Prevention of hamstring injuries

in male soccer
Exercise programs and return to play

Nick van der Horst

Cover Sharon van der Horst | CherryTells
Layout Renate Siebes | Proefschrift.nu
Printed by ProefschriftMaken | proefschriftmaken.nl
ISBN 978-90-393-6689-9

© 2017  Nick van der Horst

All rights reserved. No part of this publication may be reproduced or transmitted in any
form or by any means, electronic or mechanical, including photocopy, recording, or any
information storage or retrieved system, without permission in writing from the author.
Prevention of hamstring injuries
in male soccer
Exercise programs and return to play

Preventie van hamstringblessures in voetbal

Oefenprogramma’s en sporthervatting

(met een samenvatting in het Nederlands)

Proefschrift

ter verkrijging van de graad van doctor aan de

Universiteit Utrecht op gezag van de rector magnificus,
prof.dr. G.J. van der Zwaan, ingevolge het besluit van het
college voor promoties in het openbaar te verdedigen
op donderdag 9 maart 2017 des ochtends te 10.30 uur

door

Nick van der Horst

geboren op 14 februari 1986

te Utrecht
Promotor: Prof.dr. F.J.G. Backx

Copromotoren: Dr. D.W. Smits

Dr. B.M.A. Huisstede

The studies described in this thesis were financially supported by ZonMw (50-50130-
98-152) and the Royal Netherlands Football Association (KNVB).

The printing and distribution of this thesis was financially supported by ValD Performance,
Universitair Centrum Sportgeneeskunde (UCS), ProCarebv, Academie Instituut Fysiothe-
rapie PLUS, the Scientific College Physical Therapy (WCF) of the Royal Dutch Society
for Physical Therapy (KNGF), the Dutch Society of Physical Therapy in Sports Health
care (NVFS), Disporta, Herzog Medical, and Nederlands Paramedisch Instituut (NPi).
Nil Volentibus Arduum
 Contents

Chapter 1 General introduction 9

Chapter 2 How effective are exercise-based injury prevention 25

programmes for soccer players? A systematic review

Chapter 3 The preventive effect of the Nordic hamstring exercise on 45

hamstring injuries in amateur soccer players: study protocol
for a randomized controlled trial

Chapter 4 The preventive effect of the Nordic hamstring exercise on 61

hamstring injuries in amateur soccer players: a randomized
controlled trial

Chapter 5 Hamstring-and-lower-back flexibility in male amateur soccer 81

players

Chapter 6 No relationship between hamstring flexibility and hamstring 97

injuries in male amateur soccer players: a prospective study

Chapter 7 Return to play after hamstring injuries: a qualitative systematic 113

review of definitions and criteria

Chapter 8 Return to play after hamstring injuries in football (soccer): 145

a worldwide Delphi procedure regarding definition, medical
criteria, and decision-making

Chapter 9 General discussion 169

Summary of chapters 191

Nederlandse samenvatting 197
Dankwoord 203
About the author
Curriculum vitae 212
Publication list 213
PhD portfolio summary 214
 Chapter 1

General introduction
Chapter 1

“An ounce of prevention is worth a pound of cure”

- Benjamin Franklin (1706 – 1790)

The name of the ‘hamstrings’ muscle appears to originate from the early butchery trade
in the second half of the 16th century.1 Slaughtered pigs were hung from their strong
tendons on the back of the upper leg, hence the reference to ‘ham’ (meaning ‘crooked’
and thus referring to the knee, the crooked part of the leg) and ‘string’ (referring to the
string-like appearance of the tendons).2

10
 General introduction
1

General introduction
Injury prevention is a vital part of any sport. Soccer is the most popular sport worldwide,
with more than 275 million participants of both sexes and among all age groups.3
Unfortunately, the beneficial health effects of playing soccer regularly are tempered by
a high injury rate.4-9 Injury incidence rates of 20.4–36.9 injuries per 1000 match hours
and 2.4–3.9 injuries per 1000 training hours have been reported in male amateur soccer,
which is the largest subgroup of soccer players.4,10 Hamstring injuries are the most
common soccer-related muscle injury, accounting for 37% of all soccer muscle injuries.
They require extensive treatment and long rehabilitation periods.4,6,11,12 The amount of
tissue damage of the hamstring muscle determines when the affected player can start
playing soccer again.13 Hamstring injuries are commonly graded from 0 to 3, based on
MRI-findings (see Table 1.1).14 Ekstrand et al. found that soccer players with grade 0
hamstring injuries could resume full training after 8 (± 3) days; the lay-off time was 17
(± 10) days for grade 1 injuries, 22 (± 11) days for grade 2 injuries, and 73 (± 60) days
for grade 3 injuries.13

Table 1.1  Radiological grading of hamstring injury13

Grade 0 Negative MRI without any visible pathology

Grade I Oedema but no architectural distortion

Grade II Architectural disruption indicating partial tear

Grade III Total muscle or tendon rupture

Hamstring injuries are notorious for their high rate of recurrence (12–33%).11,12,15,16
Unfortunately, despite extensive research into the rehabilitation of hamstring injuries,
injury occurrence and recurrence rates have not improved in the last 30 years.17-19 The
high recurrence rate is suggested to be due to inadequate rehabilitation and/or a too
early return-to-play after a hamstring injury.20,21

Understanding the functional anatomy, aetiology and mechanisms of injuries is essential

to understanding the causes of any particular type of injury in a given sport.22 It also
makes it possible to design preventive strategies.22

11
Chapter 1

Terminology and functional anatomy of the hamstrings

The collective term ‘hamstrings’ refers to three posterior thigh muscles; the semitendi-
nosus muscle, the semimembranosus muscle and the biceps femoris muscle, the latter
consisting of a long head and a short head.23 The hamstring muscles originate at the
ischial tuberosity, from where the semimembranosus, semitendinosus, and long head
of the biceps femoris pass posterior from the hip and knee joints (see Figure 1.1). The
short head of the biceps femoris is monoarticular, crossing only the knee joint. The
main function of the hamstrings is knee flexion and hip extension, but they also assist
in internal (semimembranosus and semitendinosus) and external (biceps femoris) rota-
tion of the knee.

Figure 1.1  Anatomy of the hamstrings.

Aetiology and injury mechanisms of hamstring injuries

Hamstring injuries can be subdivided into two types: the stretch-type hamstring injury
and the sprint-type hamstring injury. Stretch-type hamstring injuries are caused by a
slow or sudden uncontrolled stretch and occur most frequently in dancing, gymnastics,

12
 General introduction
1

and (water)skiing.12 This type of injury typically occurs in the proximal free tendon of
the semimembranosus muscle.24 Although the clinical presentation of the stretch-type
injury is usually mild at first, this type of hamstring injury generally implies a longer
rehabilitation time.24

Sprint-type hamstring injuries occur in explosive running and cutting sports, such as
soccer, athletics, rugby, field hockey, and the various varieties of football (e.g. soccer,
Australian Rules Football, American Football etc.). In more than 80% of cases, the injury
is located in the long head of the biceps femoris.25,26 Biomechanical analyses have shown
that sprint-type hamstring injuries typically occur in the latter part of the swing phase
during sprinting.27-29 Before the foot hits the ground, the hamstring is (sub)maximally
stretched over the knee joint, but at the same time it has to counter isokinetic forces from
the preswinging leg.27,28 The higher the sprinting velocity, the greater these isokinetic
forces are.27,28 The vulnerability of the hamstrings to injury during this phase of sprinting
is associated with insufficient eccentric hamstring strength.20,30,31

The studies described in this thesis focus on sprint-type hamstring injuries, unless stated
otherwise.

Risk factors for hamstring injuries

The causes for hamstring injuries are multifactorial,32 and a number of potential risk factors
have been identified.21,33,34 Some of the risk factors are non-modifiable, such as age,
sex and ethnic origin.35 Modifiable risk factors can be divided into intrinsic and extrinsic
factors. Intrinsic risk factors are player related, such as muscle weakness, instability, poor
fatigue, poor flexibility, poor core stability, and psychological factors.21,33,34 Extrinsic
factors are environment related, such as playing surface, level of play, field position,
and insufficient warm-up.21,33,34

Review of the literature on risk factors for hamstring injuries revealed a previous hamstring
injury to be the single main risk factor for future hamstring injury,21,33,34 increasing the
risk two- to six-fold compared with no prior hamstring injury.11,36,37 Interestingly, some
studies also identified a history of other injuries, such as anterior cruciate ligament
reconstruction, calf muscle strain, and knee injuries to be associated with an increased
risk of hamstring injury.38,39 Body mass index, weight, height, body composition, hip

13
Chapter 1

internal rotation range of motion (ROM), hip external rotation ROM, MRI data, limb
dominance, playing surface, and playing position are not associated with an increased
risk of hamstring injury.33,34,40 There is conflicting evidence that older age, increased
quadriceps peak torque, reduced hip extension ROM, Aboriginal or black origin, and
hamstring flexibility and strength imbalances increase the risk of hamstring injury.33,34
The role of muscle strength and flexibility imbalances is particularly interesting because
these are modifiable risk factors and potential points of engagement for hamstring
injury prevention.

From research to real-life prevention

Considering the high (re-)injury rates as well as the impact on the injured athlete, research
on hamstring injury prevention is warranted. Finch et al. developed the ‘TRIPP-framework’
for translating research findings into real-life sports injury prevention (see Figure 1.2) .41
In the first step of the TRIPP-framework, the extent of the injury is assessed in terms of
injury incidence and severity. Then, in the second step, risk factors and injury mechanisms
that contribute to the sports injury are established. In the third step, preventive measures
to reduce the future risk and/or severity of sports injuries are developed, based on the
risk factors and injury mechanisms identified in the second step. In the fourth step,

Model TRIPP
stage

1 Injury surveillance

2 Establish aetiology and mechanisms

of injury

3 Develop preventive measures

4 “Ideal conditions”/scientific
evaluation

5 Describe intervention context to

inform implementation strategies

6 Evaluate effectiveness of preventive

measures in implementation context

Figure 1.2  The Translating Research into Injury Prevention Practice (TRIPP) framework.41

14
 General introduction
1

the preventive measures are introduced and their effectiveness evaluated. This can be
achieved by time trend analyses or, as stated by Bahr and Krosshaug, preferably by
means of a randomised controlled trial.22 In TRIPP-stage 5, the outcomes of efficacy
research are translated into actions to be actually implemented in the real-world context,
in order to develop and understand the implementation context. In the final step, the
intervention is implemented and evaluated in a real-world context. In other words: is
the scientifically proven intervention also effective in real-life? This involves considering
the complex relationships between TRIPP-steps 1 and 5 too.41

Several studies have reported epidemiological data on hamstring injuries in professional

and soccer players,6,12,42,43 from which it can be concluded that hamstring injury rates in
soccer have not improved over the last three decades.17-19 Therefore, further research
on preventive strategies for hamstring injuries is required.

Hamstring injury prevention

Many interventions for preventing of hamstring injuries have been developed and
evaluated, such as proprioceptive balance training,44-46 massage,47 education,48 functional
training and sport-specific drills,49,50 and stretching and strengthening exercises.51-54
Understanding the causes and injury mechanisms of any particular type of injury is
fundamental for developing preventive measures.22 As previously stated (see ‘aetiology
and injury mechanisms of hamstring injuries’), biomechanical analyses have shown that
the risk of hamstring injury during high-speed running is associated with inadequate
eccentric hamstring strength.20,30,31 As a result, a number of exercise programmes
focusing on eccentric hamstring strength have been developed and studied over the
past 15 years.52-57

Nordic Hamstring Exercise

The Nordic hamstring exercise or Nordic curl, a partner-exercise aimed at improving
eccentric hamstring strength, has proven promising for reducing the rate of hamstring
injury.54 The Nordic hamstring exercise can easily be incorporated into regular soccer
training sessions,54 and previous studies of male professional soccer showed that
its use reduced the incidence of hamstring injury, and especially recurrent injuries,

15
Chapter 1

by 65% to 70%.52,54 Although the results of these studies of professional soccer are
promising, differences between professional and amateur soccer players in terms of
medical supervision, level of play, training exposure, training intensity, and compliance
with preventive measures mean that data for professional players cannot necessarily
be extrapolated to amateur players. Thus the Nordic hamstring exercise needs to be
tailored, tested and evaluated in non-professional soccer players. Our Hamstring Injury
Prevention Strategies (HIPS) project, a large randomized controlled trial, investigated
the preventive effect of the Nordic hamstring exercise on hamstring injuries in male
amateur soccer players.

Return to play after hamstring injury

Unfortunately, eliminating all hamstring injuries from soccer through preventive strategies
still seems a utopia. Once the initial hamstring injury has occurred, the risk of future
hamstring injury increases two- to sixfold.11,36,37 In fact, 59% of all recurrent hamstring
injuries occur within the first month after RTP.58,59 This suggests that the high rate of
recurrent hamstring injuries is due to inadequate rehabilitation and/or a too early return
to full training and match play.20,21

In the last decade, a growing interest in research has risen on return to play after
hamstring injury, including attributed criteria for RTP after hamstring injury. Despite this,
the concept of return to play is seldom defined, and a wide variety of criteria are used to
support the return to play decision after hamstring injury. The lack of a clear definition
of return to play in the literature is a problem for clinicians as well as researchers, as it
makes comparing studies on this topic very difficult. Additionally, there is no consensus
among researchers or clinicians about which medical criteria should guide the return to
play decision after hamstring injury.

The aims and outline of this thesis

The studies described in this thesis focus on the prevention of hamstring injuries and
return to play after hamstring injuries in soccer players.

Several exercise programs, such as the well-known ‘FIFA11’,62 have been developed to
prevent soccer injuries. However, the literature on the effectiveness of these programs

16
 General introduction
1

has not been systematically reviewed. Therefore, we conducted a systematic review on

the effectiveness of general exercise-based injury prevention programmes for soccer
players (Chapter 2).

An eccentric hamstring strength-training programme based on the Nordic hamstring

exercise showed promising results in reducing hamstring injuries in professional soccer
players. However, as there are too many potential differences between professional and
amateur soccer players (such as medical supervision, level of play, training exposure,
training intensity, and compliance with preventive measures), results obtained for
professional players cannot necessarily be extrapolated to amateur soccer players.
Therefore, our HIPS (Hamstring Injury Prevention Strategies) study focused on the
effectiveness of the Nordic hamstring exercise in amateur soccer players. Chapter 3
describes the design of this randomized controlled trial.

It was hypothesized that implementation of a tailored Nordic hamstring exercise protocol

during regular training would reduce the incidence and severity of hamstring injuries.
The results of this intervention study, which involved more than 500 players from 32
amateur soccer teams in the Netherlands, are presented in Chapter 4.

In the literature, there is ongoing debate about whether hamstring flexibility is associated
with the risk of hamstring injury.21,33,34 To provide new information for this debate, a
population of amateur soccer players performed hamstring flexibility tests (e.g. the
Sit-and-Reach Test). Chapter 5 describes normative values for the sit-and-reach test in
amateur soccer players. The association between hamstring flexibility and hamstring
injury risk was analysed in Chapter 6, with adjustment for potential confounders such
as age and injury history.

Unfortunately, hamstring injuries may still occur. After the initial injury, the soccer player’s
risk of sustaining a recurrent hamstring injury increases significantly. Since most recurrent
hamstring injuries have been suggested to occur because of inadequate rehabilitation
and/or a too early return to play, evaluation of a player’s readiness for return to play is
essential to prevent recurrent hamstring injuries.20,21,58 Many different definitions and
criteria are used in research as well as daily practice to assess readiness to return to
play. In order to provide an overview of the concept of return to play after hamstring
injuries, the study described in Chapter 7 provides a systematic review of definitions
and criteria used for return to play after hamstring injury used in the literature.

17
Chapter 1

The results of this systematic review were used as a starting point for a Delphi consen­
sus procedure. A worldwide panel of experts, selected by the FIFA Medical Centers of
Excellence network, participated in the Delphi consensus procedure in order to generate
one clear definition of return to play after hamstring injury as well as its attributed criteria.
The results of this study are presented in Chapter 8.

Lastly, in Chapter 9, the general discussion addresses the most important findings of
the studies, the study limitations, and recommendations for clinicians, researchers, and
policymakers regarding future strategies for preventing hamstring injuries in soccer.

18
 General introduction
1

References
1. Golding A. Her hamstrings and her knees were stiffe. Ovid Fyrst Fower Bks. Metamorphosis II
1565:13.

2. Dictionary.com Unabridged. “hamstring”. Random House, Inc. http://www.dictionary.com/browse/

hamstring (accessed May 14, 2016)

3. FIFA. FIFA Big Count. Zürich, Switzerland: FIFA Communications Division, Information Services;
2007.

4. Van Beijsterveldt AMC, Stubbe JH, Schmikli SL, et al. Differences in injury risk and characteristics
between Dutch amateur and professional soccer players. J Sci Med Sport 2015;18(2):145-149.

5. Dvorak J, Junge A. Football injuries and physical symptoms. A review of the literature. Am J Sports
Med 2000;28(5 Suppl):S3-S9.

6. Ekstrand J, Hägglund M, Waldén M. Epidemiology of muscle injuries in professional football

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

7. Ekstrand J, Hägglund M, Waldén M. Injury incidence and injury patterns in professional football:
the UEFA injury study. Br J Sports Med 2011;45(7):553-558.

8. Schmikli SL, de Vries WR, Inklaar H, et al. Injury prevention target groups in soccer: injury
characteristics and incidence rates in male junior and senior players. J Sci Med Sport 2011;14(3):199-
203.

9. Wong P, Hong Y. Soccer injury in the lower extremities. Br J Sports Med 2005;39(8):473-482.

10. Kordi R, Hemmati F, Heidarian H, et al. Comparison of the incidence, nature and cause of injuries
sustained on dirt field and artificial turf by amateur football players. Sports Med Arthrosc Rehabil
Ther Technol 2011;3:3.

11. Hägglund M, Waldén M, Ekstrand J. Previous injury as a risk factor for injury in elite football: a
prospective study over two consecutive seasons. Br J Sports Med 2006;40(9):767-772.

12. Woods C, Hawkins RD, Maltby S, Hulse M, Thomas A, Hodson A, Football Association Medical
Research Programme. The football association medical research programme: an audit of injuries
in professional football - analysis of hamstring injuries. Br J Sports Med 2004;38(1):36-41.

13. Ekstrand J, Healy JC, Waldén M, et al. Hamstring muscle injuries in professional football: the
correlation of MRI-findings with return to play. Br J Sports Med 2012;46(2):112-117.

14. Peetrons P. Ultrasound of muscles. Eur Radiol 2002;12(1):35-43.

15. Hägglund M, Waldén M, Ekstrand J. Risk factors for lower extremity muscle injury in professional
soccer: the UEFA Injury Study. Am J Sports Med 2013;41(2):327-335.

16. Heiderscheit BC, Sherry MA, Silder A, et al. Hamstring strain injuries: recommendations for
diagnosis, rehabilitation, and injury prevention. J Orthop Sports Phys Ther 2010;40(2):67-81.

17. Ekstrand J, Gillquist J. Soccer injuries and their mechanisms: a prospective study. Med Sci Sports
Exerc 1983;15(3):267-270.

18. Werner J, Hägglund M, Waldén M, et al. UEFA injury study: a prospective study of hip and groin
injuries in professional football over seven consecutive seasons. Br J Sports Med 2009;43(13):1036-
1040.

19
Chapter 1

19. Orchard JW, Seward H, Orchard JJ. Results of 2 decades of injury surveillance and public release
of data in the Australian Football League. Am J Sports Med 2013;41(4):734-741. 


20. Opar DA, Williams MD, Shield AJ. Hamstring strain injuries: factors that lead to injury and re-injury.
Sports Med 2012;42(3):209-226. 


21. De Visser HM, Reijman M, Heijboer MP, et al. Risk factors of recurrent hamstring injuries: a systematic
review. Br J Sports Med 2012;46(2):124-130.

22. Bahr R, Krosshaug T. Understanding injury mechanisms: a key component of preventing injuries
in sport. Br J Sports Med 2005;39(6):324-329.

23. Van der Made AD, Wieldraaijer T, Kerkhoffs GM, et al. The hamstring muscle complex. Knee Surg
Sport Traumatol Arthrosc 2015;23(7):2115-2122.

24. Askling CM, Tengvar M, Saartok T, et al. Acute first-time hamstring strains during slow-speed
stretching: clinical, magnetical resonance imaging, and recovery characteristics. Am J Sports Med
2007;35(10):1716-1724.

25. Askling CM, Tengvar M, Saartok T, et al. Acute first-time hamstring strains during high-speed
running: a longitudinal study including clinical and magnetic resonance imaging. Am J Sports
Med 2007;35(2):197-206.

26. De Vos RJ, Reurink G, Goudswaard GJ, et al. Clinical findings just after return-to-play predict
hamstring re-injury, but baseline MRI findings do not. Br J Sports Med 2014;48(18):1377-1384.

27. Chumanov ES, Heiderscheit BC, Thelen DG. The effect of speed and influence of individual muscles
on hamstring mechanics during the swing phase of sprinting. J Biomech 2007;40(16):3555-3562.


28. Chumanov ES, Heiderscheit BC, Thelen DG. Hamstring musculotendon dynamics during stance
and swing phases of high-speed running. Med Sci Sports Exerc 2011;43(3):525-532.

29. Schache AG, Dorn TW, Blanch PD, et al. Mechanisms of the human hamstring muscle during
sprinting. Med Sci Sports Exerc 2012;44(4):647-658.

30. Croisier JL, Forthomme B, Namurois MH, et al. Hamstring muscle strain recurrence and strength
performance disorders. Am J Sports Med 2002;30(2):199-203.

31. Croisier JL, Ganteaume S, Binet J, et al. Strength imbalances and prevention of hamstring injury
in professional soccer players: a prospective study. Am J Sports Med 2008;36(8): 1469-1475.

32. Mendiguchia J, Alentorn-Geli E, Brughelli M. Hamstring strain injuries: are we heading in the right
direction? Br J Sports Med 2012;46(2):81-85.

33. Van Beijsterveldt AMC, van de Port IG, Vereijken AJ, et al. Risk factors for hamstring injuries in male
soccer players: a systematic review of prospective studies. Scand J Med Sci Sports 2013;23(3):253-
262.

34. Freckleton G, Pizzari T. Risk factors for hamstring muscle strain injury in sport: a systematic review
and meta-analysis. Br J Sports Med 2013;47(6)351-358.

35. Bahr R, Holme I. Risk factors for sports injuries – a methodological approach. Br J Sports Med
2003;37(5):384-392.

36. Engebretsen AH, Myklebust G, Holme I, et al. Intrinsic risk factors for hamstring injuries among
male soccer players: a prospective cohort study. Am J Sports Med 2010;38(6):1147-1153.

20
 General introduction
1

37. Verrall GM, Slavotinek JP, Barnes PG, et al. Clinical risk factors for hamstring muscle strain injury:
a prospective study with correlation of injury by magnetic resonance imaging. Br J Sports Med
2001;35(6):435-439.

38. Koulouris G, Connell DA, Brukner P, et al. Magnetic resonance imaging parameters for assessing
risk of recurrent hamstring injuries in elite athletes. Am J Sports Med 2007;35(9):1500-1506.

39. Orchard JW. Intrinsic and extrinsic risk factors for muscle strains in Australian football. Am J Sports
Med 2001;29(3):300-303.

40. Rennie DJ, Vanrenterghem J, Littlewood M, et al. Can the natural turf pitch be viewed as a risk
factor for injury within Association Football? J Sci Med Sport 2016;19(7):547-552.

41. Finch C. A new framework for research leading to sports injury prevention. J Sci Med Sport
2006;9(1-2):3-9.

42. Ueblacker P, Müller-Wohlfart HW, Ekstrand J. Epidemiological and clinical outcome comparison
of indirect (‘strain’) versus direct (‘contusion’) anterior and posterior thigh muscle injuries in male
elite football players: UEFA elite league study of 2287 thigh injuries (2001-2013). Br J Sports Med
2015;49(22):1461-1465.

43. Van Beijsterveldt AM, Steffen K, Stubbe JH, et al. Soccer injuries and recovery in Dutch male
amateur soccer players: results of a prospective cohort study. Clin J Sport Med 2014;24(4):337-
342.

44. Junge A, Lamprecht M, Stamm H, et al. Countrywide campaign to prevent soccer injuries in Swiss
amateur players. Am J Sports Med 2011;39(1):57-63.

45. Emery CA, Meeuwisse WH. The effectiveness of a neuromuscular prevention strategy to reduce
injuries in youth soccer: a cluster-randomised controlled trial. Br J Sports Med 2010;44(8):555-562.

46. Kraemer R, Knobloch K. A soccer-specific balance training program for hamstring muscle and
patellar and achilles tendon injuries: an intervention study in premier league female soccer. Am J
Sports Med 2009;37(7):1384-1393.

47. Schroeder AN, Best TM. Is self myofascial release an effective preexercise and recovery strategy?
A literature review. Curr Sports Med Rep 2015;14(3):200-208.

48. Arnason A, Engebretsen L, Bahr R. No effect of a video-based awareness program on the rate of
soccer injuries. Am J Sports Med 2005;33(1):77-84.

49. Verrall GM, Slavotinek JP, Barnes PG. The effect of sports specific training on reducing the
incidence of hamstring injuries in professional Australian Rules football players. Br J Sports Med
2005(6);39:363-368.

50. Cameron ML, Adams RD, Maher CG, et al. Effect of the HamSprint Drills training programme on
lower limb neuromuscular control in Australian football players. J Sci Med Sport 2009;12(1):24-30.

51. Jamtvedt G, Herbert RD, Flottorp S, et al. A pragmatic randomised trial of stretching before and
after physical activity to prevent injury and soreness. Br J Sports Med 2010;44(14):1002-1009.

52. Arnason A, Andersen TE, Holme I, et al. Prevention of hamstring strains in elite soccer: an
intervention study. Scand J Med Sci Sports 2008;18(1):40-48.

53. 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. Sports Med 2004;14(5):311-
317.

21
Chapter 1

54. Petersen J, Thorborg K, Nielsen MB, et al. Preventive effect of eccentric loading acute hamstring
injuries in men’s soccer: a cluster-randomized controlled trial. Am J Sports Med 2011;39(11):2296-
2303.

55. Askling CM, Karlsson J, Thorstensson A. Hamstring injury occurrence in elite soccer players
after preseason strength training with eccentric overload. Scand J Med Sci Sports 2003;13:144-
150.

56. Gabbe BJ, Branson R, Bennell KL. A pilot randomised controlled trial of eccentric exercise to prevent
hamstring injuries in community-level Australian Football. J Sci Med Sport 2006;9(1-2):103-109.

57. Engebretsen AH, Myklebust G, Holme I, et al. Prevention of injuries among male soccer players:
a prospective, randomized intervention study targeting players with previous injuries or reduced
function. Am J Sports Med 2008;36(6):1052-1060.

58. Brooks JH, Fuller CW, Kemp SP, et al. Incidence, risk, and prevention of hamstring muscle injuries
in professional rugby union. Am J Sports Med 2006;34(8):1297-1306.

59. Wangensteen A, Tol JL, Witvrouw E, et al. Hamstring reinjuries occur at the same location and
early after return to sport: a descriptive study of MRI-confirmed reinjuries. Am J Sports Med
2016;44(8):2112-2121.

60. Bizzini M, Impellizzeri FM, Dvorak J, et al. Physiological and performance responses to the
“FIFA11+” (part 1): is it an appropriate warm-up? J Sports Sci 2013;31(13):1481-1490.

61. Krist MR, van Beijsterveldt AM, Backx FJ, et al. Preventive exercises reduced injury-related costs
among adult male amateur soccer players: a cluster-randomised controlled trial. J Physiother
2013;59(1):15-23.

62. Bizzini M, Junge A, Dvorak J. Implementation of the FIFA11+ football warm-up program: how
to approach and convince the Football associations to invest in prevention. Br J Sports Med
2013;47(12):803-806.

22
General introduction
1

23
 Chapter 2

How effective are exercise-based injury

prevention programmes for soccer
players? A systematic review

A.M.C. (Anne-Marie) van Beijsterveldt

N. (Nick) van der Horst
I.G.L. (Ingrid) van de Port
F. J.G. (Frank) Backx

Sports Med 2013;43(4):257-265
Chapter 2

Abstract
Background  The incidence of soccer (football) injuries is among the highest in
sports. Despite this high rate, insufficient evidence is available on the efficacy of
preventive training programmes on injury incidence.

Objective  To systematically study the evidence on preventive exercise-based

training programmes to reduce the incidence of injuries in soccer.

Data sources  The databases EMBASE/MEDLINE, Pubmed, CINAHL, Cochrane

Central Register of controlled trials, PEDro and SPORTDiscusTM were searched
for relevant articles, from inception until 20 December 2011. The methodological
quality of the included studies was assessed using the PEDro scale.

Study selection  The inclusion criteria for this review were (1) randomized con-
trolled trials or controlled clinical trials; (2) primary outcome of the study is the
number of soccer injuries and/or injury incidence; (3) intervention focusing on a
preventive training programme, including a set of exercises aimed at improving
strength, coordination, flexibility or agility; and (4) study sample of soccer players
(no restrictions as to level of play, age or sex). The exclusion criteria were: (1) the
article was not available as full text; (2) the article was not published in English,
German or Dutch; and (3) the trial and/or training programme relates only to
specific injuries and/or specific joints. To compare the effects of the different
interventions, we calculated the incidence risk ratio (IRR) for each study.

Results  Six studies involving a total of 6099 participants met the inclusion criteria.
The results of the included studies were contradictory. Two of the six studies (one
of high and one of moderate quality) reported a statistical significant reduction in
terms of their primary outcome, i.e. injuries overall. Four of the six studies described
an overall preventive effect (IRR < 1), although the effect of one study was not
statistically significant. The three studies that described a significant preventive
effect were of high, moderate and low quality.

Conclusions  Conflicting evidence has been found for the effectiveness of exercise-
based programmes to prevent soccer injuries. Some reasons for the contradictory
findings could be different study samples (in terms of sex and soccer type) in the
included studies, differences between the intervention programmes implemented
(in terms of content, training frequency and duration), and compliance with the
programme. High-quality studies investigating the best type and intensity of
exercises in a generic training programme are needed to reduce the incidence
of injuries in soccer effectively.

26
 Injury prevention programmes for soccer players

Introduction
With approximately 265 million participants, soccer (football) is the most popular sport
in the world across both sexes and all age groups.1 In addition to the social aspect 2
of the sport, soccer also has beneficial health-related effects.2 It challenges physical
fitness by requiring a variety of skills at different intensities. Running, sprinting, jumping
and kicking are important performance components, requiring maximal strength and
anaerobic power of the neuromuscular system.3,4 Consequently, this popular sport also
has high injury rates.5

Soccer injuries come in a wide variety, but most injuries affect the lower extremities,
including the upper leg, knee and ankle.6,7 In view of the frequency of injury, the resulting
costs and not least the personal suffering of the injured players, many studies have
focused on injury prevention measures in soccer.8-10 Several options for preventing soccer
injuries have been developed, ranging from protective equipment (e.g. shin guards),11-13
to warm-up and cool-down routines.11,14-16

Intervention programmes focusing on intrinsic risk factors for specific injuries have
achieved significant reductions of soccer injuries. For instance, previous studies showed
that eccentric strength training reduced the risk of hamstring injury in heterogeneous
populations of soccer players.17-19 It has also been shown that neuromuscular training
appears to be effective to reduce the risk of anterior cruciate ligament (ACL) injury
in both male and female soccer players.20,21 A set of exercises focusing on balance,
strength, flexibility and stability has been found to reduce the risk of ACL injuries in
female youth soccer players.22,23

Despite the relatively high incidence of injuries in soccer, insufficient evidence is available
on the efficacy of generic (non-specific) preventive training programmes in reducing
injury incidence. These multifaceted programmes contain different exercises focusing
on multiple joints and/or muscle groups and target prevention of the most common
soccer injuries. The purpose of this review is to systematically examine the evidence on
the effect of preventive exercise-based training programmes to reduce the incidence
of soccer injuries in general.

27
Chapter 2

Methods

Search methods

The databases EMBASE/MEDLINE, Pubmed, CINAHL (Cumulative Index to Nursing

and Allied Health Literature), Cochrane Central Register of Controlled trials, PEDro (the
Physiotherapy Evidence Database) and SPORTDiscus were searched for relevant articles,
from inception till 20 December 2011. The search strategy for MEDLINE was set by one
author (NvdH), after which this strategy was modified for use in the other databases. The
following combination of key words was used: ((prevention AND training) AND (soccer OR
soccer) AND injury). The searches in CINAHL and SPORTDiscus were restricted to peer-
reviewed articles. The full search strategy is available on the journal website. Subsequently,
the databases were searched independently by two authors (NvdH, AvB). The results of
these searches were combined and duplicates were removed. Reference lists of included
studies and relevant systematic reviews were also screened for relevant studies.

Eligibility criteria

The relevant citations were first screened on the basis of title and abstract. Articles were
independently selected by two authors (NvdH, AvB) if the study met the following criteria.

Inclusion:
• Randomized controlled trial (RCT) or controlled clinical trial (CCT).
• Primary outcome of the study is the number of soccer injuries and/or injury incidence.
• Intervention focusing on a preventive training programme, including a set of exercises
aimed at improving strength, coordination, flexibility or agility.
• Study sample of soccer players (no restrictions as to level of play, age or sex).

Exclusion:
• The article was not available as full text.
• The article was not published in English, German or Dutch.
• The trial and/or training programme relates only to specific injuries and/or specific
joints.

Full text of relevant articles was obtained and checked for inclusion and exclusion criteria
independently by two authors (NvdH, AvB). Disagreements between the two authors

28
 Injury prevention programmes for soccer players

regarding a study’s eligibility were resolved by discussion until consensus was reached
or, where necessary, a third author (IvdP) made the final decision.

2
Data collection

The following data were extracted by two authors (NvdH, AvB): first author; year of
publication; follow-up period; number of participants; sex and age of participants;
definition primary outcome; description of the intervention; and effect of the intervention.

Initially, the effect of the intervention was assessed by analysing the results in terms of
the primary outcome of a study. If different methods are used to describe the primary
outcomes in the included studies, the incidence risk ratios (IRRs) were calculated to
compare the effects of the intervention between the studies. The IRR is the ratio of the
injury rate (injured players divided by all players) in the intervention group divided by
the corresponding rate in the control group. In addition, statistically significant results
in terms of secondary outcomes were recorded.

Assessment of risk of bias in included studies

Two authors (NvdH, AvB) independently assessed the methodological quality of the
included studies using the PEDro scale.24 The PEDro scale is an 11-item checklist, based
on expert consensus, which can be used to rapidly determine the internal validity and
statistical quality of RCTs or CCTs.25 The first item is not used to calculate the total
PEDro score, so the maximum score was 10 points. Criteria were only scored as ‘yes’
or ‘no’. Disagreements on the PEDro score were resolved by discussion between the
two assessors. If consensus was not achieved, a third author (IvdP) was consulted. A
study was considered of moderate quality if the PEDro score was at least 4, and of high
quality if the score was 6 or higher.26,27

Results

Study selection

Electronic and manual searching yielded 925 relevant articles, with 265 duplicates. Of the
remaining 660 articles, 639 were excluded after screening the title and abstract. Twenty-

29
Chapter 2

one articles were retrieved from the literature search and subsequently evaluated. After
reading the full text we excluded a further 15 articles, without disagreements between
the two authors regarding a study’s eligibility. No additional reports were found by
screening the reference lists and reviews. Articles were predominantly excluded because
the intervention protocol used was not in agreement with our definition or the article
did not describe an outcome in terms of injuries and/or injury incidence (Figure 2.1).

CINAHL Cochrane Embase / PEDro Pubmed SportDiscus

(n = 110) (n = 85) Medline (n = 14) (n = 284) (n = 269)
(n = 163)

Articles identified
through database search
(n = 925)

Duplicates
(n = 265)

Titles and abstracts

screened for relevance
(n = 660)

Excluded on basis of
title and abstract
(n = 639)

Full text screened

(n = 21)

Excluded (n = 15)
no full text (n = 2)
not in English/Dutch/German (n = 2)
no exercise-based prevention programme (n = 4)
no outcome in terms of injuries / injury incidence (n = 3)
not RCT/CCT (n = 3)
targeting specific injuries (n = 1)

Articles identified
for review
(n = 6)

Figure 2.1  Flow diagram literature search and selection.

CCT = controlled clinical trial, RCT = randomized controlled trial.

30
 Injury prevention programmes for soccer players

Study characteristics

Six studies with a total of 6099 participants were included in this review.28-33 Four studies
were RCTs28,31-33 and two CCTs.29,30 The number of participants per study ranged from 2
194 to 2540 players. The samples consisted of youth and adult soccer players, both male
and female. Except for the study by Emery et al.,28 all studies involved outdoor soccer
players. All included studies had a follow-up period of one season (ranging from 20 weeks
to 8 months), except for the study by Junge et al.30 (their follow-up period was one year
during two seasons). Table 2.1 shows the main characteristics of the included studies.

Methodological quality

The PEDro scores ranged from 2 to 8 points, with a median of 5 points. The results
of the quality assessment after consensus are presented in Table 2.2. Three of the six
included studies28,31,33 were of high methodological quality, two others of moderate
quality,29,32 and one of low quality.30 Some limitations in the low- or moderate-quality
studies were lack of randomization,29,30 low statistical power or inadequate sample size
calculation,29,30,32 no intention-to-treat analysis,29,30,32 no exposure registration,29 and
high drop-out rate.30,32

Interventions and effects

The definition used for injury was similar in nearly all studies , viz. an injury that results in
a player being unable to take full part in future soccer training or match play (‘time loss’
injury).34 Two studies also used this definition, but with the additional element of ‘or any
physical complaint caused by soccer that lasted for more than two weeks’30 and ‘soccer
injuries resulting in medical attention and/or removal from a session and/or time loss’.28

All six studies prescribed soccer-specific exercises aimed at improving strength,

coordination, flexibility or agility. One study32 required participants to do home-based
wobble-board exercises, and one study28 combined soccer-specific exercises with
home-based wobble-board training. The participants in the control group of the latter
study engaged in a home-based programme including only the stretching components.
One study30 used a multi-modal intervention programme consisting of warm-up, cool-
down, taping of unstable ankles, and rehabilitation combined with an exercise-based
programme. The exercises focused on balance, flexibility, strength, coordination,

31
 Table 2.1  Study characteristics of the included studies

32
First author, Follow-up Incidence risk
year period Participants Primary outcome Intervention * Effect of intervention ratio (IRR)
Chapter 2

Emery et One season Male and female Injuries overall, Warm-up (15 min) including Significant reduction of 0.66
al., 201028 of 20 weeks indoor soccer defined as all 5 min stretching and 10 min the primary outcome (statistically
players, n = 744 soccer injuries soccer-specific neuromuscular (p = 0.045): injury rate significant)
(intervention resulting in training programme and a in intervention group =
group: 380, control medical attention 15 min home based balance 2.08 (95% CI 1.54–2.74)
group 364), aged and/or removal training programme. injuries/1000 hours,
13–18 years. from a session control group = 3.35 (95%
and/or time loss. CI 2.65–4.17).

Heidt et al., One year of Female high- Injuries overall, Frappier Acceleration Training Significant reduction of 0.42
200029 competitive school soccer defined as all Programme: sport-specific the primary outcome (p (statistically
soccer players, n = 300 injuries which programme of cardiovascular < 0.05). significant)
participation (intervention caused the player conditioning, plyometric work,
group: 42, control to miss a game or sport cord drills, strength
group: 258), aged a practice. training, and flexibility
14–18 years. exercises. Twenty sessions over
7 weeks during pre-season.

Junge et One year Male soccer Injuries overall, General interventions such as No significant reduction 0.64
al., 200230 (during two players, n = 194 defined as any improved warm-up, regular of the primary outcome. (statistically
seasons) (intervention physical complaint cool-down, taping of unstable Statistically significant significant)
group: 101, control caused by soccer ankles, adequate rehabilitation differences were found for
group: 93), aged that lasted for and promotion of the spirit of number of injured players,
14–19 years, age = more than two fair play as well as ‘F-MARC mild injuries, overuse
16.5 ± 1.2. weeks or resulted Bricks’: balance, flexibility, injuries, noncontact
in absence from a strength, coordination, injuries, injuries incurred
subsequent match reaction time, and endurance. during training, and
or training session. Once a week supervised by a injuries of the groin.
physiotherapist.

Table 2.1 continues on next page

 Table 2.1  Continued

First author, Follow-up Incidence risk

year period Participants Primary outcome Intervention * Effect of intervention ratio (IRR)

Söderman One season Female soccer Acute lower Balance board training at No reduction of the 1.16 (not
et al., of 7 months players, n = 221 extremity injuries home (10–15 min). Initially primary outcome. statistically
200032 (intervention resulting in each day for 30 days and then Significantly higher injury significant)
group: 121, control absence from three times a week during the rate of severe injuries in
group: 100), mean at least one rest of the season. intervention group.
age (n = 140) = scheduled practice
20.5 ± 5 years. session or game.

Soligard et One season Female soccer All lower extremity The11+ intervention No significant reduction 0.67 (not
al., 200831 of 8 months players, n = 2540 injuries causing programme (20 min): running of the primary outcome. statistically
(intervention the player to be exercises, strength, balance, The risk of severe significant)
group: 1320, unable to fully take jumping, speed running. injuries, overuse injuries
control group: part in the next Every training session during and injuries overall was
1220), youth, aged match or training the season (2–5 times a significantly reduced in
13–17years, mean session. week). the intervention group.
age (n = 1892) =
15.4 ± 0.7 years.

Steffen et One season Female soccer Injuries overall, Warm-up (20 min) including 5 No reduction of the 1.20 (not
al., 200833 of 8 months players, n = 2092 defined as all min of jogging and 15 min of primary outcome. statistically
(intervention injuries causing The11intervention programme: significant)
group: 1091, the player to be core stability, balance, dynamic
control group: unable to fully take stabilization and eccentric
1001), aged 13–17 part in the next hamstring strength. Initially
years, mean age match or training every training session for 15
(n = 2020) = 15.4 session. consecutive sessions and
±.0.8 years. thereafter once a week during
the rest of the season.
* The control groups were generally asked to train (and warm-up) as usual.

