Review

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Including the Nordic hamstring exercise in injury
prevention programmes halves the rate of hamstring
injuries: a systematic review and meta-analysis of
8459 athletes
Nicol van Dyk ,1 Fearghal P Behan ,2 Rod Whiteley3
1
Aspetar Injury and Illness ABSTRACT one non-randomised) reduced injuries by approxi-
Prevention Program (ASPREV), Research question Does the Nordic hamstring mately 70% by implementing the NHE in a team’s
Aspetar Orthopaedic and Sports
Medicine Hospital, Doha, Qatar exercise (NHE) prevent hamstring injuries when included training regime.9–11
2
Research Department, Aspetar as part of an injury prevention intervention? So why then do we need a systematic review of
Orthopaedic and Sports Design Systematic review and meta-analysis. this type of intervention? Goode et al12 performed a
Medicine Hospital, Doha, Qatar Eligibility criteria for selecting studies We comprehensive systematic review but included just
3
Department of Rehabilitation, four studies, most likely due to selection criteria
considered the population to be any athletes
Aspetar Orthopaedic and Sports
Medicine Hospital, Doha, Qatar participating in any sporting activity, the intervention to that only allowed for the inclusion of randomised
be the NHE, the comparison to be usual training or other control trials, and excluded articles not written in
Correspondence to prevention programmes, which did not include the NHE, English. The most recent systematic review analysed
Dr Nicol van Dyk, Aspetar and the outcome to be the incidence or rate of hamstring the effectiveness of injury prevention programmes
Orthopaedic and Sports injuries. that included the NHE to reduce hamstring injuries
Medicine Hospital, Doha, Qatar; in football while monitoring athlete workload.8 The
Analysis The effect of including the NHE in injury
[email protected]
prevention programmes compared with controls on results from the meta-analysis suggested that teams
Accepted 27 January 2019 hamstring injuries was assessed in 15 studies that using the NHE (in isolation or as part of a larger
Published Online First reported the incidence across different sports and age injury prevention programme) reduced hamstring
26 February 2019 groups in both women and men. injury rates up to 51%. However, due to the exclu-
Data sources MEDLINE via PubMed, CINAHL via sion of studies that did not provide workload data
Ebsco, and OpenGrey. (training and match exposure) and sports other than
Results There is a reduction in the overall injury risk football, this meta-analysis omits many studies that
ratio of 0.49 (95% CI 0.32 to 0.74, p=0.0008) in favour also included the NHE. The omission of relevant
of programmes including the NHE. Secondary analyses studies in both these previous reviews might lead to
when pooling the eight randomised control studies a biased estimation of the effect when including the
demonstrated a small increase in the overall injury risk NHE in an injury prevention programme. Further
ratio 0.52 (95% CI 0.32 to 0.85, p=0.0008), still in exclusion of studies that used an observational or
favour of the NHE. Additionally, when studies with a high cross-sectional design, multiple exposure groups,
risk of bias were removed (n=8), there is an increase reporting compliance, and language, limits the
of 0.06 in the risk ratio to 0.55 (95% CI 0.34 to 0.89, generalisability of these findings. The basic clin-
p=0.006). ical question is perhaps not best answered in this
Conclusions Programmes that include the NHE reduce manner.
hamstring injuries by up to 51%. The NHE essentially We, therefore, carried out an inclusive, compre-
halves the rate of hamstring injuries across multiple hensive systematic review and meta-analysis on
sports in different athletes. the effectiveness of injury prevention programmes
Trial registration number PROSPERO that included the NHE in reducing the number of
CRD42018106150. hamstring injuries.

