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Thank YouThank YouThanks to Thanks to RUSH 2016 CHICAGO RUSH 2016 CHICAGO SPORTS MEDICINE SYMPOSIUM SPORTS MEDICINE SYMPOSIUM for the for the kind invitation to present this kind invitation to present this information information

It is indeed an honor and privilege to be It is indeed an honor and privilege to be invited to participate and share invited to participate and share

information. information.

George J. Davies, DPT, MED, PT, SCS, ATC, LAT, CSCS, NASM-PES, NASM-CES, ACSM-CET, APTA-CCI, SMAC, (REMT), FAPTA

Professor of Physical Therapy, AASU, Savannah, GA. (2004- )

Professor Emeritus UW-LaCrosse, WI. (1975-2004)

Consultant, Clinician, Co-Director Clinical and Research Services–Sports PT Residency Program , GLSM, La Crosse, WI. (1995-present)

Sports PT, Coastal Therapy, Savannah, GA. (2004- present)

Past President Sports Physical Therapy Section – APTA (1992-1998)

JOSPT - Co-Founder & Co-Editor, 1979

JOSPT - GJD-JAG Excellence in Clinical Research Award, 2004

Fellow, APTA, 2005, Hall of Fame Award, SPTS-APTA, 2006

NATA, President’s Award, 2007, NATA, Most Distinguished Athletic Trainer, 2009

Sports Health Sports Health - Co-Founder & Co-Editor, 2009

AOSSMAOSSM – Hall of Fame Award, 2013

Disclosures:Disclosures:

Associate Editor, Associate Editor, Sports HealthSports HealthElsevierElsevier--Book RoyaltiesBook RoyaltiesPUBMED ElsevierElsevier--Book RoyaltiesBook RoyaltiesHuman KineticsHuman Kinetics--Book RoyaltiesBook RoyaltiesWilliams & WilkinsWilliams & Wilkins--Book RoyaltiesBook RoyaltiesNorth American SeminarsNorth American Seminars--DVDDVDRoyalties Royalties

No ConflictsNo Conflicts

INDEX MEDICUS2015

Disclosures:Disclosures:

Editor Editor ElsevierElsevier--Book RoyaltiesBook Royalties

ConflictsConflicts

20152015

Disclosures:Disclosures:The following companies have The following companies have provided research equipment provided research equipment support to Biodynamics & Human support to Biodynamics & Human Performance CenterPerformance Center--AASU:AASU:

ArthrometricsArthrometrics, Atlanta, GA. , Atlanta, GA. Biodex, Shirley, N.Y.Biodex, Shirley, N.Y.CDM Sport/Monitored Rehab CDM Sport/Monitored Rehab Systems Fort Worth TXSystems Fort Worth TXSystems, Fort Worth, TX.Systems, Fort Worth, TX.DS2 Rehab Systems, Missouri City,DS2 Rehab Systems, Missouri City,TXTXERMI, Atlanta, GA.ERMI, Atlanta, GA.ExerToolsExerTools, Petaluma, CA., Petaluma, CA.Innovative Sports Inc, Chicago, IL. Innovative Sports Inc, Chicago, IL. TheraBandTheraBand, , HygenicHygenic Corporation,Corporation,Akron, OH. Akron, OH.

No ConflictsNo Conflicts

Disclosures:Disclosures:

“Gladly accept “Gladly accept money from money from anyone for anyone for Institutional Institutional Research Research Support….”Support….”

No ConflictsNo Conflicts

A Quantitative and Qualitative Functional Functional Testing Algorithm Testing Algorithm for

clinical decision makingclinical decision makingclinical decision making clinical decision making when examining a when examining a

patient patient following a Knee Injury

A Quantitative and Qualitative Functional Functional Testing Algorithm Testing Algorithm for

clinical decision makingclinical decision makingclinical decision making clinical decision making to return athletes back to Sports following a Knee

Injury

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We have to examine We have to examine the patient and the the patient and the

knee in order toknee in order toknee in order to knee in order to establish discharge establish discharge

criteria for RTP!criteria for RTP!

Clinical DecisionClinical Decision--Making: Specific Parameters to Making: Specific Parameters to return an athlete back to sports following a knee return an athlete back to sports following a knee

injury injury

What amazes me, is that many of us What amazes me, is that many of us need to make this decision on a need to make this decision on a regular basis, however, there are:regular basis, however, there are:

1) 1) very few guidelines published2) 2) ffew objective tests documented to support the clinical decision making process

3) 3) limited evidence to support this process

Clinical DecisionClinical Decision--Making: Specific Parameters to Making: Specific Parameters to return an athlete back to sports following a knee return an athlete back to sports following a knee

injury injury

How many of us really have specific How many of us really have specific criteria that would stand up to:criteria that would stand up to:

1 Critical peer review1. Critical peer review2. High levels of evidence to support

our clinical decision making 3. Medico-legal critical analysis

??????????

?????Questions??????????Questions?????What are the very specific very specific criteriacriteria we use to discharge a patient from rehabilitation back to a high risk activity like competitive sports ?competitive sports ?

Do we have absolute confidence in our decision making?decision making?

Clearance to Return to Clearance to Return to SportsSports

Clearance to Return to Clearance to Return to SportsSports

One method is to have baseline prebaseline pre--baseline prebaseline pre--participation participation information, and have the athlete return back to “normal” return back to “normal” for all the parameters for all the parameters

Clearance to Return to Clearance to Return to SportsSports

Clearance to Return to Clearance to Return to SportsSports

Being medically cleared medically cleared to return to sports does notdoes notreturn to sports does not does not meanmean that the patient/athlete is functionally readyfunctionally ready to return to sports!!!

“Clinical Decision Making”“Clinical Decision Making”“Clinical Decision Making”“Clinical Decision Making”

So what happens when ppan athlete returns to sports after being “cleared by us”, “cleared by us”, and then they get reinjured???

“Experience”“Experience”“Experience”“Experience”

Since I have been there and have made more

i k h imistakes than most in the audience, I can assure you that it is not a good feeling….

Clearance to Return to Clearance to Return to SportsSports

Clearance to Return to Clearance to Return to SportsSports

If a physician, physical therapist or athletic trainer allows an athlete to return to sports, they may be legally legally p , y y g yg yheld responsible held responsible if the athlete encounters a serious injury.

Creighton, DW, et.al. ReturnCreighton, DW, et.al. Return--toto--play in sport: a play in sport: a decisiondecision--based model. based model.

ClinClin J Sports Med. 20(5):379J Sports Med. 20(5):379--385, 385, 20102010

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Clinical DecisionClinical Decision--Making Making

Clinical DecisionClinical Decision--Making Making

So, what else can we do???

So how do we do it ???So how do we do it ???One way is to perform a One way is to perform a task analysis of task analysis of the specific sportthe specific sportTry to establish a Try to establish a performance metric performance metric

Check epidemiologCheck epidemiologCheck epidemiology Check epidemiology information for MOIinformation for MOIThen determine if there are Then determine if there are appropriate appropriate teststests with good with good psychometric properties psychometric properties to test and evaluate the specific “tasks” to test and evaluate the specific “tasks” for the sportfor the sport

Modifiable Risk Factors for ACLsModifiable Risk Factors for ACLsPaternoPaterno, M, et.al. AOSSM, 2014 , M, et.al. AOSSM, 2014 (Multi(Multi--factorial)factorial)

Hip IR (Transverse plan)Hip IR (Transverse plan)

Knee Dynamic Knee Dynamic valgusvalgus (Frontal plane)(Frontal plane)

Knee muscle imbalance (Knee muscle imbalance (SagitalSagital plane)plane)

(Tri(Tri--Planar etiology)Planar etiology)

Balance (Balance (BiodexBiodex Balance Balance StabilometerStabilometer(Single Leg Athletic Stance Test)(Single Leg Athletic Stance Test)

So how do we do it ???So how do we do it ???Task Analysis:Task Analysis:Energy system assessment: Energy system assessment: aerobic, aerobic, anaerobic (ATPanaerobic (ATP--PC, glycolytic systems)PC, glycolytic systems)Musculoskeletal Requirements:Musculoskeletal Requirements:Musculoskeletal Requirements: Musculoskeletal Requirements: flexibility, strength, power enduranceflexibility, strength, power enduranceNeuromotorNeuromotor skill assessmentskill assessmentTechnical assessmentTechnical assessmentInjury prevention techniques Injury prevention techniques based on based on epidemiology of injuries epidemiology of injuries

So how do we do it ???So how do we do it ???One area that seems to be One area that seems to be overlooked in a lot of the overlooked in a lot of the literature with RTP testing is:literature with RTP testing is:gg

Performing the testing in a Performing the testing in a

“fatigued state”“fatigued state”

Clinical DecisionClinical Decision--Making Making

Clinical DecisionClinical Decision--Making Making

So, what else can we do???Because whatever we are Because whatever we are doing at the present time, doing at the present time, we are NOT doing as well as we are NOT doing as well as many have advocated over many have advocated over the years!the years!