33
Injury prevention programmes for soccer players

Age is presented as mean age ± SD (if applicable). CI = confidence interval, F-MARC = FIFA Medical and Research Centre, IRR = incidence risk ratio.
2
34
Chapter 2

Table 2.2  Assessment of the methodological quality of the included studies with PEDro criteria24

Between- Point
Baseline Intention- group estimates
Random Concealed compara- Blinded Blinded Blinded Adequate to-treat compari- and
allocation allocation bility subjects therapists assessors follow-up analysis sons variability Total

Emery et al., 1 1 1 0 0 1 0 1 1 1 7
201028

Heidt et al., 1 0 0 0 0 1 1 0 1 0 4
200029

Junge et al., 0 0 1 0 0 0 0 0 1 0 2
200230

Söderman et 1 0 1 0 0 0 0 0 1 1 4
al., 200032

Soligard et al., 1 1 0 0 0 1 0 1 1 1 6
200831

Steffen et al., 1 1 0 0 0 1 1 1 1 1 7
200833
0 = no, 1 = yes.
 Injury prevention programmes for soccer players

reaction time, and endurance. The other three studies implemented a preventive training
programme during the warm-up of training sessions.29,31,33 One programme, the Frappier
Acceleration Training Programme, consists of exercises to improve speed and agility.29
Another one, called The11, focuses on core stability, balance, dynamic stabilization, 2
and eccentric hamstring strength, while the last one, The11+, combines key exercises
33

from The11 and additional exercises to provide variation and progression with running
exercises.31 The teams in the control groups of these studies were asked to continue
their warm-up and training as usual during the season. More detailed information about
the interventions studied is provided in Table 2.1.

Only two of the six studies reported a significant reduction in terms of their primary
outcome, i.e. injuries overall. One of these studies was a high-quality study,28 the other
was of moderate quality.29 Emery et al.28 showed that the injury rate in the intervention
group was significantly lower (2.08, 95% CI 1.54–2.74 injuries/1000 hours) than in the
control group (3.3, 95% CI 2.65–4.17 injuries/1000 hours). Heidt et al.29 reported a
significantly lower injury incidence in the intervention group than in the control group
(14.3% vs. 33.7%). The statistically significant results in terms of secondary outcomes
are presented in Table 2.1.

To compare the effects of the different interventions we calculated the IRR for each of the
included studies (see Table 2.1). Four of the six studies28-31 reported an overall preventive
effect (IRR < 1), although the effect in one study was not statistically significant.31 The
three studies which described a significant preventive effect were of high,28 moderate29
and low quality.30 The mean reduction in injury rate in these studies was 44%.28-30 The
mean overall reduction (for the six included studies) was 19%.28-33

Discussion
This review systematically describes the evidence from RCTs and CCTs on the effect of
generic exercise-based programmes to prevent soccer injuries. The conclusions of the six
included studies were contradictory. Only two studies reported a significant reduction in
terms of the primary outcome.28,29 The result of our analysis is inconclusive, however, as
different outcome measures and injury definitions were used. As regards the effect of the
interventions in terms of one identical outcome, namely IRR, four of the six studies28-31
described a preventive effect, although the effect in one (high-quality) study was not

35
Chapter 2

significant.31 The three studies which described a significant preventive effect were of
high,28 moderate quality29 and low quality.30 The other high-quality study reported no
differences between the two groups at all.33

The possible effect of an intervention depends on several factors, which were not
identical for all included studies. The first aspect is the study sample in the included
studies. Only two studies included male soccer players,28,30 and one of these showed a
significant reduction in terms of the primary outcome, i.e. injuries overall.28 The other four
studies included only female players and two of them showed a significant preventive
effect of the intervention.29,31 Each sex may have its own risk factors and its own risks
of sustaining an injury, or more specifically an ACL injury.35 It is well-known that female
players have a 2–3 times higher ACL injury risk than male players.36,37 Nevertheless,
a recently published review reported that females benefit less from ACL prevention
programmes than males (risk reduction of 52% vs. 85% resp.).38

Another important factor that deserves further attention is the content of the intervention
programmes analysed in this review. Despite the fact that we defined the content in the
inclusion criteria, the contents did differ, which limits their comparability. In the study by
Junge et al.30 the exercise programme was part of other general preventive interventions
such as taping, rehabilitation, and promotion of fair play. This makes it difficult to identify
the specific effect of the set of preventive exercises alone. Two other studies primarily
focused on balance training,28,32 while the remaining three studies described the effects
of a training programme focusing on several aspects like core stability, balance, strength,
and flexibility.29,31,33 A general comment regarding the content of the program is about
the rationale for specific parts of the intervention programmes in the included studies.
One can imagine that e.g. neuromuscular training can not reduce head injuries. The
hypothesis is that performing certain exercises on a regular basis would reduce the
incidence of the most common (lower extremity) injuries. However, Soligard et al. showed
no significant reduction for their primary outcome (all lower extremity injuries), while
a significant risk reduction is found for overall injuries in the intervention group.31 The
majority of the included studies targeted prevention of all injury.28-30,33

Besides the content of the programme, training frequency and duration also varied
greatly between the included studies. The frequency of the intervention programmes
ranged from one to five sessions a week, during an intervention period that ranged
from 7 weeks to 8 months. The three studies reporting a significant preventive effect

36
 Injury prevention programmes for soccer players

of the intervention programme differ greatly.28-30 The participants of one study had 20
sessions over a 7-week period.29 In the second study a physiotherapist weekly visited
one training session per team and supervised the performance of the intervention
programme. It is not reported that the teams also perform the programme without 2
supervision of the physiotherapist. The third study did not report the training frequency,
30

but the participants performed the intervention during a 20-week season.28 Although the
participants of the study by Söderman et al.32 performed the intervention three times
a week, the effect of preventive exercises in general may be positively influenced by
a higher frequency (more than once a week). Since the differences in intensity of the
programme compared to the effect of the intervention in the included studies it would
be interesting to study any underlying dose-response relationship in more detail.

Compliance may also be a key factor in the potential effect of an intervention programme.
Soligard et al.39 confirmed in a previous study that the risk of overall and acute injuries
was reduced by more than one third among players with high compliance compared
to players with intermediate compliance. Four of the six included studies recorded the
participants’ compliance with the intervention. The study by Emery et al.,28 the high-
quality study which showed a preventive effect of the intervention, did not clearly report
compliance. The authors stated that response in terms of self-reported compliance
with the home-based programme was very poor (< 15%). Completion of warm-up was
indicated for every practice and game at all teams for which weekly exposure data were
complete. It is unclear, however, whether all components of the prescribed warm-up
were completed for each session.28 In the two Norwegian studies, compliance with the
The11 programme was 52%33 vs 77% for The11+.31 Finally, Söderman et al.32 excluded
30% of the participants who had completed the study but had performed the prescribed
balance board training during fewer than 35 training sessions.

It is hard to conclude from the present review which components are relevant in injury
prevention programmes. To be able to develop effective training programmes, it is highly
important to establish the aetiology and mechanisms of injuries before introducing and
implementing a preventive measure.40,41 The training programmes implemented in the
studies included in this review involve different exercises focusing on the prevention
of the most frequently reported soccer injuries. Since these injuries have their own
aetiologies and risk factors, it is hard to design a ‘one size fits all’ intervention programme.
Even when focusing on one common type of injury in soccer (knee injuries), it still seems

37
Chapter 2

difficult to decide which exercises should be implemented in a preventive programme.

The literature reports contradictory effects of different exercises. Some studies reported
positive, preventive effects on knee injuries,22,23,42 while others reported only a trend
towards reduction,43,44 or no reduction at all.45,46 Sadoghi et al.38 recently reported on
the effectiveness of ACL injury prevention training programmes. In their review, they
suggested that such programmes have a substantial beneficial effect. However, they
were not able to recommend a specific type of prevention programme on the basis
of the currently published evidence.38 This confirms the difficulties of designing an
exercise-based intervention programme.

Before introducing and implementing a preventive training programme, it also seems

relevant to improve the ability to identify players at risk for sustaining an injury.5 This
would make it possible to design such programmes specific enough to achieve the
maximum effect. Finally, external factors like behaviour/fair play41,47 and sports culture40
play a role in sustaining injuries. A better understanding of these factors may lead to
improvements in the prevention of soccer injuries.

A limitation of our review is that the generalizability of the results remains unclear. The
included studies predominantly focused on young, female outdoor soccer players. The
participants’ age was below 19 years in five studies.28-31,33 However, the largest group of
active participants in soccer worldwide concerns is that of adult male players, who also
have high injury rates.1,5 It is also unclear if the results of our review can be generalized
to other levels of play and/or across sexes. Only two studies included male participants:
44.6% of the sample in the study by Emery et al.28 (n = 332) and the entire study sample
used by Junge et al.30 (n = 194). Generalizing the results of our review to the largest
soccer population (adult male players) must be done with considerable caution. Finally,
it is unclear whether the results reported by Emery et al.,28 who included only indoor
soccer players, can be generalized to outdoor soccer players. Although indoor and
outdoor soccer have several similarities, it is not evident that the injuries are comparable.
Some studies reported that indoor soccer has a higher injury incidence/risk than outdoor
soccer,5,48 while others described no differences between indoor and outdoor soccer in
injury incidence or risk factors.49

Drawing conclusions about the effectiveness of an intervention programme also requires

taking the choice of primary outcome in a study into account. We used the results
in terms of the primary outcome in the included studies to describe the effect of an

38
 Injury prevention programmes for soccer players

intervention, because there may be insufficient statistical power for conclusions based
on the secondary outcomes. However, some studies30,31 only reported a preventive effect
in terms of secondary outcomes. Finally, the mean IRR of the six included studies (19%
reduction) should be interpreted with care. By calculating this score the methodological 2
quality of the included studies is not taken into account. Besides this, the calculation is
not based on a meta-analysis. Ideally, relative weights should be given to each included
study before calculating the overall IRR.

Conclusion
The calculated IRRs for the studies included in our review indicate that there is conflicting
evidence for the effectiveness of exercise-based programmes to prevent soccer injuries.
There is thus a need for more high-quality studies investigating the best type and intensity
of exercises in a generic training programme (for a specific population in terms of sex,
level of play, and age), in order to reduce the incidence of injuries in soccer effectively.

Acknowledgements

No sources of funding were used for the preparation of this review. The authors have
no conflicts of interest that are directly relevant to the content of this review.

39
Chapter 2

References
1. FIFA. FIFA Big count 2006. Zurich; 2007.

2. Krustrup P, Aagaard P, Nybo L, et al. Recreational football as a health promoting activity: a topical
review. Scand J Med Sci Sports 2010;20 Suppl 1:1-13.

3. Hoff J, Helgerud J. Endurance and strength training for soccer players: physiological considerations.
Sports Med 2004;34(3):165-180.

4. Reilly T, Gilbourne D. Science and football: a review of applied research in the football codes. J
Sports Sci 2003;21(9):693-705.

5. Schmikli SL, Backx FJ, Kemler HJ, et al. National survey on sports injuries in the Netherlands:
target populations for sports injury prevention programs. Clin J Sport Med 2009;19(2):101-106.

6. Ekstrand J, Hagglund M, Walden M. Injury incidence and injury patterns in professional football:
the UEFA injury study. Br J Sports Med 2011;45(7):553-558.

7. Inklaar H. Soccer injuries. I: Incidence and severity. Sports Med 1994;18(1):55-73.

8. Mickel TJ, Bottoni CR, Tsuji G, et al. Prophylactic bracing versus taping for the prevention of ankle
sprains in high school athletes: a prospective, randomized trial. J Foot Ankle Surg 2006;45(6):360-
365.

9. Mohammadi F. Comparison of 3 preventive methods to reduce the recurrence of ankle inversion

sprains in male soccer players. Am J Sports Med 2007;35(6):922-926.

10. Waldén M, Atroshi I, Magnusson H, et al. Prevention of acute knee injuries in adolescent female
football players: cluster randomised controlled trial. BMJ 2012;344:e3042.

11. Junge A, Dvorak J. Soccer injuries: a review on incidence and prevention. Sports Med 2004;34(13):
929-938.

12. Dvorak J, Junge A, Chomiak J, et al. Risk factor analysis for injuries in football players. Possibilities
for a prevention program. Am J Sports Med 2000;28(5 Suppl):S69-S74.

13. Bir CA, Cassatta SJ, Janda DH. An analysis and comparison of soccer shin guards. Clin J Sport
Med 1995;5(2):95-99.

14. Hawkins RD, Fuller CW. A prospective epidemiological study of injuries in four English professional
football clubs. Br J Sports Med 1999;33(3):196-203.

15. Ekstrand J, Gillquist J. The avoidability of soccer injuries. Int J Sports Med 1983;4(2):124-128.

16. Ekstrand J, Gillquist J, Liljedahl SO. Prevention of soccer injuries. Supervision by doctor and
physiotherapist. Am J Sports Med 1983;11(3):116-120.

17. Arnason A, Andersen TE, Holme I, et al. Prevention of hamstring strains in elite soccer: an
intervention study. Scand J Med Sci Sports 2008;18(1):40-48.

18. Askling C, Karlsson J, Thorstensson A. Hamstring injury occurrence in elite soccer players after
preseason strength training with eccentric overload. Scand J Med Sci Sports 2003;13(4):244-250.

19. 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(11):2296-
2303.

40
 Injury prevention programmes for soccer players

20. Alentorn-Geli E, Myer GD, Silvers HJ, et al. Prevention of non-contact anterior cruciate ligament
injuries in soccer players. Part 2: a review of prevention programs aimed to modify risk factors and
to reduce injury rates. Knee Surg Sports Traumatol Arthrosc 2009;17(8):859-879.

21. Grindstaff TL, Hammill RR, Tuzson AE, et al. Neuromuscular control training programs and
noncontact anterior cruciate ligament injury rates in female athletes: a numbers-needed-to-treat 2
analysis. J Athl Train 2006;41(4):450-456.

22. Kiani A, Hellquist E, Ahlqvist K, et al. Prevention of soccer-related knee injuries in teenaged girls.
Arch Intern Med 2010;170(1):43-49.

23. Mandelbaum BR, Silvers HJ, Watanabe DS, et al. Effectiveness of a neuromuscular and
proprioceptive training program in preventing anterior cruciate ligament injuries in female athletes:
2-year follow-up. Am J Sports Med 2005;33(7):1003-1010.

24. Sherrington C, Herbert RD, Maher CG, et al. PEDro. A database of randomized trials and systematic
reviews in physiotherapy. Man Ther 2000;5(4):223-226.

25. Maher CG, Sherrington C, Herbert RD, et al. Reliability of the PEDro scale for rating quality of
randomized controlled trials. Phys Ther 2003;83(8):713-721.

26. Lievense AM, Bierma-Zeinstra SM, Verhagen AP, et al. Influence of obesity on the development
of osteoarthritis of the hip: a systematic review. Rheumatology (Oxford) 2002;41(10):1155-1162.

27. van Peppen RP, Kwakkel G, Wood-Dauphinee S, et al. The impact of physical therapy on functional
outcomes after stroke: what’s the evidence? Clin Rehabil 2004;18(8):833-862.

28. Emery CA, Meeuwisse WH. The effectiveness of a neuromuscular prevention strategy to reduce
injuries in youth soccer: a cluster-randomised controlled trial. Br J Sports Med 2010;44(8):555-562.

29. Heidt RS, Jr., Sweeterman LM, Carlonas RL, et al. Avoidance of soccer injuries with preseason
conditioning. Am J Sports Med 2000;28(5):659-662.

30. Junge A, Rosch D, Peterson L, et al. Prevention of soccer injuries: a prospective intervention study
in youth amateur players. Am J Sports Med 2002;30(5):652-659.

31. Soligard T, Myklebust G, Steffen K, et al. Comprehensive warm-up programme to prevent injuries
in young female footballers: cluster randomised controlled trial. BMJ 2008;337:a2469.

32. Söderman K., Werner S, Pietila T, et al. Balance board training: prevention of traumatic injuries
of the lower extremities in female soccer players? A prospective randomized intervention study.
Knee Surg Sports Traumatol Arthrosc 2000;8(6):356-363.

33. Steffen K, Myklebust G, Olsen OE, et al. Preventing injuries in female youth football--a cluster-
randomized controlled trial. Scand J Med Sci Sports 2008;18(5):605-614.

34. Fuller CW, Ekstrand J, Junge A, et al. Consensus statement on injury definitions and data collection
procedures in studies of football (soccer) injuries. Clin J Sport Med 2006;16(2):97-106.

35. Benjaminse A, Gokeler A, Fleisig GS, et al. What is the true evidence for gender-related differences
during plant and cut maneuvers? A systematic review. Knee Surg Sports Traumatol Arthrosc
2011;19(1):42-54.

36. Vescovi JD, VanHeest JL. Effects of an anterior cruciate ligament injury prevention program on
performance in adolescent female soccer players. Scand J Med Sci Sports 2010;20(3):394-402.

41
Chapter 2

37. Waldén M, Hagglund M, Werner J, et al. The epidemiology of anterior cruciate ligament injury in
football (soccer): a review of the literature from a gender-related perspective. Knee Surg Sports
Traumatol Arthrosc 2011;19(1):3-10.

38. Sadoghi P, von KA, Vavken P. Effectiveness of anterior cruciate ligament injury prevention training
programs. J Bone Joint Surg Am 2012;94(9):769-776.

39. Soligard T, Nilstad A, Steffen K, et al. Compliance with a comprehensive warm-up programme to
prevent injuries in youth football. Br J Sports Med 2010;44(11):787-793.

40. Finch C. A new framework for research leading to sports injury prevention. J Sci Med Sport
2006;9(1-2):3-9.

41. Verhagen EA, van Stralen MM, van MW. Behaviour, the key factor for sports injury prevention.
Sports Med 2010;40(11):899-906.

42. Caraffa A, Cerulli G, Projetti M, et al. Prevention of anterior cruciate ligament injuries in soccer.
A prospective controlled study of proprioceptive training. Knee Surg Sports Traumatol Arthrosc
1996;4(1):19-21.

43. Gilchrist J, Mandelbaum BR, Melancon H, et al. A randomized controlled trial to prevent
noncontact anterior cruciate ligament injury in female collegiate soccer players. Am J Sports Med
2008;36(8):1476-1483.

44. Hewett TE, Lindenfeld TN, Riccobene JV, et al. The effect of neuromuscular training on the incidence
of knee injury in female athletes. A prospective study. Am J Sports Med 1999;27(6):699-706.

45. Engebretsen AH, Myklebust G, Holme I, et al. Prevention of injuries among male soccer players:
a prospective, randomized intervention study targeting players with previous injuries or reduced
function. Am J Sports Med 2008;36(6):1052-1060.

46. Pfeiffer RP, Shea KG, Roberts D, et al. Lack of effect of a knee ligament injury prevention program on
the incidence of noncontact anterior cruciate ligament injury. J Bone Joint Surg Am 2006;88(8):1769-
1774.

47. Dvorak J, Junge A, Derman W, et al. Injuries and illnesses of football players during the 2010 FIFA
World Cup. Br J Sports Med 2011;45(8):626-630.

48. Hoff GL, Martin TA. Outdoor and indoor soccer: injuries among youth players. Am J Sports Med
1986;14(3):231-233.

49. Emery CA, Meeuwisse WH. Risk factors for injury in indoor compared with outdoor adolescent
soccer. Am J Sports Med 2006;34(10):1636-1642.

42
Injury prevention programmes for soccer players

43
 Chapter 3

The preventive effect of the Nordic

hamstring exercise on hamstring
injuries in amateur soccer players:
study protocol for a
randomized controlled trial

N. (Nick) van der Horst

D.W. (Dirk-Wouter) Smits
J. (Jesper) Petersen
E.A. (Edwin) Goedhart
F.J.G. (Frank) Backx

Inj Prev 2014;20(4):e8

Chapter 3

Abstract
Background  Hamstring injuries are the most common muscle injury in male ama-
teur soccer players and have a high rate of recurrence, often despite extensive
treatment and long rehabilitation periods. Eccentric strength and flexibility are
recognized as important modifiable risk factors, which has led to the development
of eccentric hamstring exercises, such as the Nordic hamstring exercise. As the
effectiveness of the Nordic hamstring exercise in reducing hamstring injuries has
never been investigated in amateur soccer players, the aim of this study is to
investigate the effect of this exercise on the incidence and severity of hamstring
injuries in male amateur soccer players. An additional aim is to determine whether
flexibility is associated with hamstring injuries.

Study design  Cluster-randomized controlled trial with soccer teams as the unit
of cluster.

Methods  Dutch male amateur soccer players, aged 18 to 40 years, were allocated
to an intervention or control group. Both study groups continued regular soccer
training during 2013, but the intervention group additionally performed the
Nordic hamstring exercise (25 sessions over 13 weeks). Primary outcomes are the
incidence of initial and recurrent hamstring injury and injury severity. Secondary
outcomes are hamstring-and-lower-back flexibility. Compliance to the intervention
protocol was also monitored.

Discussion  Eccentric hamstring strength exercises are hypothesized to reduce

the incidence of hamstring injury among male amateur soccer players by 70%.
The prevention of such injuries will be beneficial to soccer players, clubs, football
associations, health insurance companies, and society.

Trial registration  NTR3664.

46
 Hamstring injury prevention in amateur soccer: study protocol

Background
Soccer is the most popular sport worldwide, with 275 million participants of either sex
and of all ages.1 In general, sports participation generates a physically active lifestyle.
However, the beneficial health effects of sport are tempered by the risk of injury.2
Unfortunately, soccer has a high injury rate, with male amateur soccer players being
particularly prone to injury.3-7 Of all players, 60–100% sustain at least one injury per
soccer season.8,9 In terms of incidence rates in amateur players, soccer leads to 21.9
injuries per 1000 match hours and to 3.4 injuries per 1000 training hours.3-7 3
Hamstring injuries, defined as any physical complaint affecting the posterior side of
the upper leg irrespective of the need for medical attention or time loss from soccer
activities,10 are the most common soccer-related muscle injury.11,12 They account for
13–17% of all soccer injuries and require extensive treatment and long rehabilitation
periods, leading to absence from training and matches for up to 90 days.8,7,12,13 Hamstring
injuries also have a high recurrent rate, varying from 12% to 33%.12,15

Of a number of potential risk factors for hamstring injuries, such as age, previous
hamstring injury, muscle architecture, fatigue, flexibility, core stability and strength,
flexibility and strength are considered important modifiable risk factors.16-18 Biome­
chanical analyses have shown that hamstring ruptures typically occur in the latter part
of the swing phase during sprinting.19,20 Before the foot hits the ground, the hamstring
is (sub)maximally stretched over the knee joint, but at the same time it has to counter
isokinetic forces from the preswinging leg. The higher the sprinting velocity, the greater
these forces are.19,20 The vulnerability of the hamstring to injury during this phase
of sprinting is associated with inadequate eccentric strength of the hamstring.21-23
Exercises to increase eccentric muscle strength, such as the Nordic hamstring exercise
or hamstring curl have shown to reduce the rate of hamstring injury by 65–70%, and
particularly recurrent injuries, in professional soccer players.24,26

Male amateur soccer players form the largest subgroup of soccer players worldwide,
with the incidence of injury increasing with higher levels of play.3,4 Strategies to prevent
hamstring injuries, such as the Nordic hamstring exercise, may reduce the incidence of
hamstring injury, medical costs, and personal suffering of the injured player.27-29

The aims of this study are to investigate the preventive effect of the Nordic hamstring
exercise on the incidence and severity of hamstring injuries in male amateur soccer

47
Chapter 3

players and to establish whether flexibility is associated with an increased risk of

hamstring injury.

Methods/design

Design and randomization

This prospective, cluster-randomized, parallel group trial was designed in accordance

with the consolidate standards of reporting trials (CONSORT) guidelines (Figure 3.1).30
Soccer teams were used as the unit of cluster to avoid the risk of bias if individuals
were randomized to the intervention programme.31 After computer-generated random
assignment of team numbers, an equal number of teams were randomized to the control
or intervention group by an online research randomizer (www.randomizer.org).

Study setting

This trial is being carried out in collaboration with the Royal Netherlands Football
Association (KNVB). Soccer teams from four separate districts playing in Dutch first class
(“Eerste Klasse”) amateur field soccer competition were invited to participate. These
teams generally play one or two matches a week, with two or three training sessions
per week. After the four districts had been selected, instruction meetings, to inform
the purpose and methods of the study, were held for the coaches and medical staff of
participating teams, organized by the research team in each district.

Eligibility criteria

Dutch male amateur soccer players, aged 18–40 years, were eligible for inclusion.
Players who joined a participating team after the start of the trial were not included. All
players were asked to give their informed consent before the start of this study. Players
unwilling to do so were excluded from the trial.

48
  

      Okt – Nov 2012           Dec 2012 – Jan 2013               Jan – Dec 2013            Jan – Mar 2014 

 
Control group
Regular training and 
 
match play 
Recruitment of  Cluster‐Randomization  Intake measurements Prospective data  Data analysis
  collection 
teams  1:1  ‐ Baseline questionnaire  ‐ Primary & 
via KNVB  Teams as unit of cluster  ‐ Sit‐and‐Reach test  ‐ Hamstring injuries  secondary outcomes 
 
Intervention group ‐ Compliance 
Regular play + Nordic 
 
hamstring exercise 
protocol 
 

 
Enrolment  Allocation  Baseline  Follow‐up  Analysis 
 

 
Figure 3.1  Consolidate Standards of Reporting Trials (CONSORT) Flow diagram of trial design.

49
Hamstring injury prevention in amateur soccer: study protocol

3
Chapter 3

Intervention

The ‘Nordic hamstring exercise’, in literature also referred to as the Nordic Curl, improves
the eccentric strength of the hamstring muscles. The exercise is performed in pairs (see
Figure 3.2).24

Players start in a kneeling position, with the torso from the knees upward held rigid
and straight. The training partner ensures that the player’s feet are in contact with the
ground throughout the exercise by applying pressure to the player’s heels/lower legs.
The player then lowers his upper body to the ground, as slowly as possible to maximize
loading in the eccentric phase. Hands and arms are used to break his forward fall and
to push him back up after the chest has touched the ground, to minimize loading in
the concentric phase.32 The exercise was supervised by the team coach or medical staff
and took place immediately after the completion of normal training as recommended
by Small et al, before cooling-down.33

After the winter break in the 2012–2013 season (last 2 weeks in December), all teams
started their normal training schedule about 3–5 weeks before the competition restarted
(the season typically runs from July to May), which is typical for elite amateur soccer
competition in Western Europe. The intervention (see Table 3.1) started at the beginning
of this training schedule, with a constructive phase (wk 1–5) and a maintenance phase
(wk 6–13).24,25

Players in the intervention group were instructed to perform 25 sessions of the Nordic
hamstring exercise during the first 13 weeks after the winter break. Players were told

Figure 3.2  The Nordic hamstring exercise (adapted from Petersen et al.24).

50
 Hamstring injury prevention in amateur soccer: study protocol

Table 3.1  Nordic hamstring exercise protocol

Week Frequency Number of sets Repetitions per set

1 1 p/week 2 p/training 5

2 2 p/week 2 p/training 6

3 2 p/week 3 p/training 6

4 2 p/week 3 p/training 6, 7, 8

5 2 p/week 3 p/training 8, 9, 10

6–13 2 p/week 3 p/training 10, 9, 8 3

about the possibility of Delayed Onset of Muscle Soreness (DOMS), a known side-effect
of eccentric exercises.32 Players who were injured at the beginning of the intervention
could start the protocol week 1 after full recovery. Players who sustained an injury during
the intervention period, which limited the execution of the Nordic hamstring exercise,
were instructed to contact the research team.

Data collection

Baseline characteristics
Prior to the start of the intervention, all players completed a questionnaire to record
baseline characteristics: date of birth, weight, height, nationality, years of experience
as a soccer player, leg dominance, field position, preventive measures taken (such as
inlays, taping, bandages, thermal pants, muscle strengthening exercises or stretching),
and other injuries incurred before the start of the study (in particular, hamstring injuries
and anterior cruciate ligament injuries).

Hamstring injuries
The medical staff of participating teams (e.g. physical therapists and/or sports masseurs)
are responsible for registering all hamstring injuries for a full calendar year (2013). A
hamstring injury is defined as any physical complaint affecting the posterior side of
the upper leg irrespective of the need for medical attention or time loss from soccer
activities.10 A recurrent hamstring injury is defined as an injury of the same type and at the
same site as an index injury and which occurs after a player’s return to full participation
from the index injury.10 Recurrent injuries are subdivided into ‘early recurrences’ within

51
Chapter 3

2 months after a player’s return to full participation, ‘late recurrences’ between 2 and
12 months after a player’s return to full participation and ‘delayed recurrences’ more
than 12 months after a player’s return to full participation.10 All hamstring injuries are
registered on a special form, and a so-called recovery form is completed when the
player is fully recovered. Data are being collected on the epidemiology (location, type,
and duration of the injury) and aetiology (including intrinsic and extrinsic factors, such
as injury history and field condition) of the hamstring injury and information on residual
complaints and tertiary prevention.

Hamstring-and-lower-back-flexibility
Hamstring-and-lower-back-flexibility (HLBF) was measured in all players at the start of
the study, using the Sit-and-Reach Test (SRT) (see Figure 3.3).34-37

The medical staff was instructed how to perform the SRT procedure at the soccer club.
Participants were not allowed to warm up before doing the SRT. A player is asked to sit
on the floor, with the legs together, the knees extended, the ankles in 90° dorsiflexion
and the soles of the bare feet placed against the foot panel of the test box. Then, the
player is asked to place his hands on top of each other with the hand palms facing

Figure 3.3  The Sit-and-Reach Test.

52
 Hamstring injury prevention in amateur soccer: study protocol

downward, and to slowly reach forward as far as possible, moving a reach indicator
along the measuring scale on the box, and to hold the maximum stretch for 2 seconds.
The test supervisor ensures that the player’s knees, arms and fingers remain extended
throughout the test. Both knees should be locked during the test. Measurements are
repeated twice, with a 15-second interval, during which the player is allowed to sit up
straight, but not to stand up or stretch. SRT scores were recorded to the nearest 0.5 cm.
HLBF was not measured in players who were unable to perform the SRT as instructed
(e.g. because of limited knee extension after injury).
3
Exposure and compliance
The number of times a player performed the Nordic hamstring exercise protocol (inter-
vention group), the number and duration (in minutes) of training sessions (both group
and individual training) followed, and the number and duration (in minutes) of matches
played will be recorded weekly for 1 year by the team coach, using a computer-based
registration form. Match exposure is defined as play between teams from different
clubs.10 Training exposure is defined as team-based and individual physical activities
under the control or guidance of the team’s coaching or fitness staff that are aimed
at maintaining or improving players’ soccer skills or physical condition.10 Coaches will
also record reasons why players do not attend training or matches (e.g. sickness, injury,
hamstring injury, individual training, training elsewhere or other) per individual player.

The research team will remain in contact weekly (by telephone, email, or visits) with team
coaches and players having a view to encouraging compliance with data registration.
In addition, newsletters, evaluation meetings, and a website designed for this specific
study will be used to stimulate participation and compliance.

The intervention teams will be monitored with regard to implementation and perfor-
mance of the Nordic hamstring exercise and other self-initiated preventive strategies for
hamstring injuries (e.g. core stability, plyometric exercises etc.) and the control teams will
be monitored with regard to self-initiated preventive measures for hamstring injuries,
specifically the Nordic hamstring exercise.

Outcomes

Primary outcomes are the incidence of initial and recurrent hamstring injury, the severity
of the injury, and the number of intervention sessions completed. Secondary outcomes

53
Chapter 3

are hamstring-and-low-back flexibility (HLBF) and compliance. Data will be collected from
all participants. The incidence of injuries is reported as the number of injuries per 1000
player-hours for both matches and training.10 Injury severity is defined as the number
of days that have elapsed from the date of injury to the date of the player’s return to
full participation in team training and availability for match selection.10

Sample size

On the basis of the literature, we expected that the intervention would lead to a 70%
reduction in the rate of hamstring injury compared with control.24 During a soccer season,
about 1 in 11 players has a hamstring injury with a 30% chance of recurrent hamstring
injury.24 With 2-sided testing, a significance level of 0.05, and power of 0.8, each study
group should include 175 players. With a clustered design, an inflation factor (icc = 0.05)
of 1.9 was applied to the sample size, and with an estimated drop-out rate of 7%8,24
we calculated that 712 players would need to be recruited (n = 356 for intervention
group and n = 356 for control group). Since first-class amateur teams consist of about
19 players, a total of 38 teams was considered sufficient.

Statistical methods

SPSS version 21.0 will be used to analyse the quantitative data. Descriptive statistics
(means and standard deviations) will be used to describe baseline characteristics and
exposure data. The incidence of initial and recurrent hamstring injuries will be analyzed
on an intention-to-treat basis.

T-tests and Mann-Whitney U-test will be used for continuous variables and Chi-square
tests for categorical variables. Poisson general log-linear analysis and cox hazard
regression with survival curves will be used to compare the intervention and control
groups.

Compliance with the intervention will be calculated on the basis of information provided
by the team coaches. As the protocol consists of 25 sessions, compliance will be
calculated per team as: nh (amount of Nordic hamstring exercise sessions) / 25 * 100 =
% compliance. Additional analysis will be performed to check whether certain variables
are related to missing data or drop-out.

54
 Hamstring injury prevention in amateur soccer: study protocol

Ethical approval and informed consent

This trial was approved by the medical ethics committee of the University Medical
Centre Utrecht (File number 12-575/C). Where applicable, important modifications will
be communicated with the same ethics committee that proved approval. The trial was
registered in the Dutch trial register (NTR3664) as the HIPS (Hamstring Injury Prevention
Strategies) study. All participants received brief and comprehensible oral and written
information, in accordance with the Helsinki declaration.38 Informed, written consent
is obtained from all participants by one of the researchers (NH) before baseline tests. 3
Personal information about enrolled participants will be used confidentially before,
during and after the trial.

Discussion
Hamstring injuries in amateur soccer can lead to medical costs, work absenteeism,
reduced performance, and personal suffering.27 The Nordic hamstring exercise has
been shown to substantially reduce the incidence of hamstring among professional
soccer players.24-26 However, because there are differences in medical staff, level of play,
training frequency, training intensity, and compliance to preventive measures between
professional and amateur soccer players, the data for professional players cannot
necessarily be extrapolated to amateur players. Even so, it would be worthwhile to
reduce the incidence of such injuries among amateur players. Not only for the players
themselves, but also for society, health insurance companies, football associations, and
football clubs. Eccentric strength training may be an effective way to prevent these
injuries, to benefit of all concerned (more matches played, reduced absenteeism and
medical costs). This study has the advantage of a large study population (2 x 20 teams),
and the use of terminology and methodology consistent with the consensus statement on
injury definitions in soccer will generate data that can be compared with those of other
studies.10 Data modification and data loss are limited by the use of specially designed,
computer-based registration forms by team coaches and medical staff.

55
Chapter 3

Trial status
Participants were recruited in October-November 2012 and were randomized to the
intervention and control groups in December 2012. The intervention started in January
2013. Data collection is in progress and will be completed in January 2014. Data analyses
is expected to be completed in May 2014.

List of abbreviations
CONSORT: Consolidate Standards of Reporting Trials; DOMS: Delayed Onset of Muscle
Soreness; HIPS: Hamstring Injury Prevention Strategies; KNVB: Royal Netherlands
Football Association; HLBF: Hamstring-and-Low-Back-Flexibility; SRT: Sit-and-Reach Test.

Acknowledgements
The authors thank the Royal Dutch Football Association (KNVB) and players, coaches,
medical staff members and other representatives of participating clubs for their contri-
butions during the trial.

This study is funded with grants from the Netherlands Organisation for Health Research
and Development (Dnr: 50-50310-98-152) and the Royal Netherlands Football Associa-
tion (KNVB).

56
 Hamstring injury prevention in amateur soccer: study protocol

References
1. FIFA. FIFA Big Count. FIFA Communications Division, Information Services, 2007.

2. Krustrup P, Aagaard P, Nybo L, et al. Recreational football as a health promoting activity: a topical
review. Scand J Med Sci Sports 2010;20(1):1-13.

3. Dvorak J, Junge A. Football injuries and physical symptoms: a review of the literature. Am J Sports
Med 2000;28:S-3.

4. Schmikli SL, de Vries WR, Inklaar H, et al. Injury prevention target groups in soccer: injury
characteristics and incidence rates in male junior and senior players. J Sci Med Sport 2011;14(3):199-
203. 3
5. Wong P, Hong Y. Soccer injury in the lower extremities. Br J Sports Med 2005;39:473-482.

6. Ekstrand J. Epidemiology of football injuries. Sci Sports 2008;23:73-77.

7. Ekstrand J, Hägglund M, Waldén M. Injury incidence and injury patterns in professional football:
the UEFA injury study. Br J Sports Med 2011;45(7):553-558.

8. Beijsterveldt van AMC, Port van de IGL, Krist MR, et al. Effectiveness of an injury prevention
programme for adult male amateur soccer players: a cluster-randomised controlled trial. Br J
Sports Med 2012;46(16):1114-1118.

9. Chalmers DJ, Samaranayaka A, McNoe BM. Risk factors for injury in community-level football: a
cohort study. Int J Inj Contr Saf Promot 2013;20(1):68-78.

10. Fuller CW, Ekstrand J, Junge A, et al. Consensus statement on injury definitions and data collection
procedures in studies of football (soccer) injuries. Br J Sports Med 2006;40:193-201.

11. Ekstrand J, Hägglund M, Waldén M. Epidemiology of muscle injuries in professional football

(soccer). Am J Sports Med 2011b;39(6):1226-1232.

12. Woods C, Hawkins RD, Maltby S, et al. The football association medical research programme: an
audit of injuries in professional football-analysis of hamstring injuries. Br J Sports Med 2004;38:36-
41.

13. Hägglund M, Waldén M, Ekstrand J. Injuries among male and female elite football players. Scand
J Med Sci Sports 2009;19(6):819-827.

14. Hägglund M, Waldén M, Ekstrand J. Previous injury as a risk factor for injury in elite football: a
prospective study over two consecutive seasons. Br J Sports Med 2006;40:767-772.

15. Heiderscheit BC, Sherry MA, Silder A, et al. Hamstring strain injuries: recommendations for
diagnosis, rehabilitation, and injury prevention. J Orthop Sports Phys Ther 2010;40(2):67-81.

16. Freckleton G, Pizzari T. Risk factors for hamstring muscle strain injury in sport: a systematic review
and meta-analysis. Br J Sports Med 2013;47(6):351-358.

17. Mendiguchia J, Alentorn-Geli E, Brughelli M. Hamstring strain injuries: are we heading in the right
direction? Br J Sports Med 2012;46(2):81-85.

18. Beijsterveldt van AMC, Port van de IGL, Vereijken AJ, et al. Risk factors for hamstring injuries in male
soccer players: a systematic review of prospective studies. Scand J Med Sci Sports 2013;23(3):253-
262.

57
Chapter 3

19. Chumanov ES, Heiderscheit BC, Thelen DG. The effect of speed and influence of individual muscles
on hamstring mechanics during the swing phase of sprinting. J Biomech 2007;40(16):3555-3562.

20. Chumanov ES, Heiderscheit BC, Thelen DG. Hamstring musculotendon dynamics during stance
and swing phases of high-speed running. Med Sci Sports Exerc 2011;43(3):525-532.

21. Croisier JL, Forthomme B, Namurois MH, et al. Hamstring muscle strain recurrence and strength
performance disorders. Am J Sports Med 2002;30(2):199-203.

22. Croisier J, Ganteaume S, Binet J, et al. Strength imbalances and prevention of hamstring injury in
professional soccer players: a prospective study. Am J Sports Med 2008; 36(8): 1469-1475.

23. Opar DA, Williams MD, Shield AJ. Hamstring strain injuries: factors that lead to injury and re-injury.
Sports Med 2012;42(3):209-226.

24. Petersen MD, Thorberg PT, Bachmann Nielsen M, 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(11):2296-2303.

25. Arnason A, Andersen TE, Holme I, et al. Prevention of hamstring strains in elite soccer: an
intervention study. Scand J Med Sci Sports 2008;18(1):40-48.

26. Askling C, Karlsson J, Thorstensson A. Hamstring injury occurrence in elite soccer players after
preseason strength training with eccentric overload. Scand J Med Sci Sports 2003;13(4):244-250.

27. Krist MR, Beijsterveldt van AMC, Backx FJG, et al. Preventive exercises reduced injury-related
costs among adult male soccer players: a cluster-randomised trial. J Physiother 2013;59(1):15-23.

28. Beijsterveldt van AMC, Horst van der N, Port van de IGL, et al. How effective are exercise-based
injury prevention programmes for soccer players? A systematic review. Sports Med 2013;43(4):257-
265.

29. Junge A, Lamprecht M, Stamm H, et al. Country-wide campaign to prevent soccer injuries in Swiss
amateur players. Am J Sports Med 2011;39(1):57-63.

30. Moher D, Hopewell S, Schulz KF, et al. Consort 2010 explanation and elaboration: updated
guidelines for reporting parallel group randomised trials. J Clin Epidemiol 2010;63:e1-e37.

31. Torgerson DJ. Contamination in trials: is cluster randomisation the answer? BMJ 2001;322(7282):355-
357.

32. Mjølsnes R, Arnason A, Østhagen T, et al. A 10-week randomized trial comparing eccentric vs.
concentric hamstring strength training in well-trained soccer players. Scand J Sci Sports 2004;14(5):
311-317.

33. Small K, McNaughton L, Greig M, et al. Effect of timing of eccentric hamstring strengthening
exercises during soccer training: implications for muscle fatigability. J Strength Cond Res 2009;23(4):
1077-1083.

34. Wells KF, Dillon EK. The sit-and-reach. A test of back and leg flexibility. Research Quarterly 1952;23:
115-118.

35. Ayala F, Sainz de Baranda P, De Ste Croix M, et al. Criterion-related validity of four clinical tests
used to measure hamstring flexibility in professional futsal players. Phys Ther Sport 2011;12(4):175-
181.

58
 Hamstring injury prevention in amateur soccer: study protocol

36. Ayala F, Sainz de Baranda P, De Ste Croix M, et al. Absolute reliability of five clinical tests for
assessing hamstring flexibility in professional futsal players. J Sci Med Sport 2012;15(2):142-147.

37. Ayala F, Sainz de Baranda P, De Ste Croix M, et al. Reproducibility and criterion-related validity of
the sit and reach test and toe touch test for estimating hamstring flexibility in recreationally active
young adults. Phys Ther Sport 2012;13(4):219-226.

38. Krleza-Jeric K, Lemmens T. 7th revision of the Declaration of Helsinki: good news for the
transparency of clinical trials. Croat Med J 2009;50(2):105-110.

59
 Chapter 4

The preventive effect of the Nordic

hamstring exercise on hamstring
injuries in amateur soccer players:
a randomized controlled trial

N. (Nick) van der Horst

D.W. (Dirk-Wouter) Smits
J. (Jesper) Petersen
E.A. (Edwin) Goedhart
F.J.G. (Frank) Backx

Am J Sports Med 2015;43(6):1316-1323
Chapter 4

Abstract
Background  Hamstring injuries are the most common muscle injuries in soccer
and have a high rate of recurrence. Eccentric hamstrings strength is recognized
as an important modifiable risk factor. This led to the development of prevention
exercises such as the Nordic Hamstring Exercise (NHE). The effectiveness of the
NHE on hamstring injury prevention has never been investigated in amateur soccer.

