The Impact of Nordic Hamstring Exercise

and Prevention Programs on Incidence

Hamstring Injury in Football Players:
A Systematic Review and Meta-analysis

Rizkie Andika Ainur Rofiq1(B) , Suryo Saputra Perdana1 , and Amalia Nur Azizah2
1 Faculty of Medicine, Universitas Muhammadiyah Surakarta, Surakarta, Indonesia
[email protected]
2 Physiotherapy Department, National Paralympic Committee of Indonesia, Surakarta,

Indonesia

Abstract. Background: Football has a fairly high popularity and is admired by

people of various ages. Potential injury in football is rather high because, during
the game, each player is required to run at high speed. One of the most common
injuries is a hamstring injury. Thus, the purpose of this study is to ascertain whether
a program for preventing injuries that includes nordic hamstring exercises affects
the frequency of hamstring strains among football players. Method: The search
of the articles used four electronic databases (PUBMED, SCOPUS, University of
Cambridge, and PEDro) with a publication period of 2008 to 2022. Assessment
of study quality used the PEDro scale and meta-analysis used Review Manager
5.4. Results: There were eight articles in the systematic review and seven articles
in the meta-analysis. Significant results were obtained with p-value = 0.008 in
reducing the hamstring injury rate by administering injury prevention program
accompanied by nordic hamstring exercises. Conclusions: The systematic review
and meta-analysis revealed that hamstring injuries can be reduced by combining
injury prevention with nordic hamstring exercises.

Keywords: Preventive Program Injury · Nordic Hamstring Exercise · Hamstring

Injury in Soccer

1 Introduction

One of the most popular sports in the world is football, in which 3.6 million people
participate in and is favored by various age groups [1–3]. The potential injury for football
players is rather high because, during a football game, the players are required to run at
high speeds [4–7].
Causes of the injuries are excessive exercise, inadequate warm-up, age, gender, player
position, and fatigue [8]. A person with a history of previous injury entails the main risk
factor for future injury development [9]. The lower extremities, specifically the knee and
ankle joints are the most prevalent injured parts in football, and musculoskeletal strains

© The Author(s) 2023

B. Ichsan et al. (Eds.): ICHWB 2022, AHSR 61, pp. 530–545, 2023.
https://doi.org/10.2991/978-94-6463-184-5_45
 The Impact of Nordic Hamstring Exercise and Prevention Programs 531

occur in the quadriceps and hamstring muscles [10]. According to Diemer et al. (2020),
one of most common injuries in football is frequently mentioned to be a hamstring injury
[11].
Based on the results of Baseline Health Research (2013), it is recorded that the
incidences of sports injuries in Indonesia are 3,5% and in Central Java are 3,4% [12].
Injuries in football games, especially muscle injuries can be found in the main muscle
groups of the lower extremities with a percentage of 37% in the hamstring muscles, 23%
in adductor muscles, and 19% in quadriceps muscles [13]. Injuries to the hamstring have
the highest percentage of injuries among other injuries, namely 15–50% [14].
When the nordic hamstring exercise is used, hamstring injuries are reduced [15].
Due to its objective of increasing the ability to lower the rate of hamstring injuries and
hamstring muscle strength, the nordic hamstring is one of the exercises in the injury
prevention [16, 17]. Nordic hamstring exercise helps minimize hamstring strains by
65% to 70% [18].
To discover whether offering a hamstring injury prevention program simultanously
with nordic hamstring exercises will lower the frequency of hamstring strains in football
players, meta-analysis and systematic reviews should be conducted.

2 Method
According to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis
(PRISMA), this work used systematic review and meta-analysis techniques [19].

2.1 Search Strategy

The articles were searched using computerized databases. The electronic databases used
in this study are Medline Publications (PUBMED), SCOPUS, University of Cambridge,
and Physiotherapy Evidence Database (PEDro) with a publication period of 2008–2022.
The keywords in the search for articles in the database are “preventive program injury”
“nordic hamstring exercise” and “hamstring injury in soccer”.

2.2 Eligibility Criteria

The subsequent criteria for publications to be included in this study are: (1) RCT and
Cohort; (2) the population was football players; (3) used an injury prevention program
intervention accompanied by nordic hamstring exercises; (4) reported the hamstring
injuries rate. While the exclusion criteria in this study are as follows: (1) studies that
used case studies or did not use group comparisons; (2) the article was not available in
English. The purpose of this study was to compare the frequency of hamstring injuries.

2.3 Study Selection

After the overall collection of titles and abstracts, the articles underwent an eligibil-
ity check. The inclusion criteria were applied to find all pertinent articles. The article
selection process can be seen in Fig. 1.
532 R. A. A. Rofiq et al.

Fig. 1. PRISMA Flowchart

2.4 Data Extraction

Each article’s data were extracted, namely author, year, study design, sample size,
population, intervention, outcome, and results.

