Journal of Physical Education and Sport ® (JPES), Vol. 24 (issue 8), Art 219, pp. 1978 - 1983, August 2024
online ISSN: 2247 - 806X; p-ISSN: 2247 – 8051; ISSN - L = 2247 - 8051 © JPES

Original Article
Differences in eccentric hamstring force among young indonesian handball
players based on injury history
NURA MAULIDA ISNA1, OVIESTA TASHA RETYANANDA2, BAYU PRASTOWO3, MUHAMMADREZA AZIZ PRASETYA4, SYI’AR APRILLA TANAZZA5, AWANG FIRMANSYAH6, DWIKYOKTAVRIANTO7, GADIS MEINAR SARI8, LILIK HERAWATI9
1,2,7
Sport Health Science Master Program, Faculty of Medicine, Universitas Airlangga, INDONESIA
3
Department of Physiotherapy, Faculty of Health Science, University of Muhammadiyah Malang, INDONESIA
4
Department of Physical Education, Health, and Leisure, National Cheng Kung University, TAIWAN
5
Department of Sports Medicine, College of Medicine, Kaohsiung Medical University, TAIWAN
6
Department of Sport Science, Faculty of Sport Science, Surabaya State University, INDONESIA
8,9
Department of Physiology, Faculty of Medicine, Universitas Airlangga, INDONESIA
Published online: August 31, 2024
Accepted for publication : August 15, 2024
DOI:10.7752/jpes.2024.08219
Abstract:
Handball is characterized by frequent changes in direction, jumping, and intense physical contact, which
contribute to a high incidence of injuries, especially in the lower extremities. These injuries often come with therisk of re-injury or new injuries, affecting athletic performance. Assessing hamstring muscle strength, vital forknee joint stability, is a crucial approach to preventing sports injuries. Weakness in eccentric hamstring strength
can increase the risk of overuse injuries, hamstring strains, and ACL tears. Detecting muscle strength imbalancesin athletes is an effective strategy for preventing future injuries. This study aimed to compare maximum
eccentric hamstring force and assess asymmetry between the right and left legs in young male and female
handball players with differing injury histories. Performed as an analytic observational study with a crosssectional design, it involved a total sample of 82 young handball players (46 males and 36 females), grouped
according to their injury history. Participants performed an eccentric hamstring strength test using the Nordic
hamstring bilateral test, measured with the NordBord hamstring testing device (VALD Performance, Australia).
This study found a significant difference in the percentage of asymmetry between players with a history of injury
and those without (p = 0.000). However, the mean maximal hamstring eccentric strength did not differ
significantly between injury history groups in each gender. The observed higher mean percentage of hamstring
eccentric imbalance in players with a history of injury may be influenced by various factors, including player
position, rehabilitation process, training level, body composition, and overall physical performance. The highpercentage of imbalances in athletes requires careful attention to mitigate their negative effects on athletic
performance and reduce the risk of injury.
Keywords: Hamstring force, NordBord, Handball, Injury prevention, Healthy lifestyle
Introduction
Handball, a popular sport played by two teams of seven players, involves rapid transitions between
offensive and defensive roles through activities such as throwing, passing, jumping, blocking, pushing, running,and dribbling the ball into the opponent's goal to score points (Marczinka & Csáki, 2023). The mechanicalstresses from frequent direction changes and high physical contact often lead to injuries, with a prevalence rateof 82.2% (Logerstedt et al., 2022; Martín-Guzón et al., 2021; Vila et al., 2022). Sports injuries encompass pain,
discomfort, or loss of function that impair the ability to exercise, potentially leading to physical, mental, andfinancial challenges, all of which can impact both individual and team performance (Benson et al., 2024; Emery& Pasanen, 2019). These injuries arise from a complex interplay of risk factors and triggers (Bittencourt et al.,2016). Most injuries are attributed to player contact, resulting in traumatic injuries, while non-contact andoveruse injuries commonly affect the knee, shoulder, and ankle (Raya-González et al., 2020; Vila et al., 2022).