Hypothesis/purpose  This study investigated the preventive effect of the NHE on

the incidence and severity of hamstring injuries in male amateur soccer players.

Study design  Cluster-randomized controlled trial with soccer teams as the unit
of cluster.

Methods  Male amateur soccer players (mean age 24.5 years, SD 3.8 years) from
40 teams were randomly allocated to an intervention (n = 20 teams, 292 players)
or control group (n = 20 teams, 287 players). The intervention group was instructed
to perform 25 sessions of the NHE in a 13-week period. Both the intervention and
control group performed regular soccer training and were followed for hamstring
injury incidence and severity during the calendar year 2013. At baseline, perso-
nal characteristics (e.g. age, injury history, field position) were gathered from all
participants via questionnaire. Primary outcome was injury incidence. Secondary
outcomes were injury severity and compliance to the intervention protocol.

Results  In total 38 hamstring injuries were recorded, affecting 36 of 579 players

(6.2%). The overall injury incidence rate was 0.7 (95% CI, 0.6–0.8) per 1000 player
hours; 0.33 (95% CI, 0.25–0.46) in training and 1.2 (95% CI, 0.82–1.94) in matches.
Injury incidence rates were significantly different between intervention (0.25; 95%
CI, 0.19–0.35) and control group (0.8; 95% CI, 0.61–1.15) χ2(1, n = 579) 7.865, p =
0.005. Risk for hamstring injuries was reduced in the intervention group compared
to the control group (Odds Ratio, 0.282; 95% CI, 0.11–0.721) and was statistically
significant (p = 0.005). No statistically significant differences were identified bet-
ween intervention and control group regarding injury severity. Compliance to the
intervention protocol was 91%.

Conclusion  Incorporating the NHE protocol in regular amateur training signifi-

cantly reduces hamstring injury incidence, but does not reduce hamstring injury
severity. Compliance to the intervention was excellent.

62
 Hamstring injury prevention in amateur soccer

Introduction
Soccer is the most popular sport in the world with more than 275 million participants.1
Unfortunately, research on sports injuries show high injury incidence rates for soccer, with
male amateur soccer players being particularly prone to injury.2-7 Injury incidence rates
of 20.4 to 36.9 injuries per 1000 match hours and 2.4 to 3.9 injuries per 1000 training
hours have been reported in male amateur soccer.2,8,9

Hamstring injuries are the most common soccer-related muscle injury.10-12 They account
for 37% of all soccer muscle injuries, requiring extensive treatment and long rehabilitation
periods.10-13 Recurrence rates for hamstring injuries remain high (12–33%) despite
preventive measures.12-15 Multiple potential risk factors for hamstring injuries, such as
age, player position, previous hamstring injury, muscle architecture, fatigue, flexibility,
core stability and strength have been reported.16-21 4
The Nordic Hamstring Exercise (NHE) or Nordic curl has shown to be an effective tool to
increase eccentric hamstring strength, developing higher maximal eccentric hamstring
strength torques when compared to regular hamstring curls.22 Previous studies on
male professional soccer players have shown that adopting the NHE in regular training
reduced hamstring injury incidence rates by 65–70%, with a particularly preventive effect
in reducing recurrent injuries.23,24

Male amateur soccer players form the largest subgroup of soccer players worldwide.3,6
Strategies to prevent hamstring injuries, such as the NHE, may reduce the incidence
of hamstring injury, medical costs, and personal suffering of the injured player.23,25,26
Although previous studies in professional soccer have shown promising results,
differences between professional and amateur soccer players in medical staff, level of
play, training exposure, training intensity and compliance to preventive measures have
to be considered. Therefore, the findings for professional players cannot be extrapolated
to amateur soccer players.

The aim of this study was to investigate the preventive effect of the Nordic hamstring
exer­cise on the incidence and severity of hamstring injuries in male amateur soccer
players.

63
Chapter 4

Materials and methods

Study setting

The present study was a cluster-randomised controlled trial, carried out in collabora-
tion with the Royal Netherlands Football Association (KNVB). Soccer teams from four
geographically separated districts playing in high-level amateur field soccer competi-
tion (“KNVB Eerste Klasse”) were invited to participate. These teams generally play
one and sometimes two matches a week, with two or three training sessions per week.
Dutch high-level amateur soccer team generally have a physical therapist present at all
matches and training. Occasionally, a sports massage therapist is present at matches
and training, with a physical therapist available for additional consulting in case of any
injury. The trial was approved by the medical ethics committee of the University Medical
Center Utrecht (file No. 12-575/C) and registered in the Dutch trial register as the HIPS
(Hamstring Injury Prevention Strategies) study. More detailed information is available
in the study protocol.27

Eligibility criteria

Dutch male amateur soccer players aged 18–40 years were eligible for inclusion. Players
who joined a participating team after the start of the trial were not included. All players
were informed using an information letter and asked to give their informed consent
before the start of this study. Players unwilling to do so were excluded from the trial.

Randomisation procedures

Soccer teams were used as the unit of cluster to avoid the risk of bias if individuals
were randomised to the intervention programme. After computer-generated random
assignment of team numbers, an equal number of teams were randomised to the control
or intervention group by an online research randomizer (http://www.randomizer.org).

64
 Hamstring injury prevention in amateur soccer

Intervention

Nordic hamstring exercise

The ‘Nordic hamstring exercise’ (NHE), in literature also referred to as the Nordic Curl,
is designed to improve eccentric strength of the hamstring muscles.22 The exercise is
performed in pairs (Figure 4.1).23

Players start in a kneeling position, with the torso from the knees upward held rigid
and straight. The training partner ensures that the player’s feet are in contact with the
ground throughout the exercise by applying pressure to the player’s heels/lower legs.
The player then lowers his upper body to the ground, as slowly as possible to maximize
loading in the eccentric phase. Hands and arms are used to break his forward fall and
to push him back up after the chest has touched the ground, to minimize loading in
the concentric phase.22 4

Figure 4.1  The nordic hamstring exercise (adapted from Petersen et al.33).

Exercise procedures
For the purpose of the present study, the exercise was supervised by the team coach
or medical staff (e.g. physical therapist and/or sport masseur). Exercises took place
immediately after the completion of normal training as recommended by Small et al,
before cooling-down.28 After the winter break in the 2012–2013 season (last 2 weeks in
December), all teams started their normal training program about 3–5 weeks before the
competition re-started (the season runs from July to May), which is typical for amateur
soccer competition in Western Europe. The intervention (see Table 4.1) started with a

65
Chapter 4

Table 4.1  Nordic hamstring exercise protocol

Week Frequency Number of sets Repetitions per set

1 1 p/week 2 p/training 5

2 2 p/week 2 p/training 6

3 2 p/week 3 p/training 6

4 2 p/week 3 p/training 6, 7, 8

5 2 p/week 3 p/training 8, 9, 10

6–13 2 p/week 3 p/training 10, 9, 8

build up phase (wk 1–5) during preparation for competition and a maintenance phase
(wk 6–13) during competition.23,24

Instructions
Players in the intervention group were instructed to perform 25 sessions of the Nordic
hamstring exercise during the first 13 weeks after the winter break. Players were informed
about the possibility of Delayed Onset of Muscle Soreness (DOMS), a known side-effect
of eccentric exercises.22 Players who were injured at the start of the intervention could
start the protocol week 1 after full recovery. Specific instructions were provided for
players who sustained an injury during the intervention period, which limited performing
the Nordic hamstring exercise. Players sustaining an injury within the first 5 weeks of
the intervention period were instructed to restart the program after full recovery. The
program had to be restarted from one week back in the program from where the player
was when he sustained his injury. Players sustaining an injury between week 6 and week
13 of the intervention period were instructed to restart the program from week 4.

Data collection

Baseline characteristics
Prior to the start of the intervention, all players completed a questionnaire to record
baseline characteristics: date of birth, weight, height, nationality, years of experience
as a soccer player, leg dominance, field position, preventive measures taken (such as
taping, bandages, thermal pants, muscle strengthening exercises or stretching), and
other injuries incurred before the start of the study (in particular, hamstring injuries and
anterior cruciate ligament injuries).

66
 Hamstring injury prevention in amateur soccer

Hamstring injuries
The medical staff of participating teams were responsible for registering all hamstring
injuries for a full calendar year (2013). A hamstring injury was defined as any physical
complaint affecting the posterior side of the upper leg irrespective of the need for
medical attention or time loss from soccer activities.29 All hamstring injuries were
registered on a special form, and a so-called recovery form was completed when the
player was fully recovered. Data were being collected on the epidemiology (location,
type, and duration of the injury) and etiology (including intrinsic and extrinsic factors,
such as injury history and field condition) of the hamstring injury and information on
residual complaints and tertiary prevention.

Exposure and compliance

The number of times a player performed the NHE protocol (intervention group), the 4
number and duration (in minutes) of training sessions (both group and individual
training) followed and the number and duration (in minutes) of matches played were
recorded weekly for 1 year by the team coach, using a computer-based registration
form. Coaches also recorded reasons why players did not attend training or matches
(e.g., sickness, hamstring injury, other injuries, individual training, training elsewhere or
other) per individual player.

The research team had regular contact (by telephone, email, or visits) with team coaches
and players with a view to encourage compliance and data registration. In addition,
newsletters, evaluation meetings, and a website designed for this specific study were
also used to stimulate participation and compliance. The intervention teams were
monitored with regard to implementation and performance of the Nordic hamstring
exercise and other self-initiated preventive strategies for hamstring injuries (e.g. core
stability, plyometric exercises etc.). The control teams were monitored with regard to
self-initiated preventive measures for hamstring injuries, specifically the NHE.

Outcomes
The primary outcome of this study was hamstring injury incidence. Injury incidence was
reported in absolute numbers as well as an injury incidence rate for number of injuries
per 1000 player hours in both matches and training.29 Secondary outcomes were injury
severity and compliance to the intervention protocol. Injury severity was defined as the
number of days that have elapsed from the date of injury to the date of the player’s

67
Chapter 4

return to full participation in team training and availability for match selection.29 Injury
severity was also classified in subcategories as slight (0 days); minimal (1–3 days); mild
(4–7 days); moderate (8–28 days); severe (> 28 days) and career ending.29

Statistical methods

SPSS version 21.0 was used to analyse the quantitative data, using a 0.05 level of
significance for all statistical tests. Descriptive statistics (means and standard deviations)
were used to describe baseline characteristics and exposure data. Hamstring injury
incidence was analyzed based on an intention-to-treat basis. Injury incidence was only
calculated from players whose full training and match exposure during all 52 weeks of
the study was registered.

No effect of the intervention was expected until full completion of the NHE protocol.
Therefore, the period before (week 1–13) and after (week 14–52) full completion of the
NHE protocol were seperately analysed. To assess the effect of the intervention on injury
incidence and injury severity, Chi-square tests were used for categorical variables and
t-tests for continuous variables, respectively. Odds Ratios (OR) and Relative Risks (RR)
were calculated to quantify associations between intervention and injury risk.

Compliance with the intervention was calculated on the basis of information provided by
the team coaches. As the protocol consisted of 25 sessions, compliance was calculated
per team as: n (amount of Nordic hamstring exercise sessions) / 25 x 100 = % compliance.

Results
A total of 110 soccer teams from four soccer districts were asked to participate in this
study. The 40 included teams were randomized by club to the intervention and control
group. Four teams (two intervention-teams and two control-teams) withdrew participation
before the start of the study because the medical staff was not able to perform baseline
measurements as instructed. Another two teams from the control group were lost to
follow-up due to trainer and/or medical staff replacements during the study period and
two teams from the intervention group were lost to follow-up because of unwillingness
to continue the intervention and injury registration due to players’ complaints about
DOMS. Players from 32 teams completed the study: 16 teams in the intervention group

68
 Hamstring injury prevention in amateur soccer

(n = 292 players) and 16 teams in the control group (n = 287 players). Figure 4.2 shows
selection and allocation of players.

Baseline characteristics of all players included in the study are summarized by allocated
group in Table 4.2. No statistical significant differences in baseline characteristics were
found between intervention and control group.

Exposure

During the study period, players in the study had an average exposure of 92.9 (95% CI,
77.2–108.6) hours. The mean training and match exposure was 58.4 (95% CI, 41–75.8)
hours and 34.5 (95% CI, 20.5–48.5) hours, respectively. There were no significant
differences between match or training exposure between intervention and control
Figure 2.
group (Table Flow chart of study population
4.3). 4

Assessed for
Enrollment eligibility
(n = 110 teams)

Excluded
- No response (n = 32 teams)
- Declined to participate (n = 38 teams)

Randomised
(n = 40 teams)

20 teams allocated to intervention 20 teams allocated to control

- 18 teams received intervention (n = 329
Allocation - 18 teams soccer play as usual (n = 319
players) players)
- 2 teams withdrew before start of study - 2 teams withdrew before start of study

Loss to follow-up Loss to follow-up

- 2 teams discontinued intervention and Follow-up - 2 teams due to staff mutations
registration (n = 37 players) (n = 32 players)

Analysed Analysed
Analysis
(n = 16 teams; n = 292 players) (n = 16 teams; n = 287 players)

Figure 4.2  Flow chart of study population.

69
Chapter 4

Table 4.2  Baseline characteristics of soccer players in intervention and control groupa

Intervention group Control group

(n = 292) Mean (SD) / % (n = 287) Mean (SD) / %

Age (years) 24.5 (± 3.6) 24.6 (± 4.1)

Height (cm) 183.4 (± 6.4) 183.5 (± 6.4)

Weight (kg) 77.6 (± 7.8) 78.4 (± 8.2)

BMI (kg/m2) 23.1 (± 1.7) 23.3 (± 1.8)

Dutch nationality 91% (n = 263) 94% (n = 243)

Soccer experience (years) 17.8 (± 4.0) 18.3 (± 4.6)

Leg dominance
Right leg 70% (n = 203) 68% (n = 174)
Left leg 21% (n = 60) 20% (n = 52)
Two-legged 7% (n = 19) 12% (n = 31)

Field position
Forwarder 28% (n = 80) 27% (n = 69)
Midfielder 35% (n = 101) 36% (n = 92)
Defender 35% (n = 102) 36% (n = 92)
Goalkeeper 11% (n = 31) 10% (n = 25)

Preventive measures taken

Taping/bandages 1% (n = 3) 0% (n = 0)
Thermal pants 15% (n = 43) 24% (n = 50)
Strengthening exercises 15% (n = 42) 13% (n = 34)
Stretching 26% (n = 76) 32% (n = 81)

Hamstring injury in previous year 24% (n = 69) 20% (n = 47)

Other soccer injuries in previous year 60% (n = 174) 57% (n = 144)

History of ACL surgery 5% (n = 13) 5% (n = 11)

a
Values are presented in mean ± SD or percentage (No.).

Hamstring injury characteristics

During the registration period, 36 initial hamstring injuries were recorded in 579 players
(6.2%) (see Table 4.3). The overall injury rate for both groups was 0.7 (95% CI, 0.6–0.8)
per 1000 player hours; 0.33 (95% CI, 0.25–0.46) in training and 1.2 (95% CI, 0.82–1.94)
in matches. Most injuries occurred during matches when compared to training (23 vs
11 respectively; other injuries occurred during warming-up (n = 1) or were not reported
(n = 1)). No statistical significant differences were found regarding field position
(defenders 36%; midfielders 32%; attackers 32%). No hamstring injuries were recorded
for goalkeepers. Members of team medical staff reported players’ accelerations as the

70
 Hamstring injury prevention in amateur soccer

Table 4.3  Comparison of the intervention and control groupa

Intervention group Control group

Exposure in hours (SD) per player

Total exposure 90.5 (15.4) 96.6 (16.0)
Match exposure 34.0 (13.8) 35.1 (14.3)
Training exposure 56.5 (17.0) 61.5 (17.7)

Total number of hamstring injuries (HSI)b 11 25

HSI before end of intervention period (wk 1–13) 5 7
HSI after end of intervention period (wk 13–52)b 6 18

Mean days of soccer absenteeism due to HSI (SD) 31 (15) 28 (19)

Total number of injuries by HSI severityc

Slight (0 days) 0 1
Minimal (1–3 days) 0 1
Mild (4–7 days) 0 2
Moderate (8–28 days) 4 5
Severe (> 28 days) 2 9
a
Values are presented in mean ± SD or No.
4
b
Significantly different between the intervention and control groups (p < 0.05).
c
After end of intervention period (wk 13–52).

most frequent etiology (53%), more than the player decelerating (15%), shooting (6%),
slipping (3%), cutting (9%) and overstretching the knee (3%) and other (21%).

Effects of the intervention on injury incidence

Eleven hamstring injuries (31%) were recorded in the intervention group and 25 (69%)
in the control group. Five of the 11 hamstring injuries (45%) in the intervention group
and 7 of 25 hamstring injuries (28%) in the control group occurred within the 13-
week intervention period. At the end of the 13-week intervention period, there was
no statistical significant difference (p = 0.427) in hamstring injury incidence between
intervention and control group (OR 0.628; 95% CI, 0.197–1.999).

After the intervention period, 18 hamstring injuries (72%) were recorded in the control
group and 6 (55%) in the intervention group, showing a significant difference in hamstring
injuries between both groups, χ2(1, n = 579) = 7.865, p = 0.005. Risk for injuries was
reduced in the intervention group after performing the NHE protocol (RR 3.384; 95% CI,
1.362–8.409) (OR 0.282; 95% CI, 0.110–0.721) and was statistically significant (p = 0.005).

71
Chapter 4

Effects of the intervention on injury severity

After the intervention period, players in the intervention and control group were absent
from soccer play for an average of 31 (SD 15) days and 28 (SD 19) days respectively. The
difference in injury severity between intervention and control group was not statistically
significant t(22) = 0.374, p = 0.342.

Compliance

Two teams did not fully report compliance to the intervention protocol due to loss to
follow up. The compliance of intervention teams to the protocol was 91%. Reasons for
not achieving full compliance to the intervention protocol were players complaining
about DOMS and not having two training activities due to mid-week matches or other
activities. DOMS were mainly reported in the first weeks (build up phase) of the NHE
protocol. None of the teams in the control group performed a Nordic hamstring exercise
protocol comparable to the intervention program.

Discussion
This cluster-randomized controlled trial evaluated the preventive effect of the Nordic
hamstring exercise on the incidence and severity of hamstring injuries in male amateur
soccer players. The results show that performing the Nordic hamstring exercise protocol
in regular amateur soccer training results in a reduced risk of hamstring injury in male
amateur soccer players. The Nordic hamstring exercise protocol did not reduce hamstring
injury severity.

The effectiveness of eccentric strengthening for hamstring injury prevention can be

explained from previous biomechanical analyses. Hamstring ruptures typically occur in
the latter part of the swing phase during sprinting.30-32 In this phase, where the hamstrings
are (sub)maximally stretched due to hip flexion and knee extension, the hamstring
muscles have to decelerate knee extension i.e. performing an eccentric contraction in a
lengthened position.31-32 The higher the sprinting velocity, the greater these forces are.31-
32
The risk of hamstring injury during high-speed running is associated with inadequate
eccentric strength of the hamstrings.33-35

72
 Hamstring injury prevention in amateur soccer

Effective injury prevention via eccentric strengthening of the hamstring muscles has been
demonstrated before, mainly in professional soccer.23,24,36 Askling showed significant
hamstring injury incidence reduction in a subgroup of professional soccer players
performing additional hamstring strength training with eccentric overload compared
to a control group performing training as usual.36 Arnason (2008) and Petersen (2011)
also investigated the preventive effect of eccentric strengthening on hamstring injury
incidence in a much larger study population of professional soccer players.23,24 Although
a preventive effect was found, these studies were mainly conducted on professional
players. Additionally, the biggest effect was found for recurrent hamstring injuries as
defined by Fuller (2006).29 The present study did record recurrent hamstring injuries
following the same definition.29 However, since there were only two recurrent injuries
recorded, both from the same player, recurrent injuries were not included in the analyses
and effects were thus not specified for recurrent injuries as previously been done. 4
This study focused specifically on male amateur adult soccer players and was characterized
by the large study population (40 amateur teams). Other strengths of this study are the
tailored intervention design specific for amateur soccer and the high compliance to the
intervention protocol (91%) compared to similar exercise-based intervention studies.37-39

Some methodological issues should be considered. This study could have been limited
by information bias, as participants were not blinded within the study. Unfortunately, it
is usually impossible to achieve and maintain blinding in exercise-based field studies.
Athletes are taking part in the intervention and know what measures were performed
and we did not produce a sham intervention for blinding purposes.40 Second, in view
of the expected large number of hamstring injuries in this study, it was not feasible
to verify injury diagnosis by an independent medical doctor including appropriate
additional diagnostic imaging (e.g. MRI, ultrasound). The adopted definition of
hamstring injury was similar to previous research and in accordance with the consensus
statement on injury definitions in studies of soccer.23,24,29,36 Although guidelines from the
consensus statement have been generally adopted in studies of football injuries, no
subclassifications on hamstring injury type or hamstring injury location can be provided
without thorough medical assessment (preferably including MRI). Therefore, a specifically
designed hamstring injury registration form was used to verify the hamstring injury and
exclude other potential conditions for posterior upper leg pain (such as referred pain
or adductor-related injuries). When judging the distribution of hamstring injury severity

73
Chapter 4

in our study population, significantly more moderate and severe injuries are reported
than slight, minimal or mild injuries. Underreporting of slight, minimal or mild injuries
could have led to lower overall hamstring injury incidence rates, although hamstring
injury incidence rates in this study were similar to incidence rates described in a similar
population by Van Beijsterveldt et al., reporting hamstring injury incidence rates of
1.5 per 1000 player hours.10 Additionally, medical staff of participating teams were
specifically instructed on the adopted hamstring injury definition and regular contact
was established to encourage compliance to hamstring injury registration.

Previous studies, as well as Fuller’s consensus statement, have stated that injury
incidence rates should be reported as the number of injuries per 1000 hours of soccer
play.29 Although the present study intended to monitor exposure of every included
player, this study had some data loss regarding exposure due to coach and player
replacements. Exposure was therefore only calculated from data of players whose
exposure had been reported for a full year. It should be considered that for studies on
hamstring injuries it is not the amount of hours of soccer play (exposure) that might be
crucial, but rather match or training intensity. Biomechanical analyses have shown that
the hamstring muscle is particularly prone for injury during high intensity movements
in soccer such as accelerating, high speed running and cutting.31-35 Subsequently, as
previously stated by Petersen, this would require registration of individual activity and
intensity by GPS (Global Positioning System), biomechanical analyses, video and so
forth.23 From these registration methods, only high-risk activities should be registered
as exposure. Unfortunately, this approach was not feasible in the current trial. Because
all participating clubs played at the same performance level, had approximately similar
training and match exposure and were randomized by an independent randomizer we
assumed similar intensity regarding both training and matches.

Injury prevention is an essential part of sports participation in order to reduce sports

injuries, direct and indirect medical costs and personal suffering of the injured player.41
The NHE has proven to be an effective preventive measure for hamstring injuries in
soccer.23-24 Unfortunately, positive outcomes from intervention studies do not necessarily
lead to subsequent prevention of injuries.42 Interventions can only prevent injuries when
they are adopted and used by the intended end users.43 The present field study was
conducted in collaboration with the Royal Netherlands Football Association (KNVB),
team coaches, team medical staff and team players. This collaboration as well as the

74
 Hamstring injury prevention in amateur soccer

specific parameters and build-up of the intervention protocol should provide a basis for
implementation of the Nordic hamstring exercise in soccer training for Dutch amateur
teams. Policy makers and Football Associations should continue to make a joint effort
to ensure and investigate implementation of injury preventive strategies, such as the
NHE, in order to make injury prevention truly work.

As stated by Klügl, there is a lack of research on implementation and effectiveness of

injury preventive strategies in a real-world context.44 This knowledge is essential as
positive study outcomes do not directly translate into injury prevention. Future research
should therefore focus on pitfalls and opportunities on implementation of eccentric
strengthening as an injury preventive strategy in soccer. Additionally, studies with longer
follow-up should be performed to analyze the long-term effects of NHE and effectiveness
on recurrent injuries in an amateur population.
4

75
Chapter 4

References
1. FIFA. FIFA Big Count. FIFA Communications Division, Information Services, Zürich, 2007.

2. Beijsterveldt van AMC, Stubbe JH, Schmikli SL, et al. Differences in injury risk and characteristics
between Dutch amateur and professional soccer players. J Sci Med Sport 2015;18(2):145-149.

3. Dvorak J, Junge A. Football injuries and physical symptoms: a review of the literature. Am J Sports
Med 2000;28:S-3.

4. Ekstrand J. Epidemiology of football injuries. Sci Sports 2008;23:73-77.

5. Ekstrand J, Hägglund M, Waldén M. Injury incidence and injury patterns in professional football:
the UEFA injury study. Br J Sports Med 2011b;45(7):553-558.

6. Schmikli SL, de Vries WR, Inklaar H, et al. Injury prevention target groups in soccer: injury
characteristics and incidence rates in male junior and senior players. J Sci Med Sport 2011;14(3):199-
203.

7. Wong P, Hong Y. Soccer injury in the lower extremities. Br J Sports Med 2005;39:473-482.

8. Sousa P, Rebelo A, Brito J. Injuries in amateur soccer players on artificial turf: a one-season
prospective study. Phys Ther Sport 2013;14(3):146-151.

9. Kordi R, Hemmati F, Heidarian H, et al. Comparison of the incidence, nature and cause of injuries
sustained on dirt field and artificial turf by amateur football players. Sports Med Arthrosc Rehabil
Ther Technol 2011;9(3):3.

10. Beijsterveldt van AMC, Port van de IGL, Krist MR, et al. Effectiveness of an injury prevention
programme for adult male amateur soccer players: a cluster-randomised controlled trial. Br J
Sports Med 2012;46(16):1114-1118.

11. Ekstrand J, Hägglund M, Waldén M. Epidemiology of muscle injuries in professional football

(soccer). Am J Sports Med 2011a;39(6):1226-1232.

12. Woods C, Hawkins RD, Maltby S, et al. The football association medical research programme: an
audit of injuries in professional football-analysis of hamstring injuries. Br J Sports Med 2004;38:36-
41.

13. Hägglund M, Waldén M, Ekstrand J. Injuries among male and female elite football players. Scand
J Med Sci Sports 2009;19(6):819-827.

14. Hägglund M, Waldén M, Ekstrand J. Previous injury as a risk factor for injury in elite football: a
prospective study over two consecutive seasons. Br J Sports Med 2006;40:767-772.

15. Heiderscheit BC, Sherry MA, Silder A, et al. Hamstring strain injuries: recommendations for
diagnosis, rehabilitation, and injury prevention. J Orthop Sports Phys Ther 2010;40(2):67-81.

16. Beijsterveldt van AMC, Port van de IGL, Vereijken AJ, et al. Risk factors for hamstring injuries in male
soccer players: a systematic review of prospective studies. Scand J Med Sci Sports 2013b;23(3):253-
262.

17. Freckleton G, Pizzari T. Risk factors for hamstring muscle strain injury in sport: a systematic review
and meta-analysis. Br J Sports Med 2013;47(6):351-358.

18. Hägglund M, Waldén M, Ekstrand J. Risk factors for lower extremity muscle injury in professional
soccer: the UEFA Injury Study. Am J Sports Med 2013;41(2):327-335.

76
 Hamstring injury prevention in amateur soccer

19. Mendiguchia J, Alentorn-Geli E, Brughelli M. Hamstring strain injuries: are we heading in the right
direction? Br J Sports Med 2012;46(2):81-85.

20. Cloke D, Moore O, Shah T, et al. Thigh muscle injuries in youth soccer: predictors of recovery. Am
J Sports Med 2012;40(2):433-439.

21. Engebretsen AH, Myklebust G, Holme I, et al. Intrinsic risk factors for hamstring injuries among
male soccer players: a prospective cohort study. Am J Sports Med 2010;38(6):1147-1153.

22. 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;14:311-317.

23. Petersen J, Thorborg K, Bachmann Nielsen M, 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(11):2296-2303.

24. Arnason A, Andersen TE, Holme I, et al. Prevention of hamstring strains in elite soccer: an
intervention study. Scand J Med Sci Sports 2008;18(1):40-48.

25. Krist MR, Beijsterveld van AM, Backx FJG, et al. Preventive exercises reduced injury-related costs
among adult male soccer players: a cluster-randomised trial. J Physiother 2013;59(1):15-23.
4
26. Junge A, Lamprecht M, Stamm H, et al. Country-wide campaign to prevent soccer injuries in Swiss
amateur players. Am J Sports Med 2011;39(1):57-63.

27. Horst van der N, Smits DW, Petersen J, et al. The preventive effect of the Nordic hamstring exercise
on hamstring injuries in amateur soccer players: study protocol for a randomised controlled trial.
Inj Prev 2014;20(4)e8

28. Small K, McNaughton L, Greig M, et al. Effect of timing of eccentric hamstring strengthening
exercises during soccer training: implications for muscle fatigability. J Strength Cond Res
2009;23:1077-1083.

29. Fuller CW, Ekstrand J, Junge A, et al. Consensus statement on injury definitions and data collection
procedures in studies of football (soccer) injuries. Br J Sports Med 2006;40:193-201.

30. Schache AG, Dorn TW, Blanch PD, et al. Mechanisms of the human hamstring muscle during
sprinting. Med Sci Sports Exerc 2012;44(4):647-658.

31. Chumanov ES, Heiderscheit BC, Thelen DG. The effect of speed and influence of individual muscles
on hamstring mechanics during the swing phase of sprinting. J Biomech 2007;40(16):3555-3562.

32. Chumanov ES, Heiderscheit BC, Thelen DG. Hamstring musculotendon dynamics during stance
and swing phases of high-speed running. Med Sci Sports Exerc 2011;43(3):525-532.

33. Croisier JL, Forthomme B, Namurois MH, et al. Hamstring muscle strain recurrence and strength
performance disorders. Am J Sports Med 2002;30(2):199-203.

34. Croisier J, Ganteaume S, Binet J, et al. Strength imbalances and prevention of hamstring injury in
professional soccer players: a prospective study. Am J Sports Med 2008; 36(8): 1469-1475.

35. Opar DA, Williams MD, Shield AJ. Hamstring strain injuries: factors that lead to injury and re-injury.
Sports Med 2012;42(3):209-226.

36. Askling C, Karlsson J, Thorstensson A. Hamstring injury occurrence in elite soccer players after
preseason strength training with eccentric overload. Scand J Med Sci Sports 2003;13(4):244-250.

77
Chapter 4

37. Engebretsen AH, Myklebust G, Holme I, et al. Prevention of injuries among male soccer players:
a prospective, randomized intervention study targeting players with previous injuries or reduced
function. Am J Sports Med 2008;36:1052-1060.

38. Beijsterveldt van AMC, Horst van der N, Port van de IGL, et al. How effective are exercise-based
injury prevention programmes for soccer players? A systematic review. Sports Med 2013a;43(4):257-
265.

39. Janssen KW, Hendriks MRC, van Mechelen W, et al. The cost effectiveness of measures to
prevent recurrent ankle sprains: results of a 3-arm randomized controlled trial. Am J Sports Med
2014;42(7):1534-1541.

40. Boutron I, Tubach F, Giraudeau B, et al. Blinding was judged more difficult to achieve and maintain
in nonpharmacologic than pharmacologic trials. J Clin Epidemiol 2004;57(6):543-550.

41. Engebretsen L, Bahr R. Sports Injury Prevention, 1st edition 2009. Chapter 1. Blackwell Publishing.
ISBN 9781405162449.

42. Verhagen E, Finch CF. Setting our minds to implementation. Br J Sports Med 2011;45(13):1015-
1016.

43. Finch CF. A new framework for research leading to sports injury prevention. J Sci Med Sport
2006;9:3-9.

44. Klügl M, Shrier I, McBain K, et al. The prevention of sport injury: an analysis of 12,000 published
manuscripts. Clin J Sports Med 2010;20:407-412.

78
Hamstring injury prevention in amateur soccer

79
 Chapter 5

Hamstring-and-lower-back flexibility in
male amateur soccer players

N. (Nick) van der Horst

A.R. (Annique) Priesterbach
F.J.G. (Frank) Backx
D.W. (Dirk-Wouter) Smits

Clin J Sport Med 2017;27(1):20-25

Chapter 5

Abstract
Objective  This study investigated the hamstring-and-lower-back flexibility (HLBF)
of male adult amateur soccer players, using the sit-and-reach test (SRT), with a
view to obtaining population-based reference values and to determining whether
SRT scores are associated with player characteristics.

Design  Cross-sectional cohort study.

Setting  Teams from high-level Dutch amateur soccer competitions were recruited
for participation.

Participants  Dutch male high-level amateur field soccer players (n = 449), aged
18–40 years. Players with a hamstring injury at the moment of SRT-measurement
or any other injury that prevented them from following the SRT protocol were
excluded.

Main outcome measures  SRT scores were measured and then population-based
reference values were calculated: > 2SD below mean (defining ‘very low’ HLBF),
1SD–2SD below mean (‘low’ HLBF), 1SD below mean to 1SD above mean (‘nor-
mal’ HLBF), 1SD–2SD above mean (‘high’ HLBF), and > 2SD above mean (‘very
high’ HLBF). Whether SRT scores were correlated with player characteristics was
determined using a Pearson correlation coefficient or Spearman’s rho.

Results  SRT scores ranged from 0 to 43.5 cm (mean 22.0 cm, SD 9.2). The cut-off
points for population-based reference values were < 3.5 cm for ‘very low’, 3.5–1
3 cm for ‘low’, 13.0–31.0 cm for ‘normal’, 31.0–40.5 cm for ‘high’, and >40.5 cm
for ‘very high’. SRT scores were significantly associated with players’ height (ρ =
-0.132, p = 0.005), BMI (r = 0.114, p = 0.016), and history of anterior cruciate
ligament surgery (p < 0.001).

Conclusions  The present study is the first to describe the HLBF of amateur soccer
players. The SRT reference values with cut-off points may facilitate evidence-based
decision-making regarding HLBF and the SRT might be a useful tool to assess
injury risk, performance or for diagnostic purposes.

82
 HLBF in male soccer players

Introduction
The sit-and-reach test (SRT) is one of the most commonly used instruments to measure
hamstring-and-lower-back flexibility (HLBF) and is often used to diagnose or assess the
risk of injury and to evaluate performance.1,2 The classical SRT was first described by
Wells and Dillon in 1952.3 Since then, the SRT has been incorporated in many HLBF
and fitness test protocols, such as the Eurofit Test of Physical Fitness.1,4-9 The SRT has
a high intrarater reliability and test-retest reliability.2-4,8,10 For practical use by clinicians
(e.g. sports physicians, physical therapists, sports masseurs etc.), the SRT is quick and
simple to perform and requires little skill and training, both for administering the test
and interpreting the scores.5,11 Furthermore, the SRT is particularly useful in largescale
evaluation of HLBF in the field setting, such as team monitoring of HLBF over time.11,12

HLBF is an important modifiable risk factor for injuries and is easy to measure in
clinical practice by instruments such as the SRT. As such, HLBF deserves attention in
sports injury-related research.13-15 HLBF is an integral part of the current cause-effect
model for hamstring injury, although research contains controversial findings regarding
the contribution of hamstring flexibility on increased injury risk.16 Mendiguchia’s
new conceptual model for hamstring injury suggests that hamstring flexibility could
5
particularly turn into a risk factor when combined with other risk factors, such as strength,
and increase the likelihood of injury.16 Regarding the relationship between strength and
flexibility, fundamental research has shown that the ratio of the change in resistance to
the change in length of the muscle, termed stiffness, is associated with an increased risk
of injury.17-19 As a less stiff muscle can extend to a greater length, it can better absorb
applied forces.17,20 Sports requiring optimal use of the stretch-shortening cycles of the
hamstring muscles generally involve rapid acceleration and deceleration, such as is seen
in rugby, American football, and soccer, all of which are high-risk sports for hamstring
injuries.21-22 Therefore, evaluating hamstring muscle flexibility, by instruments such as
the SRT, is a regular assessment in sports medical evaluation because reduced HLBF
has been proposed as a predisposing factor for increased risk of hamstring injury.23

A reduced HLBF can be a risk factor not only for sports injuries,24-28 such as acute hamstring
injuries,27 muscle damage following eccentric exercises,26 patellar tendinopathy,28 anterior
knee pain,28 low back pain,25 but also for reduced performance.24 Competitive soccer
players have a reduced HLBF compared with recreational athletes,29,30 possibly as a result
of the long-term impact of soccer training on the muscle-tendon system. It potentially

83
Chapter 5

makes soccer players more susceptible to hamstring injuries.29,31,32 Indeed, the highest
rate of hamstring injury is seen in soccer,33 accounting for 47% of all muscle strains
in the sport and the most lost playing time when compared with all other injuries.22
Hamstring injuries are characterized by a high recurrence and substantial lost playing
time.22,34 Therefore, identifying soccer players with a reduced HLBF, measured with the
SRT, might facilitate identification of those players at risk of injury.35

Accurate diagnostics and valid prediction rules for HLBF can improve the effectiveness
of treatment, prevention, and training. However, the interpretation of outcomes for
many clinical tests, such as the SRT, is still highly subjective.36 The lack of population-
based reference data with appropriate cut-off points makes it difficult to use the results
of clinical tests for evidence-based decision-making or research.37,38 To our knowledge,
no studies have measured HLBF in soccer players. The aim of this study was to measure
HLBF in male adult amateur soccer players, with a view to establishing population-based
reference values and to determining whether HLBF in this population is associated with
specific player characteristics.

Methods
This cross-sectional study was part of the Hamstring Injury Prevention Strategies (HIPS)
study, a study of interventions to prevent hamstring injuries in male adult soccer players
in the Netherlands (trial number NTR3664).39 Baseline data, including SRT scores, of
616 soccer players were available for the current study.

Subjects

Soccer teams from Dutch high-level amateur field soccer competitions (‘1e Klasse’) were
invited to participate. Teams were included if the coaches and medical staff agreed
on participation and players were willing to sign informed consent. Male players aged
between 18 and 40 years were eligible for inclusion.

Teams were regarded as drop-out if the medical staff did not return the player
questionnaires or SRT scores of the team or did not follow the SRT testing protocol.
Individual players were excluded if they suffered from a hamstring injury at the moment
of inclusion or any other injury that prevented them from following the SRT protocol.

84
 HLBF in male soccer players

Individual players were regarded as drop-out if they were not available for flexibility
testing.

Procedures

Instruction meetings for the medical staff of participating teams were organized in each
district 2–6 weeks before the study started in January 2013. During these meetings, the
aims of the study and the SRT for flexibility measurements were explained. Team medical
staff were provided with a SRT box, written instructions, and intake questionnaires and
were responsible for collecting and returning the questionnaires and SRT scores. Data
were collected during the first soccer team activity after the winter break in January 2013.

Instruments

Intake questionnaires
Information about player characteristic (date of birth, self-reported height and weight,
nationality, years of soccer experience, dominant leg (i.e. kicking leg), field position,
current injury status, and soccer injury history) was obtained with a questionnaire. This 5
questionnaire defined soccer injuries, in accordance with Fuller’s consensus statement, as
any physical complaint sustained by a player that results from a soccer match or soccer
training, irrespective of the need for medical attention or time loss from soccer activities.40

Sit-and-Reach Test
Flexibility was measured using the classical SRT protocol as described by Ayala et al.5
Meta-analysis has shown that the classical SRT protocol has a better criterion-related
validity than modified versions of the SRT protocol.12 For this test, a standard SRT box
(30.5 cm high) with a sliding reach indicator on top of a measuring scale (0–50 cm) was
used. The 35-cm mark was aligned with the foot panel of the box. The test has a high
intra-rater reliability (Intra-class Correlation Coefficient (ICC) = 0.92–0.98) and test-retest
reliability (ICC = 0.92–0.95) for the SRT.1,2,6,10

The SRT was performed before normal training and the player was not allowed to do
any warming-up or stretching exercises before the test. The player was tested while
sitting on the floor, with the legs together, the knees extended, and the soles of the
bare feet placed against the foot panel of the test box (see Figure 5.1/Video 1). He was

85
Chapter 5

Figure 5.1  Test position of the Sit-and-Reach Test (SRT).

instructed to place his hands on top of each other with the hand palms facing downward
and to reach forward slowly, pushing the reach indicator as far as possible along the
measuring scale. Throughout the test, a member of the medical staff made sure that
the knees of the player remained extended; the knees could be fixed during the test.
The maximum position had to be reached gradually and maintained for 2 seconds. Two
measurements were taken, with a 30-second interval, for each player.5 In between the
two measurements, the player had to sit up straight so that the hip extensor muscles
were returned to a neutral position; the player was not allowed to stand up or stretch.
Test scores were recorded to the nearest 0.5 cm. If a player could not reach the zero
mark on the box, the test score was reported as zero.

Statistical analysis

All statistical procedures were performed using SPSS 22.0 (IBM Corp. 2011, Armonk,
NY, USA). Player characteristics were reported as means and standard deviations (SD)
for continuous variables (age, height, weight, BMI, soccer experience), and as number of
players and percentages for ordinal or categorical variables (nationality, leg dominance,
field position and injury history).

86
 HLBF in male soccer players

SRT scores are reported as means in cm, standard deviations (SD), range and quartiles
(5). Population-based reference values of HLBF were calculated as: > 2SD below mean
(defining ‘very low’ HLBF), 1SD–2SD below mean (‘low’ HLBF), 1SD below mean to 1SD
above mean (‘normal’ HLBF), 1SD-2SD above mean (‘high’ HLBF), and > 2SD above
mean (‘very high’ HLBF).

Pearson correlation coefficient (PCC) or Spearman’s rho was calculated to determine

whether player characteristics were correlated with SRT scores. Continuous variables were
checked for normal distribution by using the Kolmogorov-Smirnov test. Subsequently,
differences in player characteristics among subgroups of HLBF were analyzed with Chi-
Square tests and ANOVAs. Statistical significance was accepted at the p = 0.05 level.

Ethical considerations

This study was approved by the medical ethics committee of the University Medical
Center Utrecht, Netherlands (File number 12-575/C). All players were asked to provide
written informed consent prior to the start of this study. Players unwilling to do so were
excluded from the trial.
5

Results

Baseline data of 449 soccer players from 29 teams were available for analysis. A flow
chart of the study population is presented in Figure 5.2.

Inclusion (n = 591)

Intake questionnaires were not

SRT not performed / scores not completed (n = 32)
returned by team medical staff
(n = 67)
Team medical staff did not follow test
protocol as instructed (n = 43)

449 players analyzed

Figure 5.2  Flow chart of the study population.

87
Chapter 5

Player characteristics

Player characteristics are summarized in Table 5.1. Their mean age was 24.5 years (SD 3.8)
and they had played soccer for a mean of 18.1 years (SD 4.2). The right leg was dominant
in 68.1% of the players. Field positions were proportionally represented, although some
players reported multiple field positions (e.g. midfielder and forward). Almost one in
four players (23.3%) had had one or more hamstring injuries in the previous year.

