NORDIC HAMSTRING PROGRAM

Injury PreventionSport Med ‘18

January 26

Dave Wright CAT(c)

University of Guelph

Hamstring Injury Prevention

Injury Prevention: Evidence Based Literature

Hamstring injuries are the most common soccer-related muscle injury

Account for 37% of all soccer muscle injuries (Ekstrand J. et al, 2015)

Using the Nordic Hamstring Exercise in regular training reduced hamstring

injury incidence rates by 65%-70% demonstrating preventative effect in reducing

recurrent injuries (Peterson J. et al, 2011)

A random trial of using the Nordic Hamstring Exercise completed with

942 Danish soccer players resulted in:

59% less new, acute hamstring injuries with the 10 week controlled group

Re-injury rate was 86% lower in the same group (Peterson et al, 2008)

The peak muscle-tendinous force and strain for the hamstring muscle group

occurs during the terminal swing phase, just before ground contact (Thorborg et

al, 2012)

As a result, Thorborg et al recommended that eccentric muscle strength should be

performed at longer muscle-tendinous lengths representing movements and muscle

length occurring at both the knee and hip

What is the Nordic Hamstring Exercise?

Nordic Hamstring Technique Cues

Keep ankles firmly on ground or floor

Suggest to place roll under ankles to reduce pressure

stress applied to joint

Keep head, trunk, hips and thighs in a straight line

Bend from knees NOT hip or spine (knee flexion

technique)

Perform exercise slowly, under control, lowering body

as far as possible towards the ground or floor

Nordic Hamstring Exercise Benefits & Support

Evidence and research based eccentric hamstring injury prevention

exercise

Suitable for all patients and athletic abilities

Easy instruction for effective technique

No heavy equipment necessary only a soft surface

Bodyweight and gravity acts as load

Slow cadence with simple controlled movement

May perform independently or with a partner

Uses spine and hip extensors to stabilize trunk during exercise

Posterior load stabilizer assisting in minimizing translation during an

ACL mechanism of injury

Why use the Nordic Hamstring Exercise?

Well evidenced as hamstring injury prevention with

significant, supportive literature

Formally introduced in 2001 finding hamstring injuries

caused by strength deficits, notably eccentric strength

towards end range (Mjolsnes et al, 2004)

English textbook from year 1880 demonstrating Swedish

exercise methods…yet to be named Nordic Hamstring

Exercise?

“Old is new again” with Nordic Hamstring Curls seemingly

making a return…but did it really go away?

Recommended Frequency & Volume

Systematic, minimal and progressive increase in volume, reps

and load

Source: Mjolsnes et al 2004

Week Sessions/Week Sets Reps

1 1 2 5

2 2 2 6

3 3 3 6-8

4 3 3 8-10

5-10 3 3 12, 10, 8

Minimum Recommended Reps

BEGINNER

repetitions: 1 set (3 – 5 repetitions)

INTERMEDIATE

repetitions: 1 set (7 – 10 repetitions)

ADVANCED

repetitions: 1 set (minimum 12 – 15 repetitions)

Source: Mjolsnes et al 2004

Injury Prevention Protocol

Load increases as athlete can withstand the controlled, forward fall

Greatest eccentric benefit as hamstring muscle group lengthens closer to ground

When able to withstand the entire range of motion for 12 reps, increase load by adding speed to the starting phase of the motion

A partner may also increase loading further by pushing at the back of shoulders

Add the use of elastic cords to provide support and control for proper technique to end range for beginners

Source: Mjolsnes et al 2004

Assisted Nordic Hamstring Curl

Nordbord

Designed at University of Queensland, Australia

Youth Soccer Initiatives

FIFA 11+ injury preventative program

Developed by International experts from FIFA’s Medical Assessment and Research Centre (F-MARC), the Oslo Sports Trauma Research Center and the Santa Monica Orthopaedic and Sports Medicine Research Foundation

When incorporated into team warm-up, resulted in 11.5% fewer game injuries and 25.3% less injuries during training or practice (Bizzini, M., Junge, A., Dvorak, J., 2013)

Study: Barengo, N., Francisco Meneses-Echávez, J., Ramírez-Vélez, R., Cohen, D., The Impact of the FIFA 11+ Training Program on Injury Prevention in Football Players: A Systematic Review; Int. J. Environ. Res. Public Health 2014, 11(11), 11986-12000

International Professional Soccer

FCBarcelona “Muscle Injuries Clinical Guide 3.0” (January 2015)

First edition published in 2009

FCBarcelona and Aspetar Medical Staff

Why Not More Widely Used? Concern for Delayed Onset Muscle Soreness (DOMS)

Mjolsnes protocol progressively designed to minimize effects

Compliance

Program design recommends 6-10 week training periods

Current industry exercise approach is “functional” vs “isolation”

Players fail to maintain proper technique and load during full active range of motion

Cramping, dehydration a possibility?