Return to PlayReturn to PlayReturn to PlayReturn to Play69 articles69 articles7556 participants7556 participants55% RTS 55% RTS –– competitive levelcompetitive levelRTS: LSIRTS: LSI--hop test, younger age, hop test, younger age, nalenale gender, playing elite sport, gender, playing elite sport, positive psychological response positive psychological response

Arden, CL, et.al. 55% RT competitive sport following ACLArden, CL, et.al. 55% RT competitive sport following ACL--R surgery: R surgery: an updated systematic review and metaan updated systematic review and meta--analysis including aspects of analysis including aspects of physical functioning and contextual factors. physical functioning and contextual factors. BJSM 48:1543BJSM 48:1543--1552, 20141552, 2014

Return to PlayReturn to PlayReturn to PlayReturn to Play

LiteratureLiterature Review

CLINICAL ARTICLECLINICAL ARTICLEFunctional Functional progression of a progression of a patient through a patient through a rehabilitation rehabilitation programprogram

Davies, GJ, et.al. Davies, GJ, et.al. OrthopOrthop Phys Phys TherTherClinics North Clinics North America, 9:103America, 9:103--118, 2000118, 2000

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JOSPT ‘12JOSPT ‘12

Return to PlayReturn to PlayReturn to PlayReturn to Play

Thematic issue for RTP following ACLRTP following ACL--RR

SimoneauSimoneau, GG, Wilk, KE. The challenge of return to , GG, Wilk, KE. The challenge of return to sports for patients postsports for patients post--ACLACL--R. (Editorial)R. (Editorial)JOSPT. 42(4)(April):300JOSPT. 42(4)(April):300--301, 2012301, 2012

Return to PlayReturn to Play--SummarySummaryReturn to PlayReturn to Play--SummarySummary

i l l fi l l fHaines, S, et.al. Development of a Haines, S, et.al. Development of a physical performance assessmentphysical performance assessmentchecklist for athletes who sustained checklist for athletes who sustained a lower extremity injury in preparationa lower extremity injury in preparationfor return to sport: a DELPHI study.for return to sport: a DELPHI study.IJSPT. 8(1):44IJSPT. 8(1):44--53, 201353, 2013

Return to PlayReturn to Play--SummarySummaryReturn to PlayReturn to Play--SummarySummaryWeak Evidence Weak Evidence Delphi Process – battery of tests battery of tests including physiological and psychological tests Physical and psychological testsPhysical and psychological testsAt 1 year after ACL, majority RTP at previous activity level and are not influenced by RTS criteriaRTS criteria--12 constructs12 constructs>50% LSI asymmetry >50% LSI asymmetry based on RTS, place athletes at higher risk for activity

Haines, S, et.al. IJSPT, 2013Haines, S, et.al. IJSPT, 2013

Return to PlayReturn to Play--SummarySummaryReturn to PlayReturn to Play--SummarySummary

So what are So what are most cliniciansmost cliniciansmost clinicians most clinicians

doing for criteria doing for criteria for RTP?for RTP?

RTPRTP--after ACLafter ACL--RRRTPRTP--after ACLafter ACL--RRBarberBarber--Westin, SD, Noyes, Westin, SD, Noyes, FR. FR. Factors used to Factors used to determine return to determine return to unrestricted sports unrestricted sports activities after ACLactivities after ACL--R.R.Arthroscopy. 27:1697Arthroscopy. 27:1697--1705, 1705, 20112011(Systematic Review)(Systematic Review)

RTPRTP--after ACLafter ACL--RRRTPRTP--after ACLafter ACL--RRACLACL--R:R:May failMay failRates of either reinjuringRates of either reinjuringRates of either reinjuring Rates of either reinjuring an ACLan ACL--R knee or R knee or sustaining an ACL sustaining an ACL rupture to contralateral rupture to contralateral knee range from knee range from 33--49%49%

RTPRTP--after ACLafter ACL--RRRTPRTP--after ACLafter ACL--RRSystematic review:Systematic review:264 studies:264 studies:105 (40%) 105 (40%) failed to provide any failed to provide any criteria for RTPcriteria for RTP84 (32%) 84 (32%) amount of time postamount of time post--op was op was only criteria only criteria 40 (15%) 40 (15%) time and subjective criteriatime and subjective criteria35 (13%) 35 (13%) objective criteriaobjective criteriaMuscle strength, stability, Muscle strength, stability, neuromuscular control, functionneuromuscular control, function

RTPRTP--after ACLafter ACL--RRRTPRTP--after ACLafter ACL--RRSystematic review:Systematic review:264 studies:264 studies:35 (13%) 35 (13%) objective criteriaobjective criteria9 %9 %--muscle strength criteria 80muscle strength criteria 80--90%90%9 %9 % muscle strength criteria 80muscle strength criteria 80 90% 90% of Q & Hof Q & H6 % 6 % -- effusion/ROMeffusion/ROM4% 4% -- single leg hopsingle leg hop1 study 1 study –– stabilitystability1 study 1 study –– validated questionnaires validated questionnaires

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AlgorithmAlgorithmAlgorithmAlgorithmA processprocess consisting of stepssteps, each step each step depending on the outcomeoutcome of theon the outcomeoutcome of the previous one. previous one.

Stedman’s Medical Dictionary, 2002

Functional Testing AlgorithmFunctional Testing Algorithm

ClinicianClinician--rated rated impairment measuresimpairment measures

Functional Testing Algorithm for

clinical decision clinical decision makingmakingmakingmaking

For Return to Sports following a Knee InjuryKnee Injury

Davies Functional Testing AlgorithmDavies Functional Testing Algorithm

(~36 years, (~36 years, [APTA[APTA--CSM, 1980]CSM, 1980] ))

Sports Specific Tests Sports Specific Tests Lower Extremity Functional Tests Lower Extremity Functional Tests Functional Hop Tests Functional Hop Tests Functional Jump Tests Functional Jump Tests OKC Isokinetic Tests OKC Isokinetic Tests CKC Isokinetic Tests CKC Isokinetic Tests Kinesthetic/Balance Tests Kinesthetic/Balance Tests KT 1000 Tests KT 1000 Tests Basic MeasurementsBasic Measurements

FTA Specific GuidelinesFTA Specific GuidelinesLEFT LEFT –– MM--1:30; F1:30; F--2:00 minutes2:00 minutesHOP HOP -- < 10%Ht.; < 10%Ht.; < 10% < 10% bilatbilat. Comp.; . Comp.; Norms/various hops Norms/various hops JUMP JUMP -- < 15%/Ht.; Norms< 15%/Ht.; NormsOKC Isokinetics OKC Isokinetics -- < 25% bilateral < 25% bilateral comparison/other criteriacomparison/other criteriaC C ki iC C ki i 30% bil l30% bil lCKC Isokinetics CKC Isokinetics -- < 30% bilateral < 30% bilateral comparisoncomparisonKinesthetic/Balance Testing Kinesthetic/Balance Testing –– BilatBilatcompcompKT 1000 KT 1000 -- < 3 mm bilateral comparison< 3 mm bilateral comparisonBasic Measurements Basic Measurements -- < 10% bilateral < 10% bilateral comparisoncomparison

Functional Testing AlgorithmFunctional Testing Algorithm--Sports Specific Tests Sports Specific Tests Lower Extremity Functional Tests Lower Extremity Functional Tests Functional Hop Tests Functional Hop Tests Functional Jump Tests Functional Jump Tests OKC Isokinetic TestsOKC Isokinetic Tests (MMT HHD)(MMT HHD)OKC Isokinetic Tests OKC Isokinetic Tests (MMT,HHD)(MMT,HHD)CKC Isokinetic Tests CKC Isokinetic Tests (Wall (Wall

slides/scales)slides/scales)Balance Tests Balance Tests (Stork Stand Test)(Stork Stand Test)KT 1000 Tests KT 1000 Tests (“Good hands”)(“Good hands”)Basic MeasurementsBasic Measurements

