Hamstring Injury Prevention in Football-Is the Nordic Hamstring Exercise Enough?

Hamstring injuries remain one of the most prevalent and recurrent injuries within football. Research has consistently demonstrated that hamstring injuries account for a substantial proportion of all time-loss injuries in professional football, whilst recurrence rates also remain notably high (Ekstrand et al., 2011; Bisciotti et al., 2020). Despite significant advancements in sports science and medical support, hamstring injury rates within elite football continue to rise (Ekstrand et al., 2022). Consequently, practitioners have increasingly sought evidence-based prevention strategies aimed at reducing hamstring injury occurrence and recurrence. Among the most widely researched interventions is the Nordic Hamstring Exercise, an eccentric strengthening exercise designed to improve the hamstrings’ ability to tolerate the high-force lengthening actions commonly experienced during sprinting. Research has consistently demonstrated positive effects of the Nordic Hamstring Exercise on reducing hamstring injury incidence (Petersen et al., 2011, Van Dyk et al., 2019). However, despite the substantial evidence supporting the exercise, an important question remains. Is one exercise alone enough to meaningfully reduce hamstring injury risk within the highly complex and multifactorial demands of modern football?

Hamstring strain injuries are most frequently associated with high-speed running and maximal sprinting activities within football. Current literature consistently identifies sprinting actions as the primary mechanism of injury, particularly during the late swing phase where the hamstrings experience substantial eccentric loading while rapidly lengthening (Buckthorpe et al., 2017, Schache et al., 2012, Chumanov et al., 2011). During this phase, the hamstrings are required to decelerate the forward movement of the lower limb before ground contact. Among the hamstring muscle group, the biceps femoris long head is most commonly injured during these high-velocity actions (Buckthorpe et al., 2017).

The physical demands of football expose players to repeated accelerations, decelerations, sprint efforts and rapid changes of direction throughout both training and competition. Subsequently, the hamstrings are repeatedly exposed to high-intensity actions commonly associated with risk of injury. In addition to sprinting demands, several contributing risk factors have been identified within the literature including previous injury history, fatigue accumulation, excessive training loads and insufficient exposure to maximal velocity running (Bahr et al., 2015, Buckthorpe et al., 2018). Hamstring injuries are also characterised by relatively high recurrence rates, with reinjury rates frequently reported between 12–30% (Ekstrand et al., 2022). In many cases, reinjuries may be associated with unresolved neuromuscular deficits, insufficient eccentric strength development or inadequate maximal velocity exposure (Bourne et al., 2016).

An area receiving considerable attention within the literature relates to the role of eccentric hamstring strength and muscle architecture in hamstring injury risk. During maximal velocity sprinting, the hamstrings must tolerate substantial eccentric forces while operating at relatively long muscle lengths. Research from Timmins et al. (2015) demonstrated that shorter biceps femoris fascicle lengths were associated with a greater likelihood of future hamstring strain injury in elite footballers. Similarly, Bourne et al. (2017) highlighted the importance of eccentric knee flexor strength in improving the hamstrings’ capacity to tolerate sprint-related mechanical stress. Collectively, these findings have contributed to the increasing popularity of eccentric strengthening interventions as preventative strategies for hamstring injuries.

Among the most widely implemented eccentric strengthening interventions within football is the Nordic Hamstring Exercise (NHE). The exercise involves an athlete resisting a controlled forward lean from a kneeling position while the ankles are fixed, creating substantial eccentric loading through the hamstring musculature. The rationale underpinning the exercise is that increasing eccentric hamstring strength and improving muscle architecture may enhance the hamstrings’ tolerance to the high force demands experienced during sprinting actions (Bourne et al., 2016).

The popularity of the Nordic Hamstring Exercise increased substantially following the work of Petersen et al. (2011) who demonstrated significant reductions in hamstring injury incidence following implementation of a structured Nordic intervention programme in footballers. Since then, numerous studies have supported its effectiveness. Van Dyk et al. (2019) reported that teams implementing Nordic Hamstring programmes demonstrated significantly lower hamstring injury rates compared to teams who did not consistently utilise the intervention. Similarly, Al Attar et al. (2016) concluded that eccentric hamstring strengthening programmes incorporating the Nordic exercise may substantially reduce hamstring injury risk in soccer players. These reductions are proposed to occur through improvements in eccentric knee flexor strength, musculotendinous stiffness and favourable architectural adaptations such as increased fascicle length (Bourne et al., 2016). Thus, the Nordic Hamstring Exercise has become widely regarded as a must in hamstring injury prevention. Practically, Nordic Hamstring programmes commonly involve progressive increases in volume and intensity over time, typically performed one to three times per week.

Despite the evidence supporting the Nordic Hamstring Exercise, it may be overly simplistic to suggest that one exercise alone is sufficient to fully address hamstring injury risk within football. As stated earlier, hamstring injuries are highly multifactorial and influenced by numerous interacting variables (Buckthorpe et al., 2018). Subsequently, more recent literature has increasingly questioned whether isolated eccentric strengthening interventions alone are capable of adequately preparing players for the demands of elite football.

