106

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ORIGINAL ARTICLE

Risk factors for hamstring injuries in community level

Australian football
B J Gabbe, C F Finch, K L Bennell, H Wajswelner
...............................................................................................................................
Br J Sports Med 2005;39:106–110. doi: 10.1136/bjsm.2003.011197

See end of article for Objectives: To identify risk factors for hamstring injury at the community level of Australian football.
authors’ affiliations
....................... Methods: A total of 126 community level Australian football players participated in this prospective cohort
study. To provide baseline measurements, they completed a questionnaire and had a musculoskeletal
Correspondence to: screen during the 2000 preseason. All were monitored over the season. Injury surveillance and exposure
Dr Gabbe, Monash
University, Epidemiology data were collected for the full season. Survival analysis was used to identify independent predictors of
and Preventive Medicine, hamstring injury.
Central and Eastern Results: A hamstring injury was the first injury of the season in 20 players (16%). After adjustment for
Clinical School, Alfred exposure, increasing age and decreased quadriceps flexibility were identified as significant independent
Hospital, Commercial
Road, Prahran, Victoria predictors of the time to sustaining a hamstring injury. Older age (>23 years) was associated with an
3181, Australia; increased risk of hamstring injury (RR 3.8; 95% confidence interval (CI) 1.1 to 14.0; p = 0.044). Players
Belinda.gabbe@ with increased quadriceps flexibility (as measured by the modified Thomas test) were less likely to sustain a
med.monash.edu.au
hamstring injury (RR 0.3; 95% CI 0.1 to 0.8; p = 0.022).
Accepted 4 February 2004 Conclusions: The findings of this study can be used in the development of hamstring injury prevention
....................... strategies and to identify Australian football players at increased risk of hamstring injury.

H
amstring injuries are common in sprinting, dancing, Written informed consent was obtained from all subjects,
martial arts, hockey, and kicking sports such as soccer, and ethics approval was granted by the University of
American football, and Australian football.1–7 These Melbourne human research ethics committee.
injuries are often recurrent and result in considerable costs
such as missed training time, unavailability for competition, Procedures
and treatment. They have long been recognised as a priority Once recruited, all subjects were required to complete the
for efforts at prevention. Studies on their causes date back to baseline measurement procedures. All testing was completed
the 1970s,8 and many studies have been published since that in the three weeks before the start of preseason practice
have discussed the mechanisms of hamstring injury, poten- games and carried out at the clubs’ training venues. Each
tial risk factors, and rehabilitation of these injuries.2 4 5 9–11 subject had a series of musculoskeletal screening tests and
Although intrinsic factors such as age, injury history, was required to complete a questionnaire.
ethnicity, hamstring flexibility, and hamstring muscle
strength have been investigated in prospective studies, the Questionnaire
findings have been contradictory, used laboratory based Table 1 lists the information collected by questionnaire. The
testing, or identified irreversible risk factors.3 12–17 Other questionnaire aimed to capture information about: previously
proposed risk factors such as warm up habits9 and neural proposed hamstring injury risk and protective habits, such as
mobility18 have not been investigated at all or only using a warming up and use of thermal shorts; previously identified
retrospective study design respectively. hamstring injury risk factors, such as age and injury history;
Despite its classification as a body contact sport, Australian other factors that could affect hamstring injury risk, such as
football requires frequent sprinting and kicking, and there is level of competition and participation in other sports.
a high incidence of hamstring injury.6 7 Prevention of this Questionnaire items21 were shown to be reliable (level of
injury is a priority for this sport,12 13 19 making participants agreement, k.0.8), was and the validity of injury history
ideal subjects for the study of risk factors. Therefore the aim recall22 was established.
of this study was to identify risk factors for hamstring injury
in community level Australian football players.
Musculoskeletal assessment
Tests were selected on the basis of previous research,
METHODS common clinical use for the assessment of hamstring
Study design and participants injuries, ability to test at a variety of training locations,
The identification of risk factors for hamstring injury formed and requiring inexpensive equipment for testing.13 18 23–26
part of a larger study to establish risk factors for lower Intertester and intratester reliability were established if not
extremity injuries at the community level of Australian previously described.27 Table 2 provides an overview of the
football. The methodology is published elsewhere20 and only a musculoskeletal tests selected to measure the potential
summary is provided here. hamstring injury risk factors of hamstrings flexibility,
Players from four adult Victorian Amateur Football quadriceps flexibility, iliopsoas flexibility, lumbar spine range
Association clubs were recruited for this prospective cohort of movement, dorsiflexion range of movement, hip rotation
study during the 2000 preseason. All players training at the range of movement, and neural mobility.
time of baseline assessment were invited to participate and All musculoskeletal screening was performed by four
were only excluded if they were currently injured and trained testers (three qualified physiotherapists and one
therefore unable to complete the measurement process. postgraduate student with experience in musculoskeletal

