MR NICOL VAN DYK (Orcid ID : 0000-0002-0724-5997)

Article type : Original Article

Accepted Article
INTERSEASON VARIABILITY IN ISOKINETIC STRENGTH AND POOR CORRELATION WITH
NORDIC HAMSTRING ECCENTRIC STRENGTH IN FOOTBALL PLAYERS

Corresponding author:
Nicol van Dyk1, 2

Rehabilitation Department
Aspetar Orthopaedic and Sports Medicine Hospital
PO Box 29222
Aspire Zone Foundation
Doha, Qatar
nicol.vandyk@aspetar.com
Telephone: ++97 44413 2000
Fax: +974 44132020

Co-authors
Erik Witvrouw1, 2
Roald Bahr1, 3

Affiliations:
1
Aspetar Orthopaedic and Sports Medicine Hospital, Doha, Qatar
2
Department of Rehabilitation Sciences and Physiotherapy, Ghent University, Ghent, Belgium
3
Oslo Sports Trauma Research Center, Norwegian School of Sport Sciences, Oslo, Norway

This article has been accepted for publication and undergone full peer review but has not
been through the copyediting, typesetting, pagination and proofreading process, which may
lead to differences between this version and the Version of Record. Please cite this article as
doi: 10.1111/sms.13201
This article is protected by copyright. All rights reserved.
 Author acknowledgment:
I, Nicol van Dyk, acknowledge that no funding was obtained for this investigation, there is no conflict
Accepted Article
of interest to disclose, and I declare that the results of the study are presented clearly, honestly, and

without fabrication, falsification, or inappropriate data manipulation.

ABSTRACT

Introduction

In elite sport, the use of strength testing to establish muscle function and performance is common.

Traditionally, isokinetic strength tests have been used, measuring torque during concentric and

eccentric muscle action. A device that measures eccentric hamstring muscle strength while

performing the Nordic hamstring exercise is now also frequently used.

The study aims to investigate the variability of isokinetic muscle strength over time, e.g. between

seasons, and the relationship between isokinetic testing and the new Nordic hamstring exercise

device.

Methods

All teams (n=18) eligible to compete in the premier football league in Qatar underwent a

comprehensive strength assessment during their periodic health evaluation at Aspetar Orthopaedic

and Sports Medicine Hospital in Qatar. Isokinetic strength was investigated for measurement error,

and correlated to Nordic hamstring exercise strength.

Results

Of the 529 players included, 288 players had repeated tests with one/two seasons between test

occasions. Variability (measurement error) between test occasions was substantial, as demonstrated

by the measurement error (approximately 25Nm, 15%), whether separated by one or two seasons.

Considering hamstring injuries, the same pattern was observed among injured (n=60) and uninjured

(n=228) players.

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 A poor correlation (r=0.35) was observed between peak isokinetic hamstring eccentric torque and

Nordic hamstring exercise peak force. The strength imbalance between limbs calculated for both
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test modes were not correlated (r=0.037).

Conclusion

There is substantial intraindividual variability in all isokinetic test measures, whether separated by

one or two seasons, irrespective of injury. Also, eccentric hamstring strength and limb-to-limb

imbalance were poorly correlated between the isokinetic and Nordic hamstring exercise tests.

Introduction

In elite sport, the use of strength testing to establish muscle function and performance is common.1,2

Most professional football teams perform periodic health evaluations (PHE) or screening procedures

to identify athletes at risk, with a view to target injury prevention programmes to the profile of each

player, or the entire team.3 Muscle strength testing is believed to represent an important part of the

PHE, to identify strength deficits and imbalances which can be addressed to decrease injury risk. A

recent meta-analysis has shown that isokinetic strength testing has limited predictive value in

determining future risk of hamstring strain injury.4 Still, strength testing is one of the three most

commonly used screening methods in professional football,3 purportedly to determine the risk for

various types of lower limb injuries, particularly to the thigh and knee.

Traditionally, isokinetic strength tests have been used, capable of measuring torque during both

concentric and eccentric muscle action. A device specifically designed to measure eccentric muscle

strength while performing the Nordic hamstring exercise has quickly gained popularity in elite

sporting teams and sports medicine facilities. The Nordic hamstring exercise has been shown to

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 effectively reduce the risk of hamstring injury,5,6 the most common injury type in football.7

Therefore, it seems intuitive that monitoring the force produced during this test might contribute to
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appropriately define muscle strength characteristics for football players.

Several studies have investigated the reliability of standard isokinetic strength measurements,

reporting on test-retest reliability, as well as characterizing the minimal difference required between

tests to be interpreted as a meaningful change.8–10 In these studies, the test-retest measures are

performed within one to seven days. However, the variability of isokinetic muscle strength over

time, e.g. between seasons, has not been investigated, nor has the relationship between isokinetic

testing and the new Nordic hamstring exercise device. It is common practice to conduct preseason

screening, or single time point periodic health assessment that might include musculoskeletal

strength testing.3,11 Although one would expect that the tests between seasons would differ, the

amount of variability that might be expected is unknown, and therefore makes the clinical

interpretation of these data difficult.

