CONCURRENT VALIDITY OF FOUR CLINICAL TESTS
USED TO MEASURE HAMSTRING FLEXIBILITY
D. SCOTT DAVIS, RICH O. QUINN, CHRIS T. WHITEMAN, JASON D. WILLIAMS, AND COREY R. YOUNG
Division of Physical Therapy, Department of Human Performance and Exercise Science, West Virginia University, Morgantown,
West Virginia
ABSTRACT
The purpose of this study was to examine the concurrent validity of
4 clinical tests used to measure hamstring muscle length. A pilot
study (N = 10) was conducted to determine the intratester
reliability of 4 hamstring length measures: knee extension angle
(KEA), sacral angle (SA), straight leg raise (SLR), and sit and reach
(SR). The pilot investigation revealed good to excellent intratester
reliability (intraclass correlation coefficient = 0.92–0.95) for each
of the 4 tests. Eighty-one subjects (42 men and 39 women)
participated in the main investigation. Subjects were randomly
tested for each of 4 assessments of hamstring length. Concurrent
validity was determined using linear regression, correlation, and k
statistics. Correlation coefficients corresponding to the concurrent
validity of the six combinations of the 4 clinical tests revealed poor
to fair correlation (r = 0.45–0.65). The correlation coefficients for
each pair from greatest to least were SR-SA= 0.65, SLR-SR =
0.65, KEA-SLR = 0.63, KEA-SR = 0.57, SLR-SA = 0.50, and
KEA-SA = 0.45. Despite the common clinical use of these
measures to assess hamstring length, these tests do not have
sufficient concurrent validity to be used interchangeably or to
assume that they each measure the same construct (hamstring
length). Based on the results of this investigation and a review of
the literature, the authors recommend that researchers, clinicians,
and strength and conditioning specialists adopt the KEA test as
the gold standard measure for hamstring muscle length.
KEY WORDS assessment, examination, muscle length
INTRODUCTION
T
he literature describes 4 common methods of
assessing hamstring muscle length (2–25,28,29).
These include the knee extension angle (KEA) test,
the sacral angle (SA) test, the straight leg raise
(SLR) test, and the sit-and-reach (SR) test. The choice of
which test to use is often based on examiner preference, ease of
use, professional discipline, or tradition rather than scientific
Address correspondence to D. Scott Davis, dsdavis@hsc.wvu.edu.
22(2)/583–588
Journal of Strength and Conditioning Research
Ó 2008 National Strength and Conditioning Association
evidence. In order for a test to be clinically meaningful, the test
must possess a high degree of reliability and validity (26). The
purpose of this investigation was to examine the concurrent
validity of these 4 measures of hamstring muscle length.
The KEA test is performed with the patient lying supine with
both lower extremities extended. The tester flexes the
ipsilateral hip to 90° and maintains this angle while the
ipsilateral knee is passively extended. The contralateral lower
extremity is stabilized on the examination plinth. Clinically, the
endpoint is reached when either the tester feels slight resistance
or the subject reports a strong but tolerable stretching sensation
in the hamstring musculature. Using either a universal goni-
ometer or two gravity inclinometers, the tester can measure the
KEA, which is the degree of knee flexion from terminal knee
extension. Alternatively, the tester can measure the obtuse
adjacent angle measured between the femur and the tibia. The
later angle is called the popliteal angle (PA). The sum of the
KEA and the PA is 180°. The KEA test and the associated PA
test have been used extensively in the literature as a measure of
hamstring muscle length (2–4,7,12). The intratester reliability
of the KEA test has been reported to be 0.99 (11,29). A KEA of
20° has been defined as a cutoff score indicating hamstring
muscle tightness (7). Therefore, a KEA .20° indicates
hamstring muscle tightness.
The SLR test is performed with the patient lying supine
with both lower extremities extended. While maintaining the
contralateral lower extremity on the examination plinth, the
examiner passively lifts the ipsilateral lower extremity by
flexing the hip joint. The ipsilateral knee is maintained in full
extension throughout the test. The ankle is maintained in
slight plantarflexion throughout the test to avoid adverse
neural tension (10). At the end of the available range of
motion, the hip joint angle is measured with either a universal
goniometer or a gravity inclinometer. Previous research using
a gravity inclinometer reported the intratester reliability of
the SLR test to be .0.97 (14,22). A SLR of 80° has been
suggested as a cutoff score to indicate hamstring muscle
tightness (19). Therefore, a SLR measurement ,80°
indicates hamstring muscle tightness.
