In a previous post, I discussed the importance of closed kinetic chain testing in a baseball player. A quote from one of the original reliability studies on the Closed Kinetic Chain Upper Extremity Stability Test (Goldbeck & Davies 2000) provides additional support for the need for closed kinetic chain testing:
“Typically, in clinical practice, a measurement or test is performed to evaluate the status of a particular parameter, and then, based on the test results, appropriate intervention strategies are applied to improve the deficit. Clinicians must ask themselves why closed kinetic chain upper extremity exercises are being integrated into treatment programs when no testing has been performed to demonstrate any deficits in those areas”
So, if you are doing rehabilitation in the closed-kinetic chain, you need to test in the closed kinetic chain as well: trunk stability push up, Upper Quarter Y Balance Test, plank, CKCUEST, and one-arm hop test.
Goldbeck TG, Davies GJ. Test-retest reliability of the closed kinetic chain upper extremity stability test: a clinical field test. J Sport Rehabil. 2000;9:35-45.
18 Oct 2013
In the last post, I discussed the importance of having a patient or athlete demonstrate that he has basic motor control competency and capacity in the closed kinetic chain. That way there are more data points to indicate that there is a solid foundation for sport specific skills. Now I will focus on selecting tests that can be used for the upper quarter. Please note, I used upper quarter versus upper extremity intentionally given the vital connection of the upper limb to the thorax.
Before listing specific tests, it is important to consider the testing order. Prior to higher level closed chain testing, there must be basic range of motion and strength. I do want to make special note of the importance of testing grip strength with hand at side, out front and full flexion and comparing bilaterally. Symmetrical grip strength in these positions indicates that the shoulder has enough stability to generate force through the hand. Try this and you might find some interesting results.
Once that is present, I feel comfortable progressing through an upper quarter testing hierarchy.
Functional Movement Screen Trunk Stability Push Up
While I don’t perform the Trunk Stability Push Up in isolation (I use all seven tests), I do feel it is important to mention it in the hierarchy of upper quarter tests. The TSPU requires symmetrical trunk stability, scapular stability, and upper extremity strength. Before advancing to higher level tests, I want to see the person score a 2. That means that from the bottom part of a push up position, the trunk comes off floor as one unit with no sag in lumbar spine (able to perform with thumbs in-line with chin (men) or with thumbs in-line with clavicle (women)).
Once this is normal, I want see that he has bilateral static stability through prone plank position for at least 10 seconds. Then I look at unilateral stability through holding the side plank for 10 seconds. Remember, I am not trying to test endurance with these tests at this point. Endurance, power, and agility come later in the testing hierarchy.
Y Balance Test – Upper Quarter
Of course, I have a bias here. I was actually resistant to creating an upper quarter test similar to the Y Balance Test for the Lower Quarter. But now, I actually appreciate the harmony of the Upper and Lower Quarter Y Balance test and I get a ton of information from both.
There are 2 published research studies (Gorman et al 2012, Westrick et al 2012) that specifically examine Y Balance Test – Upper Quarter. Both studies found the Y Balance Test – Upper Quarter to be reliable. In addition, both studies found there was no difference in YBT-UQ performance between dominant and non-dominant limbs. This indicates that YBT-UQ performance may serve as a good measure in return to sport testing when rehabilitating shoulder, upper limb, and spine injuries. Westrick et al stated:
“Similarity on the UQYBT between dominant and non-dominant limbs indicates that performance on this test using a non-injured UE may serve as a reasonable measure for “normal” when testing an injured UE.”
In our current research, we are also finding right/left symmetry on the YBT-UQ in professional and collegiate baseball players (including pitchers). So, I think if overhead athletes and healthy adults demonstrate symmetry on the YBT-UQ, patients should demonstrate symmetry before returning to sport/activity (or at least before discharge).
In the next post, I will go through higher level upper quarter testing. This will cover testing for endurance, power, and agility including the 4 plank positions, one arm hop testing, and the Closed Kinetic Chain Upper Extremity Stability Test.
So you have decided to take the plunge — you are going to try some injury prevention with a large group or team. You have already talked with the coach and have some “buy in” (if you don’t, start here). Here are 5 things that will help make your injury prevention successful:
1. Start Small – Just like dieting, small incremental steps are key to permanent success. People hear that we test 150 athletes in 2-3 hours and give real time reports of performance, risk categories, and 3 corrective exercises for each athlete. However, this didn’t happen overnight. Just like water eroding rock over time, we gradually changed our injury prevention culture over several YEARS. If you start by simply setting a goal of making your injury prevention better than it was last year, you will gradually get there. Here are a few suggestions:
- Start with a coach you have a good relationship with and one team
- Select one or two tests to do (see below)
- Ask injury history questions
- Work with the individuals who had pain with testing
- Be sure to retest those individuals to ensure the risk factors have normalized.
