Physical Therapy in Sport 4 (2003) 159166

www.elsevier.com/locate/yptsp

Motor control and strength as predictors of hamstring injury

in elite players of Australian football
Matt Camerona,*, Roger Adamsb, Christopher Maherb
a

Physiotherapist, Sydney Swans Football Club, P.O. Box 173, Paddington, NSW 2021, Australia
b
School of Physiotherapy, University of Sydney, Sydney, Australia

Abstract
Objectives. To investigate motor control as a possible contributing factor in hamstring injuries using a test movement similar to the injurycritical phase during running. Leg swing movement discrimination (MD), thigh muscle strength as tested by Cybex isokinetic dynamometry
and previous hamstring injury history were all assessed to determine any association with subsequent hamstring injury.
Design. Prospective and retrospective observational and analytical cohort study.
Setting. A professional football club and a university laboratory.
Participants. Twenty elite level players of Australian football.
Results. In the 2 years prior to testing, 7 subjects had sustained a hamstring injury. At the time of testing, there were no significant differences
between subjects never injured and those previously injured. In the two years following testing, 6 players sustained a hamstring injury. Mean
MD score and concentric hamstring-to-quadriceps strength ratio of subsequently injured subjects were significantly worse than those
uninjured p , 0:05: Optimum cutoffs on these measures were determined.
Conclusion. Both a lower MD ability score for the backward swinging leg and an imbalance of thigh muscle strength were predictive of
hamstring injury.
q 2003 Elsevier Ltd. All rights reserved.
Keywords: Hamstrings; Injury; Motor control; Movement discrimination

1. Introduction
Hamstring strain injuries are common in all football
codes and sports involving sprinting, and are the most
frequently occurring and recurring of all injuries in
Australian football. At the elite level, hamstring injuries
occur at a rate of 6.2 injuries per club per season, and result
in 21.2 missed player games per club per season (Orchard
and Seward, 2002). These rates are the highest of all the elite
level football codes in Australia (Seward et al., 1993).
Hamstring injuries have the highest recurrence rate of all
football injuries and notwithstanding the best rehabilitation
attempts, more than one in three (34%) injuries recur within
the same season (Orchard and Seward, 2002). Risk has been
shown to be increased following previous hamstring injury
(Bennell et al., 1998; Garrett, 1996; Orchard, 2001), calf
strain injury (Orchard, 2001), and serious knee and groin
injuries (Verral et al., 2001). Risk has also been shown to be
* Corresponding author. Tel.: 61-2-9339-9135; fax: 61-2-9339-9101.
E-mail address: mcameron@cyberone.com.au (M. Cameron).
1466-853X/03/$ - see front matter q 2003 Elsevier Ltd. All rights reserved.
doi:10.1016/S1466-853X(03)00053-1

increased in players of Australian football older than

23 years of age (Orchard, 2001).
Despite the magnitude of this problem in Australian
football, the aetiology of such injuries is unclear. Factors
that have been suggested to predispose an athlete to
hamstring muscle strain injury include muscle weakness,
muscle imbalance, poor flexibility, fatigue, inadequate
warm-up, poor neuromuscular control and poor running
technique (Agre, 1985). There is little evidence for poor
flexibility as a hamstring injury predictor (Bennell et al.,
1999), and apart from muscle weakness there is no empirical
support for any of the other suggested factors (Orchard,
2001).
The hamstring muscle group reaches peak elongation and
acts eccentrically at the hip and knee during the late swing
phase of the running cycle (Frigo et al., 1979; Simonsen
et al., 1985). Kinetic and EMG studies reveal that the
hamstrings are most active and develop the greatest torques
at the hip and knee during late swing through to the midstance phase of running (Mann and Sprague, 1980;
Montgomery et al., 1994). It is during these parts of the
running cycle that the hamstrings are under the greatest

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M. Cameron et al. / Physical Therapy in Sport 4 (2003) 159166

demands and injury most likely (Mann and Sprague, 1980;