The SLR test is an attempt to indirectly measure the
functional excursion of the hamstring muscle group; however,
several confounding variables have been identified in the
literature. These variables include the possibility of neural
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Concurrent Validity of Four Clinical Tests
stretch, stretching of the hip joint capsule, inconsistency in
pelvic position, contralateral hip flexor tightness, and
limitations of motion due to fascial connections between
the posterior cruel fascia and the fascia of the posterior thigh
(5,6,10,12).
The SR test has many variations, but they are all derived
from the classic test (13,15–25). The classic SR test requires
a measuring box with a mounted ruler. The subject sits on the
floor or examination plinth with both knees extended and the
feet flat against the device. The subject is then asked to reach
forward over the measuring device and hold this position for
2 seconds. Referencing the plantar surface of the feet (zero),
the median distance for young adults 20 to 29 years of age is
5 and 8 cm for men and women, respectively (1). Several
variations of the classic SR have been proposed and exam-
ined in the literature. These include the modified SR test, the
V SR test, and the modified back saver SR test (13,15–25).
The intratester reliability of the classic SR test was reported
to be 0.98 (27).
Kendall and colleagues (19) advocate a modified version of
the SR test, called the SA test, which is intended to eliminate
many of the confounding variables associated with the SR test.
Kendall et al. (19) propose that the angle of the sacrum relative
to the examination plinth should be used instead of measuring
the distance that the subject is able to reach relative to his or
her feet. According to Kendall et al. (19), normal hamstring
length is achieved when a sacral angle of $80° relative to the
supporting surface is achieved. They suggest that this test
eliminates the influence of lumbar spine range of motion and
anthropometric issues related to the length of the arms, trunk,
and lower extremities. Kendall and colleagues (19) suggest that
this test is consistent with the results of the SLR test; however,
no evidence is offered to support this claim. A review of the
literature failed to identify any previously established intra-
tester reliability data for the SA test.
Hamstring muscle length is a fundamental measure
performed by many different disciplines across a wide variety
of settings. Although several investigations have examined
the individual validity of these tests, the authors were unable
to identify a study that examined the concurrent validity of all
4 of these methods used to measure hamstring muscle length.
Therefore, the purpose of this investigation was to determine
the concurrent validity of 4 tests (KEA, SA, SLR, SR) used to
measure hamstring muscle length.
METHODS
Experimental Approach to the Problem
In the pilot study, a test-retest research design was used to
examine the intratester reliability of 4 common measures of
hamstring muscle length (KEA, SA, SLR, and SR). The main
investigation examined the concurrent validity of the 4 ham-
string length measures using a quasi-experimental correla-
tional design. The primary focus of this investigation was to
determine a gold standard clinical measure of hamstring
muscle length. Based on previously reported anatomical and
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584 Journal of Strength and Conditioning Research
biomechanical differences among the 4 tests, it was hypoth-
esized that there would be sufficient variability among the
tests to result in weak concurrent validity. Before recruiting
the subjects, the investigation was approved by the Uni-
versity’s Institutional Review Board for the Protection of
Human Subjects.
Subjects
The subjects (N = 81) were 42 college-age men (age, 23.6 6
4.1 years) and 39 college-age women (age, 24.1 6 4.3 years).
Initially, 117 subjects were recruited to participate in this
investigation; however, 36 subjects were excluded based on
previous medical conditions identified in the exclusion
questionnaire. Subjects were also excluded if they were
found to have a KEA ,10° in order to exclude those subjects
with hyperflexibility.
All participants were asked to complete a medical history
questionnaire. Exclusion criteria consisted of previous or
current complaints of numbness, tingling, or burning in their
arms or legs; neck or back injury/pain within the past 2 years;
circulatory or neurological complaints; or lower extremity
fracture. Before testing commenced, the procedures were
explained to each participant by one of the investigators and
each subject was required to sign a consent form.
