I was performing an initial evaluation on a complex patient. Her history included a lateral ankle reconstruction five years ago with recurrent ankle instability and an ACL reconstruction 10 years prior. Over the past couple of years her knee and ankle instability worsened so much that she couldn’t play basketball at home with her kids. She opted to have both her ankle and ACL reconstructed again.
At the time of her evaluation, I had recently changed my approach to goal setting and discharge criteria. I was taught in PT school to be sure to get the patient’s goals (in this case, to be able to play basketball). But what I wasn’t doing was clearly describing and getting the patient to “sign off” on the goals that I had for her (for both return to sport and discharge…and those may be different). So I went through my discharge checklist with her. Since she was no stranger to rehab, most of the first part of the checklist made sense (normal range of motion, good strength, etc).
But when I got to the Y Balance Test she asked, “What is that?”
YES! An opportunity to talk about my favorite subject! I started to describe it verbally but decided it would be best if I just stood up and showed her. As I was doing the posterolateral reach, she stopped me. “I have never been able to do that after my previous surgeries! Do you really think I will actually be able to do that?”
“Yes, you will able to that and more! I will have utterly failed you if you can’t do this by the end rehab.”
This interaction taught me 4 important lessons:
1. Clearly articulate discharge criteria on the first day
Think of it this way, if a mother brings her teenage daughter in after ACL reconstruction, both are highly motivated to avoid a future occurrence of this type of physical and emotional pain, not to mention the financial burden. Unfortunately, much like pregnancy and childbirth (from what I have heard!), the passage of time dulls the memory of the pain encountered. Signing off on clear, objective return to play and discharge criteria at the start, minimizes the negotiating when they “feel and look ready to play.”
2. Avoid the perception of “Bait and Switch”
If the discharge criteria is not articulated clearly up front, it can feel a bit like you just want to keep the patient around for your financial gain. The surgeon told her she would be back to sports in 4-6 months. When that time rolls around, questions naturally crop up about going back to sport. If you begin defining the criteria at this point, it feels as if you just moved the finish line on her and this is incredibly frustrating. If I talk about the return to sport criteria early, it also gives me the opportunity to discuss the 4-6 month time frame that was introduced by the surgeon. I clarify that it means no earlier than 4-6 months and discuss the importance of passing all of the return to play criteria on the checklist.
3. People are highly motivated if they know they are going to be tested
Do you remember when you were given reading assignments in college? Did you do the reading? Even with the best intentions and interest in completing the assignment, more urgent tasks commonly take priority. I only did the reading if I knew that there would be a specific quiz over it. Patients are very similar. A well placed return to sport and discharge checklist can tap into a patient’s motivation. Objective physical testing criteria encourages compliance and accountability all around.
4. We can give hope
Patients sometimes lack perspective regarding recovery goals and we need to provide specifics regarding their realistic potential. Can you imagine a patient not being able to perform the posterolateral reach of the Y Balance Test after an ACL reconstruction? Obviously this patient didn’t know it was possible (or that she should be able to do it). We may take our knowledge about recovery for granted. Many patients carry fears about the future or think their pain and disability is permanent. Conveying clear expectations for the recovery of function can not only boost compliance for the effort required, but also bolsters the hope patients can have for returning to the activities that matter to them.
How do you think using a return to sport and discharge checklist early in rehabilitation could impact the people in our care?
03 Feb 2016
While I am confident my return to play checklist is a comprehensive, evidence-based way of ensuring an athlete’s durability, I think it was lacking an important element.
Recently, I was working with a patient who had an ACL reconstruction 6 months prior. She had finished physical therapy elsewhere, but the family wanted to be sure she was ready to return to sport. Her surgeon sent her to me for testing to be sure she was ready. My immediate question was, why isn’t this already being done as part of her rehabilitation process at the other facility? But that is for another post…..