Table 5.1  Player characteristics (n = 449)

Mean (SD) / %

Age (years) 24.5 (± 3.8)

Height (cm) 183.5 (± 6.4)
Weight (kg) 78.2 (± 8.2)
BMI (kg/m2) 23.2 (± 1.8)
Dutch nationality (%) 95.3% (n = 428)
Soccer experience (years) 18.1 (± 4.2)
Leg dominance
Right leg 68.1% (n = 305)
Left leg 22.8% (n = 102)
Two-legged 9.2% (n = 41)
Field position
Forward 26.9% (n = 121)
Midfielder 35.6% (n = 160)
Defender 35.9% (n = 161)
Goalkeeper 10.9% (n = 49)
Hamstring injury in previous year 23.3% (n = 99)
Other soccer injuries in previous year 60.4% (n = 269)
History of anterior cruciate ligament surgery 4.7% (n = 20)

SRT scores

SRT scores are presented in Table 5.2. The mean overall SRT score of all players was
22.0 cm (SD 9.2; range 0–43.5 cm). Fifteen players (3.3%) scored 0 cm on both tests.
The lower and upper limits of the normal range of SRT scores for this population (mean
± 1SD) were 13.0 and 31.0 cm, respectively. The lower and upper critical limit values for
HLBF (mean ± 2SD) were 3.5 and 40.5 cm, respectively. The population-based reference
values for the SRT in male adult amateur soccer players are presented in Table 5.3.

88
 HLBF in male soccer players

Table 5.2  Sit-and-Reach Test scores (n = 449)

Mean (SD) Range Quartiles (25–50–75)

SRT 1 (cm) 21.2 (± 9.2) 0.0–43.0 15.0–21.5–27.5

SRT 2 (cm) 22.8 (± 9.4) 0.0–45.0 17.0–23.5–30.0
SRTaverage (cm) 22.0 (± 9.2) 0.0–43.5 16.0–22.5–28.5

Table 5.3  Population-based reference values for the Sit-and-Reach Test

SRT score HLBF

> 40.5 Very high

31.5–40.5 High
13.0–31.0 Normal
3.5–12.5 Low
< 3.5 Very low

Player characteristics associated with SRT scores

Player height was negatively correlated with SRT scores (ρ = -0.132, p = 0.005) whereas 5
BMI was positively correlated with SRT scores (r = 0.114, p = 0.016). Players with a
history of anterior cruciate ligament (ACL) surgery had a higher SRT score (mean 7.6
cm) than players without such a history (p < 0.001). Age, weight, soccer experience, leg
dominance, field position, and previous hamstring injury were not associated with HLBF.
There was a difference in BMI between the ‘Very low HLBF’ and ‘High HLBF’ group (Δ
-1.36, p = 0.045) and for ‘history of ACL surgery’ (χ2 (4, n = 422) = 25.424, p = 0.000).

Discussion
This study investigated the HLBF of male adult amateur soccer players, with a view to
establishing population-based reference values for the SRT and to determining whether
player characteristics are associated with SRT scores.

Population-based reference values

The mean SRT score was 22.0 cm and normal values ranged from 13.0 to 31.0 cm in male
adult amateur soccer players. These soccer players had a substantially lower flexibility

89
Chapter 5

than other athletes.4,5,41 Using the same protocol, Ayala et al. found SRT scores of 35.9 (±
10.1) cm and 38.1 (± 9.7) cm among 243 recreationally active young adults (mean age 21
years).5 Soccer training reduces muscle flexibility in both the short and long term,42 and
since our participants had played soccer for an average of 18 years, this could explain
why they had lower SRT scores than the recreationally active young adults described
by Ayala et al.5 Moreover, the study population of Ayala et al. contained both men and
women, and it is recognized that women generally have higher SRT scores than men.8
The SRT scores of Spanish male professional futsal players were reported as 44.1 (± 7.8)
cm and 42.4 (± 7.5) cm.1,2 The difference in SRT scores between these studies and our
study might be due to more extensive stretching protocols during the training sessions of
professional players, which could increase their overall muscle flexibility.31 Furthermore,
unlike in our study, in the other studies participants followed a 5-minute warming-up
and stretching protocol before testing. This could have affected hamstring flexibility,
because it has been shown that 120–150 seconds of stretching results in changes in the
viscoelastic properties of muscles that last 20 minutes.43,44 Therefore most SRT-protocols,
including the original protocol by Wells and Dillon, do not recommend a warming-up
prior to testing and this study adhered to these guidelines.3

Associations with player characteristics

To our knowledge, no previous study has reported associations between HLBF and
player characteristics. We found HLBF (SRT score) to be significantly associated with
the height of adult soccer players. Our results show that taller players have lower
hamstring flexibility than shorter players. However the methodology of the SRT might
have contributed to this correlation due to differences in the proportional length of the
arms and legs, as tall adolescents with longer legs relative to their arms have a poorer
performance on the SRT.45 Clinicians could therefore consider using a modified version
of the classical SRT protocol to establish a relative zero point for each person, thereby
solving this methodological problem of tall players.45

We also found HLBF to be significantly correlated with a history of ACL surgery, with
SRT scores being substantially higher in players who had undergone surgery. In contrast,
Ekstrand and Gillquist reported no difference in lower extremity muscle tightness
between players with and without soccer injuries in the previous year.29 In their study,
Ekstrand and Gillquist analyzed all knee injuries, but did not report additional analyses

90
 HLBF in male soccer players

for players with history of ACL surgery. In players with recent ACL surgery, this increased
flexibility might be a result of rehabilitation, during which extensive (hamstring) stretching
exercises are combined with a period without soccer. Unfortunately, we do not know
whether a hamstring tendon autograft was used for ligament reconstruction, because
this could potentially help explain the change in hamstring length or flexibility in this
subgroup.46 However, since ACL surgery should, theoretically, not directly influence HLBF,
this finding suggests that ACL surgery influences SRT test scores in some other way. In
conclusion, the normal range of SRT scores presented here should not be applied to
players with a history of ACL injury.

Methodological considerations

The main strength of this study is the large, representative population of 449 soccer
players all playing at the same amateur level, with similar training and competition
loads. All player characteristics, such as age, field positions, and injury history, were
well represented among the players. Moreover, all players performed the SRT following
a standardized, easily executed protocol with the same measuring device, for which
the members of medical staff of the teams had received identical instructions. The 5
test protocol used in this study is simple and requires little skill or training, both with
regard to test administration and data interpretation.1 This enabled a team of players
to be tested in a short time, which increases the practical usability of this test for both
research purposes and in the field. This supports the representativeness and relevance
of the reported population-based SRT reference values.

A potential study limitation is the lack of a criterion standard. Several different tests to
measure hamstring flexibility or HLBF are available, such as the knee extension angle,
sacral angle, straight leg raise, toe touch test, and different versions of the SRT.4,6
However, no criterion standard has yet been established and these tests do not possess
sufficient concurrent validity to assume that they each measure solely hamstring flexibility
or HLBF.1,6 In the current study, we chose to measure flexibility with the classical SRT,
which measures a combination of hamstring and lower back flexibility (HLBF).3

It has been argued that the SRT score may be influenced by other anthropometric and
physical factors,4,6,11 such as limb and trunk length, gastrocnemius length, and flexibility
of the shoulders, spine, and ankles. We did not correct for these factors, as the test was

91
Chapter 5

performed in a way that is clinically and easily applicable on the soccer field. The SRT
reference values we determined represent statistically determined limits for HLBF in
soccer players. Given that the standard sit-and-reach box has a range of 0 to 50 cm, a
normal range of 13.0–31.0 cm leaves more room for distinguishing between players with
a high than a low HLBF. In total, 3.3% of players scored 0 cm on the SRT in this study,
and these individuals may be at risk of hamstring injuries because of a limited HLBF.

Future research

Future research will have to determine whether the SRT reference values can indeed
identify players at increased risk of hamstring injuries due to reduced flexibility. If this is
the case, then the reference values can be further refined to identify players with very
poor and very high flexibility, but also the intermediate categories of flexibility with
differing injury risk.

Practical applications
As a reduced HLBF is often suggested to be a modifiable, intrinsic risk factor for soccer
injuries and diminished performance, identification of players with reduced HLBF is
essential.34,47-49 The SRT is a preferable test for clinicians to measure HLBF as it is reliable,
quick and simple to perform, and easy for group measurements in the field setting.11,12
Normal values of the SRT for male players – the largest subgroup in soccer – provide a
basis for targeted injury prevention or performance-enhancing strategies.

The present study provides population-based reference HLBF values (measured with
the SRT) for male amateur soccer players: very low’ (< 3.5 cm), ‘low’ (3.5–12.5 cm),
‘normal’ (13.0–31.0 cm), ‘high’ (31.5–40.5 cm), and ‘very high’ (> 41.5). With a mean
SRT score of 22.0 cm, male adult amateur soccer players have a lower HLBF than other
groups of sportsmen. Coaches and practitioners should be aware of population-specific
differences when using the SRT for diagnostic purposes or to assess injury risk and/or
performance, and remember that the HLBF references values are not appropriate for
players with a history of ACL injuries.

92
 HLBF in male soccer players

References
1. Ayala F, Sainz de Baranda P, De Ste Croix M, et alF. Absolute reliability of five clinical tests for
assessing hamstring flexibility in professional futsal players. J Sci Med Sport 2012a;15(2):142-147.

2. Hui SS, Yuen PY. Validity of the modified back-saver sit-and-reach test: A comparison with other
protocols. Med Sci Sports Exerc 2000 Sep;32(9):1655-1659.

3. Wells KF, Dillon EK. The sit-and-reach. A test of back and leg flexibility. Research Quarterly
1952;23:115-118.

4. Ayala F, Sainz de Baranda P, De Ste Croix M, et al. Criterion-related validity of four clinical tests used
to measure hamstring flexibility in professional futsal players. Phys Ther Sport 2011;12(4):175-181.

5. Ayala F, Sainz de Baranda P, De Ste Croix M, et al. Reproducibility and criterion-related validity of
the sit and reach test and toe touch test for estimating hamstring flexibility in recreationally active
young adults. Phys Ther Sport 2012b;13(4):219-226.

6. Davis DS, Quinn RO, Whiteman CT, et al. Concurrent validity of four clinical tests used to measure
hamstring flexibility. J Strength Cond Res 2008;22(2):583-588.

7. Holt LE, Pelham TW, Burke DG. Modifications to the standard sit-and-reach flexibility protocol. J
Athl Train 1999;34(1):43-47.

8. Kawano MM, Ambar G, Oliveira BI, et al. Influence of the gastrocnemius muscle on the sit-and-
reach test assessed by angular kinematic analysis. Rev Bras Fisioter 2010;14(1):10-15.

9. Eurofit. Eurofit tests of physical fitness. 2nd edition; Strasbourg; 1993.

5
10. Bozic PR, Pazin NR, Berjan BB, et al. Evaluation of the field tests of flexibility of the lower extremity:
Reliability and the concurrent and factorial validity. J Strength Cond Res 2010;24(9):2523-2531.

11. López-Miñarro PA, Andújar PS, Rodriguez-Garcia PL. A Comparison of the sit-and-reach test and
the back-saver sit-and-reach test in university students. J Sports Sci Med 2009;8(1):116-122.

12. Mayorga-Vega D, Merino-Marban R, Viciana J. Criterion-related validity of sit-and-reach tests for

estimating hamstring and lumbar extensibility: a meta-analysis. J Sports Sci Med 2014;13(1):1-14.

13. van Beijsterveldt AM, van de Port IG, Vereijken AJ, et al. Risk factors for hamstring injuries in male
soccer players: A systematic review of prospective studies. Scand J Med Sci Sports 2013;23(3):253-
262.

14. Dadebo B, White J, George KP. A survey of flexibility training protocols and hamstring strains in
professional football clubs in England. Br J Sports Med 2004;38(4):388-394.

15. Reurink G, Goudswaard GJ, Tol JL, et al. Therapeutic interventions for acute hamstring injuries: a
systematic review. Br J Sports Med 2012;46(2):103-109.

16. Mendiguchia J, Alentorn-Geli E, Brughelli M. Hamstring strain injuries: Are we heading in the right
direction? Br J Sports Med 2012;46(2):81-85.

17. Magnusson SP. Passive properties of human skeletal muscle during stretch maneuvers. A review.
Scand J Med Sci Sports 1998;8(2):65-77.

18. McHugh MP, Magnusson SP, Gleim GW, et al. Viscoelastic stress relaxation in human skeletal
muscle. Med Sci Sports Exerc 1992;24(12):1375-1382.

93
Chapter 5

19. Watsford ML, Murphy AJ, McLachlan KA, et al. A prospective study of the relationship between
lower body stiffness and hamstring injury in professional Australian rules footballers. Am J Sports
Med 2010;38(10):2058-2064.

20. McNair PJ, Dombroski EW, Hewson DJ, et al. Stretching at the ankle joint: viscoelastic responses
to holds and continuous passive motion. Med Sci Sports Exerc 2001;33(3):354-358.

21. Lempainen L, Banke IJ, Johansson K, et al. Clinical principles in the management of hamstring
injuries. Knee Surg Sports Traumatol Arthrosc 2015;23(8):2449-2456.

22. Woods C, Hawkins RD, Maltby S, et al. The football association medical research programme:
An audit of injuries in professional football--analysis of hamstring injuries. Br J Sports Med
2004;38(1):36-41.

23. Witvrouw E, Mahieu N, Danneels L, et al. Stretching and injury prevention, an obscure relationship.
Sports Med 2004;34(7):443-449.

24. Croisier JL, Forthomme B, Namurois MH, et al. Hamstring muscle strain recurrence and strength
performance disorders. Am J Sports Med 2002;30(2):199-203.

25. Jones MA, Stratton G, Reilly T, et al. Biological risk indicators for recurrent non-specific low-back
pain in adolescents. Br J Sports Med 2005;39(3):137-140.

26. LaRoche DP, Connolly DA. Effects of stretching on passive muscle tension and response to eccentric
exercise. Am J Sports Med 2006;34(6):1000-1007.

27. Witvrouw E, Danneels L, Asselman P, et al. Muscle flexibility as a risk factor for developing muscle
injuries in male professional soccer players. A prospective study. Am J Sports Med 2003;31(1):41-
46.

28. Witvrouw E, Lysens R, Bellemans J, et al. Intrinsic risk factors for the development of anterior knee
pain in an athletic population. A two-year prospective study. Am J Sports Med 2000;28(4):480-489.

29. Ekstrand J, Gillquist J. The frequency of muscle tightness and injuries in soccer players. Am J
Sports Med 1982;10(2):75-78.

30. Silva DA, Petroski EL, Gaya AC. Anthropometric and physical fitness differences among brazilian
adolescents who practise different team court sports. J Hum Kin 2013;36:77-86.

31. Ayala F, Sainz De Baranda P, De Ste Croix M. Effect of active stretch on hip flexion range of motion
in female professional futsal players. J Sports Med Phys Fitness 2010;50(4):428-435.

32. Grygorowicz M, Piontek T, Dudzinski W. Evaluation of functional limitations in female soccer players
and their relationship with sports level – a cross-sectional study. PloS One 2013;8(6):e66871.

33. Heiderscheit BC, Sherry MA, Slider A, et al. Hamstring strain injuries: recommendations for
diagnosis, rehabilitation, and injury prevention. J Orthop Sports Phys Ther 2010;40(2):67-81

34. Engebretsen AH, Myklebust G, Holme I, et al. Intrinsic risk factors for hamstring injuries among
male soccer players: A prospective cohort study. Am J Sports Med 2010;38(6):1147-1153.

35. Bahr R, Krosshaug T. Understanding injury mechanisms: a key component of preventing injuries
in sport. Br J Sports Med 2005;39:324-329.

36. Scott IA, Greenberg PB, Poole PJ. Cautionary tales in the clinical interpretation of studies of
diagnostic tests. Intern Med J 2008;38(2):120-129.

94
 HLBF in male soccer players

37. Gräsbeck R. The evolution of the reference value concept. Clin Chem Lab Med 2004;42(7):692-
697.

38. Siest G, Henny J, Gräsbeck R, et al. The theory of reference values: an unfinished symphony. Clin
Chem Lab Med 2013;51(1):47-64.

39. Horst van der N, Smits DW, Petersen J, et al. The preventive effect of the Nordic hamstring exercise
on hamstring injuries in amateur soccer players: study protocol for a randomised controlled trial.
Inj Prev 2014;20(4):e8.

40. Fuller CW, Ekstrand J, Junge A, et al. Consensus statement on injury definitions and data collection
procedures in studies of football (soccer) injuries. Clin J Sport Med 2006;16(2):97-106.

41. Muyor JM, Vaquero-Cristóbal R, Alacid F, et al. Criterion-related validity of sit-and-reach and toe-
touch tests as a measure of hamstring extensibility in athletes. J Strength Cond Res 2014;28(2):546-
555.

42. Bradley PS, Portas MD. The relationship between preseason range of motion and muscle strain
injury in elite soccer players. J Strength Cond Res 2007;21(4):1155-1159.

43. Ford P, McChesney J. Duration of maintained hamstring ROM following termination of three
stretching protocols. J Sport Rehabil 2007;16(1):18-27.

44. Power K, Behm D, Cahill F, et al. An acute bout of static stretching: effects on force and jumping
performance. Med Sci Sports Exerc 2004;36(8):1389-1396.

45. Hoeger WW, Hopkins DR, Button S, et al. Comparing the sit and reach with the modified sit and
reach in measuring flexibility in adolescents. Pediatric Exercise Science 1990;2:156-162.

46. Mohtadi NG, Chan DS, Dainty KN, et al. Patellar tendon versus hamstring tendon autograft for
5
anterior cruciate ligament rupture in adults. Cochrane Database Syst Rev 2011;7(9):CD005960.

47. Benell K, Tully E, Harvey N. Does the toe-touch test predict hamstring injury in Australian Rules
footballers. Aust J Physiother 1999;45(2):103-109.

48. Gabbe BJ, Finch CF, Bennell KL, et al. Risk factors for hamstring injuries in community level
Australian football. Br J Sports Med 2005;39(2):106-110.

49. Henderson G, Barnes CA, Portas MD. Factors associated with increased propensity for hamstring
injury in English premier league soccer players. J Sci Med Sport 2010;13(4):397-402.

95
 Chapter 6

No relationship between hamstring

flexibility and hamstring injuries in
male amateur soccer players:
a prospective study

M. (Mitchell) Van Doormaal

N. (Nick) van der Horst
F.J.G. (Frank) Backx
D.W. (Dirk-Wouter) Smits
B.M.A. (Bionka) Huisstede

Am J Sports Med 2017;45(1):121-126
Chapter 6

Abstract
Background  In soccer, although hamstring flexibility is thought to play a major
role in preventing hamstring injuries, the relationship between hamstring flexibility
and hamstring injuries remains unclear.

Purpose  To investigate the relationship between hamstring flexibility and ham-

string injuries in male amateur soccer players.

Study design  Case-control study; level of evidence, 3.

Methods  This study included 450 male first-class amateur soccer players (mean
age, 24.5 years). Hamstring flexibility was measured by performing the sit-and-
reach test (SRT). The relationship between hamstring flexibility and the occurrence
of hamstring injuries in the following year, while adjusting for the possible con-
founding effects of age and previous hamstring injuries, was determined with a
multivariate logistic regression analysis.

Results  Of the 450 soccer players, 21.8% reported a hamstring injury in the
previous year. The mean (± SD) baseline score for the SRT was 21.2 ± 9.2 cm.
During the 1-year follow-up period, 23 participants (5.1%) suffered a hamstring
injury. In the multivariate analysis, while adjusting for age and previous injuries,
no significant relationship was found between hamstring flexibility and hamstring
injuries (p = 0.493).

Conclusion  In this group of soccer players, hamstring flexibility (measured with

the SRT) was not related to hamstring injury. Age and previous hamstring injuries
as possible confounders did not appear to influence this relationship. Other
etiological factors need to be examined to further elucidate the mechanism of
hamstring injury.

Clinical relevance It is not possible to predict an increased risk of hamstring

injuries in soccer by measuring hamstring flexibility.

98
 Hamstring flexibility and hamstring injuries in soccer

Introduction
Soccer is the most frequently played sport worldwide, with about 265 million registered
and unregistered players. Playing soccer is supposed to be beneficial for health because
regular exercise during sport generally reduces the risk of many diseases.1,2 However,
this statement is challenged by the relatively high risk of injury among soccer players.
In 2013, about 850,000 injuries are reported among the 1.4 million registered soccer
players in the Netherlands.3 Hamstring injuries in male amateur soccer are responsible
for 15.9% of the injuries.4 In players suffering from a hamstring injury, long-term absence
from sport, or even an early end of a sport career, is reported.5 In addition, the risk
of recurrences is 16.2%, which is above the average rate compared to other types of
sport injuries.4,6 In soccer players, hamstring flexibility is often measured to determine
the risk of incurring a hamstring injury and to decide whether exercises are needed to
increase hamstring flexibility.7 However, the relationship between hamstring flexibility
and hamstring injuries remains unclear.

A hamstring injury is defined as a muscle or tendon injury of the semitendinosus muscle,

semimembranosus muscle or biceps femoris muscle, which prevents a player from taking
full part in soccer training or matches.9 Various nonmodifiable risk factors for hamstring
injuries in soccer players have been identified, including increased age, and at least 1
previous hamstring injury.9,10 Limited hamstring flexibility is a potential modifiable risk
factor related to a hamstring injury.11

Clark12 reported that flexibility of the hamstring muscles plays a major role in sprint- 6
type hamstring injuries, which are the most frequently occurring hamstring injuries in
soccer. In the late swing phase of a sprint, with the knee at or near full extension, the
hamstring muscles are stretched and endure a maximum peak force between 85% and
95% of the gait cycle. Consequently, when the hamstring muscles are at a (sub)maximum
length during the sprint, a considerable force will be endured.13 A player with limited
hamstring flexibility is therefore assumed to be at a higher risk for an injury during a
sprint than a player who has more flexible hamstring muscles. However, the evidence
for a relationship between hamstring flexibility and hamstring injuries is conflicting.11,14,15

Two important risk factors for hamstring injuries are age and previous hamstring injuries.
Increasing age can cause a loss of muscle mass, a reduction in skeletal muscle fiber size, a
number of muscle fibers, and denervation of muscle fibers, which can result in decreased

99
Chapter 6

hamstring flexibility and an increased risk factor for hamstring injuries.16 According to
Gabbe et al.,17 a previous hamstring injury can result in increased hamstring flexibility but
also an increased risk for hamstring injuries. Therefore, because both risk factors are related
to the risk of hamstring injuries and hamstring flexibility, age and previous hamstring
injuries are possible confounders in the relationship between hamstring flexibility and
hamstring injuries. Because of these confounders, the relationship between hamstring
flexibility and hamstring injuries may have been overestimated in previous studies.11

Therefore, to verify our hypothesis, we investigated the relationship between hamstring

flexibility and hamstring injuries, after adjusting for confounders, in male amateur soccer
players.

Methods

Design

This prospective study was part of the Hamstring Injury Prevention Strategies (HIPS)
study and was carried out in close collaboration with the Royal Netherlands Football
Association (KNVB). The Medical Ethics Committee of the University Medical Centre
Utrecht approved the study (No. 12-575/C). The design of the HIPS study has already
been published.18

The aim of the HIPS study is 2-fold. First, a randomized controlled trial was performed
to study the effect of the Nordic hamstring exercise (an eccentric exercise added to
regular soccer training) on the occurrence and prevention of hamstring injuries in amateur
soccer players.19 Second, the present study examined whether limited flexibility of the
hamstring muscles is associated with an increased risk of hamstring injuries.

Participants

During October and November 2012, all male first-class amateur soccer teams in the
Netherlands (districts West 1, West 2, South 1 and East) were invited to participate in
the HIPS study. These teams play at high-level amateur soccer competitions with 1 or
sometimes 2 matches per week and 2 to 3 training sessions per week. Players of these
teams who were aged 18 to 40 years and who agreed to participate were eligible for

100
 Hamstring flexibility and hamstring injuries in soccer

inclusion in the HIPS study. All participants received an information letter providing details
on the aim of this study, the hamstring flexibility test, and data collection. After receiving
the letter, all participants were asked to provide informed consent. Exclusion criteria
for this study were: 1) being absent during the measurement of hamstring flexibility in
January 2013, 2) being unable to perform the hamstring flexibility test correctly for any
reason, or 3) suffering from a current hamstring injury.

Measurements

Player characteristics
Player characteristics were collected using a questionnaire that was filled in by all
participants at baseline of the HIPS study in January 2013. The questionnaire included
questions on age, years of soccer experience, field position, and hamstring injuries in
the year before to the study.

Hamstring flexibility
To measure hamstring flexibility, all participants performed the sit-and reach test (SRT)
supervised by a member of the medical staff of the soccer team (Figure 6.1). The SRT

Figure 6.1  The sit-and-reach test.

101
Chapter 6

is a reliable and valid test to estimate hamstring flexibility.20-22 In this study, participants
performed the SRT according to the protocol described by Ayala et al.23 No warm-up
was allowed before testing. During the test, the participant was sitting on the floor
with the knees extended and the legs together. The soles of the bare feet were placed
against the foot panel of the SRT box. The hands were placed on top of each other with
the palms facing downwards and then pushing the reach indicator on the box as far as
possible along the measuring scale. The examiner placed his hands on the knees of
the participant to keep the knees extended. The maximum score had to be maintained
for at least 2 seconds. The score on the SRT was defined as the amount of centimeters
that the participant was able to reach on the box and was registered by a member of
the medical staff of the soccer team. When it was impossible for a participant to reach
the zero mark on the box, the score on the test was 0 cm.

Diagnosis of a hamstring injury

The medical staff members of the soccer teams were instructed to diagnose hamstring
injuries according to the consensus statement of Fuller et al.:24 ‘Any physical complaint
affecting the posterior side of the upper leg, irrespective of the need for medical attention
or time loss from soccer activities’.

Procedure

Before the start of this study, the researchers instructed the medical staff of all
participating teams on how to perform the SRT and how to diagnose a hamstring injury
according to the above-mentioned definition. These instructions were provided 2 to
6 weeks before the start of the study in January 2013 during meetings in all 4 of the
participating districts. In that month, which is midseason, immediately after the winter
break in the Dutch amateur soccer season, the medical staff performed measurements
of hamstring flexibility in all participating players. In the Netherlands, high-level amateur
soccer teams generally have a physical therapist present at all matches and training
sessions. Occasionally, a sport massage therapist is present at matches and training,
with a physical therapist available for additional consulting in case of any injury. During
the 1-year period, the medical staff registered each hamstring injury of the participating
players of their team using a special injury registration form and an injury recovery form.
The registration form included questions on the mechanism of the injury in terms of
‘during a sprint’ or ‘landing after a jump’, location of the injury, and the date of the injury.

102
 Hamstring flexibility and hamstring injuries in soccer

The recovery form included a question on how long the player was absent from training
and matches. If a player was transferred to another team during the year, thereby making
registration by the medical staff impossible, the researchers periodically contacted the
individual players by telephone about possible hamstring injuries.

Statistical analysis

The minimal required sample size for the present study was calculated based on the
formula of Peduzzi et al.25 A sample of at least 300 participants was required. In this
calculation, 1 risk factor, 2 possible confounding variables, and a 10.0% risk of a hamstring
injury per year were assumed. This hamstring injury risk was based on a previous study
with a similar sample.4

Descriptive statistics were used for baseline characteristics. For player characteristics,
age and years of soccer experience (means ± SDs) were calculated. Players with a
previous hamstring injury were presented in percentages. Also, field positions were
presented in percentages.

The mean score of the SRT was calculated for all participants. Then, the mean scores
for different subgroups, based on age and previous hamstring injuries, were calculated.
Players were first divided into 2 equal age categories based on the median age. An
independent-samples t test was used to investigate significant differences (p < 0.05) in
hamstring flexibility between the 2 age categories. Second, 2 categories related to the
history of hamstring injuries were formed: participants with and participants without a
6
hamstring injury in the year before the study. An independent-samples t test was used
to investigate significant differences (p < 0.05) in hamstring flexibility between these
2 categories.

The distribution of hamstring injuries in the previously mentioned categories of age

and previous hamstring injuries was calculated and analyzed by using the chi-square
analysis. Of all hamstring injuries, the percentage of injuries related to a sprint (according
to the injury form) was calculated. Also, the mean absence from training and matches
(according to the recovery form) was calculated.

To study the relationship between hamstring flexibility as an independent variable and the
occurrence of hamstring injuries as a dependent variable, a univariate logistic regression

103
Chapter 6

analysis was used. The possible confounding variables, age (as a continuous variable)
and previous hamstring injuries, were also analyzed in univariate logistic regression to
investigate whether these variables might be related to hamstring injuries. To investigate
the relationship, after adjusting for the possible confounding effects of age and previous
hamstring injuries, a multivariate logistic regression analysis was performed. The enter
method was used to create a model that included all variables including the possible
confounders. Flexibility was considered a significant predictor when p < 0.05 in the
multivariate logistic regression analysis. All analyses were performed with the Statistical
Package of Social Sciences, version 20.0, for Windows (SPSS Inc).

Results

Inclusion of participants

In total, 621 amateur soccer players participated in the HIPS study. Of all participants,
96 were excluded because they reported a current hamstring injury or did not report
their current status. Also, 75 participants did not perform the SRT correctly at baseline
and were also excluded. Finally, 450 participants who met the inclusion criteria were
included in the present study.

Participant characteristics

The characteristics of the included participants are summarized in Table 6.1. The mean (±
SD) age of the participants was 24.5 ± 3.7 years. The mean years of soccer experience of
the participants was 18.1 ± 4.1 years. In the year before the study, 98 (21.8%) participants
reported a hamstring injury.

Hamstring flexibility

The mean scores for the hamstrings flexibility on the SRT are presented in Table 6.2.
The overall mean score for hamstring flexibility was 21.2 ± 9.2 cm. The players were
equally divided regarding their age into 2 categories, with 23.9 years as a cutoff point.
No significant differences were found in the mean SRT score between the groups on age
(p = 0.105) and previous injuries (p = 0.436) (Table 6.2). Also, years of soccer experience
and field position were not significantly related to hamstring flexibility.

104
 Hamstring flexibility and hamstring injuries in soccer

Table 6.1  Characteristics of the study participants (n = 450 soccer players)

n (%) or Mean ± SD

Age, y 24.5 ± 3.7

Years of experience 18.1 ± 4.1
Previous hamstring injury in the year before the study 98 (21.8)
Field position*
Goalkeeper 49 (10.9)
Defender 164 (36.4)
Midfielder 159 (35.3)
Attacker 118 (26.2)
* A player can hold more than 1 field position.

Table 6.2  Sit-and-reach test scores

Subgroup n (%) Score, cm, Mean ± SD

All players 450 (100.0) 21.2 ± 9.2

Age category, y
18–23.9 225 (50.0) 20.5 ± 8.7
23.9–40.0 225 (50.0) 21.9 ± 9.6
Previous hamstring injury in the year before the study*
Yes 98 (21.8) 20.6 ±10.2
No 351 (78.2) 21.4 ±8.9
* There was 1 missing value.

Hamstring injuries 6
During the study period, 23 hamstring injuries were reported, which resulted in a
hamstring injury rate of 5.1%. There was no significant relationship between the category
of age and hamstring injuries (p = 0.134) and the category of previous hamstring injuries
and hamstring injuries (p = 0.305) as analyzed with the chi-square analysis (Table 6.3).
Additionally, years of soccer experience and field position were also not significantly
related to hamstring injuries. In 17 cases (73.9%), the hamstring injury was related to a
sprint of the participant. The mean absence from soccer training and matches caused
by the injury was 35.0 ± 25.7 days.

105
Chapter 6

Table 6.3  Distribution of hamstring injuries

Subgroup n (%)

All players 23 (5.1)

Age category, y
18–23.9 8 (3.6)
23.9–40.0 15 (6.7)
Previous hamstring injury in the year before the study*
Yes 7 (7.1)
No 16 (4.6)
* There was 1 missing value.

Logistic regression

In the univariate analysis, hamstring flexibility showed no significant relationship with

hamstring injuries (p = 0.496) (Table 6.4). Adding the 2 possible confounders (age
and a previous hamstring injury) in the multivariate analysis did not influence the level
of significance (p = 0.493) (Table 6.4). Age and previous hamstring injuries were not
significantly related to hamstring injuries in both the univariate analysis (p = 0.176 and p =
0.309, respectively) and the multivariate analysis (p = 0.150 and p = 0.285, respectively).

Table 6.4  Regression analysis of factors related to hamstring injuries

Univariate analysis Multivariate analysis

Odds ratio (95% CI) p value Odds ratio (95% CI) p value

Sit-and-reach test 0.984 (0.941–1.030) 0.496 0.985 (0.942–1.029) 0.493

Age 1.074 (0.968–1.192) 0.176 1.080 (0.973–1.199) 0.150
Previous hamstring injury 1.611 (0.643–4.033) 0.309 1.657 (0.657–4.178) 0.285

Discussion
The most important finding of our study was that a relationship between hamstring
flexibility (as estimated by the SRT) and hamstring injuries was not found in male amateur
soccer players. Adjustment for confounding by age and previous hamstring injuries
did not influence these results. As far as we know, this is the first study to focus on the
relationship between hamstring flexibility and hamstring injuries that also adjusted for
possible confounding variables (age and previous hamstring injury).

106
 Hamstring flexibility and hamstring injuries in soccer

In this study, the mean score on the SRT (21.2 cm) is similar to those in two earlier studies
in which mean scores of 23.5 and 22.8 cm, respectively, were reported in recreational
active male participants (mean age, 23.6 and 22.9 years, respectively).26,27 The hamstring
injury rate (5.1%) was lower than the hamstring injury rate in the previous year (21.8%).
This could possibly be explained by the fact that the hamstring injury rate of the
previous year was calculated based on the registration forms of the participants, which
are retrospective data. This is contrary to the collected data of the hamstring injuries
during the study period, which are prospective data. Underregistration of minimal
injuries by the medical staff during the study period could be a possible explanation.
However, the hamstring injury rate in the present study was also slightly lower than that
in an earlier prospective study in amateur soccer players in the Netherlands in which
the same definition of a hamstring injury was used (10.0%),4 lower than that in a study
of professional soccer players in Denmark (12.3%),28 and much lower than that in a
large study of hamstring injuries in professional soccer players in Europe.29 A possible
explanation for this difference in injury rates may be the Nordic hamstring exercise, which
is a 13-week training program performed in the period immediately after measurements
of hamstring flexibility are taken. This intervention was part of the HIPS study and was
shown to be effective in preventing hamstring injuries.19 This could have reduced the
number of hamstring injuries in this prospective study.

Similar to our results, Arnason et al.14 and Engebretsen et al.15 did not find a relationship
between hamstring flexibility and hamstring injuries. In both these Norwegian studies,
the Passive Knee Extension Test (PKET) was used to measure hamstring flexibility. 6
However, opposite results were reported by Witvrouw et al.,11 who concluded that
limited hamstring flexibility increased the risk of hamstring injuries, albeit the difference
in hamstring flexibility between injured/uninjured players in that study was small. To
measure hamstring flexibility, they used the straight-leg-raise test (SLRT). The differences
in the tests used to measure hamstring flexibility might explain the aberrant findings
of the study of Witvrouw et al.11 when compared with our study and the Norwegian
studies.14,15

Both the SLRT and the PKET are clinical tests that can be performed best by health care
professionals.30 No validation studies can be found that have investigated the validity or
reliability of the PKET. Although the SLRT is considered the ‘gold standard’ for measuring
hamstring flexibility, evidence for the validity of this test is also lacking. Therefore, in our

107
Chapter 6

study, the SRT was used to measure the hamstring flexibility. The use of the SRT has both
negative and positive aspects. Although the reliability of the SRT is high, the score on
the test is known to be influenced by lumbar and thoracic flexibility of the participants.
Thus, the hamstring flexibility score on the SRT can be slightly underestimated or
overestimated.22,31 However, because the SRT is an easy-to-perform field test, in our
opinion, this test is more applicable for the medical staff of an amateur soccer team.
The SRT can be performed in a more standardized way than other hamstring flexibility
tests, which reduces the risk of compensation and less accuracy.

The rationale for the hypothesis that hamstring flexibility and hamstring injuries are
related is found in the kinematic process of the sprint in which hamstrings endure high
forces in a stretched position. The hamstring muscles lengthen 50 to 90% of the gait
circle during a sprint.32,33 However, there is no supporting evidence that the hamstrings
are maximally stretched during the last swing phase in a sprint. In speeds ranging
from 80% to 100% of the maximal sprint, no variation in muscular tendon stretch of
the hamstrings seems to occur. This is in contrast to the muscular tendon force of
the hamstrings, which increases significantly in speeds ranging from 80% to 100% of
a maximal sprint.32 Therefore, during a sprint, it may not be the reduced hamstring
flexibility that is responsible for a hamstring injury but the reduced eccentric hamstring
strength of a soccer player.33,34

Some methodological limitations of this study need to be addressed. First, the staff of
the amateur soccer teams diagnosed players with a hamstring injury. Generally, the staff
consists of sports massagers (nonprofessionals in sports medicine) or physical therapists.
Although the staff was well instructed by the researchers on how to diagnose hamstring
injuries before the study, the diagnosis of a hamstring injury was not confirmed by a
physician. A registration form was used to verify the hamstring injury. Other medical
conditions that can cause posterior pain of the upper leg, for example, referred pain from
the lower back or adductor-related injuries, could therefore be excluded. Second, all
types of hamstring injuries were recorded, although it was hypothesized that hamstring
flexibility might be related to sprint-type hamstring injuries. It was not possible for the
staff of the amateur soccer teams to identify the specific sprint-type injuries. However,
on the injury form, the players reported that 70% of the injuries was related to a sprint,
indicating that sprint-type injuries were the most common hamstring injuries in the
present study.

108
 Hamstring flexibility and hamstring injuries in soccer

Conclusion
The present study shows that hamstring flexibility (as estimated with the SRT) is not
related to hamstring injuries. The possible confounders of age and previous hamstring
injuries do not influence this relationship. Consequently, our results suggest that it is not
possible to identify players at risk for hamstring injuries by measuring their hamstring
flexibility.

Acknowledgement
The authors thank the Royal Netherlands Football Association (KNVB) and the players,
coaches, medical staff members, board members, and other representatives of the
participating clubs for their contributions to the trial.

109
Chapter 6

References
1. Haskell WL, Blair SN, Hill JO. Physical activity: Health outcomes and importance for public health
policy. Prev Med 2009;49(4):280-282.

2. Henchoz Y, Baggio S, N’Goran AA, et al. Health impact of sport and exercise in emerging adult
men: A prospective study. Qual Life Res 2014;23(8):2225-2234.

3. Injuries in sports 2013 (Dutch). VeiligheidNL. Available at: http://www.veiligheid.nl/sportblessures/

kennis/cijfers-over-sportblessures. Accessed November 11, 2015.

4. van Beijsterveldt AM, van de Port IG, Krist MR, et al. Effectiveness of an injury prevention programme
for adult male amateur soccer players: A cluster-randomised controlled trial. Br J Sports Med
2012;46(16):1114-1118.

5. Ekstrand J, Hagglund M, Walden M. Epidemiology of muscle injuries in professional football

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

6. Hallen A, Ekstrand J. Return to play following muscle injuries in professional footballers. J Sports
Sci 2014;32(13):1229-1236.

7. McCall A, Carling C, Nedelec M, et al. Risk factors, testing and preventive strategies for non-contact
injuries in professional football: current perceptions and practices of 44 teams from various premier
leagues. Br J Sports Med 2014;48:1352-1357.

8. Woodley SJ, Mercer SR. Hamstring muscles: Architecture and innervation. Cells Tissues Organ
2005;179(3):125-141

9. van Beijsterveldt AM, van de Port IG, Vereijken AJ, et al. Risk factors for hamstring injuries in male
soccer players: A systematic review of prospective studies. Scand J Med Sci Sports 2013;23(3):253-
262.

10. Freckleton G, Pizzari T. Risk factors for hamstring muscle strain injury in sport: A systematic review
and meta-analysis. Br J Sports Med 2013;47(6):351-358.

11. Witvrouw E, Danneels L, Asselman P, et al. Muscle flexibility as a risk factor for developing muscle
injuries in male professional soccer players. A prospective study. Am J Sports Med 2003;31(1):41-
46.

12. Clark RA. Hamstring injuries: Risk assessment and injury prevention. Ann Acad Med Singapore
2008;37(4):341-346.

13. Chumanov ES, Heiderscheit BC, Thelen DG. Hamstring musculotendon dynamics during stance
and swing phases of high-speed running. Med Sci Sports Exerc 2011;43(3):525-532.

14. Arnason A, Sigurdsson SB, Gudmundsson A, et al. Risk factors for injuries in football. Am J Sports
Med 2004;32(1 Suppl):5S-16S.

15. Engebretsen AH, Myklebust G, Holme I, et al. Intrinsic risk factors for hamstring injuries among
male soccer players: A prospective cohort study. Am J Sports Med 2010;38(6):1147-1153.

16. Gabbe BJ, Bennell KL, Finch CF. Why are older australian football players at greater risk of hamstring
injury? J Sci Med Sport 2006;9(4):327-333.

17. Gabbe BJ, Bennell KL, Finch CF, et al. Predictors of hamstring injury at the elite level of Australian
football. Scand J Med Sci Sports 2006;16:7-13.

110
 Hamstring flexibility and hamstring injuries in soccer

18. van der Horst N, Smits DW, Petersen J, et al. The preventive effect of the nordic hamstring exercise
on hamstring injuries in amateur soccer players: Study protocol for a randomised controlled trial.
Inj Prev 2014;20(4):e8

19. van der Horst N, Smits DW, Petersen J, et al. 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):1316-1323.

20. Ayala F, Sainz de Baranda P, De Ste Croix M, et al. Absolute reliability of five clinical tests for
assessing hamstring flexibility in professional futsal players. J Sci Med Sport 2012;15:142-147.

21. Gabbe BJ, Bennell KL, Wajswelner H, et al. Reliability of common lower extremity musculoskeletal
screening tests. Phys Ther Sport 2004;5:90-97.

22. Mayorga-Vega D, Merino-Marban R, Viciana J. Criterion-related validity of sit-and-reach tests for

estimating hamstring and lumbar extensibility: A meta-analysis. J Sports Sci Med 2014;13(1):1-14.

23. Ayala F, Sainz de Baranda P, De Ste Croix M, et al. Reproducibility and criterion-related validity of
the sit and reach test and toe touch test for estimating hamstring flexibility in recreationally active
young adults. Phys Ther Sport 2012;13:219-226.

