FORWARD LUNGE: A TRAINING STUDY OF ECCENTRIC EXERCISES OF THE LOWER LIMBS

SVEN JONHAGEN,1,2 PAUL ACKERMANN,3,4

1

AND

TONU SAARTOK4,5

Department of Orthopaedics, Stockholm Soder Hospital, Stockholm, Sweden; 2Institutionen Sodersjukhuset, Karolinska Institutet, Stockholm, Sweden; 3Department of Orthopaedics, Karolinska Hospital, Stockholm, Sweden; 4Section of Sports Medicine, Department of Surgical Sciences, Karolinska Institutet, Stockholm, Sweden; and 5Department of Orthopaedic Surgery, Visby Hospital, Visby, Sweden

ABSTRACT
Jonhagen, S, Ackermann, P, and Saartok, T. Forward lunge: a training study of eccentric exercises of the lower limbs. J Strength Cond Res 23(3): 972978, 2009A few studies have shown that eccentric exercise is effective for prevention and treatment of muscle injuries. Most earlier studies on eccentric exercises have used training with advanced equipment. Forward lunges are considered eccentric exercises, and they may be performed without any equipment. These exercises are commonly used by sprint runners. We performed a prospective, randomized, 6-week training study comparing the effects of walking or jumping forward lunges on hamstring and quadriceps strength and function. Thirty-two soccer players were included in the study. The forward lunge training was done as an addition to ordinary soccer training twice a week for 6 weeks. The outcome was measured by the maximal hamstring and quadriceps strength tests and by functional tests with 1-leg hop tests and 30-m sprint runs. Overall muscle pain was evaluated using a visual analogue scale score, and local pain was estimated with an algometer. Whereas the walking lunge improved hamstring strength, the jumping lunge resulted in sprint running improvements. Algometer testing showed a general increase in the pain detection thresholds of all subjects, including the controls. Thus, precautions should be taken when algometers are used for temporal studies of pain. Walking and jumping forward lunges can be used for improving hamstring strength and running speed in young soccer player. The ndings may have relevance when designing protocols for prevention and rehabilitation of muscle injuries.

INTRODUCTION

KEY WORDS athletic, algometer, hamstring, sprinting, isokinetic,

quadriceps

Address correspondence to Sven Jonhagen, sven.jonhagen@telia.com. 23(3)/972978 Journal of Strength and Conditioning Research 2009 National Strength and Conditioning Association

uscle injuries can be debilitating for active sports participants. We have previously shown that sprint runners with a history of hamstring injuries have decreased eccentric hamstring strength (12), which is also conrmed by Croisier et al. (8). Thus, decreased eccentric strength may be a risk factor for muscle injury. In prospective, randomized clinical trials, eccentric exercises have shown good results in the rehabilitation of, for instance, Achilles (9,1921) and patellar tendinopathy (15), as well as chronic lateral epikondylalgia (22). Eccentric exercise is prone to give delayed-onset muscle soreness (DOMS) with a peak at 2472 hours post exercise (1,10). There is a cellular response to eccentric exercise that includes initial tissue breakdown, followed by upregulation of the muscle protein desmin, inltration of inammatory cells, and increased permeability of the cell membrane (16). Yu et al. (25) have proposed that the DOMS after eccentric exercise may reex the myobril remodeling. The DOMS is also characterized by a signicant loss of maximal muscular strength directly after intensive exercise (5,11). Recently, eccentric hamstring training has been shown effective as a rehabilitation treatment for hamstring injuries (8), and, in another study, hamstring training has been suggested to be effective in the prevention of hamstring injuries (2). However, both these studies were performed using advanced equipment that normally is available only at certain special training centers. Thus, there is a need for studies of specic eccentric exercises, which do not require advanced equipment. In fact, one training method that athletes, especially sprint runners, commonly usethe so-called Nordic hamstringhas recently been demonstrated to increase eccentric hamstring strength more effectively than training with a dynamometer (13). We believe that the athletic community can help us in our search for new rehabilitation methods. Different kinds of forward lunges represent a training method that is widely used by athletes, especially sprint runners and jumpers. Athletic coaches consider this training to be a very strenuous

