Return to Play Criteria: Objective Testing. Thank You 9/9/2018

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Evelyn Lang
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1 Thank You Thanks to 2018 CHICAGO SPORTS MEDICINE SYMPOSIUM for the kind invitation to present and share this information It is indeed an honor and privilege to be invited to participate and thank you for your time. George J. Davies, DPT,ATC,CSCS Professor-Georgia Southern University-Armstrong Campus Sports Physical Therapist: Coastal Therapy, Savannah, GA., Gundersen Health System, LaCrosse, WI. Return to Play Criteria: Objective Testing 1

2 Don t forgot to check the PF joint also! A Quantitative and Qualitative Functional Testing Algorithm (FTA) for clinical decision making to return athletes back to Sports following a Knee Injury 2

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,

3 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 Clinical Decision-Making: Specific Parameters to return an athlete back to sports following a knee injury We have been dealing with ACLs for over 50+ years, and we still do not have a consensus for criteria for RTS Clinical Decision-Making: Specific Parameters to return an athlete back to sports following a knee injury How many of us really have specific criteria that would stand up to: 1. Critical peer review 2. High levels of evidence to support our clinical decision making 3. Medico-legal critical analysis????? 3

4 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 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 4

5 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 ACL Reconstructions Reliance on time as distinct from function to drive sport reintegration contributes to the gap between the athletes perceived versus actual sports readiness Clinical Decision- Making So, what else can we do??? Because whatever we are doing at the present time, we are NOT doing as well as many have advocated over the years! 5

6 Return to Play 69 articles 7556 participants 55% RTS competitive level RTS: LSI-hop test, younger age, male gender, playing elite sport, positive psychological response Arden, CL, et.al. 55% RT competitive sport following ACL-R surgery: an updated systematic review and meta-analysis including aspects of physical functioning and contextual factors. BJSM 48: , 2014 ACL-R Rehabilitation Reoperation and reinjury rates are high after ACL-R in the Division I athlete. Precollegiate ACL reconstruction is associated with a very high (37.1%) rate of repeat ACL re-injuries to the graft or opposite knee. The majority of athletes are able to return to play after successful reconstruction. Kamath, GV, et.al. ACL Injury, Return to Play, and Reinjury in the Elite Collegiate Athlete: Analysis of an NCAA Division I Cohort. Am J Sports Med. 42(7): , 2014 Evolution-Rehabilitation Therapeutic Exercise Programs s: Integrated approach using OKC, CKC and functional rehabilitation interventions 1980s: This began the era of OKC isokinetic testing and rehabilitation 1990s: The focus now became almost exclusively CKC exercises (because they were more functional) 2000s: This was the decade of functional rehabilitation which has continued to persist because of the supposed specificity of activities 2010s: I am hopeful that the trends will recycle and we will revert back to where we were 50 years ago with the integrated OKC, CKC, and functional rehabilitation approach. 6

last 20-25 years the emphasis has been on CKC exercises and functional rehabilitation and it has

7 Major Trends All aspects of the rehabilitation program must be FUNCTIONAL Why??? Knee Testing & Rehabilitation Therefore, one way to interpret these findings is that for the last years the emphasis has been on CKC exercises and functional rehabilitation and it has failed. However, many functional movement specialists do not want to acknowledge that what they are doing is not working. 7

8 Well Show me the evidence!!! Sorry to the functional fanatics, but functional exercises by themselves are not all that some clinicians try to promote Clinical Decision- Making So, what else can we do??? 8

9 Clearance to Return to Sports One method is to have baseline pre-participation information, and have the athlete return back to normal for all the parameters Clearance to Return to Sports Limitations with this method: what if there was already a predisposing problem that contributed to the injury but was not identified in screening 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 9

10 Modifiable Risk Factors for ACLs Paterno, M, et.al. AOSSM, 2014 (Multi-factorial) Hip IR (Transverse plan) Knee Dynamic valgus (Frontal plane) Knee muscle imbalance (Sagital plane) (Tri-Planar etiology) Balance (Biodex Balance Stabilometer (Single Leg Athletic Stance Test) Return To Sports Need to perform testing in nonfatigued state as well as fatigued state Fatigue Effects on Testing Although no patients displayed abnormal hop symmetry when nonfatigued 68% of the patients showed abnormal hop symmetry for the fatigued test condition. Functional testing should be performed both under non-fatigued and fatigued test conditions. Augustsson, J, et.al. Ability of a new hop test to determine functional deficits after ACL-R. Knee Surg Sports Traumatol Arthrosc. 12(5):350-6,

Fatigue Effects on Testing Augustsson, J, et.al. Single-leg hop testing following fatiguing exercise: reliability and biomechanical analysis. Scand J Med Sci Sports. 16(2):111-20, 2006 Ortiz, A, et.

