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Assessment of Hamstring Muscle

Length in School-aged Children Using


the Sit-and-ReachTest and the
Inclinometer Measure of
Hip Joint Angle
Background and Purpose. The sit-and-reach test (SRT) is commonly
used to assess flexibility of the spine and length of the hamstring
muscles. The purposes of this study were (1) to describe hamstring
muscle length as reflected by use of the SRT and the hip joint angle
(HJA) in children, (2) to examine the correlation between SRT and
HJA measurements, and (3) to examine gender differences for both
measures. Subjects. The participants were 410 school-aged children
(211 girls, 199 boys). Methods. Each child performed the SRT. In the
final position, the SRT score was obtained and the HJA was measured
using an inclinometer placed over the sacrum. Results. A mean SRT
value of 24 cm and a mean HJA value of 81 degrees were obtained for
all subjects. There was a strong correlation between the SRT and HJA
measurements ( ~ . 7 6 )There
. was a difference between boys and girls
for both measures. Conclusion and Discussion. The results suggest
differences in expectations for hamstring muscle length in boys and
girls. Although scores for the SRT and HJA were correlated, we prefer
to assess hamstring muscle length using HJA scores because these
scores are not influenced by anthropometric factors o r spinal mobility.
The results of this study suggest that HJA measurements guide
treatment more effectively than d o SRT measurements. [Cornbleet SL,
Woolsey NB. Assessment of hamstring muscle length in school-aged
children using the sit-and-reach test and the inclinometer measure of
hip joint angle. Phys Ther. 1996;76:850-855.1

Key Words: Fitness tests and measurements, Flexibility, Hamstring muscb length, Sit-and-reach test.

Suxy L Cornbleet
Nancy B Woolsty

Physical Therapy . Volume 76 . Number 8 . August 1996


hysical fitness testing is a routine component of ing activity. Jackson and colleagues3.12 investigated the
physical education classes in elementary and relationships between the SRT and measures of ham-
secondary schools throughout the United string muscle length (passive straight leg raise) and back
States. One area routinely addressed in most flexibility. They reported that the SRT has moderate
fitness tests is flexibility. The sit-and-reach test (SRT)' or criterion-related validity when used to reflect hamstring
a modified version of the SRT2 is typically used to muscle length but does not appear to provide a valid
evaluate flexibility of the low back and hamstring mus- assessment of back motion. Several authors4-"~~flJ3-16
cles. A score is given based on the most distant point contend that anthropometric factors, such as dispropor-
reached by both hands on a standardized box as the tionate length of the limbs relative to the trunk, may
child beiing tested leans forward in a long-sitting position influence the results of the SRT. Children with long legs
(Fig. 1). Passing scores are given when children can and a short trunk, for example, may fail the test even
reach at least 2 cm beyond their toes1 According to the though they have acceptable hamstring muscle
America.n Alliance for Health, Physical Education, Rec- length.8~11,1Wopkins15 estimated that scapular abduc-
reation, and Dance (AAHPERD), this flexibility test is tion during the SRT may account for 3 to 5 cm of
important because decreased flexibility, particularly in variation in the final score. A passing score on the SRT,
the hamstring muscles and the back, is thought to therefore, may be the result of a variety of factors. These
contribute to the development of low back pain,' but factors include various combinations of back motion and
data confirming this supposition have not been hamstring muscle length such as normal or increased
provided. motion in the back and increased hamstring muscle
length (Fig. I ) , decreased or normal back motion corn-
In the literature, the terms "flexibility" and "muscle bined with increased hamstring muscle length (Fig. 2),
length" are often used synonymously when referring to or increased back motion combined with decreased
the ability of the hamstring muscles to be lengthened to hamstring muscle length (Fig. 3); anthropometric fac-
their end range.'-'' For the purposes of this article, the tors such as long arms or short legs relative to the trunk;
term "muscle length" will be used to refer to the end and scapular abduction, which increases the reaching
range of the hamstring muscles. distance of the arms.