2.5 Assessment of Study Quality

In this study, the study quality assessment used the PEDro scale. A methodical evaluation
of the quality of studies included in systematic reviews across physiotherapy, health,
and medical research was conducted using the PEDro scale [20, 21]. The PEDro scale
included eleven points; one point was external validity, eight points were internal validity,
and two points were statistical comparisons. Interpretations of the total score are < 4
(poor); 4–5 (fair); 6–8 (good); 9–10 (excellent) [22].
 The Impact of Nordic Hamstring Exercise and Prevention Programs 533

2.6 Meta-analysis
Data from the meta-analysis were analyzed with Review Manager 5.4. The Review
Manager in this study was employed to calculate the value of differences in each group
using the 95% Confidence Interval (CI) and P value < 0.05 The P value < 0.05 showed
a noticeable difference and the P value > 0.05 indicated that there was no significant
difference.

3 Result
3.1 Search Results
The search in the electronic database found 1,044 articles, then duplicates were remoned
for for titles and abstracts and selected 723 articles. Subsequently, the articles would be
selected based on the inclusion criteria, and 35 articles were further selected. Of 27
articles were removed because they did not fit the requirements for inclusion, including
the following: (1) 19 articles did not use injury prevention interventions with nordic
hamstring exercises; (2) 5 articles did not list the hamstring strains; (3) 3 articles’ popu-
lation was not football players. As a result, Fig. 1 shows that the meta-analysis included
7 articles and 8 articles were analyzed in the systematic review.

3.2 Characteristic of Study Results

There were eight articles included in the paper, ranging from 2008 to 2019. One article
with a cohort study design and seven articles with a randomized control trials study
design, totaling 5.097 samples. The population in the article was football players aged
13–39 years. The intervention used was an injury prevention program with ordic ham-
string exercises. Four articles calculated hamstring strains, and three articles calculated
the injuries to the lower extremities (leg, ankle, knee, lower limbs, upper limbs, hip),
and one article calculating the injury rate to all parts of the body (head, upper limbs,
knee, foot, hands, torso, elbow, wrist, chest, neck, forearm, spine, arm, shoulder, wrist,
elbow) in Table 1.

3.3 Quality Assessment Results

Every article was rated “yes” or “no” (1 or 0) on the criteria listed on the PEDro scale.
The total score on the PEDro scale from criteria 2–11, the overall score was 0–11, and
criterion no. 1 was removed because it was more closely related to the external validity
[31–33]. There were two articles with “fair” interpretations and five articles with “good”
interpretations in Table 2.

3.4 Meta-analysis Results

Seven articles examined hamstring injury data by comparing two groups. The result
showed the statistical significance of reducing hamstring injury by giving an injury
prevention program accompanied by nordic hamstring training with p-value = 0.008 in
Fig. 2.
 534
Table 1. Characteristics of Studies

No. Authors Study Design Sample Population Intervention Duration Comparison Outcome Hasil
1 Engebretsen et al. RCT N: 508 Football Target EXC 10 weeks Control Injury rate ankle: IG = 13; CG
(2008) [23] group (ankle, knee, = 20
(Target hamstring,
EXC) groin)
NHE knee: IG = 7; CG =
8
R. A. A. Rofiq et al.

hamstring: IG = 23;
CG = 17
groin: IG = 11; CG
= 16
2 Soligard et al. Cluster-RCT N: 1892 13–17 years Warm Up 32 weeks Control Injury rate knee: IG = 35; CG =
(2009) [24] group (Warm (knee, ankle, 58
Up) leg, anterior
thigh,
hamstring,
hip)
Female NHE ankle: IG = 51; CG
= 52
Football leg: IG = 14; CG =
22
anterior thigh
hamstring: IG = 5;
CG = 8
(continued)
 Table 1. (continued)

No. Authors Study Design Sample Population Intervention Duration Comparison Outcome Hasil
hip: IG = 10; CG = 9
3 Petersen et al. RCT N: 942 Male Reguler 10 weeks Control Hamstring IG = 15; CG = 52
(2011) [25] Training group injury rate
(Reguler
Training)
Football NHE
4 Grooms et al. Cohort study N: 34 18–25 years F-MARC 11 6 weeks Control Injury rate hip flexor: IG = 0;
(2013) [26] + group (foot, ankle, CG = 1
(Warm Up) lower leg,
knee, thigh,
Male NHE hip) hamstring: IG = 1;
CG = 5
Football quadriceps: IG = 0;
CG = 3
groin: IG = 0; CG =
1
knee MCL: IG = 1;
CG = 0
knee meniscus: IG =
0; CG = 1
lower leg: IG = 1;
The Impact of Nordic Hamstring Exercise and Prevention Programs

CG = 1
ankle: IG = 0; CG =
0
535

(continued)
 536
Table 1. (continued)

No. Authors Study Design Sample Population Intervention Duration Comparison Outcome Hasil
midfoot: IG = 0; CG
=1
First
metatarsophalangeal
joint sprain (turf toe):
R. A. A. Rofiq et al.