One of the most common criticisms of the Nordic Hamstring Exercise relates to athlete compliance and implementation within elite football environments. Bahr et al. (2015) reported that despite strong evidence supporting the Nordic Hamstring Exercise, implementation rates amongst elite football clubs remained relatively low due to muscle soreness associated with eccentric loading, fixture congestion and limited training time. This creates an important practical issue within applied football environments as an intervention may demonstrate effectiveness within research settings, but its real-world value may ultimately depend upon consistent implementation and athlete adherence.

Additionally, some practitioners have questioned whether the Nordic Hamstring Exercise sufficiently replicates the velocity and specificity demands associated with maximal sprinting (Buckthorpe et al., 2018). While the exercise effectively develops eccentric knee flexor strength, sprinting itself remains a highly complex movement requiring force production at substantially greater contraction velocities alongside coordinated contributions from the hip, pelvis and trunk (Prince et al., 2021). Mendiguchia et al. (2020) also demonstrated that sprint exposure may produce different architectural and performance adaptations compared to isolated eccentric hamstring exercises, such as superior increases in bicep femoris long head fascicle length. Improvements in Nordic strength alone may not necessarily ensure athletes are adequately prepared for the demands experienced during maximal velocity sprinting actions in football.

Growing evidence suggests that hamstring injury prevention within football should extend beyond isolated eccentric strengthening interventions alone. Buckthorpe et al. (2018) advocates for a holistic approach to hamstring muscle strengthening, recognising the need to condition the hamstring across the force-velocity profile. More recent approaches have increasingly emphasised the importance of integrating sprint exposure, high-speed running, global strength development and load management strategies within broader hamstring injury prevention programmes (Buckthorpe et al., 2018). Rather than attempting to minimise sprint exposure due to concerns surrounding injury risk, practitioners may instead need to progressively expose athletes to the specific physical demands encountered during maximal velocity running. Research from Malone et al. (2018) demonstrated that chronic exposure to high-speed running may provide a protective effect against hamstring injury occurrence in elite footballers. Similarly, Edouard et al. (2022) proposed that regular maximal velocity sprint exposure may enhance the hamstrings’ tolerance to the neuromuscular and mechanical demands associated with high-speed running actions.

Alongside sprint exposure, broader strength training interventions may also play an important role in reducing injury susceptibility and improving tissue robustness. Multi-joint lower-body strength exercises, lumbopelvic control strategies and hip-dominant posterior chain interventions may positively influence sprint mechanics, force absorption capabilities and overall movement efficiency during high-intensity actions (Buckthorpe et al., 2018). Hamstring injury prevention may be most effective when integrated within a holistic hamstring strengthening programme rather than relying solely upon isolated eccentric strengthening interventions alone.

Ultimately, the Nordic Hamstring Exercise remains one of the most evidence supported interventions currently available for reducing hamstring injury risk within football. Research has consistently demonstrated positive effects regarding eccentric strength development, favourable muscle architectural adaptations and reductions in hamstring injury incidence. However, despite the substantial evidence supporting the exercise, hamstring injuries remain highly multifactorial and influenced by numerous interacting variables including sprint exposure, fatigue accumulation, training load management and overall physical preparation.

Thus, relying solely upon one isolated eccentric strengthening intervention may oversimplify the complexity of hamstring injury prevention within elite football. Despite growing support for more integrated prevention models, the Nordic Hamstring Exercise should still be viewed as a valuable component of hamstring injury prevention due to its strong evidence base and positive effects on eccentric strength and muscle architecture. Therefore, the most effective hamstring injury prevention programmes may not necessarily involve one “best” exercise, but instead a multi-component approach that develops the hamstrings through a variety of contraction types, joint angles and movement velocities specific to the demands placed upon the hamstring during high intensity football actions.

References

1.     Al Attar, W. S. A., Soomro, N., Sinclair, P. J., Pappas, E., & Sanders, R. H. (2016). Effect of Injury Prevention Programs that Include the Nordic Hamstring Exercise on Hamstring Injury Rates in Soccer Players: A Systematic Review and Meta-Analysis. Sports Medicine, 47(5), 907–916. https://link.springer.com/article/10.1007/s40279-016-0638-2

2.     Bahr, R., Thorborg, K., & Ekstrand, J. (2015). Evidence-based hamstring injury prevention is not adopted by the majority of Champions League or Norwegian Premier League football teams: the Nordic Hamstring survey. British Journal of Sports Medicine, 49(22), 1466–1471.