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exercise, and it is believed to act eccentrically both with regard to the quadriceps and the hamstring muscles, when breaking the ground forces. Forward lunges are performed as closed kinetic chains, which have been found to be superior to open kinetic chains when strength and functional parameters are measured (3). In this study, we investigated the acute and long-term effects of 2 kinds of forward lunges: the walking forward lunge (WFL) and the jumping forward lunge (JFL). The forward lunges are shown in Figure 1. First, the acute effects of training on performance and pain parameters were studied directly after exercise. Second, 2 days after the initial exercise, the same parameters were studied; this time period reects the impact of DOMS. Third, after a 6-week period of training, the effects on strength and performance of these 2 training regimens were examined.

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controls, were instructed to document all their daily training in a training diary. A test leader supervised the rst training session to ensure that the exercises were done correctly. For quality control, the exercises were also lmed during the supervision. After 3 weeks, another supervised training session was held, this time without lming. Evaluations of strength, functional, and pain parameters were done at 4 occasions: 1) immediately before and 2) after the rst exercise, 3) after 2 days, and 4) after 6 weeks. The subjects were instructed not to do any hard strength training 5 days before the rst and last testing sessions.
Subjects

METHODS
Experimental Approach to the Problem

The study was performed during the off-season for soccer in Sweden, from January to March. All subjects were randomized into 1 of 3 study groups. The WFL group (n = 11) performed WFLs, doing 4 sets with 12 repetitions twice a week after their ordinary training sessions. The JFL group (n = 10) performed JFLs, doing 4 sets with 12 repetitions twice a week after their ordinary training sessions. Controls (n = 11) completed their ordinary training without any intervention and, thus, served as a control group. The ordinary training was focused on general physical training during this period and included aerobic and strength training as well as speed and technical skills. Training was scheduled for 35 times a week. All players, including

Forty players in a local junior male soccer team were personally invited to participate in the study. Without giving any reason, 6 players chose to decline, and another 2 were excluded, 1 because of fever and the other because of a sprained ankle. Thus, 32 players were included. Four subjects did not perform the last test because of illness or injury unrelated to this study. Thus, 28 subjects performed all the tests and completed the study. The mean (range) age of the subjects was 18 (1720) years, their average height was 178 (166190) cm, and their mean body weight was 68 (53 82) kg. They were all well trained and had been in organized training for at least 5 years. All subjects of the study gave their written informed consent. The ethical committee at the Karolinska Institutet approved the study (03-776).
Maximal Strength Testing on a Biodex Dynamometer

Warming up included 600 m of jogging, mild stretching of the hamstrings and quadriceps, and 5 submaximal squat jumps. The subjects were thereafter seated on a Biodex isokinetic

Figure 1. Walking (a) forward lunge and jumping (b) forward lunge.

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dynamometer (Biodex Medical Systems, Shirley, NY) with a hip angle of 100. The hip and the nondominant leg that was to be examined were anchored to the bench by belts to avoid extra movements. The dominant leg was dened as the leg with which the player preferred to kick the football. During the tests, each subject held his arms folded over his chest. The motion axis of the Biodex was aligned with the bilateral motion axis of the knee joint. The lower leg was placed in the resistance arm, and the angle was calibrated with a plumb line. Concentric peak torque was tested at 180s21 for both the hamstring and quadricep muscle groups. During the test, each subject rst acquainted himself with the machine by doing a few submaximal trials, followed by 3 maximal test contractions. The test started with the quadriceps, followed by the hamstrings. The subjects were encouraged verbally and got feedback on their performance by following the torque curve displayed on the screen. The torque between 10 and 90 of knee exion was measured, and the highest peak torque value of the 3 trials was recorded.
Sprint Test Pain Evaluation Using an Algometer

