This page is continually under construction – I am still adding content and I’m always finding new references as well as changing where I find relevant information. 

Websites:

MikeReinold.comThis is a great go-to website to visit to get relevant information in the field of physical therapy, rehabilitation, and performance enhancement…especially if you are interested in the shoulder, throwing athletes/baseball.  It is geared for those practitioners in the field, but is packed with great knowledge for a large audience.

EricCressey.com – A site from a fantastic strength and conditioning coach who has a Master’s in Kinesiology and is well-repected in the performance enhancement arena.  He trains, writes and speaks with a very in-depth knowledge and understanding of how the body functions.

JeffCubos.com/ – The author of this site is a Chiropractor who takes a very active approach in treating the entire body as a functional unit and is heavily interested in all tissues involved…not just the spine.  He works with elite athletes and is an author and educator.  I really enjoy his functional approach to patient care.

GrayCook.comGray Cook is a Board-Certified Orthopedic Clinical Specialist, a Strength & Conditioning Coach and a USWLF Weightlifting Coach. He is an internationally-recognized speaker, the author of Movement: Functional Movement Systems—Screening, Assessment, Corrective Strategies (2010), along with a passionate advocate for human movement.  Gray is such a dynamic presence from whom I try to absorb as much about functionality as I can.

Greg Lehman – Greg is someone who consistently and respectfully challenges traditional views of pain, rehab and treatment/education of others.  He is highly involved in the research and is great at citing his viewpoints, which are rooted in evidence, not opinion.  I have learned a great deal from his approach to challenging convention…even moreso than his well-packaged teaching on pain science as it is understood currently.  He is very active and engaging on Twitter, as well.

Adam Meakins – Better known as the Sports Physio.  Adam pitches himself as honest, practical and evidence-based.  His approach to rehab is exercise and education only.  He makes no apologizes on his views of “Manual therapy sucks”.  Adam has facilitated my thought process in how I critically think and challenge conventional wisdom, and has brought many valuable perspectives and objections that hope to advocate for change in the rehab world…much needed change in many instances.  While I still seek Adam’s views on the PT and rehab world, I also recognize that he is intentionally inflammatory and provocative.  I feel he does this to help his in-your-face brand.  Middle of the road does not garner you popularity.  At times he is clever and funny, at times he calls out those that need to be called out, and at times he crosses the line and is non-professional and unapologetically insulting.  While I do not endorse how he carries himself, I do recommend his content to those wanting to be challenged and maybe open your mind…but not if you are easily offended.

optimumsportsperformance.com/blog/ Patrick Ward, MS LMT is a specialist in soft tissue treatment.  Here is a quote from him:  “My view of passive care is that it can be used to help “open the window” to getting you pain free or improving range of motion in some region of the body. However, if the individual does nothing when that window is opened, then the window slowly begins to close and the person is right back at where they started.”  I AGREE 100%.  This view and the content he puts out on his own website, as well as guest posts on other’s sites, is why I enjoy his knowledge and information.

MobilityWod.com/ “All human beings should be able to perform basic maintenance on themselves”.  I think Kelly Starrett, DPT is an intellgent, strong, mobile and high functioning individual.  The content he puts out is all mobility-based and very often challenges the more traditional way of thinking.  I appreciate that aspect.  I frequently check to see what he is saying.  However, he does push the envelope at times, and I think he does this to create discussion/stir the pot.  This manner of challenging the norm can be innovative – it may be too aggressive, especially for beginners, though.

Functionalanatomyblog.com Dr. Andreo Spina B. Kin, DC, FCCSS(C), D.Ac, CPT is a Sports Chiropractor, Personal Trainer, Medical Acupuncturist and creator/developer of Functional Anatomy Seminars & Functional Range Release training.  He is a very intelligent guy who talks the talk AND walks the walk.  High level training for those in the field, not geared for the lay person.

SportsRehabExpert.com – A site featuring:  Joe Heiler PT, CSCS, Michael Boyle MA, ATC; Gray Cook MSPT, OCS, CSCS; Eric Cressey MA, CSCS; Dr. Craig Liebenson D.C.; Kevin Neeld, CSCS; Darcy Norman PT, ATC, CSCS; Robert Panariello, MS, PT, ATC, CSCS; Michael Reinold, PT, DPT, ATC, CSCS; Greg Rose DC; Nick Tumminello; Tim Vagen CSCS; Charlie Weingroff PT, ATC, CSCS…among numerous other practitioners – all are very respected in their fileds.

NSCA – National Strength and Conditioning Association

PubMed.comFor anyone looking for scientific-based research and literature, this is where to go.

http://droualb.faculty.mjc.edu/Lecture%20Notes/Unit%203/muscles%20with%20figures.htm – Dr. Robert Droual at Madesto Junior College has listed Anatomy images that are wonderfully laid out in easy-to-follow and easy-to-view set up.

Books:

Pain Management

Treat Your Own backThis is a short must-have book by Robin McKenzie that addresses the best way to manage back pain efficiently and with movement, NOT immobility. 

The Trigger Point Therapy WorkbookBased on the work of Travell & Simmons, this workbook points out common sites of trigger points and shows ways to manage your own musculoskeletal pain.

How The Body Works

Assessment and Treatment of Muscle Imbalance Author, Vladimir Janda, MD was one of the first physicians to promote the  evaluation of movement quality vs. movement quantity.  He coined the term, Regional Interdependence – “The motor system functions as an entity, it is in principle a wrong approach to try to understand impairments of different parts of the motor system separately, without understanding the function of the motor system as a whole.” The concept that seemingly unrelated impairments in one area of the body may be associated with the patient’s primary complaint…Vladimir Janda.  As a physical therapist, I see this true in action every day.  Brilliant!

Movement My favorite quote – “First move well.  Then move often”  is from author, Gray Cook.  I preach this concept to my patients.   Way too often we try to do things that are good for us, but fall short because we have dysfunction in other places (i.e running, lifing weightes, walking, crunches, treadmill, swimming, etc is not always good or always bad – It is HOW we do these things).  “When challenged, the human body will always sacrifice quality over quantity”…Gray Cook.  There will be a good deal of content on my site that stems from a functional movement approach like this.  We HAVE to move well before anything else we do!

Anatomy for Runners: Unlocking Your Athletic Potential for Health, Speed, and Injury Prevention – Author, Jay Dicharry decided to combine different fields of clinical care, biomechanical analysis, and coaching to help you avoid common injuries and become the best runner you can be.  Along with clear and thorough explanations of how running influences the body, and how the body influences your running, this book answers many of the common questions that athletes have: Do runners need to stretch? What is the best way to run? What causes injuries? Which shoes are best for running? Is running barefoot beneficial?  He adds mobility and stability tests that will assess your form, and the corrective exercises, along with step-by-step photos, will improve your core and overall performance, so that you can train and run with confidence, knowing how to avoid injuries…VERY well laid out and with great analogies that make a ton of sense.  Jay Dicharry is brilliant in the field of running!

Orthopedic Physical AssessmentA textbook for those in the field of rehabilitation, but it is pretty comprehensive with the basics that provide a great foundation…not cutting edge research, but again, good foundation. 

Journals:

Journal of Orthopaedic & Sports Physical Therapy – JOSPT

American Journal of Sports Medicine – AJSM

Physical Therapy – PTJ (Journal of the APTA)

American College of Sports Medicine – ACSM

British Journal of Sports Medicice – BJSM 

International Journal of Sports Physical Therapy/North American Journal of Sports Physical Therapy – IJSPT/NAJSPT

Journal Articles (just a few examples):

Earl J, & Hoch A. (2011). A Proximal Strengthening Program Improves Pain, Function, and Biomechanics in Women With Patellofemoral Pain Syndrome. American Journal of Sports Medicine , 154-163.