Knee Surg Sports Traumatol Arthrosc. 18(11):1587-93, 2010 Frisch, A, et.al. Association between preseason functional tests and injuries in youth football: a prospective follow-up.

11 Fatigue Effects on Testing Augustsson, J, et.al. Single-leg hop testing following fatiguing exercise: reliability and biomechanical analysis. Scand J Med Sci Sports. 16(2):111-20, 2006 Ortiz, A, et.al. Fatigue effects on knee joint stability during two jump tasks in women. J Strength Cond Res. 24(4): , 2010 Orishimo, KF, et.al. Adaptations in single-leg hop biomechanics following ACL-R. Knee Surg Sports Traumatol Arthrosc. 18(11): , 2010 Frisch, A, et.al. Association between preseason functional tests and injuries in youth football: a prospective follow-up. Scand J Med Sci Sports. 21(6):e468-76, 2011 Clearance to Return to Sports Being medically cleared to return to sports Teamdoes not mean that Approach the patient/athlete is functionally ready to return to sports!!!?????questions????? What are the very specific criteria we use to discharge a patient from rehabilitation back to a high risk activity like competitive sports? Do we have absolute confidence in our decision making? 11

Clearance to Return to Sports It is no longer just about return to sport at the same pre-morbid level of participation and prevention of reinjury Clearance to Return to Sports If a physician,

12 Clearance to Return to Sports It is no longer just about return to sport at the same pre-morbid level of participation and prevention of reinjury 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 12

13 CLINICAL ARTICLE Functional progression of a patient through a rehabilitation program Davies, GJ, et.al. Orthop Phys Ther Clinics North America, 9:103118,

14 Exercise Not only can the FTA provide a criterion-based approach to RTS, But it can also serve as a guide for clinical decision making for treatment interventions 14

15 Exercise First article published in a professional journal! Functional Testing Algorithm for clinical decision making For Return to Sports following a Knee Injury 15

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

3) In certain situations the RTS decision may be reversed to a removal from sport decision.

16 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 Changing Dynamics of Knee Testing for Return To Sports 16

17 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/other criteria Kinesthetic/Balance Testing Bilat comp KT < 3 mm bilateral comparison Basic Measurements - < 10% bilateral comparison Functional Testing Algorithm Knee Stratify Patients Based On Activity Level Competitive Overhead Recreational General Orthopaedic Patients 17

Functional Testing Algorithm Knee 1980-2018 You can put Anything you Want here, Just be Systematic And complete For the Patients Activity level Competitive Overhead Recreational General Orthopaedic

18 Functional Testing Algorithm Knee You can put Anything you Want here, Just be Systematic And complete For the Patients Activity level Competitive Overhead Recreational General Orthopaedic Patients 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 Shoulder We can rehabilitate patients faster than ever because by testing them, we always know where the patient is in the rehab program and can focus the interventions specifically on the patient s particular condition and status Started as a student athletic trainer, Asst. ATC, Head ATC, PT, SCS, etc. 53 years ago.. 18

Functional Testing Algorithm Knee -1980-2018 Sport Specific Testing Lower Extremity Functional Tests Functional Hop Tests Functional Jump Tests

Competitive Recreational General Orthopaedic Patients Phys & Sports Med, 1978 Basic Measurements MD Clearance & Approval VAS (0-10 scale)

19 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 Phys & Sports Med, 1978 Basic Measurements MD Clearance & Approval VAS (0-10 scale) Anthropometric measurements AROM, PROM Special Tests Qualitative & Quantitative Movement Assessment Knee Rating scales: IKDC, etc. Time/soft tissue healing 19

Functional Testing Algorithm TIME: Soft tissue healing from the injury or from a post-surgical condition Dark Quad Tendon Pre- Op ACL Quad Tendon Graft

