Strength Training to Prevent Hamstring Injury
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1 Strength Training to Prevent Hamstring Injury Tony Shield School of Exercise & Nutrition Sciences, QUT
2
3
4 Declarations
5 A vessel for delivering coffee A vessel for delivering an eccentric contractions
6 Contents Where do our beliefs come from? Risk factors: reductionism to holism Being match fit Strength training to reduce hamstring injury Practical sessions: programming, exercises, drills
7 Themes Sell the performance benefits! Don t mention prevention (Asker, M) There is no certainty We deal with probabilities Evidence always trumps theory
8
9 WHERE DO OUR BELIEFS COME FROM?
10
11
12 Are hamstring injuries out of control everywhere?
13 Hamstring opinion AFL data 10 year trend
14 Delayed soreness & eccentric training The coach is going to kick my backside if this guy is sore tomorrow! This is going to make me sore tomorrow
15 Delayed soreness & eccentric training Tony, I can t get sore anymore!
16 Practice Evidence 1 st Convention principles
17 RISK FACTORS: REDUCTIONISM TO HOLISM
18 Bittencourt et al 2016 Br J Sports Med 50: Of course it s complex Univariate analyses Multivariate analyses Complex systems approach
19 1 Messer et al (unpublished observations) Traditional risk factors Age Injury history Hamstring & ACLR 1 Moderate to strong evidence Sex Strength? Fitness / fatigue? Weak / inconsistent evidence Flexibility???
20 1. Green, Bourne and Pizzari (2017) /bjsports in BJSM Is eccentric knee flexor strength a risk factor? Study n Sport RR or HR Opar et al 210 Aust Rules 4.3 (1.7 to 11) p = Bourne et al 178 Rugby 0.17 (0 to 2.7) p = Timmins et al 131 Soccer 4.4 (1.1 to 17.5) p = van Dyk et al 413? Soccer 1.0 (0.98 to 1.01) p = 0.36 Isokinetics 1 also suggest strength an unconvincing factor in Hams injury
21 Strength interactions? Opar et al 2015 Med Sci Sports Exerc, 47(4):
22 1 Timmins et al 2016 Br J Sports Med 50: Novel risk factors Fascicle length 1 Only 1 study on fascicle lengths as a risk factor Aponeurosis / muscle thickness ratio 2 Intramuscular coordination 2 Poor load sharing 2 No studies theory only
23 Benefits of being long & strong Timmins et al 2016 Br J Sports Med 50:
24 Schuermans et al 2016 Am J Sports Med DOI: / Load sharing Less reliance on ST & more reliance on BF (poor load-sharing) Early fatigue & Higher injury rates
25 Avrillon et al 2018 J Appl Physiol,125(4): Poor load sharing early fatigue semg measure of imbalanced hamstring use Isometric 20% of MVC to failure
26 Can we change load sharing? Poor load sharing Early fatigue Fatigue THOUGHT to be a risk factor BF LH /ST BF LH injury risk? Can we train more even usage?
27 BEING MATCH FIT
28 Premise: to minimize injury we need High levels of sports-specific fitness Repeated sprint ability while avoiding load spikes Damage resistant hamstrings muscle soreness faster recovery Sell the performance benefits!
29 To improve repeat sprint ability Run fast eg m (3min / 5min) Run fatigued eg m (24-60s) Small-sided games Run well? Is technique a factor?
30 STRENGTH TRAINING
31 Theoretical basis for eccentric training 5 days interval treadmill training 3 7 5min (90s) Vastus intermedius Impact of 20 eccentric actions Lynn, Talbot & Morgan J Appl Physiol 1998, 85:98-104
32 Images from Margaritelis et al (2015) Physiological Reports, 3(12): e12648 Possible mechanisms: adding sarcomeres Eccentric, long length conventional strength training, sprinting? Concentric, short length conventional strength training, detraining, cycling (concentric + high metabolic stress)?
