Functional Testing & Return to Sport Chris Gabriel, PT, OCS, CSCS

Page 1 of 11

OBJECTIVES

Functional Testing and Return to Sport Chris Gabriel PT, OCS, CSCS OrthoCarolina Sports Performance January 22, 2011

1. Provide a review of tests most commonly seen in the literature and used in clinical settings 2 Discuss proper testing procedures to 2. improve safety, reliability, sensitivity and specificity 3. Highlight current research trends to improve functional testing

ENTRANCE CRITERIA

Additional Considerations

• Entrance Criteria for Functional Testing Phase-

•

Hartigan, g , Axe,, Snydery Mackler, 2010 (7)

1. >= 12 weeks post-op 2. = 80% quadriceps strength index 4. Full knee ROM 5. Pain-free hopping 6. Normal gait

Knee extension peak torque/body weight ratio: 300 degrees/sec: 40% for males, 30% for females 180 degrees/sec 60% for males and 50% for females (15)

•

No post-surgical history of giving way, or a negative pivot shift

•

KT 1000 testing- no R:L difference greater that 3mm

Additional Considerations

HOP TESTING

The athlete must be able to demonstrate safe and proper form with… • vertical jumps • broad jumps • hops • direction changes at slower speeds

1. 2. 3. 4.

Single Hop for Distance (2) Timed Hop p ((2)) Triple Hop for Distance (16) Cross-over Hop for Distance (16)

Page 2 of 11

Single Hop for Distance

Timed Hop

1. The athlete stands on one leg, with his or her toes on the starting line, and performs a maximal hop horizontally, landing on the same leg 2. Arms may swing freely to assist, be held on hips or behind the back – must remain consistent 3. The distance is measured from the starting line to where the posterior heel lands 4. Landing position must be held for 2 seconds with no loss of balance or extra steps (21)

1. 6 meter distance is marked off using athletic tape 2. Athlete stands on one leg with toes on the starting line 3. The athlete is instructed to perform repeated, forceful single g leg g hops p across the finish line. These should be done as quickly as possible, while maintaining proper form 4. The test ends once the back of the heel crosses the finish line, and time is measured to the nearest 1/100 of a second

Triple Hop for Distance

Cross-over Hop for Distance

1. A strip of athletic tape, 15 cm in width and 6 meters long is placed perpendicular to the start line 2. The athlete stands on one leg with toes behind the start line 3. The athlete is instructed to perform 3 maximal effort hops in a straight line 4. End distance is measured from where the posterior heel of the last hop lands 5. Triple hop distance has been shown to be a strong predictor of lower extremity strength and power (6)

1. A strip of athletic tape, 15cm wide and 6 meters long is placed perpendicular to a starting line 2. The athlete is instructed to make 3 consecutive hops on one leg, crossing over the center t line li each h time ti 3. The athlete is not allowed to pause to control him or herself between hops and the landing must be controlled on the last hop 4. Maximum distance is measured from the posterior heel of the last hop

LSI: Limb Symmetry Index

LSI: Limb Symmetry Index

• LSI for single, triple , crossover hop =

• 85% or greater is considered normal regardless of leg dominance, gender, or sport activity level

mean distance for the involved limb

X 100

mean distance for the uninvolved limb

• LSI for timed hop = mean time on the uninvolved limb mean time on the involved limb

X100

(17)

• Uninvolved leg can be used as a reference guide regardless of leg dominance (2,14,18) • Caution- if other injury or past surgery has occurred on the “uninvolved side” - use body weight comparisons (torque or total work to body weight ratios) on isokinetic testing to provide additional data

Page 3 of 11

STATISTICAL REVIEW of HOP TESTS

RELIABILITY

• Reliability • Sensitivity • Specificity

• “The extent to which measurements are consistent, dependable, and free from error” (3) • As measured by ICC -intraclass intraclass correlation coefficient (19) .75 good reliability >.90 excellent reliability for clinical measure