A special algometer (A J Tech Commander Algometer, Kom Kare Co., Middletown, Ohio), with a point diameter of 9 mm, was used to estimate pressure pain in 8 dened muscle points of the dominant leg (Figure 2). Initially, the points were marked with a pen. The test leader pressed the algometer perpendicularly on the marked points while slowly increasing the pressure. Two values during a single pressure were recorded for each point. The rst value was the pressure of the algometer when the subject started to feel painthe pain detection threshold. The second value was the pressure of the algometer when the subject could not stand the pain any morethe pain tolerance threshold. For safety reasons, the maximal pressure of the algometer is 25 N. In the majority of the recordings, the subjects scored 25 N at the second valuethe pain tolerance threshold. The second value could, thus, not be used for statistical analysis. We therefore calculated the probability to score 25 at the rst valuethe pain detection threshold.
Statistical Analyses

Each subject performed 2 maximal 30-m sprints, after an initial acceleration distance of another 30 m. Electric timing was measured by photocells. The athletes used ordinary training shoes and ran on an indoor rubber track. They rested for about 3 minutes between races. The result of the fastest sprint was recorded.
One-Leg Hop Test

A linear mixed model was used to evaluate the differences between the randomized groups with regard to the

Each subject made 3 maximal 1-leg horizontal long jumps on the dominant leg (17). Ordinary training shoes were used, and the ground surface was an indoor rubber track. They were allowed to move their arms freely, but they were not allowed to lift their heels before takeoff. The best result was recorded, measured from the toes at toe-off to the heels at landing.
Pain Evaluation Using a Visual Analogue Scale

During the hop test, each subject also scored his pain in the jumping leg, on a visual analogue scale (VAS), with marks numbered from 0 to 10. The subjects were instructed that, on this scale, 0 was no pain or discomfort, and 10 indicated the worst pain imaginable.

Figure 2. Muscle point tested with algometer. a) Gluteus medius, b) 3 cm distal to tuber ishiadicum, c) bulk of medial hamstrings, d) bulk of lateral hamstrings, e) medial hamstrings 10 cm proximal to knee joint, f) lateral hamstrings 10 cm proximal to knee joint, g) belly of rectus femoris, and h) rectus femoris 5 cm proximal to patella.

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4 continuous outcome variables (hamstring and quadriceps strength, sprint performance, and 1-leg long jump test). The time effect was also taken into account. Because of differences at baseline, the following ratio was used in place of the original data values:

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Tx T0 T x T 0 2 Because of unequal variances for the time measures, a heterogeneous compound symmetry covariance structure was tted to each model. Different variance components were also estimated for each randomized group. For the outcome variable of hamstring strength, 1 observation was marked as having an extreme value and, hence, excluded from the analysis. For the same reason, another observation was excluded from the jump test. For the ordinal variable of the algometry score, a proportional odds model was set up to evaluate the differences between randomized groups and the Ratio

time effect. The differences in pain score, between randomized groups at the time points after and 2 days, were analyzed using the Kruskal-Wallis nonparametric test. All pairwise comparisons were adjusted using either the Bonferroni or Tukey criterion. A p value # 0.05 was considered to be statistically signicant. Spearman rank was used for correlation between VAS after 2 days and change in functional parameters.

RESULTS
Twenty-eight subjects completed the whole study. The testing equipment worked well, and the dropouts (n = 2) were attributable to injuries or diseases without relation to the study.
Hamstring Strength Testing

Results from maximal concentric hamstring strength testing are shown in Figure 3. The WFL group improved their concentric hamstring strength by 35% after 6 weeks of training, from 92 Nm before the study period to 124 Nm at the end (p , 0.001). The WFL group also showed a signicant increase in strength at day 2 compared with baseline; the mean strength at day 2 was 107 Nm (p , 0.01). The JFL group had a mean hamstring strength of 103 Nm at the start and 121 Nm after 6 weeks of training (NS). The control group had a hamstring strength of 102 Nm at baseline and 112 Nm (NS) after the 6-week period. There were no signicant differences between the training groups during the 6-week period.
Quadriceps Strength Testing

