Return to Sport Decisions?

As a Certified Athletic Trainer I have had the opportunity to  cover high school and collegiate sports; and had to make the "Hold 'Em Out, or Let 'Em Play" decision based on little to no science but rather my best guess as to if the athlete was really ready. I long desired a better way to objectively determine when an athlete was ready to participate after an injury or surgery. I dreaded confronting athletes, parents, coaches and physicians with "My Gut" answer to How long are they out?, Why are they held out?. How do you confidently answer these questions and what makes your stomach churn?


By The Way; we have objective science now that helps us answer these questions confidently.

Test Don't Guess

When Pre-Participation Physicals Become Return to Sport Testing
High School and College sports are in high gear, your the only ATC or Sport Physio at the school and now in addition to having to cover 3 levels of football, 2 soccer teams, volleyball, cross country, & fall tennis you have  a few club sports that are requesting that you help out with an injured athlete; oh I forgot that the initial injuries that are coming in the doors to the training room to be assessed/evaluated and treated.

How do you determine when to return athletes to play?

Athlete "Can I play today?, Friday night?, When?."
Coach " When will they be ready?"

Your Answer"______________________"?
My answer "When Your/their LQ-YBT and FMS scores return to baseline or better and you/they no longer have pain".


Do you have an objective baseline measure that indicates level of injury risk (any objective measure for that matter) from Pre-Season Physicals that you can use to answer the above questions? If not you should.

Test Don't Guess!

Sports Physicals: We can do better

Thousands of high school, college & university athletes are returning to campus this week and most of them are going to go through mass screening and testing for their Pre-Participation Exam (PPE/ Physicals). Depending on which state these athletes are in (USA) they may be subject to different rules and regulations for what must be included in the physical. Individual institutional requirements may also vary within a state depending on who is in charge of the sports medicine program and what research lines are currently in vogue at that institution.
Governing associations may add another layer of complexity to the paper trail. Most of these PPE's consist of check list(s) that meet legal requirements at best and add little value to efficiently identifying and categorizing athletes for future injury risk.

Currently there is little consensus in the sport medicine community about what should be (must be) included when determining the readiness of our athletes to begin/ or return to participation in competitive sports.
How do you answer these questions?:
             Who decides what constitutes a thorough Pre-Participation Physical?
             What objective tests and measures are included?
                   Which ones are meaningful? Which ones (risk factors for future injury) are modifiable?  
             When are physicals scheduled? When do we re-test prior to Return to Sport?
             Where do we conduct the testing/screening? Why?
             How does the information collected help the athlete, coach & medical staff?
             Why do we do what we do?
                   Does the PPE add value to our athletic program and sports medicine team?
                    Or does it just meet a requirement and drain the resources and energy of the staff?


I believe it is time for us to offer better than a check list to our athletes.

Pre-Participation Physicals: FMS the Reasearch

Dr. Robert Butler of the  Duke University K-Lab has put together an updated summary of the research that has been published on the Functional Movement Screen , it is a great quick read. Here are some of the highlights:

"Current research on the Functional Movement Screen suggests that the test is a reliable way to objectively measure fundamental movement patterns that are modifiable and indicative of an elevated likelihood of sustaining a musculoskeletal injury." KEY POINT the FMS helps us identify modifiable risk factors.  We as Sports Medicine professionals have been searching for a meaningful approach to clearing athletes for competition for a long time, this is a great start.

"The average score in 20-40 year olds is approximately a 15......; approximately a 1.2 composite decrease for the 50-59 year old group and an additional 1.2 composite decrease for the 60+ group." KEY POINT we can reasonably expect that FMS scores are different for different age groups. This helps us make appropriate comparisons when interpreting scores.

" ;..... it is likely that not all corrective exercise programming or strength and conditioning programming may results in a change in FMS scores." KEY POINT corrective exercise programs and performance improvement programs should be individualized; a One Size Fits All program approach does not yield optimal results.

When discussing how the FMS relates to specific sport or skill performance: "The primary take home message across these studies is that a single performance effort is not strongly correlated with FMS scores." KEY POINT the FMS allows us to assess different aspects human movement that contribute to athletic skill. 

