current success rates · 3/6/2017 1 return to sports participation and discharge testing anthony...
TRANSCRIPT
3/6/2017
1
Return to Sports Participation
and Discharge Testing
Anthony Inzillo, PT, DPT, SCS
Andrews Institute Rehabilitation Symposium:
Lower Extremity
3/4/2017
Objectives
1. Identify the components of functional testing for various lower extremity injuries
2. Provide evidence supporting the use of specific tests and minimum passing criteria
3. Understand the criteria that athletes must meet to return to participation in their sport
4. Discuss appropriate care during the transition between discharge and full return to competition
Background
• Up to 250,000 ACL injuries per year in the US.
• Annual health care cost exceeding $2 billion.
• Most occur from participation in level 1 (jumping,
pivoting, and hard cutting) sports.
• ~70% non-contact vs ~ 30% contact.
• Higher relative risk in females than in males.
• Typically a 6-12 month recovery, resulting in countless
hours of missed sport participation.
Current Success Rates
• 69 studies; 7,556 patients (mean f/u: 40 months, range: 12-156 months)
– 65% returned to their pre-injury level of sport (83% for elite athletes)
– 55% of athletes returned to competitive sports
– 81% returned to some form of sport
Included studies from 1982-2013
Included studies from 2005-2015
• 19 studies; 72,054 patients (mean f/u: 51 months, average age: 24.4)
– Total secondary ACL re-injury rate was 15% (7% ipsilateral vs 8% contralateral)
– ACL re-injury rate for patients younger than 25 was 21%
– ACL re-injury rate for athletes returning to sport was 20%
– ACL re-injury rate for athletes younger than 25 returning to sport was 23%
– Young ACLR athletes have a 30-40x greater risk than uninjured adolescents
Why do we need
Functional Testing?
• There is a high likelihood of re-injury after return to sport
• Previous injury is #1 risk factor
• There is an increased incidence of re-injury when
asymmetries exist
• In most cases, patients are trying to return to high
demand/high risk sports
• Objective, quantifiable tests allow clinicians to make
return to sport decisions more confidently
Published July 2016
• 106 patients who underwent ACL reconstruction (6 lost to withdrawal/follow up)
• Passing RTS criteria: ≥ 90% on Knee Outcome Survey-ADL scale, global rating scale of perceived
function, isokinetic quadriceps strength, and single leg hop tests
• Failing RTS criteria: Failure to achieve 90% on any of the above
• Re-injuries included acute ACL injuries, meniscus tears, cartilage injuries, MCL injury, patellar sublux
• For every 1% improvement in quadriceps strength symmetry, there was a 3% decrease in injury risk
• 4/4 patients returning to sports less than 5 months after surgery suffered a knee re-injury within 2
months of return
3/6/2017
2
When is Discharge Testing
Appropriate?
• Dependent upon each patient, diagnosis, and their progress
– Healing timeframes
– Normal clinical exam
• No pain
• No swelling/effusion
• Full ROM
• Normal MMT
• Normal joint stability
– Normal movement patterns without significant dysfunction
– Good tolerance of rehab progression including plyometrics, agility drills,
advanced strengthening
Psychological Readiness
• # 1 reason that injured athletes do not return to sport is fear of
re-injury!
• Important to use subjective questionnaires throughout the
rehab process
• Examples:
– LEFS
– KOS (ADL/Sport)
– IKDC
– Modified Cincinnati Knee Rating System
Other Factors to Consider
• Age
• Injury history
• Concomitant injuries
• Time from injury/surgery
• Time of season/career
• Type of sport (level)
• Contributing factors
Risk Factors for Injury
Non-Modifiable
• Previous injury
• Female gender
• Age
• Small notch width
• Ligamentous laxity
• Genetics?
• Small ACL size?
• Increased posterior tibial slope?
Modifiable
• High BMI
• Hormonal factors?
• Playing surface/equipment?
• Fatigue
• Asymmetries in ROM, strength,
and movement patterns
• Poor neuromuscular control
• Poor jump/landing mechanics
Functional Tests Should Be:
• Valid
• Reliable
• Supported by evidence/predictive of injury
• Cost and time efficient
– Easy to administer
– Minimal equipment required
• Performed in a cluster
• Modifiable
Components of Functional Testing
• Lower Quarter Y-Balance Test
(Neuromuscular control)
• Functional Movement Screen(Movement patterns)
• Isokinetic Testing(Strength)
• Single leg hop testing(Power/agility)
3/6/2017
3
Lower Quarter Y-Balance Test
• Test of dynamic single leg balance/stability and
predictive of injury risk
• Based on research using the Star Excursion Balance Test
described by Gary Gray in 1995
• Modified test consists of 3 reach directions
• Record furthest distance reached in 3 trials for each direction
Y-Balance Test cont.