The SR'T has been the subject of many s t u d i e ~ . " ~ , lA~ - ~ We


~ contend that a standard SRT test position can be
critique written by KendallH and studies performed by used and, if the final hipjoint angle (HJA) is measured
Jackson and colleagues3,12suggest that the SRT score rather than the final position of the hands on the SRT
does not distinguish between the contributions of the box, this provides a better reflection of hamstring mus-
low back and the hamstring muscles during this reach- cle length. Measuring the HJA rather than the distance

SL Cornhleet, PT, is Instructor and Academic Coordinator of Clinical Education, Program in Physical Therapy, Washington University
School of' Medicine, Box 8502, 4444 Forest Park Ave, St Louis, MO 63108 (US.4) (cornblee@medicine.wustl.edu).
Address all correspondence to Ms Cornbleet.

NB Woolsep. OT,PT, is Instructor, Program in Physical Therapv. Washington University School of Medicine.

This study was approved by the Instit~ltionalReview Board of Washington University.

T h ~ url~cle
s u~rrrsubmztted on ]U?LP 19, 1993, and was occrpted Febehnca~27, 1996.

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Physical 'Therapy Volume 7 6 . Number 8 . August 1996 Cornbleet and Woolsey . 851
Fi ure 3.
3
Per ormance of the sit-and-reach test, demonstrating increased back
flexibility combined with decreased hamstring muscle length.
Fi ure 1.
3
Per ormance of the sit-and-reach test, demonstrating normal back flexi-
bility and normal hamstring muscle length.
must monitor the pelvic position throughout the test.
For example, hip flexor shortness may pull the pelvis in
the direction of anterior tilt. Use of this faulty starting
i
position could result in an inaccurate assessment of
short hamstring muscle length. The use of the long-
sitting position allows both hips to move in the same
direction and eliminates the need to stabilize the pelvis
or consider the influence of hip flexor s h o r t n e s ~ . ~

Another aspect of the SRT that needs to be considered is


the criteria for passing the test. Currently, boys and girls
are required to meet the same standard.' Our clinical
experience, however, suggests that boys and girls may
Fi ure 2.
3
Per ormance of the sit-and-reach test, demonstrating normal back flexi-
normally have differences in hamstring muscle length.
bility combined with increased hamstring muscle length.
The purposes of our study were (1) to characterize
hamstring muscle length by use of the HJA and SRT
of the fingertips to the toes eliminates some anthropo- scores in a sample of school-aged children and (2) to test
metric factors or scapular abduction from influencing three hypotheses related to these measures. These
the score. We realize that this method excludes a mea- hypotheses were:
sure of back motion. We contend, however, that if back
motion is considered important for the assessment of 1. There would be a correlation between SRT scores and ,
fitness, it could be measured with a more appropriate HJA scores.
test. I 7-19
2. There would be no difference between SRT scores for
For the purpose of our study, hamstring muscle length boys and girls.
was reflected by the angle of inclination of the sacrum
and pelvis relative to thc horizontal at the point of 3. There would be no difference be~weenHJA scores for
maximal forward reach in the SRT. This represents an boys and girls.
indirect measure of the hip joint angle (HJA). Although !
several other methods of assessing hamstring muscle Method
length have been r e p 0 r t e d , ~ ~ ~ . ~we
. ' ~contend
- - 2 ~ that this
method is preferable. When compared with the standing Subjects
toe-touch test, we believe that the long-sitting position A total of 410 children (21 1 girls and 199 boys) without
eliminates posterior sway and allows for better control of known impairment of the musculoskeletal system affect-
the knee joint position and for better control of the ing the spine o r the lower extremities participated in the I
pelvis in terms of rotation or lateral The supine study. The subjects were students in kindergarten I
passive straight-leg-raising test and the supine knee through sixth grade from public and private elementary
extension test with the hip in 90 degrees of flexion are schools in St Louis County, Illinois. The subjects' ages
performed on one lower extremity while the other lower ranged from 5 to 12 years, with a mean age of 7 years 10
extremity is resting in hip and knee extension. To months. Informed consent was obtained from the par-
achieve accurate results, we believe that the examiner ents of all subjects.