Therefore, the aim of this study was twofold, a) to describe the season-to-season variability of

isokinetic strength testing in a group of professional male football players, and also determine the

influence of hamstring injury on the stability of the variable; and b) to investigate the relationship

between isokinetic muscle strength testing and eccentric strength testing using the novel Nordic

hamstring exercise device.

Methods

Study design and participants

The analyses were performed on prospectively collected data from professional male football

players as part of their annual PHE at Aspetar Orthopaedic and Sports Medicine Hospital in Doha,

Qatar. All teams (n=18) eligible to compete in the Qatar Stars League (QSL), the highest level of

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 competition in Qatar, agreed to participate in the study, with serial tests on all players from

September 2010 to June 2014. As part of the musculoskeletal component of the PHE, players who
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provided informed consent performed a strength assessment of both lower limbs in the

rehabilitation department at Aspetar. Players that did not consent or could not perform the strength

assessment due to injury were excluded. Players who performed testing during consecutive seasons

were identified for the current analyses, and grouped as players with one season and/or two

seasons between tests.

Figure 1 depicts player inclusion. Ethical approval was obtained from the Institutional Review Board,

Anti-doping Lab, Qatar (IRB project number 2012-020, IRB F2013000003).

Isokinetic strength testing

The same isokinetic strength battery was used for all tests. Knee flexion and extension strength were

tested using an isokinetic dynamometer (Biodex Multi-joint System 3, Biodex Medical Systems Inc.

New York, USA). After an explanation of the testing methodology, the player performed a 5-10 min

warm up routine, consisting of either light running or cycling on a stationary exercise bike (Bike

Forma, Technogym®, Cesena, Italy) at approximately 1 W/kg body weight, and familiarization with

the test procedure. Each player was seated on the dynamometer so that the hip was flexed to 90°,

ensuring that the dynamometer and knee joint angle were aligned. The trunk, waist and tested thigh

were fixed with straps to minimize secondary joint movement. Range of motion was determined as 0

to 90°, with gravitational correction for each limb performed at 30° in the set range of motion.

Vigorous verbal encouragement was provided by the assessors during the testing.12

Testing comprised of three different modes and speeds. Players were tested over five repetitions of

concentric knee flexion and extension at 60°/s, followed by 10 repetitions of concentric knee flexion

and extension at 300°/s. These test modes measure concentric strength of the quadriceps (knee

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 extension) and hamstring (knee flexion) muscle groups. Subsequently, players performed five

repetitions of eccentric knee extension at 60°/s to measure the eccentric strength of the hamstring
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muscle group. A 60 s rest period was observed between each set. The highest peak torque value

observed from all repetitions performed for each of the three different tests was recorded.

Nordic hamstring exercise testing

In 2014, the players also performed one set of three maximal repetitions on a device specifically

designed to measure eccentric muscle strength while performing the Nordic hamstring exercise. The

Nordic hamstring exercise was performed directly after the isokinetic testing, with at least three

minutes between tests. The device allows for separate measurements of peak eccentric strength for

each limb as described previously.13 The players were tested in a kneeling position on a padded

board, with both ankles secured immediately above the lateral malleolus by individual ankle braces.

The player was instructed to keep the trunk and hips in a neutral position with his hands held across

the chest, and then progressively lean forward at the slowest possible speed while resisting the

movement with both limbs. The highest peak force measure was recorded, as well as the average of

the peak force recorded for the three trials.

Injury surveillance

All participating QSL teams are provided with medical services by the National Sports Medicine

Programme, a department within the Aspetar Orthopaedic and Sports Medicine Hospital. This

centralized system, with a focal point for the medical care of each club competing in the QSL,

allowed for standardization of the ongoing injury surveillance through the Aspetar Injury and Illness

Surveillance Programme (AIISP).11

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 The AIISP includes prospective injury data collected monthly, with regular communication with the

responsible team physician/physiotherapist to encourage timely and accurate reporting. At the

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conclusion of each season, all the data from the individual clubs were collated into a central

database.

A hamstring injury was defined as acute pain in the posterior thigh that occurred during training or

match play, and resulted in immediate termination of play and inability to participate in the next

training session or match.14 These injuries were confirmed through clinical examination (identifying

pain on palpation, pain with isometric contraction and pain with muscle lengthening) by the club

medical team.15 If indicated, the clinical diagnosis was supported by ultrasonography and magnetic

resonance imaging at the study centre.