Stanton and Purdam, 1989). Given the high forces involved,
it would seem that hamstring weakness might predispose an
athlete to injury, however, to date, there have not been
adequate findings to support either hamstring muscle
weakness or hamstring-quadriceps strength imbalance as
risk factors (Orchard, 2001).
Muscle weakness has been the most extensively
investigated of all proposed predisposing factors for hamstring injury. Retrospective studies have suggested a
relationship between muscle weakness and hamstring injury
(Croisier and Crielaard, 2000; Crosier et al., 2002; Heiser
et al., 1984), however, retrospectivity can confound the
causes and effects of injury. The literature also contains a
small number of prospective studies, which allow firmer
conclusions to be drawn regarding the factors involved in
the prediction of injury, but the results to date are
inconsistent. Two studies using isometric hamstring
strength assessment demonstrated an association between
injury and a side-to-side deficit of 10% (Burkett, 1970) and
a lower hamstring-to-quadriceps ratio (Yamamoto, 1993).
The latter finding was supported by a study using isokinetic
dynamometry at 60 8/s, which linked injury to a hamstringto-quadriceps ratio below 0.60 (Orchard et al., 1997). In
contrast, Liemohn (1978) did not find any relationship
between injury and isometric hamstring-to-quadriceps
strength ratio, nor did a larger study examining concentric
and eccentric isokinetic strength reveal any association
between injury and similar strength ratios (Bennell et al.,
1998).
One possible causative factor of hamstring injury, that
has not been previously examined, is the accuracy of
neuromuscular control of the leg during running. Throughout the running cycle there are many challenging neuromuscular events in which the hamstring acts, for example, to
control hip and knee motion in late swing and to provide hip
extensor torque in early stance. During sprinting, these
events occur over a very short period of time, and if the
control and coordination are inadequate, then muscle strain
injury may result (Agre, 1985; Bennell et al., 1999). Control
of a limb requires that information be obtained and
integrated from proprioceptors of the entire limb, and that
control will be influenced in part by activity in the opposite
limb. Joint or single segment proprioception has been
assessed by various techniques that employ joint position
testing, kinesthaesia testing or sense of effort testing, often
in non-weight-bearing postures (Lephart and Fu, 2000).
Waddington and Adams (1999) assessed movement discrimination (MD) at the ankle based on functional movement principles, whereby subjects performed ankle
inversion movements in standing and made judgments
regarding the extent of these movements without visual
input about the movement. This requires the processing of
both afferent and efferent information about the lower limb
being tested, and performance reflects a subjects ability to
do this accurately. An association was demonstrated

Fig. 1. Left leg late swing phase of the running cycle.

between poor discrimination ability and previous ankle

sprain injury. This task was later extended to enable
assessment of MD of the knee during weight-bearing
flexion (Waddington et al., 2000).
Utilising the same functional movement principles for
the current study on hamstring function, a similar apparatus
may be employed to assess the discrimination of movement
extent using the backward swinging leg, whilst weightbearing on the other side, in order to create a functional
movement as close as possible to the movement at injury.
The position of the player while being tested is selected to
recreate the proposed movement region in which hamstring
injury occurs: between the late swing to mid-stance phases
of the running cycle (Fig. 1). Ability to accurately
discriminate swinging leg movements can be seen as
reflecting use of proprioception from the lower limbs, and
is integral to the motor control of the leg in this region of the
running cycle where hamstring injury is likely to occur.
The aim of this study was to assess swinging leg MD,
isokinetic hamstring and quadriceps strength, and history of
previous hamstring injury, in order to determine any
association these factors have with respect to subsequent
hamstring injuries in a group of elite Australian football
players.

