A Quantitative and Qualitative Functional Testing Algorithm for clinical decision making to return athletes back to Sports following a Knee Injury

Transcription

1 Thank You Thanks to OHSU for the kind invitation to present this information It is indeed an honor and privilege to be invited to participate and share information. A Quantitative and Qualitative Functional Testing Algorithm for clinical decision making to return athletes back to Sports following a Knee Injury Clinical Decision-Making: Specific Parameters to return an athlete back to sports following a knee injury What amazes me, is that many of us need to make this decision on a regular basis, however, there are: 1) very few guidelines published 2) few objective tests documented to support the clinical decision making process 3) limited evidence to support this process Return to Play-Summary So what are most clinicians doing for criteria for RTP? RTP-after ACL-R Barber-Westin, SD, Noyes, FR. Factors used to determine return to unrestricted sports activities after ACL-R. Arthroscopy. 27: , 2011 (Systematic Review) RTP-after ACL-R ACL-R: May fail Rates of either reinjuring an ACL-R knee or sustaining an ACL rupture to contralateral knee range from 3-49% RTP-after ACL-R Systematic review: 264 studies: 105 (40%) failed to provide any criteria for RTP 84 (32%) amount of time post-op was only criteria 40 (15%) time and subjective criteria 35 (13%) objective criteria Muscle strength, stability, neuromuscular control, function RTP-after ACL-R Systematic review: 264 studies: 35 (13%) objective criteria 9 %-muscle strength criteria 80-90% of Q & H 6 % - effusion/rom 4% - single leg hop 1 study stability 1 study validated questionnaires Clinical Decision- Making So, what else can we do??? 1

2 Clearance to Return to Sports One method is to have baseline preparticipation information, and have the athlete return back to normal for all the parameters So how do we do it??? One way is to perform a task analysis of the specific sport Try to establish a performance metric Check epidemiology information for MOI Then determine if there are appropriate tests with good psychometric properties to test and evaluate the specific tasks for the sport Return To Sports Need to perform testing in nonfatigued state as well as fatigued state Clearance to Return to Sports If a physician, physical therapist or athletic trainer allows an athlete to return to sports, they may be legally held responsible if the athlete encounters a reinjury. Creighton, DW, et.al. Return-to-play in sport: a decision-based model. Clin J Sports Med. 20(5): , 2010 Return to Play Literature Review CLINICAL ARTICLE Functional progression of a patient through a rehabilitation program Davies, GJ, et.al. Orthop Phys Ther Clinics North America, 9: , 2000 HOT TOPIC 2017 Literature State of the Art-RTS Key take home messages regarding definitions for return to sport (RTS) The minimum information required to define RTS is: 1) the sport and the level of participation the athlete aims to return to. 2) RTS is a continuum comprising three elements: return to participation, return to sport return to performance. 3) In certain situations the RTS decision may be reversed to a removal from sport decision. 4) The RTS decision should be shared among all stakeholders (except in the case of health risk to the athlete). Arden, CL, et.al Consensus statement on return to Sport from the First World Congress in Sports Physical Therapy. BJSM. May, 2016 The evidence emerging from this study suggests that the majority of patients who are 6 months after ACLR require additional rehabilitation to pass RTS criteria. The RTS battery described in this study may serve as a framework for future studies to implement multivariate models in order to optimize the decision-making regarding RTS after ACLR with the aim to reduce incidence of second ACL injuries. Gokeler, A, et.al. Development of a test battery to enhance safe return to Sports after ACL reconstruction. Knee Surg Sports Traumatol Arthrosc. July,