33 We still see lots of hamstring injuries so its clear that Nordics don t work. My methods work btw So why are there still so many hamstring injuries???
34 Exercise selection issues We can t know what s best But they are different
35 Bourne et al., 2016 Br J Sports Med DOI: /bjsports Exercise analysis: surface EMG (semg) Can you trust a semg study?
36 Exercise analysis: functional MRI (fmri) Great spatial resolution
37 Loading patterns & contraction modes Eccentric-only Eccentrically biased Eccentric & concentric Conventional strength training Concentrically biased Concentric-only Isometric
38 Bourne et al 2018, Sports Med; 48(2): Are loading patterns important? Ecc-only Conc-only Ecc-Conc Quasi-Isometric
39 Loading patterns & contraction modes Eccentric-only Eccentrically biased Eccentric & concentric Conventional strength training Concentrically biased Concentric-only Isometric
40 Loading patterns & contraction modes Eccentric-only Eccentrically biased Get film of conventional Nordics? Eccentric & concentric Conventional strength training Concentrically biased Concentric-only Isometric
41 Loading patterns & contraction modes Eccentric-only Eccentrically biased? Eccentric & concentric Conventional strength training Concentrically biased Concentric-only Isometric Requires low resistance in early Ecc phase & late deceleration
42 Loading patterns & contraction modes Eccentric-only Eccentrically biased 2 up, 1 down method Eccentric & concentric Conventional strength training Concentrically biased Concentric-only Isometric Lowering slowly DOES NOT MAKE an exercise eccentrically-biased!
43 Loading patterns & contraction modes Eccentric-only Eccentrically biased Eccentric & concentric Conventional strength training Concentrically biased Concentric-only Isometric Best effects at longer lengths?
44 Loading patterns & contraction modes Eccentric-only Eccentrically biased Eccentric & concentric Conventional strength training Concentrically biased Concentric-only Isometric
45 Loading patterns & contraction modes Eccentric-only Eccentrically biased Eccentric & concentric Conventional strength training Concentrically biased Concentric-only Isometric Reduces damage resistance to eccentric exercise!
46 Loading patterns & contraction modes Eccentric-only Eccentrically biased Eccentric & concentric Conventional strength training Concentrically biased Concentric-only Isometric (or pseudo-isometric?)
47 Hamstring exercise analysis Evidence for injury prevention? Which muscles / segments are preferentially targeted? Effects on fascicle lengths? Effects on performance???
48 Petersen et al 2011; van der Horst et al 2015 Knee flexor exercises: injury prevention Two large scale RCT s in football Combined results Nordic groups: 753 players 25 injuries Control groups: 768 players 77 injuries 67.5% reduction in hamstring injuries Control groups = football training only
49 Brooks et al 2006, Am J Sports Med, 34: Nordics v nothing? Are Nordics any better than conventional strength training? Survey of Rugby teams (n = 492) Hamstring training exercises Hamstring injuries Strength Strength & Flex Strength & Flex & Nordics Match Incidence a 7.5 ( ) 7.5 ( ) 4.2 ( ) * Severity b 17 (11-23) 16 (9-23) 13 (7-18) a: injuries per 1000h b: Days lost
50 Knee flexor exercises: activation patterns Fernando-Gonzalez et al 2016 Int J Sports Med, 37; ; Bourne et al 2016
51 Bourne et al 2016 Knee flexor exercises: muscle activation fmri scans pre- & post- 5 10
52 Bourne et al 2017, Br J Sports Med 51(5): Knee flexor exercises: hypertrophy % Vol
53 Handsfield et al (2017) Scand J Med Sports 27: Where NCAA sprinters store extra muscle Add. Magnus 26% Semitendinosus 54% Gluteus maximus 31% Biceps femoris (both heads) 26% Semimemb. 20% Gluteus medius 8% Gluteus minimus -3%
54 Bourne et al 2017; Now replicated in least 7 different studies Knee flexor exercises: fascicle lengths the NHE does not provide sufficient elongation stress Guex & Millet 2014 BFLH fascicle length (cm) cm ** * Pre Mid Post * > Pre ** > Mid > Control (p < 0.05)
55 Leg curl: caution required? Machines without (and some with) variable resistance provide highest levels of muscle activation at short lengths Fascicle shortening??? Avoid or at least use 2 1 method
56 Krommes et al BMC Res Notes, 2017; 10:669: Ishoi et al J Sports Sci, 2018; 36(14): Knee flexor exercises: performance??? Football + NHE v Football alone Small benefits in repeated sprint performance (Ishoi et al 2018), 5-10m speed & CMJ?