24. Fuller CW, Ekstrand J, Junge A, et al. Consensus statement on injury definitions and data collection
procedures in studies of football (soccer) injuries. Clin J Sport Med 2006;16(2):97-106.

25. Peduzzi P, Concato J, Kemper E, et al. A simulation study of the number of events per variable in
logistic regression analysis. J Clin Epidemiol 1996;49(12):1373-1379.

26. Davis DS, Quinn RO, Whiteman CT, et al. Concurrent validity of four clinical tests used to measure
hamstring flexibility. J Strength Cond Res 2008;22(2):583-588.

27. Lopez-Minarro PA, Sainz De Baranda P, Rodriguez-Garcia PL, et al. Comparison between sit-and-
reach test and V sit-and-reach test in young adults. Gazz Med Ital Arch Sci Med 2008;167(4):135-
142.

28. Petersen J, Thorborg K, Nielsen MB, et al. Acute hamstring injuries in Danish elite football: a
12-month prospective registration study among 374 players. Scand J Med Sci Sports 2010;20:588-
592. 6
29. Ekstrand J, Waldén M, Hägglund M. Hamstring injuries have increased by 4% annually in men’s
professional football, since 2001: a 13-year longitudinal analysis of the UEFA Elite Club injury
study. Br J Sports Med 2016;50(12):731-7.

30. American Academy of Orthopedic Surgeons. Joint motion: Method of measuring and recording.
12th ed. Pennsylvania State University: Churchill Livingstone; 1965:87.

31. Rodriguez-Garcia PL, Lopez-Minarro PA, Yuste JL, et al. Comparison of hamstring criterion-related
validity, sagittal spinal curvatures, pelvic tilt and score between sit-and-reach and toe-touch tests
in athletes. Medicina Dello Sport 2008;61:11-20.

32. Chumanov ES, Heiderscheit BC, Thelen DG. The effect of speed and influence of individual muscles
on hamstring mechanics during the swing phase of sprinting. J Biomech 2007;40(16):3555-3562.

33. Schache AG, Dorn TW, Blanch PD, et al. Mechanics of the human hamstring muscles during
sprinting. Med Sci Sports Exerc 2012;44(4):647-658.

34. Lee MJ, Reid SL, Elliott BC, et al. Running biomechanics and lower limb strength associated with
prior hamstring injury. Med Sci Sports Exerc 2009;41(10):1942-1951.

111
 Chapter 7

Return to play after hamstring injuries:

a qualitative systematic review of
definitions and criteria

N. (Nick) van der Horst

P.A. (Sander) van de Hoef
G. (Gustaaf) Reurink
B.M.A. (Bionka) Huisstede
F.J.G. (Frank) Backx

Sports Med 2016;46(6):899-912
Chapter 7

Abstract
Background  More than half of the recurrent hamstring injuries occur within the
first month after return-to-play (RTP). Although there are numerous studies on RTP,
comparisons are hampered by the numerous definitions of RTP used. Moreover,
there is no consensus on the criteria used to determine when a person can start
playing again. These criteria need to be critically evaluated, in an attempt to
reduce recurrence rates and optimize RTP.

Objective  To carry out a systematic review of the literature on (1) definitions of

RTP used in hamstring research and (2) criteria for RTP after hamstring injuries.

Study design  Systematic review.

Methods  Seven databases (PubMed, Embase/MEDLINE, CINAHL, PEDro, Cochra-

ne, SPORTDiscus, Scopus) were searched for articles that provided a definition
of, or criteria for, RTP after hamstring injury. There were no limitations on the
methodological design or quality of articles. Content analysis was used to record
and analyze definitions and criteria for RTP after hamstring injury.

Results  Twenty-five papers fulfilled inclusion criteria, of which 13 provided a de-

finition of RTP and 23 described criteria to support the RTP decision. “Reaching
the athlete’s pre-injury level” and “being able to perform full sport activities”
were the primary content categories used to define RTP. “Absence of pain”,
“similar strength”, “similar flexibility”, “medical staff clearance”, and “functional
performance” were core themes to describe criteria to support the RTP decision
after hamstring injury.

Conclusion  Only half of the included studies provided some definition of RTP
after hamstring injury, of which reaching the athlete’s pre-injury level and being
able to perform full sport activities were the most important. A wide variety of
criteria are used to support the RTP decision, none of which have been valida-
ted. More research is needed to reach a consensus on the definition of RTP and
to provide validated RTP criteria to facilitate hamstring injury management and
reduce hamstring injury recurrence.

PROSPERO systematic review registration number  CRD42015016510.

114
 Return to play after hamstring injury: systematic review

Introduction
“When will I be able to play again?” This question about return-to-play in sports (RTP)
is of great importance for every athlete after a hamstring injury. The major concern
of athletes, trainers, management, and other stakeholders is to start playing as soon
as possible, but this might be in conflict with the athlete’s actual physical fitness and
readiness for match play.1-3 This is emphasized by the high rate of recurrence of hamstring
injuries (12–33%).4-7 This high rate of recurrence is suggested to occur due to inadequate
rehabilitation and/or too early RTP.8,9 Of these recurrences, 59% occur within the first
month after RTP.10 Recurrent hamstring injuries require more extensive rehabilitation
than the initial injury, and a previous injury is the undisputed single risk factor for future
injury.11,12 These hamstring injury rates have not improved over the last 20–30 years in
professional soccer and Australian Football.13-15

Although there have been numerous studies of RTP after hamstring injuries in recent
years, the actual term is seldom explicitly defined, with definitions such as “return to
sport”, “return to competition”, “return to competitive play”, “return to pre-injury level”
and “return to activity” being used.16-19 Studies on RTP after other musculoskeletal
injuries such as anterior cruciate ligament injury and ankle injury, are also hampered by
the lack of a clear definition for RTP.20-22 This makes a comparison of study outcomes
difficult and emphasizes the need for a clear definition of RTP.

In addition to the lack of a clear definition of RTP, there is no consensus in the literature
or among sports medical practitioners on when an athlete is ready to resume playing
after a hamstring injury. In the absence of clear scientific evidence, RTP decisions are
not standardized,23,24 and this has prompted interest in criteria to support the RTP
decision after hamstring injury.25,26 These criteria need to be critically evaluated to reduce
recurrence rates and optimize RTP.
7
The aim of this study was therefore to carry out a systematic review of the literature on
(1) definitions of RTP used in hamstring research and (2) criteria for RTP after hamstring
injuries.

115
Chapter 7

Materials and methods

Study design

A systematic search was conducted in PubMed, Embase/MEDLINE, CINAHL, PEDro,

Cochrane, SPORTDiscus, and Scopus to collect articles describing a definition or criteria
for RTP. This review adheres to the Preferred Reporting Items for Systematic Reviews
and Meta-Analyses (PRISMA) Guidelines.27 Registration in the PROSPERO international
database of prospectively registered systematic reviews was performed prior to study
initiation (registration number CRD42015016510).28

Search strategy

The search strategies, containing key words such as “return to play”, “return to sport” and
“hamstring injury”, were developed by the primary author (NH) in collaboration with a spe-
cialized librarian (see Appendix 7.1). Searches were undertaken from the date of database
inception to November 2014. The same databases were then searched independently
by two authors (NH, SH). Cohen’s Kappa was calculated for interobserver agreement. All
references of the included studies were assessed for inclusion if missed by the initial search.

Eligibility criteria

Retrieved articles were screened by two independent authors (NH, SH). Article selection
was not limited by study design. Studies needed to describe a definition of, or criteria
for, RTP after acute hamstring injury in adult athletes (aged > 18 years). Articles that used
definitions adopted from other studies were excluded, as were studies that reported only
on RTP after surgical interventions. Additionally, articles not available as full text were
excluded, although corresponding authors were contacted for information. Differences in
article selection and inclusion between the two researchers were resolved in a consensus
meeting or, if necessary, a third author (BH) was consulted to make the final decision.

Data extraction

If multiple articles were published by the same research group and used the same
definition and/or criteria, data were extracted from only one of the articles. The following

116
 Return to play after hamstring injury: systematic review

data were extracted using standardized extraction forms by two authors (NH, SH): first
author and year of publication; population and study design; definition of hamstring
injury; definition of RTP; described criteria for RTP (Table 7.1).

Data analyses

The methodological quality of the included articles was not assessed because the aim
of this systematic review was to collate and synthesize all information on the definition
of RTP and its criteria. Descriptive statistics were used to summarize the frequency of
different study designs. Definitions of, and criteria for, RTP were analyzed by content
analysis.29,30 Two authors (NH, SH) separately performed each step of the analytical
process to ensure adequate categorization of information and appropriate thematic
analysis consistent with the literature.29 After each step, coding procedures were
discussed and if no consensus was reached, a third author (BH) made the final decision.

Content analysis

The first step in the content analysis was to create tentative labels for RTP definition and
criteria within the articles, using an open coding procedure.31 Open coding means that
notes and headings are written in the text while it is read. The written material is read
through again, and as many headings as necessary are written down in the margins to
describe all aspects of the definition and criteria for RTP.32

The second step was to perform axial coding in order to identify relationships among
open codes. Axial coding, termed “axial” because coding occurs around the axis of a
category, links categories at the level of properties and dimensions.31 Two authors [NH,
SH] independently assessed whether headings identified during open coding were
associated.30 For instance, one article might describe concentric hamstring strength 7
testing and no findings on magnetic resonance imaging (MRI) as criteria to support
the decision for RTP after hamstring injury. A second article might describe eccentric
hamstring strength testing as a criterion. A relationship between eccentric and concentric
strength testing could be identified from these codes (e.g., “strength testing”), whereas
the relationship between no findings on MRI and eccentric hamstring strength testing
is more far-fetched.

117
Chapter 7

In the third step, final content categories were identified by selective coding.31 In this
phase, content categories are established and it is determined whether axial coding
categories are correlated with these content categories (such as a hypothetical content
category “strength testing” as stated in the aforementioned example).31

Results

Search results

Of 1303 articles retrieved, 608 were excluded as duplicate publications and a further
584 were excluded after screening of the title and abstract (Figure 7.1). The remaining
full-text articles (n = 111) were checked for relevant content, based on eligibility criteria,
by two researchers (NH and SH). Five articles were identified from the reference lists
of retrieved articles. Our third author (BH) was consulted to decide on two articles for
potential inclusion. The article by Fuller et al.33 was included and one other article was
excluded.34 In total, 25 articles met the inclusion criteria. Cohen’s Kappa was 0.79 at
this point, indicating substantial agreement.35

Types of publications and their contents

Of the 25 articles, 18 were clinical studies (2 randomized controlled trials, 12 cohort

studies, 3 case series, and 1 case report), 1 a narrative review, 4 clinical commentaries,
1 a survey report, and 1 a conference abstract (Table 7.1).

Definition of RTP

Thirteen articles (52%) defined RTP (Table 7.1).

Coding
Open coding of the relevant content of the articles resulted in open codes for the
“definition of RTP after hamstring injury” (Table 7.1, “definition of RTP”). After axial
coding, related codes were grouped into two final content categories (e.g., selective
coding): “activity level” and “medical advice” (Figure 7.2).

118
 Return to play after hamstring injury: systematic review

PubMed Embase / CINAHL PEDro Cochrane Scopus SPORTDiscus

n = 208 MEDLINE n = 169 n=8 n = 180 n = 199 n = 309
n = 230

Articles obtained
from search
n = 1303
Identification

Duplicates
n = 608

Titles and abstracts

screened for relevance
n = 695

Excluded on title
Screening

and abstract
n = 584 Article not accompanied
by full-text
n=0

Full-text screened
n = 111

Identified from reference lists

Excluded n = 91
of retrieved articles
- No definition/criteria for RTP n = 77
Eligibility

n=5
- Not an acute hamstring injury n=3
- Duplicate definitions/criteria n = 11
Included

Articles identified
for review
n = 25

7
Figure 7.1  Study selection flow chart.

Activity level
Most authors used terms such as “reaching pre-injury level”36,37,41,48 and “full activ-
ity”36,44,49,53 to define RTP after hamstring injury. Other terms include “availability for
match selection and/or full training”,41,49,53 “a completed game”,39 and “a 100% recovery
score on fitness and skill testing”.33

119
120
Table 7.1  Definition of RTP and criteria for RTP after hamstring injury within the included studies – including step 1 of content analysis
Chapter 7

Study
population, sex,
age in years Definition of Definition of RTP after
Reference Study design (mean, SD) hamstring injury hamstring injuryaa Criteria for RTP after hamstring injurya

A Hamid et RCT Patients; N/R; Grade-2 hamstring Full activities with Pain free on direct palpation
al.36 Age > 18y muscle injury progressive increase Pain free on hamstring contraction
of training load until Pain free on active knee extension test
reaching pre-injury Symmetrical range of movement with
level unaffected side (difference between affected
and unaffected side of < 10°)
Concentric hamstring strength (60, 180 and
300°/s) within 10% of uninjured side

Askling et al.37 Prospective 18 sprinters; 8 F First time acute Able to train, Sprinters: competing at similar best times as
cohort study – 10 M; 15–28y sudden pain from the compete or perform pre-injury level
and posterior thigh when at their pre-injury level Dancers: being able to train and perform
15 dancers; 1 M training, competing without restriction
– 14 F; 16–24y or performing

Askling et al.38 Cohort study 11 healthy Unilateral, MRI- No signs of No pain during palpation and strength testing
students; 5 M verified acute remaining injury on No strength difference between legs
– 6 F; age 28 ± hamstring strain clinical examination of Range of motion during passive straight leg
7y and the injured leg raise should be close (< 10% deficit) to that of
11 athletes; the uninjured leg.
8 M – 3F; No pain from static contraction in the end
age 21 ± 7y position of straight leg raise

Table 7.1 continues on next page

 Table 7.1  Continued

Study
population, sex,
age in years Definition of Definition of RTP after
Reference Study design (mean, SD) hamstring injury hamstring injuryaa Criteria for RTP after hamstring injurya

Connell et Prospective 61 M Acute onset of Return to competition None provided

al.39 cohort study professional posterior thigh pain (completed game)
Australian or stiffness, disabling
Football the player from
players; training or match
age 24 ± 3.8y play

Coole and Clinical N/A Not provided Not provided Isokinetic testing within 10% of normal – equal
Gieck40 commentary flexibility
Pain free 2 mile endurance run
Pain free controlled sprinting
Pain free functional activities peculiar to sport
Full return of cerebromuscular capabilities

Cooper and Case series 25 athletes; Complete distal Play at the preinjury Return of 80% isotonic knee flexion strength as
Conway41 N/R; N/R semitendinosus level or – for those compared with the normal opposite leg
tendon athletes whose sport No pain when sprinting
ruptures was not in season – Having progressed through a sport-specific
clearance to play. functional rehabilitation program
Being cleared to play at the preinjury level of
professional or amateur competition

Table 7.1 continues on next page

121
Return to play after hamstring injury: systematic review

7
122
Chapter 7

Table 7.1  Continued

Study
population, sex,
age in years Definition of Definition of RTP after
Reference Study design (mean, SD) hamstring injury hamstring injuryaa Criteria for RTP after hamstring injurya

Delveaux et Survey report N/A Not provided Not provided Complete pain relief
al.42 Muscle strength performance
Subjective feeling reported by player
Muscle flexibility
Specific soccer test performance
Respect of a theoretical period of competition
break
Running analysis
Physical fitness
Balance control assessment
Medical imaging
Dynamic functional testing performance
Correction of potential sacroiliac or lumbar joint
dysfunction
Quadriceps – hamstrings EMG analysis

Dembowski Case report 1 M collegiate Not provided Not provided Eccentric strength within 10% of the uninvolved
et al.43 polevaulter; extremity
18y Single leg triple hop within 10% bilaterally
Pain free Illinois Agility Test within 18.4 seconds

Table 7.1 continues on next page

 Table 7.1  Continued

Study
population, sex,
age in years Definition of Definition of RTP after
Reference Study design (mean, SD) hamstring injury hamstring injuryaa Criteria for RTP after hamstring injurya

Fuller and Prospective 55 M Any injury that Achievement of a Pain free completion of match pace football
Walker33 cohort study professional prevented a player 100% recovery score element assessment at normal match speed
football players; from taking a full part on fitness and skill
N/R in training activities testing
typically planned for
the day and/or match
play not including
the day on which the
injury was sustained

Hallén and Cohort study 89 M A traumatic The decision-making Not provided

Ekstrand44 professional distraction or overuse process of returning
football teams; thigh muscle injury an injured or ill
N/R to the anterior or athlete to practice or
posterior thigh competition.
muscle groups This ultimately leads
leading to a player to medical clearance
being unable to fully of an athlete for full
participate in training participation in sports
or match play

Table 7.1 continues on next page

123
Return to play after hamstring injury: systematic review

7
124
Chapter 7

Table 7.1  Continued

Study
population, sex,
age in years Definition of Definition of RTP after
Reference Study design (mean, SD) hamstring injury hamstring injuryaa Criteria for RTP after hamstring injurya

Heiderscheit Clinical N/A Not provided Not provided Four consecutive pain-free repetitions of
et al.45 commentary maximum effort manual strength test in each
prone knee flexion position (90° and 15°)
Less than a 5% bilateral deficit should exist in
the ratio of eccentric hamstring strength (30°/s)
to concentric quadriceps strength (240°/s).
Knee flexion angle at which peak concentric
knee flexion torque occurs should be similar
between limbs.
Functional ability testing (sportrelated
movements specific to the athlete, with
intensity and speed near maximum).

Heiser et al.46 Retrospective Football A sudden pain in Not provided Run at "near-full" speed
cohort study players; the posterior thigh Display of adequate agility
N/R; N/R during a movement Strength at 95% of baseline score
requiring rapid Hamstring:quadriceps ratio of 0.55 or greater at
contraction of the a testing speed of 60°/sec.
hamstring muscles

Table 7.1 continues on next page

 Table 7.1  Continued

Study
population, sex,
age in years Definition of Definition of RTP after
Reference Study design (mean, SD) hamstring injury hamstring injuryaa Criteria for RTP after hamstring injurya

Kilcoyne et Retrospective 48 athletes; Sudden posterior Not provided Ability to perform at 90% speed during full
al.47 case series 40 M – 8 F; thigh pain while sprint drills.
age 18–20y n running or jumping, Athletes’ self-perceiving equivalent hamstring
= 30 physical disability, function and strength between injured and
age 21–25y n pain with resisted uninjured legs on strength testing
= 17 prone knee flexion, Pain-free during all drills, including rolling
and tenderness to sprints.
palpation of the
muscle-tendon unit
of the hamstring

Malliaropoulos Cohort study 260 elite track Acute, first- Training or competing Normalization of AROM deficit
et al.48 and field time posterior at preinjury level Isokinetic hamstring strength deficit of less than
athletes; 150 M thigh muscle without any symptoms 5% measured at 60°/s and 180°/s compared
– 110 F; 18–25y injury sustained or signs of injury (such with the injured side
during training or as pain, swelling, and/ No difference in singlelegged triple hop test
competition or tenderness)

Table 7.1 continues on next page

125
Return to play after hamstring injury: systematic review

7
 Table 7.1  Continued

126
Study
Chapter 7

population, sex,
age in years Definition of Definition of RTP after
Reference Study design (mean, SD) hamstring injury hamstring injuryaa Criteria for RTP after hamstring injurya

Mendiguchia Clinical N/A Not provided Not provided Optimum angle for peak torque < 28° during
and commentary knee flexion
Brughelli16 b Optimum angle for peak torque < 8° symmetry
between legs
Similar hip extension strength (< 10%
asymmetry)
Similar horizontal force between legs (< 20%
asymmetry)
Edema size and/or length as shown on MRI
Lumbar rotation stability (No anterior pelvic tilt
during ASLR test)

Moen et al.49 Prospective 80 competitive Acute, MRI-verified, Return to unrestricted Clearance by supervising physiotherapist
cohort study or recreational posterior thigh pain sports activity in
athletes; N/R; training and/or match
29 ± 7y play

Nett et al.50 Conference 24 athletes; Acute clinical grade Not provided Full hamstring strength
abstract 19 M – 5 F; 1–2 hamstring No tenderness
age 24y injuries No pain
(range 16–46y) No side-to-side differences during running

Orchard51 Clinical N/A Not provided Not provided Normal strength (> 90% of the unaffected side)
commentary Normal range of motion
Performance at training dictates readiness for
matches

Table 7.1 continues on next page

 Table 7.1  Continued

Study
population, sex,
age in years Definition of Definition of RTP after
Reference Study design (mean, SD) hamstring injury hamstring injuryaa Criteria for RTP after hamstring injurya

Petersen and Clinical N/A An incident occurring Not provided Pain-free participation in sports specific
Hölmich52 commentary during scheduled activities
games/competitions
or practice and
causing the athlete
to miss the next
game/competition or
practice session

Petersen et Case series 942 soccer Sudden physical Availability for match Consultation between medical staff and player
al.53 players; N/R; complaint of selection or full
N/R posterior thigh participation in team
sustained during training if the injury
a soccer match or occurred during a
training, irrespective period without match
of medical attention play
or time loss from
soccer activities

Reurink et al.26 Cohort study 53 M athletes; Clinical diagnosis Successful and Successful and asymptomatic completion
mean age 27y of hamstring injury asymptomatic of a functional criteria-based four-staged
(range 18–46y) by registered sports completion of physiotherapy programme, including a final
medicine physician physiotherapy supervised sport-specific (outdoor) training phase
programme, including Less than 10% side-to-side-difference at isokinetic
functional sport- strength testing
specific activities 5 days of team training before participation on
partial match play

127
Return to play after hamstring injury: systematic review

Table 7.1 continues on next page

7
 Table 7.1  Continued

128
Study
population, sex,
Chapter 7

age in years Definition of Definition of RTP after

Reference Study design (mean, SD) hamstring injury hamstring injuryaa Criteria for RTP after hamstring injurya

Sanfilippo et Prospective 25 recreational Acute, sudden onset, Not provided No significant pain with straight leg raise
al.54 cohort study athletes; hamstring injury Full hamstring strength
20 M – 5 F; No tenderness to palpation
24 ± 9y No apprehension during full effort, sport-
specific movements
Clearance by physiotherapist

Silder et al.55 RCT 24 athletes; A sudden-onset Completion of No palpable tenderness along the posterior thigh
19 M – 5 F; posterior thigh pain rehabilitation Subjective readiness (no apprehension) after
age 24 ± 9y completing a series of progressive sprints
working up to full speed
5/5 On manual muscle testing

Tol et al.25 b Cohort study 52 M players; MRI-positive Not specified Painless passing and running
mean age 24y hamstring injury Painless shooting scenarios
(range 18–38y) Painless competitive 1vs1 drills
Painless scoring scenarios

De Vos et al.56 Prospective 64 patients; Clinical and Completion of Symptom-free (e.g., pain and stiffness) during:
cohort study 61 M – 3 F; radiological criteria-based · full range of motion
median age 28y diagnosis of grade 1 rehabilitation · full-speed sprinting
(range 23–33y) or 2 acute hamstring programme · sport-specific movements (such as jumping
injury and cutting).
Clearance by physical therapist
Unhindered functional sports-specific testing
a
Step 1 of content analysis: results of open coding. b These studies used different criteria at different stages in the rehabilitation program; only criteria that
supported the final RTP-decision were included in this table. AROM = active range of motion; ASLR = active straight leg raise; EMG = electromyography;
F = female; M = male; MRI = magnetic resonance imaging; N/A = not applicable N/R = not reported; RCT = randomised controlled trial; RTP = return-to-
play; y = years; SD = standard deviation.
 Return to play after hamstring injury: systematic review

Full activity

Reaching pre-injury level “Activity level”

Completed game 

100% recovery score

Availability for match selection and/or full training

Completed rehabilitation programme

Absence of symptoms (pain, strength deficits, flexibility deficits) on  “Medical advice”

injured leg

Clearance by medical staff

Step 2. Combinations of open codes (established by axial coding) Step 3. Final content categories
(established by selective coding)

Figure 7.2  Axial and selective coding of definition for return-to-play, steps 2 and 3 of content
analysis.

Medical advice
RTP after hamstring injury was also defined on the basis of medical information.26,38,40,44,48,55,56
“Absence of symptoms on injured leg”,38,48 “clearance by medical staff”,41,44,56 and
“completion of a rehabilitation program”26,55,56 were used as terms to define RTP. Most
articles provided additional medical criteria to support the RTP definition26,38,41,48,55,56
(see next section).

RTP criteria

Of the 25 included articles, 23 articles (92%) provided criteria for RTP after a hamstring
injury (Table 7.1).
7

Coding
After open coding and subsequent axial coding of criteria for RTP (Table 7.1, “criteria
for RTP after hamstring injury”), related codes were grouped into five final content
categories (e.g., selective coding): “absence of pain”, “similar strength”, “similar
flexibility”, “medical staff clearance”, and “functional performance” (Figure 7.3).

129
Chapter 7

No pain during palpation

No pain during controlled sprinting
No pain during functional activities peculiar to sport
No pain / tenderness
No pain during Illinois Agility Test  “Absence of pain”
No pain during active knee extension test
No pain during strength testing
No pain from static contraction in end position of straight leg raise
No pain during straight leg raise
No pain during 2 mile endurance run

Equal HQ-ratio
HQ-ratio of 0.55 or greater
Equal peak torque knee flexion angle
Optimum peak torque angle < 28° during knee flexion
Optimum peak torque < 8° symmetry between legs
Equal horizontal force
Full strength  “Similar strength”
Strength at 95% of baseline
Isokinetic strength testing of affected leg within 5–10% of normal unaffected leg
Muscle strength performance
Return of isotonic knee flexion strength of 80%
Eccentric strength of affected leg within 10% of unaffected leg
Equal hip extension strength
_

Similar range of motion between legs  “Similar flexibility”

Equal flexibility

Competing at best times

Self-perceived hamstring strength
Specific soccer test performance
Running analysis
Physical fitness
_
Balance control assessment
“Functional performance”
Dynamic functional testing performance 
Running analysis
Single leg triple hop within 10%
Full speed running
Adequate agility
Full sprint drills at 90%
5 days of team training

Rehabilitation program without restrictions

Progression through a sport specific rehabilitation programme  “Medical staff clearance”
Clearance by medical staff

Respect of a theoretical period of competition break

Medical imaging
Full return of cerebromuscular capabilities  “Other”
HQ EMG analysis
Correction of SI or lumbar joint dysfunctions
Step 3. Final content
Step 2. Combinations of open codes (established by axial coding) categories (established by
selective coding)

Figure 7.3  Axial and selective coding of criteria for RTP, steps 2 and 3 of content analysis.
EMG = electromyography; HQ = hamstrings-quadriceps; RTP = return-to-play; SI = sacroiliac.

Absence of pain
Absence of pain on palpation and during performance testing was used as a criterion
for RTP after hamstring injury in 15 studies.25,26,33,36,38,40-43,45,47,50,52,54-56 In some studies, pain

130
 Return to play after hamstring injury: systematic review

was tested via direct palpation of the hamstring muscle.36,37,54,55 Askling et al. and Hamid
et al. additionally stated that hamstring contraction should not elicit pain when tested in
the end position of the passive straight leg raise.36,37 Other studies considered a pain-
free state during strength and flexibility testing as fitness for RTP, but did not mention
how strength and flexibility tests were performed.37,45,54,56 Pain-free running, such as in a
2-mile endurance run or controlled sprinting, and pain-free functional activities peculiar
to a given sport were also used as criteria for RTP.25,33,40,41,45,47,50,52,54,56

Similar strength
A similar hamstring strength in the affected and the unaffected legs was used as a
criterion in 15 studies.16,26,36,38,40-43,45-48,50,51,54,55 Most studies considered a deficit of < 10%
as being similar.16,26,36,40,43,45,46,48,54 Hamstring strength was measured in different positions
with different tools. Kilcoyne et al. assessed strength as athletes’ self-reported hamstring
function during strength testing.47 Other studies reported manual resistance testing at
the heel with the knee flexed at 0°, 15°, 45°, and 90° in prone position.38,45 There were
also variations in test procedures with the tibia in neutral, external rotated, and internal
rotated position.55 Dembowski et al. measured eccentric hamstring strength with a
hand-held dynamometer using the break method.43 Mendiguchia tested isokinetic hip
extension at 60° per second,16 where other included studies tested at 60°/s, 180°/s,
240°/s, and 300°/s.25,36,40 Cooper also assessed isotonic knee flexion strength, but
differed from other studies as the criterion for RTP required the injured leg to reach 80%
strength, instead of > 90% strength, relative to the normal opposite leg.41 Multiple studies
endorsed isokinetic strength testing under both concentric and eccentric conditions,
stating that there should be less than a 5–10% deficit in the ratio of eccentric hamstring
strength (30°/s, 60°/s, or 180°/s) to concentric quadriceps strength (240°/s) between
the injured and uninjured legs.36,45,46,48,54 Heiser et al. stated the hamstring:quadriceps
ratio should be ≥ 0.55 at a testing speed of 60°/s.46 In addition, it was suggested that
7
the knee flexion angle at which peak concentric knee flexion torque occurs should be
similar between limbs.16,45

Similar flexibility
Normal hamstring flexibility or range of motion was used as a criterion in seven
studies.36,38,40,42,45,48,51 Only the study by Askling et al. specified normal hamstring flexibility
as a < 10% deficit between the injured and the uninjured legs.38

131
Chapter 7

Flexibility or range of motion was tested via passive straight leg raise38 or by active knee
extension in supine position with the hip flexed at 90°.48 Other studies did not specify
measurement methods or cut-off values for flexibility measurements.

Functional performance
Thirteen studies reported performance during field testing as a criterion for RTP after
hamstring injury.25,26,37,42,43,45-48,50,51,53,56 One study used best sprint times comparable to
those before injury.37 Nett et al. stated that no asymmetry should occur during running,50
whereas Reurink et al. stated no asymmetry should be present during the sport-specific
(outdoor) training phase,26 although neither study defined asymmetry. Training and
performance without any restriction was also reported as a criterion.25,37,56 According to
Heiderscheit et al., functional ability testing should incorporate sport-related movements
performed at near-maximum intensity and speed.45 Tol et al. specified this further by
using pain-free running, passing, shooting, scoring, and competitive one-to-one drills as
criteria for RTP for soccer players.25 Single leg triple hops and a pain-free Illinois Agility
Test within 18.4 s were also reported as functional performance criteria for RTP after
hamstring injury.43,48 Reurink et al. additionally stated that, after full recovery, 5 days of
team training are required before clearance for (partial) match play.26

Medical staff clearance

Five studies reported that the athlete should be certified as medically fit before returning
to play,41,49,53,54,56 but few studies described how this was done. In the study by Petersen
et al., this decision was made in consultation between medical staff and the player.53
Cooper et al. mentioned additional criteria (e.g., return of > 80% isotonic knee flexion
strength as compared with the normal opposite leg, no pain when sprinting, and having
progressed through a sport-specific rehabilitation program) that need to be met before
medical staff give their approval for RTP.41 Three studies reported that the athlete should
have progressed through a sport-specific rehabilitation program without restrictions
before RTP, but none of the studies described the content of such a program.26,41,56

Other
Other criteria for RTP after hamstring injury used were full return of cerebromuscular
capabilities (not further specified by Coole et al.), extent of edema, and lumbar rotation
stability.16,40 Anterior pelvic tilt was not allowed during the active straight leg raise test

132
 Return to play after hamstring injury: systematic review

in the study by Mendiguchia and Brughelli.16 Additionally, in the study by Delvaux et

al., sports physicians reported adherence to a theoretical period of competition break,
medical imaging, correction of sacroiliac or lumbar dysfunction, and quadriceps-
hamstrings electromyography analysis as criteria for RTP.42

Discussion

Statement of principal findings

In this article, we systematically reviewed the literature on definitions and criteria for
RTP after hamstring injuries. Only 52% of the included articles defined RTP, whereas
92% provided criteria to support the RTP decision. Although different definitions have
been used, we found that terms referring to “activity level” (e.g., reaching pre-injury
level, full activity) or “medical advice” (e.g., clearance by medical staff, absence of
symptoms, and completion of a rehabilitation program) were often used to define RTP
after hamstring injury.

A variety of criteria have been used to support the RTP decision, subdivided into five
content categories: “absence of pain” (e.g., on palpation and during performance),
“similar strength” (e.g., < 10% deficit between the affected and unaffected leg), “similar
flexibility”, “medical staff clearance”, and “functional performance”.

Strengths of the study

Various medical and sport databases were used to collect detailed information on the
definition of RTP after acute hamstring injury,57 and the inclusion of studies using a
different methodology provides a broad understanding of RTP. PRISMA guidelines were
followed as much as possible to ensure transparent reporting of this systematic review.27
7

Article selection and data retrieval were done by two researchers independently, to
maximize the inclusion of relevant articles and data.58 The third author was consulted
twice to decide on the inclusion of two articles, but this did not significantly affect our
study results. We used content analysis to systematically identify and synthesize recurring
themes within the definitions of RTP after acute hamstring injury.29,30

133
Chapter 7

Limitations of the study

No search limits were placed on level of evidence, as is common in systematic reviews,

because we did not statistically analyze outcome data as such. It should be borne
in mind that none of the included articles had the aim of defining RTP or validating
specific criteria to support the RTP decision. Another potential weakness is that not all
of the studies defined hamstring injury or described the medical assessment. Thus it
cannot be excluded that study participants had other injuries causing posterior upper
leg pain (such as referred pain or adductor-related injuries), injuries for which different
RTP definitions and criteria might apply.

Strengths and weaknesses in relation to other studies

As far as we know, this is the first review of the definitions and criteria for RTP after acute
hamstring injury. In all the included articles, criteria for RTP focused on medical factors
and thus results should be interpreted in the light of medical clearance for RTP. It has
been suggested that modifiers of sport risk (e.g., type of sport, competitive level etc.)
and decisions (e.g., pressure, fear of litigation etc.) should also be considered when
determining readiness for RTP.1 A practical decision-based RTP model of Creighton et
al. guides us through three steps.1 In step 1, medical factors such as age, injury history,
psychological state, outcome of clinical tests and imaging are evaluated. In step 2, sport-
specific risk modifiers, such as type, level of sport, and player position are evaluated.
Finally in step 3, decision modifiers, such as timing in season, importance of match (e.g.
final), external pressure, and financial conflicts of interest are considered. This means
that the RTP decision should involve not only the medical doctor but also the player
and other stakeholders.2

To date, none of the RTP-criteria have been validated with regard to the RTP-decision
after hamstring injury. Only a few studies included had a primary focus on investigating
specific criteria for RTP.25,26 Reurink et al. described that at the time of RTP, 89% of all
clinically healed hamstring injuries still demonstrated increased signal intensity on MRI.26
Tol et al. found that two-thirds of the players in their study group demonstrated a >
10% deficit on hamstring isokinetic testing.25 They did not find differences in isokinetic
strength parameters in players who sustained a re-injury.25 The relationship between these
deficits at the time of RTP and the risk of re-injury is not known. In addition, it should be

134
 Return to play after hamstring injury: systematic review

considered that owing to the multifactorial condition and complexity of the hamstring
injury, a more comprehensive assessment of the different risk factors should be included.59

In a recent study, Mendiguchia et al. proposed a RTP algorithm that included criteria
for progression through each rehabilitation phase, which could assist clinical decision-
making regarding RTP after hamstring injury.16 This algorithm considers all risk factors
that potentially affect hamstring injury risk and incorporates the current literature on
biology of muscle injury and repair. A new active hamstring flexibility test, called the
“H-test”, also seems a promising tool for assessing readiness for RTP after hamstring
injury.38 It is recommended that the test be performed at the end of rehabilitation, when
other tests have indicated clinical recovery.38 Askling et al. suggested that the risk of
recurrent hamstring injury is significantly reduced if there are no signs of insecurity during
the test.38 These findings, if confirmed, may be an important first step to decreasing
the high rates of re-injury and to optimizing RTP. Functional assessment peculiar to the
given sport was also often suggested to support the RTP-decision.25,26,37,42,43,45-48,50,51,53,56
However, more comprehensive description of assessment parameters and limit values
allowing therapists to authorize (or delay) RTP, such as ‘pre-injury-level’ or ‘asymmetry
during running’, needs to be provided.

The lack of an unambiguous definition of and clear criteria for RTP after hamstring injury
makes it difficult to compare and interpret study results. For example, the study by
Hamid et al.36 used lack of pain on direct palpation, no pain on hamstring contraction,
symmetrical range of motion, and equal hamstring strength between affected and
unaffected legs as criteria for RTP. In the study by Reurink et al., participants were
required to complete, without experiencing symptoms, a functional criteria-based
four-staged physiotherapy program, which included a final supervised sport-specific
(outdoor) training phase, and to have a < 10% difference in isokinetic strength between
the affected and unaffected legs.26 Additionally, athletes were advised to have 5 days 7
of additional team training before participation in a match.26 The study of Askling et
al. differed from these studies in that RTP was self-registered by the study participants,
with participants reporting they could train/perform their sport again, regardless of
whether they had symptoms.37 While these articles have contributed to our knowledge
of hamstring injury management, the differences in definitions and criteria for RTP will
inevitably lead to a different time to RTP. Moreover, the actual timing of RTP probably
reflects the success of treatment less than the choice of definition and criteria for RTP.

135
Chapter 7

Meaning of the study: possible implications for clinicians or researchers

We found a lack of definitions of and criteria for RTP after acute hamstring injury in the
literature, which could lead to different research outcomes. Recurrence rates, which
can in part be explained by premature RTP, are still extremely high.8,9 Given the high
recurrence rates and long rehabilitation for recurrent hamstring injuries, it is essential
that clinicians have validated RTP criteria to support the RTP decision.

In the current literature, the definition of RTP after hamstring injury is based on the
athlete reaching a pre-injury level of performance or being able to perform full sport
activities and should be guided by medical advice. Clinical approval for RTP is commonly
based on the athlete experiencing no pain, achieving a similar hamstring strength and
flexibility as before injury, and performing properly on functional testing.

Establishing a definition and providing objective criteria for RTP after acute hamstring
injury is essential for injury management, particularly the prevention of recurrent
hamstring injuries. Therefore, future research should focus on achieving agreement on
the definition of RTP and criteria to guide the RTP decision. Prospective studies are
needed to validate these criteria and their correlation with successful RTP.

Conclusion
Only half of the included studies provided some definition of RTP after hamstring
injury, of which reaching the athlete’s pre-injury level of performance and being able
to perform full sport activities were important elements. Numerous criteria are used to
support the RTP decision, but none of these have been validated. Research is needed
to reach consensus on the definition of RTP and to provide validated RTP criteria to
facilitate hamstring injury management and reduce hamstring injury recurrence.

Acknowledgements
The authors would like to thank Maarten Moen, MD PhD, for his valuable advices to
this systematic review.

136
 Return to play after hamstring injury: systematic review

References
1. Creighton DW, Shrier I, Schultz R, et al. Return-to-play in sport: a decision-based model. Clin J
Sports Med 2010;20(5):379-385.

2. Matheson GO, Schultz R, Bido J, et al. Return-to-play decisions: are they the team physician’s
responsibility? Clin J Sports Med 2011;21(1):25-30.

3. Clover J, Wall J. Return-to-play criteria following sports injury. Clin J Sports Med 2010;29(1):169-
175.

4. Van Beijsterveldt AM, Steffen K, Stubbe JH, et al. Soccer injuries and recovery in Dutch male
amateur soccer players: results of a prospective cohort study. Clin J Sports Med 2014;24(4):337-
342.

5. Ekstrand J, Hägglund M, Waldén M. Epidemiology of muscle injuries in professional football

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

6. Woods C, Hawkins RD, Maltby S, et al. The football association medical research programme: an
audit of injuries in professional football-analysis of hamstring injuries. Br J Sports Med 2004;38:36-
41.

7. Hägglund M, Waldén M, Ekstrand J. Injuries among male and female elite football players. Scand
J Med Sci Sports 2009;19(6):819-827.

8. Opar DA, Williams MD, Shield AJ. Hamstring strain injuries: factors that lead to injury and re-injury.
Sports Med 2012;42(3):209-226.

9. de Visser HM, Reijman M, Heijboer MP, et al. Risk factors of recurrent hamstring injuries: a systematic
review. Br J Sports Med 2012;46(2):124-130.

10. Brooks JH, Fuller CW, Kemp SP, et al. Incidence, risk, and prevention of hamstring muscle injuries
in professional rugby union. Am J Sports Med 2006;34(8):1297-1306.

11. Beijsterveldt van AMC, Port van de IGL, Vereijken AJ, et al. Risk factors for hamstring injuries in male
soccer players: a systematic review of prospective studies. Scand J Med Sci Sports 2013;23(3):253-
262.

12. Freckleton G, Pizzari T. Risk factors for hamstring muscle strain injury in sport: a systematic review
and meta-analysis. Br J Sports Med 2013;47(6):351-358.

13. Ekstrand J, Gillquist J. Soccer injuries and their mechanisms: a prospective study. Med Sci Sports
Exerc 1983;15(3):267-270.

14. Werner J, Hägglund M, Waldén M, et al. UEFA injury study: a prospective study of hip and groin 7
injuries in professional football over seven consecutive seasons. Br J Sports Med 2009;43(13):1036-
1040.

15. Orchard JW, Seward H, Orchard JJ. Results of 2 decades of injury surveillance and public release
of data in the Australian Football League. Am J Sports Med 2013;41(4):734-741.

16. Mendiguchia J, Brughelli M. A return-to-sport algorithm for acute hamstring injuries. Phys Ther
Sport 2011;12(1):2-14.

17. Warren P, Gabbe BJ, Schneider-Kolsky M, et al. Clinical predictors of time to return to competition
and of recurrence following hamstring strain in elite Australian footballers. Br J Sports Med
2010;44(6):415-419.

137
Chapter 7

18. Askling C, Saartok T, Thorstensson A. Type of acute hamstring strain affects flexibility, strength,
and time to return to pre-injury level. Br J Sports Med 2006;40(1):40-44.

19. Comin J, Malliaras P, Baquie P, et al. Return to competitive play after hamstring injuries involving
disruption of the central tendon. Am J Sports Med 2013;41(1):111-115.

20. Grassi A, Zaffagnini S, Marcheggiani, et al. After revision anterior cruciate ligament reconstruction,
who returns to sport? A systematic review and meta-analysis. Br J Sports Med 2015;49(20):1295-
1304.

21. Warner SJ, Smith MV, Wright RW, et al. Sport-specific outcomes after anterior cruciate ligament
reconstruction. Arthroscopy 2011;27:1129-1134.

22. Clanton TO, Matheny LM, Jarvis HC, et al. Return to play in athletes following ankle injuries. Sports
Health. 2012 Nov;4(6):471-474.

23. Brukner P. Return to play – a personal perspective. Clin J Sports Med 2005;15:459-460.

24. Miller MD, Arciero RA, Cooper DE, et al. Doc, when can he go back in the game? Instr Course
Lect 2009;58:437-443.

25. Tol JL, Hamilton B, Eirale C, et al. At return to play following hamstring injury the majority of
professional football players have residual isokinetic deficits. Br J Sports Med 2014:48(18):1364-
1369.