In handball, lower extremity injuries, such as those affecting the knee, hip, and ankle, are moreprevalent than upper extremity injuries (Martín-Guzón et al., 2021; Vila et al., 2022). A history of lower
extremity injury increases the risk of re-injury or new injury and can lead to long-term negative effects on tissue
function, including muscle atrophy and reduced muscle strength (Mardani-Kivi et al., 2020). Previous researchsuggests that a history of ACL injury in female may lead to diminished knee flexor function compared to knee
extensors (Collings et al., 2021). Athletes who have recovered from previous injuries may develop
biomechanical abnormalities owing to residual effects from the rehabilitation process, which can increase theirsusceptibility to injuries in other areas (Palermi et al., 2023). To reduce the frequency of injuries in handball1978---------------------------------------------------------------------------------------------------------------------------------Corresponding Author: LILIK HERAWATI, E-mail: lilik_heraw@fk.unair.ac.id

NURA MAULIDA ISNA, OVIESTA TASHA RETYANANDA, BAYU PRASTOWO, MUHAMMAD REZAAZIZ PRASETYA, SYI’AR APRILLA TANAZZA, AWANG FIRMANSYAH, DWIKY OKTAVRIANTO,GADIS MEINAR SARI, LILIK HERAWATI--------------------------------------------------------------------------------------------------------------------------------------players, it is essential to monitor their injury history and physical condition, including muscle strength. This
proactive approach can help minimize the risk of future injuries (Bedo et al., 2019).
An effective injury prevention strategy highlighted in previous research involves addressing muscle
strength asymmetries in the lower extremities, such as those in the hamstring muscles, which can impact athletic
performance (Almeida et al., 2018; Fort-Vanmeerhaeghe et al., 2020). Hamstring muscle strength plays amultifaceted role for handball players. Its primary functions include knee flexion, hip extension, and stabilizationof the knee joint, which collectively influence running, jumping, and agility maneuvers such as acceleration,
deceleration, and changes in direction (Chang et al., 2020; Markovic et al., 2020). In addition to absolute levelsof eccentric hamstring strength, significant asymmetry between the right and left legs (greater than 15%) canconsiderably increase the risk of injury and has been identified as a predictor of injury (Bishop et al., 2022;
Claudino et al., 2021). The Nordic hamstring eccentric strength test has proven to be a valid and effective
method for both preventing and reducing the incidence of injuries, particularly those involving the hamstring
muscles (Almeida et al., 2018; Bishop et al., 2022).
Analyzing individual player profiles is an important step in injury prevention because it helps identify
hamstring eccentric strength values and potential underlying mechanisms. This information serves as a valuablereference for coaches and physiotherapists in designing targeted training programs that focus on injury
prevention, performance enhancement, and improving the overall quality of life for handball players.
Consequently, this study aims to compare hamstring muscle eccentric strength between young male and female
handball players with and without lower extremity injuries to reduce the risk of re-injury or new injuries in the
future.
Materials and Methods
ParticipantsThis study is an analytic observational research design. Data were collected from hamstring eccentric
strength examinations performed on 82 young handball players in Surabaya, Indonesia, from January to August2023. Participants were required to have no acute injuries or history of lower extremity musculoskeletal surgery
in the past 12 months. Before participation, both players and coaches were informed of the potential risks andprovided informed consent. Injury history data were collected through interviews and physiotherapist
examinations, which included details about the player's profile, injury location, and the side of the previously
injured limb. This study received approval from the Health Research Ethics Committee of the Faculty of
Medicine, Universitas Airlangga, under approval number No. 48/EC/KEPK/FKUA/2024.
