Now that you have defined your why, addressed your culture, and understand test selection, let’s get into the nitty gritty of testing a large group for systematic injury prevention. To jumpstart your efforts, I have created this calculator to help you estimate how many people you can test in a given time period. You can adjust the test selection, the number of testers, and your testing timeframe. This will initiate a good thought process for our next posts on the mechanics of testing.
Your feedback and suggestions for improving the calculator are welcome, so please post below.
Bottom Line Up Front: The individual tests selected for an injury prevention system are important and should certainly possess basic psychometric properties (reliability, predictive and discriminant validity, etc.). However, it is important to use a systematic approach for injury risk factor identification and management to ensure that a comprehensive and effective plan is provided for each individual under your care.
What to Test
Which tests should be used in an injury prevention system? It boils down to identifying and managing the known risk factors for injury. What are the most common neuromuscular risk factors for injury? They can be summed up in three categories:
- Previous injury
- Abnormal motor control (due to abnormalities in ROM, stability, coordination, balance, etc.)
Let’s look at how a successful injury prevention program, the FIFA 11+ , addresses these risk factors. There is good research showing that the FIFA 11+ successfully reduces injury rates. The researchers who developed the FIFA 11+ program address many of the neuromuscular factors related to injury, including core and leg strength, balance, and plyometrics/agility. Thus, a soccer player who has poor core strength gets a little dose of core strengthening to address his deficit (plus the other stuff he may or may not need). This a program that I highly recommend, particularly if the alternative is doing nothing. But the problem with this ‘one size fits all’ approach is that it doesn’t test any of the factors it is attempting to mitigate. There are no feedback loops and ironically, it is inefficient because of its efficiency of quickly addressing many factors in a warm up session. It gives everyone a small dose of the same thing.
Let’s consider a school that has identified children who are not reading at their grade level. A program is implemented requiring all students to spend 30 additional minutes per day performing phonics and reading. Sure, a program has been implemented to address the problem, but what about the kids with dyslexia, vision problems, or those who struggle with the alphabet? Much like the FIFA 11+, this program will help those who are ripe for it, but will not affect those who have risk factors which exclude them from benefiting. Again, the research is clear, group programs work for those athletes that they work for….but not everyone.
With regard to injury in soccer, which tests would you perform to identify all the different root causes of all the different potential injuries? This is the current dilemma in injury prevention research.
What is the solution? Systematic injury reduction requires a level of individualization. Let’s consider the Lehr et al study. Prior to the season, athletes were given a questionnaire, Functional Movement Screen and Y Balance Test. The move2perform algorithm was used, which looks at the interplay of several risk factors. For example, having pain on a test trumps movement and Y Balance Test scores. Individuals with pain land in the highest risk category. If someone has a previous injury AND motor control dysfunction, as identified by the Y Balance Test or Functional Movement Screen, they are in the second highest category. If they have no previous injury or discernible motor control dysfunction, they are in the lowest level risk category. For someone in the lowest risk category, I would proceed to higher demand screening for power, energy storing, and postural integrity under load (Fundamental Capacity Screen). However, the path would be different for those in the other risk categories.
One of the biggest mistakes I see when choosing screens is honing in on the predictive validity of a test in isolation and trying to find a single, best screen. In reality, musculoskeletal injury is multifactorial and incredibly complex. While the screen(s) you choose should be reliable, modifiable, have discriminant validity (i.e., distinguish between those with and without the disorder), and be predictive of the outcome desired outcome (e.g. injury prediction, performance improvement, identifying the barriers to skill development), it is vital to recognize that having a system that directs to multiple intervention paths is crucial. I cannot foresee a day when one screen or test will be sufficient to predict musculoskeletal injury.
An injury prevention system must be based on principles and procedures using an organized, algorithmic approach that is rooted in research. Using the Functional Movement System for injury prevention considers the interplay of the tests being used, the hierarchy of how the tests are administered and how the results are addressed. Further, it contains vital feedback loops and gives individualized action steps based on the results. As test results change, so do the action steps.
A comprehensive injury prevention system protects you from selecting isolated tests designed to identify only a certain risk factor or from attempting to manage risk factors with an injury prevention program for individuals who will not benefit.
What risk factors do we look at in our injury prevention system?
Pain with movement
Y Balance Test Composite risk cut score based on gender, sport, and competition level
Y Balance Test Asymmetry
Functional Movement Screen 0’s and 1’s
Remember, these are used to identify AND manage the most common risk factors for future injury of pain, previous injury, and abnormal motor control.
In upcoming posts we will discuss how to physically accomplish getting these risk factors tested and what to do with the results.