Functional Testing Algorithm Functional Testing Algorithm –– KneeKnee

Objective, quantitative (and Objective, quantitative (and qualitative), systematic qualitative), systematic testing and rehabilitation testing and rehabilitation methodmethod to safely and rapidlyto safely and rapidlymethod method to safely and rapidly to safely and rapidly progress a patient from progress a patient from immediate post injury/postimmediate post injury/post--op to return to full functional op to return to full functional activities and return to play in activities and return to play in sports sports

Functional Testing Algorithm Functional Testing Algorithm –– KneeKnee

Progression to the next higher level of testing difficulty is predicated predicated upon passing the prior test upon passing the prior test in the series…

Each successive test and its associated training regimen places increasing stressincreasing stress on the patient while at the same time decreasing decreasing clinical controlclinical control

Functional Testing Algorithm Functional Testing Algorithm –– KneeKnee

We can rehabilitate patients We can rehabilitate patients faster than ever because by faster than ever because by testing themtesting them, we always know, we always knowtesting themtesting them, we always know , we always know where the patient is in the where the patient is in the rehab program and can rehab program and can focus focus the interventions the interventions specifically on specifically on the patient’s particular the patient’s particular condition and statuscondition and status

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Functional Testing Algorithm –Knee -2016

Sport Specific TestingLower Extremity Functional Tests Functional Hop TestsFunctional Jump Tests

Competitive Competitive AthletesAthletes

RecreationalRecreationalFunctional Jump TestsOKC Isokinetic testing CKC Isokinetic TestingSensorimotor System Testing: Balance/Proprioceptive TestingKT 1000/2000 Basic MeasurementsBasic Measurements

RecreationalRecreationalAthletesAthletes

GeneralGeneralOrthopaedicOrthopaedic

PatientsPatients

Functional Testing AlgorithmFunctional Testing AlgorithmSports Specific Tests Sports Specific Tests Lower Extremity Functional Tests Lower Extremity Functional Tests Functional Hop Tests Functional Hop Tests Functional Jump TestsFunctional Jump TestsFunctional Jump Tests Functional Jump Tests OKC Isokinetic Tests OKC Isokinetic Tests CKC Isokinetic Tests CKC Isokinetic Tests Kinesthetic/Balance Tests Kinesthetic/Balance Tests KT 1000 Tests KT 1000 Tests Basic MeasurementsBasic Measurements

P & S M, 1978P & S M, 1978

Basic MeasurementsBasic MeasurementsBasic MeasurementsBasic MeasurementsTime/soft tissue healingTime/soft tissue healingVAS (0VAS (0--10 scale)10 scale)Anthropometric Anthropometric measurementsmeasurementsmeasurementsmeasurementsAROM, PROMAROM, PROMSpecial TestsSpecial TestsQualitative & Quantitative Qualitative & Quantitative Movement AssessmentMovement AssessmentKnee Rating scales: IKDC, etc.Knee Rating scales: IKDC, etc.

Basic MeasurementsBasic MeasurementsBasic MeasurementsBasic MeasurementsMD Clearance & Approval MD Clearance & Approval Time/soft tissue healingTime/soft tissue healingVAS (0VAS (0--10 scale)10 scale)Anthropometric measurementsAnthropometric measurementsAROM, PROMAROM, PROMSpecial TestsSpecial TestsQualitative & Quantitative Qualitative & Quantitative Movement AssessmentMovement AssessmentKnee Rating scales: IKDC, etc.Knee Rating scales: IKDC, etc.

Qualitative Movement Qualitative Movement Analysis of the Entire Analysis of the Entire Kinematic Chain in all Kinematic Chain in all Planes of Motion Planes of Motion

Regional InterdependencyRegional Interdependency

TOTAL BODY INTERDEPENDENCYTOTAL BODY INTERDEPENDENCYIf movement is one integrated If movement is one integrated

pattern, regardless of its pattern, regardless of its complexity, complexity,

then we mustthen we mustevaluate and treat evaluate and treat The The TOTAL PATIENTTOTAL PATIENT

Basic MeasurementsBasic MeasurementsBasic MeasurementsBasic MeasurementsQualitative & Quantitative Qualitative & Quantitative Movement Assessment:Movement Assessment:Step Down Tests:Step Down Tests:

Performance TestsPerformance TestsSingle Leg Step Single Leg Step DownDown AnalysisAnalysis

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Functional Testing AlgorithmFunctional Testing Algorithm

TIME:TIME:

Soft tissue healing Soft tissue healing

from the injury or

from a

post-surgical condition

ACL Quad Tendon ACL Quad Tendon Graft HealingGraft Healing

Dark Quad Dark Quad Tendon PreTendon Pre--

OpOp

6 months PO6 months PO1 month PO1 month POTime ZeroTime Zero

We still have not We still have not answered this Question?answered this Question?

Biologics and “mother nature” Biologics and “mother nature” d thd thand the:and the:

NeoangiogenesisMaturationLigamentization

Functional Testing AlgorithmFunctional Testing Algorithm

TIME:TIME: Soft Soft tissue healingtissue healingWe need similar types of outcomesWe need similar types of outcomesWe need similar types of outcomes We need similar types of outcomes regarding the regarding the biology of healingbiology of healing

We can’t hurry We can’t hurry “mother nature”;“mother nature”;

Although we are trying with all the Although we are trying with all the biologics!!!biologics!!!

Clinical Decision Making Clinical Decision Making Clinical Decision Making Clinical Decision Making Clinical Decision Making Clinical Decision Making Clinical Decision Making Clinical Decision Making

Clinical Decision Making Clinical Decision Making Clinical Decision Making Clinical Decision Making

HamstringsHamstrings

BTBBTB

Clinical Decision Making Clinical Decision Making Clinical Decision Making Clinical Decision Making

Perhaps wait for 3-6 more months to allow the biologics to “do“dothe biologics to do do their job”….their job”….

Basic MeasurementsBasic MeasurementsBasic MeasurementsBasic Measurements

Time/soft Time/soft tissuetissuetissue tissue healinghealing

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ACL Quad Tendon ACL Quad Tendon Graft HealingGraft Healing

Dark Quad Dark Quad Tendon PreTendon Pre--

OpOp

6 months PO6 months PO 1 year PO1 year PO1 month PO1 month POTime ZeroTime Zero

Clinical Decision Making Clinical Decision Making Clinical Decision Making Clinical Decision Making

Then we return Then we return him back tohim back tohim back to him back to sports sports

Functional Testing AlgorithmFunctional Testing AlgorithmSports Specific Tests Sports Specific Tests Lower Extremity Functional Tests Lower Extremity Functional Tests Functional Hop Tests Functional Hop Tests Functional Jump TestsFunctional Jump TestsFunctional Jump Tests Functional Jump Tests OKC Isokinetic Tests OKC Isokinetic Tests CKC Isokinetic Tests CKC Isokinetic Tests Kinesthetic/Balance Tests Kinesthetic/Balance Tests KT 1000/2000 TestsKT 1000/2000 TestsBasic MeasurementsBasic Measurements

KT 1000 TestsKT 1000 TestsKT 1000 TestsKT 1000 Tests KT 1000KT 1000When the KT 1000 scores are normalized according to th it i (< 3(< 3the criteria (< 3 mm (< 3 mm bilateral comparison)bilateral comparison), , or if > 3, then guarded progression to the next stage of the FTA

Functional Testing AlgorithmFunctional Testing AlgorithmSports Specific Tests Sports Specific Tests Lower Extremity Functional Tests Lower Extremity Functional Tests Functional Hop Tests Functional Hop Tests Functional Jump TestsFunctional Jump TestsFunctional Jump Tests Functional Jump Tests OKC Isokinetic Tests OKC Isokinetic Tests CKC Isokinetic Tests CKC Isokinetic Tests Kinesthetic/Balance TestsKinesthetic/Balance TestsKT 1000 Tests KT 1000 Tests Basic MeasurementsBasic Measurements

BiodexBiodexBalance Balance

StabilometerStabilometerIt has been my It has been my clinical clinical

observation observation (performance (performance motion assessment) motion assessment) that that

after a LE injury, after a LE injury, individuals individuals do not bear weight equally do not bear weight equally during doubleduring double--leg exercises, leg exercises,

especially on the especially on the

injured leginjured leg

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ClinicalClinicalBiomechanicsBiomechanics17:55117:551--554,554,

20022002

ACLACL--RR••More flexion More flexion -- WB on ACLWB on ACL--R sideR side

•• More external weight More external weight -- WB on ACLWB on ACL--R sideR side

3 months: 3 months: unweightedunweighted ACLACL--R sideR side

6 months6 months: : unweightedunweighted ACLACL--R sideR side

12 months: 12 months: normalized WB normalized WB -- ACLACL--R sideR side

Majority of patients felt like they were Majority of patients felt like they were performing equal WB on both legs performing equal WB on both legs

Balance/Proprioceptive TestingBalance/Proprioceptive TestingWhen prescribing squat exercises, it should be When prescribing squat exercises, it should be recognized that initially, patients with ACLR recognized that initially, patients with ACLR tend to unload the affected knee. tend to unload the affected knee. More symmetrical loading patterns may be achieved by inducing bilateral fatigue.

h f i d l di i ilh f i d l di i ilWhen fatigued, loading symmetry was similar When fatigued, loading symmetry was similar between this patient group and controls. between this patient group and controls. This is relevant information for those who implement rehabilitation training programs.