20 Functional Testing Algorithm TIME: Soft tissue healing from the injury or from a post-surgical condition Dark Quad Tendon Pre- Op ACL Quad Tendon Graft Healing Time Zero 1 month PO 6 months PO We still have not answered this Question? Biologics and mother nature and the: Neoangiogenesis Maturation Ligamentization 20

Dark Quad Tendon Pre- Op ACL Quad Tendon Graft Healing 9 Months Time

Bio-Psycho-Social Rehabilitation Functional Testing Algorithm Outcome

Patient-centered self-reported values Generic/Global Health-Related

21 Dark Quad Tendon Pre- Op ACL Quad Tendon Graft Healing 9 Months Time Zero 1 month PO 6 months PO 1 year PO Knee Rehabilitation: Bio-Psycho-Social Rehabilitation 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 21

22 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 ACL-RSI (return to Sport after Injury) 22

Return to Play- Psychosocial Measures Elevated pain-related fear of movement/re-injury,

to pre-injury sports participation because of fear of reinjury/lack of confidence Lentz,

Comparison of physical impairment, functional, and Psychosocial measures based on fear of

23 Return to Play- Psychosocial Measures Elevated pain-related fear of movement/re-injury, quadriceps weakness, and reduced IKDC scores distinguish patients who are unable to return to pre-injury sports participation because of fear of reinjury/lack of confidence Lentz, TA, et.al. Comparison of physical impairment, functional, and Psychosocial measures based on fear of re-injury/lack of confidence and RTS status after ACL-R. AJSM. 43(2): , 2015 Kinesiophobia Qualitative Movement Analysis of the Entire Kinematic Chain in all Planes of Motion 23

Functional Testing Algorithm Knee - 2018 Sport Specific Testing Lower Extremity

Isokinetic Testing Sensorimotor System Testing: Balance/Proprioceptive Testing KT

24 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 KT 1000 Tests 24

Functional Testing Algorithm Knee - 2018 Sport Specific Testing Lower Extremity Functional Tests Functional

Balance/Proprioceptive Testing KT 1000/2000 Basic Measurements Competitive Recreational General Orthopaedic

25 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 Need for Proprioceptive Testing & Training Knee-Proprioceptive Active Joint Replication Testing - NWB 25

26 Knee-Proprioceptive Active Joint Replication Testing - FWB 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 26

Clinical Biomechanics 17:551-554, 2002 ACL-R More flexion - WB on ACL-R side More external weight - WB on ACL-R side 3 months: unweighted ACL-R side 6 months: unweighted ACL-R side 12 months:

27 Clinical Biomechanics 17: , 2002 ACL-R More flexion - WB on ACL-R side More external weight - WB on ACL-R side 3 months: unweighted ACL-R side 6 months: unweighted 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.,

28 Continuous overlap of Rehab interventions Continuous overlap of Rehab interventions Continuous overlap of Rehab interventions 28

29 Open Kinetic Chain vs. Closed Kinetic Chain Integrated Testing & Rehabilitation 2001 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 29

30 CKC PWB Tandem Isokinetic Testing CKC PWB Reciprocal Isokinetic Testing Instrumented Shuttle with AMTI Force Plate Boering, T, Davies, GJ,

31 Shuttle kinetic and kinematic analysis for CKC L.E. exercises Merritt, AC, et.al. ACSM, Boston, MA, 2016 Boering, T, et.al. APTA-CSM, New Orleans, 2018 Methods AMTI Force Plate: Peak Eccentric Peak Concentric Methods Motion Capture: Ascension Flock of Birds Motion Capture 31

32 Double Leg Plyometric Exercise Double Leg Plyometric Exercise Methods 32

Unique CKC PRE Leg Press Test Functional Testing Algorithm Knee - 2018 Sport Specific Testing Lower Extremity Functional Tests Functional Hop Tests Functional Jump Tests OKC Isokinetic testing CKC

33 Unique CKC PRE Leg Press Test 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 Isokinetic Testing PubMed Search: 5/1/18 Isokinetics: 5,460 references Isokinetics and Knee: 2,629 (48%) 33

? Questions? So why do we have to test each link in the kinematic chain?

for weak areas. Check to see if there are deficits distant from the actual injury site.

weaknesses You know you are specifically targeting a muscle group when you test it There

