DR ALBAN FOUASSON-CHAILLOUX (Orcid ID : 0000-0002-8139-814X)

Accepted Article
Article type : Original Article

Cut-offs of isokinetic strength ratio and hamstring strain prediction in professional soccer players

Short title: Muscle injury and cut-offs strength ratios

Authors:

1,2
Dauty Marc

1,2
Menu Pierre

1, 2
Fouasson-Chailloux Alban

1
Nantes Hospital University, Physical Medicine and Rehabilitation, Hôpital Saint Jacques, 85 rue Saint

Jacques, 44035 Nantes cedex 03. France

2
INSERM UMR 1229-RMES, "Regenerative Medicine and Skeleton". Team STEP "Skeletal

physiopathology and joint regenerative medicine". Nantes University Hospital, France. School Of

Dental Surgery, Nantes University, France.

Tel: (33)2 40 84 62 11

Fax: (33)2 40 84 61 91

alban.fouassonchailloux@chu-nantes.fr

This article has been accepted for publication and undergone full peer review but has not been
through the copyediting, typesetting, pagination and proofreading process, which may lead to
differences between this version and the Version of Record. Please cite this article as doi:
10.1111/sms.12890

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 Hamstring strain injuries frequently occur during professional soccer practice. Low hamstring
Accepted Article strength represents an intrinsic modifiable risk factor but cut-offs of isokinetic knee strength ratios

are controversial to predict hamstring strain in professional soccer players. We aimed to predict

hamstring strain in accordance to cut-offs of isokinetic knee strength ratios. Bilateral, conventional

and functional isokinetic strength ratios were calculated in 194 professional soccer players at the

beginning of 15 consecutive seasons. 36 soccer players presented a moderate hamstring strain and

158 were not injured. The different calculated isokinetic ratios were compared with the right and left

limb of the uninjured population. Different usual cut-offs were tested: at 0.85 and 0.90 for the

bilateral concentric and eccentric hamstring-to-hamstring ratio, at 0.60 and 0.47 for the conventional

hamstring-to-quadriceps ratio and at 0.80 and 1 for the mixed hamstring-to-quadriceps ratio. The

specific ratios for the studied population were also determined by the 10th percentile and then

tested. Hamstring strain prediction was established in term of odds ratios. No cut-off with bilateral,

conventional or functional isokinetic strength ratio was predictive of hamstring strain after univariate

analysis. Specific cut-offs determined from the studied population were not more predictive. Very

few injured soccer players presented values under the cut-offs at 0.47 for the conventional ratio and

at 0.80 for the mixed ratio. Regardless of their values, cut-offs of isokinetic strength ratios were not

predictive of hamstring injuries. The use of isokinetic cut-offs is not recommended to predict

hamstring muscle strain in professional soccer players.

Key Terms: muscle balance, sport injury, prediction, isokinetic ratio, cut-off

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 INTRODUCTION
Accepted Article
Professional soccer participation presents a high risk of hamstring muscle injury, both during

competition and training. This risk appears unacceptable according to the accepted criteria of the

occupational health setting (Drawer & Fuller, 2002). This type of injury is recorded as the most

common injury accounting for 12% of all injuries in elite soccer players and can be responsible for

substantial time loss from sport (Hawkins et al., 2001; Petersen et al., 2010). So, hamstring injury

prevention appears as an essential goal. From different literature reviews, some risk factors have

been identified but understanding injury causes is limited. Risk factors are traditionally divided into

two categories, internal (athlete) and external (environmental) risk factors (Bahr & Holme, 2003).

