ARTICLE IN PRESS

Physical Therapy in Sport 9 (2008) 25–33

www.elsevier.com/locate/yptsp

Original research

The reliability of musculoskeletal screening tests used in cricket

Rebecca J. Dennisa,b,, Caroline F. Fincha,b, Bruce C. Elliottc, Patrick J. Farhartd
a
NSW Injury Risk Management Research Centre, University of New South Wales, Sydney, NSW 2052, Australia
b
School of Human Movement and Sport Sciences, University of Ballarat, P.O. Box 663, Ballarat, Vic. 3353, Australia
c
School of Human Movement and Exercise Science, University of Western Australia, M40835 Stirling Highway, Crawley, WA 6009, Australia
d
Cricket New South Wales, P.O. Box 333, Paddington, NSW 2021, Australia
Received 7 May 2007; received in revised form 5 September 2007; accepted 20 September 2007

Abstract

Objectives: To determine the inter- and intra-observer reliability of a field-based musculoskeletal screening protocol used to
measure potential injury risk factors in cricket fast bowlers.
Design: Test–retest reliability study.
Setting: High performance Australian cricket.
Participants: Ten volunteers. Two sports physiotherapists conducted the testing.
Main outcome measures: Participants completed the following tests: knee extension; modified Thomas test (hip extension and
abduction); hip internal and external rotation; combined elevation; ankle dorsiflexion lunge; bridging hold; prone four point hold;
and calf heel raises.
Methods: For each of the tests, the participants were tested by each physiotherapist twice, and the inter- and intra-observer
reliability were concurrently assessed.
Results: The inter-observer reliability of the tests was generally poor, with only four of the ten tests having an intraclass correlation
coefficient (ICC) greater than 0.80 (range of ICCs 0.27–0.99). The intra-observer reliability of the tests was considerably higher, with
nine tests having an ICC greater than 0.80 (range of ICCs 0.56–0.99).
Conclusions: With the exception of the bridging hold, all tests would be considered acceptable where only one observer was
conducting the testing. However, only the ankle dorsiflexion lunge, combined elevation test, calf heel raise test and prone four point
hold have acceptable reliability when there are multiple physiotherapists recording measurements.
r 2007 Elsevier Ltd. All rights reserved.

Keywords: Musculoskeletal; Reliability; Cricket; Fast bowler; Intraclass correlation coefficient

1. Introduction why an athlete may be predisposed to injury (Bahr &

Krosshaug, 2005; Finch, 2006).
The development of successful sports injury preven- Preparticipation (or baseline) screening is commonly
tion strategies relies on a solid evidence base. Sports used to measure potential intrinsic injury risk factors
injury prevention is a staged process which consists of a (DiFiori, 1999), by identifying characteristics of the
series of steps (Finch, 2006; van Mechelen, Hlobil, & musculoskeletal system that may predispose an athlete
Kemper, 1992). The second step involves developing an to injury, or to identify incomplete recovery from a
understanding of the aetiology of injury, which includes previous injury. In prospective studies, measurements
identifying intrinsic injury risk factors to understand are made on uninjured athletes at the start of a playing
season and these are related to injury outcomes during
the course of the season.
Corresponding author. This approach was taken with a prospective epide-
E-mail address: [email protected] (R.J. Dennis). miological study of 91 cricket fast bowlers. Studies have

1466-853X/$ - see front matter r 2007 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ptsp.2007.09.004
 ARTICLE IN PRESS
26 R.J. Dennis et al. / Physical Therapy in Sport 9 (2008) 25–33