Reinold M, Escamilla R, & Wilk K. (2009). Current Concepts in the Scientific and Clinical rationale behind Exercises for Glenohumeral and Scapulothoracic Musculature.  Journal of Orthopaedic & Sports Physical Therapy. (39):105-117.

Hal Townsend, F. (1991). Electromyographic Analysis of the Glenohumeral Muscles During a Baseball Rehabilitation Program. The American Journal of Sports Medicine , 264-271.

Ireland M, et al. (2003). Hip Strength in Females With and Without Patellofemoral Pain. Journal of Orthopaedic & Sports Physical Therapy, 671-676.

Mascal C., Landel R, & Powers C. (2003). Management of Patellofemoral Pain Targeting Hip, Pelvis, and Trunk Muscle Function: 2 Case Reports. Journal of Orthopaedic & Sports Physical Therapy, 647-660.

Kibler B. et al.  ( Jan 1991).  Functional Biomechanical Deficits in Running Athletes with Plantar Fasciitis.   The American Journal of Sports Medicine, 19: 66-71.

Purdam C, Jonsson P, Alfredson H, et al. (Aug 2004). A Pilot Study of the Eccentric Decline Squat in the Management of Painful Chronic Patellar Tendinopathy. British Journal of Sports Medicine, 38(4):395-7.

Jonsson P, Alfredson H. (Nov 2005). Superior Results with Eccentric Compared to Concentric Quadriceps Training in Patients with Jumper’s Knee: A Prospective Randomised Study. British Journal of Sports Medicine, 39(11):847-50.

Reinold M, Gill T.  (Jan 2009) Current Concepts in the Evaluation and Treatment of the Shoulder in Overhead Throwing Athletes, Part 1: Physical Characteristcs and Clinical Examination.  Sports Health: A Multidisciplinary Approach.  Published by SAGE on behalf of: American Orthopaedic Society of Sports Medicine.

Reinold M, Gill T, Wilk K, Andrews J.  (2010). Current Concepts in the Evaluation and Treatment of the Shoulder in Overhead Throwing Athletes, Part 2: Injury Prevention and Treatment.  Sports Health: A Multidisciplinary Approach 2:101. Published by SAGE on behalf of: American Orthopaedic Society of Sports Medicine.

Myers J, Lephart S.  (2000). The Role of the Sensorimotor System in the Athletic Shoulder. Journal of Athletic Training.  35(3):351-363.

Wilk K, Macrina L, Reinold M. (2006). Non-Operative Rehabilitation for Traumatic and Atraumatic Glenohumeral Instability. North American Journal of Sports Physical Therapy. 1:16-31.

Ghodadra N, Provencher M, Verma N, Wild K, Romeo A. (2009).  Open, Mini-open, and All-Arthroscopic Rotator Cuff Repair Surgery: Indications for Rehabilitation.  Journal of Orthopaedic & Sports Physical Therapy, 39(2): 81.

Heiler J.  Core Stability vs. Core Strength.  June 2009 from http://physicaltherapist.com.

McGill S.  (2007).  Designing Back Exercise: From Rehabilitation of Enhancing Performance. http://backfitpro.com.

Hegedus E, Goode A, Campbell S, Morin A, Tamaddoni C, et al. (2008). Physical Examination Tests of the Shoulder: A Systematic Review with Meta-Analysis of Individual Tests.  British Journal of Sports Medicine. 42(2):80-92.

Cordasco, F. (2000). Understanding Multidirectional Instability of the Shoulder. Journal of Athletic Training. 35(3): 278-285.

Wilk K, Arrigo C, Andrews J. (1997). Current Concepts: The Stabilizing Structures of the Glenohumeral Joint. Journal of Orthopaedic & Sports Physical Therapy. 25(6): 364-379.

Wilk K, Arrigo C, Andrews J. (1997). The Physical Examination of the Glenohumeral Joint: Emphasis on the Stabilizing Structures. Journal of Orthopaedic & Sports Physical Therapy. 25(6): 364-379.

Welsh C, Hanney W, Podschun L, Kolber M. (2010). Rehabilitation of a Female Dancer with Patellofemoral Pain Syndrome: Applying Concepts of Regional Interdependence in Practice. North American Journal of Sports Physical Therapy. 5(2): 85-97.

Chorba R, Chorba D, Bouillon L, Overmyer  C, Landis J. (2010). Use of a Functional Movement Screening Tool to Determine Injury Risk in Female Collegiate Athletes. North American Journal of Sports Physical Therapy. 5(2): 47-54.

American Academy of Pediatricians. Policy statement: baseball and softball. Pediatrics. 2012;129:e842-e856.

American Sports Medicine Institute. Position statement for youth baseball pitchers. http://www.asmi.org/asmiweb/position_statement.htm. Accessed March 10, 2016.

Cain EL Jr, Andrews JR, Dugas JR, et al. Outcome of ulnar collateral ligament reconstruction of the elbow in 1281 athletes: results in 743 athletes with minimum 2-year follow-up. Am J Sports Med. 2010;38:2426-2434.

Chen FS, Rokito AS, Jobe FW. Medial elbow problems in the over head throwing athlete. J Am Acad Orthop Surg. 2001;9:99-113.

Dun S, Loftice J, Fleisig GS, Kingsley D, Andrews JR. A biomechanical comparison of youth baseball pitches: is the curveball potentially harmful? Am J Sports Med. 2008;36:686-692.

Fleisig GS, Andrews JR, Cutter GR, et al. Risk of serious injury for young baseball pitchers: a 10-year prospective study. Am J Sports Med. 2011;39:253-257.

Fleisig GS, Barrentine SW, Zheng N, Escamilla RF, Andrews JR. Kinematic and kinetic comparison of baseball pitching among various levels of development. J Biomech. 1999;32:1371-1375.

Olsen SJ, Fleisig GS, Dun S, Loftice J, Andrews JR. Risk factors for shoulder and elbow injuries in adolescent baseball pitchers. Am J Sports Med. 2006;34:905-912.

Fleisig GS, Bolt B, Fortenbaugh D, Wilk KE, Andrews JR. Biomechanical comparison of baseball pitching and long-toss: implications for training and rehabilitation. J Orthop Sports Phys Ther. 2011;41:296-303.

Fleisig GS, Kingsley DS, Loftice JW, et al. Kinetic comparison among the fastball, curveball, change-up, and slider in collegiate baseball pitchers. Am J Sports Med. 2006;34:423-430.

Fleisig GS, Phillips R, Shatley A, et al. Kinematics and kinetics of youth baseball pitching with standard and lightweight balls. Sports Engineering. 2006; 9:155-163.

Fleisig GS, Weber A, Hassell N, Andrews JR. Prevention of elbow injuries in youth baseball pitchers. Curr Sports Med Rep. 2009;8:250-254.

Fortenbaugh D, Fleisig GS, Andrews JR. Baseball pitching biomechanics in relation to injury risk and performance. Sports Health. 2009;1:314-320.

Little League Baseball. Protecting young pitching arms. http://www.littleleague.org/Assets/old_assets/media/pitch_count_publication_2008.pdf. Accessed February 12, 2016.

Nissen CW, Westwell M, Õunpuu S, Patel M, Solomito M, Tate J. A biomechanical comparison of the fastball and curveball in adolescent baseball pitchers. Am J Sports Med. 2009;37:1492-1498.

Nissen CW, Westwell M, Ounpuu S, et al. Adolescent baseball pitching technique: a detailed three-dimensional biomechanical analysis. Med Sci Sports Exerc. 2007;39:1347-1357.

