Is pre-season eccentric strength testing during the nordic hamstring exercise associated with future hamstring strain injury? A systematic review and meta-analysis

Journal article

Opar, David A., Timmins, Ryan G., Behan, Fearghal P., Hickey, Jack T., van Dyk, Nicol, Price, Kara and Maniar, Nirav. (2021). Is pre-season eccentric strength testing during the nordic hamstring exercise associated with future hamstring strain injury? A systematic review and meta-analysis. Sports Medicine. 51(9), pp. 1935-1945. https://doi.org/10.1007/s40279-021-01474-1
AuthorsOpar, David A., Timmins, Ryan G., Behan, Fearghal P., Hickey, Jack T., van Dyk, Nicol, Price, Kara and Maniar, Nirav
Abstract

Background
Interventions utilising the Nordic hamstring exercise (NHE) have resulted in reductions in the incidence of hamstring strain injury (HSI). Subsequently, quantifying eccentric knee flexor strength during performance of the NHE to identify an association with the occurrence of future HSI has become increasingly common; however, the data to date are equivocal.

Objective
To systematically review the association between pre-season eccentric knee flexor strength quantified during performance of the NHE and the occurrence of future HSI.

Design
Systematic review and meta-analysis.

Data sources
CINAHL, Cochrane Library, Medline Complete, Embase, Web of Science and SPORTDiscus databases were searched from January 2013 to January 10, 2020.

Eligibility criteria for selecting studies
Prospective cohort studies which assessed the association between pre-season eccentric knee flexor strength quantified during performance of the NHE and the occurrence of future HSI.

Methods
Following database search, article retrieval and title and abstract screening, articles were assessed for eligibility against pre-defined criteria then assessed for risk of bias. Meta-analysis was used to pool data across studies, with meta-regression utilised where possible.

Results
A total of six articles were included in the meta-analysis, encompassing 1100 participants. Comparison of eccentric knee flexor strength during performance of the NHE in 156 injured participants and the 944 uninjured participants revealed no significant differences, regardless of whether strength was expressed as absolute (N), relative to body mass (N kg−1) or between-limb asymmetry (%). Meta-regression analysis revealed that the observed effect sizes were generally not moderated by age, mass, height, strength, or sport played.

Conclusion
Eccentric knee flexor strength quantified during performance of the NHE during pre-season provides limited information about the occurrence of a future HSI.