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Risk factors for hamstring injuries in Australian football 107

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Table 1 Potential risk factors for hamstring injury in Table 2 Musculoskeletal screening tests used to measure
community level Australian football potential hamstring injury risk factors in community level
Australian football
Questionnaire item Method of measurement
Potential risk factor Musculoskeletal screening test
Age Years
Playing experience Years of competition experience Hamstring flexibility Active knee extension test
24 27

Injury history History of sustaining a hamstring injury in Passive straight leg raise test27 38
previous season General lower extremity Sit and reach test
27 39

Playing position Position played on the field most regularly flexibility

Level of competition Senior (highest grade) or reserve (second Quadriceps flexibility Modified Thomas test25 27
grade) Iliopsoas flexibility Modified Thomas test
25 27

Off season training Sports played regularly Dorsiflexion ROM Dorsiflexion lunge test28
habits Frequency and hours per week spent running, Neural mobility Active slump test18 27
swimming, cycling, stretching, and weight Lumbar spine ROM Extension ROM in standing position
26 27

training Hip rotation ROM Active hip internal and external ROM in
Preseason training Sports played regularly supine position
27

habits Frequency and hours per week spent running,

swimming, cycling, stretching, and weight ROM, Range of movement.
training
Season training habits Sports played regularly
Frequency and hours per week spent running, injury for those for whom a hamstring injury was not the first
swimming, cycling, stretching, and weight sustained. Days to injury was chosen as the time variable. The
training
Protective equipment Frequency of use of thermal shorts at training
model was adjusted for exposure (total training and match
use and during matches time). Each continuous variable was dichotomised (accord-
Warm up habits Frequency of participation in warm up at ing to the mean or median) for analysis to separate the cohort
training sessions and before matches into groups based on test performance. The model selection
Cool down habits Frequency of participation in cool down at
training sessions and after matches
strategy was that recommended by Collett.31 The adjusted
Smoking history Current smoking status relative risk (RR) and 95% confidence interval (CI) were
Number of cigarettes smoked per day calculated, and Kaplan-Meier curves used to compare
subgroups.

RESULTS
screening) and performed after the club’s standard warm up Of a possible 148 players, 126 (85.1%) participated in this
of 5–10 minutes of low intensity cardiovascular activity and project. Twenty (15.9%) sustained a total of 26 hamstring
lower extremity stretches. The methodology used was injuries during the season, an incidence of 4.0 injuries per
consistent with protocols used to establish reliability.25 27 28
1000 player hours. For all players, a hamstring injury was the
first sustained for the season. Most hamstring injuries were
Outcome measures sustained during competition (76.9%), the remainder occur-
Data on injury surveillance and exposure (hours of match ring during club training sessions. Rapid acceleration during
and training participation) were collected prospectively over running or sprinting was the primary mechanism (80.8%).
the course of the season using previously published meth- The remainder occurred when the player kicked the football
ods.7 Injuries resulting in missed participation time and/or (19.2%).
treatment from a health professional were captured by the Six variables were identified as independent predictors of
surveillance system. Details on the mechanism, nature, the time to sustaining a hamstring injury through the
specific body region, and provisional diagnosis were collected survival analysis (table 3).
by the club’s physiotherapist or medical staff. Exposure time
was collected by a member of the club’s coaching staff. The
major outcome of interest was a hamstring injury diagnosed
Table 3 Independent predictors of time to sustaining a
by physical examination using the criteria:5 29 30
hamstring injury in community level Australian football
N sudden onset posterior thigh pain; Variable RR (95% CI) p Value
N tenderness on palpation;
Quadriceps flexibility
N with or without pain on stretch of the hamstring muscle
group;
Less flexible ((51˚ knee flexion)
(reference)
–