26. Reurink G, Goudswaard GJ, Tol JL, et al. MRI observations at return to play of clinically recovered
hamstring injuries. Br J Sports Med 2014;48(18):1370-1376.

27. Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA statement for reporting systematic reviews
and meta-analyses of studies that evaluate health care interventions: explanation and elaboration.
J Clin Epidemiol 2009;62(10):e1-34.

28. Booth A, Clarke M, Dooley G, et al. The nuts and bolts of PROSPERO: an international prospective
register of systematic reviews. Syst Rev 2012;1:2.

29. Krippendorff K. Content analysis: an introduction to its methodology. 2nd edn. Thousand Oaks,
California: Sage Publications; 2004.

30. Weber RP. Basic content analysis. University of California, CA: Sage Publications; 1990.

31. Strauss AL, Cobin JM. Basics of qualitative research: techniques and procedures for developing
grounded theory. Sage publications; 1998.

32. Elo S, Kyngäs H. The qualitative content analysis process. J Adv Nurs 2008;62(1):107-115.

33. Fuller CW, Walker J. Quantifying the functional rehabilitation of injured football players. Br J Sports
Med 2006;40(2):151-157.

34. DeWitt J, Vidale T. Recurrent hamstring injury: consideration following operative and non-operative
management. Int J Sports Phys Ther 2014;9(6):798-812.

35. Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics
1997;33(1):159-174.

36. A Hamid MS, Mohamed Ali MR, Yusof A, et al. Platelet-rich plasma (PRP): an adjuvant to hasten
hamstring muscle recovery. A randomized controlled trial protocol (ISCRTN66528592). BMC
Muskuloskeletal Disord 2012;6(13):138.

138
 Return to play after hamstring injury: systematic review

37. Askling CM, Saartok T, Thorstensson A. Type of acute hamstring strain affects flexibility, strength,
and time to return to pre-injury level. Br J Sports Med 2006;40:40-44.

38. Askling CM, Nilsson J, Thorstensson A. A new hamstring test to complement the clinical examination
before return to sport after injury. Knee Surg Sports Traumatol Arthrosc 2010;18(12):1798-1803.

39. Connell DA, Schneider-Kolsky ME, Hoving JL, et al. Longitudinal study comparing sonographic and
MRI assessments of acute and healing hamstring injuries. Am J Roentgenol 2004;183(4):975-984.

40. Coole WG, Gieck JH. An analysis of hamstring injuries and their rehabilitation. J Orthop Sports
Phys Ther 1987;9(3):77-85.

41. Cooper DE, Conway JE. Distal semitendinosus ruptures in elite-level athletes: low success rates
of nonoperative treatment. Am J Sports Med 2010;38(6):1174-1178.

42. Delvaux F, Rochcongar P, Bruyère O, et al. Return-to-play criteria after hamstring injury: actual
medicine practice in professional soccer teams. J Sports Sci Med 2014;13(3):721-723.

43. Dembowski SC, Westrick RB, Zylstra E, et al. Treatment of hamstring strain in a collegiate pole-
vaulter integrating dry-needling with an eccentric training program: a resident’s case report. Int J
Sports Phys Ther 2013;8(3):328-339.

44. Hallén A, Ekstrand J. Return to play following muscle injuries in professional footballers. J Sports
Sci 2014;32(13):1229-1236.

45. Heiderscheit BC, Sherry MA, Silder A, et al. Hamstring strain injuries: recommendations for
diagnosis, rehabilitation and injury prevention. J Orthop Sports Phys Ther 2010;40(2):67-81.

46. Heiser TM, Weber J, Sullivan G, et al. Prophylaxis and management of hamstring muscle injuries
in intercollegiate football players. Am J Sports Med 1984;12(5):368-370.

47. Kilcoyne KG, Dickens JF, Keblish D, et al. Outcome of Grade I and II hamstring injuries in
intercollegiate athletes: a novel rehabilitation protocol. Sports Health 2011;3(6):528-533.

48. Malliaropoulos N, Isinkaye T, Tsitas K, et al. Reinjury after acute posterior thigh muscle injuries in
elite track and field athletes. Am J Sports Med 2011;39(2):304-310.

49. Moen MH, Reurink G, Weir A, et al. Predicting return to play after hamstring injuries. Br J Sports
Med 2014;48(18):1358-1363.

50. Nett MH, Tuite MJ, Munoz del Rio A, et al. MR findings at return to sport after indirect hamstring
injury. Skeletal Radiol 2012;41:742.

51. Orchard J. Management of muscle and tendon injuries in footballers. Aust Fam Physician
2003;32(7):489-493. 7
52. Petersen J, Hölmich P. Evidence based prevention of hamstring injuries in sport. Br J Sports Med
2005;39(6):319-323.

53. Petersen J, Thorborg K, Nielsen MB, et al. The diagnostic and prognostic value of ultrasonography
in soccer players with acute hamstring injuries. Am J Sports Med 2014;42(2):399-404.

54. Sanfilippo JL, Silder A, Sherry MA, et al. Hamstring strength and morphology progression after
return to sport from injury. Med Sci Sports Exerc 2013;45(3):448-454.

55. Silder A, Sherry MA, Sanfilippo J, et al. Clinical and morphological changes following 2 rehabilitation
programs for acute hamstring strain injuries: a randomized clinical trial. J Orthop Sports Phys Ther
2013;43(5):284-299.

139
Chapter 7

56. de Vos RJ, Reurink G, Goudswaard GJ, et al. Clinical findings just after return to play predict
hamstring re-injury, but baseline MRI findings do not. Br J Sports Med 2014;48(18):1377-1384.

57. Cook D, Mulrow C, Haynes R. Systematic reviews: synthesis of best evidence for clinical decisions.
Ann Intern Med 1997;126:376-380.

58. Edwards P, Clarke M, DiGuiseppi C, et al. Identification of randomized controlled trials in systematic
reviews: accuracy and reliability of screening records. Stat Med 2002;21(11):1635-1640.

59. Mendiguchia J, Alentorn-Geli E, Brughelli M. Hamstring strain injuries: are we heading in the right
direction? Br J Sports Med 2012;46(2):81-85.

140
 Return to play after hamstring injury: systematic review

Supplementary material
Appendix 7.1  Search strategies for all databases

Search database Search string

PubMed (hamstring[tiab] OR hamstrings[tiab] OR biceps femoris[tiab]

OR semitendinosus[tiab] OR semitendinosus[tiab] OR
semimembranosus[tiab] OR thigh[tiab] OR thighs[tiab] OR upper leg[tiab]
OR upper legs[tiab]) AND (return to play[tiab] OR return to action[tiab]
OR return to sport[tiab] OR return to sports[tiab] OR return to sporting
activities[tiab] OR return to activity[tiab]OR return to competition[tiab]
OR return to training[tiab] OR sports participation[tiab] OR return to
level[tiab] OR sport participation[tiab] OR match fitness[tiab] OR training
fitness[tiab] OR return to action[tiab] OR full fitness[tiab] OR repetitive
injury[tiab] OR recurrent injuries[tiab] OR repetitive injuries[tiab] OR
recurrent strain[tiab] OR repetitive strain[tiab]) OR recurrent strains[tiab]
OR repetitive strains[tiab])

Embase - (hamstring:ti,ab OR hamstrings:ti,ab OR “biceps femoris”:ti,ab OR

Medline semitendinosus:ti,ab OR semitendinosis:ti,ab OR semimembranosus:ti,ab
OR thigh:ti,ab OR thighs:ti,ab OR “upper leg”:ti,ab OR “upper
legs”:ti,ab) AND (“return to play”:ti,ab OR “return to action”:ti,ab
OR “return to sport”:ti,ab OR “return to sports”:ti,ab OR “return
to sporting activities”:ti,ab OR “return to activity”:ti,ab OR
“return to competition”:ti,ab OR “return to training”:ti,ab OR
“sports participation”:ti,ab OR “return to level”:ti,ab OR “sport
participation”:ti,ab OR “match fitness”:ti,ab OR “training fitness”:ti,ab
OR “return to action”:ti,ab OR “full fitness”:ti,ab OR “repetitive
injury”:ti,ab OR “recurrent injuries”:ti,ab OR “repetitive injuries”:ti,ab
OR “recurrent strain”:ti,ab OR “repetitive strain”:ti,ab OR “recurrent
strains”:ti,ab OR “repetitive strains”:ti,ab)

CINAHL hamstring OR hamstrings OR biceps femoris OR semitendinosus OR

semitendinosus OR semimembranosus OR thigh OR thighs OR upper leg
OR upper legs AND return to play OR return to action OR return to sport
OR return to sports OR return to sporting activities OR return to activity
OR return to competition OR return to training OR sports participation
OR return to level OR sport participation OR match fitness OR training
fitness OR return to action OR full fitness OR repetitive injury OR
recurrent injuries OR repetitive injuries OR recurrent strain OR repetitive
strain OR recurrent strains OR repetitive strains

PEDro hamstring AND return

7
Cohrane Library (hamstring or hamstrings or “biceps femoris” or semitendinosus or
semitendinosus or semimembranosus or thigh or thighs or “upper leg” or
“upper legs”) and (“return to play” or “return to action” or “return to sport”
or “return to sports” or “return to sporting activities” or “return to activity”
or “return to competition” or “return to training” or “sports participation”
or “return to level” or “sport participation” or “match fitness” or “training
fitness” or “return to action” or “full fitness” or “repetitive injury” or
“recurrent injuries” or “repetitive injuries” or “recurrent strain” or “repetitive
strain” or “recurrent strains” or “repetitive strains”)

Appendix 7.1 continues on next page

141
Chapter 7

Appendix 7.1  Continued

Search database Search string

Scopus (TITLE-ABS-KEY((hamstring or hamstrings or "biceps femoris" or

thigh or thighs or "upper leg" or "upper legs"))) AND (TITLE-ABS-
KEY(("return to play" or "return to sport" or "return to sports" or "return
to competition" or "sports participation" or "full fitness" or "training
fitness" or "match fitness")))

SportDiscus hamstring OR hamstrings OR biceps femoris OR semitendinosus OR

semitendinosus OR semimembranosus OR thigh OR thighs OR upper leg
OR upper legs AND return to play OR return to action OR return to sport
OR return to sports OR return to sporting activities OR return to activity
OR return to competition OR return to training OR sports participation
OR return to level OR sport participation OR match fitness OR training
fitness OR return to action OR full fitness OR repetitive injury OR
recurrent injuries OR repetitive injuries OR recurrent strain OR repetitive
strain OR recurrent strains OR repetitive strains

142
Return to play after hamstring injury: systematic review

143
 Chapter 8

Return to play after hamstring injuries

in football (soccer): a worldwide Delphi
procedure regarding definition, medical
criteria, and decision-making

N. (Nick) van der Horst

F.J.G. (Frank) Backx
E.A. (Edwin) Goedhart
B. (Bionka) Huisstede
HIPS-Delphi Group

Accepted with minor revisions Br J Sports Med

Chapter 8

Abstract
Background  There are three major questions about return to play (RTP) after
hamstring injuries: How should RTP be defined? Which medical criteria should
support the RTP decision? And who should make the RTP decision?

Hypothesis/purpose  This study aimed to provide a clear RTP-definition and

medical criteria for RTP, and to discuss RTP consultation and responsibilities after
hamstring injury.

Study design  Delphi procedure.

Methods  The results of a systematic review were used as a starting point for the
Delphi procedure. Fifty-eight experts in the field of hamstring injury manage-
ment selected by 28 FIFA Medical Centres of Excellence worldwide participated.
Each Delphi round consisted of a questionnaire, an analysis, and an anonymized
feedback report.

Results  After four Delphi rounds, with more than 83% response for each round,
consensus was achieved that RTP should be defined as “the moment a player has
received criteria-based medical clearance and is mentally ready for full availability
for match selection and/or full training”. The experts achieved consensus on the
following criteria to support the RTP decision: medical staff clearance, absence of
pain on palpation, absence of pain during strength and flexibility testing, absence
of pain during/after functional testing, similar hamstring flexibility, performance on
field-testing, and psychological readiness. It was also agreed that RTP decisions
should be based on shared decision-making, primarily via consultation with the
athlete, sports physician, physiotherapist, fitness trainer, and team coach.

Conclusion  Experts achieved consensus on RTP definition, medical criteria, and

decision-making regarding RTP after hamstring injuries in football. The results are
reported in the RTP model for hamstring injuries in football.

Clinical relevance  The consensus regarding aspects of RTP should provide clarity
and facilitate the assessment of when RTP is appropriate after hamstring injury,
so as to avoid or reduce the risk of injury recurrence because of a too early RTP.

146
 Return to play after hamstring injury: Delphi procedure

Introduction
Hamstring injuries are the most prevalent muscle injury in football and 12–33% of all
athletes with a hamstring injury experience a recurrence within a year after the initial
injury.1-5 This high prevalence of injury causes an average of 18 days and three matches
missed per season.5 Professional football clubs experience between 0–16 hamstring
injuries among players per season, which corresponds to 15 matches and 90 days
missed per club per season because of hamstring injuries.1,5 The inability to play affects
the individual player and team performance. A lower injury burden and higher match
availability are significantly associated with a higher final league ranking, points per
league match, and success in the Union of European Football Association Champions
league or Europa League.6

After the initial hamstring injury, all those involved in the rehabilitation process should
make an effort to reduce the risk of injury recurrence. Recurrent injuries require more
extensive rehabilitation than initial injuries, and previous injury is an undisputed risk
factor for future injury.7,8 Particularly alarming is the observation that recurrence rates
have not improved over the last 30 years.9-11 High recurrence rates are suggested to
occur due to inadequate rehabilitation and/or too early return to play (RTP).12,13 Of all
recurrences, more than half occur within the first month after RTP.14,15 This has prompted
interest in RTP after hamstring injury.16-20

Unfortunately, different concepts of RTP make it difficult to analyse and compare various
studies of RTP after hamstring injury.21-22 It is recognized that diversity in definitions and
methodologies causes significant differences in the results and conclusions obtained
from sports injury research.23-26 However, in accordance with the Strategic Assessment
of Risk and Risk Tolerance (StARRT) framework (Figure 8.1), it is commonly agreed that
any RTP decision should be based on an assessment of the risk and the acceptable risk
tolerance threshold.27 This threshold is determined by factors such as external pressure,
pressure from the rehabilitating athlete, and timing in the season. For instance, a higher
risk threshold might be considered more acceptable if there is an important play-off
match than if there is a friendly match, because of competitiveness and potential
financial benefit.28 The risk assessment is made by assessing tissue health (e.g., patient 8
demographics, symptoms, medical history, and examination} and tissue stresses (e.g.,
type of sport, field position, competitive level, psychological readiness, etc.). So far, no
studies have specified how risk should be assessed when giving a player RTP clearance

147
 Chapter 8
Downloaded from http://bjsm.bmj.com/ on June 3, 2016 - Published by group.bmj.com

Review

5
Figure 1 TheFigure
three-step return-to-play
8.1  (RTP) framework
The Strategic (reproduced
Assessment of Riskfrom ) is Risk
and illustrated. This framework
Tolerance groups
(StARRT) factors responsible
framework for RTPfor RTP
according to the sociological
27 source of the information (medical culture, sport culture, personal decision modifiers). The first two steps assess risk,
decisions.
and the decision to RTP is based on the interaction of this risk with other factors that affect the patients’ overall well-being (decision modifiers)
(see text for details). MSK, musculoskeletal.

guides to help
afterstructure
hamstringthe thought process, and
injury, although thisthe focus is tissue.
moment vital if Tissue
injury stress is directly
recurrence is torelated to the planned activity
be prevented.
should be on the underlying concepts. (cognitive stress in concussion is activity), and is therefore con-
A recent systematic review of the literature showed sidered activity related.
that there is This
greatis diversity
in contrast in
to how
step 1 that evalu-
Step 1: Tissue Health (Medical Factors) ates Tissue Health, which exists in a particular state at a
The first stepRTP after hamstring
in figure injury
1 is to assess is defined
the stress andcan
the tissue whichparticular
criteria are used to assess RTP readiness.21
time.
absorb before becoming damaged. This is a function of the There are many different ways to categorise activity. Using the
Furthermore, because multiple stakeholders ‘FITT’
health of the tissue. For the same level of activity, the risk of
have training
their own reasons
principle, whycanRTP
activity should (or modi-
be categorised
reinjury increases with increasing
be accelerated damage toitthe
or delayed, tissue. The to fied)
is imperative according
provide clarityto on
frequency
who is (eg,to be3 days/week),
consultedintensity (eg,
assessment of tissue damage is generally evaluated through the running fast or climbing hills), timing (eg, 20 min/session) and
presence of and who and
symptoms is responsible
signs such asfor
painthe
or RTP decision.
swelling, or type. Within the biological framework, it is best to think of
diagnostic tests. ‘type’ in relation to the biological stresses that increase with the
In the original framework,5 the ‘potential seriousness’ of the specific activity and might cause injury, rather than in general
The aim
injury was included of this
in step Delphiit procedure
1 because was to provide
represents a sociological a clear
terms such definition
as running or of,swimming.
and specific criteriathe biomech-
For example,
construct related to medical factors. However, steps 1 and 2 of anics of freestyle swimming is very different from that of breast-
for, RTP and to clarify responsibilities for RTP stroke
the original framework are only supposed to assess risk. We
after hamstring injury.
(analogous to different positions in other sports).
might assess the risk of all reinjuries, or only severe reinjuries, A swimmer with pes anserine tendinopathy might not be able to
or only death. In other words, the potential seriousness is really RTP for breaststroke but might be able to RTP for freestyle.
about which outcome we are most interested in, and not about In our original framework, the ‘ability to protect’ mentioned
assessing the risk of any particular outcome. In a subsequent above was included as a Sport Modifier (step 2) even though it
section, we will discuss how the StARRT framework should be was not directly sport related. In the modified framework, the
applied when more than one risk is of interest. ability to protect an injury clearly decreases the stress applied to
the tissue and is part of step 2.
Step 2: Tissue Stresses (Sport Risk Modifiers) The original framework placed functional tests that measure
If an unhealthy tissue is exposed to only minimal stress, it con- functional capacity in step 1. However, the postinjury decrease
tinues to heal. If the stress exceeds the capacity of the tissue, an in endurance and strength, and range of motion of tissues that
injury or reinjury will occur. Therefore, the second step of the have not been injured are clearly not related to the health status
framework is148 to assess the stress that will be applied to the of the damaged tissue we are trying to evaluate, nor are they

2 of 6 Shrier I. Br J Sports Med 2015;49:1311–1315. doi:10.1136/bjsports-2014-094569

 Return to play after hamstring injury: Delphi procedure

Materials and methods

Study design and setting

This study, the HIPS (Hamstring Injury Prevention Strategies) Delphi study, used a Delphi
procedure to achieve consensus on the terminology, definition, and medical criteria for
RTP and who should be involved and responsible for the RTP decision after hamstring
injury. This study was carried out by the Department of Rehabilitation, Physical Therapy
Science, and Sport at the University Medical Centre of Utrecht, the Netherlands. Before
the start of this project, a systematic review of the definition of, and criteria for, RTP
after hamstring injury was performed.21 The results of this review were used as a starting
point for the Delphi procedure.

Delphi procedure

A Delphi procedure is basically a series of sequential questionnaires or “rounds”,

interspersed by feedback, that seeks to achieve consensus of opinion among a panel of
experts.29,30 This scientific method was originally developed in the 1950s and has since
been effectively used in sports medicine research.31-34 Each Delphi round comprised a
questionnaire, an analysis, and a feedback report.

Steering committee

The steering committee that facilitated and guided this Delphi study consisted of a full
professor in sports medicine, a senior researcher with experience in Delphi procedures, a
team doctor of a national football team, and a PhD student. All members have a clinical
(sports medicine, (sports) physical therapy) and scientific background. The steering
committee was responsible for preparing and analysing the questionnaires, as well as
for reporting the results in anonymized feedback reports.

Expert panel

The FIFA Medical Centres of Excellence, which have a demonstrable record of leadership
8
in football medicine and have been accredited through a strict selection process by FIFA,
provide a network of knowledge and experience in research and clinical management of

149
Chapter 8

hamstring injuries. All FIFA Medical Centres of Excellence (n = 40) were invited to select
one to three experts in hamstring injury management, adhering to the inclusion criteria as
listed in Table 8.1. After selection, the steering committee contacted all experts via email
to provide information on aim, methods, and privacy statements for this Delphi study.

Table 8.1  Experts’ inclusion criteria for participation to the Delphi study

Criterion number Description

1 The selected FIFA Medical Centre of Excellence considers this expert to

be a key person in the field of hamstring injury management
2 The expert is a researcher OR medical / health professional with experience
in hamstring injury
rehabilitation in a sport setting
3 The expert has sufficient knowledge of English
4 The expert has an evidence-based attitude

Procedure

Online surveys were used and adhered to principles of respondent anonymity and
feedback between rounds.29 For all Delphi rounds, experts were approached by e-mail
with a link to an online questionnaire. Experts were given 6 weeks to complete the
questionnaire, with reminders e-mailed at 3 and 5 weeks. A structured web-based
questionnaire was developed consisting of three parts: Part I for general questions about
RTP consultation and responsibilities, Part II for the definition of RTP, and Part III for
criteria to support the RTP decision after hamstring injury. During the whole procedure,
we used structured questions, such as: “Do you feel this item should be a part of the RTP
definition?” or “Do you feel this item should be a criterion to support the RTP decision
after hamstring injury?” Answer options were ‘yes’, ‘no’, or ‘no opinion’. Experts were
encouraged to provide argumentation for their answers. Topics on which no consensus
was achieved were included in the next Delphi round. For some questions, the steering
committee added a ‘note from the steering committee’, based on expert opinion or
the literature.

Cut-off point for consensus

A cut-off score of ≥ 70% agreement was proposed for consensus, because this cut-off
is often used in Delphi procedures.35-37

150
 Return to play after hamstring injury: Delphi procedure

RTP terminology

The expert panel was asked to discuss which overall term for return to play in sports
should be adopted (e.g., return to sport, return to play, return to competition, etc.).

Definition of RTP after a hamstring injury

Before the start of this Delphi strategy, potential terms regarding the definition of RTP
after hamstring injury were systematically reviewed.21 Results from this systematic review
(see Table 8.2) were included and used to start the discussion about the definition of
RTP. Experts were asked which terms should or should not be included in the definition
for RTP. Experts were also invited to respond to the definition of RTP after hamstring
injury in an open-ended fashion.

Medical criteria to support the RTP decision after a hamstring

injury

Similar to the definition of RTP, potential criteria to support the RTP decision after
hamstring injury were systematically reviewed from literature21 and used as a starting

Table 8.2  Items* included to start discussion on definition and criteria for RTP after hamstring
injury

Items for discussion on definition of RTP after hamstring injury

Availability for match selection and/or full training
Clearance by medical staff
Player’s positive mental attitude (athlete readiness)
A completed game
Full activity
A 100% recovery score on fitness and skill testing
Absence of symptoms on injured leg
Completion of a rehabilitation program
Reaching pre-injury level
Items for discussion on criteria for RTP after hamstring injury
Medical staff clearance
Absence of pain
Similar hamstring strength 8
Similar hamstring flexibility
Functional performance
* All items were derived from a systematic review by Van der Horst et al. on definition and criteria
for RTP after hamstring injury.21

151
Chapter 8

point for discussion on criteria to support the RTP decision. Experts were asked which
criteria should or should not be used to support the final RTP decision and to provide
additional criteria they though relevant.

RTP responsibilities

Stakeholders regarding RTP decision-making were derived from the literature.38,39 Experts
were additionally asked to name other stakeholders involved in RTP consultation and
decision-making.

Data analysis

Data from all Delphi rounds were extracted from the online survey database in SPSS
version 22.0 and anonymously reported in feedback reports. For questions with a
“yes/no/no opinion” answer format, the percentage of answers in each category was
calculated. Qualitative data (i.e., expert answers and argumentation) were analysed
and discussed by the steering committee. This information and the main arguments
of the experts were summarized and included in a ‘note from the steering committee’
and added to each question. If consensus was not achieved on a topic, these notes
could be included in a follow-up question on a related subject, or used to rephrase the
original question or to compose new questions on this topic.

Results
After four consecutive Delphi rounds, performed between July 2015 and July 2016,
full consensus was achieved on all topics. The final consensus is presented in the RTP
model for hamstring injuries in football (see Figure 8.2).

Expert panel

Fifty-eight experts were recruited from 28 FIFA Medical Centers of Excellence worldwide
(participating experts are included in the acknowledgements section). The experts held
different functions, such as full professor, medical director, lecturer, sports physician,
orthopaedic surgeon, physical therapist, performance coach, athletic trainer and/or

152
 Return to play after hamstring injury: Delphi procedure

Figure 8.2  The RTP model for hamstring injuries in football for RTP decision-making, RTP defini-
tion and RTP criteria after hamstring injury.

153
Chapter 8

researcher. All experts had expertise in the field of hamstring injury management. Most
members had written a number of high-quality international publications in addition to
their clinical experience in sports medicine, with an average of 15.8 (SD ± 8.2; range
3–35) years of experience in the field of hamstring injury management in football.
Response rates in this Delphi procedure were 93% (round 1), 90% (rounds 2 and 3), and
84% (round 4).

Cut-off point for consensus

In Delphi round 1, the expert panel agreed that a cut-off score of ≥ 70% would be used
to define consensus.

RTP terminology

In Delphi round 1, most experts chose either ‘return to play’ or ‘return to competition’
as the overall term to describe the final RTP moment. In Delphi round 2, consensus
was achieved to adopt return to play – including its acronym RTP – as the overall term,
arguing that it is simple, well-known, and adopted worldwide at many levels, including
conferences and publications. It was agreed that ‘return to competition’ should be
included in the definition of the generic term ‘return to play’.

Definition of RTP after a hamstring injury

In the first Delphi round, consensus was achieved to include ‘availability for match
selection and/or full training’ and ‘clearance by medical staff’ as part of the RTP definition
after a hamstring injury. There was also consensus that ‘a completed game’ should not
be included in the RTP definition, because RTP clearance should be given before a
player resumes play and availability to play a match might be based on non-medical
(e.g. tactical, team-based) factors or decisions. The expert panel additionally suggested
considering inclusion of ‘a player’s positive mental attitude (athlete’s readiness)’ in the
definition of RTP after hamstring injury. Therefore, this item was included in Delphi
round 2.

In Delphi rounds 2 and 3, there was consensus that ‘full activity’, ‘a 100% recovery score
on fitness and skill testing’, ‘absence of symptoms on injured leg’, ‘completion of a

154
 Return to play after hamstring injury: Delphi procedure

rehabilitation programme’, and ‘reaching pre-injury level’ should not be included in the
definition of RTP after hamstring injury. It was argued that these items are not specific
enough and/or should be considered as criteria for RTP, but not for RTP definition. In
Delphi round 3, consensus was achieved on including ‘a player’s positive mental attitude
(athlete readiness)’ in the definition of RTP, because mental readiness was considered
important to eliminate anxiety, and because a positive mental attitude is perceived to
diminish the risk of reinjury and to improve performance.

The expert panel achieved consensus that RTP should be defined as “the moment
a player has received criteria-based medical clearance and is mentally ready for full
availability for match selection and/or full training”.

Criteria to support the RTP decision after a hamstring injury

After discussion and specification of criteria through all rounds of this Delphi consensus
procedure, the following criteria were included: medical staff clearance, similar hamstring
flexibility (compared to pre-injury data and/or uninjured side – depending on which
data are available or are most reliable for the individual player according to the medical
staff), performance on field-testing, psychological readiness, and absence of pain on
palpation, strength testing, flexibility testing and/or functional testing. Additionally,
the expert panel stated that specification of criteria was required. The experts agreed
that ‘similar hamstring flexibility’ could involve a 0–10% difference between injured and
uninjured leg or compared with pre-injury data. The expert panel additionally achieved
consensus that hamstring flexibility should be assessed by means of both the active and
the passive straight leg raise test, as these are the most valid tests used in daily practice
and it is important to measure both the active and passive component.

With regard to ‘performance on field-testing’, the expert panel mentioned a number

of field tests used in clinical practice to support the RTP decision after hamstring injury
(see Table 8.3). In Delphi round 3, the experts were asked whether they had practical
experience with other field tests of functional performance and whether they would
recommend using these tests to support the RTP decision after hamstring injury (see
Table 8.3). Consensus was achieved that the Repeated Sprint Ability test,40 deceleration 8
drills, single leg bridge, and position-specific global positioning system (GPS)-targeted
match-specific rehabilitation were relevant functional performance tests to support the

155
Chapter 8

Table 8.3  Expert advice on functional performance tests to assess eligibility for RTP after
hamstring injury

Clinical test %* Clinical test %*

Position specific GPS targeted match 82 20 metre sprint 57

specific rehabilitation Nordic Hamstring Exercise 55
RSA (Repeated Sprint Ability) test 76 Triple Hop Test 53
Single Leg Bridge 71 Muscular Endurance 45
Deceleration drills 71 YoYo / Shuttle Run Test 43
Acceleration drills 68 Speed testing 39
T-test 63 Functional Movement Screen 35
40 metre sprint 61 Single Hop Test 33
H-test 58
* Experts stating this test could be suggested for functional performance assessment.

RTP decision after hamstring injury. The experts also commented that functional testing
should involve explosive movements to mimic the actual football performance.

No consensus was reached for the inclusion of ‘similar eccentric hamstring strength’ as a
criterion to support the RTP decision after hamstring injury. The expert panel remained
divided, with two irreconcilable opinions. One group of experts stated that similar
eccentric strength assessment is important as a criterion for RTP as the eccentric phase
is also the contraction mode in which injury occurs and strength asymmetries should
be eliminated because they can increase the risk of injury. The other group of experts
stated that strength measurements are not functional, asymmetries are normal, and that
too many factors influence the measurement of strength, so that reliable measurements
are not possible. In Delphi round 4, consensus was reached for the following criterion
‘similar eccentric hamstring strength’ (compared to pre-injury data and/or uninjured
side – depending on which data are available or are most reliable for the individual
player according to the medical staff) to support the RTP decision.

The experts agreed that ‘neuromuscular function’ should not be included as a criterion
for RTP after hamstring injury. Although the experts stated that neuromuscular function
is always important, the concept and assessment of neuromuscular function could not be
specified and was therefore not included as a criterion. The exclusion of MRI assessment
as a potential criterion for RTP decision-making after hamstring injury was supported
by recent studies.19,41 Baseline MRI parameters are not predictive of hamstring re-injury,
and MRI is not of additional predictive value compared with baseline patient history and

156
 Return to play after hamstring injury: Delphi procedure

clinical examination alone.42 Completion of a number of full training sessions was also
excluded as a criterion as ‘availability for full training and match selection’ was already
included in the definition of RTP after hamstring injury.

RTP responsibilities

In Delphi round 2, the experts agreed that the sports physician, physiotherapist,
fitness trainer, and athlete are the primary stakeholders to be consulted regarding the
RTP decision. There was discussion about the role of the team coach, who not being
medically qualified might allow an early RTP to improve team performance, despite
potential medical risks. However, in Delphi round 3, the expert panel reached consensus
on the inclusion of the team coach for RTP consultation because of his ability to assess
the sport-specific performance level, his role in team selection, and his function in the
multidisciplinary team staff. The sports physician (as head of the medical staff) was
chosen to be ultimately responsible for the RTP decision, based on input provided by
the multidisciplinary team and the athlete.

Discussion
This Delphi study involving 58 experts from 28 FIFA Medical Centers of Excellence
worldwide reached consensus on a clear definition and specific criteria for RTP after
hamstring injury and who should be consulted about RTP and take ultimate responsibility
for the RTP decision (see Figure 8.2).

Definition and medical criteria for RTP

The absence of clear and uniform definitions and medical criteria for RTP has been a
methodological issue in studies of different musculoskeletal domains, such as RTP after
anterior cruciate ligament injury, ankle injury, and concussion.43-46 If we want to prevent
injuries and avoid significant differences in results because of differences in definitions
and criteria used when investigating risk factors, prognostic factors, intervention
programmes, and so forth for RTP, it is crucial that there is a clear definition of RTP.23-26 8
Differences in the definition and criteria for RTP after hamstring injury make it difficult
to compare study results and leads to uncertainty about which findings should be

157
Chapter 8

implemented in clinical practice.21 A recent study defined the return to sport process.47
Essentially, a definition that includes multiple stages of rehabilitation is similar to a
criteria-based rehabilitation definition and is very useful for rehabilitation purposes as
it considers the entire rehabilitation and recovery process.47 However, it is important
to differentiate between the return to sport process and the final RTP decision, where
RTP is viewed as an endpoint (or primary outcome) of the return to sport process.
This Delphi study explicitly focused on the final RTP decision (when the player is fully
available for match selection and full training) and involved consensus among experts
in the field of prevention and treatment of hamstring injuries. Although not yet studied
and validated in clinical practice, this consensus statement may help clinicians faced
with the problem of when an athlete should RTP after a hamstring injury. Furthermore,
both the definition and criteria can be used in research, potentially leading to greater
uniformity and promote comparability of research.

Medical criteria for RTP after hamstring injury

Absence of pain and psychological readiness. Absence of pain on palpation of the

hamstrings, during strength and flexibility testing, and during or after functional
performance was considered important as pain is an indicator of incomplete tissue
healing. This is supported by recent evidence from De Vos et al., who showed that
patients with localized discomfort on palpation just after RTP were four times (AOR 3.95;
95% CI 1.38–11.37) more likely to sustain a re-injury than athletes without discomfort
on palpation.19 However, pain perception is not only influenced by tissue damage, but
also by cognitive factors such as fear of re-injury or fear of pain.48,49 The fear of pain or
re-injury generates avoidance behaviour.49,50 In addition, athletes mention fear of re-injury
as the main reason for not returning to sport.51 This relationship between fear of re-injury
and unsuccessful RTP led to the suggestion that psychological readiness be included
in RTP guidelines.52-54 We included psychological readiness in both the definition and
criteria for RTP after hamstring injury. However, relatively little is known about the exact
relationship between (hamstring) injury risk and psychological factors and it remains an
important topic for future research.

Similar hamstring strength and hamstring flexibility. De Vos et al. also found an isometric
knee flexion force deficit just after RTP to be associated with an increased risk of hamstring
injury.19 Our expert panel did not achieve consensus on the potential inclusion or

158
 Return to play after hamstring injury: Delphi procedure

exclusion of ‘similar eccentric hamstring strength’ as a potential criterion to support the

RTP decision, although consensus was achieved that other contraction modes should
not be included as a criterion to support the RTP decision. Previous research did not
find different strength assessments to be associated with an increased risk of hamstring
re-injury.8 Hamstring peak torque, quadriceps peak torque, and conventional concentric
hamstring:quadriceps (HQ) ratios (as measured with different test speeds and muscle
contractions) were not found to be associated with an increased risk of hamstring re-injury.8
The concentric hamstring to opposite hamstring (H:Hopp) ratio was also not associated with
an increased risk of re-injury. However, eccentric strength asymmetries were predictive
of hamstring muscle injuries in football players.55 Furthermore, in a study of professional
football players, 67% of all players clinically recovered from hamstring injuries had at
least one hamstring isokinetic testing deficit of more than 10%.20 Thus elimination of
isokinetic strength asymmetries is not a requirement for RTP, although it is not known
whether isokinetic strength deficits are associated with the risk of hamstring injury.20

From a biomechanical perspective, it is important to assess strength in a (sub)maximally

stretched position.56-59 There is ongoing debate regarding the relationship between
hamstring flexibility and risk of hamstring injury.7,8 Many studies have not found hamstring
flexibility to be a risk factor for hamstring injury.8,60 However, an active hamstring
flexibility test, called the H-test, showed promising results as a complement to clinical
examination.61 Experts in this Delphi study stated that this test seems promising as
it involves an active flexibility component as well as assessment of insecurity in the
athlete. However, there was no consensus on the inclusion of this test to support the
RTP decision because experts stated there was insufficient evidence to support use of
the test and because the test lacks functionality.

Performance on field-testing. Performance on field-testing was considered vital when

assessing RTP readiness, as it mimics the actual sports requirements. Furthermore,
many criteria-based hamstring injury rehabilitation protocols have suggested including
performance-based criteria in the end-phase, such as a normal week of training
sessions,62 sport-specific scenarios,20 and functional phase training.16 As most hamstring
injuries occur in the latter stages of a match or training, fatigue and its associated decline
in functional performance need to be considered in addition to field-testing.5,63,64 There­ 8
fore, one could argue that both qualitative and quantitative assessment of functional
performance should be performed in a fatigued state.12 Future research should focus

159
Chapter 8

on the development of a sport-specific test battery for RTP after hamstring injury, in
which functional aspects, fatigue, hamstring flexibility, absence of pain, and potentially
hamstring strength are assessed in the light of the RTP decision.

Hamstring RTP decision-making

Owing to the complexity of RTP decision-making, as well as potential competing interests

and different views of various stakeholders, it is commonly agreed that RTP decisions
should be based on multidisciplinary consultation.22,39,65 Although the sports physician is
best qualified to synthesize medical information, step 3 of the Creighton model describes
some important RTP decision modifiers (e.g., financial interests, timing in season, internal
pressure, etc.).28 Generally, the sports physician is only responsible for the medical part of
the RTP decision and does not have the final say over these decision modifiers (such as
financial, legal or team-tactical issues). Hence, the sports physician may have responsibility
for the decision without authority to make it.65 Ultimately, the best interests of the athlete
are decisive and this covers more than just the medical risk assessment.27,28,39 Therefore,
in our opinion, different stakeholders with different views should be involved in the final
RTP decision, bearing in mind the best interests of the athlete.

Strengths and weaknesses of this study

Delphi studies have the advantage of utilizing the knowledge and expertise of participating
experts to reach consensus.29,66,67 This Delphi study involved a multidisciplinary sample of
clinical and academic experts with extensive experience in hamstring injury research and
rehabilitation. Although there is no scientifically proven minimally acceptable response
rate, a response rate of 60% has been used as the threshold of acceptability.68 This
Delphi consensus study had an excellent response rate of > 83% for each Delphi round.

The results of Delphi studies should be viewed in the light of the expert panel’s opinion
at any given point in time,66 because opinions may change in the light of new evidence
and paradigm shifts.69 Therefore, both the definition and criteria for RTP after hamstring
injury should be re-evaluated in the future, based on new research findings.

When drafting this consensus, no limitations regarding (medical) staff and tools were
considered. This makes the consensus more suitable for a professional setting compared
to an amateur setting due to differences regarding team staff and (access to) tools such

160
 Return to play after hamstring injury: Delphi procedure

as GPS tracking systems. Teams with limited access to a comprehensive team staff are
advised to still consider and acknowledge the multi-faceted nature of the RTP-decision,
as discussed in this manuscript. This Delphi consensus procedure additionally advised
simpler functional tests if GPS tracking systems and/or speed measurement equipment
is unavailable (e.g. RSA test, deceleration drills etc.), although position specific GPS
targeted match specific rehabilitation was considered an important functional assessment
by the majority of our expert panel due to its ability to mimic sport specific function.

Lastly, this study provided medical criteria to assess the health status of the athlete. This
is only the first step in the three-step RTP assessment after hamstring injury (see Figure
8.1).27,28 In addition to the health status evaluation, the assessment of tissue stresses
(from type of sport, level of play, etc.) and RTP decision modifiers (timing and season,
pressure from the athlete or external, financial issues, etc.) should form a solid basis for
RTP decision-making.27,28

Meaning of the study

Although experts’ opinions are considered to be a low level of evidence, we consider

this study to be an important first step in standardizing and improving the final RTP
decision after hamstring injury. In addition, the criteria to support the RTP decision
were generated by clinical and academic authorities in the field of hamstring injury
management. These criteria will help both clinicians and (clinical) researchers to assess
the risk of RTP after hamstring injury.

Unanswered questions and future research

For future research, the authors emphasize the need for high-quality prospective research
to validate RTP criteria. Considering the multidimensional nature of hamstring injuries, RTP
criteria should not be validated as univariate factors but interaction between criteria as well
as the varying weighting of criteria due to time and circumstances need to be considered.

Conclusion 8
Experts worldwide achieved consensus on RTP terminology, definition, and medical
criteria for RTP after hamstring injuries in football. The results are reported in the RTP

161
Chapter 8

model for hamstring injuries in football. Although experts’ opinions collected in a Delphi
procedure are considered a low level of evidence, we consider this study to be an
important first step in standardizing the terminology, consultation, definition, and criteria
for RTP after hamstring injuries in football. The consensus may help both clinicians and
(clinical) researchers to assess RTP risk after hamstring injury. Validation of RTP criteria,
including tools and cut-off values, should lead to the ongoing development of this
consensus. This will support RTP decision-making with a view to reducing hamstring
injury recurrence as a result of a too early RTP.

Acknowledgements
The authors will thank FIFA and the FIFA Medical Centers of Excellence network for
their support and cooperation in expert selection and recruitment.

Furthermore, we thank the following experts from the HIPS-Delphi group for their
extensive knowledge and contributions: Ahmad CSA (US); Andersen TEA (NO); Araujo JP
(PT); Arroyo FE (MX); Askling CM (SW); Batty PD (GB); Bayraktar BB (TR); Beckmann CB
(DE); Bizzini M (SW); Cohen M (BR); Connelly SPC (GB); Constantinou D (ZA); Edwards AS
(GB); Espregueira-Mendes J (PT); Exeter DJ (NZ); Fulcher ML (NZ); aus der Fünten (DE);
Garrett WE (US); Grygorowicz M (PL); Haag TB (DE), Hejna R (PL); Houghton JM (GB);
Isik AI (TR); Kemp S (GB); Kruiswijk C (NL); Lewin GG (GB); Lewis T (GB); Lichaba M (ZA);
Loureiro N (PT); Loursac RL (FR); Maffiuletti NAM (SW); Marles AM (FR); Mendiguchia J
(SP); Miyauchi NM (JP); Moksnes HM (NO); Motaung CS (ZA); Noel EN (FR); O’Driscoll GJ
(GB); Okuwaki TO (JP); Peers K (BE); Piontek T (PL); Pruna R (SP); Ranson CA (GB); Saita
YS (JP); Santos MB (BR); Schneider CS (GE); Schwarzenbrunner KS (AT); Silvers HJ (US);
Stålman A (SW); van den Steen EV (BE); Sundelin S (SW); Tol JL (QA); Veldman NJ (NL);
Weiler R (GB); Whiteley R (QA); Witvrouw E (QA); Yekdah A (DZ); Zachazewski JE (US).

AT = Austria; BE = Belgium; BR = Brazil; DE = Germany; DZ = Algeria; ES = Spain; GB = United

Kingdom; FR = France; JP = Japan; MX = Mexico; NL = Netherlands; NO = Norway; NZ = New
Zealand; PL = Poland; PT = Portugal; QA = Qatar; SE = Sweden; SW = Switzerland; TR = Turkey;
US = United States; ZA = South Africa.