METHODS
INTRODUCTION Search strategy and study selection
It is in sports clinicians’ DNA to prevent injuries. But This review has been registered in the PROSPERO
is there evidence to answer the seemingly innocuous database (CRD42018106150). The PRISMA state-
clinical question—‘If I prescribe preventive exercise ment for systematic reviews was utilised to direct
will it reduce injuries?’ Given the substantial burden the reporting and formatting of this review.13 Rele-
of hamstring injuries,1–4 we interrogated the liter- vant articles were identified following a search of
© Author(s) (or their ature to answer one question: Does a hamstring the electronic databases: MEDLINE via PubMed,
employer(s)) 2019. No prevention exercise—The Nordic hamstring exer- CINAHL via Ebsco, and OpenGrey. Database
commercial re-use. See rights cise (NHE)—prevent hamstring injuries. entries were searched from the earliest reported
and permissions. Published Hamstring muscle injury is the most common date (January 1950 for Medline) to August 2018.
by BMJ.
muscle injury across a range of different sports.5–7 Search terms were mapped to relevant MeSH
To cite: van Dyk N, Behan FP, A number of intervention studies that used eccen- terms. Search terms were entered into the database
Whiteley R. Br J Sports Med tric strengthening reduced hamstring injuries.8 as the keywords ‘Nordic’ and ‘Russian’, which were
2019;53:1362–1370. Three large prospective trials (two randomised and grouped with the OR operator. These keywords

van Dyk N, et al. Br J Sports Med 2019;53:1362–1370. doi:10.1136/bjsports-2018-100045 1 of 10

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Figure 1 Flow chart of study selection for the analysis of the effect of prevention programmes including the NHE related to hamstring injury
rates. NHE, Nordic hamstring exercise.

were then combined with the operator AND to the keywords not meet the eligibility criteria. A third investigator (FPB) facili-
‘hamstring’ and ‘Injur*’, which produced the search strategy and tated group consensus when disagreements were identified.
the final yield. The details from the Medline search can be found Data from the selected full-text articles were independently
in the online supplementary file 1. To supplement the electronic extracted by two investigators (NVD and RW). For each study,
database search, the reference lists of relevant papers were also outcome data extracted included the number of participants and
cross-checked. Publication details from all studies identified in injury rates (or a number of hamstring injuries). The outcome
the literature search were exported to the bibliographic soft- data were imported into Review Manager (RevMan) V.5.3
ware. Once all search results were collated, titles and abstracts (Copenhagen, Denmark: The Nordic Cochrane Centre, The
were screened for eligibility. All relevant articles were identified Cochrane Collaboration, 2014) where all further analyses were
for full-text review and inclusion. The study selection process is performed.
presented in figure 1.
Assessment of methodological quality and risk of bias
Eligibility criteria The methodological quality of each study was independently
For this investigation, we considered the population to be assessed by two investigators (NVD and FPB), with the third
any athletes participating in any sporting activity, the inter- investigator (RW) resolving any discrepancies. The quality and
vention to be the NHE or any programme that included the risk of bias were evaluated according to the Cochrane risk of
NHE, the comparison to be usual training or other prevention bias tool,14 where six domains of bias are assessed: selection bias,
programmes, which did not include the NHE, and the outcome performance bias, detection bias, attrition bias, reporting bias
to be the incidence or rate of hamstring injuries. We did not and other bias. A value of high, low or unknown risk of bias was
include studies without a comparison or control group, thereby provided for each domain.
excluding case series and case studies. Studies were not excluded
based on gender, age or level of competition. There were no Data analysis
language or time limits set. The meta-analysis was performed according to the Cochrane
methodology.14 The risk ratio with 95% CI was determined for
Data extraction the outcome of hamstring injury, and calculated as: risk of an
Two investigators (NVD and RW) conducted the initial search, injury in the intervention group/risk of an injury in the control
duplicates were removed and articles were excluded if they did group. A risk ratio of 1 indicates no difference, and a risk ratio

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 Table 1 Characteristics of the included studies
Multiple injuries Level of
Study Location Sex Age Study design included Compliance (%) Study duration competition Sport Intervention group
16
Gabbe et al Australia Male 18–35 Randomised control trial No 47 1 season Amateur division Australian NHE
football
Brooks et al33 United Kingdom Male 18–40 Cohort study Yes Not reported 2 seasons 1st division Rugby Strengthening, stretching,
and NHE
Arnason et al34 Iceland and Norway Male Not reported Non-randomised control trial Yes 48 4 seasons 1st division Football Warm up; NHE
Soligard et al35 Norway Female 13–17 Randomised control trial Not reported 77 1 season Youth Football FIFA 11+ (incl NHE
programme)
Engebretsen et al17 Norway Male 17–35 Randomised control trial No 21 1 season 1–3rd division Football NHE
Petersen et al9 Denmark Male 18–40 Randomised control trial Yes 91 1 season 1st–5th division Football Regular training and NHE

van Dyk N, et al. Br J Sports Med 2019;53:1362–1370. doi:10.1136/bjsports-2018-100045

