Translation, cross-cultural adaptation and validation of the Hamstring Outcome Score (HaOS) in French for surgically treated hamstring injuries

Aurélien Hallé; Nicolas Lefevre; Pierre-Emmanuel Cailleaux; Caroline Prince; Mohamad K. Moussa; Alexandre Hardy

Abstract

Background: The Hamstring Outcome Score (HaOS) is a patient-reported outcome measure designed to assess function following hamstring injuries. No French version currently exists.Purpose: To translate, culturally adapt, and validate the HaOS in French (HaOS-Fr) in a cohort of patients undergoing surgical repair for proximal hamstring avulsion injuries (PHAI).Methods: A prospective study was conducted between July 2020 and July 2022 in a sport surgery center. Forty-eight French-speaking patients who had undergone surgical treatment for PHAI were included at 6 months postoperatively. The HaOS questionnaire was translated and culturally adapted using international guidelines, including forward and backward translation, expert committee review, and pretesting. Psychometric evaluation was performed according to COSMIN criteria. Construct validity was assessed by comparing HaOS with the UCLA activity scale, Tegner scale, Lysholm score, and subjective hip value. Discriminant validity was tested by comparing injured vs. uninjured sides. Test-retest reliability was evaluated in 10 patients. Return to sport (RTS) was also documented.Results: The HaOS-Fr showed excellent internal consistency (Cronbach’s α = 0.93) and excellent test-retest reliability (ICC = 0.90, 95% CI [0.86–0.94]). Construct validity showed strong correlation with Lysholm (r = 0.801), moderate with UCLA (r = 0.478), and weak with subjective hip value (r = 0.297); correlation with Tegner was not significant (p = 0.066). HaOS scores were significantly higher in uninjured limbs (p < 0.001). Among 48 patients, 64.6% returned to sport, and 64.5% of them at the same level. ROC analysis for RTS prediction showed AUC = 0.631 (p = 0.14). No floor or ceiling effects were detected.Conclusion: The HaOS-Fr is a valid, reliable, and feasible tool for evaluating outcomes in French-speaking patients after surgical treatment for PHAI. It enables functional assessment and contributes to reinjury risk stratification.What this study adds: This is the first French translation and cross-cultural adaptation of the Hamstring Outcome Score (HaOS) specifically validated in surgically treated proximal hamstring avulsion injuries (PHAI). The HaOS-Fr demonstrated excellent internal consistency (α = 0.93) and test–retest reliability (ICC = 0.90), strong convergent validity with Lysholm and moderate with UCLA, clear discriminant validity between injured vs uninjured limbs, and no floor/ceiling effects—supporting its clinical feasibility.How this study might affect research, practice or policy: The HaOS-Fr enables standardized, French-language functional assessment after PHAI surgery, facilitating research. Clinically, it supports follow-up and patient counseling and can contribute to reinjury-risk stratification pathways. Its adoption could harmonize outcome reporting across French-speaking centers and inform guideline development.Study Design: Prospective translation, cross-cultural adaptation, and psychometric validationLevel of evidence: IIKeywords: Hamstring injury; Return to sport; PROMs; HaOShttps://doi.org/10.70885/hmsj.2025.09.002

