3/6/2017

1

Return to Sports Participation

and Discharge Testing

Anthony Inzillo, PT, DPT, SCS

Andrews Institute Rehabilitation Symposium:

Lower Extremity

3/4/2017

Objectives

1. Identify the components of functional testing for various lower extremity injuries

2. Provide evidence supporting the use of specific tests and minimum passing criteria

3. Understand the criteria that athletes must meet to return to participation in their sport

4. Discuss appropriate care during the transition between discharge and full return to competition

Background

• Up to 250,000 ACL injuries per year in the US.

• Annual health care cost exceeding $2 billion.

• Most occur from participation in level 1 (jumping,

pivoting, and hard cutting) sports.

• ~70% non-contact vs ~ 30% contact.

• Higher relative risk in females than in males.

• Typically a 6-12 month recovery, resulting in countless

hours of missed sport participation.

Current Success Rates

• 69 studies; 7,556 patients (mean f/u: 40 months, range: 12-156 months)

– 65% returned to their pre-injury level of sport (83% for elite athletes)

– 55% of athletes returned to competitive sports

– 81% returned to some form of sport

Included studies from 1982-2013

Included studies from 2005-2015

• 19 studies; 72,054 patients (mean f/u: 51 months, average age: 24.4)

– Total secondary ACL re-injury rate was 15% (7% ipsilateral vs 8% contralateral)

– ACL re-injury rate for patients younger than 25 was 21%

– ACL re-injury rate for athletes returning to sport was 20%

– ACL re-injury rate for athletes younger than 25 returning to sport was 23%

– Young ACLR athletes have a 30-40x greater risk than uninjured adolescents

Why do we need

Functional Testing?

• There is a high likelihood of re-injury after return to sport

• Previous injury is #1 risk factor

• There is an increased incidence of re-injury when

asymmetries exist

• In most cases, patients are trying to return to high

demand/high risk sports

• Objective, quantifiable tests allow clinicians to make

return to sport decisions more confidently

Published July 2016

• 106 patients who underwent ACL reconstruction (6 lost to withdrawal/follow up)

• Passing RTS criteria: ≥ 90% on Knee Outcome Survey-ADL scale, global rating scale of perceived

function, isokinetic quadriceps strength, and single leg hop tests

• Failing RTS criteria: Failure to achieve 90% on any of the above

• Re-injuries included acute ACL injuries, meniscus tears, cartilage injuries, MCL injury, patellar sublux

• For every 1% improvement in quadriceps strength symmetry, there was a 3% decrease in injury risk

• 4/4 patients returning to sports less than 5 months after surgery suffered a knee re-injury within 2

months of return

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2

When is Discharge Testing

Appropriate?

• Dependent upon each patient, diagnosis, and their progress

– Healing timeframes

– Normal clinical exam

• No pain

• No swelling/effusion

• Full ROM

• Normal MMT

• Normal joint stability

– Normal movement patterns without significant dysfunction

– Good tolerance of rehab progression including plyometrics, agility drills,

advanced strengthening

Psychological Readiness

• # 1 reason that injured athletes do not return to sport is fear of

re-injury!

• Important to use subjective questionnaires throughout the

rehab process

• Examples:

– LEFS

– KOS (ADL/Sport)

– IKDC

– Modified Cincinnati Knee Rating System

Other Factors to Consider

• Age

• Injury history

• Concomitant injuries

• Time from injury/surgery

• Time of season/career

• Type of sport (level)

• Contributing factors

Risk Factors for Injury

Non-Modifiable

• Previous injury

• Female gender

• Age

• Small notch width

• Ligamentous laxity

• Genetics?

• Small ACL size?

• Increased posterior tibial slope?

Modifiable

• High BMI

• Hormonal factors?

• Playing surface/equipment?

• Fatigue

• Asymmetries in ROM, strength,

and movement patterns

• Poor neuromuscular control

• Poor jump/landing mechanics

Functional Tests Should Be:

• Valid

• Reliable

• Supported by evidence/predictive of injury

• Cost and time efficient

– Easy to administer

– Minimal equipment required

• Performed in a cluster

• Modifiable

Components of Functional Testing

• Lower Quarter Y-Balance Test

(Neuromuscular control)

• Functional Movement Screen(Movement patterns)

• Isokinetic Testing(Strength)

• Single leg hop testing(Power/agility)

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Lower Quarter Y-Balance Test

• Test of dynamic single leg balance/stability and

predictive of injury risk

• Based on research using the Star Excursion Balance Test

described by Gary Gray in 1995

• Modified test consists of 3 reach directions

• Record furthest distance reached in 3 trials for each direction

Y-Balance Test cont.

• 2.5x greater injury risk for >4cm difference for anterior reach in

high school basketball players

• Increased risk for composite score < 94% for high school

basketball players, < 89.6 % for college football players

(3.5x greater injury risk)

• Composite score: ((A+PM+PL) / 3x limb length) x 100

• Passing criteria• Within 4 cm of uninvolved leg for anterior direction

• Within 6 cm of uninvolved leg for posterior directions

• Composite score above cut-off point for age, sport, gender

Functional Movement

Screen (FMS®)