identified variations in technique, physical characteris- primary focus when selecting tests for inclusion in the
tics and workload as injury risk factors for this protocol. The tests chosen are commonly used in cricket
population. However, a limitation of prior studies is (although they are not specific to the sport) and were
that many have used specialised equipment and labora- primarily based on clinical assessment protocols used
tory facilities to test the fast bowlers, and the degree to with athletes (Harvey, 1998b) and incorporated proce-
which the testing procedures can be adopted in the dures described in other relevant literature (Bennell,
cricket ‘‘real world’’ is unclear. The advantages of using Talbot, Wajswelner, Techovanich, Kelly, & Hall, 1998;
a field-based screening protocol are that it can be Berryman Reese & Bandy, 2002; Gabbe et al., 2004;
conducted with easily obtainable and inexpensive Harvey, 1998a; Norkin & White, 1985).
equipment, as well as with a large number of athletes
at multiple locations. Therefore, the aim of our earlier 2.2. Participants and observers
epidemiological study (Dennis, 2006) was to identify
intrinsic risk factors for injury to fast bowlers using a The reliability assessment was conducted with 10
field-based screening protocol, which included a muscu- volunteers. Two sports physiotherapists (observers),
loskeletal assessment. with extensive clinical experience in cricket, conducted
A major issue encountered by studies of intrinsic risk the testing, with an assistant. A training session for the
factors, such as those described above, is the reliability observers and assistants was conducted by the lead
of the screening measures used. The ability for studies to author before the reliability assessment, and a detailed
clearly identify injury risk factors is highly dependent on procedures manual for the screening protocol was
the accuracy with which measurements are made (Bahr provided. The study was approved by the University
& Holme, 2003), and it is vital that the screening of New South Wales Human Ethics Review Committee
protocols are reliable (Gabbe, Bennell, Wajswelner, & and participants provided written consent.
Finch, 2004; Harvey, 1998b). Measurements need to be
reproducible over time and by different observers, as 2.3. Procedure for completing the musculoskeletal tests
well as being repeatable within a given individual
(Hayen, Dennis, & Finch, 2007). Poor reproducibility For tests requiring goniometric measurement, a
limits the ability of researchers to reach conclusions modified goniometer was used. A spirit level was
about whether a measured variable is indeed a risk attached to one arm of the goniometer, so that the
factor for injury, because it is difficult to differentiate degree of motion relative to the vertical could be
participants with or without the variable of interest if determined. The procedures for each of the tests are
there is large random measurement error (Haas, 1995; described below.
Hayen et al., 2007).
Unfortunately, the reliability of many of the tests 1. Knee extension: This test was used to assess hamstring
included in the musculoskeletal assessment of fast muscle length and the range of assisted active knee
bowlers has not previously been established for this extension in a position of hip flexion (Harvey, 1998b).
group of athletes. Therefore, this paper presents a While the participant lay in a supine position with the
reliability assessment of the tests, to inform the hip of their testing leg flexed, the observer provided
development of an appropriate field-based preparticipa- support behind the posterior thigh to hold the hip in
tion musculoskeletal screening protocol for use in 901 flexion. The participant relaxed their foot and
cricket and potentially in a range of other sports. slowly extended their knee. Once the limit of
extension was reached, the observer provided support
behind the calf while the assistant recorded knee
2. Methods extension (x1), relative to the vertical, to the nearest
degree. The final angle was calculated as 901x1. In
2.1. Development of the protocol cases where the participant was able to achieve full
knee extension, the observer flexed the knee and
The screening protocol was developed in collabora- moved the thigh to 301 past the vertical. The knee was
tion with a sports physiotherapist (PF, with 15 years of again straightened until the limit of knee extension
experience working with cricketers) and consisted of a (x1). The final angle was calculated as 1201x1.
number of tests measuring flexibility, strength, and 2. Modified Thomas test (MTT) (hip extension): The
stability. The majority of injuries reported among fast MTT assesses the flexibility of the hip flexors. The
bowlers are to the back, trunk and lower limb (Dennis, procedure used was the same as that described
Farhart, Goumas, & Orchard, 2003; Dennis, Finch, & previously (Harvey, 1998a). The participant perched
Farhart, 2005; Orchard, James, Alcott, Carter, & on the end of the bench and rolled back into a supine
Farhart, 2002), and hence the identification of injury position, while holding both knees firmly to their
risk factors for these particular body regions was the chest. They held their contralateral hip in maximal
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R.J. Dennis et al. / Physical Therapy in Sport 9 (2008) 25–33 27

Fig. 2. Prone four point hold.

with the flexible arm positioned to the opposite ASIS.

