What is missing from our return to sport testing?

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.

The Missing Link

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:

      • pain
      • coordination
      • movement
      • balance
      • neuromuscular control
      • power
      • 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.


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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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