Procedures
Pilot study. A pilot investigation was conducted before the
main investigation to establish the intratester reliability of the
4 hamstring length measures (KEA, SA, SLR, and SR). The
KEA test was performed by having the subject lie on his or her
back with the hips and knees fully extended. Gravity
inclinometers (Macklanburg-Duncan, Oklahoma City, OK)
were placed at two points on the tested lower extremity. One
inclinometer was placed on the distal thigh immediately
superior to the patella, and the second inclinometer was
placed on the distal anterior tibia. The distal edge of the
inclinometer was aligned with the superior aspect of the
medial malleolus. The tested lower extremity was then
passively raised by the examiner to 90° of hip flexion as
recorded by the inclinometer placed on the distal thigh. The
subject’s knee was then passively straightened to a point
where the subject reported a strong but tolerable stretch in
their posterior thigh. The contralateral lower extremity was
fixed to the table in full knee extension using a nylon strap
over the distal thigh. The angle of the knee (KEA) was then
measured using the inclinometer placed on the lower leg. The
adjacent PA (180 2 KEA) was used for all statistical analyses.
The SLR test was performed by having the subject lie
supine with both hips and knees fully extended. The
contralateral lower extremity was secured to the examina-
tion plinth using a nylon strap placed over the distal thigh.
A gravity inclinometer was placed on the distal leg at the level
of the medial malleolus. With the ipsilateral knee fully
extended, the tested extremity was passively raised to a point
where the subject experienced a strong but tolerable stretch in
the posterior thigh. The angle of the subject’s lower extremity

TABLE 1. Intratester reliability.
Test ICC (3,1)
KEA 0.94
SA 0.95
SLR 0.92
SR 0.94
KEA = knee extension angle; SA = sacral angle; SLR =
straight leg raise; SR = sit and reach.
from the horizontal surface of the examination plinth was
recorded from the inclinometer strapped to the distal tibia.
The SA test was performed by having the subject sit on the
examination plinth with the knees fully extended and their
hips in neutral rotation and fully adducted. The subject was
instructed to reach forward with his or her arms extended,
toward the toes, until a strong but tolerable stretch was felt in
the posterior thigh. The angle formed between the sacrum
and the horizontal plane was measured by placing a gravity
inclinometer flat against the subject’s sacrum. If the subject’s
sacrum was vertical, a measurement of zero was recorded.
Positive scores were recorded if the sacrum was unable to
obtain a vertical position as the subject reached forward.
Negative scores were recorded if the sacrum was able to flex
beyond a vertical position.
The SR test was performed by having the subject sit on the
examination plinth with the knees fully extended. The hips
were placed in neutral rotation and fully adducted. The
subject’s feet were placed flat against a standard SR measuring
device. The subject was instructed to keep his or her knees
straight while reaching forward until a strong but tolerable
stretch was felt in the posterior thigh. The distance that the
subject was able to reach forward was recorded in centimeters
from a ruler located on the SR measuring device.
Four investigators each performed one of the hamstring
length measures. Each investigator practiced their respective
examination technique for a total of 4 hours before the start of
TABLE 2. Mean (SD) for age and hamstring length measures.
Variables Men (n = 42) mean (SD) Women (n = 39) mean (SD)
Age 23.6 (4.1)
PA (180 2 KEA) 71.6 (9.6)
SA 15.7 (5.4)
SLR 75.5 (10.3)
SR 23.5 (6.7)
PA = popliteal angle; KEA = knee extension angle; SA = sacral angle; SLR = straight leg raise; SR = sit and reach.
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the study. Ten college-age participants (5 men and 5 women)
were recruited to participate in the pilot study. The examiners
were blinded to the subject’s identity by a drape placed at the
subject’s waist. Each examiner randomly tested each subject
3 times. Each subject was asked to avoid communication during
the testing procedure to ensure the blinding of the subject from
the tester. Additionally, each examiner was assigned a research
assistant who recorded the values as they were taken. This
prevented the examiner from having contact with the data
between trials. Data from the pilot study were analyzed using
a repeated-measures analysis of variance (ANOVA) and an
intraclass correlation coefficient (ICC 3,1) according to the
formula described by Shrout and Fleiss (27). The pilot study
revealed good to excellent intratester reliability (ICC = 0.92–
0.95) for each of the examiners using their assigned technique.