Statistical analyses

Data were analysed with IBM SPSS statistics, V.21 (IBM Corp, Armonk, New York, USA), using each

limb as the unit of analysis. Paired t-test were used to assess whether there were systematic

differences in the isokinetic strength variables between different test occasions (one and two

seasons in between tests). The significance level was set at p<0.05. The variability (random error)

was assessed using a two way mixed model to determine the intraclass correlation coefficient (ICC3,1)

with 95% CI, as well as the measurement error. The measurement error was determined by

calculating the difference between the standard deviation (SD) of the mean for the two test

occasions divided by the square root of 2, presented as the mean error and also expressed as a

percentage of the mean value. Effect size, which is the quantitative measure of the strength of an

observed occurrence, was calculated and interpreted as small (> 0.2), medium (> 0.5), or large (>

0.8).16 To describe the correlation between strength measured during the isokinetic and Nordic

hamstring exercise, we calculated the Pearson correlation coefficient between the peak torque for

isokinetic eccentric contraction at 60°/s, and the peak force produced during the Nordic hamstring

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 strength test. Data are presented as means with SD or 95% CI unless otherwise stated. The between-

limb strength imbalance was correlated between left and right limbs as a percentage imbalance,
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using the right limb as the base measure.

Results

Participants

Between 2010-2013, all elite male football players (n=614) that reported for screening were

considered for isokinetic testing. Of the 529 players included, 241 players did not have at least two

consecutive test measurements. The final sample therefore included 288 players (age 25 ± 5 yrs,

height 177 ± 7 cm, weight 71.5 ± 8.7 kg, BMI 22.9 ± 2.0) that performed the isokinetic test procedure

on two occasions, 240 players with one season between measurements and 86 players with two

consecutive seasons between measurements (figure 1). Those players who were unable to perform

the test due to injury, or did not consent to performing the test (n=85, age 27 ± 5 yrs, height 177 ±

7cm, weight 73.8 ± 8.7 kg, BMI 23.6 ± 1.8), were excluded from the analyses. These players were

significantly older and heavier (p<0.05, Cohen’s d of 0.4 and 0.2, respectively). Considering ethnicity,

64% of the players were Arabic, 30% black, 2% Asian, and 4% Caucasian. Playing position was

documented in four categories, goalkeepers (n=37), defenders (n=98), midfielders (n=108) and

forwards (n=45).

In 2014, 337 players (age 25.9 ± 5 years, height 176.7 ± 6.9cm, weight 72.2 ± 9.2 kg, BMI 23.1 ± 2.1)

performed Nordic hamstring exercise testing in addition to the isokinetic strength testing.

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 Interseason variability of the isokinetic tests

The mean time between measurements was 374 (226 to 560) days for players with one season
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between test occasions and 790 (551 to 867) days for players with two seasons between test

occasions.

A significant increase in isokinetic strength measurements from the first to the second test was

observed in both groups for some modes, with very small to small effect sizes (table 1 and 2).

Variability (random error) between test occasions was substantial, as demonstrated by the large

measurement error for all the contraction modes, whether separated by one or two seasons. The

same pattern was observed among players not suffering from any hamstring injuries between tests

(n=228) as for those who did have one or more hamstring injuries (n=60) (table 1). The variability

between two test occasions is illustrated for quadriceps concentric torque @ 60°/s and hamstrings

eccentric torque @60°/s in figures 2 and 3.

Relationship between isokinetic and Nordic hamstring exercise test

A poor correlation (r=0.35) was observed between peak isokinetic hamstring eccentric torque

@60°/s (Nm) (mean 207.7 ± 44.1, 82.0 to 348.4) and Nordic hamstring exercise peak force (N) (mean

298.6 ± 72.3, 121.0 to 502.5), as illustrated in figure 4. The mean imbalance between limbs was

23.0±19.8 Nm for isokinetic strength and 28.7±27.4 N for Nordic hamstring strength. The percentage

strength imbalance between limbs (left compared to right) was calculated for both test modes were

not correlated (r=0.037), as shown in figure 5.

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 Discussion

In this study of professional football players, substantial individual season-to-season variability was
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identified for isokinetic strength measurements, unrelated to any hamstring injury during the

interval. Additionally, the results from standard (isokinetic) and novel (Nordic hamstring exercise)

eccentric hamstring strength testing were poorly correlated.

Variability of isokinetic strength measurements

Isokinetic assessments are often used to establish strength profiles of athletes. The results are used

for different purposes, such as performance training, return to sport and to determine risk of injury,

particularly hamstring injuries.1,2,12,17–24 However, there seems to be a discrepancy in the literature

between intervention studies testing the effect of eccentric strength training on hamstring injury risk

and prospective cohort studies examining the association between eccentric hamstring strength and

the risk of injury. Several intervention studies have reported a reduction in hamstring injuries after

implementing various strengthening regimes.25,26 By far the largest effect has been demonstrated

with the Nordic hamstring exercise. Three large intervention studies (two randomized and one non-

randomized) have shown that injuries can be reduced by approximately 70% by implementing the

Nordic hamstring exercise in a team’s training regime.17,27,28 The results from these intervention

studies suggest that eccentric strength must represent a key risk factor for hamstring injuries.

