I am changing my Return To Play checklist

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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:Return to Sport Fatigue

  • 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.

Click Here for the Return to Play and Discharge Checklist


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?

Comment below.






  • By Dan Swinscoe 27 Feb 2016

    Great points as always Phil

  • By Mike Wehrhahn 27 Feb 2016

    Crazy you posted this! I was planning on asking you about fatigue and return to sport testing next time we talk. Awesome research.

  • By Greg Dea 27 Feb 2016

    Hi Phil,

    I’ve used un-fatigued RTP testing, as you’ve outlined above, followed by sports training, with LQYBT done post training – noting the effects you’ve stated.
    I’ve then used this as a guideline to coaching staff about RTP time-on-field.

  • By Phil Plisky 02 Mar 2016

    Thanks Dan!

  • By Phil Plisky 02 Mar 2016

    Greg, glad to here you are seeing the same things down under! I like the idea of using it as a guide in the time frame that the player is ready to practice some, but not full go.

  • By Trent Salo 02 Mar 2016

    Good stuff, Phil. Hoping to add to this literature on LQ-YBT under fatigue very soon!

  • By Phil Plisky 03 Mar 2016

    Excellent! Looking forward to it Trent!

  • By Jamie Alexander 05 Aug 2016

    Reading this takes me back to sitting across the pillar from you 1 year ago, listening to your advice as a student. Thanks for continuing to share your knowledge with others…i appreciate your insight.

  • By ruairiodonohoe 28 Feb 2017

    Hi Phil,
    Thank you very much for the information on Discharge criteria etc. With regards to the YBT in the at risk column, you say ‘Symmetrical in all reach directions’ then go on to give figures. Are these figures your ranges for asymmetry for these reach tests? Thanks for your help in advance.
    Ruairi O’Donohoe

  • By Phil Plisky 28 Feb 2017

    Thank you for the question! I can see how it is a bit unclear on the checklist. For the Y Balance Test Lower Quarter, the athlete should have less than a 4cm right/left difference in the anterior direction and less than a 6cm difference in the posterior directions. In addition, the composite score should be above the risk cut point for the athlete’s peer group (e.g. male collegiate football players)

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Phil Plisky

I want to change peoples lives through dialogue about creating an ideal career, injury prevention research, and return to activity testing.

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