Last post I left off talking about the concepts of what Return to Sport means. Now, let’s talk about what tests to use. I would like to introduce several tests that allow us to comprehensively assess an athlete’s abilities and help to determine readiness to return to sports. That said,
There are SO MANY valuable tests and ways to measure things…but we may only have time, equipment & evidence to support a handful.
Moreover, these tests need to be as readily reproducible as possible – so they do not require fancy equipment, facilities or advanced training/certifications.
With testing, there are several main themes that MUST be addressed:
- Range of motion/mobility
- Functional strength
- Sport-specific demands
I think this all makes sense and how most of us generally already approach things; however, it seems like we all handle this differently and often obscurely. So, what I want to do in this post is to elaborate on each of these above areas more specifically. I will talk about some of the best tests available. What makes them “the best” (in my opinion, and supported by the current available research) is that they are easy to reproduce, give us true objective numbers on how an athlete actually performs & they encompass the above-mentioned elements. I have attached links, some with videos, on how to complete these tests. Again, these things should be required of yourselves (or your athletes if you are in the rehab, fitness, athletic world) – to “prove” you are ready to return to your sport.
Now, not everything that is measurable is valuable, and not everything that is valuable is measurable.
As I have stated before, a battery of good, objective, reliable information will help all of us facilitate Return To Sport decision-making. Most of these tests should be utilized by all athletes, where some of the tests may be more appropriate for specific populations. Today, I am only speaking of lower extremity injuries and testing – spine and upper body injury and subsequent testing will be addressed in a later post. So, let’s begin with the most important aspect; pain…
– This should actually be measured…not just, “do you hurt?” As such, it should be measured with either the visual numerical pain scale and/or the Faces pain scale (aka Wong-Baker scale)…ideally, you should not start progressing rehab or activities, unless there is:
- No pain at rest
- Pain less than 4/10 with any activity
- Pain lasting no more than 48 hours after activity
Pain is the single greatest variable that will mitigate any advancement of your programming. Get right with pain/swelling first!
Range of Motion (ROM)
– Hip, knee, ankle
Not much needs to be said here…if you haven’t normalized your mobility, you cannot move onto anything else (for the most part). You would be building on an uneven foundation and asking for trouble down the road – Right should basically equal Left. One example of this is functional ankle dorsiflexion: From a kneeling position, place one foot in front, keeping the other knee down. Place that foot ~4 inches from wall & attempt to touch knee to wall:
- without heel coming up
- without foot collapse
- knee tracking directly over foot or slightly outside (never inside) of foot
You can measure the distance you are away from the wall and compare Right vs. Left (should be ~4 inches for most people) – complete barefoot, ideally.
– Measured with Y-balance/Modified star excursion
If you are unfamiliar with the Y Balance Test, I recommend watching this video to better understand it’s application. This one test has revolutionized the way I approach rehab progression, thus my return to sport testing. If an athlete cannot adequately control their own body weight with good symmetry and good overall reaching distance outside a typical base of support, they have no business advancing to higher level challenges…even if those challenges are “more fun”.
By that I mean the plyometric, hopping, cutting, cone, ladder, or agility work that athletes seem to love. Trust me, this is all they will care about getting to, as it is more exciting and feels more like they are doing athletic activities and not just rehab. Especially if it doesn’t cause pain. Just because something is challenging, does not mean it is a good exercise or training technique or that a person is really ready for it.
Recently, the Y Balance test has required certification to utilize and they now charge $200 for this certification (plus the cost of the kit ~$325-350). So, in effort to keep cost and availability to the masses at the forefront of a comprehensive battery of tests, I would strongly recommend utilizing taped lines of the Star Excursion Balance Test. Virtually all of the initial research on the reliability and utilization of the Y Balance Test is based on the Modified Star Excursion Balance Test…so, since the latter is free, it is a great tool to utilize. Professionally, once you feel you use this test often, it is worthwhile to become certified and purchase the actual kit.
Bunkie Test – both for symmetry and functional strength. Athlete does 5 different versions of a single leg plank with legs resting on a platform of equal length to the patient’s upper arm. They are propped onto elbow. Basically, you are looking for anterior, posterior, lateral, medial stabilizing elements…and of course, symmetry.
No pain reported with testing
- It is recommended that the position should be held for a minimum of 20 & maximum of 40 seconds.