25 Mar 2017
You are on the road to implementing an injury prevention system. You have defined your why, addressed your culture, and adjusted your mindset. The next step is to look at your current reality and define the path to your goal.
What is your current reality?
Most teams I consult with are currently collecting data that they are not even using and asking me what screens they should add. How about dealing with the information you are already collecting? Figure out how to use the data you are collecting or stop collecting it!
Here are a few questions to evaluate your current state:
What is your historical injury rate?
What measurements are you currently taking?
What are you doing with the information once you get it?
Are you re-testing?
What is working with your program? Do you have data to back up that assertion?
What isn’t working with your program? Do you have data to back up that assertion ?
What are you doing because of tradition?
Once you have answered these questions, you should have a good handle on where you are. Now you need to develop a strategy.
Developing a Strategy
Identify what to stop doing
This is the hardest part. It is easy to add screens, tests, assessments and data points. From the questions above, what data (screens/tests) did you identify that you are either not acting on, not retesting, or you found that the measure is not giving you the intended information. Again, either use it or stop collecting it! Last week we looked at a common limiting belief about time constraints. Here is an opportunity to create some time!
Dream Big (how will we accomplish our why)
When we are starting a project, we use the phrase, “start with ideal.” Given unlimited time, money, and staffing, what would you accomplish and what is the ultimate outcome? Forming an ideal and keeping it in mind at all times throughout the process helps you see the possibilities, not the barriers. Go back to your why statement for the guiding principles for your decisions.
Now determine your goals
Define the specific goals of your injury prevention system. How will you know when you have achieved success? I highly recommend that they are written in the SMART format (Specific, Measurable, Actionable, Realistic (to a degree) and have a Timeframe. For example,
We will have a player readiness rate of 98% average in the 2017 season.
Now that your start and endpoints are clear (where are you now and where you want to go), you are ready to get into the nuts and bolts of implementing your injury prevention system. Comment below with some things you will eliminate as well as your goals for this year. In the next post, I will get into the specifics of accomplishing those.
18 Mar 2017
Now that we have discussed the importance of establishing your why and creating your culture, it is important to examine the disconnect between your why statement and your current reality. But rather than starting with a look at your data collection and honing in on your current injury rate (we will get to that later), we need to consider your mindset. At this point, you may be convinced that you need an injury prevention system, but you may subconsciously be holding on to some limiting beliefs. What is your current mindset surrounding injury prevention? A lack of awareness of your beliefs can undermine your success.
To determine your current mindset, answer true or false to the following statements:
Regarding implementing an injury prevention system…
I don’t have time
I don’t have enough staff
I don’t have enough equipment
My manager doesn’t buy in
My staff doesn’t buy in
If you answer TRUE to any of these questions, you may have limiting beliefs that could stifle your systematic injury prevention efforts. It may seem benign to think or say things such as, “I don’t have time” or “I don’t have buy in,” but your thoughts frame your reality and your decision making. Limiting beliefs will sabotage your efforts. The top two reasons I see implementation of injury prevention systems fail is that a compelling why hasn’t been written and limiting beliefs have not been identified and overcome.
Let’s start by looking at the most common limiting belief: “I don’t have time.” Truth be told, none of us have time for ANYTHING! We only have time for the things we make a priority. To overcome the time limiting belief, try this exercise: “What if there was a governmental or organizational mandate that you were required to implement your ideal injury prevention system, how would you accomplish it?” If you can’t imagine your way through that scenario, your chances of success are extremely limited. You need to replace the thought “I don’t have time” with “I have the time I need to accomplish this important goal.”
To take your injury prevention efforts to the next level, write down any of the above (or other) limiting beliefs and describe how you are going to overcome them. If you continue to have trouble, refer to these other posts or check out the coaching/consulting page for personalized assistance.
In the next post, we will discuss the specific analysis of where you currently are and where you want to go.
Wanted: Extraordinary Attributes
I am blessed to work with professionals of the highest caliber in the world in rehabilitation and performance. This is most evident to me in our Sports Physical Therapy Residency team. What sets these sports residents apart? After obtaining a Doctorate in Physical Therapy, these PTs apply for a rigorous, 15 month sports physical therapy training program that requires 50-60 hours each week. Less than 10% of all doctoral students apply for a any type of residency program, and less than 1% of all PTs pursue a residency. Among the applicants to our program, only three are accepted. To say that I get to work with the best of the best of the best is an understatement. It strikes me, though, that while all of the graduates are remarkable, some stand out as extraordinary in their brilliance and success.
Over the past 10 years, I have worked diligently to identify the traits that separate the brilliantly successful from the rest. Finally, this year with the help of several books and countless discussions with our team, we were able to identify and articulate those traits. There were three essential books which aided us in expressing the expectations representative of our residency culture: Mindset, The Ideal Team Player, and Grit.
These are the characteristics of our sports residency team members:
Our residency program expects and seeks to nurture individuals who are positive, humble, hungry, people-smart, and have grit, all with a growth mindset.
One of our Residency faculty recently posted on the topic of a “growth mindset.” Reading it will give you a flavor of how deeply these values are entrenched in our program.
If your team members don’t know your vision (your why), your efforts are much less likely to succeed. Also of importance is that they know how team members are to accomplish the vision. The tactical steps about “how” things are supposed to get done come to mind for most. But, I care most about our team being aligned with our vision and possessing the character traits to carry out that vision. In my experience, this helps the end product take care of itself with the perk of eliminating micromanaging. The vision is simply accomplished by having specific goals in conjunction with continual communication and accountability.
Many people have experienced working alongside a team member who is not displaying the desired character traits. In The Ideal Team Player, Lencioni describes the requisite traits as virtues and offers solutions when they are not exhibited. If you cannot successfully “rehabilitate” a team member, liberate them from their current position. In this case, kindness is essential. And in this case, being kind means relieving the team member from their current position. When an individual is held back by your culture, you are doing them a disservice by allowing them to persist in a culture that does not match them. Let me be more clear, I have seen numerous teams that were unable to successfully implement a systematic approach to injury prevention because of one person. One person can also cause many outstanding people to leave an organization. Most of the time, this person is merely “tolerated” for who they are. In order for a team to be successful, this cannot occur.
To ensure that you are assembling the best possible team, begin by articulating what characteristics are most desirable for your team. If one of my consulting clients has questions about getting change within your organization, I first ask:
- What is your vision (your why)?
- If I were to ask your staff (and sometimes I do) what the vision is, would they know?
- What are the characteristics of your team and your team players?
Those questions have to be answered before we get into the “what” of implementing an injury prevention system. In future posts, I will be discussing the nuts and bolts of systematic injury prevention, but I can’t emphasize enough that the greatest need for most organizations is not the specifics of the system, but the foundational vision and culture to execute the details.
Share what you think the characteristics of an ideal team player are below.
24 Feb 2017
Why I think the Cubs won the World Series
In a word, culture. From any vantage point, they exude a culture with a common vision, an emphasis on continuous improvement with attention to detail, respect on all levels, and fun. I have frequently seen teams win national championships within a couple years of implementing the Functional Movement System. Why is that? Am I biased and naive enough to think that teams who have players who perform better on the overhead deep squat are destined for a title victory? By no means! I think it is the result of being purposeful in building a culture that repeatedly does the simple, little things well. This type of success has roots in embracing a culture of communication and accountability. How does this start?
In her book, Grit: The Power of Passion and Perseverance, Angela Duckworth spends a day with the Seattle Seahawks to try to understand their culture after back to back Super Bowl appearances. The first thing she notes is Head Coach Pete Carroll’s emphasis on “Starting with Why.” (See my previous post on creating your Why.)
“Once you have done the work to create that clear vision, it is the discipline and effort to maintain that vision that can make it all come true.” Pete Carroll.
An article on Seahawks.com illuminates the importance of both the culture and a compelling vision (why statement) for your screening efforts. Take a look at how they describe implementing the Functional Movement System.
“The reasons the Seahawks are incorporating these tests to launch their offseason program starts at the top with general manager John Schneider and coach Pete Carroll.
This is a vision that John and Pete have for this organization,” said Ramsden, who was the Seahawks’ head trainer for eight years and an associate trainer for five years before stepping into his new role. “They’ve put me into a position to try to bring it to life.”
But once that is developed, how do you create the culture you want that accomplishes the vision?
1. Talk about your vision — constantly.
Every team member should be able to articulate the vision. Decisions are made in accord with the vision. Motivation is drawn from the vision. Team members are held accountable to the vision. This mission must be communicated daily. Every question is an opportunity to respond in terms that underscore and propel you toward the mission.
2. The devil is in the details.
“It is not one thing, it is a million things. It’s a million details.
It is countless small things, each is doable.” Pete Carroll
Accountability is key. There is truth in the adage, “What gets measured, gets done.” Everyone wants to know what winning looks like in their particular job. In the realm of injury prevention and performance enhancement, baseline screening and re-testing is key. The reports that are shared from re-testing foster communication – communication about progress toward the vision. This helps continue the culture change and is a catalyst for buy in.
