The Road to Return-to-Play: Progression and Testing

2019 Northeast Indiana Sports Symposium

The Road to Return-to-Play:

Progression and Testing

Michael Turcovsky, DPT, SCS, ATC, COMT

Jon Dettmer, DPT, SCS, COMT


• Michael Turcovsky

• Fort Wayne, Indiana (Elmhurst HS)

• Ball State University

• Bachelor’s of Science in Athletic Training

• Indiana University

• Doctorate of Physical Therapy

• Maitland-Trained Manual Therapist

Objectives

1. Define the stages of the Return to Sport continuum.

2. Describe the purpose and need for return to play criteria for both

upper extremity injuries and lower extremity injuries.

3. Define criteria required to consider initiating return to play testing.

4. Compare various return to play tests, their research, and proper

execution of upper and lower extremity return to sport testing.

5. Explain rehabilitation techniques to help improve outcome measures

and improve probability of passing return to play testing.

6. Explain gaps in the current body of knowledge regarding RTS

testing, and consider ways to fill those gaps

2016 First World Congress Consensus Statement

Upper Extremity Return to Sport

• Return to Sport Continuum

• Return to Participation

• Return to Sport

• Return to Performance


• Return to Participation• “The athlete may be participating in rehabilitation, training

(modified or unrestricted), or in sport, but at a level lower than his

or her RTS goal. The athlete is physically active, but not yet ‘ready’

(medically, physically and/or psychologically) to RTS. It is possible

to train to perform, but this does not automatically mean RTS.”


• Return to Sport• “The athlete has returned to his or her defined sport, but is not

performing at his or her desired performance level. Some athletes

may be satisfied with reaching this stage, and this can represent

successful RTS for that individual.”


• Return to Performance• “This extends the RTS element. The athlete has gradually returned

to his or her defined sport and is performing at or above his or her

preinjury level. For some athletes this stage may be characterized

by personal best performance or expected personal growth as it

relates to performance.”



• The need:

• Average prevalence of shoulder problems in overhead athletes

in ~30%

• Substantial injury which leads to moderate or severe reduction in

sports participation or performance (or time loss) is 10-15%.

• Limited evidence which provides guidance for RTS timelines for

shoulder injuries

• RTS depends on a combination of clinical decision making,

appropriate progression of rehabilitation, and the sport.


• The need, cont’d:

• Return to sport rates for overhead athletes are widely variable

• Anywhere from 20-94% of athletes were able to return to their

preinjury level of sport following SLAP repair

• Average of 73% of overhead athletes able to return to sport

following SLAP repair

• Average of 63% of baseball players were able to return to sport

following SLAP repair


• Criteria required for consideration for RTS Testing:

• Pain is controlled and a limited factor (including psychosocial factors)

• Appropriate A/PROM for sport-specific activities

• Appropriate mechanics during AROM

• Good strength in all planes of motion


• Pain and stiffness is controlled and a limited factor

• Irritability? Quality of pain?

• Kinesiophobia?

• Utilization of modalities, medication, manual therapy, FDN, BFR3

• Have a resource if psychological counseling is needed


• Patient Self Report Outcomes2

• American Shoulder and Elbow Surgeons (ASES)

• UCLA Shoulder Rating Scale

• Shoulder Rating Questionnaire (L’Insalata Questionnaire)

• Western Ontario Shoulder Instability Index

• Kerlan-Jobe Orthopedic Clinic Questionnaire

• Costant-Murley Shoulder Score

• Single Assessment Numeric Evaluation Score

• ….AND TONS MORE!



• Overhead throwing

• Bilateral full arc of IR to ER in the shoulder vs standard measurements

• GIRD (20 deg, posterior shoulder tightness, humeral retroversion)4

• Instability/Hypermobility/Hypomobility?

• Utilization of PNF stretching, manual therapy, FDN



• Scapular dyskinesis may be a contributing factor in

conjunction with inadequate ROM.