More flexible (.51˚ knee flexion)

N with or without pain on contraction of the hamstring
muscle group.
Age
0.3 (0.1 to 0.8) 0.022

,23 years (reference) –

>23 years 3.8 (1.1 to 14.0) 0.044
Active knee extension ROM
More flexible ((27˚ knee flexion) –
Data management and analysis (reference)
Injury, exposure, and baseline assessment data were coded Less flexible (.27˚ knee flexion) 2.8 (0.9 to 8.5) 0.076
and double entered on a personal computer. Statistical Frequency of off season running
analyses were performed using SPSS for Macintosh (version None (reference) –
>1 session a week 0.4 (0.1 to 1.3) 0.140
10) (SPSS Inc, Chicago, Illinois, USA). Height
Cox proportional hazards regression31 was used to identify (181 cm (reference) –
independent predictors of hamstring injury. The time to first .181 cm 1.7 (0.5 to 5.7) 0.382
injury was considered important because of the potential for Slump ROM
More flexible ((15˚ knee flexion) –
baseline assessment factors to change after injury. Therefore (reference)
if the hamstring injury was the subject’s first injury, it was Less flexible (.15˚ knee flexion) 0.6 (0.2 to 1.9) 0.430
considered to be a hamstring case. All other subjects were Total exposure hours 1.0 (0.9 to 1.0) 0.667
considered censored, with the point of censorship defined as
ROM, Range of movement.
the end of the season for injury-free players or the time of

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108 Gabbe, Finch, Bennell, et al

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injury first during the season, a finding similar to two studies
1.0

Probability of completing season injury free

of elite Australian football players.12 17 Other prospective
0.9 studies of risk factors for hamstring injury, including those
0.8 performed in other sports, have not studied age as a risk
factor.3 14–16
0.7
As the body ages, there is a reduction in the cross sectional
0.6 area of skeletal muscle and an increase in the non-muscle
0.5
connective tissue. A reduction in type II muscle fibre size and
skeletal muscle fibre number contributes to the loss of cross
0.4 sectional area and skeletal muscle mass. As the force that a
0.3 muscle can generate is proportional to the cross sectional
> 23 years area, a reduction in muscle strength occurs with the changes
0.2 < 23 years described.32 These changes, combined with age related
0.1 denervation of muscle fibres,33 may increase the risk of
0.0
hamstring injury due to the workload placed on the
0 20 40 60 80 100 120 hamstrings muscle group during Australian football.
Time to injury (days) Although the presence of subtle age related changes in
muscle may explain the elevated risk of hamstring injury in
Figure 1 Kaplan-Meier survival curves for time to sustaining a Australian football players, the age at which significant age
hamstring injury according to age category. related changes in skeletal muscle structure affect function in
young adult athletes has not been determined.
Figure 1 shows the Kaplan-Meier curve for time to first Although age has previously been associated with ham-
hamstring injury according to age group. There was a string injury risk, the finding of quadriceps flexibility as a
significantly reduced probability of remaining hamstring significant independent predictor of hamstring injury is
injury free for players aged 23 years or more compared with novel. Previous studies have not investigated the relation
the younger group. between quadriceps flexibility and the risk of hamstring
A similar relation is shown for quadriceps flexibility, with injury despite a number of studies investigating quadriceps
players in the least flexible group (,52˚ knee flexion) having strength as a risk factor.13 15 16 34 The mechanism by which
a decreased probability of completing the season without increased quadriceps flexibility would protect against ham-
sustaining a hamstring injury (fig 2). string injury is not clear but may involve alteration in the
None of the remaining variables showed significant mechanics of running and sprinting.
relative risks (table 3), although hamstring flexibility, as In this study, quadriceps flexibility was tested in the
assessed by the active knee extension test, approached modified Thomas test position.25 In this position, the hip is
significance (p = 0.076). extended and the knee flexed with gravity. The test position
mimics the terminal stance and pre-swing position of the leg
during running and sprinting. At this point in the running
DISCUSSION cycle, the biarticular rectus femoris muscle of the quadriceps
This prospective cohort study is the first to investigate an group is lengthened over both the hip and knee, and is acting
extensive list of potential risk factors for hamstring injury in eccentrically to arrest extension of the hip and flexion of the
community level Australian football players. Using a ques- knee.35 As it stretches, the tendon of the rectus femoris
tionnaire and simple clinical measures that can be per- absorbs energy, which is released during the active flexion of
formed in a variety of locations with minimal equipment, a the hip and knee through mid to late swing, accelerating the
number of independent predictors of hamstring injury were forward movement of the leg. Before initial contact, the
identified. Age and quadriceps flexibility were significant hamstrings must contract eccentrically, generating high
independent predictors of hamstring injury in this cohort of torque, to decelerate the forward momentum of the tibia,
players, and hamstring flexibility approached significance. increasing the load on the hamstrings and thereby increasing
In this study, players aged 23 years or more were almost their susceptibility to injury.11 If the rectus femoris is very
four times as likely as younger players to sustain a hamstring tight, there may be a rise in the passive elastic recoil of the
tendon, increasing the acceleration of hip flexion and knee
extension, which must be counteracted by the eccentrically
1.0
Probability of completing season injury free