Immediately after the rst training, all groups showed signicant decreases in quadriceps strength, even the control

Figure 3. Muscle torque (Nm) in hamstrings (a) and quadriceps (b) before and after rst training session, 2 days after rst training session, and after 6 weeks of training. The WFL group performed walking forward lunges, and the JFL group performed jumping forward lunges in addition to their ordinary training. Controls did not do any extra training.

Figure 4. Thirty-meter maximal running time (1/100 second) before and after rst training session, 2 days after rst training session, and after 6 weeks of training. The WFL group performed walking forward lunges, and the JFL group performed jumping forward lunges, in addition to their ordinary training. Controls did not do any extra training.

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group (Figure 3). The WFL group had a decrease from 171 to 162 Nm (p , 0.05), the JFL group had a decrease from 150 to 132 Nm (p , 0.001), and the control group had a decrease from 169 to 157 Nm (p , 0.05). At 2 days, the JFL and control subjects still had signicant decreases in quadriceps strength compared with baseline, with mean results of 133 Nm (p , 0.05) and 156 Nm (p , 0.001), respectively. The WFL and JFL training groups had no signicant improvements in quadriceps concentric strength after the 6-week training period. The control group, however, was weaker in the quadriceps after 6 weeks; they performed 169 Nm at the beginning and 158 Nm at the end (p , 0.01). No differences were found when comparing the training groups with each other.
Sprint Running

performance by 2%, and the control group increased its performance by 1% (NS). Only the improvement by the JFL group compared with baseline was signicant (p , 0.001); there were no differences between groups. Immediately after the exercises, sprint running performance decreased by 2% in the WFL group and by 4% in the JFL group, but it decreased only by 1% in the control group. The difference between the JFL and control groups was signicant (p , 0.01).
Jumping Performance

Sprint running maximal speed was tested during a 30-m sprint (Figure 4). The WFL group increased its performance by 3% (NS) after 6 weeks of training, the JFL group increased its

All 3 groups improved their jumping performance in the 1-leg hop test after 6 weeks, but there were no differences between groups. The WFL group improved their mean performance at 6 weeks compared with baseline, from 198 to 212 cm (p , 0.001). The JFL group improved from 191 to 205 cm (p , 0.01), and the control group improved from 186 to 198 cm (p , 0.001).
Pain Measured by Visual Analogue Scale

Overall muscle pain measured by VAS was analyzed during the 1-leg jump test (Figure 5). The WFL group increased their mean VAS from 0.2 to 1.6 immediately after the exercise, whereas the mean VAS increased from 0.4 to 3.3 in the JFL group and from 0.3 to 0.6 in the control group. The difference between the JFL group and controls was statistically signicant (p , 0.01). After 2 days, the VAS for the WFL group was 2.9, and for the JFL group it was 3.5. The VAS for the control group was 1.3. The number of subjects was too small to show any group differences in VAS between the study groups. There were signicant (p , 0.05 and p , 0.01) correlations between increase in VAS after 2 days and loss of function in running (r = 0.49) and jump (r = 0.39). However, no such correlation was found in strength parameters.

Figure 5. Pain scored by VAS (number of subjects) directly after the rst training session (a) and 2 days after the rst training session (b). The WFL group performed walking forward lunges, the JFL group performed jumping forward lunges, and controls did not do any training (but they were tested with strength tests).

Figure 6. Probability to score maximum value (25) in algometer pain testing for the control group. Before exercise (1), directly after (2), after 2 days (3), and after 6 weeks (4). There is a gradual adaptation to the algometer testing. Eight different muscle points are tested.