3 Patients who return to level I sports had a 4.32 times higher injury rate than those who did not Re-injury rate was reduced by 51% for each month RTS was delayed until 9 months after surgery After 9 months, no further risk reduction was observed Grindem, H, et.al. Simple decision rules can reduce reinjury risk by 84% after ACL-R: the Delaware-Oslo ACL cohort study. BJSM. 1-16, Those who failed RTS criteria: 38.2% re-injury rate Those who passed RTS criteria: 5.6% More symmetrical quadriceps strength prior to RTS significantly reduced the knee re-injury rate Grindem, H, et.al. Simple decision rules can reduce reinjury risk by 84% after ACL-R: the Delaware-Oslo ACL cohort study. BJSM. 1-16, Functional Testing Algorithm for clinical decision making For Return to Sports following a Knee Injury Functional Testing Algorithm Knee Sport Specific Testing Lower Extremity Functional Tests Functional Hop Tests Functional Jump Tests OKC Isokinetic testing CKC Isokinetic Testing Sensorimotor System Testing: Balance/Proprioceptive Testing KT 1000/2000 Basic Measurements Competitive Recreational General Orthopaedic Patients FTA Specific Guidelines LEFT M-1:30; F-2:00 minutes HOP - < 10%Ht.; < 10% bilat. Comp.; Norms/various hops JUMP - < 15%/Ht.; Norms OKC Isokinetics - < 25% bilateral comparison/other criteria CKC Isokinetics - < 30% bilateral comparison Kinesthetic/Balance Testing Bilat comp KT < 3 mm bilateral comparison Basic Measurements - < 10% bilateral comparison Functional Testing Algorithm- Sports Specific Tests Lower Extremity Functional Tests Functional Hop Tests Functional Jump Tests OKC Isokinetic Tests (MMT,HHD) CKC Isokinetic Tests (Wall slides/scales) Balance Tests (Stork Stand Test) KT 1000 Tests ( Good hands ) Basic Measurements Functional Testing Algorithm Knee Progression to the next higher level of testing difficulty is predicated upon passing the prior test in the series Each successive test and its associated training regimen places increasing stress on the patient while at the same time decreasing clinical control Functional Testing Algorithm Knee Sport Specific Testing Lower Extremity Functional Tests Functional Hop Tests Functional Jump Tests OKC Isokinetic testing CKC Isokinetic Testing Sensorimotor System Testing: Balance/Proprioceptive Testing KT 1000/2000 Basic Measurements Competitive Recreational General Orthopaedic Patients P & S M,

4 Basic Measurements Time/soft tissue healing VAS (0-10 scale) Anthropometric measurements AROM, PROM Special Tests Qualitative & Quantitative Movement Assessment Knee Rating scales: IKDC, etc. Treatments Example Hypomobility Basic Measurements MD Clearance & Approval Time/soft tissue healing VAS (0-10 scale) Anthropometric measurements AROM, PROM Special Tests Qualitative & Quantitative Movement Assessment Knee Rating scales: IKDC, etc. Functional Testing Algorithm TIME: Dark Quad Tendon Pre- Op ACL Quad Tendon Graft Healing We still have not answered this Question? Soft tissue healing from the injury or Biologics and mother nature and the: from a post-surgical condition Time Zero 1 month PO 6 months PO Neoangiogenesis Maturation Ligamentization Dark Quad Tendon Pre- Op ACL Quad Tendon Graft Healing Knee Rehabilitation: Phase I Bio-Psycho-Social Rehabilitation Limitations of Rehabilitation Biopsychosocial Approach 9 Months 1. Fear 2. Pain catastrophizing 3. Kinesiophobia 4. PROs Time Zero 1 month PO 6 months PO 1 year PO 4

5 Functional Testing Algorithm Knee Sport Specific Testing Lower Extremity Functional Tests Functional Hop Tests Functional Jump Tests OKC Isokinetic testing CKC Isokinetic Testing Sensorimotor System Testing: Balance/Proprioceptive Testing KT 1000/2000 Basic Measurements Competitive Recreational General Orthopaedic Patients Biodex Balance Stabilometer Biodex Balance Stabilometer It has been my clinical observation (performance motion assessment) that after a LE injury, individuals do not bear weight equally during double-leg exercises, especially on the injured leg Clinical Biomechanics 17: , 2002 More flexion - ACL-R More external weight - WB on ACL-R side 3 months: unweighted ACL-R side 6 months: unweighted ACL-R side WB on ACL-R side 12 months: normalized WB - ACL-R side Majority of patients felt like they were performing equal WB on both legs Balance/Proprioceptive Testing When prescribing squat exercises, it should be recognized that initially, patients with ACLR tend to unload the affected knee. More symmetrical loading patterns may be achieved by inducing bilateral fatigue. When fatigued, loading symmetry was similar between this patient group and controls. This is relevant information for those who implement rehabilitation training programs. Webster KE 1, et.al. Symmetry of squatting and the effect of fatigue following ACL-R. Knee Surg Sports Traumatol Arthrosc., 2014 Treatment Interventions So what do we do if the patient cannot pass this part of the Functional Testing Algorithm (FTA) Balance/ Proprioceptive/ Kinesthetic Training Lab 5