Year2021
JournalSports Medicine
Journal citation51 (9), pp. 1935-1945
PublisherSpringer
ISSN0112-1642
Digital Object Identifier (DOI)https://doi.org/10.1007/s40279-021-01474-1
Scopus EID2-s2.0-85105277353
Open accessPublished as green open access
Research or scholarlyResearch
Page range1935-1945
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Open
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Output statusPublished
Publication dates
Online29 Apr 2021
Publication process dates
Accepted08 Apr 2021
Deposited17 Nov 2021
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Maniar, Nirav, Schache, Anthony G., Cole, Michael H. and Opar, David. (2019). Lower-limb muscle function during sidestep cutting. Journal of Biomechanics. 82, pp. 186 - 192. https://doi.org/10.1016/j.jbiomech.2018.10.021
Effect of acute augmented feedback on between limb asymmetries and eccentric knee flexor strength during the Nordic hamstring exercise
Wade J. Chalker, Anthony J. Shield, David Opar, Evelyne N. Rathbone and Justin Keogh. (2018). Effect of acute augmented feedback on between limb asymmetries and eccentric knee flexor strength during the Nordic hamstring exercise. PeerJ. (e4972). https://doi.org/10.7717/peerj.4972
Non-knee-spanning muscles contribute to tibiofemoral shear as well as valgus and rotational joint reaction moments during unanticipated sidestep cutting
Maniar, Nirav, Schache, Anthony, Sritharan, Prasanna and Opar, David. (2018). Non-knee-spanning muscles contribute to tibiofemoral shear as well as valgus and rotational joint reaction moments during unanticipated sidestep cutting. Scientific Reports. 8(1), pp. 1 - 10. https://doi.org/10.1038/s41598-017-19098-9
An evidence-based framework for strengthening exercises to prevent hamstring injury
Bourne, Matthew N., Timmins, Ryan Gregory, Opar, David, Pizzari, Tania, Ruddy, Joshua D., Sims, Casey, Williams, Morgan D. and Shield, Anthony J.. (2018). An evidence-based framework for strengthening exercises to prevent hamstring injury. Sports Medicine. 48(2), pp. 251 - 267. https://doi.org/10.1007/s40279-017-0796-x
The effect of Nordic hamstring exercise training volume on biceps femoris long head architectural adaptation
Presland, J. D., Timmins, R. G., Bourne, M. N., Williams, M. D. and Opar, D. A.. (2018). The effect of Nordic hamstring exercise training volume on biceps femoris long head architectural adaptation. Scandinavian Journal of Medicine & Science in Sports. 28(7), pp. 1775-1783. https://doi.org/10.1111/sms.13085
Infographic. Impact of the Nordic hamstring and hip extension exercises on hamstring architecture and morphology: Implications for injury prevention
Bourne, Matthew N., Pope, David, Duhig, Steven J., Timmins, Ryan G., Williams, Morgan D., Al Najjar, Aiman, Kerr, Graham K. and Shield, Anthony J.. (2018). Infographic. Impact of the Nordic hamstring and hip extension exercises on hamstring architecture and morphology: Implications for injury prevention. British Journal of Sports Medicine. 52(23), pp. 1490 - 1491. https://doi.org/10.1136/bjsports-2017-098730
A novel apparatus to measure knee flexor strength during various hamstring exercises: A reliability and retrospective injury study
Hickey, Jack T., Hickey, Peter F., Maniar, Nirav, Timmins, Ryan G., Williams, Morgan D., Pitcher, Christian A. and Opar, David A.. (2018). A novel apparatus to measure knee flexor strength during various hamstring exercises: A reliability and retrospective injury study. Journal of Orthopaedic and Sports Physical Therapy. 48(2), pp. 72 - 80. https://doi.org/10.2519/jospt.2018.7634
Adaptations to concurrent training in combination with high protein availability: A comparative trial in healthy, recreationally active men
Shamim, Baubak, Devlin, Brooke L., Timmins, Ryan G., Tofari, Paul, Dow, Connor Lee, Coffey, Vernon G., Hawley, John A. and Camera, Donny M.. (2018). Adaptations to concurrent training in combination with high protein availability: A comparative trial in healthy, recreationally active men. Sports Medicine. 48(12), pp. 2869 - 2883. https://doi.org/10.1007/s40279-018-0999-9
Non-knee-spanning muscles contribute to tibiofemoral shear as well as valgus and rotational joint reaction moments during unanticipated sidestep cutting
Maniar, Nirav, Schache, Anthony G., Sritharan, Prasanna and Opar, David. (2018). Non-knee-spanning muscles contribute to tibiofemoral shear as well as valgus and rotational joint reaction moments during unanticipated sidestep cutting. Scientific Reports. 8(2501), pp. 1 - 10. https://doi.org/10.1038/s41598-017-19098-9
Impact of exercise selection on hamstring muscle activation
Bourne, Matthew N., Williams, Morgan, Opar, David, Najjar, Aiman Al, Kerr, Graham K. and Shield, Anthony J.. (2017). Impact of exercise selection on hamstring muscle activation. British Journal of Sports Medicine. 51, pp. 1021 - 1028. https://doi.org/10.1136/bjsports-2015-095739