Owen et al36 UK Male 18–40 Cohort study Not reported Not reported 2 seasons Professional Football Proprioception, strength
(incl NHE)
Grooms et al37 USA Male 18–22 Cohort study Not reported 100 2 seasons Collegiate Football FIFA 11+ (incl NHE)
Sebelien et al38 Norway Male 18–39 Randomised control trial Not reported Not reported 1 season 3rd–4th division Football NHE
Seagrave et al39 USA Male 18–40 Cohort study No 31 1 season All teams (MLB) Baseball NHE
van der Horst et al10 Netherlands Male 18–40 Randomised control trial No 91 1 season Amateur Football NHE programme
Silvers-Granelli et al40 USA Male 18–25 Randomised control trial Not reported Stratified 1 season Collegiate Football FIFA 11+ (incl NHE)
del Ama Espinosa et al41 Spain Female 19–23 Randomised control trial Not reported 76–80 1 season 1st–2nd division Football NHE; EBE
Nouni-Garcia et al42 Spain Male 18–40 Cohort study Yes Not reported 2 seasons Amateur Football FIFA 11 (incl NHE)
González43 Spain Male 18 Cohort study Not reported Unknown 2 seasons Youth Football Strengthening and NHE
For all studies, the control group performed what would be considered regular training.
EBE, elastic band exercise;, ; FLS, frontal leg swing; MJ, multiple jumping; MLB, Major League Baseball Organisation; NHE, Nordic hamstring exercise; SLS, side leg swing.
Review

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 Review

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Table 2 The training protocol using the NHE across different studies (n=14)
Week Sessions per week No of repetitions
16
Gabbe et al 1–12 Not specified 12×6 (10 s rest between repetitions, 2–3 min
5 sessions over 12 weeks rest between sets)
Arnason et al34 1–5 Not specified Introduction to load
Preseason 3 3 sets, 12-10-8 reps
Competitive season 1–2 3 sets, 12-10-8 reps
Engebretsen et al17 1 1 5+5
2 2 6+6
3 3 3×6–8
4 3 3×8–10
5–10 3 12+10 + 8
Petersen et al,9 Gonzalez43 1 1 2×5
2 2 2×6
3 3 3×6–8
4 3 3×8–10
5–10 3 3 sets, 12-10-8 reps
10+ 1 3 sets, 12-10-8 reps
Van der Horst et al10 1 1 2×5
2 2 2×6
3 2 3×6
4 2 3 sets, 6-7-8
5–10 2 3 sets, 8-9-10 reps
6–13 2 3 sets, 10-9-8 reps
Soligard et al35 During warm-up prior to training
Silvers-Granelli et al40 3–4 (Level 1) (FIFA 11+) 1×3–5
Nouni-Garcia et al42 5–8 (Level 2) 1×7–10
Grooms et al37 9–12 (Level 3) 1×12–15
Owen et al36 1–10 2 2×4
11–20 2 2×6
21–30 2 2×8
31–40 2 3×6
41–58 2 3×8
Del Ama Espinosa et al41 1–8 (Phase 1) 1 1×5
9–15 (Phase 2) 1 1×5
16–23 (Phase 3) 1 1×5
Sebelien et al*38 Preseason 3 2×5, increase to 3×12
Competitive season 2 2×5, increase to 3×12
Seagrave et al39 Entire season Not specified Average of 3.5 repetitions
*Players were encouraged to increase the speed (at the beginning of the movement) and resistance (‘pushed’ by partner) of the exercise progressively. Brooks et al15 did not
report the training protocol used.
NHE, Nordic hamstring exercise.