There is some evidence to suggest that there are modifiable risk factors for hamstring muscle injury,

such as muscle strength imbalance, fatigue, and flexibility (Freckleton & Pizzari, 2013; McCall et al.,

2015). The most consistent risk factor is a prior hamstring muscle injury. Knee isokinetic strength

ratios represent a usual assessment of muscle balance and are currently used to predict hamstring

injuries (Coombs & Garbutt, 2002; Dauty et al., 2016; van Dyk et al., 2016). Poor hamstring strength

and low hamstring-to-quadriceps (H/Q) strength ratio may represent a weak risk factor (van Dyk et

al., 2016). The knee muscle imbalance was arbitrary defined by a minimum bilateral hamstring-to-

hamstring concentric and eccentric ratio at 0.85 (Orchard et al., 1997) and/or a conventional

concentric H/Q ratio at 0.60 at the angular speed of 60°/sec to prevent muscle injury in soccer

players (Heiser et al., 1984). However, to assess knee muscle balance, this conventional ratio is

limited: the hamstring peak torque is measured during knee flexion and quadriceps peak torque

during knee extension. The angle of peak torque will be different for every athlete. So, the agonist-

to-antagonist function is better evaluated by reporting the hamstring eccentric maximal peak torque

to the quadriceps concentric maximal peak torque (Dvir et al., 1989; Aagaard et al., 1995). A cut-off

superior to 1 indicates that hamstring muscle could break the concentric quadriceps muscle action

and be predictive of knee injuries (Coombs & Garbutt, 2002). More recently, Croisier et al., have used

a functional mixed ratio at different angular speeds at 30 °/sec in an eccentric mode for hamstring

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 and at 240 °/sec in a concentric mode for quadriceps (Hecc30/Qcon240) to increase the prevention
Accepted Article of hamstring injuries in soccer players (Croisier et al., 2002). The correction of this mixed ratio under

0.85 decreased the occurrence of hamstring injury after interventional study (Croisier et al., 2008).

However, the definition of muscle imbalance is not consensual (McCall et al., 2015) because the cut-

offs have been established by case-control studies and not by prospective cohort studies, without

prospective standardized data collection (Bahr & Holme, 2003).

The objective of this cohort study was to predict hamstring injury in accordance to usual cut-offs of

isokinetic knee strength ratios.

METHODS

Populations

All the professional soccer players from the same professional team, who played more than 20

professional matches per season in the French Premier and Second League were systematically

evaluated at the beginning of 15 consecutive seasons (from 1999 to 2014) without perceiving any

financial advantage. The players who presented previous hamstring injuries recurrence were

excluded because of a durable loss of strength that these various injuries could have engendered

(Askling, Karlsson, & Thorstensson, 2003). All players were followed-up during one sport season to

avoid the bias of performing repeated measures.

Individual playing positions and anthropometric data were reported. The intrinsic hamstring injury

was defined as an acute occurrence of a “physical complaint in the region of the posterior thigh

sustained during a soccer match or training, without contact, irrespective of the need for medical

attention or time loss from soccer activities” with confirmation by ultrasound and recorded from the

professional sport injury register (Petersen et al., 2011). Only moderate hamstring injuries were

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 considered (time loss between 7 to 28 days) (Hägglund et al., 2005). Minor muscle injuries (less than
Accepted Article 7 days) were excluded because of the risk of including a non-muscle pathology. Major muscle injuries

(time loss > 28 days) were excluded because that time could depend on external factors such as the

choice of trainer or the season calendar for example (Shrier et al., 2015). Other significant previous

knee injuries of the lower limb were excluded.

Ethics approval was obtained from the internal review board of the soccer team and the study was

performed in accordance with ethical standards in Sport Medicine (Dunn et al., 2007). After players’

consents, all the performance data were anonymized before analysis to ensure player confidentiality.

Material and procedure

After a 10-minute cycloergometer warm up, isokinetic strength tests were performed using a Cybex

Norm® dynamometer (Lumex Inc. Ronkoma, NY, USA). The quadriceps and hamstring torques were

gravity corrected and the dynamometer calibration was performed in accordance with the

manufacturer’s instructions. The two knees were evaluated in a random order after instruction and

with verbal encouragements and visual feedback. After familiarization with the isokinetic movement,

the soccer players were tested over 3 repetitions of concentric knee extension and flexion at 60°/sec

followed by 5 concentric repetitions at 240°/sec. Finally they performed 5 repetitions of eccentric

knee flexion at 30°/sec. The time of recovery between each series was 30 seconds of rest. The

maximal eccentric peak torque was validated when the Clasp-knife-reflex was obtained (Garrett,

1990). This reflex corresponds to muscle inhibition, depending on muscle stretch when initial force

increases (Cleland & Rymer, 1990).