6 Balance Exercise Progression for Lower Extremity Injuries (Without any equipment) 2-legged standing 2-legged toe walking 2-legged heel walking 2-legged standing - tandem 2-legged standing perturbations 2-legged standing -tandem - perturbations Balance Exercise Progression for Lower Extremity Injuries (Without any equipment) 2-legged standing - eyes closed 2-legged standing - tandem - eyes closed 2-legged standing -perturbations - eyes closed 2-legged standing -tandem - perturbations - eyes closed 2-legged standing -tandem - perturbations - eyes closed Balance Exercise Progression for Lower Extremity Injuries (Without any equipment) 1-legged standing 1-legged standing - eyes closed 1-legged standing -perturbations 1-legged standing -perturbations - eyes closed 1-legged hop and stick 1-legged hop and stick perturbations on landing 1-legged hop and stick perturbations in air Continuous overlap of Rehab interventions Continuous overlap of Rehab interventions Continuous overlap of Rehab interventions Functional Testing Algorithm Knee Sport Specific Testing Lower Extremity Functional Tests Functional Hop Tests Functional Jump Tests OKC Isokinetic testing CKC Isokinetic Testing Sensorimotor System Testing: Balance/Proprioceptive Testing KT 1000/2000 Basic Measurements Competitive Recreational General Orthopaedic Patients Treatment Interventions So what do we do if the patient cannot pass this part of the Functional Testing Algorithm (FTA) The Forgotten Exercise Wall Slides Treatment Interventions Can progress to single leg wall slides and single leg squats 6

7 Bilateral Goblet Squats The Other Forgotten Exercise Knee Flexion- Nordic/Russian/Etc. Hams Knee Flexion-Hams-Functional Specificity (Davies Adaptation) Lengthened position Faster Velocities (Manual force) TLS-Forward Lunges TLS-Monster Walks FWB- Advanced Squat Exercise Progression Lab 7

8 Knee Rehabilitation Squat Sequence Knee Rehabilitation Knee Rehabilitation Knee Rehabilitation Knee Rehabilitation Squats Bodyweight Tuck Squats - BW Toe Touch Squat Exercise 8

9 Squats BW- Overhead Face the Wall Squats - BW Hindu Squat - BW Sissy Squats Squats Smith Rack Box Squats - BB Back Squats-BB Front Squats - BB Zercher Squats BB (BB held with elbows) 9

10 Trap Bar Squats Hack (heel) Squats - BB Overhead Squats - BB Belt Squats (weight is attached to hip belt) Goblet Squats Cossack Squats Knee Rehabilitation Side to Side Squats 10

11 Sumo Squats - BB Speed Skater Squats Lunge Split Squats Lunge Split Squat Skier Squats Inside Squats Sitting Rising Test Squat (SRT) Sitting Rising Test (SRT) Brazilian researchers have revealed a simple test that may help predict your longevity in the next six or so years: how well you can sit and rise from the floor. The test is different from the long-used "chair test," which physicians sometimes use to gauge an elderly person's lower body strength by how well they can stand up from sitting in a chair. So we know what the incorrect Kinematics feel like Test: Stand to cross Legged sit and Stand The new test, a sitting-rising test (SRT), involves a score of 0-5 for each movement (sitting and rising), with a combined 10 being the highest score, awarded for those who can sit and rise from the floor without any assistance from their hands or knees. 11

12 Getting Up and Down Easily from the Floor is a Marker of Longevity The SRT test, which can be used on middle-aged and elderly adults, is incredibly simple. Sit down on the floor, and then get up, using as little assistance from your hands, knees or other body parts as possible. For each body part that you use for support, you'll lose one point from the possible top score of 10. Sitting Rising Test Squat (SRT) Test: Stand to cross Legged sit and Stand Scoring 1. Stand in comfortable clothes in your bare feet, with clear space around you. 2. Without leaning on anything, lower yourself to a sitting position on the floor. 3. Now stand back up, trying not to use your hands, knees, forearms or sides of your legs. This simple sitting test could predict how long you will live If you have trouble performing this test, your life could be cut short. Scoring The two basic movements in the sitting-rising test lowering to the floor and standing back up 1) Each scored on a 1-to-5 scale 2) one point subtracted each time a hand or knee is used for support 3) 0.5 points subtracted for loss of balance 4) single 10-point scale. Scoring Those who scored 0-3 were 6.5 times more likely to die during the study than those who scored 8-10 Those who scored 3.5 to 5.5 were 3.8 times more likely to die Those who scored 6 to 7.5 were 1.8 times more likely to die For instance, if you put one hand on the floor for support to sit down, then use a knee and a hand to help you get up, you'll "lose" three points for a combined score of 7. What do the numbers mean? They correlated strongly with participants' risk of death during the study period of just over six years. For each unit increase in SRT score, participants gained a 21 percent improvement in survival. Spanish Squat Spanish Squat 12