852 . Cornbleet and Woolsey Physical Therapy. Volume 76 . Number 8 . August 1996
80;.
-1-

Figure 5.
Normal hamstring rnuscle length but failing performance of the sit-and-
reach test due to anthropometric factors (long legs relative to trunk and
arms).
!

Figure 4.
Superior view of the ruler on the sitand-reach box. or the angle between the sacrum and the table during
forward bending in the long-sitting position. Other
investigatorsg~" also have used this value as a guideline
Instrumentation for normal hamstring muscle length.
A standard sit-and-reach box* was used to position the
subjects for the test, and the sliding ruler that is centered Procedure
on the top of the box was used to obtain the SRT scores. Each child was seated on the floor with knees fully
The markings on the ruler were positioned so that the extended and ankles in neutral dorsiflexion against the
23-crn mark represented the point at which the subjects' box (Fig. 1). The child was instructed to place one hand
fingertips were in line with their toes (Fig. 4). In this way, on top of the other and slowly reach forward as far as
the SRT score was always a positive number, even for the possible while keeping the knees extended. The hands
children who were unable to reach their toes. The were kept aligned evenly as the subject reached forward
minimal acceptable score to pass, as determined by along the surface of the box. Each child practiced the
AAHPERD," is 25 cm, or 2 cm beyond the toes, for all movement twice, and, on the third repetition, the SRT
ages and both genders and without consideration of score (in centimeters) was recorded as the final position
anthropometric variables. of the fingertips on the ruler. During the same trial, the
inclinometer was placed over the sacrum and the HJA
An inclinometert (a circular, fluid-filled goniometer) was measured and recorded.
was usetl to measure the HJA. The inclinometer was set
so that 0 degrees represented the horizontal, or 0 Data Analysis
degrees of hip joint flexion. The inclinometer was The mean for all subjects and the means for boys and
placed vertically on the sacrum so that the center of the girls were calculated for the HJA and the SRT. A t test for
inclinometer was aligned at the level of the posterior independent samples was used to examine differences
superiol- iliac spines. between boys and girls for the HJA and the SRT. The
Pearson product-moment correlation coefficient was
Interrater reliability, using an inclinometer to measure used to examine the relationship between the SRT and
the HJA, was examined for the first 20 subjects between the HJA. Raw scores were examined to determine the
-
tester 1 and tester 2. An intraclass correlation coefficient number of cases in which the scores on the two tests
(2,l) of .98 indicated to us an acceptable level of appeared to be contradictory. For example, some chil-
interrater reliability for the HJA scores. dren were able to reach at least 25 cm on the SRT box
but had decreased hamstring muscle length as defined
A passing HJA score was determined by the examiners to by the HJA (Fig. 3), whereas other children could not
be 80 degrees or more of hip joint flexion. This value reach the 25-cm mark but had normal hamstring muscle
corresponds to what Kendalls considers normal if ham- length (Fig. 5).
string rnuscle length is normal, as determined by the
final po'sition of the hip joint during straight leg raising Results
The Table presents the means and standard deviations
for the SRT and HJA. There was a difference between
'Amer-icar~.Uliance for Hraltt~,Physical Education. Recreation, and Dance, 1900
Association Dr, Reston, VA 22091. the scores for boys and girls on the HJA test (t=7.81,
Biokine~icsInc. 1710 Wesuninstel- Way, Arulapolis, MD 21401. df=408, P<.001) and on the SRT (t=5.50, df=408,

Physical Therapy . Volume 76 . Number 8 . August 1996 Cornbleet and Woolsey . 853
Table. Sit-and-Reach Test (SRT) and Hip Joint Angle (HJA) Values

All Subjects (N=410) Boys (n= 199) Girls (n=211)