• “Scapular asymmetry is normal in overhead athletes.

However, scapular upward rotation and scapular stabilizer

muscle strength are hypothesized to be key factors in optimal

sports performance”

• Scapulohumeral rhythm – scapula and humerus move in 1:2

ratio through full180 degree arc



• Manual muscle testing

• Multiple angles

• Isokinetric testing (Gold standard?)5

• Hand held dynamometry testing

• OKC strength

• CKC strength

• Plyometrics


• Criteria required for consideration for RTS Testing:

• Pain is controlled and a limited factor (including psychosocial factors)




...off to Return to Sport Testing!


• Seated Shot Put Throw

• Seated Medicine Ball Throw

• Functional Throwing Performance Index

• Closed Kinetic Chain Stability Test

• Push-Up Test

• Y Balance Testing

• Throwing Progression

• Qualitative Motion Analysis


• Seated Shot Put Throw6

• Subject is seated against wall or in chair

• 6 lb ball is thrown for distance (4 warm ups, then average of 3 trials)

• Goal is within 90% distance thrown between UEs

• MDC for dominant arm is 17 inches

• MDC for non dominant arm is 18 inches

• Reliable and cheap test of unilateral UE strength

• Consider BMI and sex to define norms7


• Seated Medicine Ball Throw

• Subject is seated in a chair or on ground against the wall and

throws a medicine ball for distance like a “chest pass”

• 3.3 lb or 6.6 lb ball

• 3 trial throws after a warm up (90 seconds between each throw)

• Highly reliable and valid when compared to Explosive Push Up

Test on force plates8 and isokinetic testing5

• No practical established normative data

• Inexpensive, safe, and reproducible


• Functional Throwing Performance Index10

• Subject stands 15’ from wall and throws a ball into a 1’x1’ box

which is 4’ from floor

• 4 sub-max to max controlled gradient warm up throws (25-100%)

• 3 sets of controlled sub-max throws for 30 seconds

• (Accurate number of throws/Total number of throws)x100=%

• Accuracy is impaired in the presence of pain

• Monitor for improvement with accuracy


• Closed Kinetic Chain Stability Test

• Subject assumes push-up position

• Men in push-up position, women can use modified push-up position on knees

• Average of 3 trials, each 15 seconds in duration

• 45 second rest time

• Subject alternates UEs to tap lines 3 feet apart

• Moderate to excellent reliability in adolescents11

• Norms

• Male collegiate baseball players – 30 touches on average12


• Push-Up Test Variations13

• Timed push-up test

• Record number of properly executed push-ups in certain time allotment

• US Army uses 2 minute Push Up Test

• US Navy uses 1 minute Push Up Test

• Push-Up Test to fatigue

• Modified Push-Up Test

• Elevated on chair or performed on knees


• Y Balance Testing – Upper Quarter14

• CKC Stability Reach Test

• One practice trial

• Max distance of 3 trials in each of the 3 directions

• Can be normalized when compared relative to UE limb length

• Scores should be within 90% when compared side to side• fmff

No difference

side to side in

uninjured

players14


• Throwing Progression

• The final phase for overhead throwing athlete

• Guided graded phases to full return to throwing

• Different guidelines for different sports

• Maintain strengthening exercises while completing

• Fatigue is major contributor to injury

• Imperative that mechanics are maintained throughout

• Warm up, Throw, Cool down, and Rest from throwing between days

• Highly variable in duration – listen to your body


• Qualitative Motion Analysis

• Do not have to be an expert on the movement

• Look for biomechanical faults or poor timing

• Use clinical reasoning to correlate


• Future of upper extremity RTS testing

• Ash Test – good preliminary testing in rugby players15


• Future of upper extremity RTS testing, cont’d

• Ball Drop Test16

• Dynamic Stabilization

• 30 second duration

• Count # of catches and releases

• 2# med ball

• Compare sides

• Goal of 90% or better

• Expectation of 110%


• Rehabilitation implications

• OKC and when to initiate CKC strengthening

• Static to dynamic activities

• Eccentric exercises completed slowly for absolute strength

(minimizing concentric phase)17

• Exercises completed fast for plyometric and endurance


• Future of upper extremity RTS testing, cont’d

• Dire need for new and exciting UE testing which is reliable, cost-

effective, practical, reproducible in clinic AND field settings, sport-

specific, all encompassing, safe, and relative to injury prevention.