Procedure and protocol test
Hamstring eccentric strength was assessed using the Nordic bilateral hamstring test with the NordBord
hamstring testing device (VALD Performance, Australia). This device has demonstrated moderate to high test–
retest reliability, with an intraclass correlation coefficient (ICC) of 0.83–0.90 for eccentric knee flexor strength,
and is commonly used in athlete populations (Almousa et al., 2023; Bishop et al., 2022). Before testing,participants performed a dynamic stretching warm-up for 5 min. During the test, players performed maximal
Nordic hamstring movements in one set of three repetitions, with a 5–10 s rest between repetitions. Participants
were instructed to kneel on the padding of the NordBord device, with a support hook positioned over the lateralmalleolus. They were instructed to maintain hip and lumbar extension during the test while leaning forward as
slowly as possible. This position was maintained maximally using both feet, with their hands ready to support
their body as they approached the floor. After completing each repetition, participants were asked to return to thestarting position before performing the next repetition. The maximum strength values for the right and left limbs,
derived from the three repetitions, were measured in Newtons (N), which can be converted to the basic unit ofkg/m2. Muscle strength imbalance between the right and left limbs was calculated as the percentage difference instrength values between the stronger and weaker limbs (0% indicates no imbalance, while values greater than 0%
indicate the dominance of strength on either the right or left side) (Benson et al., 2024; Bishop et al., 2022;
Claudino et al., 2021).
Statistical analysis
The data were analyzed using SPSS software, which provided both descriptive statistics (mean ±standard deviation) and assessments of normality. For statistical analysis, the independent T-test was used forparametric data, while the Mann–Whitney test was employed for non-parametric data. Statistical significancewas set at p < 0.05.
Results
A total of 82 young handball players (46 males and 36 females) were divided into gender-specificgroups based on their injury history. Of these players, 65% (53 players) had experienced a lower extremity
injury, including 31 males and 22 females. In the male group, the position with the highest number of injuries
was the wink position (n = 14), while in the female group, the backcourt position had the most injuries (n = 9)
(Figure 1). According to Table 1, there were no significant differences in anthropometric characteristics (age,----------------------------------------------------------------------------------------------------------------------------1979
JPES ® www.efsupit.roNURA MAULIDA ISNA, OVIESTA TASHA RETYANANDA, BAYU PRASTOWO, MUHAMMAD REZAAZIZ PRASETYA, SYI’AR APRILLA TANAZZA, AWANG FIRMANSYAH, DWIKY OKTAVRIANTO,GADIS MEINAR SARI, LILIK HERAWATI--------------------------------------------------------------------------------------------------------------------------------------weight, height, and body mass index) between the injured and uninjured groups in both male and female
categories.

Figure 1. Distribution of previously injured limb by player position in male and female handball players
Table 1. Participant characteristics
Male
FemalePreviously
Previously
p-valuep-value
Variable
Uninjured
Uninjuredinjuredinjured(n = 15)(n = 14)(n = 31)(n = 22)18.42 ± 2.13
18.73 ± 2.55
0.662
18.95 ± 2.15
17.79 ± 1.48
0.084
Age (year)
66.47 ± 13.78 64.19 ± 14.64 0.981
58.63 ± 10.74 60.25 ± 9.29
0.573
Weight (kg)172.68 ± 5.75 172.27 ± 5.69 0.367
163.00 ± 7.14 161.50 ± 6.44 0.528
Height (cm)21.62 ± 4.71
0.379
21.95 ± 2.57
23.11 ± 3.38
0.249
BMI (kg/m2) 22.20 ± 3.74
Data are presented as mean ± SD; BMI: Body mass index; p-values were calculated using theindependent t-test and Mann–Whitney test.
Maximum eccentric hamstring force
Table 2 details the differences in hamstring eccentric force between females and males based on injury
history. The analysis revealed no significant differences in maximum eccentric hamstring force in each gender
based on injury history. However, it was noted that both male and female handball players with previous injuries
exhibited higher hamstring eccentric strength values compared to those without injuries. Additionally, maleplayers demonstrated a higher mean value of maximum eccentric hamstring force compared to female players.
Table 2. Eccentric hamstring force by gender and injury history
Maximum hamstring eccentric force (MHF)nRight MHF (N)Left MHF (N)∆ MHF (N)Imbalance
MHF (%)

Male
Previously injured 31 284.27 ± 64.99
269.06 ± 62.43 30.24 ± 18.86 10.72 ± 7.01
Uninjured15 264.42 ± 53.70
264.67 ± 54.26 7.58 ± 7.34
2.95 ± 2.90
0.311
0.817
0.000*
0.000*
p-value
FemalePreviously injured 22 205.66 ± 61.08
203.36 ± 56.67 20.02 ± 13.70 9.49 ± 6.81
Uninjured
14 191.80 ± 44.53
193.16 ± 45.93 5.25 ± 6.37
2.51 ± 2.59
0.469
0.576
0.000*
0.000*
p-value
Data are presented as mean ± SD. MHF: Maximum hamstring force. N: Newton; ∆: Delta. (*)
Indicates a significant difference from the Previously injured group (p ≤ 0.05).
Imbalance in asymmetrical eccentric hamstring strength
During the eccentric hamstring test, limb asymmetry was measured by comparing the force generated
between the right and left limbs. Table 2 indicates that the delta data and the percentage of maximum eccentric
hamstring force imbalance significantly differed between groups with and without previously injured
individuals. Specifically, in males, the imbalance was 10.72 ± 7.01% in those with previous injuries compared to2.95 ± 2.90% in those without (p = 0.000). In females, the imbalance was 9.49 ± 6.81% for those with previous
injuries versus 2.51 ± 2.59% for those without (p = 0.000).
1980---------------------------------------------------------------------------------------------------------------------------JPES ® www.efsupit.roNURA MAULIDA ISNA, OVIESTA TASHA RETYANANDA, BAYU PRASTOWO, MUHAMMAD REZAAZIZ PRASETYA, SYI’AR APRILLA TANAZZA, AWANG FIRMANSYAH, DWIKY OKTAVRIANTO,GADIS MEINAR SARI, LILIK HERAWATI--------------------------------------------------------------------------------------------------------------------------------------Discussion
The high rate of injury among handball players is an important issue that requires efforts to improve thequality of life by reducing injury incidence during competition or training. Extensive research on injury
prevention has highlighted the importance of hamstring muscle eccentric strength parameters (Almeida et al.,2018; Bishop et al., 2022; Hu et al., 2023). This handball study yielded several key findings. First, male handball
players demonstrated higher maximum hamstring eccentric force values compared to females. Second, playerswith a history of injury had higher maximum hamstring eccentric force values than those without injuries. Third,
there was no significant difference in maximum hamstring eccentric force between the male and female groups.
Fourth, the percentage of hamstring eccentric force imbalance in each group significantly differed from that of
the uninjured group.
Eccentric hamstring strength in male athletes can be influenced by various factors, including training
modifications, techniques, and injury history (Alt et al., 2023). The results of this study are consistent withprevious research, which indicates that male handball players typically exhibit higher maximum eccentric
strength compared to females (Opar et al., 2015; Timmins et al., 2016). This disparity in hamstring muscle
strength between genders is attributed to differences in body composition, hormonal levels, muscle fiber types,
and individual factors such as training history and physical activity levels (Nuzzo, 2023). Muscle strength resultsfrom training adaptations that impact the body's physiological systems, including the action of testosterone, theprimary anabolic hormone that stimulates protein synthesis and inhibits protein degradation in muscles throughandrogen receptors (Gharahdaghi et al., 2020; Xu et al., 2021). Athletes who regularly engage in strength
training and possess extensive sports experience are typically better equipped to optimize their training toenhance muscle strength. These athletes often demonstrate improved muscle strength owing to adaptations inboth the muscular and neurological systems (Benson et al., 2024). Other studies have indicated that absolutehamstring eccentric strength can be influenced by factors such as age, body mass, and body composition balance,
contributing to higher maximum hamstring muscle strength values in male handball players (Buchheit et al.,2016; Jeanguyot et al., 2023).