2. Method
2.1. Participants
Twenty players of Australian football were recruited for
this study from the training squad of one professional
Australian Football League (AFL) team. All subjects were
male and the mean (SD) age was 23.6 years (3.2), height

M. Cameron et al. / Physical Therapy in Sport 4 (2003) 159166

161

185.5 cms (8.5), weight 87.8 kg (9.1), and the mean number
of AFL training years was 4.7 (3.34). Subjects were
excluded if any significant lower limb injury was sustained
in the twelve weeks immediately prior to assessment.
Approval for the study was obtained from the University of
Sydney Human Ethics Committee, and all subjects signed
an informed consent.
2.2. Tests
2.2.1. Movement discrimination testing protocol
Lower limb motor control was assessed with a purposebuilt active movement extent discrimination apparatus, the
AMEDA (Waddington and Adams, 1999). This apparatus
consists of a vertical contact plate attached to the end of the
motor-driven shaft, which sets the stop for ending leg
swinging movements at different positions. A laptop
computer controlled the Programmable Stepper Motor1
driving the shaft, with end-point re-positioning accuracy
manufacturer-specified at 0.01 mm. Five stop settings were
used to generate the five leg swing movement extents, and
these were each 5.6 mm apart. The stop positions were
located from 20 43 mm behind the posterior margin of the
heels in standing, which corresponded to an angle of the
lower limb to vertical of approximately 2 8 and represented
the position of the leg at early to mid-stance phase of
running (see Fig. 2).
Testing of leg swing movement commenced with
subjects in normal weight-bearing stance astride the
apparatus, heads up and eyes focused on a point on the
wall opposite, so that they had no direct vision of their foot
or the contact plate. The contact plate was set to one of the
five positions and on command, subjects transferred weight
to one leg, actively lifted the tested leg to touch the start bar,
before swinging the limb backward toward the plate until
contact was made, and then returning to standing (Fig. 2).
After this movement the subject identified which one of the
five stop settings (i.e. movement extents) they had just
experienced.
Each subject was given a series of trial leg swing
movements on the AMEDA in order to familiarize them
with the feel of each stop setting prior to data collection.
Following this, all of the five stop positions were presented
eight times in random order. Subjects were allowed only one
leg swing movement for each trial. After each movement
the subject was asked which of the five stop numbers they
felt corresponded to the movement extent performed. The
reported stop position was recorded for the forty trials, and
no feedback as to reporting accuracy was provided. Both
legs of each subject were tested and the side first tested was
randomly determined. From this testing, a measure of a
subjects ability to differentiate between different movement extents was obtained.
1
RS Components Pty Ltd, 129 137 Beaconsfield Street, 2141
Silverwater, NSW, Australia.

Fig. 2. A subject standing on the active movement discrimination apparatus

and swinging the right leg to contact the start bar (A) and then the stop
plate (B).

2.2.2. Muscle strength testing protocol

Strength measurements were conducted on all players in
the pre-season of 2000 at the Sport Science Department of
the New South Wales Academy of Sport, University of
Sydney, Australia. Knee flexion and extension concentric
strength were assessed with a Cybex II Isokinetic
Dynamometer2 using a protocol which most players had
experienced at previous screening sessions. Warm-up prior
to data collection consisted of five minutes cycling on a
stationary bike and stretching of the lower limb musculature. For isokinetic testing, subjects were positioned in
sitting with straps around the thigh, waist and chest, with
arms folded across the chest. The axis of rotation of the
dynamometer was aligned with the centre of the lateral
femoral condyle as outlined by Perrin (1993). The shin pad
of the dynamometer shaft was placed 2 cm proximal to the
lateral malleolus. After set-up, subjects completed several
submaximal knee flexion/extension trials. Torque and
displacement were determined at an angular velocity of
60 8/s, on both legs, and for both knee flexion and extension.
At each direction, subjects were required to exert maximum
effort for three repetitions, and the mean of the two highest
torque values was recorded. A minimum two-minute
recovery period was imposed between repeated trials. The
order of leg testing was randomised, however, the quadriceps was tested prior to the hamstrings.
The Cybex II dynamometer was computer-interfaced and
torque and angular displacement data were collected for 5 s
at a sampling rate of 1000 Hz. This information was stored
to disk for later processing, which included the determination of peak torque that in all instances occurred after the
impact spike (Kannus, 1994). Given this protocol, ramping
and damping procedures were considered unnecessary.
Prior to, and after testing, the torque output of the Cybex
was calibrated by measuring a range of known torques
according to the manufacturers specification. Peak torque
values were normalised for body weight for each subject to
2
Cybex International Inc, 10 Trotter Drive, Medway, MA 02053,
USA.