contracting hamstrings. Therefore a greater load may be

0.9 placed on the hamstring muscles, potentially increasing their
0.8 chance of failure and the risk of injury.
Hamstring flexibility approached significance as a predictor
0.7
of injury, but the remaining predictors in the final model—
0.6 neural mobility, height, and off season running frequency—
0.5
did not. A detailed discussion of the mechanisms by
which these factors affect hamstring injury risk is not
0.4 necessary.
0.3 Whether these results can be extrapolated to elite level
> 51°
Australian football or other sports is difficult to discern. There
0.2 < 51° is a paucity of information comparing the characteristics of
0.1 players from different levels of Australian football and
0.0 therefore whether the findings would hold true for elite
0 20 40 60 80 100 120 participants is uncertain. Most of the hamstring injuries in
Time to injury (days) this group occurred during sprinting, an activity inherent to a
number of sports. Consideration should be given to investi-
Figure 2 Kaplan-Meier curves for time to sustaining a hamstring injury gating these attributes as potential risk factors for hamstring
according to category of quadriceps flexibility. injury in sprinting sports.

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Risk factors for hamstring injuries in Australian football 109

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What is already known on this topic What this study adds

Prospective studies on a variety of potential risk factors for This study of community level Australian football players
hamstring injury in sport are lacking. Previous studies of elite confirms increasing age, but also identifies decreased
Australian football players have identified age, injury history, quadriceps flexibility, as independent predictors of hamstring
and aboriginality as predictors of hamstring injury. injury in this group of athletes.