Impact of the Nordic hamstring and hip extension exercises on hamstring architecture and morphology: Implications for injury prevention
Bourne, Matthew N., Duhig, Steven J., Timmins, Ryan, Williams, Morgan, Opar, David, Najjar, Aiman Al, Kerr, Graham K. and Shield, Anthony J.. (2017). Impact of the Nordic hamstring and hip extension exercises on hamstring architecture and morphology: Implications for injury prevention. British Journal of Sports Medicine. 51(5), pp. 469 - 477. https://doi.org/10.1136/bjsports-2016-096130
Biceps femoris architecture : The association with injury and response to training
Timmins, Ryan. (2017). Biceps femoris architecture : The association with injury and response to training. British Journal of Sports Medicine. 51(6), pp. 547-548. https://doi.org/10.1136/bjsports-2016-097044
There is strength in numbers for muscle injuries it is time to establish an international collaborative registry
Van Dyke, Nicol, Van der Made, Anne D., Timmins, Ryan, Opar, David and Tol, Johannes L.. (2017). There is strength in numbers for muscle injuries it is time to establish an international collaborative registry. British Journal of Sports Medicine. https://doi.org/10.1136/bjsports-2016-097318
Effect of prior injury on changes to biceps femoris architecture across an Australian football league season
Timmins, Ryan, Bourne, Matthew N., Hickey, Jack, Maniar, Nirav, Tofari, Paul, Williams, Morgan and Opar, David. (2017). Effect of prior injury on changes to biceps femoris architecture across an Australian football league season. Medicine and Science in Sports and Exercise. 49(10), pp. 2102 - 2109. https://doi.org/10.1249/MSS.0000000000001333
Criteria for progressing rehabilitation and determining return to play clearance following hamstring strain injury: A systematic review
Hickey, Jack, Timmins, Ryan G., Maniar, Nirav, Williams, Morgan and Opar, David. (2017). Criteria for progressing rehabilitation and determining return to play clearance following hamstring strain injury: A systematic review. Sports Medicine. 47(7). https://doi.org/10.1007/s40279-016-0667-x
Predictive modeling of hamstring strain injuries in elite Australian footballers
Ruddy, Joshua, Shield, Anthony J., Maniar, Nirav, Williams, Morgan D., Duhig, Steven J., Timmins, Ryan, Hickey, Jack, Bourne, Matthew N. and Opar, David. (2017). Predictive modeling of hamstring strain injuries in elite Australian footballers. Medicine and Science in Sports and Exercise. 50(5), pp. 1 - 30. https://doi.org/10.1249/MSS.0000000000001527
Running exposure is associated with the risk of hamstring strain injury in elite Australian footballers
Ruddy, Joshua D., Pollard, Christopher, Timmins, Ryan, Williams, Morgan, Shield, Anthony and Opar, David. (2017). Running exposure is associated with the risk of hamstring strain injury in elite Australian footballers. British Journal of Sports Medicine. https://doi.org/10.1136/bjsports-2016-096777
Drop punt kicking induces eccentric knee flexor weakness associated with reductions in hamstring electromyographic activity
Duhig, Steven J., Williams, Morgan, Minett, Geoffrey M., Opar, David and Shield, Anthony J.. (2017). Drop punt kicking induces eccentric knee flexor weakness associated with reductions in hamstring electromyographic activity. Journal of Science and Medicine in Sport. 20(6), pp. 595 - 599. https://doi.org/10.1016/j.jsams.2016.09.006
Muscle activation patterns in the Nordic hamstring exercise: Impact of prior strain injury
Bourne, Matthew N., Opar, David, Williams, Morgan, Najjar, Aiman Al and Shield, Anthony J.. (2016). Muscle activation patterns in the Nordic hamstring exercise: Impact of prior strain injury. Scandinavian Journal of Medicine & Science in Sports. 26(6). https://doi.org/10.1111/sms.12494
Biceps femoris architecture and strength in athletes with a prior ACL reconstruction
Timmins, Ryan G., Bourne, Matthew N., Shield, Anthony J., Williams, Morgan, Lorenzen, Christian and Opar, David A.. (2016). Biceps femoris architecture and strength in athletes with a prior ACL reconstruction. Medicine and Science in Sports and Exercise. 48(3), pp. 337-345. https://doi.org/10.1249/MSS.0000000000000783
Hamstring strength and flexibility after hamstring strain injury: A systematic review and meta-analysis
Maniar, Nirav, Shielf, Anthony J., Williams, Morgan D., Timmins, Ryan G. and Opar, David A.. (2016). Hamstring strength and flexibility after hamstring strain injury: A systematic review and meta-analysis. British Journal of Sports Medicine. 50(15), pp. 909-920. https://doi.org/10.1136/bjsports-2015-095311
Is there evidence to support the use of the angle of peak torque as a marker of hamstring injury and re-injury risk?
Timmins, Ryan G., Shield, Anthony J., Williams, Morgan D. and Opar, David A.. (2016). Is there evidence to support the use of the angle of peak torque as a marker of hamstring injury and re-injury risk? Sports Medicine. 46(1), pp. 7-13. https://doi.org/10.1007/s40279-015-0378-8
Effect of high-speed running on hamstring strain injury risk