of <1 indicate a positive intervention effect. In this meta-anal- relevant study for inclusion. Following communication with one
ysis, a random-effects model was selected, based on the assump- author of two eligible studies, one of the two shortlisted studies
tion that the studies included diverse populations and different was excluded, as there was overlapping data between the studies.
contexts. The NHE intervention also varied in terms of dose and Consequently, the final number of studies for inclusion was 15.
test procedure.
Sensitivity analyses were performed to determine the differ- Characteristics of the included studies
ence in outcome when (1) only including ‘high’-quality studies The characteristics of the 15 studies included in the anal-
(randomised control trials), (2) removing studies at high risk ysis are summarised in table 1. Eight controlled trials (seven
of allocation, detection or attrition bias, and (3) examining the randomised and one non-randomised) and seven cohort studies
pooled effect when excluding each study individually. were included. The studies represent different regions, including
North America (n=3), UK and Europe (n=7), Scandinavia (n=5)
RESULTS and Australia (n=1). Two studies were performed in female
Identification of studies athletes, while the remaining 13 studies included male athletes.
The initial database search yielded a total of 1590 potentially The investigations were performed mainly in football (soccer),
relevant studies. After reviewing the titles and abstracts, 15 full- with one investigation in rugby, baseball and Australian football,
text articles were retrieved for analysis. Searching the reference respectively. The definition of injury and re-injury (or recurrent
lists and the authors’ personal databases revealed one additional injury) varied somewhat across the 15 included studies. Seven

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Figure 2 Risk of bias summary. The authors’ judgements about each risk of bias item is presented as percentages across all included studies.

studies do not report whether multiple injuries were included, 0.74, p=0.0008) (figure 4). Statistical heterogeneity across the
four studies reported on recurrent injuries and four studies different studies was large (I2=74%).
included only index injuries. Compliance is not reported in five
studies, while four studies observed compliance of <50%. The Sensitivity analysis
remaining six studies all reported compliance of over 70%. The The pooled data for only the randomised control trials were
level of sport varied across the different studies and included analysed and the point estimate changed by 0.03 (RR 0.52,
the highest level of competition, subdivisions (second to fifth) 95% CI 0.32 to 0.85, p=0.0008) (figure 5). Additional sensi-
in football, all competition levels in major league baseball, tivity analyses were performed by removing studies with high
including collegiate, youth and amateur players. The players risk of allocation and detection bias, as well as one study with a
were aged 18–40 years, apart from one study in youth players high risk of attrition bias (figure 6), with a change in the point
(13–18 years). The NHE programme was used in isolation in six estimate of 0.06 (RR 0.55, 95% CI 0.34 to 0.89, p=0.006). The
studies, while four studies included the NHE as part of the FIFA overall shift in effect size when systematically removing each
11+ programme. All the other investigations included the NHE study individually was small (figure 7).
together with other strength, flexibility or warm-up exercises.
The prescription and training volume of the NHE protocol used DISCUSSION
for each study are presented in table 2. In this systematic review and meta-analysis, including 8459
athletes and 525 hamstring injuries, the primary outcome was
Methodological quality and risk of bias the overall hamstring injury rates when introducing the NHE as
The risk of bias assessment is summarised in figure 2. A high risk a preventative measure. The results indicate a statistically signif-
of performance and detection bias was identified, with moderate icant and clinically meaningful reduction of 51% in hamstring
selection bias. Attrition and reporting bias was low across the injuries for all athletes competing at different levels of competi-
included studies. The individual assessment of high, low or tion and across multiple sports. These results support the use of
unknown risk of bias for each individual study is presented in the NHE in prevention programmes.
table 3. It is important to compare the results of this systematic review
In the examination of the funnel plots, there is slight asym- with previous findings from similar investigations. In 2010,
metry, indicating that risk of publication bias may not be present Goldman and Jones reported in a Cochrane review on interven-
(figure 3). No adjustment of the overall point estimate was tions aimed at reducing hamstring injuries.15 Of the six studies
warranted. included, only two investigated the NHE as an intervention,16 17
and the results were inconclusive as to the effectiveness of the
Meta-analysis interventions. In 2014, Goode et al performed an intention to
The pooled data for 8459 individuals including 525 hamstring treat analysis and in their study, eccentric strengthening, with
injuries were analysed from the 15 included studies. Expo- good compliance, seemed to be successful in hamstring injury
sure data were not available for six studies. In the remaining prevention.12 However, due to strict inclusion criteria, only four
nine studies, the incidence of hamstring injuries (weighted by studies were included, one of which involved a form of eccen-
sample size) was 0.1/1000 hour for players exposed to NHE, tric training other than the NHE.18 In a recent meta-analysis of
and 0.2/1000 hour in those players who continued with usual injury prevention programmes including the NHE, hamstring
training. injuries were reduced by up to 51% compared with teams that
The pooled results show a 51% overall reduction in hamstring did not use any intervention.8
injury in the intervention group that included the NHE Different methodological approaches meant that previous
compared with the control group (RR 0.49, 95% CI 0.32 to meta-analysis only included studies in football and that reported