References

  1. Ekstrand J, Waldén M, Hägglund M. Hamstring injuries have increased by 4% annually in men’s professional football, since 2001: a 13-year longitudinal analysis of the UEFA Elite Club injury study. Br J Sports Med. 2016;50(12):731-737. doi:10.1136/bjsports-2015-095359
  2. Lefèvre N, Moussa MK, Valentin E, et al. Predictors of Early Return to Sport After Surgical Repair of Proximal Hamstring Complex Injuries in Professional Athletes: A Prospective Study. Am J Sports Med. 2024;52(4):1005-1013. doi:10.1177/03635465231225486
  3. Lefèvre N, Coughlan A, Valentin E, et al. Magnetic resonance imaging should be the first‐line imaging modality for investigating suspected proximal hamstring avulsion injuries. Knee Surg Sports Traumatol Arthrosc. Published online May 20, 2024:ksa.12258. doi:10.1002/ksa.12258
  4. Bodendorfer BM, Curley AJ, Kotler JA, et al. Outcomes After Operative and Nonoperative Treatment of Proximal Hamstring Avulsions: A Systematic Review and Meta-analysis. Am J Sports Med. 2018;46(11):2798-2808. doi:10.1177/0363546517732526
  5. Van Der Made AD, Peters RW, Verheul C, et al. Proximal hamstring tendon avulsions: comparable clinical outcomes of operative and non-operative treatment at 1-year follow-up using a shared decision-making model. Br J Sports Med. 2022;56(6):340-348. doi:10.1136/bjsports-2021-104588
  6. Piposar JR, Vinod AV, Olsen JR, Lacerte E, Miller SL. High-Grade Partial and Retracted (<2 cm) Proximal Hamstring Ruptures: Nonsurgical Treatment Revisited. Orthop J Sports Med. 2017;5(2):232596711769250. doi:10.1177/2325967117692507
  7. Sallay PI, Hunker PJ, Brown L. Measurement of baseline shoulder function in subjects receiving workers’ compensation versus noncompensated subjects. J Shoulder Elbow Surg. 2005;14(3):286-297. doi:10.1016/j.jse.2004.08.010
  8. Shambaugh BC, Wuerz TH, Miller SL. Does Time From Injury to Surgery Affect Outcomes After Surgical Repair of Partial and Complete Proximal Hamstring Ruptures? Orthop J Sports Med. 2020;8(8):232596712094631. doi:10.1177/2325967120946317
  9. Lefèvre N, Freiha K, Moussa MK, et al. Risk Factors for Rerupture After Proximal Hamstring Avulsion Injury Including the Optimal Timing for Surgery. Am J Sports Med. Published online March 14, 2024:03635465241233734. doi:10.1177/03635465241233734
  10. Bertiche P, Mohtadi N, Chan D, Hölmich P. Proximal hamstring tendon avulsion: state of the art. J ISAKOS. 2021;6(4):237-246. doi:10.1136/jisakos-2019-000420
  11. Hillier-Smith R, Paton B. Outcomes following surgical management of proximal hamstring tendon avulsions: a systematic review and meta-analysis. Bone Jt Open. 2022;3(5):415-422. doi:10.1302/2633-1462.35.BJO-2021-0196.R1
  12. Jokela A, Stenroos A, Kosola J, Valle X, Lempainen L. A systematic review of surgical intervention in the treatment of hamstring tendon ruptures: current evidence on the impact on patient outcomes. Ann Med. 2022;54(1):978-988. doi:10.1080/07853890.2022.2059560
  13. Reza T, Hinkle AJ, Perez-Chaumont A, Brown SM, Mulcahey MK. Systematic Review of Outcome Measures Used After Proximal Hamstring Repair. Orthop J Sports Med. 2021;9(5):232596712110051. doi:10.1177/23259671211005101
  14. Lefevre N, Kassab Hassan S, Valentin E, et al. Validation of the Parisian Hamstring Avulsion Score (PHAS) in the Evaluation and Follow-up of Patients Operated for Proximal Hamstring Avulsion. Am J Sports Med. Published online February 14, 2024:03635465241227434. doi:10.1177/03635465241227434
  15. Engebretsen AH, Myklebust G, Holme I, Engebretsen L, Bahr R. Prevention of Injuries among Male Soccer Players: A Prospective, Randomized Intervention Study Targeting Players with Previous Injuries or Reduced Function. Am J Sports Med. 2008;36(6):1052-1060. doi:10.1177/0363546508314432
  16. Van De Hoef PA, Brink MS, Van Der Horst N, Van Smeden M, Backx FJG. The prognostic value of the hamstring outcome score to predict the risk of hamstring injuries. J Sci Med Sport. 2021;24(7):641-646. doi:10.1016/j.jsams.2021.01.001
  17. Beaton DE, Bombardier C, Guillemin F, Ferraz MB. Guidelines for the Process of Cross-Cultural Adaptation of Self-Report Measures: Spine. 2000;25(24):3186-3191. doi:10.1097/00007632-200012150-00014
  18. Mokkink LB, Prinsen CAC, Bouter LM, Vet HCWD, Terwee CB. The COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) and how to select an outcome measurement instrument. Braz J Phys Ther. 2016;20(2):105-113. doi:10.1590/bjpt-rbf.2014.0143
  19. Amstutz HC, Thomas BJ, Jinnah R, Kim W, Grogan T, Yale C. Treatment of primary osteoarthritis of the hip. A comparison of total joint and surface replacement arthroplasty. J Bone Joint Surg Am. 1984;66(2):228-241.
  20. Zahiri CA, Schmalzried TP, Szuszczewicz ES, Amstutz HC. Assessing activity in joint replacement patients. J Arthroplasty. 1998;13(8):890-895. doi:10.1016/S0883-5403(98)90195-4
  21. Tegner Y, Lysholm J. Rating systems in the evaluation of knee ligament injuries. Clin Orthop. 1985;(198):43-49.
  22. Lysholm J, Tegner Y. Knee injury rating scales. Acta Orthop. 2007;78(4):445-453. doi:10.1080/17453670710014068
  23. Leopold VJ, Homm PM, Krüger D, Hipfl C, Perka C, Hardt S. The Subjective Hip Value is a Valid, Reliable, and Responsive Instrument for Assessing Hip Function in Primary Total Hip Arthroplasty. J Arthroplasty. 2024;39(7):1789-1795. doi:10.1016/j.arth.2024.01.061
  24. Mukaka MM. Statistics corner: A guide to appropriate use of correlation coefficient in medical research. Malawi Med J J Med Assoc Malawi. 2012;24(3):69-71.
  25. Park SH, Goo JM, Jo CH. Receiver Operating Characteristic (ROC) Curve: Practical Review for Radiologists. Korean J Radiol. 2004;5(1):11. doi:10.3348/kjr.2004.5.1.11
  26. Koo TK, Li MY. A Guideline of Selecting and Reporting Intraclass Correlation Coefficients for Reliability Research. J Chiropr Med. 2016;15(2):155-163. doi:10.1016/j.jcm.2016.02.012
  27. Sandmann G, Hahn D, Amereller M, et al. Mid-term Functional Outcome and Return to Sports after Proximal Hamstring Tendon Repair. Int J Sports Med. 2016;37(07):570-576. doi:10.1055/s-0035-1564170
  28. Lefevre N, Bohu Y, Naouri JF, Klouche S, Herman S. Returning to sports after surgical repair of acute proximal hamstring ruptures. Knee Surg Sports Traumatol Arthrosc. 2013;21(3):534-539. doi:10.1007/s00167-012-2204-2
  29. Bowman EN, Marshall NE, Gerhardt MB, Banffy MB. Predictors of Clinical Outcomes After Proximal Hamstring Repair. Orthop J Sports Med. 2019;7(2):232596711882371. doi:10.1177/2325967118823712
  30. French SR, Kaila R, Munir S, Wood DG. Validation of the Sydney Hamstring Origin Rupture Evaluation (SHORE): a clinical hamstring assessment tool. Bone Jt J. 2020;102-B(3):388-393. doi:10.1302/0301-620X.102B3.BJJ-2019-0840.R1

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