Duhig, Steven, Shield, Anthony, Opar, David, Gabbett, Tim, Ferguson, Cameron and Williams, Morgan. (2016). Effect of high-speed running on hamstring strain injury risk. British Journal of Sports Medicine. 50(24). https://doi.org/10.1136/bjsports-2015-095679
Short biceps femoris fascicles and eccentric knee flexor weakness increase the risk of hamstring injury in elite football (soccer): a prospective cohort study
Timmins, Ryan G., Bourne, Matthew N., Shield, Anthony J., Williams, Morgan, Lorenzen, Christian and Opar, David. (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(24). https://doi.org/10.1136/bjsports-2015-095362
Architectural changes of the biceps femoris long head after concentric or eccentric training
Timmins, Ryan G., Ruddy, Joshua D., Presland, Joel, Maniar, Nirav and Williams, Morgan. (2016). Architectural changes of the biceps femoris long head after concentric or eccentric training. Medicine and Science in Sports and Exercise. 48(3), pp. 499-508. https://doi.org/10.1249/MSS.0000000000000795
Reliability of measures of quadriceps muscle function using magnetic stimulation
Tofari, Paul J., Opar, David, Kemp, Justin Guy, Billaut, Francois and Cormack, Stuart John. (2016). Reliability of measures of quadriceps muscle function using magnetic stimulation. Muscle & Nerve. https://doi.org/10.1002/mus.24926
Architectural adaptations of muscle to training and injury: A narrative review outlining the contributions by fascicle length, pennation angle and muscle thickness
Timmins, Ryan G., Shield, Anthony J., Williams, Morgan D., Lorenzen, Christian and Opar, David. (2016). Architectural adaptations of muscle to training and injury: A narrative review outlining the contributions by fascicle length, pennation angle and muscle thickness. British Journal of Sports Medicine. 50(23). https://doi.org/10.1136/bjsports-2015-094881
Comparisons of eccentric knee flexor strength and asymmetries across elite, sub-elite and school level cricket players
Chalker, Wade J., Shield, Anthony J., Opar, David and Keogh, Justin W. L.. (2016). Comparisons of eccentric knee flexor strength and asymmetries across elite, sub-elite and school level cricket players. PeerJ. 4, pp. 1 - 10. https://doi.org/10.7717/peerj.1594
What do submarines have in common with diabetes?
Rio, Ebony, Timmins, Ryan Gregory and Opar, David. (2016). What do submarines have in common with diabetes? British Journal of Sports Medicine. 50(16), pp. 955 - 956. https://doi.org/10.1136/bjsports-2016-096646
The juxtaposition of science and medicine in sport. Can we all play together nicely?
Opar, David and Rio, Ebony. (2015). The juxtaposition of science and medicine in sport. Can we all play together nicely? British Journal of Sports Medicine. 49(10), pp. 640 - 641. https://doi.org/10.1136/bjsports-2015-094819
Eccentric knee flexor strength and risk of hamstring injuries in Rugby Union: A prospective study
Bourne, Matthew, Opar, David, Williams, Morgan and Shield, Anthony. (2015). Eccentric knee flexor strength and risk of hamstring injuries in Rugby Union: A prospective study. American Journal of Sports Medicine. 43(11), pp. 2663 - 2670. https://doi.org/10.1177/0363546515599633
Acute injuries in track and field athletes : A 3-year observational study at the penn relays carnival with epidemiology and medical coverage implications
Opar, David, Drezner, Jonathan, Shield, Anthony, Williams, Morgan, Webner, David, Sennett, Brian, Kapur, Rahul, Cohen, Marc, Ulager, James, Cafengiu, Ana and Cronholm, Peter F. (2015). Acute injuries in track and field athletes : A 3-year observational study at the penn relays carnival with epidemiology and medical coverage implications. American Journal of Sports Medicine. 43(4), pp. 816 - 822. https://doi.org/10.1177/0363546514562553
Comparison of anthropometry, upper body strength and lower body power characteristics in different levels of Australian Football players
Bilsborough, Johann, Greenway, Kate, Opar, David, Livingstone, Steuart, Cordy, Justin, Bird, S. and Coutts, Aaron. (2015). Comparison of anthropometry, upper body strength and lower body power characteristics in different levels of Australian Football players. Journal of Strength and Conditioning Research. 29(3), pp. 826 - 834. https://doi.org/10.1519/JSC.0000000000000682
Eccentric hamstring strength and hamstring injury risk in Australian footballers
Opar, David A., Williams, Morgan D., Timmins, Ryan G., Duhig, Steven and Shield, Anthony J.. (2015). Eccentric hamstring strength and hamstring injury risk in Australian footballers. Medicine and Science in Sports and Exercise. 47(4). https://doi.org/10.1249/MSS.0000000000000465
The effect of previous hamstring strain injury on the change in eccentric hamstring strength during preseason training in elite Australian footballers