Isokinetic strength ratios were calculated from measurements of maximal quadriceps and hamstring

peak torques at different angular velocity and muscle contraction mode. Bilateral concentric

hamstring-to-hamstring ratios (H/Hcon) were calculated at 60°/sec and eccentric ratios (H/Hecc) at

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 30°/sec. Two different cut-offs were considered at 0.85 and 0.90 (Orchard et al., 1997; Daneshjoo et
Accepted Article al., 2013). The conventional hamstring-to-quadriceps ratios (H/Qcon) were calculated at 60°/sec.

Two different cut-offs were considered at 0.47 and 0.60 (Heiser et al., 1984; Croisier et al., 2002). The

functional hamstring-to-quadriceps ratio (Hecc/Qcon) was defined by calculating eccentric hamstring

at 30°/sec relative to concentric quadriceps strength at 240°/sec (Croisier et al., 2008). Two different

cut-offs were considered at 0.80 and 1 (Croisier et al., 2002; Fousekis et al., 2011). Because of the

specificity of the studied population - professional soccer players-, the specific cut-offs for all the

calculated ratios were tested after determination of the 10th percentile, so that 10% of the

population was below that cut-off

All these ratios were calculated on the left and right limbs for the uninjured population. For the

injured population, the bilateral ratios were calculated by dividing the injured limbs from the

uninjured ones. For the conventional and functional ratios, only the injured limbs were compared.

Moderate relative reliability of 0.85 was established for strength ratio by intraclass correlation

coefficient (Impellizzeri et al., 2008).

Statistical analysis

From this cohort that we followed during one sport season after isokinetic tests, we identified two

populations according to the occurrence or not of hamstring injuries. Statistical analysis were

performed using the SPPS 23.0 software (IBM corp. Dublin, Ireland). Univariate analysis (independent

t-test) and Chi-2 test were used to compare quantitative and qualitative data of the injured and

uninjured populations. The results were considered significant at the 5% critical level (p<0.05). The

prediction of hamstring injury occurrence (hamstring injury vs. no hamstring injury) was assessed

using odds-ratios, where the effect of each risk factors (strength ratio) was tested separately as

categorical variable (under or upper the cut-off) (Bahr & Holme, 2003).

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 RESULTS
Accepted Article
Three-hundred and four professional soccer players were eligible but 110 cases were not included

because of previous lower limb injuries or because they played less than 20 matches at professional

level. One hundred ninety four players were followed and thirty-six of them (18.5%) presented a

hamstring injury during the followed season. The anthropometric parameters and the playing

positions on the field were not different between the injured population and the uninjured one

(Table 1). The hamstring injuries occurred in the right limb for 22 players and in the left limb for 14

players. The time loss was of 24.5 +- 22 days [8-106]. The mean duration between isokinetic tests and

hamstring injury was 114 ± 86 days [8-263].

The different ratios are shown in Table 2 and we found no difference between the injured population

and the uninjured one. The specific cut-offs for every calculated ratios determined from the 10th

percentile are shown in Table 3. Because the 95%-confident interval includes the value 1, there is no

significant association between the strength ratio and the occurrence of hamstring injury. No cut-off

can predict the occurrence of hamstring injury. The cut-offs at 0.47 and 0.80 for the conventional and

mixed ratios respectively seem to be too low to be used as a reference because only one injured

player out of 36 (2.7%) had been detected thanks to these cut-offs (Table 3).