This study has a number of strengths. The prospective

design enabled the identification of potential causal relations, cannot be altered, the findings of this study clearly identify
and a large number of potential risk factors were studied. All older Australian football players as a key target group for
injuries resulting in missed participation time were captured hamstring injury prevention activities, and suggest that
by the surveillance system, and complete exposure data were further research to identify the mechanisms by which
collected for all 126 subjects. Sufficient information for the increasing age leads to greater hamstring injury risk is
application of survival analysis methods was collected, required. In contrast with age, quadriceps flexibility can be
enabling a more sophisticated approach to predicting the directly manipulated through stretching programmes in an
onset of hamstring injury. Rather than just comparing the attempt to reduce hamstring injury risk. However, identifica-
injured with uninjured players, we considered the time to tion of the best programmes to improve flexibility of this
injury onset, and therefore adjustment for exposure time was muscle group is necessary, and a randomised controlled trial
possible. of developed programmes is warranted to determine their
Limitations to this study also exist and must be acknowl- effectiveness at reducing hamstring injury risk.
edged. Hamstring injury was a relatively common event, with
16% of the cohort sustaining at least one. However, the ACKNOWLEDGEMENTS
number of cases in the multivariate modelling (20) was This research was partially supported by a grant from the Australian
relatively small, limiting the power of the study and the Physiotherapy Association (Victorian Branch). The staff and players
ability to identify all but the largest effects.36 Although of the Hampton Rovers Amateur Football Club, Old Haileybury
Amateur Football Club, Ormond Amateur Football Club, and the Old
potential causal relations—that is, risk factors—could be
Melburnians Football Club are sincerely thanked for their participa-
identified using the prospective study design described, tion in this research. Dr Annie Solterbeck, from the Statistical
causality itself could not be established. Further studies are Consulting Centre at the University of Melbourne, is thanked for her
required to establish whether changes to the risk factors time and expertise. Dr Anthony Schache is also thanked for his
identified do result in altered hamstring injury risk. thoughts and biomechanical expertise. BG was supported by a Public
The diagnosis of hamstring injury was made using clinical Health Research Fellowship from the National Health and Medical
criteria, rather than imaging. Imaging, such as ultrasound or Research Council of Australia.
magnetic resonance, was not used because of the cost and the
.....................
fact that these techniques are not yet standard protocol for
diagnosis of hamstring injuries. Whether other injuries were Authors’ affiliations
B J Gabbe, Monash University, Melbourne, Victoria, Australia
included as hamstring injuries because of the diagnostic
C F Finch, University of New South Wales, Sydney, Australia
criteria used could not be determined. However, all diagnoses K L Bennell, University of Melbourne, Melbourne, Australia
were made by qualified health professionals, and the findings H Wajswelner, Australian Institute of Sport, Belconnen, ACT, Australia
of this study should hold true for injuries meeting the stated
Competing interests: none declared
criteria.
The study could be considered a cluster design because of
the recruitment of clubs from a single league. Potentially, the REFERENCES
use of a cluster sample leads to a greater homogeneity of the 1 Askling C, Lund H, Saartok T, et al. Self-reported hamstring injuries in student-
population studied, further increasing the difficulty of dancers. Scand J Med Sci Sport 2002;12:230–5.
2 Devlin L. Recurrent posterior thigh symptoms detrimental to performance in
identifying subtle causal relations. However, although this rugby union. Predisposing factors. Sports Med 2000;29:273–87.
is a possibility, a similar study found the design effect to be 3 Witvrouw E, Danneels L, Asselman P, et al. Muscle flexibility as a risk factor
close to one, suggesting no clustering.37 Therefore data were for developing muscle injuries in males professional soccer players. Am J Sports
Med 2003;31:41–6.
not analysed to account for a cluster effect.
4 Heiser T, Weber J, Sullivan G, et al. Prophylaxis and management of
The possibility of selection bias cannot be ignored, as not hamstring muscle injuries in intercollegiate football players. Am J Sports Med
all players could be recruited at baseline because of injury 1984;12:368–70.
and non-attendance at preseason training sessions. These 5 Kroll P, Raya M. Hamstring muscles: an overview of anatomy, biomechanics
and function, injury etiology, treatment and prevention. Crit Rev Phys Rehabil
groups may warrant further investigation to determine Med 1997;9:191–203.
whether the risks of hamstring injury are different in those 6 Orchard J, Seward H. Epidemiology of injuries in the Australian Football
who sustain injuries in the preseason period and those who League, seasons 1997–2000. Br J Sports Med 2002;36:39–45.
fail to complete a preseason training period. 7 Gabbe B, Finch C, Wajswelner H, et al. Australian football: injury profile at
the community-level. J Sci Med Sport 2002;5:149–60.
8 Burkett L. Causative factors in hamstring strains. Med Sci Sport Ex
CONCLUSIONS 1970;2:39–42.
9 Worrell T. Factors associated with hamstring injuries. An approach to
This study was undertaken to address the paucity of treatment and preventative measures. Sports Med 1994;17:338–45.
information on risk factors for hamstring injury, particularly 10 Coole W, Gieck J. An analysis of hamstring strains and their rehabilitation.
in Australian football at the community level where these J Orthop Sports Phys Ther 1987;9:77–85.
injuries are both common and costly to clubs and players. 11 Stanton P, Purdam C. Hamstring injuries in sprinting: the role of eccentric
exercise. J Orthop Sports Phys Ther 1989;10:343–9.
Overall, despite the relatively small number of hamstring 12 Orchard J. Intrinsic and extrinsic risk factors for muscle strains in Australian
injuries sustained by the cohort, the study identified a football. Am J Sports Med 2001;29:300–3.
number of potential causal relations between baseline factors 13 Orchard J, Marsden J, Lord S, et al. Preseason hamstring muscle weakness
and hamstring injury. In particular, age and quadriceps associated with hamstring muscle injury in Australian footballers. Am J Sports
Med 1997;25:81–5.
flexibility were the only two significant independent pre- 14 Bennell K, Tully E, Harvey N. Does the toe-touch test predict hamstring injury
dictors of time to hamstring injury. Although age itself in Australian Rules footballers? Aust J Physiother 1999;45:103–9.