13 Spanish Squat Goblet Squats-Unstable Surface Functional Testing Algorithm Knee Sport Specific Testing Lower Extremity Functional Tests Functional Hop Tests Functional Jump Tests OKC Isokinetic testing CKC Isokinetic Testing Sensorimotor System Testing: Balance/Proprioceptive Testing KT 1000/2000 Basic Measurements Competitive Recreational General Orthopaedic Patients Functional Tests LE FUNCTIONAL TESTS Single Leg Hop Tests Single leg forward hop Triple hop for distance Single leg timed hop Cross-over hop for distance Agility Tests Shuttle run Side step Carioca LEFT Performance Tests Single Leg Step Down Analysis Drop Jump Test Performance Tests OUCH! Drop Jump Test Analysis 13

14 Functional Testing Algorithm Sports Specific Tests Lower Extremity Functional Tests Functional Hop Tests Functional Jump Tests OKC Isokinetic Tests CKC Isokinetic Tests Kinesthetic/Balance Tests KT 1000 Tests Basic Measurements Davies Modified Jump/Hop Tests Both legs = Jump Test Uninvolved Leg = Hop Test Involved Leg = Hop Test Arms clasped behind back Minimal neck movements Minimal trunk movements Segmented Contributions to forces in vertical jump Components Knee 56% Ankle 22% Trunk 10% Arm Swing 10% Head Swing 2% Total Performance Average 78% Optimal Timing of Segmented 84% Performance Lathan, Komi, Europ J App Phys, 1978 Davies Modified Jump Test Both legs = Jump Test Uninvolved Leg = Hop Test Involved Leg = Hop Test Absolute (Quantitative Number) vs. Relative Data (Normalized to patient s height) 14

15 Functional Jump Test Relative Data Males Females R + L 100% / HT. 90% / HT. Treatment Interventions So what do we do if the patient cannot pass this part of the Functional Testing Algorithm (FTA) Double Leg Jump Lab Double Leg Side Jumps Double Leg Diagonal Jumps Double Leg Jump & Stick Double leg Plyo Box Jumps Functional Testing Algorithm Sports Specific Tests Lower Extremity Functional Tests Functional Hop Tests Functional Jump Tests OKC Isokinetic Tests CKC Isokinetic Tests Kinesthetic/Balance Tests KT 1000 Tests Basic Measurements Functional Hop Test Hop is on one leg 15

16 Psychological Readiness Test Quantitative (LSI) vs Qualitative values Performance Quantitative analysis is part of assessment But, also important to Perform qualitative assessment of the concentric power performance phase And most importantly Eccentric deceleration phase SINGLE LEGGED HOP TESTS IKDC ONE LEG HOP TEST STANDARDIZED INSTRUCTIONS MULTIPLE VARIATIONS BASED ON SPECIFIC FUNCTION OF ATHLETE / PATIENT BEING TESTED BILATERAL COMPARISON & NORMATIVE DATA ELLENBECKER & DAVIES, 2001 Treatment Interventions So what do we do if the patient cannot pass this part of the Functional Testing Algorithm (FTA) Single Leg Squat Progression Lab Bulgarian Squats 16

17 Bulgarian Squats Bulgarian Squats Airplane Squat Airplane Squat Single Leg Squat Shrimp Squats - BW (Flamingo Squat) Single Leg Spanish Squat Hawaiian Squats 17

18 Pistol Squats Pistol Squat - BW Pistol Squat with Weights Pistol Squat Pistol Squat Pistol Squat Pistol Squat 18

19 Pistol Squat Single Leg-RDLs Single Leg Lateral Bounds Single Leg Diagonal Bounds Single Leg Hop & Stick Single Leg Ant Box Jumps Single Leg Ant BOSU Jumps Functional Testing Algorithm Knee Sport Specific Testing Lower Extremity Functional Tests Functional Hop Tests Functional Jump Tests OKC Isokinetic testing CKC Isokinetic Testing Sensorimotor System Testing: Balance/Proprioceptive Testing KT 1000/2000 Basic Measurements Competitive Recreational General Orthopaedic Patients LE FUNCTIONAL TESTS Agility Tests Shuttle run Side step Carioca LEFT 19