DISCUSSION

The hamstring injury prediction by low hamstring muscle strength is still controversial. A recent

literature analysis including four studies (195 participants) did not support hamstring concentric peak

torque as a risk factor for hamstring muscle strain injuries (Freckleton & Pizzari, 2013). After

hamstring eccentric isokinetic strength assessment, Bennell et al. reported the same conclusion in

Australian Rules football (Bennell et al., 1998). From a large soccer player cohort; van Dyk et al.

reported weak risk factors of hamstring injury after measuring lower concentric and eccentric

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 hamstring torques at 60°/sec, adjusted for body weight by analyzing the limbs as unit (van Dyk et al.,
Accepted Article 2016). In other words, all the uninjured limbs of the uninjured and the injured players were

compared with the injured limbs, in order to increase the size-effect.

When isokinetic strength ratios are used and cut-offs taken as references, the prediction depends on

isokinetic assessment. Orchard et al. were the first authors to assess prediction by a canonical

discriminant analysis of athletes as units of measurement (Orchard et al., 1997). From 6 injured

Australian footballers, 4 presented values in the lowest quartile for both calculated ratios at 60°/s

(bilateral < 0.92 and conventional < 0.60) and the other two presented values in the lowest quartile

for one of each. In competitive sprinters, if conventional ratio at 180°/s is less than 0.60, it increases

the risk of hamstring injury by 17 (OR: 17.4; 95%IC: 1.3-231) (Yeung, Suen, & Yeung, 2009).

Moreover, the conventional ratio at 60°/s was not predictive in NFL players (Zvijac et al., 2013). After

meta-analysis, the conventional hamstring-to-quadriceps ratio at 60°/sec was not predictive in 216

participants (Freckleton & Pizzari, 2013).

Concerning the bilateral hamstring-to-hamstring ratio at 60°/sec less than 0.85, a prediction in the

eccentric mode in soccer players was reported (OR: 3.88; 95%IC: 1.13-13.23) (Fousekis et al., 2011).

For Dauty et al., this bilateral concentric hamstring-to-hamstring ratio presented a good specificity of

82% but poor sensibility of 32% (Dauty et al., 2016). However, no prediction can be done individually

in soccer players during a one season follow-up from the cut-offs (Dauty, Potiron-Josse, &

Rochcongar, 2003).

For the mixed ratio, no prediction was found for a cut-off less than 1 (Fousekis et al., 2011). But a risk

factor was reported by Croisier et al. in association with another isokinetic strength deficit in soccer

players (Croisier et al., 2008). The occurrence of hamstring injuries was 4 times more likely if no

correction of muscle imbalance was realized and controlled to normalize isokinetic strength under

cut-offs.

However, the challenge is to define cut-offs from the concept of muscle balance (McCall et al., 2015).

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 For the conventional hamstring-to-quadriceps ratio at 60°/s, different values were used and
Accepted Article established from case control or interventional study to define muscle imbalance. Heiser et al. were

the first to propose the cut-off value of 0.60 in football players (Heiser et al., 1984). After

compensating training to correct this ratio, only 1% of the players presented primary hamstring

injuries with no recurrence against 7.6% with 31.7% of recurrence if compensating training was not

done. Conventional ratios were similar between 14 hamstring injuries and 29 non-hamstring injuries

in professional soccer players (Paton et al., 1989). In the same way, because 47% of Australian Rules

footballers presented a bilateral ratio less than 0.90 and 77% a conventional ratio less than 0.60, the

risk of hamstring injury could not be predicted by these cut-offs (Bennell et al., 1998). More recently,

Croisier et al. proposed different cut-offs depending on the dynamometer used (Croisier et al., 2008).

The cut-offs were 0.85, 0.47 and 0.80 for the bilateral, conventional and mixed ratios respectively

when the Cybex® dynamometer was used and 0.85, 0.45 and 0.89 with the Biodex® dynamometer.