Hip abduction was recorded to the nearest degree,
with the line perpendicular to that of the ASIS
considered as 01. A negative angle represented hip
adduction and a positive represented hip abduction.
4. Hip internal and external rotation: This test was used
to assess the range of hip rotation in a neutral hip
position (Harvey, 1998b). The participant lay in a
prone position with both knees bent to 901, chin
resting on the bench and arms by their sides. The
participant then straightened their contralateral knee.
To determine internal rotation, the participant was
asked to let the ankle of the testing leg move laterally
as far as possible, while the observer ensured that
Fig. 1. Modified Thomas test (hip abduction). pelvic motion and/or hip flexion did not occur. To
determine external rotation, the participant was
asked to let the ankle of their testing leg drop
flexion with both arms, while their testing leg was towards the opposite side of the body as far as
lowered towards the floor. An assistant supported possible. For both internal and external rotation, the
this position by pushing gently on the contralateral assistant measured the angle formed by the line of the
knee. The participant was asked to relax the hip and tibia, relative to the vertical, to the nearest degree.
thigh muscles of their testing leg so that a passive end 5. Combined elevation test: The combined elevation test
point position was obtained due to gravity alone. The assesses combined thoracic extension (strength and
axis of the goniometer was placed over the greater range of motion), shoulder girdle flexion and scapula
trochanter, with the fixed axis directed vertically retraction (Harvey, 1998b). The participant lay in a
using the spirit level. The moveable arm of the prone position on the floor, with both arms out-
goniometer was pointed toward the lateral knee joint stretched. They kept elbows extended, thumbs locked
line, representing the line of the femur. The observer together and palms facing towards the floor. For the
then assessed the hip angle relative to the horizontal, duration of the test, the participant kept their feet,
or 01-axis, to the nearest degree. A negative angle hips, chest, and chin on the ground. They were asked
represented flexion above the horizontal and a to take a breath in and hold, and then raise both arms
positive represented extension below the horizontal. off the floor as high as possible, without flexing their
3. MTT (hip abduction): The MTT was also used to elbows. A tape measure was used to measure the
measure the degree of hip abduction. The same perpendicular distance from the base of the meta-
starting position as the previous test was used and the carpal of the thumb to the floor, to the nearest 0.5 cm.
test procedure was modified from previous research 6. Prone four point hold: This test was chosen to assess
(Harvey, 1998a). When the participant was in the the length of time that the participant could maintain
supine position, the assistant held the contralateral a neutral lumbopelvic position in a four point hold
hip in maximal flexion and added external rotation in position. The participant lay in a prone position on
order to move the anterior superior iliac spine (ASIS) the floor, resting on their forearms, with elbows
of the left and right side into a parallel alignment flexed at 901. Their forearms were held parallel to
(Fig. 1). Hip abduction angle was measured with the each other, shoulder width apart. Participants were
centre of the goniometer over the ipsilateral ASIS, not permitted to grip their hands together at any
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28 R.J. Dennis et al. / Physical Therapy in Sport 9 (2008) 25–33

stage during the test. Their feet were placed in a push-

up position, with ankles flexed and the base of their
toes on the floor. Participants were instructed to pull
their navel in towards their spine and hold. They then
raised their trunk off the floor, resting on their
forearms and toes, holding a neutral lumbopelvic
position as long as possible (Fig. 2). The test was
terminated if the participant experienced back pain, if
they could no longer hold the neutral position (as
determined by the observer) or if they could simply
not sustain the prone hold any longer. A stopwatch
was used to determine the length of time the
participant held a neutral position, to the nearest
second.
7. Bridging hold: The bridging hold assesses gluteal
musculature strength and endurance. The participant
lay supine on the floor, with both knees bent at 901.
They raised their hips and pelvis off the floor in order
to attain a continuous alignment from the shoulder,
through the hip, through to the knee. They then Fig. 4. Ankle dorsiflexion lunge.
raised their contralateral foot off the floor and with
their foot in a neutral position, fully extended their
knee (Fig. 3). The participant was asked to use the prevent it from lifting off the floor and manually
gluteal muscles to maintain the same height of the locked the subtalar joint so it remained in a neutral
ASIS of the left and right side, and stop the lower position throughout the test. The participant lunged
back from arching. They held this position for as long forward until their knee touched the wall (Fig. 4).
as possible, until the position was no longer held The maximum distance from the great toe to the wall
correctly (as determined by the observer), the was recorded to the nearest 0.1 cm.
participant experienced low back or hamstring pain 9. Calf heel raises: This test was used to assess
or could simply not hold the position any longer. endurance of the ankle plantarflexor muscles in a
Duration of the hold was recorded to the nearest weightbearing task. With bare feet, the participant
second. stood with the balls of their feet on the edge of a step
8. Ankle dorsiflexion lunge: This test measures the range with their heels off the step. The participant was
of dorsiflexion at the ankle joint. A tape measure was instructed to stand on one foot and to rise onto the
fixed along the floor with the 0 cm point at the ball of that foot as high as possible, then slowly lower
junction of the floor and wall. The participant their heel, while maintaining knee extension through-
positioned their foot beside the tape so that their out the movement. The heel raise/lower cycle was
heel line and big toe were aligned beside the tape repeated continuously (without a rest) until the
measure. The observer held the participant’s heel to participant was unable to rise through full range
with the knee extended. They were asked to perform
the heel raises at a rate of approximately one cycle
per second.