IG = 1; CG = 0
5 Sebelien et al. RCT N: 119 18–39 years Warm Up 5 weeks Control Hamstring IG = 0; CG = 6
(2014) [27] group (Warm injury rate
Up)
Male NHE
Football
6 Del Ama RCT N: 43 Female Training 21 weeks Control Hamstring IG = 1; CG = 5
Espinosa et al. Program group injury rate
(2015) [28] (Training
Program)
Football NHE
(continued)
 Table 1. (continued)

No. Authors Study Design Sample Population Intervention Duration Comparison Outcome Hasil
7 Silvers-Granelli Cluster-RCT N: 1.525 18–25 years FIFA 11+ 32 weeks Control Injury rate knee: IG = 34; CG =
et al. (2015) [29] group (Warm (knee, ankle, 102
Up) hamstring,
head, foot,
groin, hip,
shoulder,
quadriceps,
leg, hand,
spine, torso,
elbow, neck,
wrist, chest,
arm,
forearm)
Male NHE ankle: IG = 59; CG
= 115
Football hamstring: IG = 16;
CG = 55
head: IG = 31; CG =
61
foot: IG = 22; CG =
49
groin: IG = 23; CG
The Impact of Nordic Hamstring Exercise and Prevention Programs

= 48
(continued)
537
 538
Table 1. (continued)

No. Authors Study Design Sample Population Intervention Duration Comparison Outcome Hasil
hip: IG = 16; CG =
45
shoulder: IG = 6; CG
= 30
quadriceps: IG = 25;
R. A. A. Rofiq et al.

CG = 44
leg: IG = 25; CG =
39
hand: IG = 6; CG =
10
spine: IG = 8; CG =
30
torso: IG = 9; CG =
10
elbow: IG = 2; CG =
9
wrist: IG = 0; CG =
7
neck: IG = 1; CG =
6
chest: IG = 0; CG =
3
arm: IG = 1; CG = 1
(continued)
 Table 1. (continued)

No. Authors Study Design Sample Population Intervention Duration Comparison Outcome Hasil
forearm: IG = 0; CG
=1
8 Elerian, RCT N: 34 21–35 years Warm Up 12 weeks Control Hamstring IG = 1; CG = 4
El-Sayyad, and Group (Dose injury rate
Dorgham (2019) difference)
[30]
Male NHE
Football
RCT = Randomized Controlled Trial; EXC = Exercise; NHE = Nordic Hamstring Exercise; MCL = Medial Collateral Ligament; IG = Intervention
Group; CG = Control Group
The Impact of Nordic Hamstring Exercise and Prevention Programs
539
540 R. A. A. Rofiq et al.

Fig. 2. Forest Plot: Nordic Hamstring Exercise and Prevention Program Injury on Incidence
Hamstring Injury

Table 2. Assessment of Study Quality PEDro Scale

Study Criteria Total

1 2 3 4 5 6 7 8 9 10 11
Engebretsen et al. (2008) 0 1 0 1 0 0 0 1 0 1 0 4
Soligard et al. (2009) 1 1 1 1 0 0 0 1 1 1 1 7
Petersen et al. (2011) 0 1 0 1 1 1 1 1 0 1 1 8
Sebelien et al. (2014) 1 1 0 1 1 0 0 1 0 1 1 6
Del Ama Espinosa et al. (2015) 0 1 0 1 1 0 1 1 0 1 0 6
Silvers-Granelli et al. (2015) 1 1 0 1 0 0 0 1 0 1 1 5
Elerian, El-Sayyad, and Dorgham (2019) 1 1 1 1 0 0 0 1 0 1 1 6
“1” = “yes”; “0” = “no”; Criteria: 1 Requirements for eligibility were stated (not used for scoring);
2 Randomly selected groups were assigned to subjects; 3 The allocation was concealed; 4 At
the beginning, the groups perspectives on the most crucial prognostic factors were identical; 5
The subjects were all blinded; 6 All therapists who delivered the therapy were blinded; 7 Every
assessor who took at least one measurement major outcome was blinded; 8 More than 85% of the
participants, who were initially divided into groups had measurements of at least one important
outcome; 9 The treatment or control condition was administered to all subjects for whom outcome
measurements were available, or in the event that this was not possible, data for at least one
significant outcome was evaluated using the “intention-to-treat” method; 10 At least one critical
outcome was in the between-group statistical comparison data given; 11 For at least one important
result, the study gave both point measurements and variability measures.