From these cut-offs, more than 46% of professional soccer players presented muscle imbalance. This

result was comparable with those of Daneshjoo et al. who reported 41% of young soccer players with

muscle imbalance but with a cut-off at 0.90 for the bilateral ratio (Daneshjoo et al., 2013). However,

in 2015, these cut-offs might be very low because only 24% of professional soccer players presented

muscle imbalance and no player presented a conventional ratio less than 0.47 or a mixed ratio less

than 0.80 (Ardern et al., 2015). These results are comparable with ours because only one injured

player presented values less than the cut-off of each ratio in our cohort study. But other explanations

could be given. Firstly, the inclusion of soccer players, with previous histories or recurrences of

hamstring injuries, could explain very low ratios in eccentric and concentric because hamstring

muscle strength was reduced. After previous injuries, 64% of soccer players presented muscle

imbalance against 33% in uninjured players (Lehance et al., 2009). In Irish Gaelic football, the

conventional ratio at 60°/s after hamstring injury was less than those measured without injury (0.61

+- 0.1 vs 0.69 +- 0.1) (O’Sullivan et al., 2008). Secondly, the cut-offs could be different according to

the practiced sport (Cheung, Smith, & Wong, 2012). Collegiate soccer players presented a significant

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 specific high conventional ratio at 60°/s (0.63 +- 0.07) by comparison with court sports such as
Accepted Article basketball and volleyball (0.58 +- 0.08). Thirdly, the method used to validate the maximal eccentric

pick torque is rarely described. If the Clasp-knife-reflex is not reached, a poor evaluation is at risk and

could explain a very low eccentric hamstring pick torque and consequently a very low bilateral and

mixed ratio. This reflex corresponds to a muscle inhibition which persists beyond the termination of

stretch during eccentric contraction. It is neither due to Golgi tendon organ nor to secondary spindle

afferents (Cleland & Rymer, 1990). This explains why we have determined the specific cut-offs of the

studied sport cohort. Based on the 10th percentile, the specific cut-offs were different for the

conventional ratio of 0.55 and bilateral eccentric ratio less than 0.83. The best cut-off for the mixed

ratio was near 1. However, no more hamstring injury prediction was reported.

Limitations

The number of hamstring injuries was limited to calculate injury prediction, despite the duration of

the study. We can explain that by the strict inclusion criteria of soccer players to reduce biases

related to a non-homogeneous population. Bahr and Holmes suggested that 30 to 40 injured players

would be needed to detect strong to moderate associations and 200 cases are needed to find small

to moderate associations (Bahr & Holme, 2003). The mechanism of hamstring injury was not

reported and it might have been interesting to know if the injury had occurred in surpassing the

tolerance of hamstring muscle to resist to knee extension (Coombs & Garbutt, 2002). Indeed, the

mixed ratio was developed to approach this mechanism. The period between isokinetic tests and the

occurrence of hamstring injuries was not considered. Dauty et al. have shown a prediction

probability limited beyond 3 months (Dauty et al., 2016). From a statistical point of view, the

interaction with isokinetic ratios remains unknown because all the potential risks to explain

hamstring injuries, such as age, fatigue, and flexibility, have not been studied (Freckleton & Pizzari,

2013; McCall et al., 2015).

Perspectives

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 Hamstring strain injuries represent the most frequent muscle injuries during professional soccer
Accepted Article practice (Dauty & Collon, 2011). Sport pre-season isokinetic testing is recommended to measure

hamstring strength. Isokinetic cut-offs have been developed to define knee muscle imbalance and so

the risk of knee muscle injuries (Heiser et al., 1984; Dvir et al., 1989; Coombs & Garbutt, 2002;

Croisier et al., 2008). Low hamstring isokinetic strength represents a modifiable risk factor in

professional soccer players (Orchard et al., 1997). From this report, we have calculated isokinetic

ratios to investigate knee muscle balance. Different cut-offs usually used in the literature were tested

to verify if they were predictive of intrinsic hamstring injury. Isokinetic strength ratios inferior to the

cut-offs of bilateral, conventional and mixed ratios were not predictive of hamstring injuries in

professional soccer players. In conclusion, Hamstring injury prediction has to be assessed by

continuous isokinetic muscle strength values and not by isokinetic cut-offs (van Dyk et al., 2016).