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M. Cameron et al. / Physical Therapy in Sport 4 (2003) 159166

allow comparison of knee flexion and extension concentric

strength between subjects.
2.2.3. Procedure
Previous hamstring injury occurrence in the two years
prior to the study was determined by questionnaire and
review of club injury records, and an injury was deemed to
be significant if any missed matches resulted. All subjects
were tested prior to the 2000 football season, and monitored
throughout the 2000 and 2001 seasons for significant
hamstring injury. The club medical officer made a diagnosis
of significant hamstring injury upon satisfying all of the
following criteria
(a) acute onset of pain in the posterior thigh during
training or a match
(b) posterior thigh pain reproduced with stretch, contraction and palpation of the hamstring muscle
(c) hamstring muscle injury demonstrated by magnetic
resonance imaging (MRI)
(d) at least one match missed due to hamstring injury
The medical officer was blind to the results of MD and
isokinetic testing.
2.2.4. Statistical analysis
The reported stop positions obtained from discrimination
testing were cast into stimulus-response matrices, and nonparametric signal detection analysis was used to obtain MD
scores, defined as the area under the Receiving Operating
Characteristic (ROC) curves (McNicol, 1972). ROC curves
were used to plot the probability of correctly identifying the
extreme stop positions against the probability of incorrectly
labeling them as other stop positions. The area under a ROC
curve provides an overall measure of stop position
discrimination ability in this task, and was calculated with
the ROC subroutine in SPSS 10.0 for Windows. An area of
0.5 corresponds to chance whereas 1.0 corresponds to
perfect discriminability (Maher and Adams, 1995). From
the strength data, peak concentric torque of the hamstring
and quadriceps muscle groups were used in data analysis,
and a hamstring-to-quadriceps strength ratio (H/Q) was
calculated for each leg of each subject. These data were
analysed with SPSS 10.0 for Windows software. Prospective and retrospective injured/uninjured grouping structures
were created by the occurrence of hamstring injuries in the
two-year period following measurement, and by the past
history of hamstring injuries in the two years preceding
measurement. Thus determined, separate ANOVAs were
conducted on the muscle strength and MD variables, with
factors Injury Status (injured/uninjured) and Side (dominant/non-dominant).
Previous injury, MD, and hamstrings and quadriceps
muscle strength variables were evaluated by the use of ROC
curves as to their performance of predicting prospective
injury status grouping. Use of ROC curves, originally

developed to measure the ability of a subject to differentiate

between different stimuli (Green and Swets, 1966), has been
extended to medical research, where the curves have been
used to examine a diagnostic tests discriminative capability
for determining presence of disease or injury (Swets et al.,
2000). Applied in this way, curves were generated by
plotting the true-positive rate (sensitivity) and false-positive
rate (1-specificity) along the vertical and horizontal axes for
each of the predictor variables. The area under the ROC
curve is the most useful comparative measure of the
performance of screening tests (Hanley and McNeil, 1982;
Park et al., 2002), and a value over 0.8 can be interpreted as
a test with good predictive power (Meijer et al., 2002).
Areas under the ROC curve were calculated using SPSS
10.0 for Windows, and comparisons between variables and
calculations of cut-off points were performed with Prediction program version 3.0.

