen J, Thorborg K, Nielsen MB,
Budtz-Jørgensen E, Hölmich P. Preven-
tive effect of eccentric training on acute
hamstring injuries in men’s soccer:
a cluster-randomized controlled trial.
Am J Sports Med. 2011;39:2296–2303.
Objective: To investigate the effectiveness
of a 10-week hamstring exercise training
program in reducing the incidence and
severity of new and recurrent hamstring
injuries among male soccer players.
Design: Cluster-randomized (by team)
controlled trial, stratified by level of play
and geographic location. Sample size
was calculated with 80% power to show
a relative risk reduction for injury of
50% at P # 0.05.
Setting: Soccer community study in
Denmark during the period January to
December 2008.
Participants: Teams in the top 5 soccer
divisions (2 professional and 3 amateur)
The authors reported no conflicts of interest.
Correspondence about the original article: Jesper
Petersen, MD, PhD, Department of Orthopae-
dic Surgery, Amager Hospital, Italiensvej 1,
Copenhagen DK-2300, Denmark (jesper.pe-
tersen@dadlnet.dk).
Sport Medicine Journal Club
sion criterion for teams was that they
already used eccentric hamstring exer-
cises, and for participants was that they
joined the teams after the beginning of
the season. Of 116 teams, 54 were eligi-
ble and willing to be randomized and 50
were included in the analysis (942
players).
Intervention: Teams in both the interven-
tion and control groups followed their
normal training programs. At the begin-
ning of the study period, the intervention
teams added 27 sessions of the Nordic
hamstring exercise (after warm-up) during
the 10-week period of the mid-season
break. The exercise begins with the player
kneeling with the torso upright and rigid,
and the feet held down to the ground by
a partner. The player lowers his torso for-
wards toward the ground braking with his
hamstring muscles until the chest reaches
the ground (eccentric phase). He returns
to the upright position, pushing with his
hands to minimize the concentric phase
load. Sessions per week and sets and rep-
etitions per session increased to 3, 3, and
12, respectively. Team coaches super-
vised the sessions.
Main Outcome Measures: A hamstring
injury was defined as an acute occurrence
of a “physical complaint in the region of
the posterior thigh sustained during a soc-
cer match or training, irrespective of the
need for medical attention or time loss
from soccer activities.” Injuries were
recorded by the teams’ medical staff on
standardized forms. Only first injuries
during the season were included and
recorded as first-time injuries or recurren-
ces of injuries sustained before the sea-
son. Severity of injury was defined by
number of days lost from full participa-
tion in games and practices.
Main Results: Injury rates per 100 player
sessions were lower for the intervention
group (3.8) than for the control group
(13.1); thus, the rate ratio (RR) adjusted
for age, level of competition, and previous
injury was 0.293 (95% confidence interval
[CI], 0.150-0.572). Both rates of new and
recurrent injuries were lower for the inter-
vention group than for the control group
(new injuries: RR, 0.410; 95% CI, 0.180-
0.933; recurrent injuries: RR, 0.137; 95%
CI, 0.037-0.509). The 15 injuries in the
intervention group resulted in absence of
454 days from soccer (mean, 30.3; SD,
www.cjsportmed.com | 85
Sport Medicine Journal Club
18.3; range, 7-64 days per injury), whereas
51 injuries in the control group resulted in
1344 days absent (mean, 26.4; SD, 19.5;
range, 4-89 days per injury). Mean sever-
ity of injuries (days absent) was not sig-
nificantly different (P = 0.16) between
groups. Delayed onset muscle soreness,
but no other adverse effect, was reported
by most members of the intervention
group during the training period.
Conclusions: An eccentric hamstring
exercise program was associated with
lower rates of new and recurrent hamstring
injuries in Danish male soccer players.
COMMENTARY
Sports medicine researchers regu-
larly seek to identify training techniques
and exercise protocols that reduce the
incidence of injuries during sports. The
report by Petersen et al offers encourag-
ing evidence in a cluster-randomized con-
trolled trial that a simple eccentric
hamstring exercise (Nordic hamstring exer-
cise1) protocol, which requires no special
equipment, is associated with a substantial
reduction in the incidence of hamstring
strain injuries in professional and amateur
Danish soccer players. Relative risks in the
eccentric hamstring exercise group of over-
all, new, and recurrent injuries were only
29%, 41%, and 14% of those in the control
group.
