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

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

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

.
Physical 'Therapy Volume 7 6 . Number 8 . August 1996 Cornbleet and Woolsey . 851

Fi ure 1.
3
Per ormance of the sit-and-reach test, demonstrating normal back flexi-
bility and normal hamstring muscle length.
Fi ure 2.
3
Per ormance of the sit-and-reach test, demonstrating normal back flexi-
bility combined with increased hamstring muscle length.
of the fingertips to the toes eliminates some anthropo-
metric factors or scapular abduction from influencing
the score. We realize that this method excludes a mea-
sure of back motion. We contend, however, that if back
motion is considered important for the assessment of
fitness, it could be measured with a more appropriate
test. I 7-19
For the purpose of our study, hamstring muscle length
was reflected by the angle of inclination of the sacrum
and pelvis relative to thc horizontal at the point of
maximal forward reach in the SRT. This represents an
indirect measure of the hip joint angle (HJA). Although
several other methods of assessing hamstring muscle
length have been r e p 0 r t e d , ~ ~ ~ . ~we
. ' ~contend
- - 2 ~ that this
method is preferable. When compared with the standing
toe-touch test, we believe that the long-sitting position
eliminates posterior sway and allows for better control of
the knee joint position and for better control of the
pelvis in terms of rotation or lateral The supine
passive straight-leg-raising test and the supine knee
extension test with the hip in 90 degrees of flexion are
performed on one lower extremity while the other lower
extremity is resting in hip and knee extension. To
achieve accurate results, we believe that the examiner
852 . Cornbleet and Woolsey
Fi ure 3.
3
Per ormance of the sit-and-reach test, demonstrating increased back
flexibility combined with decreased 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
normally have differences in hamstring muscle length.
The purposes of our study were (1) to characterize
hamstring muscle length by use of the HJA and SRT
scores in a sample of school-aged children and (2) to test
three hypotheses related to these measures. These
hypotheses were:
1. There would be a correlation between SRT scores and ,
HJA scores.
2. There would be no difference between SRT scores for
boys and girls.
3. There would be no difference be~weenHJA scores for
boys and girls.
!
Method
Subjects
A total of 410 children (21 1 girls and 199 boys) without
known impairment of the musculoskeletal system affect-
ing the spine o r the lower extremities participated in the I
study. The subjects were students in kindergarten I
through sixth grade from public and private elementary
schools in St Louis County, Illinois. The subjects' ages
ranged from 5 to 12 years, with a mean age of 7 years 10
months. Informed consent was obtained from the par-
ents of all subjects.
Physical Therapy. Volume 76 . Number 8 . August 1996