2. Categorize to maximize your resources – Particularly when testing large groups, it can be a daunting task to try addressing the risk factors you find. If you categorize individuals by their degree of risk (Lehr 2013), you can make the process more manageable. Check out how a Division III college did it with their Body Armor Program.
3. It’s gonna take a village – I frequently feel like I am on an “injury prevention island”. With some discussion, I do find many like-minded individuals. Some have tried injury prevention strategies before only to stop because they didn’t have good buy in. Others (particularly coaches) want to implement injury prevention, but don’t know how. Still others have misconceptions about how long it is going to take or how difficult it is. Just like other behavioral change, Start with Why to get people on board. When talking with a coach, discuss performance and durability benefits. For medical personnel, discuss keeping our athletes healthy and on the field. Also, think outside of the box when assembling your team of testers. Elicit the help of students (of any type: exercise physiology, PT, ATC, etc can help with the simpler testing), coaches (corralling the athletes), parents (ensuring forms are completed), and front desk personnel (data entry). They can all do something to help.
4. Use reliable, evidenced-based, predictive tests that can be completed quickly – Most frequently, I use injury history, Y Balance Test and Functional Movement Screen (I clearly acknowledge my bias here — I would love to hear what you use).
5. Start with Return to Sport Testing – Remember, previous injury is the most consistently reported risk factor for future injury so be sure you are using predictive, evidence based tests in your discharge protocol. Over the next several posts, I will take research based look at discharge testing and answer some commonly asked questions like:
- What should the limb symmetry be for hop testing? (hint: it is NOT 90%)
- What percent of athletes return to sport after ACL reconstruction?
- Do strength and range of motion testing matter?
- What does research tell us about basic movement testing?
So, if you are currently doing injury prevention, write down your goals for making your injury reduction strategies better than next year. If you haven’t started, utilize a few of the strategies to get started on a small scale. For those of you who have implemented injury prevention programs, please share your strategies with the group by commenting below.
When it comes to injury prevention, we are all excited, passionate and ready to get started only to hit road blocks: No one seems to want to give it the attention that it deserves. Coaches don’t want to give up valuable practice time, parents can’t fit it into jam packed schedules, and athletes, well, they are athletes!
Over the past 15 years, I have made many failed attempts at implementing injury prevention programs, so I would like to share with you what I have learned. After a great Twitter Chat with #solvePT, I decided to focus this blog post on talking with coaches and parents.
Some of the best injury prevention researchers in the world looked back at their injury prevention efforts with a huge cohort of female handball teams over a 10 year period (Mykelbust et al 2013). One of their key findings is that for injury prevention to be successful you “must have the coach as a “partner” in the process”. But how exactly do you do that?
Frequently, because of our passion, we provide too much information and end up sounding like a pushy salesperson. When talking with coaches and parents I suggest breaking it down into several steps:
- Step #1: Ask, “Can I test your team/athlete to see how they are doing?” Don’t promise too much. Just mention that there is some good research about the ability to identify athletes at more risk of injury and improve their performance. (Remember: researchers have found that the message should focus on both performance and prevention — also remember that if you are on the bench with an injury, you can’t perform!)
- Step #2 After testing, don’t say anything. Wait for coach/parent to say: “How did they do?” Now you have some buy in because they are asking the question — you are not pushing information
- Step #3 Tell them how they did: “I found these risk factors and research indicates that puts them at risk for injury.” Then be quiet. This is THE hardest part!
- Step #4 Parent/Coach says “Well, what are YOU going to do about it?” I say smiling, “I’m glad you asked.” — Total buy in
- Step #5 Present your evidence-based injury prevention strategy by changing the modifiable risk factors you tested
While these steps are the best way I have found to have the conversation, it is by no means 100% effective. I think the other key ingredient is persistence. Mykelbust et al said it best:
“persistent effort to promote injury prevention over several years, using every opportunity available”
It can take years to change the culture of any organization. In future posts, I will talk about specific implementation strategies. Sign up for this blog to be sure you get notified when it comes out.
I really want to hear from you. What strategies have you found to be successful to get people on board with your passion?
23 May 2013
Myklebust G, Skjølberg A, Bahr R. ACL injury incidence in female handball 10 years after the Norwegian ACL prevention study: important lessons learned. Br J Sports Med. 2013 May;47(8):476-9
After implementing ACL prevention programs in handball teams for over 10 years, the authors sought to answer the question of what made the injury prevention programs successful. They came to 3 main conclusions for successful programs:
- “must have coach as a “partner” in the process.”