However, a recent meta-analysis29 documents that prospective cohort studies have failed to

consistently identify hamstring strength as a strong risk factor associated with injury.12,26,30–33

The large variability observed in this study might explain the apparent incongruity between

intervention studies, consistently showing the positive effect of eccentric strengthening, and the lack

of strong evidence to support this in prospective cohort studies. Prospective studies are based on a

one-time baseline strength test, and with a variability (measurement error) of approximately 25 Nm

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 (15%) between strength tests separated by one season as observed in this study, it seems that large

fluctuations in hamstring strength occur within seasons. This would make it difficult to identify any
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relationship between hamstring strength and injury risk, if such a relationship even exists.

An obvious question is how much of the observed variability is due to measurement error and how

much is real. The reliability of standardized isokinetic testing has been reported previously, claiming

high reproducibility if adequate calibration, gravity correction, and patient positioning were

standardized.8–10 In a previous study from our centre that matches the methods used in this present

investigation, Otten et al reported on the reliability of isokinetic testing, utilizing the same isokinetic

dynamometer, and with the same skilled assessors conducting the testing.34 In this study, tests were

performed on four occasions with a minimum of 48 h of rest between each testing session. Although

the ICC for quadriceps and hamstrings peak torque was again interpreted as reliable (>0.8), the

standard error of the measurement was reported as 16.4 Nm and 10.5 Nm, respectively. The

measurement errors in our study were 24.5 Nm and 15.7 Nm, suggesting an additional 50%

variability in these two measures. In other words, both studies identify substantial random error

when performing these isokinetic tests, and it seems clear that this increases when tests are

separated by one or two seasons.

A potential explanation for the variability observed is injuries incurred during the season, particularly

hamstring injuries. However, the season-to-season variability observed was similar for uninjured and

injured players across all the modes of testing. All the players were deemed fit to play at the time of

testing, but it should be noted that we have only investigated the effect of hamstring injuries, not

any other injuries between test occasions. However, as hamstring injuries are the most likely to

affect hamstring strength, it seems highly unlikely that the variability observed is due to inter-test

injuries.

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 Correlation of isokinetic torque and Nordic hamstring eccentric force

The Nordic hamstring exercise is today often used to measure hamstring strength, and determining
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risk of lower limb injury.23,24,35 This is the first study to determine the correlation between the Nordic

hamstring exercise and conventional isokinetic strength test using a dynamometer. Unexpectedly,

we found a poor correlation between the Nordic hamstring exercise and isokinetic tests, as well as

no correlation between the bilateral imbalances identified in either test.

These tests are biomechanically different in nature, and muscle activation patterns will be

different,36,37 which may influence how well they correlate. Bourne et al reported that Nordic

hamstring exercise provide the largest stimulus to changes in biceps femoris fascicle length,38 which

might explain the effect of the intervention on reducing injury risk, since decreased fascicle length

has been reported as a risk factor for hamstring injury.24 Unfortunately, none of the intervention

studies measure the effect of the intervention on muscle architecture, or any other factor, and are

therefore not able to identify the mechanism responsible for the preventative effect.

Although the effect of reducing risk of hamstring injury using the Nordic hamstring exercise has been

well established,5 when implemented as a screening tool, it has yielded mixed results.19,21,23,24

Engebretsen et al found no significant association when it was used as a simple visual assessment of

test performance.21 Subsequent studies positively identified players with inferior eccentric strength

(measured by a novel device) as being at increased risk of hamstring injury.23,24 However, in a cohort

of rugby players, between-limb imbalances and not eccentric strength was associated with the risk

of hamstring injury.19

The quantification of this exercise by Opar et al13 provided the opportunity to test how well it

compares to other forms of measuring strength, in particular isokinetic testing, which has been

described as the gold standard of strength testing.39

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 Although both tests are assumed to measure the same trait, eccentric force production, the low

correlation suggests that they do not.

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Importantly, there are two main differences between the test modes. Firstly, the position in which

the two tests are performed have opposing features. For the isokinetic test, the strength is

measured as the limb performs a unilateral movement in a seated position, with the hip in flexion. In

contrast, the Nordic hamstring exercise test measures the strength of both limbs in a bilateral

movement, with the player in a kneeling position and the hips extended. Secondly, the units of

measurement are also different; isokinetic strength is measured as torque and Nordic hamstring

strength as force. Perhaps these central differences can explain why we do not find any correlation

between isokinetic and Nordic hamstring strength testing.

Even if the force and torque measurements do not correlate between test modes, one might expect

any limb-to-limb strength imbalance to favour the same side using both devices; however, these did

not correlate at all (Figure 5). One hypothesis to explain this is the bilateral deficit, the reduction in

amount of force produced from bilateral movements compared to the sum of forces produced

unilaterally by the left and right limbs when tested alone.40,41 The Nordic hamstring test measures

the imbalance when both legs are tested together, in contrast to the isokinetic test, where unilateral

strength tested for each leg separately.