• Consists of 7 body weight tests that require a combination of

mobility, stability, and motor control

• Systematic way to observe movement patterns and identify

dysfunctions and asymmetries

• Each test is given a score of 0-3

– 3- The movement pattern is complete and consistent with the test

definition

– 2- The movement pattern demonstrates compensation or faulty form

– 1- The movement pattern is incomplete and was not performed

consistent with the test definition

– 0- Pain is present

Functional Movement Screen

Min Passing Score: 15/21

FMS® Continued

• Scores of 14/21 or lower indicate elevated risk of serious

injury

– 11.67x more likely than those scoring > 14

– 15% pre-test probability to 51% post-test probability

– ≤14 : 70% injured

– ≥15 : 16.7% injured

Isokinetic Testing

• Tests maximum torque produced by quadriceps and

hamstrings at 180 deg/sec and 300 deg/sec

• Greater than 15% quadriceps strength deficit negatively

affects function and performance Schmitt et al

• Goals: Quadriceps and hamstrings strength at least 90% of

uninvolved leg

Normal hamstring/quadriceps ratio

Normal knee ext torque-body weight ratio

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Single Leg Hop Testing

• Average of 2 successful trials measured in centimeters

• Limb Symmetry Index = score on involved leg x 100

score on uninvolved leg

• Classically, 85-90% LSI has been the cut-off to be cleared for

return to sport but…

• Series of 3 tests– Single hop for distance

– Triple hop for distance

– Triple crossover hop for distance

• At 24 weeks post-op ACL reconstruction, the average overall Limb Symmetry Index was 88.5% and the average Lower Extremity Functional Scale score was 69.3.

• 69.3 LEFS= Moderate difficulty with:

• “Your usual hobbies, recreational or sporting activities”

• “Running on even ground”

• “Running on uneven ground”

• “Making sharp turns while running fast”

• “Hopping”

• Munro & Herrington 2011 found that the average LSI for the four hop tests was 100% (98 to 102%.) and that 100% of healthy subjects have at least an LSI of 90%

• “Given our current re-injury rate, I suggest hop testing LSI should at least be above 95% and recommend it to be above 97%-100%” - Phil Plisky

Not good enough…

Hop Testing cont.

– Nearly 100% for bilateral tests, low 90’s for single leg tests

– Limb symmetry index for healthy controls is around 100%

Myer et al. J Orthop Sports Phys Ther. 2011 Jun; 41(6): 377–387

Goal: 95-100%

LSIPlisky, et al.

Jumping/Landing Quality

• Tuck jump and drop jump assessments

– Tuck jump (10 sec)

• Thighs parallel to floor and equal

• No valgus on take-off or landing

• Good foot placement/timing

• Quiet landings and equal weight bearing

– Drop jump (12.5” box)

• Good form with bilateral and unilateral tests

• Good jumping/landing technique with no valgus

collapse

– Both can be assessed using slow motion video

Review of Passing Criteria

• Normal clinical exam– No pain, swelling, or symptoms with ADL’s or rehab activities

– Normal ROM, MMT, joint mobility, flexibility, stability

• Y-Balance Test– Within 4 cm for anterior reach and within 6 cm for posterior reaches

– Composite score above cut-off point for sport, gender, and activity level

• Functional Movement Screen– Total score above 14/21 and no 0’s (pain), 1’s, or asymmetries

• Isokinetic Testing– 90% quadriceps and hamstrings strength index (85% for practice/field)

• Hop Testing– 95% Limb Symmetry Index for single hop, triple hop, and crossover hop

• Passing score on subjective questionnaire (psychological readiness)

• Normal mechanics with tuck jump and drop jump assessments

• Good tolerance of position specific activity progression

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What does it mean?

• Athlete is allowed to begin position specific drills and

activities with their team and coaches

• Still need to work with position coaches, athletic trainers,

and strength/performance coaches until everyone feels

confident that the athlete is ready to return to

competition

• No specific time frame on this stage

• Communication between all members of the sports

medicine team is crucial!

Goals of this stage

• Proficiency with reactive agility drills specific to their

sport/position

• Improve strength, endurance, and athleticism to

withstand demands of the sport

• Prepare athlete to compete at a level at or above their

competition

– Restore strength/speed/agility/reaction time to normal

limits so that these athletes aren’t put at a further

disadvantage when put against an opponent

• Remember the highest risk factor for suffering an injury!

• Be sure that the athlete can protect themselves

How can we test this?

• Performance tests within normal ranges for the athlete’s sport, level, and position

• NFL Combine tests

– 40- yard dash

– Vertical jump

– Broad jump

– 20 yard shuttle

– 60 yard shuttle

– 3 cone drill

– Bench press

Basketball

• NBA Combine tests

– 185 lb bench press

– Standing vertical jump

– Max vertical jump

– ¾ court sprint

– Lane agility drill

– Shuttle run

– Shooting tests

Baseball

• Spring training performance tests

– Standing vertical jump

– Standing broad jump

– 10 yard explosion

– 300 yard shuttle

– 30 second cone hop

– Agility test (5-10-5 shuttle)

http://www.stack.com/a/testing-for-baseball-with-the-mets

Soccer

• MLS Combine tests

– Speed test (30-meter dash)

– Agility Test (5-10-5 shuttle)

– Power Test (vertical jump)

• Yo-yo tests

– Aerobic capacity, running economy, change of direction

– Not currently included in combine

3/6/2017

6

• Continued work with performance coaches and position coaches

during this stage is paramount

• Must understand the unique demands of each sport and position

Conclusion

• An athlete’s ability to return to play will be based on successful

completion of an appropriate rehabilitation program, meeting

minimum passing criteria on return to participation testing, and their

progression through sport/position specific activities.

• Rehabilitation should be individualized and tailored for the unique

needs/demands of each patient while using best available evidence.

• Return to sport decisions should be made as a team and based on a

cluster of subjective/objective findings and consideration of

situational factors.

• As a field, we need to be more consistent in establishing and

enforcing objective return to play criteria.

THANK

YOU!

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