www.bjsportmed.com
110 Gabbe, Finch, Bennell, et al

Br J Sports Med: first published as 10.1136/bjsm.2003.011197 on 21 January 2005. Downloaded from http://bjsm.bmj.com/ on November 24, 2019 by guest. Protected by copyright.
15 Bennell K, Wajswelner H, Lew P, et al. Isokinetic strength testing does not 27 Gabbe B, Bennell K, Wajswelner H, et al. The reliability of commonly used
predict hamstring injury in Australian Rules footballers. Br J Sports Med lower limb musculoskeletal screening tests. Physical Therapy in Sport
1998;32:309–14. 2004;5:90–7.
16 Yamamoto T. Relationship between hamstring strains and leg muscle strength. 28 Bennell K, Talbot R, Wajswelner H, et al. Intra-rater and inter-rater reliability
A follow-up study of collegiate track and field athletes. J Sports Med Phys of a weight-bearing lunge measure of ankle dorsiflexion. Aust J Physiother
Fitness 1993;33:194–9. 1998;44:175–80.
17 Verrall G, Slavotinek J, Barnes P, et al. Clinical risk factors for hamstring 29 Baquie P. Could this be a hamstring injury? Aust Fam Physician
muscle strain injury: a prospective study with correlation of injury by magnetic 1999;28:1053–4.
resonance imaging. Br J Sports Med 2001;35:435–40. 30 Best T, Garrett W. Hamstring strains. Expediting return to play. Phys
18 Turl S, George K. Adverse neural tension: a factor in repetitive hamstring Sportsmed 1996;24:37–44.
strain. J Orthop Sports Phys Ther 1998;27:16–21. 31 Collett D. Modelling survival data in medical research. London: Chapman and
19 Gabbe B, Finch C, Wajswelner H, et al. Does community-level Australian Hall, 1994:72, 78–190.
football support injury prevention research? J Sci Med Sport 2003;6:231–6. 32 Doherty T. The influence of aging and sex on skeletal muscle mass and
20 Gabbe B, Finch C, Wajswelner H, et al. Predictors of lower extremity injuries strength. Curr Opin Clin Nutr Metab Care 2001;4:503–8.
at the community-level of Australian football. Clin J Sport Med 33 Kirkendall D, Garrett W. The effects of aging and training on skeletal muscle.
2004;14:56–63. Am J Sports Med 1998;26:598–602.
21 Gabbe B. Risk factors for lower limb injuries at the community-level of 34 Worrell T, Perrin D, Gansneder B, et al. Comparison of isokinetic strength and
Australian football. PhD thesis. Centre for Sports Medicine Research and flexibility measures between hamstring injured and noninjured athletes.
Education, School of Physiotherapy. Melbourne: University of Melbourne, J Orthop Sports Phys Ther 1991;13:118–25.
2003. 35 Novachek T. The biomechanics of running. Gait Posture 1998;7:77–95.
22 Gabbe B, Finch C, Bennell K, et al. How valid is a self-reported 12-month 36 Bahr R, Holme I. Risk factors for sports injuries: a methodological approach.
sports injury history? Br J Sports Med 2003;37:545–7. Br J Sports Med 2003;37:384–92.
23 Bennell K, Malcolm S, Thomas S, et al. Risk factors for stress fractures in track 37 Finch C, Da Costa A, Stevenson M, et al. Sports injury experiences from the
and field athletes. Am J Sports Med 1996;24:810–18. Western Australian sports injury cohort study. Aust N Z J Public Health
24 Gajdosik R, Lusin G. Hamstring muscle tightness: reliability of an Active-Knee- 2002;26:462–7.
Extension test. Phys Ther 1983;63:1085–90. 38 Butler D. Mobilisation of the nervous system. Melbourne: Churchill
25 Harvey D. Assessment of the flexibility of elite athletes using the modified Livingstone, 1991:127–32.
Thomas test. Br J Sports Med 1998;32:68–70. 39 Keogh J. The use of physical fitness scores and anthropometric data to predict
26 Grant M, Purdam C, Schache A, et al. Pre-participation screening of athletes. selection in an Under-18 Australian Rules Football team. J Sci Med Sport
Screening test protocols booklet. Canberra: Olympic Athlete Program, 1998. 1999;2:125–33.