Sabick MB, Kim YK, Torry MR, Keirns MA, Hawkins RJ. Biomechanics of the shoulder in youth baseball pitchers: implications for the development of proximal humeral epiphysiolysis and humeral retrotorsion. Am J Sports Med. 2005;33:1716-1722.

Stop Sports Injuries. http://www.stopsportsinjuries.org. Accessed on March 19, 2014

https://mikereinold.com/tag/weighted-ball-program. Accessed on March 10, 2016

Hodgins JL, Vitale M, Arons RR, Ahmad CS. Epidemiology of Medial Ulnar Collateral Ligament Reconstruction: A 10-Year Study in New York State. Am J Sports Med. 2016 Mar;44(3):729-34.

Images:

Many images are used from Google Images and are used to demonstrate movement techniques and not intended to infringe upon any creative property, as this site is for educational and non-profit use.

Literature Reviews:

Functional Movement Screen
Chorba RS, Chorba DJ, Bouillon LE, Overmyer CA, Landis JA. Use of functional movement screening tool to determine injury risk in female collegiate athletes. N Am J Sports Phys Ther. 2010;5:47-54.

Summary – 38 Division II female collegiate athletes were involved in this study (basketball, volleyball, soccer). FMS was performed pre-season and athletes were tracked for injuries throughout the season. Results: Scoring 14/21 or less was significantly associated with injury, resulting in a 4x greater risk of lower extremity. 69% of those who scored 14/21 or less suffered a lower extremity injury.

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Bardenett SM, Micca JJ, Denoyelles JT, Miller SD, Jenk DT, Brooks GS. Functional movement screen normative values and validity in high school athletes: Can the FMS™ be used as a predictor of injury?. Int J Sports Phys Ther. 2015;10(3):303-8.

Summary – 167 high school athletes across a variety of sports were tested using the FMS tool and tracked for injury throughout their season. Results: No statistically significant difference between overall score and injury was noted. However, this study provides normative data on the FMS tool and its 7 components for high school athletes in general. Overall scores for non-injured athletes were 13.11+-1.69 and injured athletes scores were 13.00+-2.32.

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Garrison M, Westrick R, Johnson MR, Benenson J. Association between the functional movement screen and injury development in college athletes. Int J Sports Phys Ther. 2015;10(1):21-8.

Summary – 160 collegiate athletes (men and women of a variety of sports) were scored on the FMS tool pre-season and tracked for injury during season. Results: 52 of the athletes in the study sustained some type of injury requiring medical attention. Overall scores for the injured group were 13.6 while the non-injured group were 15.5, indicating a statistically significant difference. A major finding of the study was that scoring 14/21 or less on the FMS tool combined with a history of injury resulted in a 15-fold increase in injury risk compared to an athlete scoring 15/21 or higher and with no history of injury.

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Cuchna JW, Hoch MC, Hoch JM. The interrater and intrarater reliability of the functional movement screen: A systematic review with meta-analysis. Phys Ther Sport. 2015;

Summary – Seven papers were assessed to determine interrater and intrarater reliability of the FMS tool. Results: The FMS had moderate reliability for both forms. ICC for interrater reliability was 0.843 and the ICC for intrarater reliability was 0.869. Overall, the authors concluded that the FMS is a reliable tool for clinical practice.

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Kiesel K, Plisky PJ, Voight M. Can serious injury in professional football be predicted by a preseason functional movement screen? NAJSPT. 2007;2(3):147-158

Summary – One professional football team performed the FMS tool pre-season (N=46) and was tracked for serious injury (>3 weeks on the injury reserve list) throughout the season. Results: Scoring 14 or less on the FMS tool was able to predict serious injury with a specificity of 0.91, odds ratio of 11.67, and a positive likelihood ratio of 5.92.

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Kiesel KB, Plisky PJ, Butler RJ. Functional Movement Test Scores Improve following an Offseason Intervention Program in Professional Football Players. Scand J Med Sci Sport 2011; 21(2): 287-92.

Summary – 62 professional football players performed the FMS during the off-season then underwent a 7 week intervention program to combat asymmetries in movement. The FMS was then administered post-intervention: Results: This study demonstrated that FMS scores can improve with targeted intervention. However, it cannot be concluded that an improved FMS score results in a decreased injury risk.

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FOTO (CAT)

Hart DL, Wang YC, Stratford PW, Mioduski JE. A computerized adaptive test for patients with hip impairments produced valid and responsive measures of function. Arch Phys Med Rehabil. 2008;89(11):2129-39.

Summary – To describe the use of a computerized adaptive test (CAT) in routine clinical practice and evaluate content coverage and construct validity, sensitivity to change, and responsiveness of hip CAT functional status (FS) measures. Two hundred fifty-seven outpatient rehabilitation clinics in 31 states (United States). Two samples were examined: intake and discharge rehabilitation FS data from patients (N=8714) treated for hip impairments between January 2005 and June 2007 and data from patients (N=444) used to develop the hip CAT were examined for comparison (2002-2004).
Results: Sixty-one percent of patients obtained discharge FS measures greater than or equal to minimal detectable change (95% confidence intervals). Change of 6 FS units (scale: 0-100) represented minimal clinically important improvement, which 64% of patients obtained. The hip CAT was efficient; produced valid, responsive measures of FS for patients receiving therapy for hip impairments; and functioned well in routine clinical application but would benefit from more difficult items.
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Hart DL, Mioduski JE, Stratford PW. Simulated computerized adaptive tests for measuring functional status were efficient with good discriminant validity in patients with hip, knee, or foot/ankle impairments. J Clin Epidemiol. 2005 Jun;58(6):629-38. PubMed PMID: 15878477

Summary –
To develop computerized adaptive tests (CATs) designed to assess lower extremity functional status (FS) in people with lower extremity impairments using items from the Lower Extremity Functional Scale and compare discriminant validity of FS measures generated using all items analyzed with a rating scale Item Response Theory model (theta(IRT)) and measures generated using the simulated CATs (theta(CAT)).
Patients were separated into three body part specific groups. Three body part specific CATs were developed: each was 70% more efficient than using all LEFS items to estimate FS measures. Conclusion: Body part-specific simulated CATs were efficient and produced precise measures of FS with good discriminant validity
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Wang YC, Hart DL, Stratford PW, Mioduski JE. Clinical interpretation of computerized adaptive test-generated outcome measures in patients with knee impairments. Arch Phys Med Rehabil. 2009 Aug;90(8):1340-8. PubMed PMID: 19651268.

Summary – To describe meaningful interpretations of functional status (FS) outcomes measures estimated using a body-part specific computerized adaptive test (CAT). Outpatient physical therapy clinics (291 clinics) in 30 U.S. states. Sample of 21,896 patients with knee impairments receiving outpatient physical therapy.
RESULTS:
We investigated 4 approaches to clinically meaningful interpretations of outcomes data: (1) 95% confidence interval for each score estimate, (2) percentile rank of FS scores, (3) responsiveness, and (4) functional staging. Overall, precision of a single score was estimated by FS score +/-5. Based on score distribution, percentile ranks at 25th, 50th, and 75th percentiles corresponded to intake FS scores of 33, 42, and 51 and discharge FS scores of 51, 61, and 74, respectively. Results showed that 9 or higher FS change units represented statistically and clinically important improvement. Patients were classified into 6 hierarchical levels of FS using functional staging.
CONCLUSIONS:
Results suggest how CAT-generated outcomes measures can be interpreted to assist clinicians and patients during rehabilitation.
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Hart DL, Wang YC, Stratford PW, Mioduski JE. Computerized adaptive test for patients with knee impairments produced valid and responsive measures of function. J Clin Epidemiol. 2008;61:1113-24.