Strengths and Limitations

A major strength of this study is that all tests performed utilized the same isokinetic testing system

with highly experienced assessors, and it was performed in a single clinical setting for professional

athletes. This reflects a “real world” scenario and might contribute to the external validity of the

study.

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 Limitations to this investigation includes no recording of exposure to football training and match

play, specific strength training or interventions aimed at prevention across the different clubs. This
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study was performed in a multinational, multi-language setting, and while every effort was made to

guarantee that players comprehended the test procedure and directions, it is possible that some

players did not fully understand the instructions. In our clinical setting, a formal familiarization

procedure was not possible, and the change we observe between seasons may partly be due to a

learning effect between the test sessions. We also acknowledge the homogeneity of our study

population of professional male football players, which limits the generalization of these findings to

other sports, age groups, or female players.

Conclusion

There is substantial intraindividual variability in all isokinetic test measures, whether separated by

one or two seasons, and irrespective of injury. Also, eccentric hamstring strength and limb-to-limb

imbalance were poorly correlated between the isokinetic and Nordic hamstring exercise test.

Perspective

The use of strength testing to establish muscle function and performance in elite sport is common.1,2

Muscle strength testing is believed to represent an important part of the PHE, identifying strength

deficits and imbalances which can be addressed to decrease injury risk. Strength testing is one of the

three most commonly used screening methods in professional football,3 to determine the risk for

various types of lower limb injuries, particularly to the thigh and knee. The large variability observed

in this study might explain the apparent incongruity between intervention studies, consistently

showing the positive effect of eccentric strengthening, and the lack of strong evidence to support

this in prospective cohort studies. The variability (measurement error) of approximately 25 Nm

This article is protected by copyright. All rights reserved.

 (15%) between strength tests separated by one season as observed in this study, indicating that

large fluctuations in hamstring strength occur within seasons, makes it difficult to identify any
Accepted Article
relationship between hamstring strength and injury risk. There is substantial intraindividual

variability in all isokinetic test measures, whether separated by one or two seasons, and irrespective

of injury. This might explain the disparity we observe between prospective cohort and intervention

studies considering eccentric strength, and suggest that other mechanisms might be responsible for

the preventative effect of eccentric training. Eccentric hamstring strength and limb-to-limb

imbalance were poorly correlated between the isokinetic and Nordic hamstring exercise test,

indicating that these tests might measure different characteristics of strength.

References

1. Charteris J. Effects of velocity on upper to lower extremity muscular work and power output
ratios of intercollegiate athletes. Br J Sports Med. 1999;33:250–254.

2. Magalhaes J, Oliveira J, Ascensao A, Soares J. Concentric quadriceps and hamstrings isokinetic

strength in volleyball and soccer players. J Sports Med Phys Fitness. 2004;44:119.

3. McCall A, Dupont G, Ekstrand J. Injury prevention strategies, coach compliance and player
adherence of 33 of the UEFA Elite Club Injury Study teams: a survey of teams’ head medical
officers. Br J Sports Med. 2016;50:725-730.

4. Green B, Bourne MN, Pizzari T. Isokinetic strength assessment offers limited predictive validity
for detecting risk of future hamstring strain in sport: a systematic review and meta-analysis. Br
J Sports Med. 2018;52:329-336.

5. Al Attar WSA, Soomro N, Sinclair PJ, Pappas E, Sanders RH. 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 Med. 2017;47:907-916.

6. Thorborg K, Krommes KK, Esteve E, Clausen MB, Bartels EM, Rathleff MS. Effect of specific
exercise-based football injury prevention programmes on the overall injury rate in football: a
systematic review and meta-analysis of the FIFA 11 and 11+ programmes. Br J Sports Med.
2017;51:562-571.

7. Hagglund M, Walden M, Ekstrand J. Injury incidence and distribution in elite football-a

prospective study of the Danish and the Swedish top divisions. Scand J Med Sci Sports.
2005;15:21-28.

8. Feiring DC, Ellenbecker TS, Derscheid GL. Test-retest reliability of the Biodex isokinetic
dynamometer. J Orthop Sports Phys Ther. 1990;11:298–300.

This article is protected by copyright. All rights reserved.

 9. Pincivero DM, Lephart SM, Karunakara RA. Reliability and precision of isokinetic strength and
muscular endurance for the quadriceps and hamstrings. Int J Sports Med 1997;18:113-7.

10. McCleary RW, Andersen JC. Test-retest reliability of reciprocal isokinetic knee extension and
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flexion peak torque measurements. J Athl Train. 1992;27:362-5.

11. Bakken A, Targett S, Bere T, et al. Interseason variability of a functional movement test, the 9+
screening battery, in professional male football players. Br J Sports Med. September
2016:bjsports-2016-096570.

12. Van Dyk N, Bahr R, Whiteley R, et al. Hamstring and quadriceps isokinetic strength deficits are
weak risk factors for hamstring strain injuries: a 4-year cohort study. Am J Sports Med.
2016;44:1789-1795.