2.4. Procedure for conducting the reliability assessment

2.4.1. Range of motion tests

The participants were required to attend one appoint-
ment, in which they were tested by each observer twice,
in the order of Observer 1, Observer 2, Observer 1,
Observer 2. The tests were conducted in the same order
each time, with 10-min rest breaks between each session
for the following tests: knee extension; MTT (hip
extension and abduction); hip internal and external
rotation; combined elevation; and ankle dorsiflexion
Fig. 3. Bridging hold. lunge. The assistant recorded the measurements for each
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R.J. Dennis et al. / Physical Therapy in Sport 9 (2008) 25–33 29

test and at the end of each session they filed the provided previously (Hayen et al., 2007). The SEM, also
recording sheet. This was done so that the observers known as measurement error, was expressed in the same
could not see the results of the first session when they units as the test was measured (e.g. degrees). It is
were completing the second session. possible to translate the test statistic for the SEM into a
standard normal critical value, which represents the
2.4.2. Muscular endurance tests minimum difference between measurements that needs
A different method was used to assess the reliability of to be exceeded to be confident that a real change has
the bridging hold, prone four point hold and calf heel occurred (Hayen et al., 2007).
raise tests, because they are measures of muscular The classification system for determining acceptable
endurance and require maximal effort. The scores for ICCs adopted in this paper was that of Landis and
multiple trials could be vastly different and this would Koch (1977). This classifies ICCs as slight (0.00–0.20),
result in poor inter- and intra-observer reliability results. fair (0.21–0.40), moderate (0.41–0.60), substantial
However, these differences would not necessarily be a (0.61–0.80), and almost perfect (0.81–1.00). Finally, to
result of measurement error by the observer. Therefore, determine if there was any ‘‘learning’’ effect because the
the participants only completed one trial for these tests, participants completed each test four times, or observer
which was examined simultaneously by both observers. order effect, a general linear repeated measures model
A video camera was positioned side-on to the partici- was conducted using SPSS for Windows.
pant to record the trial (sagittal plane). The footage was
later viewed by each observer to determine his or her 3. Results
scores for a second ‘‘trial’’, to allow the calculation of
inter- and intra-observer reliability. For the bridging The inter-observer reliability of the tests is presented
hold and prone four point hold, the video camera was in Table 1 and the intra-observer reliability is shown in
positioned approximately 30 cm off the ground (in line Table 2. Generally, the inter-observer reliability of the
with the height of the pelvis). For the calf heel raises, the tests was low, with only four of the ten tests being
video camera was approximately 100 cm off the ground. considered almost perfect with an ICC greater than
For the four point prone hold and the bridging hold, 0.80. The intra-observer reliability of the tests was
the observers each had a stopwatch. The participant considerably higher than inter-observer reliability,
held the position for as long as possible until failure. The with nine tests in the category of almost perfect. The
observers did not stop the participant during the test if 95% CIs were wide, especially for inter-observer
they were no longer holding the correct position. reliability. It should also be noted that the SEM critical
Instead, they noted the time at which they would value, which represents the minimum difference between
usually terminate the test. A similar process was used for measurements that needs to be exceeded to be confident
the calf heel raises. Both observers observed the trial that a real change has occurred, was high for many of
while the video footage was being captured and did not the tests when considering inter-observer reliability.
stop the participant if they were no longer raising the Whereas, it was considerably lower for intra-observer
heel through a full range with the knee extended. reliability.
Instead, they noted the number of correctly completed As presented in Table 3, the repeated measures
trials. The observers did not communicate during the analysis identified two of the ten tests as having a
test, and on completion of the trial recorded their results significant association for the trial number and one test
on separate blank recording sheets. Approximately, as having a significant association for the observer
15 min after the muscular endurance tests had been number. None of the tests demonstrated a significant
completed the observers individually reviewed the video interaction between the observer and trial number.
footage and recorded their assessments.