• 2.5x greater injury risk for >4cm difference for anterior reach in
high school basketball players
• Increased risk for composite score < 94% for high school
basketball players, < 89.6 % for college football players
(3.5x greater injury risk)
• Composite score: ((A+PM+PL) / 3x limb length) x 100
• Passing criteria• Within 4 cm of uninvolved leg for anterior direction
• Within 6 cm of uninvolved leg for posterior directions
• Composite score above cut-off point for age, sport, gender
Functional Movement
Screen (FMS®)
• Consists of 7 body weight tests that require a combination of
mobility, stability, and motor control
• Systematic way to observe movement patterns and identify
dysfunctions and asymmetries
• Each test is given a score of 0-3
– 3- The movement pattern is complete and consistent with the test
definition
– 2- The movement pattern demonstrates compensation or faulty form
– 1- The movement pattern is incomplete and was not performed
consistent with the test definition
– 0- Pain is present
Functional Movement Screen
Min Passing Score: 15/21
FMS® Continued
• Scores of 14/21 or lower indicate elevated risk of serious
injury
– 11.67x more likely than those scoring > 14
– 15% pre-test probability to 51% post-test probability
– ≤14 : 70% injured
– ≥15 : 16.7% injured
Isokinetic Testing
• Tests maximum torque produced by quadriceps and
hamstrings at 180 deg/sec and 300 deg/sec
• Greater than 15% quadriceps strength deficit negatively
affects function and performance Schmitt et al
• Goals: Quadriceps and hamstrings strength at least 90% of
uninvolved leg
Normal hamstring/quadriceps ratio
Normal knee ext torque-body weight ratio
3/6/2017
4
Single Leg Hop Testing
• Average of 2 successful trials measured in centimeters
• Limb Symmetry Index = score on involved leg x 100
score on uninvolved leg
• Classically, 85-90% LSI has been the cut-off to be cleared for
return to sport but…
• Series of 3 tests– Single hop for distance
– Triple hop for distance
– Triple crossover hop for distance
• At 24 weeks post-op ACL reconstruction, the average overall Limb Symmetry Index was 88.5% and the average Lower Extremity Functional Scale score was 69.3.
• 69.3 LEFS= Moderate difficulty with:
• “Your usual hobbies, recreational or sporting activities”
• “Running on even ground”
• “Running on uneven ground”
• “Making sharp turns while running fast”
• “Hopping”
• Munro & Herrington 2011 found that the average LSI for the four hop tests was 100% (98 to 102%.) and that 100% of healthy subjects have at least an LSI of 90%
• “Given our current re-injury rate, I suggest hop testing LSI should at least be above 95% and recommend it to be above 97%-100%” - Phil Plisky
Not good enough…
Hop Testing cont.
– Nearly 100% for bilateral tests, low 90’s for single leg tests
– Limb symmetry index for healthy controls is around 100%
Myer et al. J Orthop Sports Phys Ther. 2011 Jun; 41(6): 377–387
Goal: 95-100%
LSIPlisky, et al.
Jumping/Landing Quality
• Tuck jump and drop jump assessments
– Tuck jump (10 sec)
• Thighs parallel to floor and equal
• No valgus on take-off or landing
• Good foot placement/timing
• Quiet landings and equal weight bearing
– Drop jump (12.5” box)
• Good form with bilateral and unilateral tests
• Good jumping/landing technique with no valgus
collapse
– Both can be assessed using slow motion video
Review of Passing Criteria
• Normal clinical exam– No pain, swelling, or symptoms with ADL’s or rehab activities
– Normal ROM, MMT, joint mobility, flexibility, stability
• Y-Balance Test– Within 4 cm for anterior reach and within 6 cm for posterior reaches
– Composite score above cut-off point for sport, gender, and activity level
• Functional Movement Screen– Total score above 14/21 and no 0’s (pain), 1’s, or asymmetries
• Isokinetic Testing– 90% quadriceps and hamstrings strength index (85% for practice/field)
• Hop Testing– 95% Limb Symmetry Index for single hop, triple hop, and crossover hop
• Passing score on subjective questionnaire (psychological readiness)
• Normal mechanics with tuck jump and drop jump assessments
• Good tolerance of position specific activity progression
3/6/2017
5
What does it mean?
• Athlete is allowed to begin position specific drills and
activities with their team and coaches
• Still need to work with position coaches, athletic trainers,
and strength/performance coaches until everyone feels
confident that the athlete is ready to return to
competition
• No specific time frame on this stage
• Communication between all members of the sports
medicine team is crucial!
Goals of this stage
• Proficiency with reactive agility drills specific to their
sport/position
• Improve strength, endurance, and athleticism to
withstand demands of the sport
• Prepare athlete to compete at a level at or above their
competition
– Restore strength/speed/agility/reaction time to normal
limits so that these athletes aren’t put at a further
disadvantage when put against an opponent
• Remember the highest risk factor for suffering an injury!
• Be sure that the athlete can protect themselves
How can we test this?