RELIABILITY of HOP TESTS

RELIABILITY of HOP TESTS

Hop tests have demonstrated high testretest reliability in normal, young adults • Single Hop for Distance= 0.92 to 0.96 • Timed Hop= 0.66 to 0.92 • Triple Hop for Distance= 0.95 to 0.97 • Cross-over Hop for Distance= 0.93-0.96

High reliability for ACL reconstructed patients has been demonstrated as well • Single Hop for Distance= 0.76-0.96 (11,20) • Timed Ti d H Hop= 0.82-0.96 0 82 0 96 (9,20) • Triple Hop for Distance= 0.88 (20) • Cross-over Hop for Distance= 0.84-0.94 (9,20)

Logerstedt et al. JOSPT 2010 (12)

SENSITIVITY and SPECIFICITY

SENSITIVITY and SPECIFICITY

• Sensitivity- percent probability that the tests would demonstrate abnormal lower limb symmetry values in ACL deficient patients (10)

Ideal test should be:

• Specificity- percent probability that the tests would demonstrate normal lower limb symmetry values in normal patients (10)

• •

sensitive enough to detect a deficiency if it is present (avoid too many false negatives), specific enough not to over-report deficiencies that are not there (avoid too many false positives)

We would like both to be as close to 100% as possible but there is generally some trade off.

Page 4 of 11

SENSITIVITY and SPECIFICITY

Improving Sensitivity of Hop Tests

In general, hop testing has shown:

Perform tests as a battery: •

• High specificity 94-97% (16) • But lower sensitivity 38-58% (16,22) i.e. too many ACL deficient knees could be a identified as normal

Functional Ability Test (10)

•

Noyes and colleagues (16) found sensitivity improved to 62% when the results of the single leg g hop p and timed hop p were combined Itoh and colleagues (10) found the percentage of ACL-deficient patients with functional asymmetry in at least one of four tests was 82% (figure 8 hop, up down hop, side hop, single hop)

Improving Sensitivity of Hop Tests Testing when the athlete is fatigued: Augustsson 2004 (1) • Examined a pre-exhaustion protocol to determine functional deficits • Improved sensitivity of single-leg hop test to 68% when the subject was fatigued, and 84% when a one rep max strength test was considered

LATE STAGE TESTING Once the athlete has demonstrated proficiency on the more basic functional tests, higher level testing can be considered. This will place a higher functional demand on the knee, and come closer to approximating the stresses of sport. This will lead to improved sensitivity rates as fewer deficient knees will be able to “sneak rates, sneak by by.”

• Single Limb Vertical Hop • Modified Agility T-test

Single Limb Vertical Hop • Chalk mark on the wall • Vertec

Pros: inexpensive, commonly available in clinics, li i ttraining i i rooms Cons: arm swing has been shown to influence vertical jump height performance and therefore makes it an invalid assessment of lower extremity function (23)

Page 5 of 11

Single Limb Vertical Hop

Single Limb Vertical Hop

• Contact Mat/Force Platform

Contact Mat/Force Platform – Examples

Pros: 1. Eliminates the need to use the arms 2. Allows the recording of other data in addition to jump height: ground reaction force, time on the ground, power, counter movement depth

1. 1 2. 3. 4.

Cons:

Accupower AMTI -Hickey 2009 (8) Swift Performance - Meylan 2009 (13) Jumpergometer – Fitronic -Petsching 1998 (18) MuscleLab, Ergotest Technology -Gustavsson 2006

5.