13. Opar DA, Piatkowski T, Williams MD, Shield AJ. A novel device using the nordic hamstring
exercise to assess eccentric knee flexor strength: a reliability and retrospective injury study. J
Orthop Sports Phys Ther. 2013;43:636-640.

14. Eirale C, Farooq A, Smiley FA, Tol JL, Chalabi H. Epidemiology of football injuries in Asia: A
prospective study in Qatar. J Sci Med Sport. 2013;16:113-117.

15. Tol JL, Hamilton B, Eirale C, Muxart P, Jacobsen P, Whiteley R. At return to play following
hamstring injury the majority of professional football players have residual isokinetic deficits.
Br J Sports Med. 2014;48:1364-1369.

16. Cohen J, Cohen P, West SG, Aiken LS. Applied multiple regression/correlation analysis for the
behavioral sciences. Routledge; 2013.

17. Arnason A, Sigurdsson SB, Gudmundsson A, Holme I, Engebretsen L, Bahr R. Risk factors for
injuries in football. Am J Sports Med 2004;32:5S–16

18. Bennell K, Wajswelner H, Lew P, et al. Isokinetic strength testing does not predict hamstring
injury in Australian Rules footballers. Br J Sports Med. 1998;32(4):309–314.

19. Bourne MN, Opar DA, Williams MD, Shield AJ. Eccentric knee flexor strength and risk of
hamstring injuries in rugby union: a prospective study. Am J Sports Med. 2015;43:2663-2670.

20. Brooks JHM. Incidence, Risk, and prevention of hamstring muscle injuries in professional rugby
union. Am J Sports Med. 2006;34:1297-1306.

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

22. Kong PW, Burns SF. Bilateral difference in hamstrings to quadriceps ratio in healthy males and
females. Phys Ther Sport. 2010;11:12-17.

23. Opar DA, Williams MD, Timmins RG, Hickey J, Duhig SJ, Shield AJ. Eccentric hamstring strength
and hamstring injury risk in australian footballers: Med Sci Sports Exerc. 2015;47:857-865.

24. Timmins RG, Bourne MN, Shield AJ, Williams MD, Lorenzen C, Opar DA. Short biceps femoris
fascicles and eccentric knee flexor weakness increase the risk of hamstring injury in elite
football (soccer): a prospective cohort study. Br J Sports Med 2016;50:1524-1535.

This article is protected by copyright. All rights reserved.

 25. 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;13:244–250.

26. Croisier J-L, Ganteaume S, Binet J, Genty M, Ferret J-M. Strength imbalances and prevention of
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hamstring injury in professional soccer players: a prospective study. Am J Sports Med.
2008;36:1469-1475.

27. Petersen J, Thorborg K, Nielsen MB, Budtz-Jørgensen E, Hölmich P. Preventive effect of

eccentric training on acute hamstring injuries in men’s soccer: a cluster-randomized controlled
trial. Am J Sports Med. 2011;39:2296-2303.

28. Van der Horst N, Smits D-W, Petersen J, Goedhart EA, Backx FJG. The preventive effect of the
nordic hamstring exercise on hamstring injuries in amateur soccer players: a randomized
controlled trial. Am J Sports Med. 2015;43:1316-1323.

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

30. Van Dyk N, Bahr R, Burnett AF, et al. A comprehensive strength testing protocol offers no
clinical value in predicting risk of hamstring injury: a prospective cohort study of 413
professional football players. Br J Sports Med. 2017;51:1695-1702.

31. Fousekis K, Tsepis E, Poulmedis P, Athanasopoulos S, Vagenas G. 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.

32. Orchard J, Marsden J, Lord S, Garlick D. Preseason hamstring muscle weakness associated with
hamstring muscle injury in Australian footballers. Am J Sports Med. 1997;25:81–85.

33. Sugiura Y, Saito T, Sakuraba K, Sakuma K, Suzuki E. Strength deficits identified with concentric
action of the hip extensors and eccentric action of the hamstrings predispose to hamstring
injury in elite sprinters. J Orthop Sports Phys Ther. 2008;38:457-464.

34. Otten R, Whiteley R, Mitchell T. Effect of subject restraint and resistance pad placement on
isokinetic knee flexor and extensor strength: implications for testing and rehabilitation. Sports
Health. 2013;5:137-142.

35. Messer D, Bourne M, Timmins R, Opar D, Williams M, Shield A. Eccentric knee flexor strength
and hamstring injury risk in athletes with history of anterior cruciate ligament reconstruction.
Br J Sports Med. 2017;51:363–363.

36. Bourne MN, Williams MD, Opar DA, Al Najjar A, Kerr GK, Shield AJ. Impact of exercise selection
on hamstring muscle activation. Br J Sports Med. 2017;51:1021-1028.

37. Zebis MK, Skotte J, Andersen CH, et al. Kettlebell swing targets semitendinosus and supine leg
curl targets biceps femoris: an EMG study with rehabilitation implications. Br J Sports Med.
2013;47:1192-1198.