During her testing I found:
- painful and dysfunctional squatting pattern (hips shifting away from surgical knee)
- dysfunctional trunk stability push up
- painful posterior rocking clearing test
- Y Balance Test Lower Quarter composite score below peer referenced risk cut point
- decreased broad jump distance
- 20% single leg hop asymmetry (I did not continue with triple hop due to safety concerns)
- Substantial Deficit Move2Perform category
Was she ready or not? Clearly she was not. Had the family not insisted on additional formal testing, she would have become another re-tear statistic. After 3 months of additional rehab with intermittent visits (1x per week for the first 3 weeks, then once every two weeks, then once a month) the testing was repeated. She performed much better, but was still lacking a bit of distance with broad jump and triple hop (although symmetrical) . What I noticed in her rehabilitation sessions was that she would have decreased knee control as the session progressed.
While I knew that fatigue amplifies motor control deficits, I never formally included testing under fatigue conditions as part of my return to sport criteria. I had only used fatigue in the past to “prove” that someone was not ready or if I noticed that their mechanics tended to decline with fatigue. However, there is enough research on the effect of fatigue on a previously injured person’s motor control that it is worth considering it as part of the criteria.
Researchers have found on the Y Balance Test Lower Quarter that a fatigue protocol decreases reach distances (Sarshin 2012). Even the original Star Excursion Balance Test research found that in people with chronic ankle instability the test results when fatigued compared to the un-fatigued condition are much worse on the involved side. The uninvolved side does decrease but not nearly as much as the involved side.
Basically, fatigue amplifies the motor control deficits that are found in the injured limb. Another example of this in the literature is Augustsson et al who found a similar decrease in performance with functional hop testing after fatigue in patients post ACL reconstruction. They found while most passed hop testing with about 90% limb symmetry index under normal conditions , when fatigued the study showed two thirds of the subjects LSI dropped below 90% (see this post to see why 90% may not be enough).
Fatigue can be accomplished in multiple ways. For example, you can use cycle ergometry followed by lunges or intense sport specific drills to fatigue someone before testing. Researchers have found that the more intense the fatiguing activity, the greater the decrease in motor control as measured by the Y Balance Test. A BORG scale of over 15 can be used to help ensure the activity is intense enough. Activities should be either sustained anaerobic activity or high intensity intervals to best produce the fatigue. Remember, when interpreting the results of testing, we are more concerned about amplified left/right asymmetry in unilateral activities like the Y Balance Test or single leg triple hop, rather than just a decrease in overall performance. For example, the Y Balance Test Anterior Reach Asymmetry changing from 3cm to 6cm is more significant than if the Y Balance Test Composite Reach decreases from 102% to 95%.
I think testing with fatigue on board is an important condition to add to return to sport criteria. I recommend getting your baselines in an un-fatigued situation, but in order to confirm that rehabilitation has normalized the motor control changes that occur after injury and to be certain that the player is indeed ready to return to sport, go ahead and fatigue them and see if there is a side-to-side difference. This is supported by research and certainly an evidence-based way to go about return to sport and discharge testing.
I would love to hear your thoughts!
Do you do return to sport testing under fatigue conditions?
If so, what fatigue protocol do you use?
12 Jul 2015
Please help guard your kids from their next ACL tear. Please.
As a father of 4 boys, protecting their health and wellbeing is of utmost importance to me. My wife and I believe sports participation offers our children physical, emotional, and leadership benefits. Unfortunately, sports injuries are costly both physically and emotionally. It seems that injuries are just part of the package. Or are they?
These injuries can be reduced. That’s right, we know how to predict and prevent ACL tears and all of the subsequent misery. We know how to prevent ankle sprains and other maladies. The real problem is that we just can’t get parents and health care providers to take action.
Numerous researchers, myself included, have dedicated their lives to injury prediction and prevention. So, what do we know? By combining multiple, easy to perform movement tests and other evidence-based risk factors, we were able to develop an injury risk algorithm that categorizes an athlete’s injury risk. We put the algorithm into a novel software application called Move2Perform, making injury risk prediction available to fitness and health care professionals globally.