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González43

?
Garcia et al42
Nouni

−
Espinosa et al41
del Ama

−
Granelli et al40
Silvers-

−
Horst et al10
Van der

Figure 3 Funnel plot based on SE and log risk ratio of the studies
in assessing publication bias. The diagonal lines represent the pooled
−

injury risk ratio (RR) which is the summary measure of the study. The
Seagrave et al39

vertical tips of the diagonal lines are the overall effect and the lateral
ends on the x-axis are the associated CIs.
+

−
Sebelien et al38

exposure. The present meta-analysis included an additional 10

studies, 2 of which were published after the previous meta-anal-
ysis reported in 2016. There is an overall pooled-effect of 51%
−

reduction of hamstring injuries when the NHE is implemented.

Grooms et al37

This confirms the previous findings, irrespective of a large

amount of heterogeneity identified between the studies in the
present analysis. However, the use of the NHE in practice and its
+

implementation as a prevention measure is limited.19

Owen et al36

Systematic reviews should inform clinical practice where they

can
+

−
?

Staying up to date with the latest scientific evidence is chal-

Engebretsen et al17 Petersen et al9

lenging for all clinicians. A recent educational review advocated

three key steps in making quality decisions about evidence in
practice: (1) systematically searching and assessing the quality
−

of published literature, (2) combining quality research evidence

with quality clinical evidence, and (3) considering the feasibility
Positive signs indicate a high risk of bias, negative signs indicate a low risk of bias and question marks indicate an unknown risk of bias.

of use in the practical setting.20 Systematic reviews promise a

high-quality, comprehensive summary of the research regarding
Assessment of methodological quality for each study

an intervention, such as NHE for preventing hamstring injuries.

And while we might expect systematic reviews to be accurate,
Soligard et al35

they are bound by certain decision-making in how they are

conducted. To ensure methodological rigour, most reviews and
−

−
meta-analyses impose strict selection criteria.21 22 The purpose
Arnason et al34

is to ensure methodological quality, allowing the subsequent

analysis to be performed with greater precision and accuracy.
However, readers must stay alert to publications with provoca-
+

−
?
tive titles but clinical conclusions that are not fully supported by
the study results.23
Brooks et al33

In the case of the NHE, the strict methodological selection

criteria might disguise the simple clinical question: regardless
+

−
of gender, sport or age, will the NHE reduce hamstring inju-
Gabbe et al16

ries if I prescribe them? Many clinicians are faced with a similar

reality—managing male and female athletes from a range of
different sports and age groups. Therefore, we pragmatically
Random sequence −

−
included more clinically heterogeneous studies in this analysis.

(detection bias)

(reporting bias)
(selection bias)

(selection bias)

(attrition bias)
and personnel

outcome data
(performance
Table 3

Apart from the clinical diversity represented in these studies

Risk of bias

concealment

participants

assessment

Incomplete
Blinding of

Blinding of
generation

Other bias
Allocation

reporting
Selective
outcome
domain
(different participant characteristics performed in different

bias)
settings), the importance of methodological and statistical
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Figure 4 Primary analysis of overall hamstring injury rates in NHE prevention programmes compared with control intervention. M-H, Mantel-
Haenszel; NHE, Nordic hamstring exercise.