Questions?


References1. Ardern CL, et al. 2016 Consensus statement on return to sport from the First World Congress in Sports Physical Therapy,

Bern Br J Sports Med 2016;0:1–12.

2. LA Michener, et al. Position Statement National Athletic Trainers’ Association Position Statement: Evaluation,

Management, and Outcomes of and Return-to-Play Criteria for Overhead Athletes With Superior Labral Anterior-Posterior

Injuries. Journal of Athletic Training 2018;53(3):

3. V Korakakis et al. Blood flow restriction-induced analgesia in patients with anterior knee pain. JSAMS Jan 2017 1:08 (232)

4. MB Rose, T Noonan. Glenohumeral internal rotation deficit in throwing athletes: current perspectives. Open Access

Journal of Sports Medicine 2018:9 69–78

5. D Borms et al. Upper Quadrant Field Tests and Isokinetic Upper Limb Strength in Overhead Athletes. J Athl Train. 2016

Oct; 51(10): 789–796.

6. Negrete RJ, Hanney WJ, Kolber MD, Davies GJ, Ansley MK, McBride AB, Overstreet AL. Reliability, Minimal detectable

change, and normative values for testes of upper extremity function and power. J Strength Cond Res. 2010;24: 3318-

3325.

7. TL Chmielewski et al. Normalization Considerations for Using the Unilateral Seated Shot Put Test in Rehabilitation. J

Orthop Sports Phys Ther 2014;44(7):518-524.

8. Harris C, Wattles AP, DeBeliso M, Sevene-Adams, PG, Berning JM, Adams KJ. The Seated Medicine Ball Throw as a

Test of Upper Body Power in Older Adults. Journal of Strength and Conditition Research. 2011; 25(8): 2344-2348.


References9. Ardern CL, et al. 2016 Consensus statement on return to sport from the First World Congress in Sports Physical Therapy,

Bern Br J Sports Med 2016;0:1–12.

10.C.A. Wassinger et al. The role of experimentally-induced subacromial pain on shoulder strength and throwing accuracy.

Manual Therapy. 2012 Oct;17(5):411-5

11.Valeria et al. Test-Retest reliability of the closed kinetic chain upper extremiry stability test in adolescents. Int J Sports

Phys Ther. 2017 Feb; 12(1): 125–132.

12.Roush et al. Reference Values for the Closed Kinetic Chain Upper Extremity Stability Test (CKCUEST) for Collegiate

Baseball Players. N Am J Sports Phys Ther. 2007 Aug 2(3):159-163.

13.https://www.topendsports.com/testing/tests/push-up.htm

14.Butler RJ, et al. Bilateral Differences in the Upper Quarter Function of High School Aged Baseball and Softball Players.

The International Journal of Sports Physical Therapy. 2014; 9(4): 518-524.

15.Ashworth B, Cohen DD. Force awakens: a new hope for athletic shoulder strength testing Br J Sports Med 2018

16.Wilk K. Return to Play Criteria in the Overhead Thrower. Presentation. Combined Sections Meeting. New Orleans Feb

2018

17.Cools AM, Johansson FR, Borms D, Maenhout A. Prevention of shoulder injuries in overhead athletes: a science-based

approach. Braz J Phys Ther. 2015 Sept-Oct; 19(5):331-339.