Testing procedure. The main study was conducted in
a laboratory with 4 examination stations (KEA, SA, SLR,
and SA) on two separate occasions within a 1-week period. To
prevent measurement error related to repeat testing (sarco-
mere give), subjects randomly rotated among the 4 stations.
The right hamstring was measured for the SLR and KEA
tests, while the SR and SA tests required a simultaneous test
of both lower extremities. The tests were performed in the
same manner as described in the pilot investigation.
Statistical Analyses
Data from the main investigation were analyzed using JMP
5.1 statistical software (SAS Institute, Cary, NC). Descriptive
statistics (mean and SD) were calculated for age, gender,
and each of the 4 measures of hamstring muscle length. As
described by Portney and Watkins (26), simple linear regres-
sion analysis and Pearson correlation coefficients were cal-
culated for each combination of the 4 testing procedures to
determine concurrent validity. Beta coefficients, probability
values, and SEs were calculated for each regression analysis.
Additionally, the test results were dichotomized based on
published cutoff scores for each of the 4 tests, and k statistics
were calculated for each pair of the 4 testing procedures.
Gender differences were examined using an independent
t-test with a predetermined a level of 0.05.
All subjects (N = 81) mean (SD)
24.2 (4.3) 23.7 (3.9)
77.7 (9.5) 74.6 (10.0)
18.6 (6.6) 17.1 (6.1)
82.8 (10.8) 79.0 (11.1)
26.8 (7.6) 25.1 (7.3)
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Concurrent Validity of Four Clinical Tests

TABLE 3. Comparison of hamstring length among TABLE 5. Kappa correlations.

men and women.
KEA SR SA
Variable Prob . | t |
SLR 0.36 0.39 Unable to evaluate
SLR 0.0027* KEA 0.42 Unable to evaluate
KEA 0.0056* SR Unable to evaluate
SR 0.0421*
SA 0.0281* KEA = knee extension angle; SR = sit and reach; SA =
sacral angle; SLR = straight leg raise.
*P , 0.05.
SLR = straight leg raise; KEA = knee extension angle;
SR = sit and reach; SA = sacral angle.

negative = normal hamstring length), k correlations (Table 5)

were calculated to determine the agreement among the 4
tests. Kappa values were unattainable for each of the pairings
RESULTS
of SA because all the subjects were found to be negative using
The pilot study yielded excellent intratester reliability with the SA test. Kappa agreement among the 4 tests was found to
ICC (3,1) values ranging from 0.92 to 0.95 for all 4 techniques be fair.
(Table 1). Table 2 contains the mean and SD for age and each
of the hamstring length measures. Independent t-tests (Table 3)
revealed a significant difference in hamstring length between DISCUSSION
men and women for each of the 4 hamstring length measures. Previous investigations have identified good to excellent
Women were found to have 8.5, 9.7, 14.0, and 18.5% more intratester reliability of these commonly used measures of
flexibility than their male counterparts for KEA, SLR, SR, hamstring muscle length; however, to date, no investigation
and SA tests, respectively. has attempted to identify the concurrent validity of all 4 tests.
Although each of the 4 tests has been reported to be The results of this investigation support the excellent
a measure hamstring muscle length, the measurements are intratester reliability of these tests, but the results fail to
unique and agreement among the raw scores is impossible. support adequate concurrent validity among these clinical
In order to determine the concurrent validity of the 4 ham- measures using either the raw scores or the dichotomized
string length measures, simple linear regression and Pearson’s scores based on previously published cutoff values. The
correlation coefficient (Table 4) were calculated for each com- coefficient of determination (R2), which is simply the square
bination of the 4 tests. This analysis identified poor to fair of the Pearson product moment correlation coefficient (r),
correlation among all pairs of the 4 tests. represents the amount of variability in y that is explained by x.