34 ? Questions? So why do we have to test each link in the kinematic chain? Advantages of OKC/Isolated Exercises Check for proximal and distal muscles compensating for weak areas. Check to see if there are deficits distant from the actual injury site. Prevent compensations from other muscle groups in the kinetic chain from masking weaknesses You know you are specifically targeting a muscle group when you test it There is a correlation between OKC testing and functional activities Well REFERENCE documented in the knee. Seminal Article 34

35 REFERENCE Lower-extremity compensations following ACL reconstruction Ernst, GP, et.al. PT, 80: , 2000 Vertical Jump - No difference in summated ext. moment OKC testing - Knee extensor moment significantly lower Hip and/or ankle extensors compensate for knee OKC Testing And/or Rehab OKC Testing And/or Rehab 35

36 Entire chapter on isokinetic testing and data analysis; i.e., TRTD, TAE Entire chapter on correlation of isokinetic torque curves with pathologies 1984 Isokinetic Data What information do we use from isokinetics? ALLOMETRIC SCALING Data Analysis (Davies, GJ, A Compendium of Isokinetics, 1984, 1992) Bilateral comparison (LSI) (+10%) Unilateral ratio of agonist/antagonist Torque to body weight (relative/normalized data) TAS, TBS Angle specific torques TAE/TRTD (POWER) Endurance analysis Normative data Functional correlation Sport specific correlation 36

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.

Return to Play Importance of Quads Early resolution of quadriceps strength deficits may be important for improving confidence and knee-related function.

37 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, Return to Play Importance of Quads Early resolution of quadriceps strength deficits may be important for improving confidence and knee-related function. Interestingly, QSBW with isokinetic testing, had a stronger association with function in patients who did not RTS at 6 months Lentz, TA, et.al. Comparison of physical impairment, functional, and Psychosocial measures based on fear of reinjury/lack of confidence and RTS status after ACL-R. AJSM. 43(2): , 2015 OKC Testing and Correlation to Functional Performance 37

38 Isokinetic Testing and Correlation to Functional Performance Wilk, KE, et al. The relationship between subjective knee scores, isokinetic (OKC) testing, and functional testing in the ACL-reconstructed knee. JOSPT 20(2): 60-73, 1994 Petsching, R, et.al. The relationship between isokinetic quadriceps strength test and hop tests for distance and one-legged vertical jump test following ACL-R. JOSPT. 28:23-31, 1998 Wells, et.al. Adolescent ACLR: a retrospective analysis of quadriceps strength recovery and return to full activity after surgery. J Pediatr Orthop. 29:486-9, 2009 Eitzen, I, et.al. Preoperative quadriceps strength is a significant predictor of knee function two years after ACL-R. Br. J Sports Med. 43: , 2009 Keays, SL, et.al. Factors involved in the development of OA after ACL surgery. AJSM. 38: , 2010 Eitzen, I, et.al. ACL-deficient potential copers and non-copers reveal different isokinetic quadriceps strength profiles in the early stage after injury. AJSM. 38: , 2010 Zebis, MK, et.al. Rapid hamstring/quadriceps force capacity in male and female elite soccer players. JSCR. 25: , 2011 Baltaci, G, et.al. The outcomes of ACLR and rehabilitated knees vs healthy knees: a functional comparison. Acta Orthop traumatol Turc. 46:186-95, 2012 Artero, EG, et.al. Criterion-related validity of field-based muscular fitness tests in youth. J Sports Med Phys Fitness. 52: , 2012 Kong, DH, et.al. Validation of functional performance tests after ACL-R. Knee Surg Relat Res. 24:40-5, 2012 Angelozzi, M, et.al. Rate of force development as an adjunctive outcome measure for return-to-sport decisions after ACL-R. JOSPT. 42: , 2012 Schmitt, LC, et.al. The impact of quadriceps femoris strength asymmetry on functional performance at return to sport following ACL-R. JOSPT. 42: , 2012 Discharge General Orthopaedic Patients Functional Testing Algorithm Knee Sport Specific Testing Lower Extremity Functional Tests Functional Hop Tests Functional Jump Tests CKC Isokinetic Testing OKC Isokinetic testing CKC Isokinetic Testing Sensorimotor System Testing: Balance/Proprioceptive Testing KT 1000/2000 Basic Measurements Competitive Recreational General Orthopaedic Patients 38

39 June, Open Kinetic Chain vs. Closed Kinetic Chain (Functional WB Position) Integrated Testing & Rehabilitation 39

40 CKC WB Isokinetic Testing 40

Discharge Recreational Functional Testing Algorithm Knee - 2018 Sport Specific Testing Lower