3. Communicate to foster buy in.
Accountability is important, but without a supportive culture it can lead to individualism as well as the temptation to “cook the books”. If I am going to be held accountable for improving someone’s movement screen score, I might be tempted to fudge that score in order to look better. This is where vulnerability and mutual support are crucial. Everyone “has each other’s back” has to be the attitude. An emphasis must be made on helping one another identify and removing resistance to implementation along the way. A ‘no blame’ policy assists in navigating through hurdles. When communication or accountability breaks down for any portion of the organization, even if a single person fails to act in the direction of the vision, it could thwart the efforts of the whole group.
So why do teams tend to win after implementing the Functional Movement System? I believe it is the result of their commitment to communication and accountability, and a willingness to start with the little things to pursue a common vision. This communication, accountability, and adherence to the vision permeates the culture and spills over into every area. It makes sense that teams that have created a culture embodying these values would be inclined to adopt a comprehensive system for injury prevention. In my next post, we will continue to talk about developing your culture with your team members.
Post below about how have you seen doing the little things right over and over again can lead to outrageous success in large goals?
Discovering Your Why
In the previous post, I discussed the characteristics of successful teams utilizing systematic injury prevention. A team transformed their entire organization’s injury prevention system in one pre-season! A key factor was that they started with why.
Why start with why? Because the success of your mission depends on it. If you don’t convey the foundational why, the how and what become much more difficult to accomplish. When people are exposed to something new, resistance and defensiveness are common reactions. If you can connect the emotional part of their brain with a compelling why, it becomes a bridge for collaboration.
The number one question I get is, “How do I get buy in from (coaches, players, clinic managers, parents, etc.)?” People hit the barriers regarding time, resources, and personality and can’t seem to overcome them. This can usually be traced back to not communicating a compelling why statement. A very clear why statement is essential to lead your team through the dark days of no one buying in. A crystal clear ‘why’ can lead your team to a certain victory by communicating in a way that prompts behavior change.
Shared beliefs and an understanding of the greater purpose, enables an organization to get behind the steps required to accomplish the mission. Why do you or your organization care about injury prevention? Do you believe that your competitive advantage comes from keeping players on the field in the first place? Is this where your physical performance efforts are rooted? The goal is for stakeholders at all levels of an organization to be able to able to answer this question consistently: “Why are we doing this?”
Here is an example of great “why” answer:
“We believe that we can affect the durability of our players by systematic screening, testing, and intervention. Our competitive advantage as a team comes from creating durable players. Last year, we had too many injuries that kept key players from performing their best. We are doing this so players can stay on the field with a foundation that is ripe for enhancing performance.”
If you haven’t read Start with Why, block out 18 minutes on your calendar this week to view Simon Sinek’s TED Talk . I find it beneficial to watch this video regularly to ensure that my communication starts with why and then addresses the how and the what. The heart of the matter, and golden key to unlocking doors through communication, is in the why.
While developing a why statement might seem to be a cheesey, pointless exercise that a consultant on team building makes you do, it is crucial to communicating effectively!
How to formulate your Why
Define your beliefs. Dream big and make it meaningful. “To prevent injuries” will inspire no one. Yet, I hear it all the time! “To prevent injuries” is a what statement. What are your beliefs about human movement and the science of injury prevention? Ultimately, why do you want to prevent injuries? To win the championship? To reduce costs? To keep the factory worker gainfully employed so she can take care of her family? To help children embrace a lifestyle that includes physical activity? Here are some steps to developing your why:
1) Admit that injury prevention is just a means to an end. Injury prevention is a step along the way to a bigger destination.
2) Identify your why – What do you believe?
Begin your why statement with I believe….
I wrote this when I started this blog a few years ago:
I believe we need a musculoskeletal disease prevention revolution.
I believe that we can identify those at risk for preventable injury before it happens.
I believe that we can keep people from being re-injured after their initial injury.
I believe we can KNOW when someone is ready to go back to their activity.
I believe that the musculoskeletal health of every person should be tested as part of an annual exam and prior to initiating exercise. Everyone should know their musculoskeletal “number” — just like they know their blood pressure.
I believe we can, no NEED, to work together across professions to do this. It is going to take a village!
Notice, the purpose of this blog was not “to reduce injury rates.” Again, what do you believe? Mull over your beliefs as you develop your why statement.
3) Consider and define why it matters to you and your team
What will happen if you achieve it? (both long and short term)
What will happen if you don’t? (both long and short term)
Injury prevention efforts should lead to the “team’s” desired outcome . What common outcome would every team member want to achieve? We can get pigeon holed in our view and our own goals. With a thoughtfully crafted why statement, you will be ready to tackle the barriers that you will encounter along the way. In future posts, we will address those common barriers.
Please write in the comments below “why statements” you have developed to help our community of readers.
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 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?