In addition to examining the reliability of the 4 tests using The largest correlation coefficient in this investigation was
raw values, the data were dichotomized to indicate a positive (r = 0.65) for the SR-SA pairing, which represents a R2 of
or negative test for each subject based on normative cutoff 0.43. Therefore, only 43% of the variability in the SA test was
values reported for each testing procedure. After reducing the explained by the SR test.
data to a nominal variable (positive = tight hamstrings; The lack of concurrent validity among these 4 tests raises
questions related the appropriateness of some of these tests as
a valid measure of hamstring muscle length. This investiga-
tion also supports previous concerns related to the anatomical
structures, which may confound some of these tests. Variables
TABLE 4. Regression analysis among the 4 tests.
that may have contributed to the poor correlation among
Tests b r R2 SE Prob . | t | these tests include adverse neural tension, differences in the
testing positions (supine vs. seated), bilateral vs. unilateral
SLR and KEA 0.57 0.63 0.40 0.08 ,0.0001 lower extremity testing, differences associated with pelvic
SLR and SR 0.42 0.65 0.41 0.06 ,0.0001
position and stability, variability in anthropometric variables
SLR and SA 0.28 0.50 0.25 0.05 ,0.0001
KEA and SR 0.41 0.57 0.33 0.07 ,0.0001 such as body segment length, and the contribution of other
KEA and SA 0.27 0.45 0.20 0.06 ,0.0001 noncontractile tissues such as the deep and superficial fascia.
SR and SA 0.55 0.65 0.43 0.07 ,0.0001 Neural tension associated with some of these tests may
pose a threat to obtaining accurate range of motion
SLR = straight leg raise; KEA = knee extension angle;
SR = sit and reach; SA = sacral angle. measurements because muscle length testing often requires
a subjective response of a strong but tolerable stretch from the
subject. Neural tension has been reported to be a confounding
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586 Journal of Strength and Conditioning Research


factor that is exacerbated by ankle dorsiflexion (10,21).
Liemohn et al. (21) found that ankle dorsiflexion compared
to ankle plantarflexion significantly limited the available
range of motion when performing a 1-leg SR test. They
reported a 3-cm improvement when the ankle was allowed to
plantarflex. They speculated that fascial attachments be-
tween the gastrocnemius and the hamstrings and neural
tension contributed to the difference associated with ankle
position. Three of the 4 tests (KEA, SLR, and SA) in this
investigation were performed with the ankle(s) comfortably
plantarflexed, while the SR test was the only test in which the
ankles were dorsiflexed.
Previous research has shown that there is significantly less
pelvic rotation when performing the KEA test than when
performing the SLR test (5). Bohannon et al. (5) reported
a mean pelvic rotation of 32.1° associated with the SLR test.
Additionally, they reported that for every 1.7° degrees of hip
motion, there is 1° of pelvic motion when performing the
SLR test. Fredriksen et al. (9) examined the pelvic con-
tribution associated with a modified KEA test with the hip
initially in 120° of hip flexion. They reported the median
pelvic contribution to be only 4.1°.
Concern has also been raised about the influence of con-
tralateral hip flexor length when performing the SLR test
(5,9). Gadjosik et al. (10) found similar results when test-
ing the SLR with the contralateral leg stabilized on the
examination plinth and when the contralateral hip was
slightly flexed to allow the lumbar spine to rest flat on the
examination plinth. While Cameron et al. (6) found that
placing the contralateral knee in 90° flexion significantly
increased the SLR test compared to when the contralateral
leg is maintained on the examination plinth. This demon-
strates the potential affects associated with contralateral hip
and pelvis position.
The authors anticipated poor concurrent validity between
the supine and seated tests since the seated SA and SR tests
measure bilateral hamstring length rather than unilateral
hamstring length measured by the KEA and SLR tests.
Another potential confounding variable is related to anthro-
pometric variability among the subjects. As discussed by
Kendall et al. (19), trunk and extremity length variability has
the potential to significantly affect the SR test.
Finally, it is important to note that the SA test was unable to
classify any subject in this sample of young healthy adults as
tight, using the guidelines offered by Kendall et al. Given that
the other three tests (KEA, SLR, and SR) all identified
subjects in this sample as positive (tight hamstring) raises
concerns about the cutoff score offered by Kendall et al. (19)
for the SA test in young healthy adults.