2.5. Statistical analyses 4. Discussion

A method for the concurrent assessment of inter- Pre-participation screening is a commonly used
and intra-observer reliability was used to calculate method for the collection of data relating to potential
intraclass correlation coefficients (ICCs) (Eliasziw, intrinsic risk factors. So that the data collected during
Young, Woodbury, & Fryday-Field, 1994; Hayen these pre-participation screenings can be used to identify
et al., 2007). A review paper discussing the application injury risk factors and subsequently inform the devel-
of this statistical method to sports injury research has opment of effective injury prevention strategies, it is
been published (Hayen et al., 2007). vital that the screening protocols are reliable. This study
The results presented include the ICCs, confidence has demonstrated that the intra-observer reliability of a
intervals (CIs) for the ICCs, and the standard error of musculoskeletal assessment used with cricket fast
measurement (SEM), the definitions of which have been bowlers is generally high. However, the inter-observer
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30 R.J. Dennis et al. / Physical Therapy in Sport 9 (2008) 25–33

Table 1
Inter-observer reliability of the musculoskeletal screening protocol

Screening test Inter-observer reliability

ICC 95% CI SEM SEM critical value Classification

Knee extension (deg) 0.40 0.00, 0.79 5.5 15.1 Fair

MTT hip extension (deg) 0.27 0.00, 0.76 6.6 18.4 Fair
MTT hip abduction (deg) 0.29 0.00, 0.71 2.5 7.2 Fair
Hip internal rotation (deg) 0.30 0.00, 0.78 8.9 24.6 Fair
Hip external rotation (deg) 0.66 0.25, 0.90 5.0 13.8 Substantial
Ankle dorsiflexion lunge (cm) 0.96 0.89, 0.99 0.4 1.1 Almost perfect
Combined elevation test (cm) 0.87 0.63, 0.97 1.9 5.4 Almost perfect
Calf heel raises 0.99 0.98, 1.00 0.3 0.8 Almost perfect
Bridging hold (s)a 0.56 0.42, 0.88 24.8 68.7 Moderate
Prone four point hold (s)a 0.89 0.79, 0.97 15.7 43.6 Almost perfect

MTT: Modified Thomas test; ICC: intraclass correlation coefficient; CI: confidence interval; SEM: standard error of measurement.
a
Video footage was used to determine the reliability of these tests.

Table 2
Intra-observer reliability of the musculoskeletal screening protocol

Screening test Intra-observer reliability

ICC 95% CI SEM SEM critical value Classification

Knee extension (deg) 0.86 0.43, 0.95 2.6 7.2 Almost perfect
MTT hip extension (deg) 0.97 0.84, 0.99 1.3 3.7 Almost perfect
MTT hip abduction (deg) 0.83 0.21, 0.92 1.3 3.5 Almost perfect
Hip internal rotation (deg) 0.94 0.68, 0.97 2.7 7.5 Almost perfect
Hip external rotation (deg) 0.88 0.54, 0.96 3.0 8.3 Almost perfect
Ankle dorsiflexion lunge (cm) 0.98 0.92, 0.99 0.3 0.8 Almost perfect
Combined elevation test (cm) 0.97 0.88, 0.99 1.0 2.7 Almost perfect
Calf heel raises 0.99 0.97, 1.00 0.3 0.8 Almost perfect
Bridging hold (s)a 0.56 0.00, 0.83 24.8 68.7 Moderate
Prone four point hold (s)a 0.89 0.62, 0.97 15.7 43.6 Almost perfect
a
Video footage was used to determine the reliability of these tests.