- Start with either leg, on the first test, but then should start with that leg for each test.
- Take a 10 second rest between each leg for each individual test.
- Take a 30 second rest between each test.
- Can be done with shoes or without, if needing cushioning, use a yoga mat or towel. Ensure that the stool/step does not move/slide away.
- Stop the test if there is pain.
Asymmetry or lower hold times can indicate decreased stability/endurance.
– Measured with Hop Testing
I feel hop testing is one of those polarizing topics. People either love or hate them…here are the 3 that we like to use and how they are executed in attempt to gain a true reflection of the athlete’s given performance. Time and time again I have seen athletes complete these and leave either feeling very good overall about their symmetry and how their injured lower extremity has responded OR that this testing has highlighted some persisting deficits and that they really aren’t as good as they thought they were. For all testing:
- Look for symmetry
- Do 2 practice trials/test.
- Each test gets 4 trials to get 3 good scores.
- Athlete must stick the landing = when they land, they can’t shift the landing foot, or put the other foot or hand down & must demonstrate control of forward and lateral momentum. Basically, they should be able to hold the landing long enough for the tester to put a piece of tape at their heel after land.
- Measure to the nearest half inch at the back of the heel on the landing leg.
- Use the best of the three trials as your score and divide the worst leg by the best leg to get your percentage. Should be completed with shoes on.
- Stop the test if there is pain.
Single leg broad jump – standing on one leg behind the start line, athlete tries to jump forward as far as they can once.
Triple hop – standing on one leg behind the starting line, athlete jumps as far as they can 3 consecutive times with minimal pause between each jump, trying to jump as far as they can in 3 consecutive jumps
Triple hop crossover – Standing on one leg behind the starting line and to one side of the measuring tape. Left leg is down if they are on the right of the tape, right leg is down if they are on the left of the tape. First jump will be in a lateral direction to the stance leg. Athlete jumps forward/diagonally across the tape, jumps forward/diagonally back across the tape and then again forward/diagonally a third time back across the tape.
– This area is one that will differ the most. Power/speed/agility is nothing without control. We HAVE to get right with the areas above first. Once we do that, I have to acknowledge, there is nothing that replicates kicking, throwing, hitting, shooting, passing, dribbling or catching a ball. But doing so at the intensity and velocity required of your sport is something that each athlete should gradually return to and not something to jump back into with high volume and maximal intensities. I will speak more about training to return to sport in a future post with regards to a specific sport.
For now, I want to move onto several very good testing options that can help determine ability to execute things like: agility, power, speed, endurance…some may be more relevant than others depending on the sport you play (like T-Test for basketball players vs. 5-10-5 for football players). Several of these could be categorized more as “performance” measures, but several also can help to highlight asymmetries that may still exist…and asymmetries are known risk factors for potential injury risk.
– There are several options – I will mention 3:
This primary purpose for any agility testing and training is to measure ability and comfort to change direction with speed. These 3 are easy to set up, have minimal equipment/space needs and involve speed and directional changes. In fact, the NSCA (disclaimer, I am a member) published normative values and validated the use of these tests recently…see link(s) for details.
T-Test – 3 cones placed 5 yards apart, one cone placed even with the middle cone 10 yards away forming a T. In attempts to control variability, make sure that the participant side steps and does not cross one leg over the other. Make sure that the participant touches each cone when they first get to it. (Cone B when they first sprint forward and the far left and far right cones – C & D) when they get to it to make sure that they don’t stop short. Make sure to re-touch B before backpedalling…there is never need to touch A. Speed to complete the course is timed. 3 trials are completed with a 60 second rest break between each trial.
Pro Agility (aka 5-10-5) – The 5-10-5 consists of rapid directional changes in a linear plane. The setup for is simple…three cones that are placed 5 yards apart from one another in a straight line. The athlete straddles the middle cone and places the LEFT hand on the cone if going LEFT to start (opposite for the RIGHT). The athlete then sprints to the LEFT and touches the cone with his/her LEFT hand. They then change direction and sprint all the way to the farthest cone (10 yards away) and touches that cone with the RIGHT hand. The athlete changes direction one more time and sprints across the starting cone. The time starts when the athlete lifts his/her hand and stops when the athlete crosses the middle cone again…the athlete can touch lines instead of cones, which is why it is suggested they be required to touch the base of the cone to help standardize.