This study is funded by the Royal Netherlands Football Association (KNVB).

162
 Return to play after hamstring injury: Delphi procedure

References
1. Ekstrand J, Waldén M, Hägglund M. Hamstring injuries have increased by 4% annually in men’s
professional football, since 2001: a 13-year longitudinal analysis of the UEFA Elite Club injury
study. Br J Sports Med 2016;50(12):731-737.

2. Hägglund M, Wálden M, Ekstrand J. Injuries among male and female elite football players. Scand
J Med Sci Sports 2009;19(6):819-827.

3. Ekstrand J, Hägglund M, Waldén M. Epidemiology of muscle injuries in professional football

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

4. van Beijsterveldt AM, van de Port IG, Krist MR, et al. Effectiveness of an injury prevention programme
for adult male amateur soccer players: a cluster-randomised controlled trial. Br J Sports Med 2012;
46(16):1114-1118.

5. Woods C, Hawkins RD, Maltby S, et al. The Football Association Medical Research Programme:
an audit of injuries in professional football – analysis of hamstring injuries. Br J Sports Med 2004;
38(1):36-41.

6. Hägglund M, Waldén M, Magnusson H, et al. Injuries affect team performance negatively in

professional football: an 11-year follow-up of the UEFA Champions League injury study. Br J Sports
Med 2013;47(12):738-742.

7. van Beijsterveldt AM, van de Port IG, Vereijken AJ, et al. Risk factors for hamstring injuries in male
soccer players: a systematic review of prospective studies. Scand J Med Sci Sports 2013;23(3):253-
262.

8. Freckleton G, Pizzari T. Risk factors for hamstring muscle strain injury in sport: a systematic review
and meta-analysis. Br J Sports Med 2013;47(6):351-358.

9. Ekstrand J, Gillquist J. Soccer injuries and their mechanisms: a prospective study. Med Sci Sports
Exerc 1983;15(3):267-270.

10. Werner J, Hägglund M, Waldén M, et al. UEFA injury study: a prospective study of hip and groin
injuries in professional football over seven consecutive seasons. Br J Sports Med 2009;43(13):1036-
1040.

11. Orchard JW, Seward H, Orchard JJ. Results of 2 decades of injury surveillance and public release
of data in the Australian Football League. Am J Sports Med 2013;41(4):734-741. 


12. Opar DA, Williams MD, Shield AJ. Hamstring strain injuries: factors that lead to injury and re-injury.
Sports Med 2012;42(3):209-226.

13. De Visser HM, Reijman M, Heijboer MP, et al. Risk factors of recurrent hamstring injuries: a systematic
review. Br J Sports Med 2012;46(2):124-130.

14. Wangensteen A, Tol JL, Witvrouw E, et al. Hamstring reinjuries occur at the same location and
early after return to sport: a descriptive study of MRI-confirmed reinjuries. Am J Sports Med 2016;
44(8):2112-2121.

15. Brooks JH, Fuller CW, Kemp SP, et al. Incidence, risk, and prevention of hamstring muscle injuries
in professional rugby union. Am J Sports Med 2006;34(8):1297-1306.
8
16. Mendiguchia J, Alentorn-Geli E, Brughelli M. A return-to-sport algorithm for hamstring injuries.
Phys Ther Sport 2011;12(1):2-14.

163
Chapter 8

17. Orchard J, Best TM, Verrall GM. Return to play following muscle strains. Clin J Sport Med 2005;
15(6):436-441.

18. Reurink G, Goudswaard GJ, Tol JL, et al. MRI observations at 
return to play of clinically recovered
hamstring injuries. Br J
Sports Med 2014;48(18):1370-1376.

19. De Vos RJ, Reurink G, Goudswaard GJ, et al. Clinical findings just after return to play predict
hamstring re-injury, but baseline MRI findings do not. Br J Sports Med 2014;48(18):1377-1384.

20. Tol JL, Hamilton B, Eirale C, et al. At return to play following hamstring injury the majority of
professional football players have residual isokinetic deficits. Br J Sports Med 2014;48(18):1364-
1369.

21. Van der Horst N, van de Hoef S, Reurink G, et al. Return to play after hamstring injuries: a qualitative
systematic review of definitions and criteria. Sports Med 2016;46(6):899-912.

22. Schultz R, Bido J, Shrier I, et al. Team clinician variability in return-to-play decisions. Clin J Sport
Med 2013;23(6):456-461.

23. Finch CF. An overview of some definitional issues for sports injury surveillance. Sports Med 1997;
24(3):157-163.

24. Junge A, Dvorak J. Influence of definition and data collection on the incidence of injuries in football.
Am J Sports Med 2000;28(5 Suppl):S40-46.

25. Fuller CW, Ekstrand J, Junge A, et al. Consensus statement on injury definitions and data collection
procedures in studies of football (soccer) injuries. Br J Sports Med 2006;40(3):193-201.

26. Brooks JH, Fuller CW. The influence of methodological issues on the results and conclusions from
epidemiological studies of sports injuries: illustrative examples. Sports Med 2006;36(6):459-472.

27. Shrier I. Strategic Assessment of Risk and Risk Tolerance (StARRT) framework for return-to-play
decision-making. Br J Sports Med 2015;49(20):1311-1315.

28. Creighton DW, Shrier I, Schultz R, et al. Return-to-play in sport: a decision-based model. Clin J
Sport Med 2010;20(5):379-385.

29. Hasson F, Keeney S, McKenna H. Research guidelines for the Delphi survey technique. J Adv Nurs
2000;32(4):1008-1015.

30. Powell C. The Delphi technique: myths and realities. J Adv Nurs 2003;41(4):376-382.

31. Dalkey N, Brown B, Cochran S. 1969. The Delphi method, III: use of self ratings to improve group
estimates. Santa Monica, CA: Rand Corp. Publication RM-6115-PR.

32. Weir A, Brukner P, Delahunt E, et al. Doha agreement meeting on terminology and definitions in
groin pain in athletes. Br J Sports Med 2015;49(12):768-774.

33. Sullivan SJ, Schneiders AG, McCrory P, et al. Physiotherapists’ use of information in identifying a
concussion: an extended Delphi approach. Br J Sports Med 2008;42(3):175-177.

34. Donaldson A, Cook J, Gabbe B, et al. Bridging the gap between content and context: establishing
expert consensus on the content of an exercise training program to prevent lower-limb injuries.
Clin J Sport Med 2015;25(3):221-229.

35. Verhagen AP, de Vet HC, de Bie RA, et al. The Delphi list: a criteria list for quality assessment of
randomized clinical trials for conducting systematic reviews developed by Delphi consensus. J
Clin Epidemiol 1998;51(12):1235-1241.

164
 Return to play after hamstring injury: Delphi procedure

36. Kleynen M, Braun SM, Bleijlevens MH, et al. Using a Delphi technique to seek consensus regarding
definitions, descriptions and classifications of terms related to implicit and explicit forms of motor
learning. PLoS One 2014;26(9):e100227.

37. Huisstede BM, Hoogvliet P, Coert JH, et al. Multidisciplinary consensus guideline for managing
trigger finger: results from the European HANDGUIDE Study. Phys Ther 2014;94(10):1421-1433.

38. Shrier I, Charland L, Mohtadi NG, et al. The sociology of return-to-play decision making: a clinical
perspective. Clin J Sport Med 2010;20(5):333-335.

39. Shrier I, Safai P, Charland L. Return to play following injury: whose decision should it be? Br J
Sports Med 2014;48(5):394-401.

40. Impellizzeri FM, Rampinini E, Castagna C, et al. Validity of a repeated-sprint test for football. Int
J Sports Med 2008;29(11):899-905.

41. Reurink G, Whiteley R, Tol JL. Hamstring injuries and predicting return to play: ‘bye-bye MRI?’ Br
J Sports Med 2015;49(18):1162-1163

42. Wangensteen A, Almusa E, Boukarroum S, et al. MRI does not add value over and above patient
history and clinical examination in predicting time to return to sport after acute hamstring injuries:
a prospective cohort of 180 male athletes. Br J Sports Med 2015;49(24):1579-1587.

43. Grassi A, Zaffagnini S, Marcheggiani Muccioli GM, et al. After revision anterior cruciate ligament
reconstruction, who returns to sport? A systematic review and meta-analysis. Br J Sports Med
2015;49(20):1295-1304.

44. Warner SJ, Smith MV, Wright RW, et al. Sport-specific outcomes after anterior cruciate ligament
reconstruction. Arthroscopy 2011;27:1129-1134.

45. Clanton TO, Matheny LM, Jarvis HC, et al. Return to play in athletes following ankle injuries. Sports
Health 2012;4(6):471-474.

46. Echemendia RJ, Giza CC, Kutcher JS. Developing guidelines for return to play: consensus and
evidence-based approaches. Brain Inj 2015;29(2):185-194.

47. Ardern CL, Glasgow P, Schneiders A, et al. 2016 Consensus statement on return to sport from
the First World Congress in Sports Physical Therapy, Bern. Br J Sports Med 2016;50(14):853-
864.

48. Niederstrasser NG, Meulders A, Meulders M, et al. Pain catastrophizing and fear of pain predict
the experience of pain in body parts not targeted by a delayed-onset muscle soreness procedure.
J Pain 2015;16(11):1065-1076.

49. Meulders A, Vansteenwegen D, Vlaeyen JW. The acquisition of fear of movement-related pain and
associative learning: a novel pain-relevant human fear conditioning paradigm. Pain 2011;152(11):
2460-2469.

50. Geisser ME, Haig AJ, Wallbom AS, et al. Pain-related fear, lumbar flexion, and dynamic EMG
among persons with chronic musculoskeletal low back pain. Clin J Pain 2004;20:61-69.

51. Kvist J, Ek A, Sporrstedt K, et al. Fear of re-injury: a hindrance for returning to sports after anterior
cruciate ligament reconstruction. Knee Surg Sport Traumatol Arthrosc 2005;13:393-397. 8
52. Podlog L, Heil J, Schulte S. Psychosocial factors in sports injury rehabilitation and return to play.
Phys Med Rehabil Clin N Am 2014;25(4):915-930.

165
Chapter 8

53. Lentz TA, Zeppieri G Jr, George SZ, et al. Comparison of physical impairment, functional, and
psychosocial measures based on fear of reinjury/lack of confidence and return-to-sport status after
ACL reconstruction. Am J Sports Med 2015;43(2):345-353.

54. Ardern CL, Taylor NF, Feller JA, et al. A systematic review of the psychological factors associated
with returning to sport following injury. Br J Sports Med 2013;47(17):1120-1126.

55. Fousekis K, Tsepis E, Poulmedis P, et al. Intrinsic risk factors of non-contact quadriceps and hamstring
strains in soccer: a prospective study of 100 professional players. Br J Sports Med 2011;45:709-
714.

56. Chumanov ES, Heiderscheit BC, Thelen DG. The effect of speed and influence of individual muscles
on hamstring mechanics during the swing phase of sprinting. J Biomech 2007;40(16):3555-3562.

57. Chumanov ES, Heiderscheit BC, Thelen DG. Hamstring musculotendon dynamics during stance
and swing phases of high-speed running. Med Sci Sports Exerc 2011;43(3):525-532.

58. Proske U, Morgan DL, Brockett CL, et al. Identifying athletes at risk of hamstring strains and how
to protect them. Clin Exp Pharmacol Physiol 2004;31(8):546-550.

59. Brockett CL, Morgan DL, Proske U. Human hamstring muscles adapt to eccentric exercise by
changing the optimum length. Med Sci Sports Exerc 2001;33:783-790.

60. Van Doormaal MC, van der Horst N, Backx FJ, et al. No relationship between hamstring flexibility
and hamstring injuries in male amateur soccer players: a prospective study. Am J Sports Med
2016;[ePub].

61. Askling CM, Nilsson J, Thorstensson A. A new hamstring test to complement the common clinical
examination before return to sport after hamstring injury. Knee Surg Sports Traumatol Arthrosc
2010;18(12):1798-1803.

62. Valle X, Tol JL, Hamilton B, et al. Hamstring muscle injuries, a rehabilitation protocol purpose.
Asian J Sports Med 2015;6(4):e25411.

63. Mair SD, Seaber AV, Glisson RR, et al. The role of fatigue in susceptibility to acute muscle strain
injury. Am J Sports Med 1996;24(2):137-143.

64. Croisier JL. Factors associated with recurrent hamstring injuries. Sports Med 2004;34(10):681-695.

65. Matheson GO, Schultz R, Bido J, et al. Return-to-play decisions: are they the team physician’s
responsibility? Clin J Sport Med 2011;21(1):25-30.

66. Keeney S, Hasson F, McKenna H. Consulting the oracle: ten lessons from using the Delphi technique
in nursing research. J Adv Nurs 2006;53(2):205-212.

67. Mullen PM. Delphi: myths and reality. J Health Organ Manag 2003;17(1):37-52.

68. Johnson TP, Wislar JS. Response rates and nonresponse errors in surveys. JAMA 2012;307(17):1805-
1806.

69. Quatman CE, Quatman CC, Hewett TE. Prediction and prevention of musculoskeletal injury: a
paradigm shift in methodology. Br J Sports Med 2009;43(14):1100-1107.

166
Return to play after hamstring injury: Delphi procedure

167
Chapter 9

General discussion
Chapter 9

General discussion
The aim of this thesis was to improve strategies for preventing hamstring injuries during
soccer. The rationale behind the studies was threefold: 1) there is a high incidence
of hamstring injuries in male soccer players, 2) these injuries affect players and team
performance, and 3) the Royal Netherlands Football Association (KNVB) would like to
reduce the number of hamstring injuries in soccer. Two large projects were designed
to improve and/or develop evidence-based strategies targeting hamstring injury
prevention.

The first project, called HIPS (Hamstring Injury Prevention Strategies), focused on the
prevention of hamstring injuries by means of a tailored exercise programme, called the Nordic
hamstring exercises (NHEs), carried out during soccer training. This study also investigated
the association between hamstring flexibility and the occurrence of hamstring injuries.
The second project, called HIPS-2, focused on return to play (RTP) after hamstring
injuries in soccer. Definitions, criteria, and decision-making regarding RTP after hamstring
injuries were investigated.

The main findings of both projects, NHEs, hamstring injury risk factors, RTP after
hamstring injury, and implementation issues are discussed individually in this chapter,
covering primary findings, methodological issues, and future directions. Furthermore,
based on the primary findings, advice and recommendations for clinical practice are
provided.

Main findings
This thesis kicked off with a systematic review of the literature on the effectiveness
of exercise-based injury prevention programmes for soccer players (Chapter 2). We
found that evidence for many of these general exercise-based prevention programmes
is conflicting. Compliance with the intervention and the specificity of the intervention
programme were found to be important determinants of effectiveness.

The first HIPS study focused on the effect of an eccentric strength-training programme
for preventing or reducing the occurrence of hamstring injuries in amateur soccer players
(Chapter 3; study protocol). In a randomized controlled trial (RCT), we concluded that
incorporating a tailored NHE programme into the training schedule of amateur soccer

170
 General discussion

players significantly reduces the incidence of hamstring injury (Chapter 4). Furthermore,
the HIPS study analysed the relationship between hamstring flexibility and hamstring
injury risk. Population-based reference values for a hamstring flexibility test were
established (Chapter 5), and a subsequent study found that hamstring flexibility is not
associated with hamstring injuries in male amateur soccer players (Chapter 6).

The second HIPS study focused on the prevention of recurrent hamstring injuries in
soccer players after they return to play. In a systematic review, it was concluded that
the concept of RTP is still poorly defined and that a wide variety of criteria are used to
support the RTP decision, none of which have been validated (Chapter 7). Subsequently,
the results of this systematic review were used to perform a worldwide Delphi consensus
strategy, in which an expert panel discussed and reached consensus on the definition
and criteria for RTP after hamstring injury (Chapter 8).

Nordic Hamstring Exercise (NHE)

Nordic hamstring exercise and hamstring injury prevention

The risk of a hamstring injury was reduced 3- to 4-fold in male amateur soccer teams
that incorporated our tailored NHE programme into their regular training programme.
NHE programmes have previously shown their worth in preventing hamstring injury in
professional football.1-3 But due to some essential differences between professional
and amateur soccer players with regard to the availability of medical staff, level of play,
training exposure, training intensity, and compliance with preventive measures, the
findings for professional players could not be extrapolated to amateur players, until
now. Important factors that should be considered for effectiveness of NHEs in amateur
soccer players are optimizing the dose-response relationship, inspiring compliance, and
tailoring the intervention programme to the amateur soccer season.

Methodological considerations

Dose-response relationship. Our study showed that NHEs can reduce hamstring injury
risk in amateur soccer players. However, in a previous study performed by our research
group, NHEs were performed in the same population and under the same conditions,
but did not show a preventive effect on hamstring injuries.4 One of the major limitations

171 9
Chapter 9

discussed by van Beijsterveldt et al. was the fact that the dosage (e.g., frequency,
intensity, timing in training and season) of the exercises, specifically addressing NHEs,
might have been too low in their intervention programme to decrease the injury rate.4

To date, no studies have investigated the dose-response relationship of NHEs. The pro-
tocol as performed in this thesis had a preventive effect that was maintained throughout
the soccer season or during a 1-year follow-up, but no studies have collected data for
longer than one year. Furthermore, alongside these quantitative aspects, it is important
to investigate how well the exercises of the NHE protocol are performed. The active fixa-
tion of the hips and the amount of range of motion over the knee joint (e.g., the range
of the forward falling motion) during the exercise as well as the speed with which the
exercise is done can alter the intensity and potentially effectiveness of NHE protocols.3
Therefore, team coaches and medical staff are advised to supervise both quantitative
and qualitative aspects when their players are performing NHEs.

On the basis of personal clinical experience, I would recommend that the NHE protocol
should be tailored based on risk stratification. For instance, players with a minimal risk
(e.g., no history of hamstring injuries) can probably suffice with the protocol used in our
study. However, players at risk of hamstring injuries (e.g., with a history of one or more
hamstring injuries) should perhaps repeat the protocol again after each summer or winter
break, or prolong the maintenance phase of the protocol throughout the season. There
is some indirect evidence to support this view, as Petersen et al. showed that NHEs
are particularly effective for players with a history of hamstring injuries,1 but the effect
of tailoring the exercise protocol based on risk stratification warrants further research.

Compliance. With a reported rate of 91%, compliance in our study was excellent. We
considered clear instructions to team coaches and staff members on the importance
of injury prevention for both injury reduction and team performance to be essential,
because coaches and staff are the primary stakeholders involved in explaining preventive
measures to players. Furthermore, we explained to all players that Delayed Onset of
Muscle Soreness (DOMS) is a normal side-effect of the NHE programme, in order to
eliminate potential drop-out or poor intervention compliance due to DOMS.3,5 Many
studies have shown that poor compliance with preventive measures significantly
influences study outcomes,6,7 so any research group or clinician is advised to stimulate
compliance to optimize effectiveness of the injury prevention programme.

172
 General discussion

Tailoring prevention programmes. Our NHE protocol was tailored to the amateur
soccer season, as it is recognized that tailoring exercises to a specific type of sport
potentially improves compliance.8 There has been anecdotal criticism of NHEs by
physical trainers and exercise therapists, on the basis that NHEs are not sport-specific
enough to stimulate running or soccer biomechanics. Our research group has taken these
remarks into consideration and are currently conducting a new national RCT into the
effective­ness of a bounding (alternate leg jumping) exercise programme for hamstring
injury prevention. However, a recent review has provided indisputable evidence of the
functional consequences of different contraction modes for exercises.9 On the basis of
this knowledge, eccentric training via exercises such as NHEs should be viewed as a
key element for functional training and injury prevention. Furthermore, I believe that the
statement that exercise-based injury prevention must always be sport specific should be
countered. The proven effectiveness of NHEs with regard to hamstring injury prevention
keeps players on the pitch for more matches per season, and this is ultimately the aim
of injury prevention.

Future directions for NHEs

The NHE protocol, an eccentric strengthening programme, has proven its worth in field
studies and in fundamental and biomechanical studies. Hence, one should acknowledge
Kristian Thorborg’s statement that “hamstring eccentrics are hamstring essentials”.10 But
effective interventions only work if people do them. Factors that motivate or discourage
individual soccer players and staff members to perform these exercises need to be
investigated and addressed. Furthermore, considering DOMS and training schedules,
more insight into the optimal dose-response relationship for the NHE programme could
benefit its effectiveness and usefulness.

Risk factors for hamstring injury

Hamstring flexibility as a risk factor for hamstring injury

We concluded that hamstring flexibility is not associated with hamstring injury risk.
Potential confounders, such as age and previous hamstring injury, did not influence this
relationship. This means that, on the basis of our results, the sit-and-reach test (SRT) for

173 9
Chapter 9

hamstring flexibility should not be used to identify players at risk of hamstring injury.
Although flexibility imbalances are particularly interesting in the risk factor model for
hamstring injuries because this is modifiable, evidence is still contradictory.11,12 One
important methodological limitation regarding research on hamstring flexibility as a
risk factor for hamstring flexibility risk is that no hamstring flexibility test has both good
validity and good reliability.13,14

Methodological considerations

Hamstring flexibility testing. The HIPS study used the SRT to measure hamstring flexibility.
While the SRT has excellent reliability, is quick, easy to perform, and requires minimal
skill and training, other tests can also be used to measure hamstring flexibility. Flexibility
is typically recognized as the maximum ROM in a joint or series of joints.15 Angular tests
that specifically measure hip flexion with the knee extended (active straight leg raise
test and passive straight leg test) or the range of knee extension with the hip in 90
degrees (knee extension test) measure hamstring extensibility.13 However, angular tests
are time consuming and need sophisticated instruments and trained and experienced
assessors.13,14 Hence, angular tests are recommended for individual assessment by a
clinician (e.g., sports physician, physical therapist), but the SRT is preferable for large-
scale evaluation of hamstring flexibility in a field setting.13,14,16,17

(Anti-)Reductionism. When putting research into risk factors for hamstring injuries into a
broader perspective, an important methodological limitation needs to be considered.
A major issue in research into hamstring injuries – but also in sports injury research in
general – derives from the philosophical model of reductionism, in which researchers
try to simplify and reduce a complex phenomenon, such as a hamstring injury, into its
most elementary parts and then hypothesize how these parts interact and lead to a
hamstring injury.

The majority of reductionist research into risk factors for hamstring injuries has applied
correlation-based analytical methods (e.g., regression), where a linear and unidirectional
cause and effect is hypothesized. Although useful for identifying linear relationships,
these methods are unable to establish and test a web of causal relationships, which
may include varying weighting of variables and feedback loops.18 Attempts to include
larger sample sizes (200 subjects) and a higher incidence of hamstring injury (20–50

174
 General discussion
Downloaded from bjsm.bmj.com on July 9, 2013 - Published by group.bmj.com

Editorial
injuries) in research designs, to enable the use of multivariate analyses,19 would have the

ease on transverse same limitations. Overlooking or obscuring data because of reductionist methodology
ng to recruitment may cause oversimplified interpretations and justifications for predictive models.
ate spatial patterns
Consequently, there is often a discrepancy between the ‘high-quality predictive models’
cle activation.72 –76
at different preven- used in research and the everyday situation in the clinic.
different patterns
t, and this degree As such, our knowledge of how hamstring injuries develop could potentially benefit
between proxi-
ns. These fi ndings greatly from antireductionist thinking and modelling. Quatman et al. advocated
f Askling et al69 –71 this paradigm shift from a reductionist to an antireductionist view with regard to
uggest that the pre-
musculoskeletal injuries.20 Based on this antireductionist view, Mendiguchia et al. already
will depend on the
s specific anatomic proposed a model in which tissue architecture, injury history, fatigue, strength, flexibility,
and core stability all interact with each other, providing a better understanding of the
hat the prevalence
ry is much higher multifactorial nature of a hamstring injury (see Figure 9.1).21
mstrings.77 Thelen Figure 1 Current cause – effect model for hamstring strain injury.
e elongation peak
is during sprints
lation phase, and
de, with increased
the medial ham-
al aponeurosis of
narrower than the
ld explain the fi nd-
h increases during
he unique architec-
hysiological cross-
urosis size) of the
xplain the greater
red to other mus-
a single muscle, it
he use of complex
Figure9.1 
Figure 2 New conceptual
Model modelstrain
for hamstring for hamstring
injury bystrain injury. et al.21
Mendiguchia
s that the great-
ps femoris muscle
entric contraction to the current reductionist model used to may skip the influence of core muscles43
ea adjacent to the study hamstring injuries. and many other parameters like adverse
For example, studies have shown that neural tension is not85a risk factor for hamstring
us junction.79 This Research has traditionally assumed a neural tension on flexibility itself.
results shown with injury.12,22
However,
reductionistic viewadverse
84 whereneural tension
a linear and can influence ROM.15 A reduced
This analytical approach, hip allows
ROM is
ng strain injury in unidirectional causal-effect model was correlational and regression
associated with loss of strength,15,23 and strength deficits in turn are associated with an analysis.
ver, as the authors systematically followed in many top- Both may be useful when developing a
esirable to confi rm increased
ics. This risk of hamstring
reductionist injury.
model
12,24-27
is clearly This simplified
research example
question,couldbut potentially show
the knowledge
influenced by that
the is
Western understand- 84
ng all the muscles how a variable not actually consideredthey provide
a risk factor may
may be too limited.
become a risk factor in
ated model during ing of any phenomenon and conceives With these caveats in mind, one must
combination
any system withas theother
sumfactors, increasing
of its parts (fig- thetrylikelihood
to considerof ainjury. 21

less reductionistic model
ure 1). The medical understanding of in which the whole body is involved,
the human body as an entity assembled assuming that parts are not homogeneous
from many pieces stems from Aristotle’s and that intimate relationships are pres-
rticle are to review premises, showing the ancestral origin ent in a non-random fashion.84 This new
regarding risk fac- of this still current reductionist model. conceptual model would assume an inter-
uries, to highlight These parts are studied analytically in connected, multidirectional and synergic
s of the current lit- order to defi ne the contribution of each interaction between all parts (figure 2).
175 9
he adequacy of the one into the whole. Currently, there is With this model, many assumptions
stigating this issue. no clear explanation or robust model about hamstring injuries may be cleared.
Chapter 9

Future directions for risk factor analysis

The model for hamstring strain injury proposed by Mendiguchia provides a solid basis
for clinicians and researchers, but in my opinion the model still lacks some potential
risk factors, such as psychosocial, environmental, and proprioceptive factors.28-32
Psychological factors, such as trait anxiety, negative life events, stress, and daily hassles,
are significantly associated with both injury and illness.33 The role of proprioceptive
aspects in relation to injury risk and how some of the clumsiness that occurs after intense
(eccentric) exercise may be proprioceptor mediated have been thoroughly described
by Proske and Gandevia.31 As proprioception decreases with fatigue, fatigue could also
contribute to an increased injury risk and is worth further investigation.31

I feel that in future studies of risk factors for hamstring injury, Mendiguchia’s conceptual
model should be extended to include other factors that are potentially related to
hamstring injury risk. Furthermore, it seems clear that the antireductionist conceptual
model, which shows the inter-relationships between different factors involved in
hamstring injuries, provides a better understanding of the multifactorial nature of the
hamstring injury. It emphasizes the more ‘real-world’ context of the hamstring injury
problem, moving away from the reductionist view and methodology that prevails in
current scientific literature.

Key points HIPS project

• Nordic hamstring exercises are an effective tool for hamstring injury prevention.
• Nordic hamstring exercises can easily be incorporated into regular amateur
soccer training.
• Compliance with the Nordic hamstring exercise programme is a key factor.
• Male amateur soccer players have reduced hamstring flexibility compared with
a general (athletic) population.
• Hamstring flexibility measurements on the sit-and-reach test are not related
to the incidence of hamstring injury.
• Hamstring flexibility does not have a linear and unidirectional association with
the incidence of hamstring injury, but the role of hamstring flexibility and the
interaction with other risk factors for hamstring injuries remains unclear.

176
 General discussion

RTP after hamstring injury

Definition of Return-to-Play after hamstring injury

In our Delphi consensus study, we concluded that RTP as a primary outcome should be
defined as “the moment a player has received criteria-based medical clearance and is
mentally ready for full availability for match selection and/or full training”. This definition
should not be confused with recent work from Ardern et al., who published a consensus
statement on the definition of return to sport.33 They defined the RTP process, which I
feel is no different from current rehabilitation concepts.34,35

In our study, we aimed to define the end-stage for RTP and which criteria could assist
clinicians to make this final decision on whether a player can resume play or not. As
more than 60 internationally acknowledged experts in the field of hamstring injury
management reached consensus on a clear and specific definition for RTP after hamstring
injury, clinicians and researchers involved with RTP after hamstring injury are advised
to adopt this definition.

Criteria for RTP after hamstring injury

The consensus from our Delphi strategy stated which criteria should and should not
support the final decision regarding RTP readiness in order to prevent re-injury. It is
important to appreciate that our Delphi project aimed at providing clear and specific
medical criteria to support the RTP decision after hamstring injury. In a recent study
in which similar criteria were used, it was concluded that a combination of initial and
follow-up physical therapy examinations predict the time to RTP.36 This emphasizes
the importance of a thorough clinical examination of the athlete’s health status for RTP
decision-making. However, as described in the three-step framework of Shrier et al.,
evaluating health status is only the first step in the RTP decision-making process (see
Figure 9.2).37 Assessment of medical criteria can only support the final RTP decision
if tissue stresses (Step 2) and RTP decision modifiers (Step 3) are also considered. For
example, with regard to tissue stress, players in different playing positions experience
different forces and therefore have different injury risks (e.g., a forward will generally
sprint more per game than a goalkeeper).38-40 Risk tolerance modifiers are factors that
may change the decision if only Steps 1 and 2 of the model are considered.37,41 For

177 9
 Chapter 9

instance, time in the playing season can modify the RTP decision because it may be
less important if the player can resume playing earlier during the off-season. In contrast,
for a final or important play-off match (potentially leading to trophies, bonus payments,
scholarship, promotion, and so forth), the same level of injury risk might change the
balance of advantages and disadvantages of the RTP decision into early RTP.37

The medical criteria and arguments for these criteria mentioned by our Delphi consensus
experts will help clinicians to assess the health status of the athlete. These criteria in
combination with the assessment of the risk of sports participation and RTP decision
modifiers will contribute to a thorough assessment of the risks and benefits of any RTP
decision. Downloaded from http://bjsm.bmj.com/ on June 3, 2016 - Published by group.bmj.com

Review

5
Figure 1 TheFigure
three-step
9.2 return-to-play (RTP) framework
The Strategic Assessment(reproduced
of Riskfrom
and) Risk
is illustrated.
ToleranceThis (StARRT)
framework groups factors for
framework responsible
return-for RTP
according to the sociological source of the information (medical culture, sport culture, personal decision modifiers). The first two steps assess risk,
to-play (RTP) decisions. 37
and the decision to RTP is based on the interaction of this risk with other factors that affect the patients’ overall well-being (decision modifiers)
(see text for details). MSK, musculoskeletal.

guides to help structure the thought process, and the focus tissue. Tissue stress is directly related to the planned activity
should be on the underlying concepts. (cognitive stress in concussion is activity), and is therefore con-
sidered activity related. This is in contrast to step 1 that evalu-
Step 1: Tissue Health (Medical Factors) ates Tissue Health, which exists in a particular state at a
The first step in figure 1 is to assess the stress the tissue can particular time.
absorb before178becoming damaged. This is a function of the There are many different ways to categorise activity. Using the
health of the tissue. For the same level of activity, the risk of ‘FITT’ training principle, activity can be categorised (or modi-
reinjury increases with increasing damage to the tissue. The fied) according to frequency (eg, 3 days/week), intensity (eg,
assessment of tissue damage is generally evaluated through the running fast or climbing hills), timing (eg, 20 min/session) and
 General discussion

RTP: who is responsible?

The question about who is responsible for making the RTP decision is complex.
Different stakeholders (e.g., athlete, team physician, physical therapist, coach, sponsor,
agent, athletics trainer, etc.) may have different views regarding the RTP decision. All
stakeholders weigh the pros and cons of returning the athlete to play, which include
not only the risk of re-injury (determined by tissue health and tissue stress), but also
the importance of the competition, financial considerations, and legal liability.37,41,42 To
complicate this even more, we know that different clinicians weigh RTP factors differently
and provide different restrictions given the same clinical context.43 In a survey by Shrier
et al, medical doctors, physical therapists, and athletic therapists were all asked to
indicate which profession was best able to evaluate the RTP criteria.44 Each clinician
group generally believed that their own profession was best able to evaluate the RTP
criteria.44 Regardless of ability, the question remains whether the sports physician (or
any other clinician) is in the best position to make the final RTP decision because they
may have the responsibility but not the authority to do so.45 This again emphasizes the
importance of shared decision-making when faced with the RTP question.

In my opinion, the discussion about RTP responsibility should not be about which
stakeholder is ultimately responsible, but about the focus of all stakeholders. This
focus should always be on the best interests of the player, and these interests are not
necessarily a low risk of re-injury, game participation, or financial gain. All stakeholders
have the responsibility to consult and inform both the player and each other about the
risks and benefits of any RTP decision, with the best interests of the player as top priority.

Methodological considerations

Delphi procedures are still considered low level of evidence as Delphi procedures may
lead to a weakened version of the best opinion and that anonymity may lead to a lack of
accountability of views expressed and encourage hasty decisions.47 However, our HIPS-
2 study included an impressive expert panel, including 58 world-leading experts with
extensive track records in the management of hamstring injuries. Any Delphi procedure
mainly relies on the combined expertise of the expert panel,46 which brings a wide range
of direct knowledge and experience to the decision-making process. Ultimately, Delphi
procedures benefit from a democratic and structured approach, where bias through

179 9
Chapter 9

status or dominant personality is avoided because of expert anonymity.47 Of course, the

results and expert consensus need to be critically assessed in future research to validate
and further develop our RTP model for hamstring injuries in football.

Future directions for RTP after hamstring injuries

The StARRT model (Figure 9.2) provides a great framework for RTP decision-making.37
However, it is unclear how RTP is defined in this model. Furthermore, while the framework
provides clinical considerations, it is not specific about how these considerations
contribute to the final RTP risk assessment. The results from our Delphi strategy could
be a first step toward clarifying and specifying the RTP risk assessment as proposed by
the StARRT framework. In future research, RTP criteria after hamstring injury suggested
by our expert panel need to be validated in prospective studies. Based on the findings
of such studies, the RTP model for hamstring injuries in football can be updated to
improve RTP decision-making after hamstring injury, resulting in a reduced risk of
recurrent hamstring injuries as a result of a (too) early RTP.

Key points HIPS-2 project

• When discussing RTP, it is imperative that all researchers and clinicians are
clear and unambiguous about the definition of RTP.
• Criteria to support the RTP decision after hamstring injury are described in
this thesis and should be integrated in any RTP decision-making process after
hamstring injury
• The RTP decision should always be based on shared decision-making, with
priority given to the best interests of the athlete.

From research to real world prevention: implementation

This thesis does not include a separate chapter specifically focusing on implementation.
However, it is recognized that there is a gap between research and the real-world context.
Considering the content of our studies and the lack of knowledge transfer from research
to clinical practice, it is essential to discuss some implementation issues.

180
 General discussion

Implementation models

In order that measures that have proven effective in an experimental setting actually
prevent the occurrence of injury in a real-world context, the measures need to be
acceptable, adopted, and complied with by the intended users (e.g., athletes, sports
participants etc). The HIPS study was designed and tailored to the amateur soccer
population, with a view to the future implementation of its findings. Dissemination
of study results was achieved by adopting the Knowledge Transfer Scheme with the
cooperation of the Royal Netherlands Football Association (KNVB), amateur clubs,
different platforms where technical and medical staff members of clubs are trained, and
the Dutch Association of Sports Medicine (VSG).48

Methodological considerations

The gap between research and real-world context. The implementation of evidence-
based injury prevention programmes is still a challenge.49-52 In spite of a well-designed
dissemination strategy, unpublished data from a follow-up study of our first HIPS project
confirm that there is a gap between our effective research results and implementation
in the real-world context. The majority of participants from the original HIPS study (68%
from intervention group and 94% from control group players) indicated that – although
mostly aware of the preventive effect – they seldom or never performed the NHE
programme 3 years after the HIPS study (publication in preparation). Personal motivation,
effectiveness, and knowledge of the NHE programme were indicated as important
factors for adherence to the NHE programme, and these findings are in accordance
with other literature.51,53 Most interestingly, a recent publication by Bahr et al. confirmed
the lack of NHE implementation in 50 professional Champions League and Norwegian
Premier League teams.54 In that study, only 10.7% of the teams performed the full NHE
protocol, and 83.3% of these teams were reported to be non-compliant with the NHE
programme despite compelling evidence of its effectiveness.54

In our HIPS study, we found that team coaches had a crucial role in compliance. In other
words, injury prevention is not only the domain of the medical staff. At an amateur
level, coaches will have to make time in their training schedule for the exercises and in
some cases even monitor the performance of NHEs, which could hinder compliance.51,52
However, players generally carry out their team coach’ orders, and so preventive

181 9
Chapter 9

strategies will only work if supported by the team coach. Players, coaches, and medical
staff are largely aware of the benefits of injury prevention, but this does not necessarily
mean that soccer teams adopt preventive strategies.

Future directions for implementation

So how can we bridge the gap between research and real-world context? Although
there is a long way to go regarding the implementation of preventive strategies in sports
injury prevention, researchers in this field have the opportunity to be involved in the
implementation process. Researchers need to engage relevant stakeholders and end-
user groups during a study and develop multifaceted strategic approaches towards injury
prevention in a real-world context.50 The RE-AIM framework appears to be a good tool
for the scientific evaluation of implementation of preventive measures.55 The RE-AIM
framework aims to evaluate the public health impact of health promotion interventions
through assessment of Reach, Efficacy, Adoption, Implementation, and Maintenance.55
These important aspects of implementation research have recently been integrated in
a tool that has been specifically developed to bridge the gap between science and
practice, called the ‘Knowledge Transfer Scheme’ (KTS).48

Advice for clinical practice

The aim of this thesis was to improve strategies for hamstring injury prevention in
soccer. On the basis of our findings and experience, the following advice is relevant to
clinical practice:

There is no such thing as a generic exercise-based injury prevention programme for

soccer players. Unfortunately, evidence shows that we cannot prevent all injuries with
one exercise programme. Soccer teams consist of multiple (often 18–23) players,
and each player has his/her own injury risk profile. Pre-selection based on injury risk
profiling is essential to provide targeted injury prevention and increase the likelihood
of reducing soccer-related injuries.

Performing a NHE protocol in regular training can reduce (3-to 4-fold) the risk
of hamstring injuries. This is important for both the injured player and team
performance, as high injury rates are associated with reduced team performance.56

182
 General discussion

However, compliance with the protocol is critical, both quantitative (e.g., following
the protocolled sessions, sets and repetitions) and qualitative (e.g., performing
the NHE conform instructions). Clinicians, medical staff, and other stakeholders
in preventing hamstring injury should make an effort to optimize compliance and
supervise the qualitative performance of the NHE programme.

Hamstring flexibility scores on the SRT should not be used to identify soccer players
at risk for future hamstring injury. Considering the multifactorial nature of hamstring
injuries, other risk factors, such as previous injury, strength, fatigue, architecture, and
core stability, should be considered as interacting risk factors and thus be assessed
and addressed. While hamstring flexibility was not identified as a risk factor, more
knowledge is needed about the interaction of hamstring flexibility with other
(potential) risk factors and its role in hamstring injury prediction.

Any clinician assessing the RTP readiness of a soccer player should consider testing
for ‘absence of pain on palpation’, ‘absence of pain during strength and flexibility
testing’, ‘absence of pain during functional performance’, ‘absence of pain after
functional testing’, ‘similar flexibility’, ‘psychological readiness / athlete’s confidence’,
‘medical staff clearance’, and ‘performance on field testing’ (e.g., the repeated
sprint ability test, deceleration drills, single leg bride, and position specific GPS
targeted match specific rehabilitation). It is not advised to include ‘MRI findings’,
‘similar concentric or isometric strength’, ‘neuromuscular function’, and ‘completion
of a number of full friendly matches/training sessions’ as criteria to support the RTP
decision. Assessment of the factors to support the RTP decision can assist in the
evaluation of tissue health. To make the final RTP decision, assessment of the risk
of specific activities (e.g., type of sport, competitive level, etc.) and risk tolerance
(e.g., timing and season, pressure, etc.) need to be considered as well.

The RTP decision should be a multidisciplinary decision, including consultation of

sports physician, physical therapist, fitness trainer, team coach, and last but not least:
the athlete. The best interests of the athlete should always be the main focus, even
though on some occasions this might conflict with the interests of some stakeholders.
Hence, open communication between all stakeholders is essential when faced with
RTP decision-making.

183 9
Chapter 9

Narrowing the gap between research and the real-world context is a responsibility
of both the research community and clinicians. The research community (especially
applied research) should not strive for effective interventions, but for fewer injuries
in a real-world context. This means that the development of effective interventions is
only one aspect, but end-users need to adopt these interventions in order for them
to truly work. Hence, researchers should already consider implementation strategies
in the development phase of a new study.

Furthermore, as more and more evidence for strategies to prevent hamstring

injury becomes available, clinicians should incorporate this knowledge into daily
practice. Clinicians need to be actively involved in identifying factors that obstruct
the implementation of effective, evidence-based preventive strategies, to improve
efforts to reduce the incidence of soccer-related hamstring injuries.

Conclusion
Hamstring injuries in amateur soccer can be prevented by incorporating a NHE pro-
gramme in regular amateur soccer training. Owing to the multifactorial nature of
hamstring injuries both clinicians and scientific researchers need to acknowledge that
eccentric strengthening is just one component of the prevention of hamstring injuries
and that different components can vary in time and due to differing circumstances. If,
in spite of prevention programmes, all goes wrong and the player sustains a hamstring
injury, experts have reached consensus about specific criteria that should guide the
decision about whether a player can return to play.

Ultimately, developing and validating injury prevention programmes is not enough.53

Anyone affiliated with sports injury research should take on the responsibility to support
the implementation of preventive strategies to reduce hamstring injuries, so that research
findings actually benefit injury prevention in a real-world context. And end-users need
to be made aware of the potential of hamstring injury prevention strategies.

After all, an ounce of prevention is worth a pound of cure. - Benjamin Franklin (1706–1790)

184
 General discussion

References
1. Petersen J, Thorborg K, Bachmann Nielsen M, 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(11):2296-2303.

2. Arnason A, Andersen TE, Holme I, et al. Prevention of hamstring strains in elite soccer: an
intervention study. Scand J Med Sci Sports 2008;18(1):40-48.

3. 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;14:311-317.