Summary
"In summary, the Functional Movement Screen is a reliable tool that can be used to identify individuals who are more likely to become injured." KEY POINT we can identify limitations and asymmetries that have the potential to contribute to future injury.

"It has also been observed that improvement in the composite FMS score can occur through some movement related training programs." KEY POINT  we can make a meaningful difference for our athletes and clients by lowering their potential for future injury by applying an individualized approach.

Thank you Dr. Butler for summarizing the research.

ppg

Pre-Participation Physicals: Upper Quarter Y Balance Test

As we continue to develop our approach to testing and screening here is a look back at some of the topics covered:  Hop Testing, Lower extremity Balance Testing, Movement Screening, Ankle range of motion testing, Painful Athletes.

Our next stop on this journey:
UQ-YBT
The Upper Quarter Y Balance Test (UQ-YBT) is a relatively new test that looks at the upper extremities in a closed kinetic chain posture. The test is performed starting from the "Up" position of a push up; the athlete maintains single hand balance (the stance hand) on one side while simultaneously reaching to the edge of their ability (stability) with the other in 3 directions. The test is then repeated on the other side and results are compared for symmetry and against their peer group (same age, gender, sport, & competition level). 

It can be a challenging test for many as it can quickly identify an individuals Right/Left differences (asymmetries) and add to the objective measures we are basing our Pre-Participation & Return to Sport recommendations on.
Here is a quick video demonstrating the UQ-YBT (Upper Quarter Y-Balance Test)

Creating Change: Return to Sport and Pre-Participation Physicals

Join me in creating a better system for evaluating and assessing athletes prior to Sports Participation &/or Return to Sport post injury/surgery. Seth Godin has given us a fantastic example (found here) of how we can work together in a short period of time to foster the growth and development of ideas by taking risks and working together.

If you are part of the sports medicine team and desire to improve our current system for determining readiness of individuals for athletic participation (injury prediction & prevention), please comment &/or contact me, together we can  go further faster.

ppg

paul@TankGym.com

Pre-Participation Physicals: Hop Testing

As we continue to develop our comprehensive approach to Pre-Participation Physicals; & Return to Sport(RTS) Testing more on RTS to come; Hop Testing is our focus today.Let's start with LSI.

Limb Symmetry Index: The LSI provides a ratio comparing the performance between 2 lower extremities of the same individual; this is clinically useful in determining lower extremity asymmetry.J Orthop Sports Phys Ther 2001;3 1:145-151.

If you are not familiar with Hop Testing I will cover the basics and here are a few articles to help get you started: Interrater Reliability of Functional Performance Test for Subjects With Patellofemoral Pain Syndrome ; &  Hop Testing Provides a Reliable and Valid Outcome Measure During Rehabilitation After Anterior Cruciate Ligament Reconstruction 

Hop Testing has been in the research literature for some time and performance described in term of limb symmetry. An article from 1990 : describes the testing method and begins to define normative measure for individuals who were ACL deficient  and compare them to a healthy population. We administer the Hop Test by comparing single limb performance, Right versus Left, of one individual in a Single Hop for distance, Triple Hop for distance, Triple Crossover Hop for distance and a Timed Hop (covering 6 meters). We then use the LSI we discussed above to give us a better picture of that individuals performance, Right versus Left lower extremity. After completion of the Hop Test, & other objective measures we have been discussing, we enter the data into Move2Perform in order to compare them against their peers. When making PPE and RTS recommendations we must consider the peer group. What is a persons peer group you ask:An individuals Age, Gender, Sport & Competition Level are all parts that make up a peer group. From many other studies, many using the SEBT, we know that athletes of different ages, genders, sports and competition levels perform differently.

A few recent articles go further than the early studies to suggest that 85% and even 90% LSI may not be stringent enough criteria when determining an individuals readiness to return to activity.

Myer et. al. & Grindem et. al. 

Hop testing is another great objective measure to include in your screening and testing of athletes and individuals prior to beginning or returning to activity and sport. Later we will discuss why we utilize many different tests and measures in musculoskeletal screening.