Webster KEWebster KE11, et.al. Symmetry of squatting and the , et.al. Symmetry of squatting and the effect of fatigue following ACLeffect of fatigue following ACL--R. R. Knee Knee SurgSurg Sports Sports TraumatolTraumatol ArthroscArthrosc.., 2014 , 2014

Balance/Kinesthetic/Balance/Kinesthetic/proprioceptive Testingproprioceptive TestingIf the measurements are within within 10%10% of normal, the patient progressesp g

If the measurements are not not within 10%within 10% of normal, then the rehab program is focusedfocused on kinesthetic/proprioceptive exercises

ContinuousContinuousoverlap of overlap of

RehabRehabinterventionsinterventions

ContinuousContinuousoverlap of overlap of

R h bR h b ContinuousContinuousRehabRehabinterventionsinterventions

ContinuousContinuousoverlap of overlap of

RehabRehabinterventionsinterventions

Functional Testing Algorithm –Knee -2016

Sport Specific TestingLower Extremity Functional Tests Functional Hop TestsFunctional Jump Tests

Competitive Competitive AthletesAthletes

RecreationalRecreationalFunctional Jump TestsOKC Isokinetic testing CKC Isokinetic TestingSensorimotor System Testing: Balance/Proprioceptive TestingKT 1000/2000 Basic MeasurementsBasic Measurements

RecreationalRecreationalAthletesAthletes

GeneralGeneralOrthopaedicOrthopaedic

PatientsPatients

Functional Testing AlgorithmFunctional Testing AlgorithmSports Specific Tests Sports Specific Tests Lower Extremity Functional Tests Lower Extremity Functional Tests Functional Hop Tests Functional Hop Tests Functional Jump Tests Functional Jump Tests OKC I ki ti T tOKC I ki ti T tOKC Isokinetic Tests OKC Isokinetic Tests CKC Isokinetic Tests (Single leg CKC Isokinetic Tests (Single leg

wall slides, Leg Press) wall slides, Leg Press) Kinesthetic/Balance Tests Kinesthetic/Balance Tests KT 1000 Tests KT 1000 Tests Basic MeasurementsBasic Measurements

Open Kinetic Chain vs.

Closed Kinetic Chain

Open Kinetic Chain vs.

Closed Kinetic Chain

Integrated Testing &

Rehabilitation

Integrated Testing &

Rehabilitation

20012001

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CKC CKC PWBPWB

IsokineticIsokineticTestingTesting

Linea BiLinea Bi--lateral Tandem lateral Tandem Concentric/Eccentric ExercisesConcentric/Eccentric Exercises

Linea BiLinea Bi--lateral Reciprocallateral ReciprocalConcentric ExercisesConcentric Exercises

CKCCKCCKC CKC PWBPWBIsokineticIsokineticTestingTesting

Shuttle Shuttle –– kinetic and kinematic analysis kinetic and kinematic analysis for CKC L.E. exercises for CKC L.E. exercises

CKC CKC –– TestingTestingWith CKC testing everything everything is being testedis being tested and we do NOT KNOW which muscles are contributing to the force production; Or which muscles are which muscles are NOTNOTcontributingcontributing to the force production

Functional Testing Algorithm –Knee -2016

Sport Specific TestingLower Extremity Functional Tests Functional Hop TestsFunctional Jump Tests

Competitive Competitive AthletesAthletes

RecreationalRecreationalFunctional Jump TestsOKC Isokinetic testing CKC Isokinetic TestingSensorimotor System Testing: Balance/Proprioceptive TestingKT 1000/2000 Basic MeasurementsBasic Measurements

RecreationalRecreationalAthletesAthletes

GeneralGeneralOrthopaedicOrthopaedic

PatientsPatients

Functional Testing AlgorithmFunctional Testing AlgorithmSports Specific Tests Sports Specific Tests Lower Extremity Functional Tests Lower Extremity Functional Tests Functional Hop Tests Functional Hop Tests Functional Jump TestsFunctional Jump TestsFunctional Jump Tests Functional Jump Tests OKC Isokinetic OKC Isokinetic Tests (MMT/HHD) Tests (MMT/HHD) CKC Isokinetic Tests CKC Isokinetic Tests Kinesthetic/Balance Tests Kinesthetic/Balance Tests KT 1000 Tests KT 1000 Tests Basic MeasurementsBasic Measurements

?? Questions Questions ??

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

Advantages of OKC/Isolated ExercisesAdvantages of OKC/Isolated ExercisesCheck for proximal and distal muscles compensating for weak areas.Check to see if there are deficits distantfrom 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 itThere is a correlation between OKC testing and functional activities

REFERENCEREFERENCEREFERENCEREFERENCEWell Well documented documented in the knee….in the knee….

SeminalSeminalArticleArticle

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REFERENCEREFERENCEREFERENCEREFERENCELowerLower--extremity extremity compensations compensations following ACL reconstructionfollowing ACL reconstructionErnst, GP, et.al. PT, 80:251Ernst, GP, et.al. PT, 80:251--260, 2000260, 2000

Vertical JumpVertical Jump -- No differenceNo difference ininVertical Jump Vertical Jump No differenceNo difference in in summated ext. momentsummated ext. momentOKC testing OKC testing -- Knee extensor moment Knee extensor moment significantly lowersignificantly lower

Hip and/or ankle extensors Hip and/or ankle extensors compensatecompensate for knee for knee

Isokinetic TestingIsokinetic Testing

PubMed Search: PubMed Search: 77/1/16/1/16

Isokinetics:Isokinetics: 5 4605 460Isokinetics: Isokinetics: 5,460 5,460 referencesreferences

IsokineticsIsokinetics and Knee: 2,629 and Knee: 2,629 (48%)(48%)

OKCOKCTestingTestingAnd/orAnd/or//RehabRehab

Entire chapter Entire chapter on on isokinetic testing isokinetic testing and data analysis; and data analysis; i.e., i.e., TRTD, TAETRTD, TAE

Entire chapter Entire chapter on on correlation of correlation of isokinetic torque isokinetic torque

i hi h

19841984

curves curves with with pathologies pathologies

Isokinetic DataIsokinetic DataWhat information do we use from

isokinetics?

Data AnalysisData Analysis(Davies, GJ, A Compendium of Isokinetics, (Davies, GJ, A Compendium of Isokinetics, 1984, 1992)1984, 1992)••Bilateral comparisonBilateral comparison

••Unilateral ratio of agonist/antagonistUnilateral ratio of agonist/antagonist

••Torque to body weight (relative/normalized data)Torque to body weight (relative/normalized data)••TAS, TBSTAS, TBS

••Angle specific torquesAngle specific torques

••TAE/TRTDTAE/TRTD

•Endurance analysis

•Normative data

•Functional correlation

•Sport specific correlation

Return to PlayReturn to PlayImportance of QuadsImportance of Quads

Return to PlayReturn to PlayImportance of QuadsImportance of Quads

Early resolution of Early resolution of quadriceps strength quadriceps strength deficitsdeficits may be important for improving may be important for improving confidence and kneeconfidence and knee--related function.related function.

Interestingly, Interestingly, QSBW with isokinetic QSBW with isokinetic testingtesting, had a stronger association with , had a stronger association with function in patients who did not RTS at 6 function in patients who did not RTS at 6 months months

Lentz, TA, et.al. Comparison of physical impairment, functional, and Lentz, TA, et.al. Comparison of physical impairment, functional, and Psychosocial measures based on fear of Psychosocial measures based on fear of reinjuryreinjury/lack of confidence/lack of confidenceand RTS status after ACLand RTS status after ACL--R.R.AJSM. 43(2):345AJSM. 43(2):345--353, 2015353, 2015

Importance of QuadsImportance of QuadsEitzenEitzen, I, et.al. Preoperative quadriceps , I, et.al. Preoperative quadriceps strength is a significant predictor of knee strength is a significant predictor of knee function two years after ACLfunction two years after ACL--R. R. Br. J Sports Med. 43:371Br. J Sports Med. 43:371--376, 2009376, 2009

Preoperative quadriceps muscle strength Preoperative quadriceps muscle strength has has significant negative consequences for the significant negative consequences for the longlong--term functional outcome after ACL term functional outcome after ACL reconstruction. Patients with quad deficits reconstruction. Patients with quad deficits above above 20%20% also had SS strength deficits 2 also had SS strength deficits 2 years after surgery.years after surgery.