20 FUNCTIONAL TESTS-Applicability OTHER LE FUNCTIONAL TESTS Stair hopple Single leg lateral hop Side jump test Vertical jump Stair running Figure-of-eight T-Test Pro-Agility LEFT LEFT (Lower Extremity Functional Test) Sprint-Front Sprint - Retro Run Side Shuffles Both Ways Cariocas Both Ways Figure 8 s Both Ways 45 Angle Cuts Both Ways 90% Angle Cuts Both Way Cross-Over Steps Both Ways Sprint - Front Sprint Retro Run Simulation of multiple sports performance characteristics in an in-clinic functional test Lower Extremity Functional Test 10% Puke Factor!!! WOW!!! That s a pretty complicated test; but is it really reliable? ICCs LOWER EXTREMITY FUNCTIONAL TEST (LEFT) 20

21 LEFT When the LEFT is normalized according to the criteria (< 10% from the normative data), then progression is to the next stage of the FTA Return to Play These results suggest a significant relationship between LE OKC testing (reciprocal leg press, single leg squat, knee extension) and CKC functional tests (single leg hop, vertical jump, speed/agility test). Negrete, R, et.al. The relationship between isokinetic OKC and CKC lower extremity strength and functional performance. J Sport Rehab Return to Play Lower Extremity Functional Test Brumitt, J, Heiderscheidt, BC, Manske, RM, Niemuth, PE, Rauh, MJ. Functional testing and predication of LE or low back injury among D-III collegiate athletes. Internat J Sports Phys Ther. 8(3):2013 BCH (~20 years ago) RMM (~20 years ago) PEN (~40 years ago) Return to Play Lower Extremity Functional Test Brumitt, J, Heiderscheidt, BC, Manske, RM, Niemuth, PE, Rauh, MJ. Functional testing and predication of LE or low back injury among D-III collegiate athletes. J Sport Rehab, 2016 Treatment Interventions So what do we do if the patient cannot pass this part of the Functional Testing Algorithm (FTA) Functional Exercises Progression Lab Jump Squats - BW 21

22 Alien Squat Jump Tuck Squats - BW Advanced Exercises Other examples of advanced exercises Nordic Hamstring Exercise Controlled Short Arcs Nordic Hamstring Exercise Rotational Short Arcs Nordic Hamstring Exercise with Assistance Faster Angular Velocity Lengthened Nordic Hamstring Exercise with Rebound Faster Angular Velocity Lengthened Nordic Hamstring Exercise with Rotational Rebound Fastest Angular Velocity Lengthened Nordic Hamstring Exercise with External Force Rebound Response 22

23 Fastest Angular Velocity Lengthened Nordic Hamstring Exercise with External Force and Rotational Rebound Response Spanish Squat with Support Short Arcs Spanish Squat Short Arcs Spanish Squat with Rotations Faster Angular Velocity Lengthened Spanish Squats with Rebound Fastest Angular Velocity Lengthened Spanish Squats with External Force Rebound Response Faster Angular Velocity Lengthened Single Leg Spanish Squats with Rebound Fastest Angular Velocity Lengthened Spanish Single Leg Squat with Rotational Rebound Response Fastest Angular Velocity Lengthened Spanish Single Leg Squat with External Force Rebound Response 23

24 Fastest Angular Velocity Lengthened Spanish Single Leg Squat with External Force and Rotational Rebound Response Plyo Box Jumps: Dynamic Valgus Preventive Intervention Depth Jumps: Dynamic Valgus Preventive Intervention Lunge Progression Lunge Jump Progression Tuck Jump Progression Lateral Jump Progression Single Leg Anterior Progression Single Leg Lateral Progression 24

25 Functional LE Neuromuscular Exercises Functional Exercises Progression Lab Jump & Stick Exercises Anterior Lateral Posterior Anterior Diagonal Posterior Diagonal Resisted Jump & Stick Exercises Anterior Lateral Posterior Anterior Diagonal Posterior Diagonal Jump & Bound Exercises Anterior Lateral Posterior Anterior Diagonal Posterior Diagonal Hop & Stick Exercises Anterior Lateral Posterior Anterior Diagonal Posterior Diagonal Resisted Hop & Stick Exercises Anterior Lateral Posterior Anterior Diagonal Posterior Diagonal Hop & Bound Exercises Anterior Lateral Posterior Anterior Diagonal Posterior Diagonal 25