57 Hip extensor exercises: injury prevention??? No RCT s, no non-random trials, zip Morgan s hypotheses aren t exercise dependent But remember Brooks et al (2006)??? May need eccentrically-biased or eccentric-only methods for optimal benefits?
58 Bourne et al 2017, Br J Sports Med 51(5): Hip extensor exercises: activation patterns + Glute maximus, Adductor magnus, Trunk extensors
59 Bourne et al 2017, Br J Sports Med 51(5): Hip extensor exercises: hypertrophy % Vol
60 Bourne et al (2017) Br J Sports Med 51(5): Hip v knee movements & hamstring hypertrophy 35 % Volume Increase BFLH BFSH ST SM
61 Image from Bourne et al 2018 Sports Med 48(2): Hip extension for rehab of the BF LH? BF LH atrophy 4y after strain injury in an elite (+8m) long jumper Normal training is not enough!!!
62 Bourne et al o Hip extension: fascicle lengths BFLH fascicle length (cm) ** * ** * 2.2cm 1.3cm Pre Mid Post * > Pre ** > Mid > Control (p < 0.05)
63 Stiff leg deadlift: activation patterns Suits 2 1 method MRI image - Tesch, 1999 Target Bodybuilding; Ono et al 2011 Res Sports Med, 19(1):42-52
64 Long lever bridge: activation pattern Bourne et al 2018, Int J Sports Med, 39(2):
65 Pollard et al., 2019, Scand J Med Sci Sports, doi.org/ /sms Razor curl: fascicle lengths High levels of hamstring activation Pseudo-isometric: No changes in FL!
66 Ploutz-Snyder et al 1995 Am J Physiol Regulatory Integrative Comp Physiol, 269: Squats: Activation patterns 10 strength trained men after 6 10 squats
67 Norrbrand et al 2011 Aviat Space Environ Med, 82:13-19 Squats: BF little more active than bone marrow T2 relaxations times in10 strength trained men pre & post 5 10 squats
68 Illera-Dominguez et al., 2018 Front. Physiol, 9:1265 Flywheel squat: activation patterns 8 untrained men, 2 women after 10 10
69 Enocson et al 2005 Eur J Appl Physiol, 94: Leg press: Activation patterns 8 strength trained men after 5 10 at each load
70 Lunge: Activation patterns MRI image from Tesch, 1999 Target Bodybuilding
71 Simultaneous hip and knee extension exercises Lack of hamstring activity no performance or injury prevention benefits
72 van Hooren & Bosch (2017a&b) J Sports Sci 35(23): & 35(23): The argument for isometrics That hamstring fascicles behave isometrically in sprinting So train isometrically rather than (or in addition to?) eccentrics Evidence for isometric behaviour Current biomechanical models assume eccentric behaviour
73 van Hooren & Bosch (2017a&b) J Sports Sci 35(23): & 35(23): Because Level 1 evidence for 50-66% reductions in injury rates Evidence trumps theory
74 van Hooren & Bosch (2017a&b) J Sports Sci 35(23): & 35(23): The arguments for & against isometrics That injury may occur when fascicles fail to remain isometric & actively lengthen So eccentric training should work as it would increase damage resistance And there is that tricky matter of EVIDENCE trumping theory
75 van Hooren & Bosch (2017a&b) J Sports Sci 35(23): & 35(23): The arguments for & against isometrics More transfer to sprinting? How are these specific in speed, posture or ROM? Nordics do not improve sprint coordination What gym exercise does?