38. Bourne MN, Duhig SJ, Timmins RG, et al. Impact of the Nordic hamstring and hip extension
exercises on hamstring architecture and morphology: implications for injury prevention. Br J
Sports Med. 2017;51:469-477.

This article is protected by copyright. All rights reserved.

 39. Stark T, Walker B, Phillips JK, Fejer R, Beck R. Hand-held dynamometry correlation with the
gold standard isokinetic dynamometry: a systematic review. PM&R. 2011;3:472-479.

40. Jakobi JM, Chilibeck PD. Bilateral and unilateral contractions possible differences in maximal
Accepted Article
voluntary force. Can J Appl Physiol 2001; 26:12-33.

41. Sale, Digby G. Neural adaptation to,strength training. In: Komi, Paavo, editorStrength and
Power in Sport, Second Edition Blackwell Science Ltd, Oxford, UK; 2008: p. 281-314.

LEGENDS OF TABLES AND FIGURES

Figure 1 Flow chart demonstrating the inclusion of players over different seasons

Figure 2 Scatter plot presenting the isokinetic quadriceps concentric torque @60°/s for injured

(n=51, closed symbols) and uninjured (n=189, open symbols) for season 1 (test 1) and season 2 (test

2). The hatched line represents the identity line.

Figure 3 Scatter plot presenting the isokinetic hamstrings eccentric torque @60°/s for injured (n=51,

closed symbols) and uninjured (n=189, open symbols) for season 1 (test 1) and season 2 (test 2). The

hatch line represents the identity line.

Figure 4 Scatter plot with correlation between isokinetic hamstring eccentric peak torque @ 60°/s

and Nordic hamstring exercise peak force for injured (n=31, closed symbols) and uninjured (n=306,

open symbols).

Figure 5 Scatter plot illustrating the correlation of between-limb imbalance (expressed as a

percentage of left compared to right for isokinetic hamstring eccentric peak torque @ 60°/s (x-axis)

and Nordic hamstring exercise peak force (y-axis) for injured (n=31, closed symbols) and uninjured

(n=306, open symbols) players.

Table 1 Interseason comparison of isokinetic strength testing for players with one season between

measurements (n=240).

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 Table 2 Interseason comparison of the isokinetic strength tests for players with two seasons

between measurements (n=86).

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Accepted Article

Table 1 Interseason comparison of isokinetic strength testing for players with one season between measurements (n=240).
Difference test 2 to test 1
Test 1 (mean±SD) Test 2 (mean±SD) ICC (95% CI) Effect size (d) p-value Measurement Error
(mean, 95% CI)
Nm Nm Nm Nm (%)
Quadriceps concentric at 60/s
All 234.1 (42.5) 235.1 (45.4) 1.0 (-5.8 to 3.7) 0.71 (0.67 to 0.81) 0.02 0.72 24.5 (10.5)
Injured 227.0 (41.9) 235.9 (45.3) 8.9 (-8.3 to 26.0) 0.68 (0.51 to 0.96) 0.2 0.31 24.7 (10.9)
Uninjured 235.0 (42.5) 235.1 (45.5) 0.1 (-5.8 to 6.0) 0.69 (0.67 to 0.82) 0.02 0.98 24.4 (10.4)
Hamstrings concentric at 60/s
All 123.7 (23.0) 128.6 (26.1) 4.9 (1.7 to 8.1) 0.63 (0.60 to 0.76) 0.2 0.002 15.7 (12.7)
Injured 121.3 (20.5) 127.1 (27.8) 5.8 (-3.7 to 15.5) 0.57 (0.46 to 1.09) 127 0.23 16.4 (13.6)
Uninjured 124.0 (42.5) 128.7 (25.9) 4.7 (1.5 to 8.1) 0.60 (0.59 to 0.76) 0.2 0.005 15.6 (12.6)
Quadriceps concentric at 300/s
All 131.9 (24.6) 136.3 (26.8) 4.4 (1.9 to 6.9) 0.79 (0.78 to 0.90) 0.2 0.01 12.4 (9.4)
Injured 129.3 (23.7) 135.7 (27.8) 6.4 (-3.7 to 16.6) 0.75 (0.67 to 1.11) 0.3 0.21 13.0 (10.1)
Uninjured 132.2 (24.7) 136.4 (26.8) 4.2 (0.7 to 7.7) 0.78 (0.72 to 0.91) 0.2 0.02 12.3 (9.3)
Hamstrings concentric at 300/s
All 93.9 (21.3) 98.6 (21.4) 4.7 (2.3 to 7.8) 0.56 (0.55 to 0.75) 0.2 0.0003 14.5 (15.4)
Injured 92.4 (21.2) 98.7 (20.5) 6.3 (-1.9 to 14.5) 0.66 (0.43 to 0.85) 0.3 0.13 12.2 (13.2)
Uninjured 94.1 (21.3) 98.6 (21.6) 4.5 (2.0 to 7.8) 0.55 (0.48 to 0.64) 0.2 0.001 14.8 (15.7)
Hamstrings eccentric at 60/s
All 181.7 (37.0) 185.5 (39.5) 3.8 (-0.9 to 9.1) 0.52 (0.47 to 0.64) 0.1 0.1 26.6 (14.6)
Injured 176.4 (32.5) 170.4 (33.4) 5.8 (-7.3 to 19.4) 0.52 (0.25 to 0.78) 0.2 0.37 23.2 (13.2)
Uninjured 182.3 (37.4) 187.2 (39.8) 4.9 (-0.1 to 10.5) 0.52 (0.46 to 0.64) 0.1 0.05 26.9 (14.8)
*Mean ± SD for test 1 (season 1) and test 2 (season 2), mean interseason difference, measurement error (ME) from test 1 (season 1) to test 2 (season 2) are reported. ICC,
intraclass correlation coefficient, Nm, Newton-meter, d, Cohen’s d.
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Accepted Article