A study by Lehr et al validated this algorithm in collegiate athletes. Lehr’s study demonstrated that athletes who were categorized by the Move2Perform software as being in the highest two risk categories were 3.5 times more likely to get hurt than their peers. Interestingly, no athletes who were in the optimal (lowest risk for injury) group were injured — apparently being “protected” from injury.
A similar algorithm has been developed for the U.S. military. Our ability to test and categorize many people quickly led a team of researchers to replicate the injury prediction in sports for the U. S. Military. The result was a 5 year research project called the MP3 study—Improving Military Power, Performance, through Prevention – which developed an injury predication algorithm for our service members. In addition, these sports and military algorithms are now being applied in the occupational setting.
But what can I do as a parent?
There are several steps parents can take to decrease their child’s risk of injury. Begin by embracing prevention. Like vehicles, bodies require preventative maintenance. Youth does not insulate your child from injury. A comprehensive movement “check up,” annually at minimum, is essential for musculoskeletal health.
In addition, here are 6 suggestions you can implement as a parent to help protect your child from injury (I will expand on each of these in subsequent posts):
1) Don’t have your child specialize in one sport too early or play too often. Using the guideline of no more hours per week in sports practice or competition then their age can solve a lot of problems
2) Find a provider using the best evidence available for your child’s movement screening
3) Be sure research-validated testing is performed pre-season and between sport seasons
4) Ensure that the risk factors identified during testing are corrected and verify that they have been corrected with re-testing
6) If your child does get injured, insist on standardized, evidence-based return to sport testing prior to being released from medical care. Being pain-free and “feeling great at practice” is not sufficient.
I realize it is hard to make injury prevention measures a priority between all of the practices and games, but identifying and correcting faulty movement patterns is essential to musculoskeletal health. We schedule maintenance for our cars to avoid inconvenient breakdowns. We see the dentist twice a year for precisely the same reason. It’s time we embrace the wonderful truth about injury prevention—injuries can be predicted and prevented.
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
- The Selective Functional Movement Assessment top tier testing reliability was examined in two ways:
categorizing each of the 7 patterns into pattern into 4 categories (FN, FP, DN, DP) or by the criteria checklist (the criteria by which each movement is determined to be functional or not). Both methods demonstrated good to excellent reliability in raters who have experience with the grading (i.e. greater than 25 hours experience with the SFMA). Raters with only 8 hours experience had poor reliability. This speaks to the importance of training AND practice in clinically assessing movement (Juneau et al and Glaws et al)
- An individualized corrective program based on movement deficits identified by screening improved collegiate softball players Move2Perform injury risk category. In addition, the FMS and YBT scores improved with significant difference from baseline to final testing in both screens. With regard to overall injury-risk category, there was a 31.2% reduction from high-risk to low-risk categories with this individualized injury-prevention program. The researchers suggested further risk reduction may have occurred if all of the players in the highest risk category (substantial risk) received one on one interventions (Erion et al)
- A high percentage of athletes after ACL reconstruction cleared by the surgeon to return to sport did not pass even basic injury prediction tests including the Functional Movement Screen and Y Balance Test Lower Quarter. The authors stated, “progressive standardized tests of neuromuscular function may be beneficial to add to the interdisciplinary decision making process when returning patients safely to their prior level of sports participation” (Butler et al)
Erion A, Alm A, Hudson C, Matsel K. Athlete-Specific Corrective Exercises Improve Functional Movement Tests and Injury Risk Categories in a Collegiate Softball Team. Platform Presentation. J Orthop Sports Phys Ther. 2014;44(1): A53-4.
Juneau CM ,Hewett T, , Glaws K, Becker L, Di Stasi S. Inter- and Intra-rater Reliability of the Selective Functional Movement Assessment in a Healthy Population. Platform Presentation. J Orthop Sports Phys Ther. 2014;44(1): A53.
Glaws K, Juneau CM, Becker L, Di Stasi S, Hewett T. Intra- and Inter-rater Reliability of the Standard Scoring of the Seven Fundamental Movements of the Selective Functional Movement Assessment (SFMA) in Healthy Adults. Platform Presentation. J Orthop Sports Phys Ther. 2014;44(1): A53.
Butler RJ, Mayer S, MD, Garrett W, Taylor D, Moorman C, Toth A, Queen R. Functional testing differences in ACL reconstruction patients cleared vs. not cleared to return to sports using clinical examination. Platform Presentation. J Orthop Sports Phys Ther. 2014;44(1) A34
While there has been a lot of great information presented, here are a few pearls from the first day:
- Not surprisingly, wrestlers perform better than baseball players on the Upper Quarter Y Balance Test. Just like the Lower Quarter Y Balance Test, norms and risk cut points need to be gender, age, sport/activity specific. Want more info in need for population specific norms CLICK HERE
- Shoulder flexion ROM limitation may be a risk factor for injury in professional baseball pitchers. This was not presented as formal research, but was briefly mentioned as an upcoming publication during the morning throwing athlete session. I am intrigued.
- Asymmetrical Lower Quarter Y Balance Test at 12 weeks status post ACL reconstruction identifies those who won’t pass hop testing at time of return to sport. This is important as it can identify early those who may need different rehab strategies before higher level (e.g. plyometric) activity can be performed
Garrison C, Wolf G, Bothwell J, Conway J, Thigpen C. Single Leg Squat Symmetry at 3 months is related to Single Leg Functional Performance at Time of Return to Sports Following Anterior Cruciate Ligament Reconstruction. Platform Presentation. J Orthop Sports Phys Ther. 2014;44(1):A50-51.
Myers HS, Poletti M, Butler R. Functional Performance on the Upper-Quarter Y Balance Test Differs Between Throwing Athletes and Wrestlers. Poster presentation. J Orthop Sports Phys Ther. 2014;44(1):170.
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.
22 Jan 2014
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
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.
I am frequently asked, “What tests are available when doing return to sport testing for a baseball pitcher?” When I start to suggest some closed kinetic chain tests like the Closed Kinetic Chain Upper Extremity Stability Test and the Upper Quarter Y Balance Test, I immediately get the next question of
“Why should I test someone in the closed kinetic chain when his sport is exclusively performed in the open kinetic chain?”
“Closed kinetic chain testing is not “functional” for a baseball pitcher, why do it?”
First, we must define the goal of testing. Is replicating the sport or activity that the person is returning to our goal? I am not sure I have the ability or equipment needed to evaluate a baseball pitcher that moves at over 8,000 degrees per second. In order to capture that speed accurately, sophisticated (and typically time consuming and costly) biomechanical analysis is required.
The problem is, even with that huge quantity of precise data, it does not tell us WHY the elbow or shoulder is in a certain position. Is it a problem with technique, or is it an underlying thoracic mobility or dynamic core stability issue? For that, I need different testing.
My goal in testing the upper quarter in the overhead athlete is to determine if the person has the fundamental mobility, stability, and motor control that is the foundation for human movement regardless of the speed. This foundation includes not only glenohumeral joint stability and scapular stability, but how that extremity integrates with the core.
Most clinicians would agree that basic range of motion and strength need to be present prior to sport. Beyond traditional goniometer and muscle testing, one of the best ways of evaluating an athlete that has adequate mobility and stability is through testing in the closed kinetic chain. If the athlete can demonstrate that he has basic motor control competency and capacity in the closed kinetic chain, I have more data points to indicate that he has a solid foundation for sport specific skills, like hurling a small projectile thousands of degrees per second.
I want to first see that he has bilateral static stability through plank and push up type positions. Then progressing to unilateral static postures like the side bridge. Ultimately, I really want to see how the person responds when challenged and deficits are typically best seen at the limit of stability.
What do you think about testing open kinetic chain athletes in the closed kinetic chain and what tests do you use? Let’s start a discussion.