Test X SD Range X SD Range X SD Range I

SRT (cm) 24 8 2-67 22 7 -2-37 26 7 7-67


l4JA ("1 81 11 54-11 1 75 10 54-1 00 85 10 55-11 1

P<.001). The correlation between the SRT and HJA the test as an exercise is greatest for children who have
scores was significant (,F .76, dJ=408, P<.05). Although normal hamstring muscle length or for children who can
over half (58%) of the variability in the SRT scores was reach their toes but have decreased hamstring muscle
accounted for by the variability in the HJA scores, it is length. There is no evidence to support the need to
important to examine those 73 cases (18%) in which a increase hamstring muscle length beyond normal or that
child passed one test but not the other. For example, 25 improving the SRT score is associated with a change in
children (6%) passed the SRT (225 cm) but failed the hamstring muscle length. As noted by Kendall and
HJA test (<80°), indicating decreased hamstring muscle McCreary,R having children who can reach their toes but
length. Although back motion was not measured using a who have short hamstring muscles practice the long-
modified Schober's techniqueIs or the two-inclinometer sitting stretch might further increase their back motion,
te~hnique,~7J%~isual appraisal suggested that in most of and this could produce little change in their hamstring
these cases, the spine was relatively more flexible than muscle length.
the hips and contributed most to the total performance
of forward bending (Fig. 3 ) . Conversely, 48 children We believe that the use of the inclinometer to measure
(12%) failed the SRT (<25 cm) but had passing HJA the HJA as an indicator of hamstring muscle length
scores (>80°), indicating normal to increased hamstring during the SRT is simple, yields reliable measurements,
muscle length. In these cases, it appeared that either and is not influenced by anthropometric factors. We
anthropometric factors (long legs, short arms or trunk) realize that this method does not include a measure of
(Fig. 5) or limited flexibility in the spine prevented the back motion. We contend, however, that the SRT is not
children from reaching their toes during the SRT. a valid measure of back motion,"12 and, if back motion
is considered important to measure, that other methods
Discussion such as the use of the inclinometer have been described
The overall mean for our HJA measurements and should be used."-l9
(HJA=81°) correlates to the value previously suggested I
by Kendalls as indicating normal hamstring muscle Our future studies will include (1) use of the inclinom-
length (80") in adults or children. In addition, our eter to measure both the HJA and lumbar spine motion
results indicate that hamstring muscle length is less in in school-aged children and (2) investigation of a
boys than in girls. This finding is supported by studies change in hamstring muscle length or back motion as a
that suggest that in the 5- to 10-year-old age group, girls result of practicing forward bending in the long-sitting
are more flexible than b o y ~ . l " l ~Shephard
~'~ and col- position.
leaguesI0 also found that in adults aged 45 to 75 years,
scores on the SRT were greater for women than for men. Conclusion
These results suggest that we should modify our expec- The measurement of flexibility is an important compo-
tations for hamstring muscle length based on gender. nent of fitness testing. The SRT is useful for examining
hamstring muscle length, but more attention needs to
The correlation between the HJA and SRT scores sug- be given to the final position of the hip joint rather than
gests that both tests reflect hamstring muscle length. the final position of the fingertips. Measuring the HJA
The SRT and modified versions of the SRT, however, with an inclinometer while using the SRT position, in
continue to focus on the distance of the fingertips to the our opinion, provides a reliable and simple measure that
toes as the final measure. Because this measure is reflects hamstring muscle length. Examiners should also
influenced by a variety of factors, as previously discussed, recognize that there are differences in hamstring muscle
the results may be misleading when developing strate- length between boys and girls. I

gies for interventions.


Acknowledgments
In the majority of cases, the typical action taken in We thank Barbara J Norton, PT, and Shirley A Sahr-
response to the SRT score is to have the child practice mann, PhD, PT, FAPTA, for their consultation through-
forward bending in the long-sitting position as an exer- out this project. [

I
cise to improve the score. Our concern about practicing I

I
854 . Cornbleet and Woolsey Physical Therapy. Volume 76 . Number 8 . August 1996 j
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Physical Therapy Volume 76 . Number 8 . August 1996 Cornbleet and Woolsey . 855