Summary –
Assess practicality of using a computerized adaptive test (CAT) in routine clinical practice, perform a psychometric evaluation of content range coverage and test precision, and assess known group construct validity, sensitivity to change and responsiveness of knee CAT functional status (FS) measures. A convenience sample of 21,896 patients with knee impairments receiving outpatient physical therapy in 291 clinics in 30 U.S. states (2005-2007).
RESULTS:
The CAT used an average of seven items to produce precise estimates of FS that adequately covered the content range with negligible floor and ceiling effects. Test information functions and standard errors supported FS measure precision. FS measures discriminated patients by age, symptom acuity, surgical history, condition complexity, and prior exercise history in clinically logical ways. Seventy-two percent of patients obtained discharge FS measures > or = minimal detectable change (95% confidence interval). Change of 9 FS units (0-100 scale) represented minimal clinically important improvement, which 67% of patients obtained.
CONCLUSION:
The knee CAT was efficient and produced precise, valid, and responsive measures of FS for patients receiving therapy for knee impairments and functioned well in routine clinical application.
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Wang YC, Hart DL, Stratford PW, Mioduski JE. Clinical interpretation of computerized adaptive test generated outcomes measures in patients with foot/ankle impairments. J Orthop Sport Phys 2009;39(10):753-64.

Summary –
Prospective cohort study of 10,287 patients with foot/ankle impairments receiving outpatient physical therapy.
Performed 4 approaches to clinically interpret outcomes data. First, used the standard error of the estimate to construct a 90% confidence interval for each CAT estimated score. Second, presented the percentile rank of FS scores. Third, used 2 threshold approaches to define individual-patient-level change: statistically reliable change and clinically important change. Last, illustrated a functional staging method.
RESULTS:
Precision of a single score was estimated by an FS score of +/-4. Based on score distribution, percentile ranks at 25th, 50th, and 75th percentiles corresponded to intake FS scores of 38, 47, and 57, and discharge FS scores of 52, 64, and 77, respectively. Minimal detectable change supported 7 or more FS change units out of 100 represented statistically reliable change, and ROC analyses supported 8 or more FS change units represented minimal clinically important improvement. Using a functional staging system, we established 5 hierarchical functional status levels.
CONCLUSION:
CAT-generated outcome measures can be interpreted to improve clinical interpretation and to assist clinicians in using patient-reported outcomes during therapy practice.
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Hart DL, Wang YC, Stratford PW, Mioduski JE. Computerized adaptive test for patients with foot or ankle impairments produced valid and responsive measures of function. Qual Life Res. 2008;17:1081-91.

Summary – Data from 10,287 patients with foot or ankle impairments receiving outpatient physical therapy were analyzed. We first examined the unidimensionality, fit, and invariance IRT assumptions of the CAT item bank. Then we evaluated the efficiency of the CAT administration and construct validity and sensitivity of change of the foot/ankle CAT measure of lower-extremity functional status (FS).
RESULTS:
Results supported unidimensionality, model fit, and invariance of item parameters and patient ability estimates. On average, the CAT used seven items to produce precise estimates of FS that adequately covered the content range with negligible floor and ceiling effects. Patients who were older, had more chronic symptoms, had more surgeries, had more comorbidities, and did not exercise prior to receiving rehabilitation reported worse discharge FS. Seventy-one percent of patients obtained statistically significant change at follow-up. Change of 8 FS units (scale 0-100) represented minimal clinically important improvement.
CONCLUSIONS:
We concluded that the foot/ankle item bank met IRT assumptions and that the CAT FS measure was precise, valid, and responsive, supporting its use in routine clinical application.
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Wang YC, Hart DL, Stratford PW, Mioduski JE. Clinical interpretation of a lower-extremity functional scale-derived computerized adaptive test. Phys Ther. 2009 Sep;89(9):957-68. PubMed PMID: 19628577.
Summary – The purpose of this study was to describe meaningful interpretations of functional status (FS) outcome measures estimated with a body part-specific CAT developed from the Lower-Extremity Functional Scale (LEFS).
This investigation was a prospective cohort study of 8,714 people who had hip impairments and were receiving physical therapy in 257 outpatient clinics in 31 states (United States) between January 2005 and June 2007.
RESULTS:
The precision of a single score was estimated from the FS score +/-4. On the basis of the score distribution, 25th, 50th, and 75th percentile ranks corresponded to intake FS scores of 40, 48, and 59 and discharge FS scores of 50, 61, and 75, respectively. The reliable change index supported the conclusion that changes in FS scores of 7 or more units represented statistically reliable change, and receiver operating characteristic analyses supported the conclusion that changes in FS scores of 6 or more units represented minimal clinically important improvement. Participants were classified into 5 hierarchical levels of FS using a functional staging method.
CONCLUSIONS:
The results demonstrated how outcome measures generated from the hip LEFS CAT can be interpreted to improve clinical meaning. This finding might facilitate the use of patient-reported outcomes by clinicians during rehabilitation services.

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Star Excursion & Y Balance Test

Gribble PA, Hertel J, Plisky P. Using the Star Excursion Balance Test to assess dynamic postural-control deficits and outcomes in lower extremity injury: a literature and systematic review. J Athl Train. 2012;47(3):339-57.
Summary – SEBT (with all 8 directions): Intratester reliability (0.78 to 0.96), Intertester reliability (0.35 to 0.84 day 1 & 0.81 to 0.93 day 2). Poor Intertester reliability was attributed to a learning/practice effect. They recommended having participants perform 6 practice trials in each direction before recording scores to reduce this.
Y-Balance Test: Intratester reliability (0.85 to 0.89), Intertester reliability (0.97 to 1.00)
Male and female high school basketball players from 7 schools – athletes with anterior right-to-left reach differences of more than 4 cm were 2.5 times more likely to sustain lower extremity injuries. They also found that girls with a composite reach score of less than 94% of their limb length were 6.5 times more likely to sustain a lower extremity injury.
Conclusions:
“The Modified SEBT has been shown to be a reliable measure and has validity as a dynamic test to predict risk of lower extremity injury, to identify dynamic balance deficits in patients with a variety of lower extremity conditions, and to be responsive to training programs in both healthy participants and participants with lower extremity injuries. Clinicians and researchers should be confident in employing the SEBT as a lower extremity functional test.”
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Clanton TO, Matheny LM, Jarvis HC, Jeronimus AB. Return to play in athletes following ankle injuries. Sports Health. 2012;4(6):471-4.
“Once an ankle sprain occurs, up to 80% will suffer recurrent sprains, and up to 72% develop recurrent symptoms or chronic instability…Recurrence most strongly correlates with premature return to sport and a prior ankle injury.”
CKC Dorisflexion Lunge Test. “The distance from the foot to the wall is measured; less than 9 to 10 cm is considered restricted. Also, the angle of the tibial shaft in reference to the wall is measured; less than 35° to 38° is restricted. The intra- and interrater reliability of this test has been confirmed. This test is predictive of future injury in cricket and soccer.”
SEBT & YBT “The posteromedial component is the most representative of overall performance on the original 8 components. The SEBT has excellent intraobserver reliability and is sensitive for ankle instability. The SEBT is a predictive measure of lower extremity injury in high school basketball players.”
Agility T-Test. “Typical times for athletic adults are between 8.9 to 13.5 seconds; high reliability has been demonstrated.”
Vertical Leap Test: “Efficiency index = weight (lb) × jump (in) / height (in). The sargent jump test is a reliable test for the estimation of explosive power of the lower limb.”
Psychological Factors: “Athletes who demonstrate apprehension, fear, or anxiety are at a much greater risk of reinjury, and there is often a deleterious effect on athletic performance. Scoring systems can formally assess this component: Trait Sport Confidence Inventory, State Sport Confidence Inventory, and the Injury-Psychological Readiness to Return to Sport Scale.”
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Brumitt J, Heiderscheit BC, Manske RC, Niemuth PE, Rauh MJ. Lower extremity functional tests and risk of injury in division iii collegiate athletes. Int J Sports Phys Ther. 2013;8(3):216-27.