heterogeneity, and how it may influence results must not be over- the analysis has a dramatic outcome on the overall effect of the
looked. Grindem et al suggest different measures of assessing meta-analysis (figure 7), which suggests that no individual study
statistical heterogeneity, such as a funnel plot or the I2 statistic.24 grossly influenced the overall findings. Based on these results,
Although studies were purposefully included that would increase clinicians are encouraged to include the NHE in their prevention
the heterogeneity, the risk of bias assessment (figure 2) and funnel efforts to reduce the number of hamstring injuries, regardless of
plot (figure 3) suggest that it was acceptable in this analysis. To sporting code, gender or age.
account for methodological heterogeneity, a further sensitivity
analysis was performed. When only randomised controlled trials
were included, considering these studies to represent the highest Study biases and limitations
level of evidence for this type of intervention, the overall pooled Moderate selection bias was present in the studies included, and
effect changes only minimally (figure 5). And after removing a high risk of performance bias (figure 2). However, blinding the
studies at high risk of bias (all studies that were determined to assessor or the participant to the intervention is likely impossible
present a high risk of allocation and detection bias, and one in this type of study, as it would be difficult to introduce an NHE
study due to attrition bias), there is again no substantial change placebo. A high risk of detection bias is present, and blinded
in the overall effect (figure 6). assessors would have reduced the potential bias when outcomes
It is worth highlighting that there was no significant reduc- are measured.
tion of hamstring injuries in the two studies investigating the Substantial variability is present in the training protocol across
effect of the NHE in female populations. Similarly, one study in different studies (table 2). It is not clear what the ideal prescrip-
Australian rules football demonstrated no significant reduction tion of the exercise is, although recent studies have demonstrated
in hamstring injuries. However, none of the studies included in similar tissue adaptation and strengthening when comparing low

Figure 5 Secondary analysis of overall hamstring injury rates in NHE prevention programmes compared with control intervention when only
including randomised control trials. M-H, Mantel-Haenszel; NHE, Nordic hamstring exercise.

van Dyk N, et al. Br J Sports Med 2019;53:1362–1370. doi:10.1136/bjsports-2018-100045 7 of 10

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Figure 6 Secondary analysis of overall hamstring injury rates in NHE prevention programmes compared with control intervention when excluding
studies at high risk of allocation, detection and attrition bias. M-H, Mantel-Haenszel; NHE, Nordic hamstring exercise.

and high volume training regimes.25 Regardless, we observe four studies reporting on recurrent injuries. Seven studies do not
a strong overall effect even with a large amount of variability report on whether the injuries included were either index inju-
between studies. ries or included recurrent injuries as well; therefore, a conclusive
The risk of an index hamstring injury is different from a recur- recommendation is not possible.
rent hamstring injury.3 5 6 Only four studies in our meta-analyses
focus on index injury, while the risk reduction is greater in the Clinical implications
A large amount of evidence now supports the use of the
NHE to prevent hamstring injuries. The overall effectiveness
of this exercise has been demonstrated repeatedly, although
the mechanisms by which the NHE provides a protective
effect is not yet fully understood. The NHE may increase
fascicle length, leading to morphological changes that may
protect the hamstring muscle from injury.26 Harøy et al have
demonstrated that when performing the NHE as part of a
prevention programme, an increase in strength is observed27;
increasing eccentric strength may reduce the risk associated
with a hamstring injury. The value of eccentric training and
the NHE is recognised at elite level football,28 but the adop-
tion of the exercise into regular training programmes is poor,19
and the overall use of the NHE in other sports is not known.
The need for better understanding the factors surrounding
the implementation of prevention programmes in sport has
been highlighted through the Translating Research into Injury
Prevention Practice framework.29

What is already known

► Hamstring muscle injury is a common muscle injury across

different sporting codes that affects many athletes. The
Nordic hamstring exercise (NHE) is an effective injury
prevention tool that may reduce the number of hamstring
injuries if implemented successfully.
► Systematic reviews should inform clinical practice where
possible, and clinicians can be confident that the inclusion
of a NHE programme is supported when hamstring injury
reduction is a goal.
► To improve adaptation and implementation of the NHE,
the focus should be directed towards dose–response
Figure 7 Sensitivity analysis demonstrating the change in effect by
relationships, as well as compliance and adherence with
systematically removing individual studies included in the meta-analysis.
the prescribed exercise to improve prevention programme
The effect size shown is the pooled effect when a single (named) study
efficacy.
is removed, with the overall effect listed as a reference.