Table 3
Musculoskeletal screening tests with a significant association for trial or observer number identified by repeated measures analysis

Screening test Association for trial number

Trial 1 mean SD Trial 2 mean SD F-statistic p-Value

Hip internal rotation (deg) 46.1 10.52 44.6 10.19 7.154 0.025
Bridging hold (s)a 45.8 24.36 71.7 36.17 15.077 0.004
Association for observer number

Observer 1 mean SD Observer 2 mean SD F-statistic p-Value

MTT hip abduction (deg) 12.4 2.99 10.2 2.23 6.839 0.028

SD ¼ standard deviation.
a
Video footage was used to determine the reliability of this test.

reliability of many of the tests was poor. This has There are no universally applicable standards as to
implications for the use of this protocol to identify how high the ICC must be to constitute acceptable
injury risk factors, as establishing reliability is a reliability in sports injury risk factor research. Therefore
prerequisite for ascertaining the validity of the risk in the absence of clear guidelines, it would seem
factor measures. reasonable to consider those tests with reliability
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R.J. Dennis et al. / Physical Therapy in Sport 9 (2008) 25–33 31

considered almost perfect (ICC ¼ 0.80–1.00) as accep- The inter-observer reliability was generally not as
table for the purposes of large injury risk factor high, but the ankle dorsiflexion lunge, combined
identification studies. The majority of the musculoske- elevation test, calf heel raise test and prone four point
letal screening tests demonstrated excellent intra- hold demonstrated almost perfect inter-observer relia-
observer reliability, with ICCs above 0.80 and low bility and would again be considered acceptable. This is
SEM critical values. The only exception was the of particular importance to large-scale injury risk factor
bridging hold test, with an ICC of 0.56. It is difficult identification studies, because multiple observers often
to compare these findings with previous research, as contribute measurements to determine injury risk. The
different statistical methods to determine the ICCs have SEM critical value is of particular interest when
been used. Many sports injury studies have used the considering the reliability of tests to be used in such
mean of two measurements to determine ICCs (Hayen research projects. For some tests, only a small difference
et al., 2007). This has the effect of inflating the ICC, as between measurements would need to be observed to be
the mean of multiple measurements will be higher than confident of a real difference. Whereas, for other tests
that based on a single measurement (Eliasziw et al., the SEM critical values were high, such as the bridging
1994; Fleiss, 1986; Hopkins, 2000). This may partially hold where 43.6 s difference would be needed to be sure
explain the apparent poor inter-observer reliability of that the measurements between multiple observers, or
many of the tests. Consistent with the findings of this between different time periods for the same observer,
study, previous studies have reported high intra- were indeed different.
observer reliability of the MTT (Gabbe et al., 2004; This study has contributed important information for
Harvey, 1998a) and the ankle dorsiflexion lunge the development of reliable screening protocols for use
(Bennell et al., 1998). with fast bowlers, and potentially other athletes.
The inter-observer reliability of the ankle dorsiflexion However, the limitations of this reliability assessment
lunge, the combined elevation test, calf heel raise test are acknowledged. The validity of the tests was not
and the prone four point hold was almost perfect. For assessed, but as described earlier, the tests were based on
the ankle dorsiflexion lunge and calf heel raise test, the well-established clinical and field assessment tools for
SEM critical values demonstrated that only a small use with athletes. However, future research may
difference would need to be recorded to be confident consider the validity (the degree to which the test
there was a real variation between the observers. For measures what it is supposed to measure) of these tests,
example, for ankle dorsiflexion, a difference of only in addition to reliability. Another limitation was that a
1.1 cm would need to be recorded between different small number of participants were recruited. This is not
observers to be confident of a real difference in the dissimilar to previous reliability studies that have only
measurements. When considering the test–retest relia- enrolled 10–20 participants, but ideally a larger number
bility of a single observer, a difference of only 0.8 cm of participants would have been recruited. The current
would need to be identified. The ankle dorsiflexion was study was limited by wide 95% CIs surrounding the
the only one of these tests using the same protocol as in ICCs, particularly for the assessment of inter-observer
previous research, which also reported high inter- reliability. Future research with a larger sample may
observer reliability of this test (Bennell et al., 1998). avoid this problem. Finally, this reliability assessment
The remaining tests in the protocol demonstrated lower used a short time interval to separate the testing sessions
ICCs for inter-observer reliability, ranging between 0.27 and the reliability of the measurements represents their
and 0.66. Of these, the MTT demonstrated much lower reproducibility only within this particular time frame.
inter-observer reliability than has been reported in Analyses were conducted to determine if there was
previous research (Gabbe et al., 2004), which may be any ‘‘learning’’ effect during this reliability assessment.
due to the differences in the statistical methods used For hip internal rotation, there was a reduction in joint
(Hayen et al., 2007). range of motion from the first to the second trial
With the exception of the bridging hold test, all of the completed with each observer, but the magnitude of this
tests in the musculoskeletal screening protocol demon- is not likely to be clinically relevant. For the bridging
strated almost perfect intra-observer reliability and hold, there was a significant increase from the first to the
would be considered acceptable tests for those occasions second trial and this is most likely due to the use of
where only one observer was conducting multiple video footage, which indicates that this is not a reliable
measurements. However, it must be noted that the tests method to conduct this test of muscular endurance.
would only be acceptable when an observer collects valid Only one of the tests (the MTT, assessing hip abduction)
information. For example, an observer may demonstrate demonstrated a significant difference for the means of
high intra-observer reliability when recording joint range observers 1 and 2, but this difference may not have been
of motion, but the results will not be valid if the observer clinically relevant.
consistently over-estimates the motion of interest. It is unclear as to why the inter-observer reliability
Validity was not assessed in this study. was poor for the majority of the tests, but it may be
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32 R.J. Dennis et al. / Physical Therapy in Sport 9 (2008) 25–33