Despite the fact that the authors were unable to find a study
that examined all 4 tests concurrently in the same sample,
several investigations have examined the concurrent validity
of individual pairs. Liemohn and colleagues (22) examined
the concurrent validity of the SR test compared to the
criterion SLR test. Using a relatively small sample (N = 40),
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Journal of Strength and Conditioning Research | www.nsca-jscr.org
Liemohn et al. reported a fair correlation (r = 0.71) between
the SR test and the SLR test. The correlation between the SR
test and SLR test in this investigation was found to be 0.65,
which is only slightly lower than the results reported by
Liemohn et al. (22).
Gajdosik et al. (12) examined the concurrent validity of the
SLR test and KEA test and reported a correlation of 20.66,
which is very consistent with the 0.63 correlation found in
this investigation. The sign difference is related to the fact
that this investigation used PA = 180 2 KEA for all statistical
analysis. Thus, as SLR increased, the popliteal angle also
tended to increase.
Minkler and Patterson (24) reported the concurrent validity
of the SR test with the SLR test to be 0.75. Additionally,
Simoneau (28) examined the concurrent validity of the SR test
and SLR test (N = 34) and reported a correlation of 0.78.
Although Simoneau (28) acknowledged the potential contri-
bution of the spine to the SR test, he indicated that hamstring
flexibility was the largest single contributor of motion in the
SR test. Despite the unquestionable influence of the ham-
strings on the SR test, Simoneau suggested muscle-specific
length tests (KEA and SLR) were more appropriate than
a single flexibility test that measures the contribution of
multiple body segments. The SR to SLR correlation in this
investigation was 0.65, slightly less than that reported by both
Minkler and Patterson (24) and by Simoneau (28).
This investigation has several potential limitations. The
foremost limitation was the use of multiple testers. In order to
maximize the sample size and to improve the logistics of the
investigation, 4 testers were used. To minimize potential
differences based on tester, each tester practiced and gained
proficiency in 1 of the 4 tests. While the intratester reliability
of the testers was established, it is unclear whether the same
tester performing each test would demonstrate a stronger
correlation among the 4 tests. To promote consistency among
the 4 tests, the degree of stretch was determined by the subject
rather than the testers. Future investigations should con-
sider using a potentiometer normalized to body weight as an
attempt to consistently apply the same stretching force.
Although the authors attempted to control for sarcomere give
by randomly assigning the testing order of the 4 tests, future
investigation should consider a short bout of stretching prior
to the testing session to help eliminate the short-term gains
associated with repeated testing. This investigation used
a relatively large sample size (N = 81); however, the subjects
were homogeneous based on age, which limits the external
validity of the results.
The 4 tests were not compared to a specific criterion test;
instead, the concurrent validity of each pair was examined.
Despite not identifying a specific criterion test for this
investigation, the investigators suggest that the KEA test with
the ankle plantarflexed be adopted as the gold standard based
on the body of knowledge currently available. Further study is
warranted to determine the influence of the fascia and other
noncontractile tissues on these tests. Based on the results of
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Concurrent Validity of Four Clinical Tests
this investigation, there is poor to fair concurrent validity
among these 4 common measures of hamstring muscle length
and ,50% of the variability of any test is explained by any
other test.
PRACTICAL APPLICATIONS
Several reliable tests are available for clinicians to use to assess
hamstring muscle length; however, the validity of these tests
as a measure of hamstring muscle length has been questioned.
As such, a gold standard test has not been clearly established
and adopted by clinicians, coaches, and strength and
conditioning specialists. This investigation found poor to fair
concurrent validity among the 4 most common techniques
(KEA, SA, SLR, and SR) used to measure hamstring muscle
length. The results of this investigation also found poor
agreement among these tests when dichotomized to positive
and negative tests based on previously published cutoff values.
This investigation supports previously published concerns
regarding the potential for multiple confounding variables
when using the SA, SLR, and SA tests. Based on the results of
this investigation, these tests should not be used interchange-
ably when assessing hamstring muscle length. Based on the
body of knowledge currently available, the authors suggest
that the KEA test be adopted by all strength and conditioning
specialists as the gold standard hamstring length measure
until further research can identify a more valid measure of
hamstring length.
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