Just Jump System by Probotics- Burr 2007(4)

1. Cost/availability

(5)

Just Jump System by Probotics

Just Jump System by Probotics

• • •

Portable Moderate cost Excellent reliability

1 Jump Mode:

•

Multiple Test Options: -1 u j mp -4 u j mps - sprint timer

ICC= 997 Burr 2007 (4) ICC=.997

Just Jump System by Probotics

• Left display is hang time in seconds and Right g display p y is jjump p height in inches • Do not allow the athlete to land knees in the “tuck position”

Single Leg Vertical Hop in the Literature Gustavsson 2006 (5) showed a battery of 3 tests revealed a high level of sensitivity (when at least one was abnormal)

4 Jump Mode: • Display shows ground time, ELPF (explosive leg gp power factor: air time divided by ground time), average jump height in inches

one leg vertical hop, hop side hop, hop single leg hop • •

87% sensitivity in patients with an ACL injury 91% in patients who had undergone ACL reconstruction

Page 6 of 11

Single Leg Vertical Hop in the Literature

Modified Agility T-test

• Petshnig 1998 - “one-legged vertical jump test is capable of detecting functional limitations of the lower limb following knee ligament reconstruction up to 54 weeks post-operatively” (18)

• Involves cutting and side shuffling to only one side per trial, so right to left comparison is possible (8,15) • Hickey et al al. 2009 showed good reliability between testing days (ICC=0.825) (8) • Goal is 10 % symmetry (15)

Modified Agility T-test

Modified Agility T-test

Performance ( 8) 1. Run 15 feet 2. Cut laterally and shuffle 15 feet- no cross over allowed 3. Backpedal 15 feet 4. Run forward 15 feet 5. Cut laterally and shuffle 15 feet 6. Backpedal 15 feet across finish line

IMPROVING FUNCTIONAL TESTING

IMPROVING FUNCTIONAL TESTING

Summary:

•

• •

•

Ensure the athlete can demonstrate symmetry on the more basic tests before advancing to higher level testing Consider the demands of the sport and level of the athlete when choosing tests. Not all of the higher level tests may be appropriate- look at your risk to benefit ratio. Use a test battery or group of tests to maximize sensitivity and ensure that deficient athletes are not cleared for sport

•

• •

Ensure that the same tester performs the tests at different points in the rehab process Standardize warm-up and testing procedures, including hand placement to minimize compensation from the arms that could alter tests results Ensure that the athlete wears the same shoes for all test dates Consider testing when the athlete is fatigued for later stage testing

Page 7 of 11

TAKE HOME POINTS

Good Teamwork=Success

• There is no consensus on timeframe for return to sports s/p ACL reconstruction • Do not rely solely on one test, or looking at the calendar to make return to sport decisions • Keep abreast of new research on improving current testing protocols, and criteria based late stage rehab (15) • Allow a gradual transition- drills in practice, unopposed practice, opposed practice, scrimmage, game situation • Continue to re-assess over the long term

• Accept input from all members of the rehab team

MD

ATHLETE/ PARENT

PT

RETURN TO SPORT

SPORT COACH

ATC

STRENGTH COACH

REFERENCES

THANK YOU !

5. Gustavsson A, et al. A test battery for evaluating hop performance in patients who have undergone ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 2006; 14: 778-788. 6. Hamilton, RT, Schultz SJ, Schmitz RJ Perrin DH. Triple-hop distance as a valid predictor of lower limb strength and power. Journal of Athletic Training Training. 2008; 43(2): 144 144-151. 151 7. Hartigan EH, Axe MJ, Snyder-Mackler L. Time line for noncopers to pass return-to-sports criteria after anterior cruciate ligament reconstruction. J Orthop Sports Phys Ther. 2010; 40: 141-154. 8. Hickey KC, Quatman CE, Myer GD, Ford KR, Brosky JA, Hewitt TE. Methodological Report: Dynamic field tests used in an NFL combine setting to identify lower-extremity functional asymmetries. J Strength Cond Res. 2009; 23: 2500-2506.