Previous research has found that athletes with hamstring injuries lasting more than three weeks often
exhibit weakness in the injured limb compared to the uninjured limb (Palermi et al., 2023; Vicens-Bordas et al.,2020). However, this study found different results, showing no significant differences in maximum eccentric
hamstring force between genders based on injury history. This contrasts with earlier studies, which reported a
reduction in hamstring eccentric strength in athletes with previous injuries compared to those without suchinjuries. These findings may be associated with the prevalence of wing and backcourt players in the injury group.
Previous research has indicated that wing players in handball, who frequently engage in rapid direction changes
and high-intensity running, typically exhibit higher lower limb muscle strength (Fort-Vanmeerhaeghe et al.,2020; Gaamouri et al., 2023). Similarly, backcourt players also demonstrate greater lower limb strength, which is
crucial for jumping movements used to defend and block opponents' shots effectively (Gaamouri et al., 2023).
This optimal lower limb strength may have led to the injured group displaying higher muscle strength values
compared to the uninjured group.
Muscle imbalances in athletes with a history of injuries are a common issue that can increase the risk of
re-injury or new injuries. Athletes who have experienced hamstring injuries may be particularly vulnerable tostrength imbalances owing to changes in muscle activation patterns after the injury. These changes cannegatively impact movement biomechanics and strength performance (Kwak & Oh, 2023; Palermi et al., 2023).
A study of young female handball athletes found that muscle imbalances, particularly hamstring weakness, aremore prevalent than quadriceps imbalances and can increase the risk of musculoskeletal injuries (Almousa et al.,2023; Collings et al., 2021; Wiprich et al., 2022). This finding aligns with previous research, which indicates thatthe percentage of eccentric hamstring force imbalance is significantly higher in both male and female athleteswith a history of injuries compared to those without such injuries (Benson et al., 2024; Bishop et al., 2022; Opar
et al., 2015). Long-term hamstring strength imbalances can lead to compensatory mechanisms, chronic pain, andfatigue, which can worsen the issue and increase the risk of injury (Benson et al., 2024; Kwak & Oh, 2023;
Palermi et al., 2023). This underscores the need for handball teams to carefully assess and address muscle
imbalances, particularly after injuries, to reduce the risk of re-injury or new injuries. Such measures are crucial
for preventing negative impacts on both individual players and the team as a whole.
Conclusions
In this study, differences in maximal hamstring eccentric strength based on injury history wereprimarily observed in the values of limb-side comparisons and bilateral asymmetry. The mean maximum
hamstring eccentric strength values for both the right and left sides were higher in the injured group. This can be
attributed to factors such as player position, the rehabilitation process, training factors, body composition, thelevel of handball training, and an understanding of the importance of hamstring muscle strength. The highpercentage of imbalance in some athletes highlights the need for targeted muscle strength training to reduce its
negative impact on performance. When assessing physical performance, it is crucial to account for specific----------------------------------------------------------------------------------------------------------------------------1981
JPES ® www.efsupit.roNURA MAULIDA ISNA, OVIESTA TASHA RETYANANDA, BAYU PRASTOWO, MUHAMMAD REZAAZIZ PRASETYA, SYI’AR APRILLA TANAZZA, AWANG FIRMANSYAH, DWIKY OKTAVRIANTO,GADIS MEINAR SARI, LILIK HERAWATI--------------------------------------------------------------------------------------------------------------------------------------characteristics such as coaching background, length of experience, and history of training programs for eachhandball player. Further research is needed to explore the factors influencing physical performance in handball
players, particularly those with a history of injury. Additionally, establishing normative data and standardizing
maximum hamstring muscle strength measurements will be important for providing accurate references andbenchmarks for handball athletes.
Acknowledgments
We would like to thank the Indonesia Handball Association and KineticX Sport Science & Body
Performance for their collaboration in obtaining the data. The authors would like to thank Falcon Scientific
Editing (https://falconediting.com) for proofreading the English language in this paper.
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