3.     Bisciotti, G. N., Chamari, K., Cena, E., Carimati, G., Bisciotti, A., Bisciotti, A., Quaglia, A., & Volpi, P. (2020). Hamstring Injuries Prevention in Soccer: A Narrative Review of Current Literature. Joints, 7(3).https://doi.org/10.1055/s-0040-1712113

4.     Bourne, M. N., Timmins, R. G., Opar, D. A., Pizzari, T., Ruddy, J. D., Sims, C., Williams, M. D., & Shield, A. J. (2017). An Evidence-Based Framework for Strengthening Exercises to Prevent Hamstring Injury. Sports Medicine, 48(2), 251–267. https://doi.org/10.1007/s40279-017-0796-x

5.     Bourne, M. N., Williams, M. D., Opar, D. A., Al Najjar, A., Kerr, G. K., & Shield, A. J. (2016). Impact of exercise selection on hamstring muscle activation. British Journal of Sports Medicine, 51(13), 1021–1028. https://doi.org/10.1136/bjsports-2015-095739

6.     Buckthorpe, M., Gimpel, M., Wright, S., Sturdy, T., & Stride, M. (2017). Hamstring muscle injuries in elite football: translating research into practice. British Journal of Sports Medicine, 52(10), 628–629. https://doi.org/10.1136/bjsports-2017-097573

7.     Buckthorpe, M., Wright, S., Bruce-Low, S., Nanni, G., Sturdy, T., Gross, A. S., Bowen, L., Styles, B., Della Villa, S., Davison, M., & Gimpel, M. (2018). Recommendations for hamstring injury prevention in elite football: translating research into practice. British Journal of Sports Medicine, 53(7), 449–456.

8.     Chumanov, E. S., Schache, A. G., Heiderscheit, B. C., & Thelen, D. G. (2011). Hamstrings are most susceptible to injury during the late swing phase of sprinting. British Journal of Sports Medicine, 46(2), 90–90. https://doi.org/10.1136/bjsports-2011-090176

9.     Edouard, P., Mendiguchia, J., Guex, K., Lahti, J., Prince, C., Samozino, P., & Morin, J.-B. (2022). Sprinting: a key piece of the hamstring injury risk management puzzle. British Journal of Sports Medicine, 57(1), bjsports-2022-105532. https://doi.org/10.1136/bjsports-2022-105532

10.  Ekstrand, J., Bengtsson, H., Waldén, M., Davison, M., Khan, K. M., & Hägglund, M. (2022). Hamstring Injury Rates Have Increased during Recent Seasons and Now Constitute 24% of All Injuries in Men’s Professional football: the UEFA Elite Club Injury Study from 2001/02 to 2021/22. British Journal of Sports Medicine, 57(5), 292–298. https://doi.org/10.1136/bjsports-2021-105407

11.  Ekstrand, J., Hägglund, M., & Waldén, M. (2011). Epidemiology of Muscle Injuries in Professional Football (Soccer). The American Journal of Sports Medicine, 39(6), 1226–1232. https://doi.org/10.1177/0363546510395879

12.  Malone, S., Owen, A., Mendes, B., Hughes, B., Collins, K., & Gabbett, T. J. (2018). High-speed running and sprinting as an injury risk factor in soccer: Can well-developed physical qualities reduce the risk? Journal of Science and Medicine in Sport, 21(3), 257–262. https://doi.org/10.1016/j.jsams.2017.05.016

13.  Mendiguchia, J., Conceição, F., Edouard, P., Fonseca, M., Pereira, R., Lopes, H., Morin, J.-B., & Jiménez-Reyes, P. (2020). Sprint versus isolated eccentric training: Comparative effects on hamstring architecture and performance in soccer players. PLOS ONE, 15(2), e0228283. https://doi.org/10.1371/journal.pone.0228283

14.  Petersen, J., Thorborg, K., Nielsen, M. B., Budtz-Jørgensen, E., & Hölmich, P. (2011). Preventive effect of eccentric training on acute hamstring injuries in men’s soccer: a cluster-randomized controlled trial. The American Journal of Sports Medicine, 39(11), 2296–2303. https://pubmed.ncbi.nlm.nih.gov/21825112/

15.  Prince, C., Morin, J.-B., Mendiguchia, J., Lahti, J., Guex, K., Edouard, P., & Samozino, P. (2021). Sprint Specificity of Isolated Hamstring-Strengthening Exercises in Terms of Muscle Activity and Force Production. Frontiers in Sports and Active Living, 2. https://doi.org/10.3389/fspor.2020.609636

16.  Schache, A. G., Dorn, T. W., Blanch, P. D., Brown, N. A. T., & Pandy, M. G. (2012). Mechanics of the Human Hamstring Muscles during Sprinting. Medicine & Science in Sports & Exercise, 44(4), 647–658. https://doi.org/10.1249/mss.0b013e318236a3d2

17.  Timmins, R. G., Bourne, M. N., Shield, A. J., Williams, M. D., Lorenzen, C., & Opar, D. A. (2015). Short biceps femoris fascicles and eccentric knee flexor weakness increase the risk of hamstring injury in elite football (soccer): a prospective cohort study. British Journal of Sports Medicine, 50(24), 1524–1535. https://doi.org/10.1136/bjsports-2015-095362

18.  van Dyk, N., Behan, F. P., & Whiteley, R. (2019). Including the Nordic hamstring exercise in injury prevention programmes halves the rate of hamstring injuries: a systematic review and meta-analysis of 8459 athletes. British Journal of Sports Medicine, 53(21), 1362–1370. https://doi.org/10.1136/bjsports-2018-100045