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10 van der Horst N, Smits DW, Petersen J, et al. The preventive effect of the nordic
What are the findings hamstring exercise on hamstring injuries in amateur soccer players: a randomized
controlled trial. Am J Sports Med 2015;43:1316–23.
► Hamstring injuries are reduced by 50% when the NHE is 11 Arnason A, Sigurdsson SB, Gudmundsson A, et al. Risk factors for injuries in football.
Am J Sports Med 2004;32:5–16.
introduced as preventative training, confirming previous 12 Goode AP, Reiman MP, Harris L, et al. Eccentric training for prevention of hamstring
findings isolated to football. injuries may depend on intervention compliance: a systematic review and meta-
► The overall effectiveness of the NHE remains unchanged analysis. Br J Sports Med 2015;49:349–56.
despite a large amount of heterogeneity between the studies 13 Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items for systematic reviews
in terms of age, gender and type of sport. and meta-analyses: the PRISMA statement. Ann Intern Med 2009;151:264–9.
14 Higgins JPT, Green S. Cochrane handbook for systematic review of interventions
► There is a large amount of variability in the training protocols version 5.1. 0: The Cochrane Collaboration. 2011.
used to introduce eccentric training through the NHE. 15 Goldman EF, Jones DE. Interventions for preventing hamstring injuries: a systematic
review. Physiotherapy 2011;97:91–9.
16 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;9:103–9.
Perhaps a key component to ensuring greater success in our
17 Engebretsen AH, Myklebust G, Holme I, et al. Prevention of injuries among male
implementation efforts is understanding the context in which soccer players: a prospective, randomized intervention study targeting players with
the intervention is being introduced.30 31 This would require the previous injuries or reduced function. Am J Sports Med 2008;36:1052–60.
involvement of key stakeholders in the process of injury preven- 18 Askling C, Karlsson J, Thorstensson A. Hamstring injury occurrence in elite soccer
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Only when we design our prevention programmes to address 19 Bahr R, Thorborg K, Ekstrand J. Evidence-based hamstring injury prevention is not
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This systematic review and meta-analysis demonstrate that the research. Educational Researcher 2002;31:15–21.
NHE is effective in reducing hamstring injuries. There is, unsurpris- 23 Weir A, Rabia S, Ardern C. Trusting systematic reviews and meta-analyses: all that
ingly, a large amount of heterogeneity across multiple sports and glitters is not gold!. Br J Sports Med 2016;50:1100–1.
24 Grindem H, Mansournia MA, Øiestad BE, et al. Was it a good idea to combine the
differences such as age and gender between athletes, but the overall studies? Why clinicians should care about heterogeneity when making decisions
effectiveness of the NHE remains unchanged, and clinicians are based on systematic reviews. Br J Sports Med 2018:bjsports-2018-099516.
encouraged to include the NHE in their prevention programmes. 25 Presland JD, Timmins RG, Bourne MN, et al. The effect of Nordic hamstring exercise
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Contributors NvD and RW: concept, design and analysis, writing and editing of Sci Sports 2018;28:1775–83.
the manuscript. FPB: analysis, writing and editing of the manuscript. 26 Timmins RG, Bourne MN, Shield AJ, et al. Short biceps femoris fascicles and eccentric
knee flexor weakness increase the risk of hamstring injury in elite football (soccer): a
Funding The authors have not declared a specific grant for this research from any prospective cohort study. Br J Sports Med 2016;50:1524–35.
funding agency in the public, commercial or not-for-profit sectors. 27 Harøy J, Thorborg K, Serner A, et al. Including the copenhagen adduction exercise in
Competing interests None declared. the FIFA 11+ Provides missing eccentric hip adduction strength effect in male soccer
players: a randomized controlled trial. Am J Sports Med 2017;45:3052–9.
Patient consent for publication Not required. 28 McCall A, Dupont G, Ekstrand J. Injury prevention strategies, coach compliance and
Provenance and peer review Not commissioned; externally peer reviewed. player adherence of 33 of the UEFA Elite Club Injury Study teams: a survey of teams’
head medical officers. Br J Sports Med 2016;50:725–30.
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30 McKay CD, Steffen K, Romiti M, et al. The effect of coach and player injury knowledge,
ORCID iDs
attitudes and beliefs on adherence to the FIFA 11+ programme in female youth
Nicol van Dyk http://orcid.org/0000-0002-0724-5997
soccer. Br J Sports Med 2014;48:1281–6.
Fearghal P Behan http://orcid.org/0000-0001-9578-5725
31 Bolling C, van Mechelen W, Pasman HR, et al. Context matters: revisiting the first step
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