• Photo References• https://img.buzzfeed.com/buzzfeed-static/static/2016-03/10/16/enhanced/webdr05/enhanced-23042-1457644753-

1.jpg?downsize=700%3A%2A&output-quality=auto&output-format=auto

• https://whatsnew2day.com/out-of-shape-gymgoer-gets-revenge-on-bodybuilder-by-hitting-a-sticker-on-his-back

• https://www.physio-pedia.com/images/9/96/Scapulohumeral_rhythm-1-.png

• https://cdn11.bigcommerce.com/s-13ttxa/images/stencil/original/products/13651/13655/microfet-2-handheld-

dynamometer-hoggan-health__83577.1414615937.jpg?c=2

• https://www.menshealth.com/fitness/a19537746/pushup-mistakes-0/

• Google image search

https://whatsnew2day.com/out-of-shape-gymgoer-gets-revenge-on-bodybuilder-by-hitting-a-sticker-on-his-back

https://whatsnew2day.com/out-of-shape-gymgoer-gets-revenge-on-bodybuilder-by-hitting-a-sticker-on-his-back

https://www.physio-pedia.com/images/9/96/Scapulohumeral_rhythm-1-.png

https://www.menshealth.com/fitness/a19537746/pushup-mistakes-0/


BREAK

Return to Sport Testing of the

Lower Extremity

Speaker Background

• Jon Dettmer, PT, DPT, SCS, COMT

• Norwell HS – local

• Concentration in sports and avoiding math classes

• Huntington University

• Bachelor’s of Science – Exercise and movement Science

• Washington University in St. Louis

• Doctorate in Physical Therapy

• Work experience: Less than most of you (I’m working on

it)

Why RTS testing?

• Enormous pressure is place on the medical

professional when making decisions about

whether an athlete is safe to return to play after

an injury

• Objective data with some evidence behind it can

be extremely helpful

• Re-injury rates are too high• Good RTS tests should bring this down

What makes a good test?

• Reliability

• The degree to which the test is free of error

• Responsiveness

• Minimal clinically important difference (MCID) or

Minimal importance change (MIC) must be

GREATER than the minimal detectable change

(MDC)


• Validity: Does what your testing even

matter?

• Criterion Validity: How well does it

correlate with the gold standard?• Predictive validity: How well can your test predict a

certain outcome—like an injury

• Construct validity: How well does your test correlate

with a construct like “strength” or “function”


• Easy to reproduce

• Simple

• Requires little equipment (not everyone has

force plates and 3D motion analysis ya nerds)

Who/when do we test?

• Who?

• Any athlete who has been pulled from sports

participation due to injury

• Special care is taken with post-op patients

returning to sport

Who/when do we test?

• When?

• When they’re ready

• Qualitative vs. Chronological is preferred

within reason

• *This only works if we know what we’re doing..

Which we need to prove

Criteria for RTS testing:

• Appropriate tissue healing

• Surgeon guides this process

• Pain is eliminated

• (May consider low pain in non-surgical)

• They have a good chance at passing

• Don’t set them up for failure…

RTS Test Contents• Strength

• Dynomometer

• Isokintetic

• Power

• Jump

• CKC

• Physical performance Tests (PPT)• Power

• Agility

• Speed

RTS Test Contents

• Static Ligament Tests• KT-1000/2000

• Lachman / Pivot shift

• Sport Specific

• Sprint

• Cut

• Run Route

• Spike

Strength Tests

• Limb Symmetry Index (LSI)

• Often 90% symmetry of quadriceps and

hamstrings (We include hip Abduction)

• Estimated Pre-Injury Capacity (EPIC) N=70

→ 40 achieved 90% LSI SLH and Quad → 16/40 achieved EPIC

90% symmetry

• 11 retears→ 8/11 passed LSI → 2 of those 8 passed EPIC

• Wellsandt 2011

Power

• Single leg Vertical Jump

• CKC Power

• Leg Press

• 5 rep at BW

Physical Performance Tests

• There are a bunch..