Recommendation: Quad strength < 20% Recommendation: Quad strength < 20% before ACLbefore ACL--R R (IMPORTANCE(IMPORTANCE--PREPRE--HAB)HAB)

OKC TestingOKC TestingOKC Testing OKC Testing and and

Correlation to Functional Correlation to Functional PerformancePerformance

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Isokinetic Testing and Correlation to Isokinetic Testing and Correlation to Functional Performance Functional Performance

Wilk, KE, et al. Wilk, KE, et al. The relationship between subjective knee scores, isokinetic The relationship between subjective knee scores, isokinetic (OKC) testing, and functional testing in the ACL(OKC) testing, and functional testing in the ACL--reconstructed knee. JOSPT reconstructed knee. JOSPT 20(2): 6020(2): 60--73, 73, 19941994PetschingPetsching, R, et.al. , R, et.al. The relationship between isokinetic quadriceps strength test The relationship between isokinetic quadriceps strength test and hop tests for distance and oneand hop tests for distance and one--legged vertical jump test following ACLlegged vertical jump test following ACL--R. R. JOSPT. 28:23JOSPT. 28:23--31, 31, 19981998Wells, et.al. Wells, et.al. Adolescent ACLR: a retrospective analysis of quadriceps strength Adolescent ACLR: a retrospective analysis of quadriceps strength recovery and return to full activity after surgery. J recovery and return to full activity after surgery. J PediatrPediatr OrthopOrthop. 29:486. 29:486--9, 9, 20092009EitzenEitzen, I, et.al. , I, et.al. Preoperative quadriceps strength is a significant predictor of Preoperative quadriceps strength is a significant predictor of knee function two years after ACLknee function two years after ACL--R. R. Br. J Sports Med. 43:371Br. J Sports Med. 43:371--376, 376, 20092009KeaysKeays SL et alSL et al Factors involved in the development of OA after ACL surgeryKeaysKeays, SL, et.al. , SL, et.al. Factors involved in the development of OA after ACL surgery. AJSM. 38:455-463, 2010 2010 EitzenEitzen, I, et.al. , I, et.al. ACLACL--deficient potential deficient potential coperscopers and nonand non--coperscopers reveal different reveal different isokinetic quadriceps strength profiles in the early stage after injury. AJSM. isokinetic quadriceps strength profiles in the early stage after injury. AJSM. 38:58638:586--593, 593, 20102010ZebisZebis, MK, et.al. , MK, et.al. Rapid hamstring/quadriceps force capacity in male and female Rapid hamstring/quadriceps force capacity in male and female elite soccer players. JSCR. 25:1989elite soccer players. JSCR. 25:1989--1993, 1993, 20112011BaltaciBaltaci, G, et.al. , G, et.al. The outcomes of ACLR and rehabilitated knees The outcomes of ACLR and rehabilitated knees vsvs healthy healthy knees: a functional comparison. knees: a functional comparison. ActaActa OrthopOrthop traumatoltraumatol TurcTurc. 46:186. 46:186--95, 95, 20122012ArteroArtero, EG, et.al. , EG, et.al. CriterionCriterion--related validity of fieldrelated validity of field--based muscular fitness tests based muscular fitness tests in youth. J Sports Med Phys Fitness. 52:263in youth. J Sports Med Phys Fitness. 52:263--272, 272, 20122012Kong, DH, et.al. Kong, DH, et.al. Validation of functional performance tests after ACLValidation of functional performance tests after ACL--R.R.Knee Knee SurgSurg RelatRelat Res. 24:40Res. 24:40--5, 5, 20122012AngelozziAngelozzi, M, et.al. , M, et.al. Rate of force development as an adjunctive outcome Rate of force development as an adjunctive outcome measure for returnmeasure for return--toto--sport decisions after ACLsport decisions after ACL--R. JOSPT. 42:772R. JOSPT. 42:772--780,780, 20122012Schmitt, LC, et.al. Schmitt, LC, et.al. The impact of quadriceps The impact of quadriceps femorisfemoris strength asymmetry on strength asymmetry on functional performance at return to sport following ACLfunctional performance at return to sport following ACL--R. JOSPT. 42:750R. JOSPT. 42:750--759759, , 20122012

Wilk, KE, et al.Wilk, KE, et al.

The relationship between subjective The relationship between subjective knee scores, isokinetic (OKC) testing, knee scores, isokinetic (OKC) testing, and functional testing in the ACLand functional testing in the ACL--reconstructed kneereconstructed knee

JOSPT 20(2): 60JOSPT 20(2): 60 73 1994 (73 1994 (BregBreg SeminalSeminalJOSPT 20(2): 60JOSPT 20(2): 60--73, 1994 (73, 1994 (BregBregAward Winning Paper)Award Winning Paper)

Results: A Results: A positive correlationpositive correlation was was noted between isokinetic knee noted between isokinetic knee extension peak torque (180, 300extension peak torque (180, 300°°/sec) /sec) and subjective knee scores, and the 3 and subjective knee scores, and the 3 hop tests (p <0.001)hop tests (p <0.001)

ArticleArticle

OKC (Isolated) TestingOKC (Isolated) TestingPetschingPetsching, R, et.al. The relationship between , R, et.al. The relationship between isokinetic quadriceps strength test and hop isokinetic quadriceps strength test and hop tests for distance and onetests for distance and one--legged vertical jump legged vertical jump test following ACLtest following ACL--R. JOSPT. 28:23R. JOSPT. 28:23--31, 199831, 1998

PPMCPPMC--Moderate correlationsModerate correlationsPPMCPPMC Moderate correlations Moderate correlations between peak torque and single between peak torque and single hop, triple hop and vertical jumphop, triple hop and vertical jump

Whether D or ND leg is involved, Whether D or ND leg is involved, the uninvolved limb can be used the uninvolved limb can be used for LSIfor LSI

Isokinetic Testing Isokinetic Testing BaltaciBaltaci, G, et.al. The outcomes of ACLR and , G, et.al. The outcomes of ACLR and rehabilitated knees rehabilitated knees vsvs healthy knees: a functional healthy knees: a functional comparison.comparison.ActaActa OrthopOrthop traumatoltraumatol TurcTurc. 46:186. 46:186--95, 201295, 2012

Th t d l dTh t d l d––The study revealed a The study revealed a significant correlation significant correlation between the vertical hop between the vertical hop and isokinetic strength in and isokinetic strength in the isokinetic teststhe isokinetic tests

Isokinetic Testing Isokinetic Testing ArteroArtero, EG, et.al. Criterion, EG, et.al. Criterion--related validity of fieldrelated validity of field--based muscular fitness tests in youth. based muscular fitness tests in youth. J Sports Med Phys Fitness. 52:263J Sports Med Phys Fitness. 52:263--272, 2012272, 2012

All fieldAll field--based tests (standing long based tests (standing long jump, squat jump, jump, squat jump, countermovement jump, etc. were countermovement jump, etc. were significantly associated with significantly associated with isokinetic peak torque and power isokinetic peak torque and power (p<0.001 in all cases)(p<0.001 in all cases)

Isokinetic Testing Isokinetic Testing Kong, DH, et.al. Validation of functional Kong, DH, et.al. Validation of functional performance tests after ACLperformance tests after ACL--R.R.Knee Knee SurgSurg RelatRelat Res. 24:40Res. 24:40--5, 20125, 2012

In the ACLIn the ACL--R group, the IKDC R group, the IKDC score, score, TegnerTegner activity score, activity score, extensor power at 60extensor power at 60°°/s, and /s, and one leg hop test also showed one leg hop test also showed high correlation between each high correlation between each testtest

Functional Testing AlgorithmSports Specific Tests

Lower Extremity Functional Tests Functional Hop Tests

Functional Jump Tests Functional Jump Tests

CKC I ki ti T tCKC I ki ti T tCKC Isokinetic TestsCKC Isokinetic Tests

OKC Isokinetic Tests OKC Isokinetic Tests CKC Isokinetic Tests CKC Isokinetic Tests

Kinesthetic/Balance Tests Kinesthetic/Balance Tests KT 1000 Tests KT 1000 Tests

Basic MeasurementsBasic Measurements

June, June, 20002000

20012001

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Open Kinetic Chain vs.