- The prevention program was efficient
- The message “we delivered to coaches in seminars, through pamphlets, interviews and on our website, was no longer ‘may reduce injury risk’, but ‘will reduce injury risk by at least 50%’. This ‘specific’ information meets one of the Heath Brothers’ criteria for ‘sticky’ messages—messages that have influence.”
Finally, the authors concluded:
“Risk factor studies are necessary to identify the individual’s needs for special training and optimise the selection of preventive exercises. In the meantime, we suggest that team sports include prevention exercises in their warm-up, tailor the exercise programme to the specific sport and focus on coach education as a key factor”
Asymmetries are common in the human body and can lead to a wild goose chase in musculoskeletal assessment. But how do we know which asymmetries are important and will lead to injury? Well, let’s look at some common misconceptions as well as the research.
Common Misconceptions About Asymmetries
1. If someone performs well at their sport with an asymmetry, the asymmetry doesn’t matter.
Who ever said that asymmetry IS related to performance? Asymmetry is related to injury risk, not necessarily performance. While I am concerned about performance, I am more concerned about keeping them in the sport and participating without being encumbered by injury.
2. Asymmetries are only important if they cause pain.
I am mostly concerned with asymmetries that cause movement inefficiency or are related to injury risk. To me, asymmetrical fundamental movement patterns will lead to injury or inefficiency (i.e. energy expenditure that is unnecessary for performance of the activity).
3. There is no research that indicates asymmetry increases risk of injury
Those who have an anterior reach distance asymmetry on the Y Balance Test (Star Excursion Balance Test) are at increased risk of injury in high school basketball and multiple collegiate sports (Plisky 2006, Lehr 2013)
Those who have an asymmetry on the Functional Movement Screen (Kiesel 2013 in press) are at increased risk of injury in professional football
Strength and flexibility asymmetries:
- Athletes experienced more lower extremity injuries if they had knee flexor and hip extensor strength asymmetries (Knapick 1991, Nadler 2001)
- Eccentric hamstring strength asymmetries were at greater risk of sustaining a hamstring muscle strain. (Fousekis 2011)
- Hamstring/quad ratio asymmetry (Soderman 2001)
- Ankle strength asymmetry (Baumhauer 1995)
Asymmetrical landing patterns predict second ACL tear in previously reconstructed athletes (Paterno 2010)
Bottom Line: I really don’t put much stock into isolated bony asymmetries (e.g. torsions, misalignments, etc.), but I do feel that modifiable movement asymmetries that are related to risk of future injury are extremely important. Further, the literature is replete with studies that indicate asymmetries exist after pathology (Gribble 2013, Hewett 2013). Since previous injury is the most robust risk factor for future injury, we owe it to our athletes to normalize these modifiable risk factors.
What do you think?
What research is there to support using the Upper Quarter Y Balance Test for return to sport testing?
Just like other return to sport tests, there is very little in the literature (really nothing). As far as the Upper Quarter Y Balance Test, there are 2 research studies (Gorman et al 2012, Westrick et al 2012). Both studies found the Y Balance Test – Upper Quarter to be reliable. In addition, both studies found there was no difference in YBT-UQ performance between dominant and non-dominant limbs. This indicates that YBT-UQ performance may serve as a good measure in return to sport testing when rehabilitating shoulder and arm injuries. Westrick et al state:
“Similarity on the UQYBT between dominant and non-dominant limbs indicates that performance on this test using a noninjured UE may serve as a reasonable measure for “normal” when testing an injured UE.”
We are also finding right/left symmetry on the YBT-UQ in professional and collegiate baseball players (including pitchers). So, I think if overhead athletes and healthy adults demonstrate symmetry on the YBT-UQ, that patients should demonstrate symmetry before return to sport/activity (or at least before discharge).
Other tests to consider are the Closed Kinetic Chain Upper Extremity Stability Test and the One Armed Hop test. But remember, these measure power (versus dynamic control near limit of stability) in a very limited dynamic range compared to the Y Balance Test. The YBT-UQ uniquely requires stability at the person’s limit of stability in a one-arm push up position unlike planks, side bridges, trunk flexor/extensor endurance tests and the CKCUEST. Westrick et al report:
“There was a significant fair to moderate association between performance on the UQYBT and the CKCUEST, LTET, and push-ups. These results suggest the tests are interrelated but do not necessarily assess equal components of UE CKC ability.”