Summary –
Prospective cohort study of DIII athletes from multiple sports looking at standing long jump (SLJ) test, the single?leg hop (SLH) for distance test, and the lower extremity functional test (LEFT) as preseason screening tools to identify collegiate athletes who may be at increased for low back or lower extremity injury.
“The single?leg hop for distance and the lower extremity functional test, when administered to Division III athletes during the preseason, may help identify those at risk for a time?loss low back or lower extremity injury.”

LEFT (Lower Extremity Functional Test) (forward run, backward run, side shuffle, carioca, figure 8 run, 45º cuts, 90º cuts)
Female athletes with LEFT scores <118 s were 6 times more likely (OR=6.4, 95% CI: 1.3, 31.7) to sustain a thigh or knee injury.

SLH (Single Leg Hop for Distance)
Female athletes with > 10% asymmetry SLH distances had a 4?fold increase in foot or ankle injury (cut point: >10%; OR=4.4, 95% CI: 1.2, 15.4).
Limitation Notes
Male athletes with higher SLH were more likely to be injured. Proposed reasoning is more playing time and more dynamic lower extremity sport with sprinting/cutting.
Male athletes with higher LEFT scores were more likely to be injured.
Population was not homogeneous, multiple sports were studied.

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Plisky PJ, Rauh MJ, Kaminski TW, Underwood FB. Star Excursion Balance Test as a predictor of lower extremity injury in high school basketball players. J Orthop Sports Phys Ther. 2006;36(12):911-9.

Summary – Prospective Cohort of 235 high school basketball players.

“The reliability of the SEBT components ranged from 0.82 to 0.87 (ICC3,1) and was 0.99 for the measurement of limb length. Logistic regression models indicated that players with an anterior right/left reach distance difference greater than 4 cm were 2.5 times more likely to sustain a lower extremity injury (P_.05). Girls with a composite reach distance less than 94.0% of their limb length were 6.5 times more likely to have a lower extremity injury (P_.05).”

Limitations
1 basketball season at 7 high schools
Data set that was used to determine the ROC cutoff point was used to test the cutoff point in the prediction model.
DIR was collected monthly, not weekly.
One time completion of questionnaire at end of season.
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Plisky PJ, Gorman PP, Butler RJ, Kiesel KB, Underwood FB, Elkins B. The reliability of an instrumented device for measuring components of the star excursion balance test. N Am J Sports Phys Ther. 2009;4(2):92-9.

Summary – Sample of 15 male collegiate soccer players.
“The ICC for intrarater reliability ranged from 0.85 to 0.91 and for interrater reliability ranged from 0.99 to 1.00. Composite reach score reliability was 0.91 for intrarater and 0.99 for interrater reliability.”
“A need exists to collect normative data using the Y Balance Test™ on varied populations (e.g. collegiate, high school, basketball, hockey, elderly, firefighters, etc). With normative data and prospective studies, the Y Balance Test™ could be evaluated for prediction of injury in different populations and establish acceptable reach distances for each population.”
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Hop Testing

Hegedus EJ, Mcdonough S, Bleakley C, Cook CE, Baxter GD. Clinician-friendly lower extremity physical performance measures in athletes: a systematic review of measurement properties and correlation with injury, part 1. The tests for knee function including the hop tests. Br J Sports Med. 2015;49(10):642-8.

Summary – There are six physical performance tests (PPTs) pertinent to the knee that have been substantially studied so that we have some idea of their metrics (reliability, agreement, validity, responsiveness) in an athletic population: the one leg hop for distance, the triple hop for distance, the 6?m timed hop, the crossover hop for distance, the triple jump, and the single leg vertical leap. The one leg hop for distance is the most studied PPT at the knee and yet we know only that this test is discriminative in males with ACL tears and that it is responsive to rehabilitation after ACL tear. For all other PPTs at the knee, there is limited, conflicting or unknown evidence regarding their measurement properties. The ability of PPTs to predict knee injury is unknown. Caution is urged in making any firm clinical conclusions based on the results of PPTs when testing the knee and in deciding whether an observed change in these outcome measures is meaningful in athletes

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Reid A, Birmingham TB, Stratford PW, Alcock GK, Giffin JR. Hop testing provides a reliable and valid outcome measure during rehabilitation after anterior cruciate ligament reconstruction. Phys Ther. 2007; 87(3):337-49.

Summary – 42 patients who had undergone ACL reconstruction participated in the study, ages 15-45. Results: The authors concluded that these hop tests are reliable and valid for this population and should be recommended for clinical practice and research.

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Munro AG, Herrington LC. Between-session reliability of four hop tests and the agility T-test. J Strength Cond Res. 2011; 25(5):1470-7.

Summary – Study participants included 11 male and 11 female college-aged recreational athletes. This study showed that all three hop tests for distance were reliable and can be performed in the clinical setting. However, the timed-hop test did not display good reliability which questions its use. However, there is a learning effect with the hop tests which should be accommodated by adequate practice trials.

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Myer GD, Schmitt LC, Brent JL, Ford KR, Barber Foss KD, Scherer BJ, Heidt RS Jr, Divine JG, Hewett TE. Utilization of modified NFL combine testing to identify functional deficits in athletes following ACL reconstruction. J Orthop Sports Phys Ther. 2011; 41(6):377-87.

Summary – This study was a case control design. It looked at 18 patients of high-school age that had come back to their sport within a year of having an ACL reconstruction.There were 20 control group members that were matched for age, gender, and sport for each of the experimental group participants. Bilateral tasks (vertical jump, bilateral broad jump), modified bilateral tasks (long shuttle, modified agility T-Test, pro shuttle), and unilateral single leg tasks (single hop, triple hop, triple crossover hop) were performed. This study demonstrated that Limb Symmetry Index from unilateral hopping tests were able to differentiate between athletes with ACL reconstruction versus control subjects whereas bilateral and modified bilateral tasks were not able to differentiate between the study and control groups.

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Hamilton RT, Shultz SJ, Schmitz RJ, Perrin DH. Triple-hop distance as a valid predictor of lower limb strength and power. J Athl Train. 2008;43(2):144-51.

Summary – Study participants included 40 NCAA Division I-AA soccer athletes with equal distribution between genders. Triple hop distance and a variety of strength, power, and balance measures were completed in order to determine how well triple hop distance correlated with these measures. Overall, the study concluded that the triple hop test is a good predictor of lower extremity strength and power.
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Hamilton RT, Shultz SJ, Schmitz RJ, Perrin DH. Triple-hop distance as a valid predictor of lower limb strength and power. J Athl Train. 2008;43(2):144-51.

Summary – Within-subjects correlational design, 40 D-I soccer players.
Triple hop was compared to vertical jump, isokinetic quadriceps/hamstring strength, BESS balance test.
“Triple-hop distance was a strong predictor of lower limb muscular strength and power in healthy collegiate soccer athletes, supporting the test’s clinical use as a preseason screening test in this population.”
THD score was not related/correlated to BESS balance score.

