A True Tale of Two Teams: Team #1

A soccer team wanted to reduce injuries. Well, not exactly.  The real passion was provided by a local physical therapist who wanted to reduce injuries on this particular soccer team. The PT volunteered his time and implemented the FMS and Lower Quarter Y Balance Testing for this group. The first year it was a challenge simply to get the testing scheduled and completed. But each year, the testing got easier and eventually the Upper Quarter Y Balance Test was added.

Every year, the players received their Move2Perform reports with the risk category (Lehr et al) as well as 3 corrective exercises to perform. There was little buy in from coaches and athletes, little follow up and no re-testing occurred. After the 4th year, the athletic trainer was exceptionally frustrated as the injury rate was still sky high. He told a colleague, “The FMS doesn’t work.  Players who score a 16 are still getting hurt! We need to do more and different screening.”

Fortunately, the testing data was kept and it was analyzed. Over the past four years, 17 athletes with preventable, time loss lower-extremity injuries were identified. Their Move2Perform category was then examined and these results showed that 13 of the 17 players were in the moderate or substantial risk category at the start of the season in which the injury occurred. Is the problem that the tests were not identifying the players who were at risk?  No.  The problem is that the athletes who were identified as at substantial or moderate risk for injury did not receive appropriate intervention strategies and re-testing.

A True Tale of Two Teams: Team #2  

A baseball team wanted to reduce injuries. Well, not exactly.  The entire sports medicine and performance team wanted to revamp their injury prevention system. They wanted something stable, reliable, and scalable. They hired a consultant to systematize their injury prevention. After working with the consultant, they elected to do the FMS and Y Balance Test and categorize athletes using the Move2Perform software. They created a mission statement and goals. After testing, they developed a strategy for each player to address the deficits found. They had a re-testing schedule and organizational accountability for the outcomes.

At the end of the season, they had one of the lowest injury rates in their history as well as one of the lowest injury rates among their peers. They found that if a player entered the season with deficits (in the higher risk Move2Perform categories), they were 4 times more likely to get injured. If they were able to improve the deficits and get the player into a lower risk category, they did not get injured. The next year, they had a plan to improve their testing, intervention strategy, and outcomes.

Both teams used testing for injury prevention.  Why was only one team successful? Here are a few of my observations of the successful team:

  • They started with Why: One team recognized that the best way to improve player performance was to keep them on the field in the first place (prevent injury).  Each staff member from lowest level to highest level gave the same answer to the question:     Why are we doing this?

 “Last year, we had too many injuries that kept key players from performing their best.

We are doing this so everyone can stay on the field with top notch performance.”

  • They had entire organizational buy in from coaching, strength and conditioning, rehabilitation, and medical staff. They owned and internalized the process. The system became part of their culture.
  • They analyzed their current state: What was their historical injury rate? What were they currently doing? What was working, what wasn’t? What tests or screens were providing meaningful information? What things were they collecting because of tradition?
  • They had a written mission statement and objectives. They effectively communicated why, how, and what they were doing.
  • They use multiple risk factors and categorize their team members by systematically weighting those factors. They don’t rely on a single risk factor for their risk identification and intervention strategies.
  • They financially invested in the system. When things are free, people don’t see as much value in them as when they purchase them.
  • After testing, they had clearly written intervention strategies that were communicated among all involved parties.
  • They monitored their outcomes and developed strategies for improvement.
  • And finally, the successful team had a checklist throughout the continuum of care and across disciplines.

Bottom line: The successful team improved player performance by implementing systematic injury prevention. Future posts will expand upon each of the characteristics and describe implementation strategies. Subscribe here to be sure you receive future posts.

Have you identified other characteristics of teams successfully implementing systematic injury reduction and performance improvement? Add your comment below to help better our community.

I wrote a post for Medbridge on the Common misconceptions of the Functional Movement Screen. Here are the 3 misconceptions I covered:Trunk Stability Push Up

 

Misconception #1: The Functional Movement Screen isn’t really a screen because it’s not sensitive

Misconception #2: The Functional Movement Screen is designed to be diagnostic

Misconception #3: The Functional Movement Screen results relate to how the person will perform under load or in competition

 

To read the entire post CLICK HERE

Disclosure: I teach an online Return to Sport Testing course for MedBridge. To find out why I recommend MedBridge CLICK HERE

 

 

Recently, I tested a player in professional sports who had the following Y Balance Test and Functional Movement Screen scores.