3. Results
In the two seasons following testing, six subjects
sustained one or more significant hamstring muscle strains.
In the two seasons prior to testing, seven subjects had
experienced hamstring muscle strains, and two of these
subjects were in the group of six injured in the subsequent
period. There was no past history of hamstring injury in 4 of
the 6 subsequently injured subjects.
Mean MD scores and thigh concentric strength variables
for the groups are given in Table 1. With respect to the
prospective analyses, MD scores were significantly worse in
those subsequently injured compared to the subsequently
uninjured group F1; 18 9:44; p 0:007: No player
with a MD score above the group mean subsequently injured
a hamstring, but six of the ten players with scores below the
mean did incur injury. Subsequently injured subjects also
had significantly lower hamstrings-to-quads (H/Q) strength
ratios F1; 18 8:75; p 0:008 and significantly greater
quadriceps strength adjusted for their body weight
F1; 18 6:13; p 0:02 than uninjured subjects. Hamstring muscle strength values, however, showed no
Table 1
Mean (SD) movement discrimination score (MD), relative peak torques
(N m/kg) and hamstring-to-quadriceps (H/Q) ratio for previously and
subsequently injured and uninjured players
Previously

MD score
Hamstring
Quadriceps
H/Q ratio
a

Subsequently

Injured
n 7

Uninjured
n 13

Injured
n 6

Uninjured
n 14

0.75 (.15)
2.05 (.30)
3.15 (.22)
0.64 (.07)

0.80 (.16)
2.02 (.24)
3.03 (.32)
0.67 (.09)

0.69 (.10)
1.95 (.15)
3.30 (.24)
0.59 (.03)

0.82 (.15)a
2.08 (.30)
2.99 (.29)a
0.69 (.09)a

Statistically significant difference p , 0:05:

M. Cameron et al. / Physical Therapy in Sport 4 (2003) 159166

Table 2
Area under the ROC curve (Area), standard error (SE), asymptotic
significance p and 95% confidence interval (CI) for hamstring injury
predictor variables: movement discrimination score (MD), relative peak
hamstring (H) and quadriceps (Q) torque, hamstring-to-quadriceps ratio
(H/Q), and previous hamstring injury (Prev Inj)
Variable

Area

SE

CI

MD score
H
Q
H/Q
Prev Inj

0.869
0.607
0.827
0.881
0.488

0.080
0.124
0.099
0.077
0.144

0.011
0.458
0.023
0.008
0.934

0.7121.026
0.3540.851
0.6341.020
0.7301.032
0.2060.770

significant differences between groups F1; 18

0:83; p 0:37:
When the group was separated into previously injured
and uninjured subjects, there were no significant differences
on any of the variables. No differences were found between
dominant and non-dominant sides in either the prospective
or retrospective analyses, and there were no interactions
between side and injury status. Because there are strong
temporal and spatial relationships between the lower limbs
during locomotion (Shapiro et al., 1981), indicating a high
level of inter-limb coordination, the two legs during running
have been considered a single coordinative structure
(Sherwood, 1989). Accordingly, the two limbs for each
subject were averaged to give a single score for MD and for
each strength assessment. These form the data presented in
Table 1. To examine the injury-predictive capability of the
tested variables, mean MD score, hamstring and quadriceps

163

strength, and H/Q ratio across limbs were calculated for

each player. The ability of each variable to predict
hamstring injury was evaluated by calculating the area
under the relevant ROC curve. These values, level of
significance and confidence intervals are presented in
Table 2.
Movement discrimination score, quadriceps strength and
H/Q ratio were significant predictors of hamstring injury
based on the area under the ROC curve. Pair-wise
comparisons revealed no significant difference between
MD score and quadriceps strength in terms of their value as
predictors z 0:3278; p 0:3715 or H/Q ratio z
0:1038; p 0:4587; or between quadriceps strength
and H/Q ratio z 0:4107; p 0:3406: There was no
significance difference between hamstring and quadriceps
strength z 1:1230; p 0:1307 as injury predictors,
however, there was a significant difference in hamstring
injury predictive value between hamstring strength and H/Q
ratio z 2:8558; p 0:0021 and between hamstring
strength and MD score z 1:9295; p 0:0268: Hamstring strength and previous hamstring injury were individually not significant predictors of subsequent hamstring
injury, and there were no significant differences between
them. The sample size was too small to permit the development of an equation combining the predictor variables.
To develop cut-points or decision thresholds (Swets et al.,
2000) for the significant hamstring injury predictor
variables, sensitivity and specificity values and a summary
measure, Youdens index, were calculated for each variable,
and are presented in Table 3. Youdens index is the best