Limitation Notes
Only tested dominant limb
Data was not normalized by height and weight
5 weeks difference between THD and VJ testing and isokinetic testing.
Multiple testers
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Van der does HT, Brink MS, Benjaminse A, Visscher C, Lemmink KA. Jump Landing Characteristics Predict Lower Extremity Injuries in Indoor Team Sports. Int J Sports Med. 2016;

Summary – Seventy-five indoor team-sport athletes (i.e., basketball, volleyball, etc.) were screened with a bilateral and unilateral jump-landing stability test before their competitive season. The tests were recorded with specialized cameras that provided 3-dimensional kinematics and kinetics.
“Statistical analyses showed that acute ankle injury was prevalent in athletes who demonstrated less stability in the forward and diagonal jump direction as well as greater ankle dorsiflexion moment during landing. Overuse knee injuries were higher in those with a smaller knee flexion moment and greater vertical ground reaction forces. Ultimately, the researchers found that athletes showing less unilateral stability and suboptimal landing technique were more likely to sustain an injury.”

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Munro AG, Herrington LC. Between-session reliability of four hop tests and the agility T-test. J Strength Cond Res. 2011;25(5):1470-7.

Summary –
22 participants, university recreational athletes.
“In the current study, we found that 3 practice trials were enough in the single and triple hop tests, whereas 4 trials were needed during the crossover hop, probably because of the increased complexity of the task at hand. Learning effects were different between genders for the timed hop, with men needing less familiarization than women did. Learning effects in the agility T-test have not previously been investigated, with studies simply stating that participants were allowed to familiarize themselves with the test or no practice trials were given at all. We found that only 1 practice trial was needed in both genders for familiarization purposes.”
“… the lowest score of 0.66 was for the timed hop, which mirrors our finding for the male timed hop. When the values for the timed hop are removed, ICC scores, including those from the current study, range from 0.80 to 0.99, which indicates that the hop for distance tests are reliable. The low reliability scores for the timed hop are reflected in the small effect size and power values this test produced; this calls into question whether this particular test should be included in injury and rehabilitation screening.”
“Furthermore 40% of subjects had an LSI of >= 95% in all tests and at least 64% of subjects had an LSI of >= 95% for one hop test. These findings suggest that despite previous recommendations that LSI scores of >=85% indicate that ‘normal’ limb symmetry exists, this value should in fact be increased to 90%.”
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40 Yard Sprint
Mann JB, Ivey PJ, Brechue WF, Mayhew JL. Validity and reliability of hand and electronic timing for 40-yd sprint in college football players. J Strength Cond Res. 2015;29(6):1509-14.

Summary – 81 college football players participated in this study. Novice versus experienced timers were compared to determine reliability of hand timing. This study concluded that 40 yard sprint trials have a high relative reliability, regardless if it is timed electronically or by hand. However, hand timing results in significantly faster sprint trial times.

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Pro Agility (5-10-5)

Stewart PF, Turner AN, Miller SC. Reliability, factorial validity, and interrelationships of five commonly used change of direction speed tests. Scand J Med Sci Sports. 2014;24(3):500-6.

Summary – This study utilized 44 physical education students (mean age of 16.7 years) of both genders with at least two years of athletic experience. Overall, the study determined that all tests are reliable and valid measures of change of direction and speed. The five tests studied were the Pro Agility, Illinois Agility, L-Run, T-Test, and 505 agility test.
https://www.nsca.com/education/articles/assessing_agility_using_testing/

This link gives normative data of the 5-10-5 test for football (males), soccer (both genders), and volleyball (females) of various competitive levels.

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Agility

Illinois Agility Test and Y- Balance Test as predictors of Lower Extremity Injuries in High School Cross Country Runners: A Pilot Study – Thompson

Summary – Case Study following high school cross country runners years 13-18.
Runners Get Hurt!
“2006 study by Raugh “ the incidence of lower-extremity injuries is high for cross-country runners, especially girls.”
“2013 study by Steib et al found negative effects to balance in athletes after fatigue-inducing running. These negative effects were even worse if the athletes had suffered a previous injury.”
Limitations:
Case Study & No Data Collection, just opinion.
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Assessing Agility Using the T Test and Illinois Test
http://www.topendsports.com/testing/tests/t-test.htm

T Test:  Take the best time of three successful trials to the nearest 0.1 seconds. The table below shows some scores for adult team sport athletes.

Males (seconds) Females (seconds)
Excellent < 9.5 < 10.5
Good 9.5 to 10.5 10.5 to 11.5
Average 10.5 to 11.5 11.5 to 12.5
Poor > 11.5 > 12.5

http://www.topendsports.com/testing/norms/illinois.htm

Illinois Agility:  The target group is national level 16 to 19 year olds.

Rating Males (seconds) Females (seconds)
Excellent < 15.2 < 17.0
Above Average 16.1-15.2 17.9-17.0
Average 18.1-16.2 21.7-18.0
Below Average 18.3-18.2 23.0-21.8
Poor > 18.3 > 23.0

Table source: Davis B. et al; Physical Education and the Study of Sport; 2000

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Hachana Y, Chaabène H, Nabli MA, et al. Test-retest reliability, criterion-related validity, and minimal detectable change of the Illinois agility test in male team sport athletes. J Strength Cond Res. 2013;27(10):2752-9.

Summary –
Repeat measurements of 105 male team sport athletes.
“The MDC95 value for the IAGT was 0.52 seconds.”
“The COD IAGT seems to be a reliable and valid test, whose performance is significantly related to speed rather than to acceleration and leg power.”
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Sporis G, Jukic I, Milanovic L, Vucetic V. Reliability and factorial validity of agility tests for soccer players. J Strength Cond Res. 2010;24(3):679-86.
Summary –
150 elite and junior soccer players
“It can be concluded that of the 6 agility tests used in this study, the 9-3-6-3-9 m with backward and forward running, T-test, and sprint 9-3-6-3-6-9 m with 180 degree turns are the most reliable and valid tests for estimating the agility of soccer players.”
“According to the results of the study, the TT proved to be the most appropriate for estimating the agility of defenders, the SBF, and S180 degrees for estimating the agility of midfielders, whereas the Sprint 4 x 5m test can be used for estimating the agility of attackers.”
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Bunkies

Brumitt J. The bunkie test: descriptive data for a novel test of core muscular endurance. Rehabil Res Pract. 2015;780127. doi: 10.1155/2015/780127.

Summary – This study provides normative data for the Bunkie test in a healthy college-aged population (n=112). For the 5 hold positions, the mean score was approximately 40 seconds for each of the four positions except the medial stabilizing line which was typically between 20 and 30 seconds. Slight differences were observed between genders and when subjects with low versus high BMI were compared. This article can help guide rehabilitation professionals when comparing patients scores to normal, healthy subjects.

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De Witt B, Venter R. The “Bunkie” test: Assessing functional strength to restore function through fascia manipulation. J Bodyw Mov Ther. 2009; 13:81-88.

Summary – This is the initial article that proposed “Bunkie” testing to diagnose and treat fascia dysfunction in athletes. The test and implications of the test are described in detail.

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Other Research

Wang HK, Chen CH, Shiang TY, Jan MH, Lin KH. Risk-factor analysis of high school basketball-player ankle injuries: a prospective controlled cohort study evaluating postural sway, ankle strength, and flexibility. Arch Phys Med Rehabil. 2006;87(6):821-5.

Summary –
Prospective cohort study of 42 high school basketball players.
Outcome measures: isokinetic ankle strength, single leg stance postural sway, and ankle dorsiflexion flexibility.
Results: “Eighteen ankle sport injuries were recorded for 42 players during the follow-up season. High variation of postural sway in both anteroposterior and mediolateral directions corresponded to occurrences of ankle injuries (P=.01, odds ratio [OR]=1.220; P< .001, OR=1.216, respectively). All other variables were not associated with injury.”
Conclusions: Asymmetrical single leg stance postural sway may be predictive of ankle injury in basketball players.
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Hubbard TJ, Kramer LC, Denegar CR, Hertel J. Contributing factors to chronic ankle instability. Foot Ankle Int. 2007;28(3):343-54.