related to the observers using different landmarks or implications for the use of these tests both in clinical
varying force in determining the end-point for the and research environments. Further work is necessary to
range of motion tests (Gajdosik & Bohannon, 1987; develop a comprehensively reliable field-based screening
MacDermid, Chesworth, Patterson, & Roth, 1999; protocol so that it is possible to accurately identify
Martin & McPoil, 2005). The poor reliability of the injury risk factors for fast bowlers.
bridging hold test may be due to the inability of the
observers to accurately detect any change in the position
of the hips in the second ‘‘trial’’, when using video Acknowledgements
footage of the single trial conducted. The observers
reported difficulty in examining the movement of the RD was supported by an NHMRC Public Health
hips and pelvis when using the two-dimensional video PhD scholarship during the data collection and analysis
footage, and therefore, this method of assessing phase, and by an NHMRC Population Health Capacity
performance in this test is limited. It must also be noted Building Grant in Injury Prevention, Trauma and
that because only a single trial was completed for the Rehabilitation during the reporting and publication
muscular endurance tests, only differences in the phase. CF was supported by an NHMRC Principal
measurements recorded by the observers could be Research Fellowship. Funding for the project was
identified. In contrast, four trials were completed for provided by Cricket Australia. The authors wish to
the joint range of motion tests and so differences in both acknowledge the valuable contributions of Andrew
the measurements recorded by the observers, and Hayen, Andrew Nealon, Kate Watson, Kevin Sims,
differences in the performance of the participants, could Danny Redrup, Marc Portus, Andrew McIntosh, and
be identified. the participants in the study.
Further studies should endeavour to identify reliable
field-based tests for ongoing use with fast bowlers and Conflict of interest
other athletes. It may be necessary to adopt different There are no conflicts of interest.
testing procedures, such as the positions used (e.g. prone
vs. supine), and the type of measurement adopted (e.g.
active vs. passive). It may be adequate to retain the same References
protocol, but necessary to simply conduct more
Bahr, R., & Holme, I. (2003). Risk factors for sports injuries—A
comprehensive training of the observers and the methodological approach. British Journal of Sports Medicine, 37,
assistants. Finally, it may be possible that only those 384–392.
tests conducted in a laboratory are able to provide both Bahr, R., & Krosshaug, T. (2005). Understanding injury mechanisms:
valid and reliable information for fast bowlers and that A key component of preventing injuries in sport. British Journal of
it is simply not possible to assess these measures in a Sports Medicine, 39, 324–329.
Bennell, K. L., Talbot, R. C., Wajswelner, H., Techovanich, W., Kelly,
field-based environment. D. H., & Hall, A. J. (1998). Intra-rater and inter-rater reliability of
a weight-bearing lunge measure of ankle dorsiflexion. Australian
Journal of Physiotherapy, 44, 175–180.
5. Conclusions Berryman Reese, N., & Bandy, W. D. (2002). Joint range of motion and
muscle length testing. Sydney, Australia: W.B. Saunders Company.
Dennis, R. J. (2006). Risk factors for repetitive microtrauma injury to
Sports injury prevention requires a firm evidence base. adolescent and adult cricket fast bowlers. Ph.D. thesis, University of
An important component of this is the accuracy and New South Wales, Sydney, Australia.
reliability of measurements taken in studies attempting Dennis, R., Farhart, P., Goumas, C., & Orchard, J. (2003). Bowling
to identify risk factors for injury. This study has workload and the risk of injury in elite cricket fast bowlers. Journal
of Science and Medicine in Sport, 6, 359–367.
established the reliability of a screening protocol for
Dennis, R. J., Finch, C. F., & Farhart, P. J. (2005). Is bowling
fast bowlers to measure potential risk factors for injury; workload a risk factor for injury to Australian junior cricket fast
it also has implications for screening completed with bowlers? British Journal of Sports Medicine, 39, 843–846.
athletes in other sports. All tests (except the bridging DiFiori, J. (1999). Overuse injuries in children and adolescents. The
hold) would be considered acceptable where only one Physician and Sports Medicine, 27, 75–89.
observer was conducting the tests with all study Eliasziw, M., Young, S. L., Woodbury, M. G., & Fryday-Field, K.
(1994). Statistical methodology for the concurrent assessment of
participants. However, only the ankle dorsiflexion interrater and intrarater reliability: Using goniometric measure-
lunge, combined elevation test, calf heel raise test and ments as an example. Physical Therapy, 74, 777–788.
prone four point hold have high enough inter-observer Finch, C. (2006). A new framework for research leading to sports
reliability to use where there are multiple observers injury prevention. Journal of Science and Medicine in Sport, 9, 3–9.
recording measurements. It should be noted that for Fleiss, J. L. (1986). Reliability of measurement. In J. L. Fleiss (Ed.),
The design and analysis of clinical experiments. New York: Wiley.
many tests, the minimum difference between measure- Gabbe, B. J., Bennell, K. L., Wajswelner, H., & Finch, C. F. (2004).
ments that needs to be exceeded to be confident that a Reliability of common lower extremity musculoskeletal screening
real change has occurred is quite high. This has tests. Physical Therapy in Sport, 5, 90–97.
 ARTICLE IN PRESS
R.J. Dennis et al. / Physical Therapy in Sport 9 (2008) 25–33 33