26 Exercise Progression for Lower Extremity Injuries 1-legged hop and stick - reaction drills 1-legged hopping to opposite leg and stick - front, side, back 1-legged hopping to opposite leg and stick - perturbations - front, side back 1-legged triple hop 1-legged cross-over hop 2-Legged Twisting Exercises 90 Twisting rotations 180 Twisting rotations 270 Twisting rotations 360 Twisting rotations Functional Testing Algorithm Knee Sport Specific Testing Lower Extremity Functional Tests Functional Hop Tests Functional Jump Tests OKC Isokinetic testing CKC Isokinetic Testing Sensorimotor System Testing: Balance/Proprioceptive Testing KT 1000/2000 Basic Measurements Competitive Recreational General Orthopaedic Patients Specificity Testing This is individualized to the patient and his/her specific ADL s vocational or recreational activities Treatment Interventions So what do we do if the patient cannot pass this part of the Functional Testing Algorithm (FTA) Knee Rehabilitation-Phase V Return to Activity (recreational sports, competitive sports) Emphasis on POWER Emphasis on REACTIVE TRAINING Specificity Sport specific movements based on a task analysis Reactive specificity drills Functional Exercises Progression Lab Fast Feet Agility Drill CW/CCW 26

27 Fast Feet Ant BOSU Drills Fast Feet Lat BOSU Drills Ant Box Plyos Side shuffles Athletic Ready Position Diagonal Bounders Scissor Jumps Crossing Side steps, Cariocas, Grapevines, Braiding Functional-Athletic Ready Position Functional Testing Algorithm Outcome performance scales (PROs): Clinician-generated impairment measurements Patient-centered self-reported values Generic/Global Health-Related Quality of Life (HRQOL) scales Generic Joint/pathology scales Specific Joint/activity level scales 27

28 LE Specific Outcome Scales Smith, MV, et.al. Lower extremity-specific measures of disability and outcomes in orthopaedic surgery. J Bone Joint Surg-AM. 94: , 2012 Outcome Scales KOOS IKDC Lysholm Cincinnati Knee Rating Scale Tegner Activity Scale ACL Quality of Life Marx Activity Scale Return to Play- Psychological Factors Knee impairments and psychological variables were associated with self-report of function Kinesiophobia needs to be addressed in rehab Lentz, et.al. Factors associated with function after ACLR. Sports Health. 1:47-53, 2009 Functional Testing Algorithm After passing the tests, the athlete returns to: Sport specific training programs Practice simulations Practices Scrimmages Competition Knee Rehabilitation Summary And Conclusions Functional Testing Algorithm Knee Sport Specific Testing Lower Extremity Functional Tests Functional Hop Tests Functional Jump Tests OKC Isokinetic testing CKC Isokinetic Testing Sensorimotor System Testing: Balance/Proprioceptive Testing KT 1000/2000 Basic Measurements Competitive Recreational General Orthopaedic Patients Functional Testing Algorithm Sports Specific Tests Lower Extremity Functional Tests Functional Hop Tests Functional Jump Tests OKC Isokinetic Tests CKC Isokinetic Tests Kinesthetic/Balance Tests KT 1000 Tests Basic Measurements FTA Specific Guidelines LEFT M-1:30; F-2:00 minutes HOP - < 10%Ht.; < 10% bilat. Comp.; Norms/various hops JUMP - < 15%/Ht.; Norms OKC Isokinetics - < 25% bilateral comparison/other criteria CKC Isokinetics - < 30% bilateral comparison Kinesthetic/Balance Testing Bilat comp KT < 3 mm bilateral comparison Basic Measurements - < 10% bilateral comparison 28

29 Functional Testing Algorithm Knee Clinical decision making (CDM) (based on history, subjective exam, objective physical exam, imaging, etc.) states the athlete is ready to return to activity But if we also have all the functional tests to support the CDM, it strengthens the argument to return the athlete back to activity safely. Clinical Implications As Davies has said for the last 52+ years, it MUST be an INTEGRATED APPROACH for testing and rehabilitation!!! Thank You Thank You 29