Move2Perform Report High YBT Low FMS

Test 1 Graph

 Move2Perform Report High YBT low FMS

 

If you will notice, his Y Balance Test Lower Quarter scores were great – symmetrical and above the risk cut point for his gender, sport, and competition level. But his Functional Movement Screen was riddled with fundamental movement pattern deficits and asymmetries. This a classic example of why both tests are necessary for a more complete profile of the athlete’s motor control of body weight.

In an unpublished analysis of 1490 athletes/active individuals, we found 677 (45%) passed the Y Balance Test Lower Quarter and of those 677 that passed, 243 (35%) failed the FMS. So, if you only use the Y Balance Test Lower Quarter, you will miss about 16% of the athletes who are at risk of injury.

However, consider another athlete on the same team:

Move2Perform Report low YBT good FMS

Test 2 Graph

 Move2Perform Report Good FMS poor YBT

As you can see with this player, his FMS score was good (no zero’s or one’s). While he may possess movement competence as demonstrated by the Functional Movement Screen, he has deficits in his motor control capacity as measured by the Y Balance Test Lower Quarter. But with an anterior reach asymmetry and a composite score below his peers (other professional baseball players), he is at risk of injury. His dynamic left/right imbalance and decreased performance at his limit of stability is a substantial risk factor for injury.

If we go back to the analysis of the 1490 athletes/active individuals, we found that 535 (35%) passed FMS and of those 535 that passed, 253 (47%) failed the Y Balance Test Lower Quarter.  If you just use the FMS, you will miss about 17% of the total number of athletes who are at risk injury.

Thus, it is important to use both the Functional Movement Screen and Y Balance Test for a more complete profile of the athlete as well as the most robust injury risk prediction (see Lehr et al 2013). Or at a minimum, establish basic motor control competency with the Functional Movement Screen first, then move on to the Y Balance Test.

What do you think?

I spend a lot of time discussing that the Functional Movement Screen (FMS) and Selective Functional Movement Assessment (SFMA) are not intended to be sport specific or even “Functional” measures. The FMS and SFMA are used to determine if a person has the underlying movement competency to serve as the foundation for his or her activity.
So why are there age, gender, and sport/activity specific norms and risk cut points for the Y Balance Test? Isn’t that a contradiction?

When it comes to higher level testing (such as dynamic balance), there can be an activity specific balance adaptation that occurs. To see how this plays out as different norms and injury risk cut points, check out this short video

 

Move2Perform chart

 

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:

teamwork - ants

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.

Here are a few of the studies demonstrating using the Y Balance Test as a predictive tool

Injury Prediction

Plisky PJ, Rauh MJ, Kaminski TW, Underwood, FB. Star Excursion Balance Test predicts lower extremity injury in high school basketball players. J Orthop Sports Phys Ther. 2006;36(12):911-9

  • “Players with an anterior right/left reach distance difference greater than 4 cm were 2.5 times more likely to sustain a lower extremity injury (P<.05). Girls with a composite reach distance less than 94.0% of their limb length were 6.5 times more likely to have a lower extremity injury (P<.05).”
  • TAKE HOME MESSAGE: This was the first study demonstrating the Star Excursion Balance Test’s predictive ability. If you athletes have an asymmetry or low composite score, they may be at great risk of injury. Thus, one should consider using the SEBT for return to sport testing and in the pre-participation physical.

Gribble PA, Hertel J, Plisky PJ. Using the Star Excursion Balance Test to Assess Dynamic Postural Control Deficits and Outcomes in Lower Extremity Injury – A Literature and Systematic Review. J Athl Train. 2012;47(3):339-57.

  • “The Star Excursion Balance Test is a reliable measure and a valid dynamic test to predict risk of lower extremity injury, to identify dynamic balance deficits in patients with lower extremity conditions, and to be responsive to training programs in healthy participants and those with lower extremity conditions.”
  • TAKE HOME MESSAGE: The Star Excursion & Y Balance Test should be used for return to sport testing, pre-participation physicals, and annual musculoskeletal exams.

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.

Wild Goose Chase

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 1991Nadler 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.”

Y-Balance Test - Medial

Y-Balance Test - Infero Lat

Y-Balance Test - Sup Lat

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.”

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Phil Plisky

I want to change peoples lives through dialogue about injury prevention research and return to activity testing.

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