Table 3
Sensitivity (SENS), specificity (SPEC), and Youdens index (YI) for movement discrimination (MD), hamstring-to-quadriceps strength ratio (H/Q) and
relative quadriceps (Q) peak torque (Nm/kg) cut-point values
MD score

H/Q score

QUAD peak torque

SCORE

SENS

SPEC

YI

SCORE

SENS

SPEC

YI

SCORE

SENS

SPEC

YI

0.94
0.93
0.91
0.90
0.88
0.87
0.80
0.79
0.79
0.78

1
1
1
1
1
1
1
1
1
1

0.07
0.14
0.21
0.29
0.36
0.43
0.50
0.57
0.64
0.71

0.07
0.14
0.21
0.29
0.36
0.43
0.50
0.57
0.64
0.71

0.82
0.76
0.75
0.72
0.69
0.68
0.67
0.66

1
1
1
1
1
1
1
1

0.14
0.21
0.29
0.43
0.50
0.57
0.64
0.71

0.14
0.21
0.29
0.43
0.50
0.57
0.64
0.71

2.44
2.64
2.86
2.88
3.00
3.02

1
1
1
1
0.83
0.83

0.07
0.14
0.29
0.43
0.50
0.71

0.07
0.14
0.29
0.43
0.33
0.55

0.77
0.77
0.75
0.74
0.73
0.73
0.72
0.71
0.68
0.50

0.83
0.83
0.67
0.67
0.50
0.33
0.33
0.33
0.17
0

0.71
0.79
0.79
0.86
0.86
0.86
0.93
1
1
1

0.55
0.62
0.45
0.52
0.36
0.19
0.26
0.33
0.17
0

0.65
0.62
0.61
0.6
0.59
0.58
0.57
0.55

0.83
0.83
0.67
0.50
0.33
0.33
0.17
0

0.71
0.86
0.86
0.86
0.86
1
1
1

0.55
0.69
0.52
0.36
0.19
0.33
0.17
0

3.18
3.26
3.28
3.34
3.36
3.40
3.50
3.56

0.67
0.67
0.50
0.50
0.33
0.17
0.17
0

0.79
0.86
0.86
0.93
0.93
0.93
1
1

0.45
0.52
0.36
0.43
0.26
0.10
0.17
0

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M. Cameron et al. / Physical Therapy in Sport 4 (2003) 159166

summary measure of a diagnostic tests ability (Biggerstaff,

2000), and is calculated for a given cut-point by adding the
sensitivity and specificity values and subtracting one.