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TABLE 1. Probability to score 25 (pain detection threshold) 2 days after walking forward lunge, jumping forward lunge, and controls for different muscle points. Muscle point Gluteus medius Distal lat hamstring Rectus femoris Distal to tuber ishii Lateral hamstring Distal med hamstring Medial hamstring Distal rectus femoris Walking Jumping lunge lunge Controls 0.31 0.32 0.41 0.49 0.57 0.63 0.64 0.66 0.22 0.23 0.30 0.37 0.46 0.51 0.52 0.55 0.51 0.52 0.61 0.68 0.76 0.79 0.80 0.82

Pain Measured by Algometer

We found that the probability to score 25 increased signicantly during the testing period (Figure 6). The odds ratio between the rst and the fourth test sessions was 3.3 (p , 0.0001). There were also signicant differences between the points that were tested. Gluteus medius was least tolerable to pressure pain, and the most tolerable point was 5 cm proximal to the patella. The probability values of scoring 25 at 2 days after exercise, for each group and point, are shown in Table 1.

DISCUSSION
Junior soccer players underwent a 6-week training study of 2 types of forward lunge. No differences could be found between the study groups. This can be explained by the power, by the fact that the number of subjects was too small to detect differences, or by the fact that that the intervention was done during too short a period. However, compared with baseline, the WFL group improved the hamstring strength, whereas the JFL group improved the performance of sprint running. Different kinds of forward lunges are considered by athletic coaches to be very strenuous. These exercises also are thought to be eccentric when breaking the ground forces at the rst part of the stance phase. One typical characteristic of an eccentric exercise is the loss of strength after an intense bout of contractions (5,11). Immediately after exercise, the JFL group exhibited decreased hamstring concentric strength as compared with baseline (Figure 3a), indicating that the work performed by the hamstring muscles during the JFLs was strenuous and/or eccentric. This nding was supported by the signicantly decreased sprint performance in the JFL group, compared with the control group (Figure 4), right after exercise. All 3 groups, including the control group, demonstrated signicant decreases in quadriceps strength immediately after training (Figure 3b). This was probably caused by exhaustion from the testing procedure itself.