Gajdosik, R. L., & Bohannon, R. W. (1987). Clinical measurement of Landis, J. R., & Koch, G. G. (1977). The measurement of observer
range of motion. Review of goniometry emphasizing reliability and agreement for categorical data. Biometrics, 33, 159–174.
validity. Physical Therapy, 67, 1867–1872. MacDermid, J. C., Chesworth, B. M., Patterson, S., & Roth, J. H.
Haas, M. (1995). How to evaluate intraexaminer reliability using an (1999). Intratester and intertester reliability of goniometric
interexaminer reliability study design. Journal of Manipulative and measurement of passive lateral shoulder rotation. Journal of Hand
Physiological Therapeutics, 18, 10–15. Therapy, 12, 187–192.
Harvey, D. (1998a). Assessment of the flexibility of elite athletes using the Martin, R. L., & McPoil, T. G. (2005). Reliability of ankle goniometric
modified Thomas test. British Journal of Sports Medicine, 32, 68–70. measurements: A literature review. Journal of the American
Harvey, D. (1998b). Screening test protocols. Pre-participation screening Podiatric Medical Association, 95, 564–572.
of athletes: A program developed by the Australian Institute of Sport, Norkin, C. C., & White, D. J. (1985). Measurement of joint motion: A
Olympic Athlete Program and the Australian Sports Injury Prevention guide to goniometry. Philadelphia, PA: F.A. Davis Company.
Taskforce. Canberra, Australia: Australian Sports Commission. Orchard, J., James, T., Alcott, E., Carter, S., & Farhart, P.
Hayen, A., Dennis, R. J., & Finch, C. F. (2007). Determining the (2002). Injuries in Australian cricket at first class level
intra- and inter-observer reliability of screening tools used in 1995/1996 to 2000/2001. British Journal of Sports Medicine, 36,
sports injury research. Journal of Science and Medicine in Sport, 10, 270–274.
201–210. van Mechelen, W., Hlobil, H., & Kemper, H. C. (1992). Incidence,
Hopkins, W. G. (2000). Measures of reliability in sports medicine and severity, aetiology and prevention of sports injuries. A review of
science. Sports Medicine, 30, 1–15. concepts. Sports Medicine, 14, 82–99.