Reliability and validity of three pain provocation tests used for the diagnosis of chronic proximal hamstring tendinopathy
Cacchio A., Borra F., Severini G., Foglia A., Musarra F., Taddio N., De Paulis F.
British Journal of Sports Medicine. 2012; 46:883-887.
Proximal hamstring tendinopathy is an overuse injury and the main symptom is typically an ill-defined pain during activity in the area of the ischial tuberosity. Due to injuries with similar symptoms (e.g., piriformis syndrome) it is difficult to correctly diagnose proximal hamstring tendinopathy. Therefore, the objective of this study was to assess the reliability and validity as well as the sensitivity and specificity of 3 pain provocation tests for the diagnosis of proximal hamstring tendinopathy. Ninety-two professional athletes with (n = 46) and without (n = 46) proximal hamstring tendinopathy were included in this study. All the athletes underwent a clinical examination of the pelvic, hip, and back region. After that, the athlete’s history was taken. A positive diagnosis of proximal hamstring tendinopathy was made by an expert physician when an athlete had pain in the lower gluteal region (visual analog scale score of ≥ 4 cm), tenderness at the ischial tuberosity (mild to considerable pain), and positive findings on magnetic resonance imaging. Three physiotherapists performed the three pain provocation tests after being trained to perform the tests by a physician. The Puranene-Orava test required the patients to stretch their own hamstring muscles in a standing position with the hip at 90 degrees and the knee fully extended with the foot on a support. The second pain test was the bent-knee stretch which required the patients to lay supine while the examiner maximally flexed the patient’s hip and knee of the symptomatic leg and then slowly straightened the knee. The third pain test was the modified bent-knee stretch that required the patients to lay supine with their legs fully extended. The examiner then maximally flexed the hip and knee of the symptomatic leg and finally rapidly extends the knee. All three tests were assessed based on a 4-point pain scale (no pain to unbearable pain). The three physiotherapists were blinded to whether the patients were diagnosed with proximal hamstring tendinopathy. The physiotherapists independently performed the exams bilaterally with each test randomized (all exams were performed within a 30 minute session). Among 35 participants, two examiners performed a second evaluation 3 days later at the same time of the day as the previous test with no therapy in between. Inter-examiner and intra-examiner reliability were good for both symptomatic and asymptomatic patients. The Puranene-Orava test had high sensitivity and specificity along with a positive predictive value (PPV, true positive findings divided by all positive findings with test) of 81%, and a negative predictive value (NPV, true negative findings divided by all negative findings with the test) of 77%. The bent-knee stretch had a high sensitivity and specificity with a PPV of 86%, and a NPV of 85%. The modified bent-knee stretch also had a high sensitivity and specificity with a PPV of 91%, and a NPV of 89%.
Based on the reliability and validity calculations for the Puranene-Orava, bent-knee stretch, and modified bent-knee stretch we can infer that they may be good tests to assess proximal hamstring tendinopathy. All 3 tests must be easy to perform since both the inter-examiner and intra-examiner reliability (repeatability) scores were high to very high, respectively. The 3 tests seem to have moderate-to-good levels of diagnostic validity. The least accurate test was the Puranene-Orava. This may be due to the test being performed by the patient and that the patient may stop the test early due to pain. The most accurate test was the modified bent-knee stretch, which may elicit a greater pain response due to the examiner rapidly extending the knee. The authors suggest that these tests are not strong enough to make a clinical diagnosis alone and that they should be used in conjunction with magnetic resonance imaging. Have you calculated inter-examiner or intra-rater reliability at your clinics for repeatability and consistency? Do you have any experience with these three tests? What diagnostic tests do you use to assess proximal hamstring tendinopathy?
Written by: Jane McDevitt MS, ATC, CSCS
Reviewed by: Jeffrey Driban
Related Posts:Cacchio A, Borra F, Severini G, Foglia A, Musarra F, Taddio N, & De Paulis F (2012). Reliability and validity of three pain provocation tests used for the diagnosis of chronic proximal hamstring tendinopathy. British Journal of Sports Medicine, 46 (12), 883-7 PMID: 22219215