Summary –
30 participants with diagnosed unilateral chronic ankle instability and control group had measures of ankle laxity and hypomobility, static and dynamic balance (Y-BAL), ankle and hip strength, lower extremity alignments, and flexibility taken on both limbs.
“…measures significantly predictive of CAI were increased inversion laxity (r(2) change = 0.203), increased anterior laxity (r(2) change = 0.11), more missed balance trials (r(2) change = 0.094), and lower plantarflexion to dorsiflexion peak torque (r(2) change = 0.052). Symmetry indices comparing the side-to-side differences of each measure also were calculated for each dependent variable and compared between groups. The measures significantly predictive of CAI were decreased anterior reach (r(2) change = 0.185), decreased plantarflexion peak torque (r(2) change = 0.099), decreased posterior medial reach (r(2) change = 0.094), and increased inversion laxity (r(2) change = 0.041).”
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Hubbard TJ, Kramer LC, Denegar CR, Hertel J. Correlations among multiple measures of functional and mechanical instability in subjects with chronic ankle instability. J Athl Train. 2007;42(3):361-6.

Summary –
Descriptive study with a correlational design, 30 subjects with CAI.
“A significantly strong relationship was noted between hip abduction and extension strength ( r = .70). Additionally, hip abduction ( r = .51, r = .49) and extension strength ( r = .48, r = .49) correlated with the posterior-medial and posterior-lateral reach directions of the SEBT, respectively. In addition to requiring balance on the affected limb, the posterior directions may require considerable hip strength. The stronger the hip abductors and extensors, the further subjects were able to reach in both directions. This indicates that the dynamic balance deficits seen in the ankles with CAI may also be related to weakness in the hip abductors and extensors.”
“The r values we report compare favorably with those reported by Hertel et al. From the results of these 2 studies, it is apparent that not all components of the SEBT need to be tested as a result of the redundancy in the tasks.”
If an athlete has poor dynamic balance, hip strength should also be addressed during rehabilitation.
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Bizzini M, Hancock D, Impellizzeri F. Suggestions from the field for return to sports participation following anterior cruciate ligament reconstruction: soccer. J Orthop Sports Phys Ther. 2012;42(4):304-12.

Summary –
“Incorporating the soccer ball and soccer-specific equipment (shoes) in phase 2 is not only important to enhance soccer- specific neuromuscular stabilization strategies but also to promote a positive psychological attitude in rehabilitation. “
“Rehabilitation programs have been shown to fail due to a rapid increase in exercise load, whether of speed or duration, or the addition of different exercises that place a higher demand on the knee and graft. “
“…to return to full participation after ACL surgery, the soccer player must make a successful progression through the described rehabilitation phases and show satisfactory (as judged by the sports physiotherapist) Yo-Yo and RSSA test results. “
ACL Screening Test: “The Landing Error Scoring System, developed by Padua et al.”
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Sikka R, Fetzer G, Hunkele T, Sugarman E, Boyd J. Femur fractures in professional athletes: a case series. J Athl Train. 2015;50(4):442-8.
Summary –
“4 professional athletes sustained isolated femur fractures during regular-season games. 2 athletes played hockey, 1 played football, and 1 played baseball. 3 players were treated with anterograde intramedullary nails, and 1 was treated with retrograde nailing. All players missed the remainder of the season. At an average of 9.5 months (range, 7–13 months) from the time of injury, all athletes were able to return to play. One player required the removal of painful hardware, which delayed his return to sport. “
“In professional athletes, return to play from isolated femur fractures treated with either an anterograde or retrograde intramedullary nail is possible within 1 year. Return to the previous level of performance is possible, and it is important to develop management protocols, including rehabilitation guidelines, for such injuries. “
Anterograde: Hip abductor weakness, thigh pain
Retrograde: Increased chance of knee pain

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Miller BS, Downie BK, Johnson PD, et al. Time to return to play after high ankle sprains in collegiate football players: a prediction model. Sports Health. 2012;4(6):504-9.
Summary –
Prospective case study, including 20 D1 Football players with diagnosed high ankle sprain.
“In conclusion, (1) injury severity on physical examination as defined by height of tenderness of the interosseous membrane and (2) player position are associated with the time needed
to return to unrestricted athletic activity”=lineman return faster.
“Mean time to return to unrestricted play was 15.5 ± 9.5 days (range, 2-30 days).”
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Chinn L, Hertel J. Rehabilitation of ankle and foot injuries in athletes. Clin Sports Med. 2010;29(1):157-67, table of contents.
Summary – Limited specific measurable RTP outcome measures for Foot/Ankle
RTP Recommendations for Lateral Ankle Sprain: “Full return to activity should be a gradual progression to stress the ligaments without causing further harm. Full activity should be allowed once the athlete has complete range of motion, 80% to 90% of pre-injury strength, and a normal gait pattern including the ability to perform sport-specific tasks, such as cutting and landing without compensation because of the injury. The athlete should be capable, without pain or swelling, to complete a full practice.”
RTP Recommendations for Achilles Tendonitis: “Athletes should be allowed to compete when full range of motion and strength has returned. The athlete should have regained endurance in the involved limb and be capable of completing a full practice without pain. Depending on the sport, some athletes may be able to compete while suffering from Achilles tendonitis. However, patients should be informed that the condition will not go away without proper rest and treatment.”
Patient Education: “Hill workouts should be done at a maximum of once a week to allow the body time to heal. Similar to any chronic injury to the feet, shoes must be evaluated. Athletes need to learn and understand their foot type and the proper shoes for their foot type. Also, shoes should be replaced every 500 miles or at a maximum of 2 years…Finally, the lack of flexibility is often the main culprit in Achilles tendonitis.”
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Creighton DW, Shrier I, Shultz R, Meeuwisse WH, Matheson GO. Return-to-play in sport: a decision-based model. Clin J Sport Med. 2010;20(5):379-85.

Summary –

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Kamath GV, Murphy T, Creighton RA, Viradia N, Taft TN, Spang JT. Anterior Cruciate Ligament Injury, Return to Play, and Reinjury in the Elite Collegiate Athlete: Analysis of an NCAA Division I Cohort. Am J Sports Med. 2014;42(7):1638-43.
Summary –
Study Design: Case series following a cohort of D1 athletes. “The study cohort consisted of athletes who were enrolled at the university and listed on varsity sports rosters from 2000 to 2009 and who either underwent pre-collegiate ACL reconstruction or suffered an ACL injury and underwent reconstruction after matriculation.”
“High levels of both graft failure and contralateral injuries are seen in the younger and pre-collegiate athletes who suffer an ACL injury and go on to participate in collegiate athletics. In the present study, the risk of graft failure or contralateral ACL injuries was 17.1% and 20.0%, respectively, in the collegiate athlete who underwent ACL reconstruction during high school.”
“A successful return to participation in varsity-level collegiate sports at the NCAA Division I level is common after ACL reconstruction. Elite-level adolescent athletes who undergo pre-collegiate ACL reconstruction have high rates of graft failure, subsequent reinjuries, and contralateral ACL injuries. “
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Ardern, Clare L., et al. “A systematic review of the psychological factors associated with returning to sport following injury.” British Journal of Sports Medicine, 15 Nov. 2013, p. 1120+. Health Reference Center Academic, Accessed 30 Jan. 2017.