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Accepted Article
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Table I: Injured and uninjured population characteristics

Injured players (n=36) Uninjured players (n=158) p

Age (years) 23.4 +- 4.4 22.4 +- 4.1 0.64

Weight (Kg) 75.4 +- 6 75.1 +- 6.1 0.77

Height (cm) 180.3 +- 4.7 180.2 +- 5.6 0.90

Body Mass Index (kg/m2) 23.1 +- 1.1 23.1 +- 1.3 0.80

Playing position: 0.64

Goalkeepers 3 22

Defenders 7 30

Midfielders 16 55

Forwards 10 75

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 Table 2: Strength ratios comparison between injured (n=36) and uninjured soccer players (n=158)
Accepted Article depending on the right or the left limb reference.

Injured players Uninjured players

Inj/uninj limb R/L limb L/R limb

H/Hcon60 1.04 +- 0.14 1.01 +- 0.12 1.00 +- 0.14

H/Hecc30 1.01 +- 0.20 0.99 +- 0.14 1.02 +- 0.15

Injured limb Right limb Left limb

H/Qcon60 0.68 +- 0.10 0.66 +- 0.10 0.66 +- 0.09

Hecc30/Qcon240 1.31 +- 0.24 1.31 +- 0.27 1.34 +- 0.28

No significant difference was found (t-test)

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 Table 3: Univariate analysis including bilateral, functional and mixed ratios depending of the chosen
Accepted Article cut-off

n injured players under the cut-off / Odd ratio 95%IC p

n uninjured players under the cut-off

H/Hcon 60 R/L <0.9 7/25 0.77 0.30-1.97 0.37

H/Hcon 60 R/L ≤0.85 3/10 0.74 0.19-2.87 0.44

H/Hcon 60 R/L <0.87 4/13 0.76 0.23-2.49 0.42

H/Hcon 60 L/R <0.9 7/31 1.01 0.40-2.52 0.59

H/Hcon 60 L/R <0.85 3/13 0.98 0.26-3.65 0.60

H/Hcon 60 L/R <0.86 4/15 0.89 0.27-2.85 0.52

H/Hecc 30 R/L <0.9 9/47 1.17 0.51-2.71 0.43

H/Hecc 30 R/L <0.85 5/26 1.22 0.43-3.43 0.46

H/Hecc 30 R/L <0.80 3/13 0.98 0.26-3.65 0.60

H/Hecc 30 L/R <0.9 9/30 0.70 0.30-1.65 0.27

H/Hecc 30 L/R <0.85 5/17 0.74 0.25-2.18 0.38

H/Hecc 30 L/R <0.83 4/11 0.63 0.19-2.11 0.32

H/Qcon 60 R <0.6 5/42 2.24 0.81-6.15 0.07

H/Qcon 60 R ≤0.47 1/4 0.90 0.09-8.38 0.64

H/Qcon 60 R <0.55 1/16 3.94 0.50-30 0.13

H/Qcon 60 L <0.6 5/41 2.17 0.79-5.96 0.09

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 H/Qcon 60 L ≤0.47 1/2 0.44 0.04-5.08 0.46
Accepted Article
H/Qcon 60 R <0.55 1/17 4.22 0.54-32 0.11

Hecc30/Qcon240 R <1 4/41 0.77 0.25-2.51 0.43

Hecc30/Qcon240 R <0.80 1/2 0.44 0.04-5 0.46

Hecc30/Qcon240 R <1.01 3/14 1.09 0.29-3.93 0.61

Hecc30/Qcon240 L <1 4/16 0.90 0.28-2.87 0.53

Hecc30/Qcon240 L <0.80 1/5 1.14 0.13-10 0.69

Hecc30/Qcon240 R <0.99 3/13 0.98 0.26-3.65 0.60

In bold, specific cut-off calculated from the 10th percentile of the studied population

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