4. Discussion
Three measuresbackward leg swing MD, hamstring
strength relative to quadriceps strength and quadriceps
strength relative to body weightwere found to predict
hamstring injury in a subsequent two-season period. The
number of players sustaining a hamstring injury in this study
was equivalent to a seasonal rate of 15% and is similar to the
rate of 14% described by a previous study of injuries in
Australian football at this level (Seward et al., 1993).
First, on a test utilizing a movement similar to the action
at the most likely time of injury, subsequently hamstringinjured players had below average MD ability, and this
would suggest that it is players with poor lower limb
proprioception and motor control who are at risk of
hamstring injury. If an error is made in the control of the
swinging lower leg at a time in the running cycle when high
hamstring tissue forces exist, then a strain injury is possible.
The performance of swinging leg MD testing as a
screening tool for hamstring injury was assessed using ROC
curve analysis. Movement discrimination testing is a good
predictor of subsequent hamstring injury, as indicated by
obtaining an area under the ROC curve of 0.869. A range of
MD scores were assessed as the cut-point or decision
threshold for this measure, whereby players scoring below
this point are deemed to have a positive test and predicted to
sustain a hamstring injury, and scores above this point are
deemed negative and not predicted to injure. Consequently,
sensitivity and specificity values were calculated for each
decision threshold and are listed in Table 3. The Youdens
index for each MD score acting as the decision threshold is
also indicated in Table 3. A MD score of 0.78 corresponds
to the decision threshold with the highest Youdens index of
0.71, having 100% sensitivity and 71.4% specificity. These
values suggest that the MD test is better at identifying those
players unlikely to injure, and that some players testing
positive are able to avoid injury for other reasons. As with
any predictive test, the cut-point can be varied according to
the requirements of the clinician. In professional football
where hamstring injuries are one of the most frequently
occurring and recurring injuries, and players do have the
opportunity to engage in injury prevention programs, the
identification of any player at risk is worthwhile. In this
situation, the cost of false positives is less than the cost of
false negatives, (i.e. not identifying players who subsequently sustain a hamstring injury). However, leg swing
MD testing lacks clinical usefulness without an intervention
program to rectify any deficit, and this is a direction for
future research.
In relation to the second significant injury predictor, over
the two-year study period, those players who sustained

a hamstring injury also had a lower H/Q strength ratio when

measured using isokinetic dynamometry at 60 8/s. The
magnitude of the difference in H/Q ratio between injured
and uninjured groups is similar to a previous study of elite
footballers (Orchard et al., 1997). However, from the third
significant injury predictor identified, it would seem that it is
the increased quadriceps strength rather than a decrease in
hamstring strength that is responsible for the reduced H/Q
ratio in the injured group of this study. This is a finding that
has not been reported previously. The increased quadriceps
strength of injured subjects suggests that footballers who
develop excessive quadriceps strength increase the risk of
hamstring injury, despite otherwise adequate hamstring
strength. The hamstring and quadriceps muscles co-contract
during the early stance phase of running as the knee flexes
after ground contact then extends. If quadriceps force
development during this co-contraction is in excess of the
hamstring muscle groups capacity, then hamstring injury
may be possible. There is further co-contraction later in
stance and a shift from hip extension and knee flexion
torques, to hip flexion and knee extension dominance in
mid-stance (Mann and Sprague, 1980). It is at this point that,
Yamamoto (1993) suggests an imbalance between the
hamstrings and the hip flexor rectus femoris may result in
injury. The development of additional quadriceps strength
may result in an athlete running at a speed or with a
technique that predisposes the insufficient hamstring muscle
to injury (Muckle, 1982).
Players of Australian football would be aware of the
common and recurring nature of hamstring injuries, and
may be purposefully increasing their hamstring strength
training. This may involve increasing the number of lower
limb strength exercises generally, and as a consequence, the
quadriceps muscles may be strengthened to a point that
places the hamstrings at further injury risk, despite any
previous strength gains.
From the data here, low H/Q ratio and excessive
quadriceps strength are two strength factors that are
associated with an increased hamstring injury risk in
Australian football. Both factors can be considered to be
good predictors of hamstring injury with areas under the
ROC curve of 0.881 and 0.827, respectively. Table 3
contains the sensitivity and specificity values, and Youdens
index for the corresponding H/Q ratios found in this study.
The traditional H/Q ratio of 0.60, when used as a cut-point
for identifying at-risk players, results in this test variable as
having 50% sensitivity, 85.7% specificity and Youdens
index of 0.36. If 0.60 is used, half of the hamstring-injured
players would be missed, however, if the cut-point is raised
to 0.66 then sensitivity increases to 100%, specificity falls to
71.4%, and Youdens index nearly doubles to 0.71. None of
the players in this study with a H/Q ratio above 0.66
sustained a hamstring injury in the two years subsequent to
testing. These findings suggest that a higher H/Q ratio of
0.66 should be used as the threshold for detecting elite
players of Australian football at-risk of hamstring injury.