Isokinetic Testing Sensorimotor System Testing: Balance/Proprioceptive Testing KT 1000/2000

41 Discharge Recreational 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 Need for Functional Testing! 41

42 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 Performance Tests Drop Jump Test Analysis 42

Functional Testing Algorithm Knee - 2018 Sport Specific Testing Lower Extremity Functional Tests Functional Hop Tests Functional Jump Tests OKC Isokinetic testing CKC Isokinetic Testing Sensorimotor

43 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 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 43

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

44 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) (Allometric Scaling) 44

45 Functional Jump Test Relative Data Males Females R + L 100% / HT. 90% / HT. Modified Double Leg Jumps- Duuuh! 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 45

46 Functional Hop Test Hop is on one leg Psychological Readiness Test Quantitative (LSI) vs Qualitative values 46

important to Perform qualitative assessment of the concentric

47 Quantitative (LSI)(+10%) 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 47

SINGLE LEGGED HOP TESTS STANDARDIZED INSTRUCTIONS MULTIPLE VARIATIONS BASED ON SPECIFIC FUNCTION OF ATHLETE / PATIENT BEING TESTED IKDC ONE LEG HOP TEST BILATERAL COMPARISON & NORMATIVE DATA

48 SINGLE LEGGED HOP TESTS STANDARDIZED INSTRUCTIONS MULTIPLE VARIATIONS BASED ON SPECIFIC FUNCTION OF ATHLETE / PATIENT BEING TESTED IKDC ONE LEG HOP TEST BILATERAL COMPARISON & NORMATIVE DATA ELLENBECKER & DAVIES, 2001 Research Demonstrating Hop Tests Correlation to Function Meyer, GD, et.al. JOSPT. 41: , 2011 Arden, CL, et.al. AJSM. 39: , 2011 Grinden, H, et.al. AJSM. 39: , 2011 Logerstedt, D, et.al. AJSM. 40: , Meyer, G, et.al. AJSM. 40: ,

Single Leg Squat Leg Abduction Functional Testing Algorithm Knee - 2018 Sport Specific Testing Lower Extremity Functional Tests Functional Hop Tests Functional Jump Tests OKC Isokinetic testing CKC

49 Single Leg Squat Leg Abduction 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 49

50 Lower Extremity Functional Test: Simulation of multiple sports performance characteristics in an in-clinic functional test 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 LEFT-Rationale Quantitative and Qualitative assessment Acceleration Deceleration Multiple LE stresses Multiple change of directions Progressively harder movements patterns Non-fatigued state Fatigued state 50

51 Lower Extremity Functional Test 10% Puke Factor!!! 51

52 WOW!!! That s a pretty complicated test; but is it really reliable? ICCs LOWER EXTREMITY FUNCTIONAL TEST (LEFT) 52

53 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 correlation 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 Exercise IJSPT 12(3)216,

54 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 Specificity Testing Return to Activity (recreational sports, competitive sports) Emphasis on POWER Emphasis on REACTIVE TRAINING 54

55 Need for Functional Training! FUNCTIONAL TESTS-Applicability Need for Functional Training 55

Sport Specific Tests When the sport specific tests are normalized according to the criteria (< 10 % compared to sport specific data), then progression is to return the patient back to practice and

56 Sport Specific Tests When the sport specific tests are normalized according to the criteria (< 10 % compared to sport specific data), then progression is to return the patient back to practice and then competitive sports Functional Testing Algorithm After passing the tests, the athlete returns to: Sport specific training programs Practice simulations Practices Scrimmages Competition Just Completed the FTA 56

Return to Play FPTs as a measure of function: 71%-used a battery of tests 29% used a single test None of studies have construct or predictive validity for return to sport

57 Return to Play FPTs as a measure of function: 71%-used a battery of tests 29% used a single test None of studies have construct or predictive validity for return to sport Narducci, E, et.al. The clinical utility of functional performance tests within one-year post-acl-r: a systematic review. IJSPT.6: , 2011 Summary And Conclusions Always learning!!! 57

58 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 58

59 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 53+ years, it MUST be an INTEGRATED APPROACH for testing and rehabilitation!!! Always Believe! 59

60 Thank You to the 2018 Chicago Sports Medicine Symposium Thank You 60

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

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