Study strengths include cluster ran-
domization that was stratified by level of
play and geography, large numbers of
participants, assessment of injury severity
by days of absence from soccer, the
adequate 12-month study period, differ-
entiation between new and recurrent
injuries, diagnoses based on clinical rather
than diagnostic imaging findings, and the
exclusion of recurrences of injuries
previously recorded in the season,
which could have resulted in an over-
estimation of the effects of the inter-
vention. Previous studies of eccentric
hamstring exercises and soccer-related
hamstring injury prevention were limited
by a lack of randomization, inadequate
numbers of subjects, differences in base-
line characteristics between the interven-
tion and control groups, and differences
among studies in exercise protocols and
control group interventions.1–3
The authors correctly remark that
proper blinding of a nonpharmacologic
study is difficult to achieve. This may
86 | www.cjsportmed.com
Clin J Sport Med  Volume 23, Number 1, January 2013
have introduced a bias toward the inter-
vention group because European soccer
players were already beginning to rec-
ognize the potential benefits of Nordic
hamstring exercises at the time of this
trial. The effects resulting from grouping
together professional and amateur soccer
players in the study are unknown. Fur-
thermore, the description of the study
methods does not elaborate on the extent
of coach education and their supervision
of proper exercise technique, including the
optimal sequence of hip and hamstring
muscle activation and correct foot posi-
tioning to work both medial and lateral
hamstrings. Finally, the subject numbers
are slightly below the pretrial 1000 sub-
jects intended for inclusion in the study.
The study provides encouraging
results and raises additional questions:
Should all players, only previously injured
players, or only players at high risk for
hamstring injury be targeted for the eccen-
tric hamstring protocol? Is the Nordic
hamstring program the most effective
eccentric hamstring exercise protocol? Is
the more intensive “hamstring lowers3”
eccentric exercise protocol preferable?
Should eccentric hamstring exercise proto-
cols additionally incorporate alternative
forms of exercise such as isometrics, core
strengthening, proprioception, and running
instruction training? Is it possible to design
exercise protocols that target specific ham-
string locations (eg, proximal/distal and
medial/lateral) for injury prevention? Is
the Nordic hamstring program effective
for women, children, and adolescents?
Despite the questions left unanswered,
the results of the authors’ commendable
methods and rigorously collected data
clearly support the inclusion of some
form of eccentric hamstring exercises to
help prevent hamstring strain injuries in
adult soccer players. The benefits may be
most pronounced in those at high risk for
hamstring injuries.
Andrew W. Nichols, MD
Department of Family Medicine
and Community Health
John A. Burns School of Medicine
University of Hawai’i at Manoa
Honolulu, Hawai’i, USA
REFERENCES
1. Arnason A, Andersen TE, Home I, et al. Pre-
vention of hamstring strains in elite soccer: an
intervention study. Scand J Med Sci Sports.
2008;18:40–48.
2. Majølsnes R, Arnason A, Østhagen T, et al. A
10-week randomized trial comparing eccentric
vs concentric hamstring strength training in
well-trained soccer players. Scan J Med Sci
Sports. 2004;14:311–317.
3. Brockett CL, Morgan DL, Proske U. Human
hamstring muscles adapt to eccentric exercise
by changing optimum length. Med Sci Sports
Exerc. 2001;33:783–790.
Progressive Strengthening
Exercises for Subacromial
Impingement Syndrome
Holmgren T, Hallgren HB, Öberg B,
Adolfsson L, Johansson K. Effect of
specific exercise strategy on need for
surgery in patients with subacromial
impingement syndrome: randomised
controlled study. BMJ. 2012;344:e787.
Objective: To compare the effectiveness
of specific exercises for the rotator cuff
and scapular stabilizers with unspecific
exercises in the treatment of subacromial
impingement syndrome.
Design: Randomized controlled trial
with 3 months of follow-up. Participants
and the single assessor were blinded to
group assignment. Sample size was cal-
culated with 80% power to show
a minimum clinically important differ-
ence of 10% on the Constant–Murley
score at P # 0.05.
Setting: Tertiary study in Linköping,
Sweden, between January 2008 and
February 2010.
Participants: Patients on the waiting list
for arthroscopic subacromial decompres-
sion were recruited from the Department
of Orthopaedics at University Hospital.
Inclusion criteria were 30-65 years of
age; a 6-month duration of the current epi-
sode of pain in the proximal-lateral aspect
of the upper arm; lack of response to con-
servative treatment; and positive results on
the Neer test and 2 of the following tests:
Hawkins-Kennedy, Jobes, and Patte.
Exclusion criteria were other conditions
such as malignancy, osteoarthritis, os
acromiale, joint instability, frozen shoul-
der, and symptoms originating in the
Source of funding for the original study: No external
funding.
Correspondence about the original article:
T. Holmgren, PT, MSc, Department of Med-
ical and Health Sciences, Division of Physio-
therapy, Linköping University, Linköping,
Sweden (theresa.holmgren@liu.se).
Ó 2013 Lippincott Williams & Wilkins