M. Cameron et al. / Physical Therapy in Sport 4 (2003) 159166

The hamstring injury risk associated with high quadriceps strength relative to body weight poses an interesting
clinical dilemma in professional football. Intervention to
reduce quadriceps strength may involve reducing leg weight
training, however, this may have performance repercussions
and be undesirable in a large proportion of players. A high
quadriceps strength cut-off will decrease the number of
players involved in any intervention program that may harm
performance, however, it will increase the number of
injuries missed i.e. false negatives. Considering the
consequences of injury and intervention, the relationship
between excessive quadriceps strength and hamstring injury
deserves to be further investigated.
A ratio of eccentric hamstring and concentric
isokinetic strength has been suggested as useful in
assessment of hamstring-injured subjects (Aagaard et al.,
1995; Croisier and Crielaard, 2000). A significant
difference in such a ratio in previously hamstring-injured
athletes was demonstrated in a retrospective investigation
(Crosier et al., 2002), but not in a prospective study
(Bennell et al., 1998). There are no prospectively
designed studies supporting an eccentric/concentric ratio
identifying hamstring injury risk athletes, however, there
is with a concentric only ratio (Orchard et al., 1997). The
current study was also limited to only concentric strength
and ratios, however, these findings suggest that the early
stance phase of running involving concentric hamstring
activity, rather than the eccentric late swing phase, may
be a more likely region of hamstring injury. The role of
eccentric strength and the region of the running cycle of
hamstring injury deserve further investigation.
Eccentric strength assessment involves some injury risk,
particularly in hamstring muscles (Orchard et al., 2001),
therefore a concentric thigh strength assessment is recommended for the pre-season screening of hamstring injury
risk in participants of Australian football. The motor control
test did not place any stress on capacity to generate force, on
range, or on speed, but it did challenge the capacity of the
players to make fine discriminations between different
extents of backward leg swinging movements. The motor
control measure does not produce muscle pain or fatigue, is
less disruptive to training, and is a useful screening tool for
hamstring injury risk at any time of the season.
The results of this study support an association between
hamstring injury and both a low MD score and a high degree
of hamstring and quadriceps strength imbalance. Crosier
et al. (2002) argue that the relationship between muscle
imbalance and injury has always been a logical assumption,
however, we would argue that the relationship between poor
accuracy in relevant movement control and hamstring injury
is equally logical. One possible explanation for the pattern
of predictors observed here is that weight training to
develop leg strength can improve quadriceps strength
relatively more easily than hamstring strength, yet without
the level of motor control needed for injury-free performance with a stronger system. One implication is that there

165

may exist an interaction between thigh muscle strength and

leg swing MD such that a deficit in one variable can be
compensated by a higher ability in the other. The decision
threshold for each variable and any possible interaction need
to be validated in a subsequent group of footballers. Future
research should also be directed at training methods that can
reliably improve MD in backward leg swing, in order to
reduce the risk of hamstring injury.

5. Conclusion
The findings of this study suggest that poor leg
neuromuscular control may be a significant contributor to
hamstring injury. Data in this study has also supported the
injury risk of a low hamstring-to-quadriceps ratio. Investigations into only a single contributing factor are likely to
lack agreement due to the multi-factorial nature of hamstring strain injury. This study has linked two variables
poor leg MD and thigh muscle strength imbalancewith an
increased risk of hamstring injury. At this point, it is
recommended that players be screened for hamstring injury
risk with leg motor control testing and thigh muscle strength
measurements, so that changes obtained in these values
could be used as a basis for designing effective injury
prevention programs.

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