ELECTRONIC PAGES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Online case reports

T
he following electronic only articles are published in normal during asymptomatic intervals. KLS most often
conjunction with this issue of BJSM (see also pages 69 presents in adolescent males, with complete recovery by the
and 101) 3rd to 4th decade of life. Possible precipitating factors include
excessive workload, febrile illness, and respiratory infections.
Propagation of stress fracture of the patella Presented is a classical case of KLS in an adolescent male
M A A Crowther, A Mandal, P P Sarangi athlete. The patient’s history, complete laboratory results,
Anterior knee pain in athletes is common and usually self and symptoms are discussed. Possible treatments for this
limited. There should be a high index of suspicion and low disorder are also mentioned, along with diagnostic criteria.
threshold for special imaging in cases with acute onset and (Br J Sports Med 2005;39:e7) http://bjsm.bmjjournals.com/
specific tenderness. The risk of propagation of stress fracture cgi/content/full/39/1/e7
of the patella in athletes is highlighted. The case report
presented illustrates the potential sequence of events.
False aneurysm of the common femoral vein in a
(Br J Sports Med 2005;39:e6) http://bjsm.bmjjournals.com/
cgi/content/full/39/1/e6 footballer
M Karahan, S Isbir, F Baltacyoglu, et al
Kleine-Levin syndrome: a unique cause of fatigue in Traumatic false aneurysm of the femoral vein has never been
an athlete reported in the English literature. The case is here reported of
C M J Conklin, J E Taunton a footballer with a traumatic false aneurysm of the common
Kleine-Levin syndrome (KLS) is a rare disorder characterised, femoral vein which was initially misdiagnosed as an arterial
most notably, by periodic episodes of hypersomnolence and pseudoaneurysm. This is a very rare clinical condition, but
hyperphagia. Associated features of the disorder include a this diagnosis should be among those considered for
lack of concentration, mood changes, and anxiety. Laboratory posttraumatic unexplained thigh pain after trauma.
tests may show slight changes in the electroencephalogram. (Br J Sports Med 2005;39:e8) http://bjsm.bmjjournals.com/
However, clinical presentation and laboratory tests are cgi/content/full/39/1/e8

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