Closed Kinetic Chain

(Functional WB Position)

Open Kinetic Chain vs.

Closed Kinetic Chain

(Functional WB Position)

Integrated Testing &

Rehabilitation

Integrated Testing &

Rehabilitation

CKC WB Isokinetic TestingCKC WB Isokinetic Testing Functional Testing Algorithm –Knee -2016

Sport Specific TestingLower Extremity Functional Tests Functional Hop TestsFunctional Jump Tests

Competitive Competitive AthletesAthletes

RecreationalRecreationalFunctional Jump TestsOKC Isokinetic testing CKC Isokinetic TestingSensorimotor System Testing: Balance/Proprioceptive TestingKT 1000/2000 Basic MeasurementsBasic Measurements

RecreationalRecreationalAthletesAthletes

GeneralGeneralOrthopaedicOrthopaedic

PatientsPatients

Functional Functional

TestsTests

LE FUNCTIONAL TESTSLE FUNCTIONAL TESTSSingle Leg Hop Single Leg Hop

TestsTestsSingle leg forward hop

Agility Agility TestsTests

Shuttle Shuttle hopTriple hop for distanceSingle leg timed hopCross-over hop for distance

runrunSide Side stepstepCariocaCariocaLEFTLEFT

Performance TestsPerformance TestsSingle Leg Step Single Leg Step DownDown AnalysisAnalysis

Performance TestsPerformance TestsDrop Jump TestDrop Jump Test Analysis Analysis

Functional Testing AlgorithmFunctional Testing AlgorithmSports Specific Tests Sports Specific Tests Lower Extremity Functional Tests Lower Extremity Functional Tests Functional Hop Tests Functional Hop Tests Functional Jump TestsFunctional Jump TestsFunctional Jump TestsFunctional Jump TestsOKC Isokinetic Tests OKC Isokinetic Tests CKC Isokinetic Tests CKC Isokinetic Tests Kinesthetic/Balance Tests Kinesthetic/Balance Tests KT 1000 Tests KT 1000 Tests Basic MeasurementsBasic Measurements

Davies’ Modified Davies’ Modified Jump/Hop TestsJump/Hop Tests

Both legs = Jump TestBoth legs = Jump Test

Uninvolved Leg = Hop TestUninvolved Leg = Hop Test

Involved Leg = Hop TestInvolved Leg = Hop Test

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Arms clasped Arms clasped behind backbehind back

Minimal neck Minimal neck movementsmovementsmovementsmovements

Minimal trunk Minimal trunk movementsmovements

Segmented Contributions Segmented Contributions to forces in vertical jumpto forces in vertical jump

ComponentsComponentsKneeKnee 56% 56% AnkleAnkle 22% 22% TrunkTrunk 10% 10% Arm SwingArm Swing 10% 10% Head SwingHead Swing 2%2%Total Performance AverageTotal Performance Average 78% 78% Optimal Timing of SegmentedOptimal Timing of Segmented 84% 84%

Performance Performance LathanLathan, , KomiKomi, , EuropEurop J App Phys, 1978J App Phys, 1978

Davies’ Modified Davies’ Modified Jump TestJump Test

Both legs Jump TestBoth legs Jump TestBoth legs = Jump TestBoth legs = Jump Test

Uninvolved Leg = Hop TestUninvolved Leg = Hop Test

Involved Leg = Hop TestInvolved Leg = Hop Test

Absolute (Quantitative Absolute (Quantitative Number) vs. Relative Number) vs. Relative

Data Data

(Normalized to (Normalized to patient’s heightpatient’s height))

Functional Jump TestFunctional Jump Test

Relative DataRelative Data

Males Females

R + L 100% / HT. 90% / HT.

Functional Testing AlgorithmFunctional Testing AlgorithmSports Specific Tests Sports Specific Tests Lower Extremity Functional Tests Lower Extremity Functional Tests Functional Hop Tests Functional Hop Tests Functional Jump TestsFunctional Jump TestsFunctional Jump Tests Functional Jump Tests OKC Isokinetic Tests OKC Isokinetic Tests CKC Isokinetic Tests CKC Isokinetic Tests Kinesthetic/Balance Tests Kinesthetic/Balance Tests KT 1000 Tests KT 1000 Tests Basic MeasurementsBasic Measurements

Functional Functional Hop TestHop Test

Hop is Hop is on on one one legleg

Psychological Readiness TestPsychological Readiness TestQuantitativeQuantitative(LSI) (LSI) vsvsvsvsQualitativeQualitativevaluesvalues

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PerformancePerformanceQuantitative analysisQuantitative analysis is part of is part of assessmentassessmentBut, also important to But, also important to Perform Perform qualitative qualitative assessmentassessment of the concentric of the concentric power performance phasepower performance phaseAnd most importantlyAnd most importantlyEccentric deceleration phaseEccentric deceleration phase

SINGLE LEGGED HOP TESTSSINGLE LEGGED HOP TESTS

STANDARDIZED INSTRUCTIONSMULTIPLE VARIATIONSVARIATIONS BASED ON SPECIFIC FUNCTION OF ATHLETE / PATIENT BEING TESTED

SINGLE LEG HOPSINGLE LEG HOPHand Hand placement placement variesvariesLand onLand onLand on Land on same legsame legAverage 3 Average 3 trials each trials each legleg

IKDC ONE LEG HOP TESTIKDC ONE LEG HOP TESTBILATERAL COMPARISON & NORMATIVE DATA

ELLENBECKER & DAVIES, 2001

TRIPLE HOP FOR TRIPLE HOP FOR DISTANCEDISTANCE

Hand Hand placement placement variesvariesvariesvaries33rdrd hop land hop land on one footon one foot11--3 trials 3 trials each legeach leg

SINGLE LEG TIMED HOPSINGLE LEG TIMED HOPHand Hand placement placement 6 meter 6 meter linelineSingle leg Single leg hop entire hop entire distancedistance11--3 trials 3 trials each legeach leg

CROSSCROSS--OVER HOP OVER HOP FOR DISTANCEFOR DISTANCE

6 meter line, 6 meter line, 15 cm wide15 cm wide3 single leg 3 single leg 3 single leg 3 single leg hops for hops for distancedistance–– 11stst hop hop

medialmedial11--3 trials 3 trials each legeach leg

Return to sport following ACL Injuries Return to sport following ACL Injuries

Meyer, GD, et.al. Utilization of modified NFL Meyer, GD, et.al. Utilization of modified NFL combine testing to identify functional combine testing to identify functional deficits in athletes following ACL deficits in athletes following ACL reconstructions. JOSPT. 41: 377reconstructions. JOSPT. 41: 377--387, 2011387, 2011

Whil il t l d fi it t iWhil il t l d fi it t iWhile unilateral deficits are present in While unilateral deficits are present in individuals following ACLindividuals following ACL--R, they may not be R, they may not be evident during bipedal performance or evident during bipedal performance or during modified versions of doubleduring modified versions of double--limb limb performance activities. performance activities. Isolation of the Isolation of the involved limb with unilateral hopping tasks involved limb with unilateral hopping tasks should be used to identify deficits in should be used to identify deficits in performance. performance.