1. Augustsson J, Thomee R, Karlsson J. Ability of a new hop test to determine functional deficits after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2004; 12: 350-356. 2. Barber SD, Noyes FR, Mangine RE et al: Quantitative assessment of functional limitations in normal and anterior cruciate ligamentligament deficient knees. Clinical Orthopedics 1990; 255: 204-214. 3. Bolgla LA, Keshula DR. The reliability of lower extremity functional performance tests. J Orthop Sports Phys Ther 1997; 26(3): 138 142. 4. Burr JF, Jamnik VK, Dogra S, Gledhill N. Evaluation of jump protocols to assess leg power and predict hockey playing potential. J Strength Cond Res. 2007; 21: 1139-1145.

9. Hopper DM, Goh SC, Wentwortgh LA, et al. Test-rest reliability of knee rating scales and functional hop tests one year following anterior cruciate ligament reconstruction. Physical Therapy in Sport. 2002; 3: 10-18. 10. Itoh H, Kurosaka M, Yoshiya S, Ichihashi N, Misuno K. Evaluation of functional deficits determined byy four different hop p tests in patients with anterior cruciate ligament deficiency. Knee Surg Sports Traumatol Arthrosc 1998; 6: 241-245. 11. Kramer JF, Nusca D, Fowler P, Webster-Bagaert S. Test-retest reliability of the one-leg hop test following ACL reconstruction. Clinical J Sport Med. 1992; 2: 240-243. 12. Logerstedt DS, Snyder-Mackler L, Ritter RC, Axe MJ, Godges JJ. Knee stability and movement coordination impairments: knee ligament sprain. J Orthop Sports Phys Ther. 2010; 40: A1-A37. . .

Page 8 of 11

13. Meylan C, McMaster T, Cronin J, Mohammed NI, Rogers C, Deklerk M. Single-leg lateral, horizontal, and vertical jump assessment: reliability, interrelationships, and ability to predict sprint and changeof-direction performance. J Strength Cond Res. 2009; 23: 11401147. 14. McElveen MT,, Rieman BL,, Davies GJ. Bilateral comparison p of propulsion mechanics during single-leg vertical jumping. J Strength Cond Res. 2010; 24: 375-381. 15. Myer GD, Paterno MV, Ford KR, Quatman CE, Hewett TE. Rehabilitation after anterior cruciate ligament reconstruction: criteria based progression through the return to sport phase. J Orthop Sports Phys Ther 2006: 36: 385-402. 16. Noyes FR, Barber SD, Mangine RE. Abnormal lower limb symmetry determined by functional tests after anterior cruciate ligament rupture. Am J Sports Med 1991; 19: 513-518.

17. Noyes FR, Barber SD, Mooar LA. A rationale for assessing sports activity levels and limitations in knee disorders. Clinical Orthop 1989; 246: 238-249. 18.Petchnig R, Barron R, Albrecht M. The relationship between isokinetic quadriceps strength test and hop tests for distance and one-legged gg vertical jjump p test following g anterior cruciate ligament g reconstruction. J Orthop Sports Phys Ther 1998; 28(1):23-31. 19.Portney L, Watkins MP, Foundations of Clinical Research: Applications to Practice. Norwalk, CT: Appleton and Lange, 1993. 20.Reid A, Birmingham TB, Stratford PW, Alcock GK, Griffin JR. Hop testing provides a reliable and valid outcome measure during rehabilitation after anterior cruciate ligament reconstruction. Physical Therapy. 2007; 87(3): 337-349. .

21.Reiman M, Manske R. Functional Testing in Human Performance. Human Kinetics. 2009, Champaign IL. 22.Tegner Y, Lysholm J, Lysholm M, Gillquist J. A performance test to monitor rehabilitation and evaluate anterior cruciate ligament injuries. Am J Sports Med. 1986; 14: 156-159. 23 Young WB, 23.Young WB MacDonald C, C Flowers MA. MA Validity of double double- and single-leg vertical jumps as tests of leg extensor muscle function. J Strength Cond Res. 2001; 15: 6-11. A special thanks to Hunter Yard for assistance with photos and videos

Page 9 of 11

Notes:

Page 10 of 11

Notes: