We’ve been discussing return to sport and discharge testing. In our last post, we met Jane, a 36 year old with knee and hip pain due to lack of systematic discharge testing after her ACL reconstruction 20 years earlier. This left her with modifiable risk factors and now pain. Worse yet, she is trying to get into shape but is struggling due to this recent “injury.” Remember, we can prevent these injuries, but the key is systematic testing at return to sport and discharge. But before we get into the specific tests and criteria, let’s discuss how we should go about selecting those tests.
Obviously, the test should be reliable and measure the domain that you are trying to test. But which domains should we test? Using a Delphi study method, Haines et al created a checklist of domains that an expert panel felt were important to include in return to sport testing. The domains that the experts suggested testing included:
- neuromuscular control
- sport specific movements
- strength and range of motion ** this is my addition (we will discuss the research related to these and risk of injury)
I think we all would agree with the above list, but how do we go about selecting the specific test and criteria for return to sport or discharge? I believe most of us already test those domains, but our current standard of care is leaving people with a substantial risk of future injury.
What are we missing? I believe we are missing 3 key concepts in return to sport and discharge testing:
1) When possible, the tests we use should be predictive of injury
– Could you imagine if your primary care physician could do a few simple tests that could quickly give you a snapshot of your risk of a disease? Wouldn’t you expect her to perform them? As a matter of fact, they currently do (think heart rate and blood pressure). We owe this to our patients in rehabilitation as well. But when it comes to return to sport, I believe we put too much and too early emphasis on tests requiring high level physical function and other sport specific tests. While those are important, I think we need to consider tests predictive of injury or that identify traits that lead to susceptibility to injury.
2) The tests need to be arranged in a hierarchical fashion ( This case study in BJSM is a start).
– Currently, I think we assume (often unconsciously) that if an athlete can hop/cut/run well, then they have the foundational requirements of ROM, strength, basic movement and balance. Or, that those foundational traits are not as important. But frequently, this is not the case. There is little need to perform testing at higher levels of function if there is a fatal flaw in movement or balance at lower levels of function. If the athlete passes the higher level testing, they too ASSUME that they are good to go.
3) We need to set the minimum criteria for discharge to be near what a person at “Normal” risk would score on the test (and I would argue it should be even higher than that).
– Since we know that athletes who have been previously injured are more likely to be injured again and that motor control changes frequently remain after injury, we should demand that their test results are close to normal prior to discharge. What if you had a disease and your blood levels indicated that it was advanced and you underwent treatment and they retested your blood and found that you were better, but not normal. What would your response be? Mine would be “Is it possible to get it back to normal or is this as good as it gets?” We need to have the same attitude toward one of our largest, most expensive systems — the neuromuscular system
So, with those concepts in mind, here is what I am now giving patients at the start of their care. This list includes most of my discharge criteria. Over the next several posts, I will go through the research regarding these tests as well as any others that are suggested. Add any tests that you think are missing below.
11 Jun 2013
Not because we want to autograph our great work, but to signify that we have completed the safety checks to ensure we have removed all modifiable risk factors for injury. Why did surgeons implement signing the operative knee before surgery? As ridiculous as it sounds, the wrong knee had mistakenly been operated on. It doesn’t happen very often, but what it does, it can be catastrophic. Why should rehabilitation providers sign that they have removed all modifiable risk factors after rehabilitation?
Because we are unknowingly discharging numerous patients with modifiable risk factors for future injury. In fact, almost certainly many more patients are being discharged with modifiable risk factors than wrong knees are being operated on — and the long-term consequences can be just as catastrophic.
Let’s hear what happened to Jane:
Jane is a 36-years-old mother of two, whose youngest is 18 months. Since the birth of her children Jane’s priorities have shifted and she no longer gets to the gym as much as she’d like. She enjoys exercises, but with two kids and full-time job it’s hard to squeeze in a regular routine. As a result, Jane has put on few pounds, a fact that pushed her to recommit to getting back into shape despite her busy schedule.
In the course of her new workout routine, she developed hip and knee pain. She went to her physician and he diagnosed her with early onset knee osteoarthritis. How can that be, she’s only 36?
Looking back over Jane’s medical history, we discover that 20 years ago she had an ACL reconstruction, with several months of rehabilitation. Considering this prior injury, was Jane’s early onset of osteoarthritis just a natural course of the ACL tear, or was there something that could have been done differently to prevent her current condition? Let’s look at her post-operatively:
The rehabilitation provider that worked with Jane had her start with basic range of motion and strengthening and then progressed her through a myriad of exercises from low to high level. Finally, Jane was doing plyometrics (programs proven to reduce injury), running, and cutting and was ready to return to sport. Her strength and ROM looked good and so did her running and cutting. Jane said she was feeling great! So she went back to sport.
Here’s the problem: Previous injury is the most consistently reported risk factor for future injury in athletics. Here is one of my favorite injury epidemiologists summarizing his research findings:
“Looking at 70 teams, in 18 countries, over 8 seasons (9,000 injuries), we have found that previous injury is by far the greatest predictor of future injury in football.”
Soccer Industry Medical Symposium 2009
But what is more important is that, numerous researchers have found that modifiable risk factors remain after rehabilitation (eg. jump landing asymmetry remains 2 years after ACL reconstruction and predicts second ACL tear). If you would like to dive into that concept in more depth, check out this short video
What this means is that without standardized, systematic, and stringent return to sport and discharge testing, we are likely to discharge patients with modifiable risk factors. We MUST stop this. Since I have implemented systematic discharge and return to sport testing, I am SHOCKED to find out how frequently I am wrong — the patient appears to be normal (even by my “trained” eye) but testing reveals something completely different.
So, are you willing to sign your patient’s leg, arm or back? I am…..but in the mean time, I have to go apologize to some of my previous patients. Fortunately, Jane is fictional but represents a large percentage of our patients.
Over the next several posts, I hope we can all discuss what the evidenced based discharge tests should be and what is considered passing. What tests do you think should be included? Post them below so we can discuss them in this forum.