• Performance tests within normal ranges for the athlete’s sport, level, and position
• NFL Combine tests
– 40- yard dash
– Vertical jump
– Broad jump
– 20 yard shuttle
– 60 yard shuttle
– 3 cone drill
– Bench press
Basketball
• NBA Combine tests
– 185 lb bench press
– Standing vertical jump
– Max vertical jump
– ¾ court sprint
– Lane agility drill
– Shuttle run
– Shooting tests
Baseball
• Spring training performance tests
– Standing vertical jump
– Standing broad jump
– 10 yard explosion
– 300 yard shuttle
– 30 second cone hop
– Agility test (5-10-5 shuttle)
http://www.stack.com/a/testing-for-baseball-with-the-mets
Soccer
• MLS Combine tests
– Speed test (30-meter dash)
– Agility Test (5-10-5 shuttle)
– Power Test (vertical jump)
• Yo-yo tests
– Aerobic capacity, running economy, change of direction
– Not currently included in combine
3/6/2017
6
• Continued work with performance coaches and position coaches
during this stage is paramount
• Must understand the unique demands of each sport and position
Conclusion
• An athlete’s ability to return to play will be based on successful
completion of an appropriate rehabilitation program, meeting
minimum passing criteria on return to participation testing, and their
progression through sport/position specific activities.
• Rehabilitation should be individualized and tailored for the unique
needs/demands of each patient while using best available evidence.
• Return to sport decisions should be made as a team and based on a
cluster of subjective/objective findings and consideration of
situational factors.
• As a field, we need to be more consistent in establishing and
enforcing objective return to play criteria.
THANK
YOU!
Resources• Ardern CL, Taylor NF, Feller JA, Webster KE. Fifty-five per cent return to competitive sport following anterior cruciate
ligament reconstruction surgery: an updated systematic review and meta-analysis including aspects of physical functioning
and contextual factors. Br J Sports Med. 2014 Nov;48(21):1543-52. doi: 10.1136/bjsports-2013-093398. Review. PubMed
PMID: 25157180.
• Grindem H, Snyder-Mackler L, Moksnes H, Engebretsen L, Risberg MA. Simple decision rules can reduce reinjury risk by 84%
after ACL reconstruction: the Delaware-Oslo ACL cohort study. Br J Sports Med. 2016 Jul;50(13):804-8. doi: 10.1136/bjsports-
2016-096031. PubMed PMID: 27162233; PubMed Central PMCID: PMC4912389.
• Kiesel K, Plisky PJ, Voight M. Can serious injury in professional football be predicted by a preseason Functional Movement
Screen? N Am J Sports Phys Ther. 2007; 2(3):76-81.
• Lai CC, Ardern CL, Feller JA, Webster KE. Eighty-three per cent of elite athletes return to preinjury sport after anterior cruciate
ligament reconstruction: a systematic review with meta-analysis of return to sport rates, graft rupture rates and performance
outcomes. Br J Sports Med. 2017 Feb 21. pii: bjsports-2016-096836. doi: 10.1136/bjsports-2016-096836. [Epub ahead of
print] Review. PubMed PMID: 28223305
• Longerstedt D, Lynch A, Risberg MA, Snyder-Mackler L. Single Leg Hop Tests As Predictors of Self Reported Knee Function
After Anterior Cruciate Ligament Reconstruction. AM J Sports Med. 2011 Nov;39(11):2347-54. doi:
10.1177/0363546511417085. Epub 2011 Aug 9.
• Myer G, Ford K, Hewett T. Tuck Jump Assessment for Reducing Anterior Cruciate Ligament Injury Risk. Athl Ther Today. 2008
Sep 1; 13(5): 39–44.
• Myer G, Schmitt L, Brent J, Ford K, Foss K, Scherer B, Heidt R, Divine J, Hewett T. Utilization of Modified NFL Combine Testing
to Identify Functional Deficits in Athletes Following ACL Reconstruction. J Orthop Sports Phys Ther. 2011 Jun; 41(6): 377–387.
• 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
• Ostenberg A, Roos E, Ekdahl C, Roos H. Isokinetic knee extensor strength and functional performance in healthy female
Soccer players.Scand. J Med Sci Sports 1998 Oct; 8(5 Pt 1): 257-64
• Plisky PJ, Rauh MJ, Kaminski TW, Underwood, FB. Star Excursion Balance Test predicts lower extremity injury in high school
basketball players. J Orthop Sports Phys Ther. 2006;36(12):911-919.
• http://philplisky.com/90-limb-symmetry-index-is-not-enough/#.WLpJnG_yvIU
• 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
• Schmitt L, Paterno M, Hewett T. The Impact of Quadriceps Femoris Strength Asymmetry on Functional Performance at Return
to Sport Following Anterior Cruciate Ligament Reconstruction. J Orthop Sports Phys Ther. 2012 Sep; 42(9): 750–759.
• Wiggins AJ, Grandhi RK, Schneider DK, Stanfield D, Webster KE, Myer GD. Risk of Secondary Injury in Younger Athletes After
Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis. Am J Sports Med. 2016 Jul;44(7):1861-
76. doi: 10.1177/0363546515621554. PubMed PMID: 26772611.