Differentials: fatigue, sciatic nerve (Slump Test), lumbar spine, anterior pelvic tilt, poor gluteal muscle activation…

Open chain exercise

Inhibition: hamstring injury rehabilitation protocols too conservative?

Bilateral exercise rather than independent or single side exercise for muscle balance

Does not increase concentric hamstring strength during technique

Nordic Hamstring as Rehab Exercise

“If you think hamstring exercises must be

‘functional’, be aware that data shows

structure matters.”

“Examine the athlete, not the image of the

injured hamstring.” Kristian Thorborg PhD, Sports Orthopedic Research Centre -

Copenhagen

Lengthening Protocol

Source: Askling et al, 2014

Preventative Muscle Activations &

Stabilizers

Opposite arm/leg raise (50% gluteus maximus

activation prior to each leg lift):

Bridging/table top with leg lift:

(progress by extending leg on floor)

Implementation Techniques

Team or Group Applications:

Complete during dedicated gym sessions

Team or group circuit training combined with agility skills development or conditioning drills

Off-day training post warm up, mobility, flexibility and fascial release/foam roller techniques

Team or Individual off-season or LTD training programs

Incorporate FIFA 11+ as group warm up

Begin with only 1 session/week to a program maximum of 3 sessions/week as recommended by Mjolsnes chart

Perform in conjunction with spine and gluteal muscle patterns for global trunk stabilization and intrinsic muscle balance

References Ekstrand J, Hagglund M, Walden M. Epidemiology of Muscle Injuries in Professional Football (Soccer). Am J

Sports Med. 2011;39(6):1226-1232

Peterson J, Thorborg K, Bachmann Nielsen M, Budt-Jorgensen E, Holmich P. Preventative Effect of Eccentric Training on Acute Hamstring Injuries in men’s soccer; A Cluster-Randomized Controllecd Trial. Am J Sports Med. 2011;39(11):2296-2303

van der Horst N, Smits D-W, Petersen J, Goedhart E A, Backx F J.G. The Preventive Effect of the Nordic Hamstring Exercise on Hamstring Injuries in Amateur Soccer Players: A Randomized Controlled Trial. Am J Sports Med. 2015;43(6):7

Mjølsnes R, Arnason A, Osthagen T, et al. A 10-week randomized trial comparing eccentric vs. concentric hamstring strength training in well-trained soccer players. Scand J Med Sci Sports 2004;14:311–17.

Petersen J, Thorborg K, Nielsen MB, et al. Preventive effect of eccentric training on acute hamstring injuries in men's soccer: a cluster-randomized controlled trial. Am J Sports Med 2011;39:2296–303

FCBarcelona Muscle Injuries Clinical Guide 3.0; January 2015 in collaboration with Aspetar Medical Staff

Bizzini, M., Junge, A., Dvorak, J., (2013.) Implementation of he FIFA 11+ football warm up program: How to approach and convince the Football associations to invest in prevention. British journal of sports medicine, bjsports-2012-092124

Arnason A., Anderson TE, Holme I, et al. Prevention of hamstring strains in elite soccer: an intervention study. Scand J Med Sci Spors 2008; 18:40-8

Askling CM, Tengvar M, Thorstensson A. Acute hamstring injuries in Swedish elite football: a perspective randomized controlled clinical trial comparing two rehabilitation protocols. Br J Sports Med 2013;47;953-9

Ditroilo M, De Vito G, Delahunt E. Kinematic and electromyographic analysis of the Nordic Hamstring Exercise. 2013 Oct;23(5):1111-8

Timmins R, Porter K, Williams M, et al. Biceps femoris muscle architecture—the influence of previous injury. Br J Sports Med 2014;48:665–6

Sherry MA, Best TM. A comparison of 2 rehabilitation programs in the treatment of acute hamstring strains. J Orthop Sports Phys Ther2004;34:116–25

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Thank you