4. Van Beijsterveldt AM, van de Port IG, Krist MR, et al. Effectiveness of an injury prevention
programme for adult male amateur soccer players: a randomised controlled trial. Br J Sports Med
2012;46(16):1114-1118.

5. Gabbe BJ, Branson R, Bennell KL. A pilot randomised controlled trial of eccentric exercise to
prevent hamstring injuries in community-level Australian Football. J Sci Med Sport 2006;9(1-2):103-
109.

6. Van Reijen M, Vriend I, van Mechelen W, et al. Compliance with sports injury prevention interventions
in randomised controlled trials: a systematic review. Sports Med 2016;46(8):1125-1139.

7. Goode AP, Reiman MP, Harris L, et al. Eccentric training for prevention of hamstring injuries may
depend on intervention compliance: a systematic review and meta-analysis. Br J Sports Med 2015;
49(6):349-356.

8. Jack K, McLean SM, Moffett JK, et al. Barriers to treatment adherence in physiotherapy outpatient
clinics: a systematic review. Man Ther 2010;15:220-228.

9. Narici M, Franchi M, Maganaris C. Muscle structural assembly and functional consequences. J Exp
Biol 2016;219(Pt 2):276-284.

10. Thorborg K. Why hamstring eccentrics are hamstring essentials. Br J Sports Med 2012;46(7):463-
465.

11. Van Beijsterveldt AM, van de Port IG, Vereijken AJ, et al. Risk factors for hamstring injuries in male
soccer players: a systematic review of prospective studies. Scand J Med Sci Sports 2013;23(3):253-
362.

12. Freckleton G, Pizzari T. Risk factors for hamstring muscle strain injury in sport: a systematic review
and meta-analysis. Br J Sports Med 2013;47(6):351-358.

13. Mayorga-Vega D, Merino-Marban R, Viciana J. Criterion-related validity of sit-and-reach test for

estimating hamstring and lumbar extensibility: a meta-analysis. J Sports Sci Med 2014;13(1):1-
14.

14. Castro-Piñero J, Chillón P, Ortega FB, et al. Criterion-related validity of sit-and-reach and modified
sit-and-reach test for estimating hamstring flexibility in children and adolescents aged 6-17 years.
Int J Sports Med 2009:30;658-662.

15. McHugh MP, Kremenic IJ, Fox MB, et al. The role of mechanical and neural restraints to joint range
of motion during passive stretch. Med Sci Sports Exerc 1998;30(6):928-932.

185 9
Chapter 9

16. Ayala F, Sainz de Baranda P, De Ste Croix M, et al. Reproducibility and criterion-related validity of
the sit and reach test and toe touch test for estimating hamstring flexibility in recreationally active
young adults. Phys Ther Sport 2012;13:219-226.

17. Bozic PR, Pazin NR, Berjan BB, et al. Evaluation of the field tests of flexibility of the lower
extremity: reliability and the concurrent and factorial validity. J Strength Cond Res 2010;24:2523-
2531.

18. Mabry PL, Olster DH, Morgan GD, et al. Interdisciplinarity and systems science to improve
population health: a view from the NIH Office of Behavioral and Social Sciences Research. Am J
Prev Med 2008;35(2 Suppl):211-224S.

19. Bahr R, Krosshaug T. Understanding injury mechanisms: a key component of preventing injuries
in sport. Br J Sports Med 2005;39(6):324-329.

20. Quatman CE, Quatman CC, Hewett TE. Prediction and prevention of musculoskeletal injury: a
paradigm shift in methodology. Br J Sports Med 2009;43(14):1100-1107.

21. Mendiguchia J, Alentorn-Geli E, Brughelli M. Hamstring strain injuries: are we heading in the right
direction? Br J Sports Med 2012;46(2):81-85.

22. De Visser HM, Reijman M, Heijboer MP, et al. Risk factors of recurrent hamstring injuries: a systematic
review. Br J Sports Med 2012;46(2):124-130.

23. Oh JS, Cynn HS, Won JH, et al. Effects of performing an abdominal drawing-in maneuver during
prone hip extension exercises on hip and back extensor muscle activity and amount of anterior
pelvic tilt. J Orthop Sports Phys Ther 2007;37:320-324.

24. Croisier JL, Forthomme B, Namurois MH, et al. Hamstring muscle strain recurrence and strength
performance disorders. Am J Sports Med 2002;30(2):199-203.

25. Croisier JL, Ganteaume S, Binet J, et al. Strength imbalances and prevention of hamstring injury in
professional soccer players: a prospective study. Am J Sports Med 2008;36(8):1469-1475.

26. Fousekis K, Tsepis E, Poulmedis P, et al. Intrinsic risk factors of non-contact quadriceps and hamstring
strains in soccer: a prospective study of 100 professional players. Br J Sports Med 2011;45(9):709-
714.

27. Van Dijk N, Bahr R, Whiteley R, et alE. Hamstring and quadriceps isokinetic strength deficits are weak
risk factors for hamstring strain injuries: a 4-year cohort study. Am J Sports Med 2016;44(7):1789-
1795.

28. Van der Does HT, Brink MS, Otter RT, et al. Injury risk is increased by changes in perceived recovery
by team sport players. Clin J Sport Med 2016 [Epub].

29. Ardern CL, Taylor NF, Feller JA, et al. Psychological responses matter in returning to preinjury level
of sport after anterior cruciate ligament reconstruction surgery. Am J Sports Med 2013a;41(7):1549-
1558.

30. Ardern CL, Taylor NF, Feller JA, et al. A systematic review of the psychological factors associated
with returning to sport following injury. Br J Sports Med 2013b;47(17):1120-1126.

31. Proske U, Morgan DL, Brockett CL, et al. Identifying athletes at risk of hamstring strains and how
to protect them. Clin Exp Pharmacol Physiol 2004;31(8):546-550.

32. Verhagen EA, van Stralen MM, van Mechelen W. Behaviour, the key factor for sports injury
prevention. Sports Med 2010;40(11):899-906.

186
 General discussion

33. Ardern CL, Glasgow P, Schneiders A, et al. 2016 Consensus statement on return to sport from the
First World Congress in Sports Physical Therapy, Bern. Br J Sports Med 2016;50(14):853-864

34. Mendiguchia J, Brughelli M. A return-to-sport algorithm for acute hamstring injuries. Phys Ther
Sport 2011;12(1):2-14.

35. Tol JL, Hamilton B, Eirale C, et al. At return to play following hamstring injury the majority of
professional football players have residual isokinetic deficits. Br J Sports Med 2014;48(18):1364-
1369.

36. Jacobsen P, Witvrouw E, Muxart P, et al. A combination of initial and follow-up physiotherapist
examination predicts physician-determined time to return to play after hamstring injury, with no
added value of MRI. Br J Sports Med 2016;50(7):431-439.

37. Shrier I. Strategic Assessment of Risk and Risk Tolerance (StARRT) framework for return-to-play
decision making. Br J Sports Med 2015;49(20):1311-1315.

38. Engebretsen AH, Myklebust G, Holme I, et al. Intrinsic risk factors for hamstring injuries among
male soccer players: a prospective cohort study. Am J Sports Med 2010;38(6):1147-1153.

39. Brooks JH, Fuller CW, Kemp SP, et al. Incidence, risk, and prevention of hamstring muscle injuries
in professional rugby union. Am J Sports Med 2006;34:1297-1306. 


40. Woods C, Hawkins RD, Maltby S, et al. The Football Association Medical Research Programme: an
audit of injuries in professional football–analysis of hamstring injuries. Br J Sports Med 2004;38:36-
41. 


41. Creighton DW, Shrier I, Schultz R, et al. Return-to-play in sport: a decision-based model. Clin J
Sport Med 2010;20(5):379-385.

42. Maron BJ, Brown RW, McGrew CA, et al. Ethical, legal, and practical considerations impacting
medical decision-making in competitive athletes. Med Sci Sports Exerc 1994;26:S230-S237.

43. Schultz R, Bido J, Shrier I, et al. Team clinician variability in return-to-play decisions. Clin J Sports
Med 2013;23(6):456-461.

44. Shrier I, Safai P, Charland L. Return to play following injury: whose decision should it be? Br J
Sports Med 2014;48:394-401.

45. Matheson GO, Schultz R, Bido J, et al. Return-to-play decisions: are they the team physician’s
responsibility? Clin J Sports Med 2011;21(1):25-30.

46. Lindeman C. Delphi survey of priorities in clinical nursing research. Nursing Research 1975;24:434-
441.

47. Powell C. The Delphi technique: myths and realities. J Adv Nurs 2003;41(4):376-382.

48. Verhagen E, Voogt N, Bruinsma A, et al. A knowledge transfer scheme to bridge the gap between
science and practice: an integration of existing research frameworks into a tool for practice. Br J
Sports Med 2014;48(8):698-701.

49. Finch CF. A new framework for research leading to sports injury prevention. J Sci Med Sport 2006;
9(1-2):3-9.

50. Finch CF. No longer lost in translation: the art and science of sports injury prevention implementation
research. Br J Sports Med 2011a;45(16):1253-1257.

187 9
Chapter 9

51. Finch CF, White P, Twomey D, et al. Implementing an exercise-training programme to prevent
lower-limb injuries: considerations for the development of a randomised controlled trial intervention
delivery plan. Br J Sports Med 2011b;45(10):791-796.

52. Finch CF, Doyle TL, Dempsey AR, et al. What do community football players think about different
exercise-training programmes? Implications for the delivery of lower limb injury prevention
programmes. Br J Sports Med 2014;48(8):702-707.

53. O’Brien J, Donaldson A, Finch CF. It will take more than an existing exercise program to prevent
injury. Br J Sports Med 2016;50(5):264-265.

54. Bahr R, Thorborg K, Ekstrand J. Evidence-based hamstring injury prevention is not adopted by the
majority of Champions League or Norwegian Premier League football teams: the Nordic Hamstring
survey. Br J Sports Med 2015;49(22):1466-1471.

55. Glasgow RE, Vogt TM, Boles SM. Evaluating the public health impact of health promotion
interventions: the RE-AIM framework. Am J Public Health 1999;89(9):1322-1327.

56. Hägglund M, Waldén M, Magnusson H, et al. Injuries affect team performance negatively in
professional football: an 11-year follow-up of the UEFA Champions League injury study. Br J Sports
Med 2013;47(12):738-742.

188
General discussion

189 9
Summary of chapters
Summary of chapters

The aim of the studies reported in this thesis was to investigate strategies for the
prevention of hamstring injuries. Soccer is the most popular sport worldwide, and
regularly playing soccer has positive health effects. However, soccer also has high
injury rates, with hamstring injuries being the most prevalent muscle injury of all.
Hamstring injuries lead to personal suffering for the injured player, medical costs,
work absenteeism, and decreased team performance. In spite of efforts to reduce the
occurrence of hamstring injuries in soccer, injury rates have not decreased over the
last three decades. Therefore, research on hamstring injury prevention is necessary to
reduce hamstring injury rates.

Exercise programmes to reduce soccer injuries are easy to implement during regular
training sessions, are cost effective, and can even improve performance. In Chapter 2, a
systematic review of the literature was performed to analyse the effectiveness of general
exercise-based training programmes in the prevention of soccer injuries. It was concluded
that there is inconclusive evidence about the effectiveness of these programmes.
Compliance with the exercise programme and tailoring the exercise programme to the
intended users (based on injury type, age, sex differences, type of sport, etc.) were found
to be important factors influencing the effectiveness of exercise programmes.

The studies described in Chapter 3 (study protocol) and Chapter 4 (study results)
therefore focused on an exercise-based injury prevention programme that specifically
aims to reduce the risk of hamstring injury, namely, the Nordic Hamstring Exercise
(NHE). In a randomized controlled trial involving 579 high-level amateur soccer players,
we found that a tailored 12-week NHE protocol implemented during regular amateur
soccer training (compliance was excellent) resulted in a three- to fourfold reduction
in the risk of hamstring injury, but it did not influence the severity of injuries (e.g. the
number of days that elapsed from the date of injury to the date of the player’s return to
full participation in team training and availability for match selection).

In the same high-level amateur soccer population, Sit-and-Reach Tests (SRT) were
performed to assess hamstring and lower back flexibility. It is generally assumed that
soccer players have reduced hamstring flexibility as a result of the long-term impact
of soccer training and that this could increase the risk of hamstring injury. In the study
reported in Chapter 5, population-based reference values for the SRT were obtained. We
concluded that, compared with reference values reported in other (sports) populations,
soccer players have lower scores on the SRT. In addition, SRT scores were found to be

192
 Summary of chapters

associated with the players’ height, body mass index, and history of anterior cruciate
ligament injury.

Chapter 6 presents our findings on the relationship between hamstring flexibility and
hamstring injury risk. In a longitudinal cohort study, we found that there is no relationship
between hamstring flexibility and hamstring injury risk. Possible confounders, such as
age and previous hamstring injury, did not appear to influence this relationship.

If preventive measures fail and the athlete sustains a hamstring injury, the first thing almost
every athlete wants to know is: “When will I be able to play again”? This question about
return-to-play (RTP) after hamstring injury is a subject of growing interest in conferences,
the media, clinical practice, and the scientific literature, although the concept of RTP
remains unclear.

In the study described in Chapter 7, we systematically reviewed the literature on

definitions of, and criteria for, RTP after hamstring injury used in clinical research. Only
a few studies have given a definition of, or criteria for, RTP. Of the studies that reported
a definition of RTP, “reaching the athlete’s pre-injury level” and “being able to perform
full sport activities” were identified as core themes to define RTP after hamstring injury.
“Absence of pain”, “similar strength”, “similar flexibility”, “medical staff clearance”,
and “functional performance” were core themes to describe criteria to support the RTP
decision after hamstring injury.

On the basis of this literature review, we carried out a Delphi consensus procedure
(Chapter 8) to clarify the definition of, and criteria for, RTP after hamstring injury. A
worldwide panel of experts selected by the FIFA Medical Centers of Excellence achieved
consensus that RTP after hamstring injury should be defined as ‘the moment the player
has received criteria-based clearance and is mentally ready for full availability for match
selection and/or full training.’ The expert panel also reached consensus that the absence
of pain on palpation, during strength and flexibility testing, and during performance
testing, similar hamstring flexibility, psychological readiness, performance on field
testing, and medical staff clearance were important criteria to assess RTP readiness
after hamstring injury. MRI findings, neuromuscular function, similar concentric/isometric
hamstring strength, and completion of a number of full friendly matches/training sessions
are NOT relevant to the RTP readiness assessment. Similar eccentric hamstring strength
was included as a potential criterion.

193
Summary of chapters

Chapter 9 presents a general discussion of the main findings of our studies regarding
Nordic hamstring exercises, hamstring injury risk factors, RTP after hamstring injury,
and implementation issues. We need to consider the multifactorial nature of hamstring
injuries in both research and clinical practice, and recognize that effective interventions
will only lead to fewer hamstring injuries in a real-world context if these interventions
are adopted by the intended end-users. Therefore, future research should focus on the
implementation of preventive measures that have proven to be effective. After all, an
ounce of prevention is worth a pound of cure!

194
Summary of chapters

195
Nederlandse samenvatting
Nederlandse samenvatting

Het doel van dit proefschrift was om preventieve maatregelen voor hamstringblessures
in het voetbal te onderzoeken. Voetbal is wereldwijd de populairste sport en regel-
matig voetballen leidt tot positieve gezondheidseffecten door versterking van kracht,
uithoudingsvermogen en het neuromusculaire systeem. Deze gezondheidswinst wordt
echter deels belemmerd door de vele blessures, en hamstringblessures zijn daarbij de
meest voorkomende spierblessure. Hamstringblessures leiden tot persoonlijk leed voor
de geblesseerde speler, medische kosten, werkverzuim, en slechtere teamprestaties.
Ondanks grote inspanningen om het aantal hamstringblessures in het voetbal terug
te dringen, is het aantal hamstringblessures in de afgelopen 30 jaar niet verminderd.
Onderzoek naar preventieve maatregelen voor hamstringblessures in het voetbal blijft
noodzakelijk om het aantal hamstringblessures terug te dringen.

Oefenprogramma’s ter preventie van voetbalblessures zijn makkelijk uitvoerbaar in

normale voetbaltrainingen, kosteneffectief en kunnen zelfs een positieve invloed
hebben op prestaties. In Hoofdstuk 2 analyseerden wij middels een systematisch
literatuuronderzoek de effectiviteit van generieke oefenprogramma’s op de preventie
van voetbalblessures. We concludeerden dat er onvoldoende bewijs was voor een
positief effect van generieke oefenprogramma’s ter preventie van voetbalblessures.
Therapietrouw aan het oefenprogramma en aanpassing van het oefenprogramma aan
de wensen en omstandigheden van de eindgebruikers (op basis van blessuretype,
leeftijd, geslacht, sporttype, enz.) werden benoemd als belangrijke factoren voor de
effectiviteit van oefenprogramma’s.

Hoofdstuk 3 (studieprotocol) en Hoofdstuk 4 (studieresultaten) beschrijven een studie

naar de effectiviteit van een preventief oefenprogramma, genaamd de Nordic hamstring
exercise (NHE), dat zich specifiek richt op het verminderen van het risico op hamstring-
blessures. In een gerandomiseerd onderzoek met controlegroep werden 579 amateur-
voetballers uit de KNVB 1e klasse geïncludeerd. De resultaten toonden aan dat de groep
die een speciaal voor amateurvoetballers ontwikkeld 13-weeks NHE-protocol uitvoerde
(met uitstekende therapietrouw), drie tot vier maal minder risico hadden op het oplopen
van een hamstringblessure vergeleken met de controlegroep. De blessure-ernst (het
aantal dagen afwezig vanaf het moment van blessure tot terugkeer naar teamtraining
en wedstrijdbeschikbaarheid) was niet verschillend tussen de twee groepen.

Bij dezelfde KNVB 1e klasse amateurvoetballers werden ook metingen afgenomen

om de hamstringflexibiliteit in kaart te brengen. Er wordt algemeen aangenomen dat

198
 Nederlandse samenvatting

voetballers stijvere hamstrings hebben als gevolg van een functionele aanpassing door
het langdurige voetballen. Deze stijfheid van de hamstrings zou in relatie kunnen staan
met een toegenomen hamstringblessurerisico.

In Hoofdstuk 5 beschrijven we normatieve waarden voor de Sit-and-Reach test (SRT),

een simpele test voor hamstringflexibiliteit, vanuit onze populatie mannelijke amateur-
voetballers. Vergeleken met referentiewaarden uit andere sporten had onze populatie
voetballers lagere scores op de SRT. De scores op de SRT werden positief geasso-
cieerd met de lichaamslengte, body mass index, en voorgeschiedenis met voorste
kruisbandreconstructie.

Hoofdstuk 6 beschrijft onze bevindingen over de relatie tussen hamstringflexibiliteit

en hamstringblessurerisico. In een prospectief cohortonderzoek werd geconcludeerd
dat er geen relatie is tussen hamstringflexibiliteit en hamstringblessurerisico. Mogelijke
confounders leeftijd en voorgeschiedenis met hamstringblessure leken deze relatie niet
te beïnvloeden.

Als het ondanks de preventieve maatregelen toch mis gaat, stelt iedere voetballer
dezelfde vraag: “Wanneer mag ik weer spelen?” Deze vraag over het zogenaamde
Return-to-Play (RTP) moment kan in de praktijk lastig te beantwoorden zijn. Enerzijds
wil de speler zo snel mogelijk terugkeren, anderzijds moet een herhaling van de ham-
stringblessure voorkomen worden. Vanwege de complexiteit van de RTP-beslissing
heeft RTP in de laatste jaren steeds meer aandacht gekregen in de wetenschappelijke
literatuur, praktijk, media en op (inter-)nationale congressen. Desondanks is het concept
RTP nog onduidelijk.

In Hoofdstuk 7 onderzochten we daarom de wetenschappelijke literatuur naar definities

van RTP en criteria die werden gehanteerd om de RTP-beslissing na een hamstring-
blessure te ondersteunen. Weinig studies beschreven een definitie of criteria voor RTP.
De studies die dat wel deden, benoemden ‘het bereiken van het niveau van voor de
blessure’ en ‘alle sportactiviteiten kunnen uitvoeren’ als kernthema’s voor de definitie
van RTP na een hamstringblessure. Criteria die werden gebruikt om de RTP-beslissing
na een hamstringblessure te ondersteunen werden ingedeeld in de kernthema’s ‘geen
pijn’, ‘gelijke kracht’, ‘gelijke flexibiliteit’, ‘functionele prestatie’, en ‘vrijwaring van de
medische staf’.

199
Nederlandse samenvatting

Op basis van dit literatuuronderzoek werd vervolgens een Delphi consensusprocedure

uitgevoerd (Hoofdstuk 8) om helderheid en specificiteit te verkrijgen over de definitie
en criteria voor RTP na een hamstringblessure. Een wereldwijd expertpanel dat werd
samengesteld door de FIFA Medical Centers of Excellence (bestaande uit 58 experts)
bereikte overeenstemming dat de definitie van RTP na een hamstringblessure zou moe-
ten zijn: ‘het moment dat de speler op basis van criteria vrijwaring heeft gekregen van
de medische staf en mentaal klaar is om beschikbaar te zijn voor volledige training en
wedstrijden’. Criteria ter ondersteuning van de RTP-beslissing na een hamstringblessure
zijn: geen pijn bij palpatie, bij kracht- en flexibiliteitstesten, en bij functionele prestatie,
gelijke hamstringflexibiliteit, mentale gereedheid, functionele prestaties, en vrijwaring
van de medische staf. MRI-bevindingen, neuromusculaire functie, gelijke isometrische/
concentrische kracht, en het voltooien van een aantal trainingen/wedstrijden zouden
NIET gebruikt moeten worden als criterium. Gelijke excentrische kracht werd geïnclu-
deerd als een mogelijk criterium.

Hoofdstuk 9 sluit af met een algemene discussie over de belangrijkste bevindingen van
onze studies, de Nordic hamstring exercises, risicofactoren voor hamstringblessures,
RTP na een hamstringblessure en implementatie. Er wordt benadrukt dat we het multi-
factoriële karakter van de hamstringblessure moeten erkennen in zowel onderzoek als
praktijk. Verder leiden effectieve interventies alleen tot minder hamstringblessures als
interventies ook daadwerkelijk blijven worden uitgevoerd door de beoogde eindge-
bruikers. Toekomstig onderzoek zal zich dan ook moeten richten op de implementatie
van bewezen effectieve maatregelen naar het voetbalveld. Immers, voorkomen is beter
dan genezen!

200
Nederlandse samenvatting

201
Dankwoord
Dankwoord

Voetballen en onderzoek doen. Beiden zijn zonder teamgenoten niet mogelijk.

“Alleen kan je niks, je moet het samen doen” zei Johan Cruijff (1947-2016).

Het schrijven van een dankwoord is dan ook het leukste gedeelte, want het doet je
beseffen hoe gezegend je bent om in aanraking te komen met zoveel enthousiaste, lieve,
deskundige en professionele mensen. Woorden schieten te kort om mijn waardering en
respect voor eenieder te uiten, maar met veel plezier deel ik mijn ‘All-Star Team’ met u:

De hoofdtrainers: Frank Backx en Edwin Goedhart.

Frank, jij hebt mij een unieke kans gegeven met het eerste HIPS-project. Je vakinhou-
delijke kennis, je opbouwende feedback, en je steun op alle fronten waren fantastisch.
Tekenend voor je betrokkenheid is het feit dat je altijd op de hoogte was van mijn
voetbalresultaten. Jouw inspanningen zullen voor mij en mijn omgeving een leven lang
betekenis hebben en daar wil ik je mijn diepste dank voor geven.
Edwin, soms wist ik niet hoe je het deed. Ondanks alle drukte bij de KNVB, de
ontwikkelingen met de KNVB Campus en je verplichtingen bij het nationale elftal wist
je toch altijd energie te steken in de gezamenlijke projecten. Zonder jouw inspanningen

204
 Dankwoord

waren er nooit zoveel teams en experts geïncludeerd in de projecten. Daarnaast hield

je het onderzoeksteam scherp op de klinische relevantie. Bedankt voor je inspanningen
en onze prettige onderlinge samenwerking.

De assistent-trainers: Dirk-Wouter Smits en Bionka Huistede.

Dirk-Wouter, jouw prettige manier van begeleiden en het bieden van structuur en
overzicht hebben enorm bijgedragen aan mijn ontwikkeling en productiviteit als
onderzoeker. Jij gaf rust, ondersteuning en overzicht wanneer ik weer alle kanten op
vloog. Daarnaast was het bijzonder dat je ‘gewoon’ in de auto stapte om met mij alle
deelnemende clubs door het hele land te bezoeken, zodat de HIPS-1 studie tijdig kon
beginnen. Bedankt!
Bionka, jij viel in de tweede helft in toen de wedstrijd al voor een groot deel gespeeld
was. Het was prettig om in die fase iemand met ervaring in Delphi-procedures in het
elftal te hebben en ik heb veel van je geleerd over de onderzoekswereld.

De keeper. De eerste in de opstelling, want zonder keeper is een resultaat niet mogelijk.
Alle participanten aan de studies vervulden deze essentiële rol; zonder jullie deelname
en toewijding hadden de studies in dit proefschrift nooit uitgevoerd kunnen worden. Het
expert panel van de Delphi studie en spelers, trainers, medische stafleden en overige
participanten aan de studies; mijn excuses voor de vele telefoontjes en e-mails, maar
het resultaat heeft er mogen zijn. Dank voor al jullie inspanningen. Hopelijk draagt het
onderzoek bij aan jullie blessurevrije toekomst.

De centrale verdedigers: rotsen in de branding. Centrale verdedigers bieden stabiliteit

aan de hele ploeg.
Karl en Annette van der Horst, mijn ouders, alles begint bij jullie. De steun en liefde,
in alle opzichten, is een voorrecht en mijn dank is niet in woorden uit te drukken.
Dione, mijn lieve, mooie, fantastische vrouw. De persoon die jij bent en de liefde, steun
en ruimte die je geeft, zorgen ervoor dat we dit traject hebben kunnen doorlopen.
Jayson, ondanks dat mijn laptop regelmatig ingepikt werd door Bumba: ik ben enorm
trots op je! Pa, ma, Dione, Jayson: ik hou van jullie.

De backs: dynamisch, snel en ondersteunen de centrale verdedigers wanneer er gaatjes

vallen.
Randy & Adele Pietersz, mijn schoonouders, dank voor jullie onvoorwaardelijke steun
en de vele oppasuurtjes voor onze zoon.

205
Dankwoord

De controlerende middenvelders: zorgen voor de balans in een elftal.

Vrienden en collegae van het Academie Instituut.
Aan mijn vrienden: de boog kon niet altijd gespannen staan. Zonder de gezellige
avondjes stappen, eten, voetbal kijken en meer van die ongein had dit traject niet tot
stand kunnen komen.
Aan mijn collegae: ik heb het voorrecht om mijn onderzoeksactiviteiten te combineren
met mijn werk als fysiotherapeut in een geweldig team op het Academie Instituut.
Maarten van der Worp; het is heerlijk om met jou inhoudelijk te kunnen sparren over
zowel de patiënt als het onderzoek. En jouw promotietraject was natuurlijk prima
materiaal om af te kijken. Holger Drechsler; ik kijk op naar de manier waarop jij je
inzet voor zowel de praktijk als de patiënt. Iedere 1e-lijns (sport-)fysiotherapeut heeft
aan jou een geweldig voorbeeld. Cees van Maanen †, jouw kennis, onvoorwaardelijke
inzet, collegialiteit en vertrouwen zullen altijd herinnerd worden. Ook mijn andere (ex-)
collegae Fia Wessels, Ria Mouthaan, Sam Beenhakker, Simone Gouw, Geiske de
Vries, Gwen Vester, Maud Eeuwen, Ron Verweel, Sam Beenhakker, Anna Ruighaver,
HAP Homeruslaan: wanneer de drukte opliep, waren jullie er altijd om te ondersteunen.
Dank daarvoor.

De ‘nummer 10’; creatieve geest, inspirator.

Anton de Wijer, mijn ontwikkeling heeft plaats kunnen vinden door de inspiratie die ik
ontleen uit onze gesprekken en door jou aan het werk te zien met collegae en patiënten.
Het is een zegen dat we dagelijks in de praktijk contact kunnen hebben en jouw inzet
voor de patiënten alsook de inhoud van ons vak is bewonderenswaardig. Bedankt voor
het klankbord en de inspiratiebron die je bent.

De buitenspelers: creatief, dynamisch en een uitstekende voorzet in huis. Spelen soms

hun eigen wedstrijd, maar in goede vorm zijn ze zeer bepalend in het eindresultaat.
Alle co-auteurs en stagiaires: Guus Reurink, Jesper Petersen, Ingrid van de Port,
Annique Priesterbach, Kayleigh Polman, Mitchell van Doormaal, Milan Klein, Paul
van Otterloo: bedankt voor jullie energie en samenwerking.
Sander van de Hoef. Naast dat we enorm kunnen lachen, kunnen we ook zeer
productief zijn: een gouden mix. Prachtig dat je de onderzoekslijn in het voetbal met
jouw vervolgproject in ere houdt!

Spits, afmaker.
Drie spitsen die alle drie een basisplek verdienen, het is alsof ik Lionel Messi, Zlatan

206
 Dankwoord

Ibrahimovic en Cristiano Ronaldo in één elftal heb. Alle drie uniek, alle drie briljant, en
alle drie vlak voor de goal tijdens de finale van dit proefschrift.
Basia Verwey, de moeder en herder van het Academie Instituut. We kunnen altijd bij je
terecht en je verbondenheid met de medewerkers en de praktijk is uniek en bewonde-
renswaardig. Jij geloofde in mij in een fase dat ik zelf nog zoekende was. In de praktijk
geef je altijd de ruimte en ben je een enorme steun geweest bij de totstandkoming van
dit proefschrift. Dank voor alle kansen die je biedt en de persoon die je bent.
Nick Olthof, ik ben trots dat jij straks naast mij staat om het proefschrift te verdedigen.
Met een geweldige bak humor en productiviteit hebben we de opleiding Fysiothera-
piewetenschappen doorlopen. Er moet gezegd worden dat jouw inspanningen voor
hoofdstuk 2 van dit proefschrift bijgedragen hebben aan de uiteindelijke publicatie,
waarvan akte. Ik bewonder hoe je je eigen lijn hebt gekozen en met jouw intelligentie
en visie gaat de onderzoekswereld (en hopelijk ook de fysiotherapeutische zorg) zeker
nog heel veel van je horen.
Sharon van der Horst, mijn zusje en partner in life. Ook al ben je mijn lieve kleine zusje,
je bent een geweldige vrouw met de kracht van een leeuw: of er nu op Jayson gepast
moest worden, een website gemaakt moest worden of een logo voor onze projecten
bedacht moest worden: ik kon altijd met een glimlach naar jou stappen en dan was
het in no-time gefixt. Het is heel bijzonder dat we ook samen de vormgeving van het
uiteindelijke proefschrift hebben uitgewerkt. Weet dat je ook altijd op mij kan terug
vallen zoals ik dat bij jou kan.

Naast de eerste elf, maakt een sterke bank uiteindelijk ook een sterk elftal.

Jane Sykes, ieder Engelstalig artikel werd textueel door jou naar een hoger niveau
getild. Namens mijzelf en waarschijnlijk vooral ook eenieder die de artikelen heeft
gelezen: bedankt!

De opleiding Fysiotherapiewetenschap met geweldige docenten als Martijn Pisters,

Tim Takken, Marco van Brussel, Cas Kruitwagen en meer. Het was een stevig traject,
maar de opleiding heeft de basis gelegd voor mijn competenties als onderzoeker. Nu,
tegen het eind van mijn promotietraject, besef ik des te meer hoe belangrijk een goede
opleiding is om de inhoud van onderzoek te kunnen bewaken en succesvol uit te voeren.

Team SCORE: Anne-Marie van Beijsterveldt, Sandor Schmikli en Mark Krist. De afstu-
deerstage voor Fysiotherapiewetenschap bracht met jullie hulp direct een prachtige

207
Dankwoord

publicatie. Bedankt voor jullie begeleiding in de eerste fase van mijn ontwikkeling als
onderzoeker.

Mijn overige collegae die direct of indirect ook betrokken waren bij de totstandkoming
van dit proefschrift: de FIFA Medical Centres of Excellence, de medewerkers van het
KNVB SMC, medewerkers van de afdeling Revalidatie & Sport van het UMC Utrecht,
de monitors tijdens het HIPS-1 project, KNVB Districtmanagers; ook jullie wil ik bij deze
bedanken voor de prettige samenwerking.

Aan alle voetbalvrienden: teamgenoten, trainers en overige stafleden: spelen in een

1e elftal en promoveren kostte – uiteraard alleen in uiterste nood – nog wel eens een
wedstrijd of een transfer. Desalniettemin ben ik jullie dankbaar dat jullie mij er ieder
weekend rond de wedstrijd weer aan herinneren wat nu écht belangrijk is in het leven.

208
Dankwoord

209
About the author

Curriculum vitae
Publication list
PhD portfolio summary
About the author

Curriculum vitae
Nick van der Horst was born 14 February 1986 in
Utrecht, the Netherlands. He more or less grew up
on the soccer courts. After he left the Koningin Wil-
helmina College in Culemborg when he was 16, he
started studying physiotherapy at the Hogeschool
Utrecht. He followed internships at the UEFA Under
21 EURO Championship, the professional Dutch
soccer club N.E.C. Nijmegen, and the Academie In-
stituut Utrecht, which has been his primary employer
ever since. At the Academie Instituut Utrecht, his
work involves orthopaedic sports-related primary health care, supervising internships,
and teaching bachelor and master students of (sports) physiotherapy. During his studies
for a Masters degree, he followed courses in clinical exercise physiology and applied
sports psychology at the Free University, Amsterdam, and additionally specialized in
musculoskeletal ultrasound. In 2012, he was awarded a Masters degree in Physical
Therapy Sciences from the University of Utrecht.

The personal drive to study soccer injuries and their prevention brought him into contact
with Prof. Dr. Frank Backx, who offered him with an internship within the SCORE project.
The SCORE project, which primarily focused on the effectiveness of the ‘FIFA11’ warm-
up programme in soccer, was supervised by Dr. Anne-Marie van Beijsterveldt and led
to a follow-up study of hamstring injury prevention strategies (HIPS). In 2012, Nick was
appointed junior researcher in the HIPS study, which was initiated in close collaboration
with the Royal Netherlands Football Association (KNVB).

When not treating, studying, or investigating soccer injuries, Nick can still be found on the
soccer court with his son Jayson, under the loving supervision of his beautiful wife Dione.

212
 About the author

Publication list

International, peer-reviewed publications

Van der Worp MP, van der Horst N, de Wijer A, Backx FJG. Iliotibial Band Syndrome
(ITBS) in runners: a systematic review. Sports Med 2012;42(11):969-992.

Van Beijsterveldt AMC, van der Horst N, van de Port IGL, Backx FJG. How effective are
exercise-based injury prevention programmes for soccer players? A systematic review.
Sports Med 2013;43(4):257-265.

Van der Horst N, Smits DW, Petersen J, Goedhart E, Backx FJ. The preventive effect
of the Nordic Hamstring exercise on hamstring injuries in amateur soccer players: study
protocol for a randomised controlled trial. Inj Prev 2014;20(4):e8.

Van der Horst N, Smits DW, Petersen J, Goedhart E, Backx FJ. 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):1316-1323.

Van der Horst N, Priesterbach A, Backx F, Smits DW. Hamstring-and-lower-back flexibility

in male amateur soccer players. Clin J Sports Med 2017;27(1):20-25.

Van Doormaal M, van der Horst N, Backx FJG, Smits DW, Huisstede BMA. No
relationship between hamstring flexibility and hamstring injuries in male amateur soccer
players: a prospective study. Am J Sports Med 2017;45(1):121-126.

Van der Horst N, van de Hoef S, Reurink G, Huisstede BMA, Backx F. Return to play
after hamstring injuries: a qualitative systematic review of definitions and criteria. Sports
Med 2016;46(6):899-912.

Van der Horst N, Backx FJG, Goedhart E, Huisstede BMA. Return to play after hamstring
injuries in football (soccer): a worldwide Delphi procedure regarding definition, medical
criteria, and decision-making. Br J Sports Med [accepted with minor revisions].

National, peer reviewed publications

Van der Horst N. Hoe omgaan met hamstringblessures? Deel I. Sportgericht 2015;1:28-34.

Van der Horst N. Hoe omgaan met hamstringblessures? Deel II. Sportgericht 2015;2:28-32.

Van der Worp M, Drechsler H, van der Horst N. Het iliotibiale bandsyndroom bij hard-
lopers. Physios 2016;1:9-14.

213
About the author

PhD portfolio summary

Name PhD student: Nick van der Horst

UMC Utrecht department: Sports Medicine
PhD period: 28.09.2012 – 09.03.2017
Promotor: Prof. dr. F.J.G. Backx
Supervisors: Dr. D.W. Smits, dr. B.M.A. Huisstede

1. PhD training Year

Courses
• Basiscursus Regelgeving en Organisatie van Klinische trials (BROK), UMC 2016
Utrecht, the Netherlands
• Workshop systematic reviews of clinimetric properties of measurements, 2013
VUMC Amsterdam, the Netherlands

(Inter)national conferences - attendance

• Danish Sports Medicine Annual Congress (2x), Kopenhagen, Denmark 2015, 2017
• Dutch Sports Medicine Society Annual Congress (5x), Ermelo & Eindhoven, 2012–2016
the Netherlands
• Society of Physiotherapists in Professional Football (VFBV) Annual Congress, 2013, 2015,
Zeist, Utrecht & Arnhem, the Netherlands 2016
• Symposium Sports Injury Prevention VeiligheidNL, Amsterdam, the 2016
Netherlands
• FIFA Football Medicine Conference, London, Great Britain 2016
• The Scientific College Physical Therapy (WCF) of the Royal Dutch Society for 2016
Physical Therapy (KNGF) Annuall Congress, Amersfoort, the Netherlands
• 1st World Congress of Sports Physical Therapy on Return to Play, Bern 2015
Switzerland
• EFSMA 9th European Congress on Sports Medicine, Antwerp, Belgium 2015
• IOC World Conference on Prevention of Injury & Illness in Sport, Monaco 2014

(Inter)national conferences – podium presentations

• Return to Play criteria and re-injury risk in acute hamstring injuries 2017
Danish Sports Medicine Annual Congress, Kopenhagen, Denmark – Invited
lecture
• No relationship between hamstring flexibility and hamstring injuries in male 2016
amateur soccer players: a prospective study
Dutch Sports Medicine Society Annual Congress, Ermelo, the Netherlands
• Definition and medical criteria for return to play after hamstring injuries: 2016
results of a worldwide Delphi procedure
Dutch Sports Medicine Society Annual Congress, Ermelo, the Netherlands
• Return to play after hamstring injuries: a systematic review on definitions 2015
and criteria
Dutch Sports Medicine Society Annual Congress, Ermelo, the Netherlands
• Hamstring injury prevention in amateur soccer 2015
EFSMA 9th European Congress on Sports Medicine, Antwerp, Belgium

214
 About the author

• Hamstring injury prevention in amateur soccer 2015

Danish Sports Medicine Annual Congress, Kopenhagen, Denmark – Invited
lecture
• Effective hamstring injury prevention in male amateur soccer using the 2014
Nordic hamstring exercise – an RCT
IOC World Conference on Prevention of Injury & Illness in Sport, Monaco
• The preventive effect of the Nordic hamstring exercise on hamstring injuries 2014
in amateur soccer
Dutch Sports Medicine Society Annual Congress, Ermelo, the Netherlands
• Normative values of the Sit-and-Reach Test for hamstring flexibility in male 2013
amateur soccer players
Dutch Sports Medicine Society Annual Congress, Ermelo, the Netherlands
• HIPS – Hamstring Injury Prevention Strategies 2013
Society of Physiotherapists in Professional Football (VFBV) Annual Congress,
Zeist, the Netherlands – Invited lecture

(Inter)national conferences – poster presentations

• Return to play after hamstring injuries: a qualitative systematic review of 2016
definitions and criteria
FIFA Football Medicine Conference, London, Great Britain
• Return to play after hamstring injuries: a qualitative systematic review of 2015
definitions and criteria
1st World Congress of Sports Physical Therapy on Return to Play, Bern
Switzerland

Other podium presentations

• Preventive exercises for hamstring injuries 2016
MarkTwo Symposium, Ede, the Netherlands – Invited lecture
• Hamstring Injury Prevention 2016
Dutch Society of Physical Therapy in Sports Health care (NVFS) general
assembly – Invited lecture
• Clinical Health Scientist… and now?! 2016
“Meet the expert”, Physical Therapy Sciences, Utrecht University, the
Netherlands – Invited lecture
• Hamstrings in running performance and running injuries 2014
Seminar running injuries, Utrecht, the Netherlands – Invited lecture

2. Teaching activities

• Masterclass hamstring injuries (with Dr. G. Reurink) 2017

NPi, Arnhem, the Netherlands
• Masterclass hamstring injury management 2016
Utrecht University of Applied Sciences, Utrecht, the Netherlands
• External reviewer bachelor theses Physiotherapy 2013–2016
Fontys Hogeschool, Eindhoven, the Netherlands
• Hamstring injuries: etiology, diagnostics, management and prevention 2013
MSP Educations, Leiden, the Netherlands

215
About the author

3. Supervising

• Adherence to prevention programs in amateur soccer within a real-world 2016

context: a follow-up study. P. Van Otterlo, Master of Physical Therapy and
Sports student, Avans+ Breda, the Netherlands
• The long-term effect of the Nordic hamstring exercise on hamstring injuries 2016
in a real-world context: a follow-up study. M. Klein, Master of Physical
Therapy and Sports student, Avans+ Breda, the Netherlands
• Playing again after hamstring injury in amateur soccer players: expert 2014
opinions on return to play criteria. P.A. van de Hoef, Physiotherapy Science
student, Utrecht University, the Netherlands
• The preventive effect of the Nordic hamstring curl in male amateur soccer 2014
players: the differences in hamstring injury incidence between subgroups
at risk and optimization of tailored training programs. K.J. Polman,
Physiotherapy Science student, Utrecht University, the Netherlands
• Hamstring flexibility as a risk factor for a hamstring injury in male amateur 2014
soccer players: a prospective cohort study. M.C.M. van Doormaal,
Physiotherapy Science student, Utrecht University, the Netherlands
• Reference values for the Sit-and-Reach test in Dutch male adult amateur 2013
soccer players and player characteristics associated with hamstring and
lower back flexibility. A. Priesterbach, Selective Utrecht Medical Master
student, Utrecht University, the Netherlands

4. Other

• Reviewer for international journals: 2014–2017

British Journal of Sports Medicine
American Journal of Sports Medicine
Sports Medicine
Journal of Sports Sciences: Science and Medicine in Football
Medicine & Science in Sports & Exercise

216