Summary –
Eleven studies that evaluated 983 athletes and 15 psychological factors were included for review. The three central elements of self-determination theory-autonomy, competence and relatedness were found to be related to returning to sport following injury. Positive psychological responses including motivation, confidence and low fear were associated with a greater likelihood of returning to the preinjury level of participation and returning to sport more quickly. Fear was a prominent emotional response at the time of returning to sport despite the fact that overall emotions became more positive as recovery and rehabilitation progressed.
CONCLUSIONS:
There is preliminary evidence that positive psychological responses are associated with a higher rate of returning to sport following athletic injury, and should be taken into account by clinicians during rehabilitation.

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Ardern, Clare L, et al. “It is time for consensus on return to play after injury: five key questions.” British Journal of Sports Medicine, 1 May 2016, p. 506+. Health Reference Center Academic, Accessed 30 Jan. 2017. http://bjsm.bmj.com/content/50/14/853.full.pdf+html

Summary – Deciding when to return to sport after injury is complex and multifactorial—an exercise in risk management. Return to sport decisions are made every day by clinicians, athletes and coaches, ideally in a collaborative way. The purpose of this consensus statement was to present and synthesise current evidence to make recommendations for return to sport decision-making, clinical practice and future research directions related to returning athletes to sport. A half day meeting was held in Bern, Switzerland, after the First World Congress in Sports Physical Therapy. 17 expert clinicians participated. 4 main sections were initially agreed upon, then participants elected to join 1 of the 4 groups—each group focused on 1 section of the consensus statement.

CONCLUSIONS Combining information from a biological, psychological and social standpoint, while considering the risks can help all RTS decision-makers—whether they be clinicians, athletes, coaches or other stakeholders—make optimal decisions. Integrating clinical expertise, research evidence and athlete preferences is important for RTS decision-making and for longer-term RTS success. RTS criteria for many common injuries are not based on solid scientific evidence. Future research should focus on a standardised approach to defining, measuring and reporting of RTS outcomes, and on identifying the prognostic factors for RTS.

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Myer, Et al. “Utilization of Modified NFL Combine Testing to Identify Functional Deficits in Athletes Following ACL Reconstruction”. J Orthop Sports Phys Ther. 2011 June ; 41(6): 377–387.

Summary – Eighteen patients who returned to their sport within a year following ACL reconstruction (95% CI: 7.8 to 11.9 months from surgery) participated (ACLR group). These individuals were asked to bring 1 or 2 teammates to serve as control participants, who were matched for sex, sport, and age. Functional performance was tested using the broad jump, vertical jump, modified long shuttle, modified pro shuttle, modified agility T-test, timed hop, triple hop, single hop, and crossover hop tests.

RESULTS—The functional performance measurements of skills requiring bilateral involvement of both lower extremities showed no group differences between the ACLR and control groups (P>. 05). An overall group difference (P = .006) was observed for the combined limb symmetry index (LSI) measures. However, the modified double-limb performance tasks (long shuttle, modified agility T-test, and pro shuttle) were not, independently, sufficiently sensitive to detect limb deficits in individuals with ACL reconstruction. Conversely, the LSI on the distance measures of the single-limb performance tasks all provided moderate to large effect sizes to differentiate between the ACLR and control groups, as the individuals who had ACL reconstruction demonstrated involved limb deficits on all measures (P<.05). Finally, the LSI for the timed hop test was not different between groups (P>.05).

CONCLUSIONS—These findings indicate that, while unilateral deficits are present in individuals following ACL reconstruction, they may not be evident during bipedal performance or during modified versions of double-limb performance activities. Isolation of the involved limb with unilateral hopping tasks should be used to identify deficits in performance.

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Cortez N, Onate J, Van Lunen B. Pivot task increases knee frontal plane loading compared with sidestep and drop-jump. J Sports Sci. 2011 Jan; 29(1): 83–92.

Summary – The purpose of this study was to assess kinematic and kinetic differences between three tasks (drop-jump, sidestep cutting, and pivot tasks) commonly used to evaluate anterior cruciate ligament risk factors. Nineteen female collegiate soccer athletes from a Division I institution participated in this study. Participants performed a drop-jump task, and two unanticipated tasks, sidestep cutting and pivot. The pivot task had lower knee flexion (?41.2 ± 8.8°) and a higher valgus angle (?7.6 ± 10.1°) than the sidestep (?53.9 ± 9.4° and ?2.9 ± 10.0°, respectively) at maximum vertical ground reaction force. The pivot task (0.8 ± 0.3 multiples of body weight) had higher peak posterior ground reaction force than the drop-jump (0.3 ± 0.06 multiples of body weight) and sidestep cutting (0.3 ± 0.1 multiples of body weight), as well as higher internal varus moments (0.72 ± 0.3 N · m/kg · m) than the drop-jump (0.14 ± 0.07 N · m/kg · m) and sidestep (0.17 ± 0.5 N · m/kg · m) at peak stance. During the pivot task, the athletes presented a more erect posture and adopted strategies that may place higher loads on the knee joint and increase the strain on the anterior cruciate ligament.

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Hanson AM, et al. Muscle Activation During Side-Step Cutting Maneuvers in Male and Female Soccer Athletes. J Athl Train. 2008 Mar-Apr; 43(2): 133–143.

Summary – Examining sex differences in lower extremity muscle activation between male and female soccer athletes at the National Collegiate Athletic Association Division I level during 2 side-step cutting maneuvers.
Methods: Twenty males and 20 females – In a single testing session, participants performed the running-approach side-step cut and the box-jump side-step cut tasks.
Surface electromyographic activity of the rectus femoris, vastus lateralis, medial hamstrings, lateral hamstrings, gluteus medius, and gluteus maximus was recorded for each subject.
Results: Females displayed greater vastus lateralis activity and quadriceps to hamstrings coactivation ratios during the preparatory and loading phases, as well as greater gluteus medius activation during the preparatory phase only. No significant differences were noted between the sexes for muscle activation in the other muscles analyzed during each task.

Conclusions: The quadriceps-dominant muscle activation pattern observed in recreationally active females is also present in female soccer athletes at the Division I level when compared with similarly trained male soccer athletes. The relationship between increased quadriceps activation and greater incidence of noncontact ACL injury in female soccer athletes versus males requires further study.
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Ardern CL, Glasgow P, Schneiders A, et al. 2016 Consensus statement of return to sport from the First World Congress in Sports Physical Therapy, Bern. Br J Sports Med 2016, 50: 853-864. Originally published online May 25, 2016.

Deciding when to return to sport after injury is complex and multifactorial—an exercise in risk management.Return to sport decisions are made every day by clinicians, athletes and coaches, ideally in a collaborative way. The purpose of this consensus statement was to present and synthesise current evidence to make recommendations for return to sport decision-making,clinical practice and future research directions related to returning athletes to sport. A half day meeting was held in Bern, Switzerland, after the First World Congress in Sports Physical Therapy. 17 expert clinicians participated.4 main sections were initially agreed upon, then participants elected to join 1 of the 4 groups—each group focused on 1 section of the consensus statement.Participants in each group discussed and summarised the key issues for their section before the 17-member group met again for discussion to reach consensus on the content of the 4 sections. Return to sport is not a decision taken in isolation at the end of the recovery and rehabilitation process. Instead, return to sport should be viewed as a continuum, paralleled with recovery and rehabilitation. Biopsychosocial models may help the clinician make sense of individual factors that may influence the athlete’s return to sport, and the Strategic Assessment of Risk and Risk Tolerance framework may help decision-makers synthesise information to make an optimal return to sport decision. Research evidence to support return to sport decisions in clinical practice is scarce. Future research should focus on a standardised approach to defining, measuring and reporting return to sport outcomes, and identifying valuable prognostic factors for returning to sport.

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