4 Discussion

The meta-analysis and systemic review purpose were to determine the impact of giving a
program for injury prevention together with nordic hamstring exercises on the frequency
of hamstring strains. FIFA 11+ is one of the prevention programs, in which the program
is an alternative warm-up to treat injuries in the lower extremities in football. Injury
prevention programs can be carried out before and after exercise [34]. The goal of the
nordic hamstring exercise is to improve the hamstring’s eccentric strength to prevent
hamstring injuries [24].
 The Impact of Nordic Hamstring Exercise and Prevention Programs 541

Giving an injury prevention program accompanied by nordic hamstring exercises

may cause architectural changes in the muscles, especially in the biceps femoris muscle,
when the condition of the fascicle biceps femoris can be lengthened after being treated
with an injury prevention program accompanied by nordic hamstring exercises. The
benefit of fascicle biceps femoris lengthening is it could increase muscle extensibility,
which can affect the risk of injury. Thus, an improving hamstring eccentric strength
and the possibility of hamstring strains can be reduced by extending the biceps femoris
fascicle, resulting in a reduction in hamstring injuries’ frequency [35, 36].
The meta-analysis studying seven articles with a randomized controlled trial showed
significant results in providing an injury prevention program accompanied by nordic
hamstring exercises to improve the hamstring strains rate in football players. These
results correspond to previous studies, according to Del Ama Espinosa et al. (2015),
compared two groups, namely the intervention group and the control group. Eccentric
training program of nordic hamstring exercises were given to the intervention group for
23 weeks. The exercise program for the control group incorporated multiple jumping
(MJ) and side leg swings (SLS). The results of the occurrence of hamstring strains in
the control group were 23.8% and the intervention group was 4.5%. Due to the small
number of samples (n: 43), the study’s primary found there was no significant difference
between groups in the statistical part, but the intervention program implemented could
reduce hamstring strains by 81% [28].
In Soligard et al. (2009) study, with a total sample of 1.892, two groups were created
from the sample, namely the control group with intervention of a warm-up that was
commonly used and the intervention group which was given injury prevention program
accompanied by nordic hamstring exercises. According to this study, severe injuries
could be decreased by half and the risk of injury could be cut by up to a third, however
the main results of lower extremities did not reach significance. Nevertheless, there was
a considerable decline in several factors, and hamstring injury is one of them. It obtained
3.1% in the intervention group and 3.7% in the control group. The main result did not
reach significance due to the low level of compliance in the program implementation
since players who followed the guidelines often had a lesser risk of injury [24].
The study conducted by Soligard et al. (2009) was relevant with Silvers-Granelli
et al. (2015) that used FIFA 11+ intervention accompanied by nordic hamstring and
compared two groups. Intervention given to this study statistically reduced injury rate in
male football players significantly with the intervention group (n:675), having a 5.6%
hamstring injury percentage and in the control group (n: 850) 8.3%. The compliance
level in football players greatly affected the injury rate because the higher the level of
the player’s compliance, the lower the level of reported injuries, and when the training
program was being implemented, ensuring the players were not fatigued was essential
[29].
Based on the study conducted by Elerian, El-Sayyad, and Dorgham (2019), the
interventions used were warmup and nordic hamstring exercises. Additionally, it was
also divided into three groups, namely: (1) the first intervention group was given the
nordic hamstring before and after the exercise; (2) the second intervention group was
only administered with the nordic hamstring before the exercise; and (3) nordic ham-
string exercise was not treated to the control group. The training program was given for
542 R. A. A. Rofiq et al.

12 weeks. There were significant differences in the hamstring injury rates in each group,
namely (1) the first intervention group was 5.9%; (2) the second intervention group was
23.5%; and (3) control group was 62.5%. The level of compliance in each group was
rather high (>95%), and injury risk decreased as more players complied [30].
According to Whalan et al.’s (2019) research, there were distinct major variations
between the two groups, each of which showed a different reduction in injury rates,
namely the FIFA 11+ standard group was 38% and the P2 post group was 35%. The
hamstring injury rate in FIFA11+ standard group was 51 and the P2 group post was
45. In the P2 group post, modifications to FIFA11+ were made, namely rescheduling
FIFA11+ by doing sessions 1 and 3 at the beginning of the exercise and part 2 (nordic
hamstring) after the end of the workout, which was the cool-down period. Rescheduling
can increase compliance and program effectiveness [34].

5 Conclusion

Based on the findings of systematic review and meta-analysis to determine the impact of
injury prevention programs and nordic hamstring exercises on the frequency of hamstring
strains in football players, it is revealed that there was a declining trend in the hamstring
strains rate. Further research should consider the sample’s compliance with the given
program because of its importance to the study’s findings, as well as reconsidering the
number of samples that will be used in the study.

Acknowledgment. All authors fully contributed from the initiation of the article writing to its
completion. The authors would like to thank the Physiotherapy Study Program of the Universitas
Muhammadiyah Surakarta for the support until the completion of this article.

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