Table 2 Interseason characteristics of the isokinetic strength tests for players with two seasons between measurements (n=86)*
Test 1 (mean±SD) Test 2 (mean±SD) Difference test 2 to test 1 ICC (95% CI) Effect size (d) p-value Measurement Error
(mean, 95% CI)
Nm Nm Nm Nm (%)
Quadriceps concentric at 60/s
All 225.2 (40.3) 238.5 (44.1) 13.3 (4.3 to 22.3) 0.69 (0.63 to 0.87) 0.3 0.004 23.8 (10.6)
Injured 215.1 (42.5) 220.9 (41.6) 5.8 (-35.2 to 47.8) 0.78 (0.22 to 1.31) 0.1 0.77 19.6 (9.1)
Uninjured 225.8 (40.3) 239.6 (44.2) 13.8 (4.5 to 23.0) 0.68 (0.62 to 0.87) 0.3 0.003 24.0 (10.6)
Hamstrings concentric at 60/s
All 122.3 (22.8) 128.4 (22.1) 6.1 (0.9 to 11.1) 0.65 (0.51-0.74) 0.3 0.01 13.3 (10.9)
Injured 123.5 (20.1) 128.5 (16.8) 5.0 (-13.5 to 23.4) 0.50 (-0.23 to 1.1) 0.3 0.58 13.2 (10.7)
Uninjured 122.1 (23.0) 128.3 (22.4) 6.2 (0.6 to 11.5) 0.65 (0.52 to 0.75) 0.3 0.02 13.4 (10.9)
Quadriceps concentric at 300/s
All 129.2 (25.7) 135.0 (26.5) 5.8 (0.3 to 11.4) 0.67 (0.58 to 0.81) 0.2 0.04 15.0 (11.6)
Injured 128.8 (33.9) 127.6 (20.4) 1.2 (-26.8 to 29.1) 0.40 (-0.25 to 0.73) 0.04 0.93 22.5 (17.5)
Uninjured 129.2 (25.3) 135.4 (26.8) 6.2 (0.5 to 12.0) 0.69 (0.61 to 0.85) 0.2 0.03 14.5 (11.2)
Hamstrings concentric at 300/s
All 93.4 (20.8) 96.2 (20.6) 2.8 (-1.1 to 7.8) 0.53 (0.41-0.66) 0.1 0.14 14.1 (15.1)
Injured 94.8 (19.0) 97.1 (16.7) 2.3 (-15.6 to 20.1) 0.67 (0.01 to 1.17) 0.1 0.79 10.3 (10.9)
Uninjured 93.3 (21.0) 95.9 (20.9) 2.9 (-1.2 to 8.0) 0.53 (0.40 to 0.67) 0.1 0.15 14.3 (15.3)
Hamstrings eccentric at 60/s
All 176.2 (38.0) 187.9 (38.9) 11.7 (5.3 to 21.7) 0.51 (0.39-0.65) 0.3 0.001 26.5 (15.0)
Injured 175.1 (37.5) 191.6 (48.5) 16.5 (-23.0 to 63.6) 0.43 (-0.63 to 1.79) 0.4 0.35 34.0 (19.4)
Uninjured 176.3 (38.1) 187.7 (38.4) 11.4 (4.6 to 21.5) 0.52 (o.39 to 0.65) 0.3 0.002 26.2 (14.9)
*Mean ± SD for test 1 (season 1) and test 2 (season 3), mean interseason difference, measurement error (ME) from test 1 (season 1) to test 2 (season 3) are reported. ICC,
intraclass correlation coefficient, Nm, Newton-meter, d, Cohen’s d.
This article is protected by copyright. All rights reserved.
Accepted Article

This article is protected by copyright. All rights reserved.

Accepted Article

This article is protected by copyright. All rights reserved.

Accepted Article

This article is protected by copyright. All rights reserved.

Accepted Article

This article is protected by copyright. All rights reserved.