76 Sports Performance and Science Reports The arguments for & against isometrics Any high intensity training will have positive effects Ignores what we know about damage resistance Conc training shortens fascicles Eccentrics are also the most intense of all contraction modes
77 The arguments for & against isometrics Evidence still trumps theory Eccentrics Isometrics
78 Exercise selection for performance Limited evidence No comparisons to alternatives Hip exercise more beneficial?
79 STRENGTH TRAINING PROGRAMMING
80 Training for strength: Conc-Ecc exercises Strength 1-3 sets 6-10 reps Novices 3-6 sets 1-6 reps strong people Rest periods minutes Not as critical for Ecc-only exercise Frequency 2-3 / week
81 Prescription guidelines for eccentrics Mjolsnes protocol proven injury prevention effects Rest periods not given: 1-3 minutes = pragmatic Petersen et al 2011
82 Intensity: eccentrics Most often with body mass ~ % of 1RM? Do you really need control? Was there a lot of control in the RCT s with 67.5% fewer injuries? Physios: are you control freaks???
83 Sims et al Unpublished results Does rep range matter? 3 10 v 5 6 No effect on average strength across a training session
84 Presland et al 2018 Scand J Med Sci Sports, 28(7): Low volume Nordic training High Volume Low Volume Week Freq Sets Reps Freq Sets Reps
85 Low volume Nordic training Presland et al 2018 Scand J Med Sci Sports, 28(7):
86 Presland et al 2018 Scand J Med Sci Sports, 28(7): Low volume Nordic training Effects reversed in 14 days! But maintained with 8 reps per week Not yet proven to reduce injuries!
87 Shield & Murphy (2018) Sports Performance & Science Reports, Apr 25 Leicester City s in-season strength work Also HSR!
88 Strength v Strength-endurance training Concentric Strength Eccentric Strength Isokinetic eccentric knee flexor strength loss with little or no concentric decline This may impair SSC performance on the pitch GRFs & COD?
89 Can we prevent this? Eccentric Torque Repeated sprint training? Eccentric strength and mixed (Ecc-Conc) strengthendurance training have positive effects! Greig (2008)
90 Eccentric training & eccentric strength loss Strength 5 4 Loaded Strength-End 5 12 Assisted Eccentric (isokinetic) strength loss after the modified (45m) BEAST running protocol 4 weeks; 2/week Matthews et al 2017 Physical Therapy in Sport, 25: 39-46
91 Strength training & eccentric strength loss Strength (3min) Strength-Endurance (90 45s) Eccentric (isokinetic) strength loss after the BEAST90 running protocol 7 weeks; 3/week Delextrat et al 2018 Frontiers in Physiology, 9: 1059
92 Pre- or Post training? (or separate???) Petersen et al 2011 Petersen et al 2011 van der Hosrt et al 2015 FIFA-11+ studies (although some extra benefits to doing both!)
93 Pre- or Post training? (or separate???) Consider athlete & coach fear, training status, volume & intensity That both seem to reduce injury rates??? Adaptations differ??? FL? 1 Strength gains Strength loss after repeated sprints 2 1 Lovell et al 2018 Scand J Med Sci Sports, 28(2): Small et al 2009 J Strength Cond Res, 23(4):1077-
94 Tack så mycket QUT team Past & Present David Opar Morgan Williams Matthew Bourne Ryan Timmins Steven Duhig Casey Sims Daniel Messer Robert Buhmann
95 Low intensity Nordics For rehab Eccentric push-ups Resist with knee flexors Lift with arms Keeps hamstrings at moderate lengths Can start eccentrics 20-50% of maximum
96 High intensity Nordics For overload 1 st rep is slow (~480N) 2 nd -5 th rep deliberately faster with brakes applied late in the movement Rep 2 = ~530N Can use extra loads
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