!
Figure 4.
Superior view of the ruler on the sitand-reach box.
Instrumentation
A standard sit-and-reach box* was used to position the
subjects for the test, and the sliding ruler that is centered
on the top of the box was used to obtain the SRT scores.
The markings on the ruler were positioned so that the
23-crn mark represented the point at which the subjects'
fingertips were in line with their toes (Fig. 4). In this way,
the SRT score was always a positive number, even for the
children who were unable to reach their toes. The
minimal acceptable score to pass, as determined by
AAHPERD," is 25 cm, or 2 cm beyond the toes, for all
ages and both genders and without consideration of
anthropometric variables.
An inclinometert (a circular, fluid-filled goniometer)
was usetl to measure the HJA. The inclinometer was set
so that 0 degrees represented the horizontal, or 0
degrees of hip joint flexion. The inclinometer was
placed vertically on the sacrum so that the center of the
inclinometer was aligned at the level of the posterior
superiol- iliac spines.
Interrater reliability, using an inclinometer to measure
the HJA, was examined for the first 20 subjects between
tester 1 and tester 2. An intraclass correlation coefficient
(2,l) of .98 indicated to us an acceptable level of
interrater reliability for the HJA scores.
A passing HJA score was determined by the examiners to
be 80 degrees or more of hip joint flexion. This value
corresponds to what Kendalls considers normal if ham-
string rnuscle length is normal, as determined by the
final po'sition of the hip joint during straight leg raising
'Amer-icar~.Uliance for Hraltt~,Physical Education. Recreation, and Dance, 1900
Association Dr, Reston, VA 22091.
Biokine~icsInc. 1710 Wesuninstel- Way, Arulapolis, MD 21401.
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).
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
for normal hamstring muscle length.
Procedure
Each child was seated on the floor with knees fully
extended and ankles in neutral dorsiflexion against the
box (Fig. 1). The child was instructed to place one hand
on top of the other and slowly reach forward as far as
possible while keeping the knees extended. The hands
were kept aligned evenly as the subject reached forward
along the surface of the box. Each child practiced the
movement twice, and, on the third repetition, the SRT
score (in centimeters) was recorded as the final position
of the fingertips on the ruler. During the same trial, the
inclinometer was placed over the sacrum and the HJA
was measured and recorded.
Data Analysis
The mean for all subjects and the means for boys and
girls were calculated for the HJA and the SRT. A t test for
independent samples was used to examine differences
between boys and girls for the HJA and the SRT. The
Pearson product-moment correlation coefficient was
used to examine the relationship between the SRT and
the HJA. Raw scores were examined to determine the
-
number of cases in which the scores on the two tests
appeared to be contradictory. For example, some chil-
dren were able to reach at least 25 cm on the SRT box
but had decreased hamstring muscle length as defined
by the HJA (Fig. 3), whereas other children could not
reach the 25-cm mark but had normal hamstring muscle
length (Fig. 5).
Results
The Table presents the means and standard deviations
for the SRT and HJA. There was a difference between
the scores for boys and girls on the HJA test (t=7.81,
df=408, P<.001) and on the SRT (t=5.50, df=408,
Cornbleet and Woolsey . 853
Table. Sit-and-Reach Test (SRT) and Hip Joint Angle (HJA) Values
All Subjects (N=410)
Test X SD Range X SD
SRT (cm) 24 8 2-67 22
l4JA ("1 81 11 54-11 1 75
P<.001). The correlation between the SRT and HJA
scores was significant (,F .76, dJ=408, P<.05). Although
over half (58%) of the variability in the SRT scores was
accounted for by the variability in the HJA scores, it is
important to examine those 73 cases (18%) in which a
child passed one test but not the other. For example, 25
children (6%) passed the SRT (225 cm) but failed the
HJA test (<80°), indicating decreased hamstring muscle
length. Although back motion was not measured using a
modified Schober's techniqueIs or the two-inclinometer
te~hnique,~7J%~isual appraisal suggested that in most of
these cases, the spine was relatively more flexible than
the hips and contributed most to the total performance
of forward bending (Fig. 3 ) . Conversely, 48 children
(12%) failed the SRT (<25 cm) but had passing HJA
scores (>80°), indicating normal to increased hamstring
muscle length. In these cases, it appeared that either
anthropometric factors (long legs, short arms or trunk)
(Fig. 5) or limited flexibility in the spine prevented the
children from reaching their toes during the SRT.
Discussion
The overall mean for our HJA measurements
(HJA=81°) correlates to the value previously suggested
by Kendalls as indicating normal hamstring muscle
length (80") in adults or children. In addition, our
results indicate that hamstring muscle length is less in
boys than in girls. This finding is supported by studies
that suggest that in the 5- to 10-year-old age group, girls
are more flexible than b o y ~ . l " l ~Shephard
~'~ and col-
leaguesI0 also found that in adults aged 45 to 75 years,
scores on the SRT were greater for women than for men.
These results suggest that we should modify our expec-
tations for hamstring muscle length based on gender.
The correlation between the HJA and SRT scores sug-
gests that both tests reflect hamstring muscle length.
The SRT and modified versions of the SRT, however,
continue to focus on the distance of the fingertips to the
toes as the final measure. Because this measure is
influenced by a variety of factors, as previously discussed,
the results may be misleading when developing strate-
gies for interventions.
In the majority of cases, the typical action taken in
response to the SRT score is to have the child practice
forward bending in the long-sitting position as an exer-
cise to improve the score. Our concern about practicing
854 . Cornbleet and Woolsey
Boys (n= 199) Girls (n=211)
Range X SD Range I
7 -2-37 26 7 7-67
10 54-1 00 85 10 55-11 1
the test as an exercise is greatest for children who have
normal hamstring muscle length or for children who can
reach their toes but have decreased hamstring muscle
length. There is no evidence to support the need to
increase hamstring muscle length beyond normal or that
improving the SRT score is associated with a change in
hamstring muscle length. As noted by Kendall and
McCreary,R having children who can reach their toes but
who have short hamstring muscles practice the long-
sitting stretch might further increase their back motion,
and this could produce little change in their hamstring
muscle length.
We believe that the use of the inclinometer to measure
the HJA as an indicator of hamstring muscle length
during the SRT is simple, yields reliable measurements,
and is not influenced by anthropometric factors. We
realize that this method does not include a measure of
back motion. We contend, however, that the SRT is not
a valid measure of back motion,"12 and, if back motion
is considered important to measure, that other methods
such as the use of the inclinometer have been described
and should be used."-l9
I
Our future studies will include (1) use of the inclinom-
eter to measure both the HJA and lumbar spine motion
in school-aged children and (2) investigation of a
change in hamstring muscle length or back motion as a
result of practicing forward bending in the long-sitting
position.
Conclusion
The measurement of flexibility is an important compo-
nent of fitness testing. The SRT is useful for examining
hamstring muscle length, but more attention needs to
be given to the final position of the hip joint rather than
the final position of the fingertips. Measuring the HJA
with an inclinometer while using the SRT position, in
our opinion, provides a reliable and simple measure that
reflects hamstring muscle length. Examiners should also
recognize that there are differences in hamstring muscle
length between boys and girls. I
Acknowledgments
We thank Barbara J Norton, PT, and Shirley A Sahr-
mann, PhD, PT, FAPTA, for their consultation through-
out this project. [
I
I
I
Physical Therapy. Volume 76 . Number 8 . August 1996 j
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