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Return to sport following ACLReturn to sport following ACL--RRArden, CL, et.al. Return to Arden, CL, et.al. Return to preinjurypreinjury level of level of competitive sport after ACLcompetitive sport after ACL--R surgery. R surgery. AJSM. 39:538AJSM. 39:538--543, 2011543, 2011

12 months: 33% attempted competitive sports12 months: 33% attempted competitive sportsIKDC scores did not discriminate who returned IKDC scores did not discriminate who returned to sports to sports pp

Patients with good hop test results (>85% Patients with good hop test results (>85% LSI) were more likely to return than patients LSI) were more likely to return than patients with poor results (<85% LSI)with poor results (<85% LSI)

People may require a longer postPeople may require a longer post--op rehab op rehab period than that typically advocated to return period than that typically advocated to return to competitive sport after ACLto competitive sport after ACL--R surgery R surgery

Return to sport following ACL Injuries Return to sport following ACL Injuries GrindemGrindem, H, et.al. Single, H, et.al. Single--legged hop tests as legged hop tests as predictors of selfpredictors of self--reported knee function in reported knee function in nonoperativelynonoperatively treated individuals with ACL injury. treated individuals with ACL injury. AJSM. 39:2347AJSM. 39:2347--2354, 20112354, 2011

ROCROC--measure of discriminate accuracymeasure of discriminate accuracy

Optimal Single leg hop for distance LSIOptimal Single leg hop for distance LSI

Combinations of any 2 of 4 singleCombinations of any 2 of 4 single--legged hop tests legged hop tests did not give higher discriminative accuracydid not give higher discriminative accuracy

LSI (88%) LSI (88%) –– sensitivity (71.4%) & specificity sensitivity (71.4%) & specificity (71.7%)(71.7%)

Single hop for distance (LSI) significantly predicated Single hop for distance (LSI) significantly predicated selfself--reported knee function after 1 year in a reported knee function after 1 year in a nonoperativleynonoperativley treated ACLtreated ACL--injured patientsinjured patients

Return to sport following ACL Injuries Return to sport following ACL Injuries LogerstedtLogerstedt, D, et.al. Single, D, et.al. Single--legged hop tests as legged hop tests as predictors of selfpredictors of self--reported knee function after ACLreported knee function after ACL--R: the DelawareR: the Delaware--Oslo Cohort study. AJSM. 40:2348Oslo Cohort study. AJSM. 40:2348--2356, 2012.2356, 2012.

Crossover hop and 6Crossover hop and 6--m timed hop LSI 6 months m timed hop LSI 6 months after ACLafter ACL R were the strongest individual predictorsR were the strongest individual predictorsafter ACLafter ACL--R were the strongest individual predictors R were the strongest individual predictors of selfof self--reported knee function.reported knee function.

<88% cutoff score at 6 months may benefit from <88% cutoff score at 6 months may benefit from targeted training to improve LSI. >88% targeted training to improve LSI. >88% -- good knee good knee function at 1 yearfunction at 1 year

SingleSingle--legged hop tests conducted 6 months after legged hop tests conducted 6 months after ACLACL--R can predict the likelihood of successful and R can predict the likelihood of successful and unsuccessful outcomes 1 year after ACLunsuccessful outcomes 1 year after ACL--R.R.

Return to sport following ACL Injuries Return to sport following ACL Injuries Meyer, G, et.al. No association of time from surgery Meyer, G, et.al. No association of time from surgery with functional deficits in athletes after ACLwith functional deficits in athletes after ACL--R: R: Evidence for objective returnEvidence for objective return--toto--sports. AJSM. sports. AJSM. 40:225640:2256--2263, 20122263, 2012

••Athletes cleared by MDs to RTP.Athletes cleared by MDs to RTP.Athletes cleared by MDs to RTP.Athletes cleared by MDs to RTP.

••Deficits in unilateral force development (vertical Deficits in unilateral force development (vertical jump height) and GRF persist in an athlete’s single jump height) and GRF persist in an athlete’s single limb performance after ACLlimb performance after ACL--R and full RTP. SingleR and full RTP. Single--leg hop test asymmetry (LSI)leg hop test asymmetry (LSI)

••Deficits independent of time.Deficits independent of time.

Functional Testing AlgorithmFunctional Testing AlgorithmSports Specific Tests Sports Specific Tests Lower Extremity Functional TestsLower Extremity Functional TestsFunctional Hop Tests Functional Hop Tests Functional Jump TestsFunctional Jump TestsFunctional Jump Tests Functional Jump Tests OKC Isokinetic Tests OKC Isokinetic Tests CKC Isokinetic Tests CKC Isokinetic Tests Kinesthetic/Balance Tests Kinesthetic/Balance Tests KT 1000 Tests KT 1000 Tests Basic MeasurementsBasic Measurements

LE FUNCTIONAL TESTSLE FUNCTIONAL TESTSAgility Agility TestsTests

Sh ttlSh ttlShuttle runShuttle runSide stepSide stepCariocaCarioca

LEFTLEFT

SHUTTLE RUNSHUTTLE RUN

6.3 meter surface6.3 meter surfaceInjured leg must Injured leg must

h h b lih h b litouch each baselinetouch each baselineStop after 4 lengthsStop after 4 lengths1 practice1 practice1 timed trial1 timed trial

SIDE STEPSIDE STEP6.3 meter surface6.3 meter surfaceStop after 4 lengthsStop after 4 lengthsNo crossover with stepsNo crossover with stepsNo crossover with stepsNo crossover with stepsStep on each baseline Step on each baseline 1 practice1 practice1 timed trial1 timed trial

CARIOCACARIOCA6.3 meter surface6.3 meter surfaceMust crossover step Must crossover step and step on each and step on each b lib libaselinebaselineStop after 4 lengthsStop after 4 lengths1 practice1 practice1 timed trial1 timed trial

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FUNCTIONAL TESTSFUNCTIONAL TESTS--ApplicabilityApplicability Functional Testing Algorithm –Knee -2016

Sport Specific TestingLower Extremity Functional Tests Functional Hop TestsFunctional Jump Tests

Competitive Competitive AthletesAthletes

RecreationalRecreationalFunctional Jump TestsOKC Isokinetic testing CKC Isokinetic TestingSensorimotor System Testing: Balance/Proprioceptive TestingKT 1000/2000 Basic MeasurementsBasic Measurements

RecreationalRecreationalAthletesAthletes

GeneralGeneralOrthopaedicOrthopaedic

PatientsPatients

OTHER LE FUNCTIONAL TESTSOTHER LE FUNCTIONAL TESTSStair hopple Stair hopple Single leg lateral hopSingle leg lateral hopSide jump testSide jump testVertical jump Vertical jump j pj pStair runningStair runningFigureFigure--ofof--eighteightTT--TestTestProPro--AgilityAgilityLEFTLEFT

Functional Testing AlgorithmFunctional Testing AlgorithmSports Specific Tests Sports Specific Tests Lower Extremity Functional TestsLower Extremity Functional TestsFunctional Hop Tests Functional Hop Tests Functional Jump TestsFunctional Jump TestsFunctional Jump Tests Functional Jump Tests OKC Isokinetic Tests OKC Isokinetic Tests CKC Isokinetic Tests CKC Isokinetic Tests Kinesthetic/Balance Tests Kinesthetic/Balance Tests KT 1000 Tests KT 1000 Tests Basic MeasurementsBasic Measurements

LEFT (Lower Extremity FFunctional unctional TTest)est)

SprintSprint--Front Front Sprint Sprint -- Retro Run Retro Run Side Shuffles Side Shuffles –– Both Ways Both Ways CariocasCariocas –– Both Ways Both Ways Figure 8’s Figure 8’s –– Both WaysBoth Ways4545°° Angle Cuts Angle Cuts –– Both WaysBoth Ways90% Angle Cuts 90% Angle Cuts –– Both WayBoth WayCrossCross--Over Steps Over Steps –– Both Ways Both Ways Sprint Sprint -- Front Front Sprint Sprint –– Retro RunRetro Run

Simulation of Simulation of multiple sports multiple sports performance performance

characteristics in characteristics in an an inin--clinic clinic

functional testfunctional test

Lower Extremity Functional TestLower Extremity Functional Test 10% “Puke Factor”!!! WOW !!!WOW !!!That’s a pretty complicatedcomplicated

test; but is it really reliable?

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ICCsICCs.95.95--.97.97

LOWER EXTREMITY LOWER EXTREMITY FUNCTIONAL TEST (LEFT)FUNCTIONAL TEST (LEFT) LEFTLEFT

When the When the LEFTLEFT is is li d di tli d di tnormalized according to normalized according to

the criteria the criteria (< 10% from (< 10% from the normative data)the normative data), then , then progression is to the next progression is to the next stage of the FTAstage of the FTA

Return to PlayReturn to PlayReturn to PlayReturn to PlayThese results suggest a significant These results suggest a significant relationship between LE OKC relationship between LE OKC testing (reciprocal leg press, single testing (reciprocal leg press, single leg squat, knee extension) and CKC leg squat, knee extension) and CKC f ti l t t ( i l l hf ti l t t ( i l l hfunctional tests (single leg hop, functional tests (single leg hop, vertical jump, speed/agility test).vertical jump, speed/agility test).