• Most frequently studied are for knee and

include:

1. Single leg hop for distance (SLHD)

2. 6 meter timed hop

3. Crossover hop for distance

4. Triple Hop

Single leg hop for distance

• Instructions: Begin on a single leg and

hop for distance

Triple Hop

• Same as previous but 3 jumps

• Carry momentum

• Stick landing carrying more speed

Crossover Hop

• 3 hops on single leg back and forth over

15 cm line

• Commonly the scariest for everyone

involved

6-meter timed hop

• Unlimited number of jumps needed to

travel 6 meters

• Scoring based on speed

Symmetry vs. Distance Standards

Davies 2017

Hegadus 2015 Systematic Review

• SLHD: most studied, only know it is discriminative of

males with ACL tears and is responsive to rehab

• All other PPTs: Limited, conflicting, or unknown evidence

regarding measurement properties

• Ability of PPTs to predict injury is unknown

• Caution is urged when making clinical decisions based

off of these tests

So are PPTs worthless?

• Maybe they need to be part of a cluster of

tests?• When these 4 hop tests were paired with isokinetic

hamstring and quad testing 90% LSI resulted in 5.6%

re-injury vs. 38.2% in level 1 sports (Grindem 2016)

• When paired with strength LSI (isokinetic), those who

passed hop testing (t-test instead of 6m) were 4x less

likely to retear (Kyritsis 2015)

So are PPTs Worthless?• Maybe the quality of jump test completion

matters? (Spoiler: it does) • Transverse hip, frontal knee, sagital knee moments, and

postural stability deficits were very sensitive in prediction

of second ACL injury (Paterno 2010)

• Symmetry of distance does not equal normal mechanics,

opposite is more likely (Wren 2018)

Compensations

• Lack of knee extension strength is

correlated with errors in landing

mechanics (Schmitt 2015, Wren 2018,

Paterno 2010)

• Clinical implications

Common Compensations

• Excessive hip strategy

• Hip flexion vs. knee flexion

• Lateral lean for weak abductors

• Contralateral hip flexion for momentum

• Decreased knee flexion

• Heavy reliance on calf, hamstring

Common Issues

• Lack of eccentric control

• Giving way

• Landing rigid

• Hip adduction/Internal rotation

• Hip abductors

• Poor pronation control

• Dumb shoes

Less Studied PPTs

• Y-balance

• LEFT

• Tuck jump – anecdotal

• Skater jump – anecdotal

• Overspeed cutting – anecdotal

Y-Balance

• Y-Balance or Star Excursion Balance Test

(Plisky 2006)

• Anterior reach distance difference > 4cm =

2.5x greater LE injury rate

• Girls with composite reach distance <94% of

their height = 6.5x greater risk of injury

Lower Extremity Functional Test

(LEFT ) Davies 2002

LEFT Test cont.• https://www.youtube.com/watch?v=fxEvp6VGfB8 …its

actually quite simple

• Established Norms

• Injury predictor?

• DIII athletes: Female >118sec 6x more likely to sustain thigh or

knee injury (Brumitt 2013)

• DIII athletes: Male < 100sec were more likely to sustain time loss

low back or leg injury, or foot/ankle injury (Brumitt 2013)

• Did not predict LQ injury (Brumitt 2018)

• May be useful as a fatigue protocol?

https://www.youtube.com/watch?v=fxEvp6VGfB8

How we move forward:

• 1) Implement the subpar tests we already have

• Systematic review by Barber-Weinstein in 2011

indicated that only 13% of studies indicated objective

criteria for unrestricted return to sport

• 2) Develop better tests that more accurately

determine who is safe to return

• Consider: Sex, age, sport differences

• How tough is too tough?

How we move forward:

• 3) Figure out what changes at 9 months (the

most current recommendation on when to return

to play after ACLR (Kaplan 2019))

• 4) Develop more test for ankle and hip

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Documents

The Road to Return-to-Play: Progression and Testing