Even though the subjects were randomized by lot to either training group, there were differences in baseline values. There were no differences between the groups in anthropometric data that could explain the minor differences in baseline values for the various tests. In this study, no eccentric strength testing on the Biodex was performed. We did not want the testing procedure itself to produce extra eccentric training because it is known that 1 bout of eccentric exercise can have a major impact on muscle adaptation (7). We believe that the sprint test represents a good test of eccentric muscle function (2), and thus we included functional testing, which is also recommended by other authors (4,18). Concentric strength testing is, however, less interchangeable than functional testing (14). Another characteristic of eccentric exercise, especially if it is unaccustomed, is the DOMS that typically occurs after 2 days. After 2 days, the VAS pain scoring for the WFL and JFL groups was 2.9 and 3.5, respectively, whereas this score for the control group was only 1.3. The number of subjects, however, was too small to show any statistically signicant difference between groups. As can be seen in Figure 5b, about half (n = 10) of the subjects from the WFL and JFL groups scored very high (VAS = 57) after 2 days and, thus, seemed to experience a distinct DOMS, whereas the other half (n = 11) scored very low (VAS = 02). It could be speculated that different preparations explain this phenomena; that is, those who did not have any DOMS may have been used to similar exercises earlier. Interestingly, DOMS had a negative impact on functional parameters such as running and jumping, but it had no impact on strength parameters. We wanted to nd out whether there were differences in pain perceptions from different muscles and different parts of the muscles using the algometer. The algometer has been used in studies of muscle pain (23), and it has been shown to have acceptable reproducibility (6). We found that those young soccer players were able to tolerate pressure pain very well. Interestingly, the probability of scoring 25 N increased signicantly during the testing period. Thus, it seems that the subjects were able to tolerate pain better with time. This contradicts, in some aspects, the good reproducibility of the algometer reported above (6). Earlier studies (24), though, have shown similar phenomena when measuring pain thresholds with heat. However, as far as we know, this has not been reported earlier concerning pressure algometers. This nding is important to consider if the algometer is used to evaluate treatment for pain in clinical studies. After 6 weeks of training, the WFL group had a 35% increase in concentric strength of the hamstrings, an increase that is surprisingly high. In the study of the Nordic hamstring exercise (13), soccer players increased their isometric hamstring strength by 7% and their eccentric strength by 11% after a 10-week training period. This difference may be explained by the age and level of the players; we used junior players, but in the Norwegian study the
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participants were probably older than ours and, possibly, more trained. Neither of the groups increased their quadriceps strength signicantly, but the control group had a signicant decrease (27%) of their quadriceps strength. This is difcult to explain because one would think that these adolescent athletes would increase their muscle strength by their ordinary soccer training. The players who trained using JFLs had a small but signicant increase in sprint performance after the 6-week training period. The exercise also gave cause to a signicant acute soreness and decrease in sprint performance directly after the rst training session compared with controls. Thus, it seems that the JFL training method might have a signicant impact on sprint performance. Surprisingly, algometer testing itself increases the possibility for tolerating pressure pain. This is important to consider when using algometers in clinical trials.
7. Crameri, RM, Langberg, H, Teisner, B, Magnusson, P, Schroder, HD, Olesen, JL, Jensen, CH, Koskinen, S, Suetta, C, and Kjaer, M. Enhanced procollagen processing in skeletal muscle after a single bout of eccentric loading in humans. Matrix Biol 23: 259264, 2004. 8. Croisier, JL, Forthomme, B, Namurois, MH, Vanderthommen, M, and Crielaard, JM. Hamstring muscle strain recurrence and strength performance disorders. Am J Sports Med 30: 199203, 2002. 9. Fahlstrom, M, Jonsson, P, Lorentzon, R, and Alfredson, H. Chronic Achilles tendon pain treated with eccentric calf-muscle training. Knee Surg Sports Traumatol Arthrosc 11: 327333, 2003. 10. Friden, J, Sjostrom, M, and Ekblom, B. A morphological study of delayed muscle soreness. Experientia 37: 506507, 1981. 11. Jonhagen, S, Ackermann, P, Eriksson, T, Saartok, T, and Renstrom, PA. Sports massage after eccentric exercise. Am J Sports Med 32: 14991503, 2004. 12. Jonhagen, S, Nemeth, G, and Eriksson, E. Hamstring injuries in sprinters. The role of concentric and eccentric hamstring muscle strength and exibility. Am J Sports Med 22: 262266, 1994. 13. Mjolsnes, R, Arnason, A, Osthagen, T, Raastad, T, and Bahr, R. A 10-week randomized trial comparing eccentric vs. concentric hamstring strength training in well-trained soccer players. Scand J Med Sci Sports 14: 311317, 2004. 14. Ostenberg, A, Roos, E, Ekdahl, C, and Roos, H. Isokinetic knee extensor strength and functional performance in healthy female soccer players. Scand J Med Sci Sports 8: 257264, 1998. 15. Panni, AS, Tartaroni, M, and Maffulli, N. Patellar tendinopathy in athletes. Outcome of nonoperative and operative management. Am J Sports Med 28: 392397, 2000. 16. Peters, D, Barash, IA, Burdi, M, Yuan, PS, Mathew, L, Friden, J, and Lieber, RL. Asynchronous functional, cellular and transcriptional changes after a bout of eccentric exercise in the rat. J Physiol 553: 947957, 2003. 17. Petschnig, R, Baron, R, and Albrecht, M. The relationship between isokinetic quadriceps strength test and hop tests for distance and one-legged vertical jump test following anterior cruciate ligament reconstruction. J Orthop Sports Phys Ther 28: 2331, 1998. 18. Pincivero, DM, Lephart, SM, and Karunakara, RG. Relation between open and closed kinematic chain assessment of knee strength and functional performance. Clin J Sport Med 7: 1116, 1997. 19. Roos, EM, Engstrom, M, Lagerquist, A, and Soderberg, B. Clinical improvement after 6 weeks of eccentric exercise in patients with mid-portion Achilles tendinopathya randomized trial with 1-year follow-up. Scand J Med Sci Sports 14: 286295, 2004. 20. Shalabi, A, Kristoffersen-Wilberg, M, Svensson, L, Aspelin, P, and Movin, T. Eccentric training of the gastrocnemius-soleus complex in chronic Achilles tendinopathy results in decreased tendon volume and intratendinous signal as evaluated by MRI. Am J Sports Med 32: 12861296, 2004. 21. Silbernagel, KG, Thomee, R, Thomee, P, and Karlsson, J. Eccentric overload training for patients with chronic Achilles tendon paina randomised controlled study with reliability testing of the evaluation methods. Scand J Med Sci Sports 11: 197206, 2001. 22. Svernlov, B and Adolfsson, L. Non-operative treatment regime including eccentric training for lateral humeral epicondylalgia. Scand J Med Sci Sports 11: 328334, 2001. 23. Waling, K, Sundelin, G, Ahlgren, C, and Jarvholm, B. Perceived pain before and after three exercise programsa controlled clinical trial of women with work-related trapezius myalgia. Pain 85: 201207, 2000. 24. Yarnitsky, D, Sprecher, E, Zaslansky, R, and Hemli, JA. Multiple session experimental pain measurement. Pain 67: 327333, 1996. 25. Yu, JG, Carlsson, L, and Thornell, LE. Evidence for myobril remodeling as opposed to myobril damage in human muscles with DOMS: an ultrastructural and immunoelectron microscopic study. Histochem Cell Biol 121: 219227, 2004.