Negrete, R, et.al. The relationship between Negrete, R, et.al. The relationship between isokinetic OKC and CKC lower extremity isokinetic OKC and CKC lower extremity strength and functional performance. strength and functional performance. J Sport Rehab. 2002J Sport Rehab. 2002

Return to PlayReturn to PlayReturn to PlayReturn to PlayLower Extremity Functional Test

BrumittBrumitt, J, , J, HeiderscheidtHeiderscheidt, BC, , BC, ManskeManske, RM, , RM, NiemuthNiemuth, PE, , PE, RauhRauh, MJ. , MJ. Functional testing and predication of LE or low back injury Functional testing and predication of LE or low back injury among Damong D--III collegiate athletes. III collegiate athletes. InternatInternat J Sports Phys J Sports Phys TherTher. 8(3):2013. 8(3):2013BCH (~20 years ago)BCH (~20 years ago)RMM (~20 years ago)RMM (~20 years ago)PEN (~40 years ago)PEN (~40 years ago)

Functional Testing AlgorithmFunctional Testing AlgorithmSports Specific TestsSports Specific TestsLower Extremity Functional Tests Lower Extremity Functional Tests Functional Hop Tests Functional Hop Tests Functional Jump TestsFunctional Jump TestsFunctional Jump Tests Functional Jump Tests OKC Isokinetic Tests OKC Isokinetic Tests CKC Isokinetic Tests CKC Isokinetic Tests Kinesthetic/Balance Tests Kinesthetic/Balance Tests KT 1000 Tests KT 1000 Tests Basic MeasurementsBasic Measurements

Specificity Specificity TestingTesting

This isThis is individualizedindividualizedThis is This is individualizedindividualizedto the patientto the patient and and his/her specific ADL’s his/her specific ADL’s vocational or vocational or recreational activitiesrecreational activities

Sport Specific TestsSport Specific TestsWhen the sport specific When the sport specific tests are normalized tests are normalized according to the criteriaaccording to the criteria (<(<according to the criteria according to the criteria (< (< 10 % compared to sport 10 % compared to sport specific dataspecific data), then ), then progression is to return the progression is to return the patient back to practice and patient back to practice and then competitive sportsthen competitive sports

Functional Testing AlgorithmFunctional Testing Algorithm••Outcome performance scales:Outcome performance scales:

••ClinicianClinician--generatedgenerated impairment impairment measurementsmeasurements

••PatientPatient--centered selfcentered self--reportedreported valuesvalues••PatientPatient centered selfcentered self reported reported valuesvalues

••Generic/GlobalGeneric/Global HealthHealth--Related Quality of LifeRelated Quality of Life(HRQOL) scales(HRQOL) scales

••Generic Joint/pathology Generic Joint/pathology scales scales

••Specific Joint/activity Specific Joint/activity level scales level scales

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LE Specific LE Specific Outcome ScalesOutcome ScalesSmith, MV, et.al. Smith, MV, et.al. Lower extremityLower extremity--specific specific yy ppmeasures of disability measures of disability and outcomes in and outcomes in orthopaedic surgery.orthopaedic surgery.J Bone Joint J Bone Joint SurgSurg--AM. AM. 94:46894:468--477, 2012477, 2012

Outcome ScalesOutcome ScalesKOOSKOOSIKDCIKDCLysholmLysholmyyCincinnati Knee Rating Cincinnati Knee Rating ScaleScaleTegnerTegner Activity ScaleActivity ScaleACL Quality of Life ACL Quality of Life Marx Activity Scale Marx Activity Scale

Return to PlayReturn to Play--Psychological FactorsPsychological Factors

Return to PlayReturn to Play--Psychological FactorsPsychological Factors

Knee impairments and Knee impairments and psychological variables were psychological variables were associated with selfassociated with self report ofreport ofassociated with selfassociated with self--report of report of functionfunctionKinesiophobiaKinesiophobia needs to be needs to be addressed in rehab addressed in rehab

Lentz, et.al. Factors associated with function Lentz, et.al. Factors associated with function after ACLR. after ACLR. Sports Health. 1:47Sports Health. 1:47--53, 200953, 2009

Return to PlayReturn to Play--Psychosocial Measures Psychosocial Measures

Return to PlayReturn to Play--Psychosocial Measures Psychosocial Measures

Elevated painElevated pain--related fear of related fear of movement/removement/re--injuryinjury, quadriceps , quadriceps weakness, and reduced IKDC scores weakness, and reduced IKDC scores distinguish patients who are unabledistinguish patients who are unabledistinguish patients who are unable distinguish patients who are unable to return to preto return to pre--injury sports injury sports participation because of participation because of fear of refear of re--injury/lack of confidenceinjury/lack of confidence

Lentz, TA, et.al. Comparison of physical impairment, functional, and Lentz, TA, et.al. Comparison of physical impairment, functional, and Psychosocial measures based on fear of rePsychosocial measures based on fear of re--injury/lack of confidenceinjury/lack of confidenceand RTS status after ACLand RTS status after ACL--R.R.AJSM. 43(2):345AJSM. 43(2):345--353, 2015353, 2015

Return to PlayReturn to PlayReturn to PlayReturn to PlayFPTs as a measure of function: FPTs as a measure of function:

71%-used a battery of tests

29% used a single test

None of studies have construct or None of studies have construct or predictive validity for “return to predictive validity for “return to sport”sport”

NarducciNarducci, E, et.al. The clinical utility of functional , E, et.al. The clinical utility of functional performance tests within oneperformance tests within one--year postyear post--ACLACL--R: aR: asystematic review. IJSPT.6:333systematic review. IJSPT.6:333--342, 2011342, 2011

Return to PlayReturn to PlayReturn to PlayReturn to Play69 articles69 articles7556 participants7556 participants55% RTS 55% RTS –– competitive levelcompetitive levelRTS: LSIRTS: LSI--hop test, younger age, hop test, younger age, mmale gender, playing elite sport, ale gender, playing elite sport, positive psychological response positive psychological response

Arden, CL, et.al. 55% RT competitive sport following ACLArden, CL, et.al. 55% RT competitive sport following ACL--R surgery: R surgery: an updated systematic review and metaan updated systematic review and meta--analysis including aspects of analysis including aspects of physical functioning and contextual factors. physical functioning and contextual factors. BJSM 48:1543BJSM 48:1543--1552, 20141552, 2014

Functional Testing Algorithm• After passing the tests, the athlete After passing the tests, the athlete returns to:returns to:

• Sport specific training programs p p g p g

• Practice simulations

• Practices

• Scrimmages

• Competition

SummarySummary

AndAnd

C l iC l iConclusionsConclusions

Functional Testing AlgorithmFunctional Testing AlgorithmSports Specific Tests Sports Specific Tests Lower Extremity Functional Tests Lower Extremity Functional Tests Functional Hop Tests Functional Hop Tests Functional Jump TestsFunctional Jump TestsFunctional Jump Tests Functional Jump Tests OKC Isokinetic Tests OKC Isokinetic Tests CKC Isokinetic Tests CKC Isokinetic Tests Kinesthetic/Balance Tests Kinesthetic/Balance Tests KT 1000 Tests KT 1000 Tests Basic MeasurementsBasic Measurements

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FTA Specific GuidelinesFTA Specific GuidelinesLEFT LEFT –– MM--1:30; F1:30; F--2:00 minutes2:00 minutesHOP HOP -- < 10%Ht.; < 10%Ht.; < 10% < 10% bilatbilat. Comp.; . Comp.; Norms/various hops Norms/various hops JUMP JUMP -- < 15%/Ht.; Norms< 15%/Ht.; NormsOKC Isokinetics OKC Isokinetics -- < 25% bilateral < 25% bilateral comparison/other criteriacomparison/other criteriaC C ki iC C ki i 30% bil l30% bil lCKC Isokinetics CKC Isokinetics -- < 30% bilateral < 30% bilateral comparisoncomparisonKinesthetic/Balance Testing Kinesthetic/Balance Testing –– BilatBilatcompcompKT 1000 KT 1000 -- < 3 mm bilateral comparison< 3 mm bilateral comparisonBasic Measurements Basic Measurements -- < 10% bilateral < 10% bilateral comparisoncomparison

Functional Testing Algorithm Functional Testing Algorithm ––KneeKnee

Clinical decision making (CDM) Clinical decision making (CDM) (based on history, subjective exam, objective physical exam, imaging, etc.) states the athlete is ready to

t t ti itreturn 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 ImplicationsClinical ImplicationsAs As Davies Davies has said has said

for the last 51 for the last 51 years, it years, it MUSTMUST be an be an y ,y ,

INTEGRATED INTEGRATED APPROACH for APPROACH for

testing and testing and rehabilitation !!!rehabilitation !!!

Thanks ToThanks ToRush Sports Rush Sports

MedicineMedicineSymposiumSymposium

Thank YouThank You