Opar, David A., Williams, Morgan D., Timmins, Ryan G., Hickey, Jack, Duhig, Steven J. and Shield, Anthony J.. (2015). The effect of previous hamstring strain injury on the change in eccentric hamstring strength during preseason training in elite Australian footballers. American Journal of Sports Medicine. 43(2), pp. 377-384. https://doi.org/10.1177/0363546514556638
Biceps femoris long head architecture: A reliability and retrospective injury study
Timmins, Ryan Gregory, Shield, Anthony, Williams, Morgan, Lorenzen, Christian and Opar, David. (2015). Biceps femoris long head architecture: A reliability and retrospective injury study. Medicine and Science in Sports and Exercise. 47(5), pp. 905 - 913. https://doi.org/10.1249/MSS.0000000000000507
Biceps femoris long head architecture: The association with hamstring injury and response to training
Timmins, Ryan Gregory. (2015). Biceps femoris long head architecture: The association with hamstring injury and response to training [Thesis]. https://doi.org/10.4226/66/5a9cbd05b0b98
The accuracy and precision of DXA for assessing body composition in team sport athletes
Bilsborough, Johann, Greenway, Kate, Opar, David, Livingstone, Steuart, Cordy, Justin and Coutts, Aaron. (2014). The accuracy and precision of DXA for assessing body composition in team sport athletes. Journal of Sports Sciences. 32(19), pp. 1821 - 1828. https://doi.org/10.1080/02640414.2014.926380
Is there a potential relationship between prior hamstring strain injury and increased risk for future anterior cruciate ligament injury?
Opar, David and Serpell, Benjamin. (2014). Is there a potential relationship between prior hamstring strain injury and increased risk for future anterior cruciate ligament injury? Archives of Physical Medicine and Rehabilitation. 95(2). https://doi.org/10.1016/j.apmr.2013.07.028
Reduced biceps femoris myoelectrical activity influences eccentric knee flexor weakness after repeat sprint running
Timmins, R. G., Opar, D. A., Williams, M. D., Schache, A. G., Dear, N. M. and Shield, A. J.. (2014). Reduced biceps femoris myoelectrical activity influences eccentric knee flexor weakness after repeat sprint running. Scandinavian Journal of Medicine & Science in Sports. 24(4), pp. e299-e305. https://doi.org/10.1111/sms.12171
The financial cost of hamstring strain injuries in the Australian Football League
Hickey, Jack, Shield, Anthony J., Williams, Morgan D. and Opar, David A. (2014). The financial cost of hamstring strain injuries in the Australian Football League. British Journal of Sports Medicine. 48(8), pp. 729-730. https://doi.org/10.1136/bjsports-2013-092884
Acute hamstring strain injury in track-and-field athletes: A 3-year observational study at the Penn Relay Carnival
Opar, David, Drezner, Jonathan, Shield, Anthony, Williams, Morgan, Webner, David, Sennett, Brian, Kapur, Rahul, Cohen, M., Ulager, James and Cafengiu, Ana. (2014). Acute hamstring strain injury in track-and-field athletes: A 3-year observational study at the Penn Relay Carnival. Scandinavian Journal of Medicine & Science in Sports. 24(4). https://doi.org/10.1111/sms.12159
A novel device using the Nordic hamstring exercise to assess eccentric knee flexor strength: A reliability and retrospective injury study
Opar, David, Piatowski, Timothy, Williams, Morgan and Shield, Anthony J.. (2013). A novel device using the Nordic hamstring exercise to assess eccentric knee flexor strength: A reliability and retrospective injury study. Journal of Orthopaedic and Sports Physical Therapy. 43(9), pp. 636 - 640. https://doi.org/10.2519/jospt.2013.4837
Rate of torque and electromyographic development during anticipated eccentric contraction is lower in previously strained hamstrings
Opar, David A., Williams, Morgan D., Timmins, Ryan G. and Dear, Nuala M. (2013). Rate of torque and electromyographic development during anticipated eccentric contraction is lower in previously strained hamstrings. The American Journal of Sports Medicine. 41(1), pp. 116-125. https://doi.org/10.1177/0363546512462809
The role of neuromuscular inhibition in hamstring strain injury recurrence
Fyfe, Jackson, Opar, David, Williams, Morgan and Shield, Anthony. (2013). The role of neuromuscular inhibition in hamstring strain injury recurrence. Journal of Electromyography and Kinesiology. 23(3), pp. 523-530. https://doi.org/10.1016/j.jelekin.2012.12.006
Knee flexor strength and bicep femoris electromyographical activity is lower in previously strained hamstrings
Opar, David A., Williams, Morgan D., Timmins, Ryan G., Dear, Nuala M. and Shield, Anthony J. (2013). Knee flexor strength and bicep femoris electromyographical activity is lower in previously strained hamstrings. Journal of Electromyography and Kinesiology. 23(3), pp. 696-703. https://doi.org/10.1016/j.jelekin.2012.11.004
Hamstring strain injuries : Factors that lead to injury and re-injury
Opar, David A., Williams, Morgan D. and Shield, Anthony J. (2012). Hamstring strain injuries : Factors that lead to injury and re-injury. Sports Medicine. 42(3), pp. 209-226. https://doi.org/10.2165/11594800-000000000-00000