Editorial review: recommendations for hamstring injury prevention in elite football: translating research into practice

Key points

1. 01Hamstring strain injuries are the most common time-loss injury in elite football, and their incidence is increasing despite growing research
2. 02The Nordic hamstring exercise programme reduces injury risk by 65-70% but only 11% of elite European teams fully adopt it
3. 03A five-point holistic strategy covers: hamstring strengthening, training load balance, lumbopelvic stability, physical conditioning, and movement quality
4. 04Acute:chronic workload ratio monitoring, particularly for high-speed running, is highlighted as one of the most important modifiable risk factors
5. 05Individual player profiling and stakeholder buy-in are essential for effective programme implementation

How it was conducted

Design

Narrative evidence-based review and expert practice recommendation paper (Education reviews article)

Setting

Elite professional football (soccer), primarily English Premier League context (Southampton FC) with reference to Champions League and Norwegian Premier League surveys

Focus

Translation of hamstring strain injury prevention research into elite football practice

Approach

Synthesis of prospective and retrospective risk factor research, intervention studies, and practitioner anecdotal experience

Programme framework

Five-point strategy: hamstring strengthening, training load optimisation, lumbopelvic stability, physical conditioning, movement quality

What they found

• Only 11% of elite European Champions League (n=32) and Norwegian Premier League (n=18) teams fully adopted the Nordic hamstring exercise programme in recent surveys
• Eccentric strength training reduces HSI risk by 65%-85% and increases biceps femoris long head fascicle length by 16%-34% after 5-10 weeks
• Players with BFlh fascicle length <10.6 cm had a fourfold greater risk of HSI; risk reduced by 75% per 0.5 cm increase in fascicle length
• Elevated high-speed running in the week before injury was associated with a 6.4 times increased risk of HSI
• The programme targets acute:chronic workload ratio below 1.4 (peak 1.35) with deload weeks remaining above 0.8 to prevent acute injury risk spikes
• A leg-length asymmetry greater than 1.8 cm was linked with a fourfold heightened risk of HSI
• Players with poor eccentric hamstring strength (<350 N) or right-to-left asymmetry >10% are flagged as high risk on NordBord assessment

Limitations

• The recommendations are not wholly evidence-based; they blend research evidence with anecdotal clinical experience, which limits generalisability
• No prospective outcome data are reported for the described five-point programme, so its real-world effectiveness remains unvalidated
• Risk factor interactions are poorly understood in the literature, and the causal weight assigned to each factor in the programme is largely expert opinion
• The programme was developed in an elite English Premier League context and may not translate directly to lower-level or under-resourced football environments

Why it matters

For patients

Players and athletes can understand that injury prevention requires a personalised, multi-component approach rather than a single exercise programme.

For clinicians

Sports medicine and conditioning staff in football should consider moving beyond isolated interventions like the Nordic hamstring exercise and adopt a structured, individualised, multi-factor prevention framework with load monitoring at its core.

For readers

This paper bridges the gap between published research and practical application, providing a framework that can be adapted at both elite and amateur levels of football.