PRACTICAL APPLICATIONS
Forward lunges are easy to perform in the open eld without any specic equipment. There are many types of lunges. In conclusion, we have found that a 6-week period of training with WFLs improved hamstring strength, whereas training with JFLs improved sprint running performance. Thus, different kinds of forward lunges are benecial for different muscle properties and could be included in training programs for young soccer players. For example, junior soccer players may include 2 3 12 WFLs and 2 3 12 JFLs twice a week in their ordinary training during the off-season. These exercises can be performed on the soccer eld.

ACKNOWLEDGMENTS
This study was supported by the Swedish Sports Research Council (grant 135-04) and the Karolinska Institute foundations. We wish to thank physiotherapists Jenny Fridh and Linda Waara for skilful technical assistance. Jacob Bergstrom KI Lime is acknowledged for help with the statistical work. Illustrations are made by Lars Gyldorf and Eva Hall. There are no conicts of interest.

REFERENCES
1. Armstrong, RB, Warren, GL, and Warren, JA. Mechanisms of exercise-induced muscle bre injury. Sports Med 12: 184207, 1991. 2. Askling, C, Karlsson, J, and Thorstensson, A. Hamstring injury occurrence in elite soccer players after preseason strength training with eccentric overload. Scand J Med Sci Sports 13: 244250, 2003. 3. Augustsson, J, Esko, A, Thomee, R, and Svantesson, U. Weight training of the thigh muscles using closed vs. open kinetic chain exercises: a comparison of performance enhancement. J Orthop Sports Phys Ther 27: 38, 1998. 4. Augustsson, J and Thomee, R. Ability of closed and open kinetic chain tests of muscular strength to assess functional performance. Scand J Med Sci Sports 10: 164168, 2000. 5. Byrne, C, Eston, RG, and Edwards, RH. Characteristics of isometric and dynamic strength loss following eccentric exercise-induced muscle damage. Scand J Med Sci Sports 11: 134140, 2001. 6. Chesterton, LS, Barlas, P, Foster, NE, Baxter, GD, and Wright, CC. Gender differences in pressure pain threshold in healthy humans. Pain 101: 259266, 2003.

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