Illinois Agility Test – Cones are placed in a rectangle, with the cones on the start line 10 yards away from the cones on the opposite line. The cones on the start & finish line are 5 yards away from each other. 4 more cones are placed in the center of the rectangle at an equal distance apart (3.3 yards) with the first cone and last cone in a line with the top and bottom cones making up the perimeter of the rectangle. Participant starts on their stomach by the left most corner cone with arms by their shoulders (the video link has the athletes start standing, which is an option if you choose). At the “Go” command the athlete gets up, runs forward to the corner cone directly in front of them. They turn around this cone and run diagonally back to the middle cone on the starting line, slaloms through the middle cones and then slaloms back to through them to the starting line. They turn around the last middle cone and run diagonally towards the cone at the far upper right cone, turns around it and runs straight back to the through the last cone. Time to complete the course is noted, 3 trials are completed with 60 second rest break between each trial.
– Measured with horizontal and vertical power (depending on the sport may indicate a greater need for one vs. another)
- Standing bilateral broad jump for distance – Athlete stands with toes on a line and jumps out as far as possible.
- Shoes on
- Do 2 practice trials
- Test gets 4 trials to get 3 good scores.
- Athlete must stick the landing = when they land, they can’t shift the landing foot, or put the other foot or hand down and demonstrating control of forward and lateral momentum. Basically, they should be able to hold the landing long enough for the tester to put a piece of tape at their heel after they land
- Measure to the nearest half inch at the back of the heel on the landing leg.
- Use the best of the three trials as your score
- Stop the test if there is pain.
- Vertical jump for height double and single leg – the athlete stands with side to a wall and reaches up with the hand closest to the wall. Keeping the feet flat on the ground, the point of the fingertips is marked or recorded. This is called the standing reach height. The athlete then stands away from the wall, and leaps vertically as high as possible using both arms and legs to assist in projecting the body upwards. Attempt to touch the wall at the highest point of the jump. The difference in distance between the standing reach height and the jump height is the score. The best of three attempts is recorded. The vertical jump test can also be performed using a specialized apparatus called the Vertec. Can be done with both feet and done single limb to compare symmetry of each leg.
– Measured with a straight line sprint
30 Yard or 40 Yard Dash
This test measures your ability to accelerate to full speed quickly & your reaction time. Start, with both feet behind the starting line and at least one hand down. This starting position should be held for 3 seconds prior to starting. You may lean across the starting line, but no rocking is allowed.
The timing starts from the first movement (if using a stopwatch) or when the timing system is triggered, and finishes when the chest crosses the finish line and/or the finishing timing mechanism is triggered…there is even an app that can help time this more accurately. The athlete gets 2 trials with the best time taken to the nearest 2 decimal places.
– Measured with the Yo-Yo Intermittent Recovery Test (aka the beep test).
Use cones to mark out three lines as per the diagram below; two cones at 20 meters (the actual endurance part of the test) and one cone at 5 meters (the recovery part of the test) apart. The athlete starts behind the middle line, and begins running 20 m when instructed by the audio voice/recording and 1st beep. This athlete must jog down and touch the cone/line that is 20m away and return to the starting point. There will be a beep to start, a beep at the halfway point 20m away and a beep when the athlete should cross the original starting line (3 beeps). There is an active recovery period (10 seconds intermittent recovery test version). A warning is given when the athlete does not complete a successful out and back in the allocated time, the test is over for the athlete the next time they do not complete a successful down and back in the allotted time. They will take the last interval as their “score”. The score can be interpreted by the total distance covered, level number achieved, or speed level…the test gets faster, but the distances, recovery time and instructions do not change. (you can view this video for more details). Also, see the link to suggested values to help guide decision-making.
Whew! That is a big list with a lot of tests…I tried to pare it down with those dimensions that should be more or less a required set of tests/measures. I hope this can serve as a guide for the various elements that should be addressed when it comes to overall readiness for return to athletics.
Something I will definitely get to in future posts is the idea of how to train – fitness, energy systems, strength and conditioning & sport skills along the way (while the athlete is injured and not able to fully participate in their respective sport, they CAN and SHOULD still train). A caveat I will mention in advance is that all of my thoughts & opinions have been through professional experience, personal experience, ongoing learning and a ton of collaboration with others in this field (other PTs, strength coaches, athletic trainers, physicians, surgeons, etc.). They have all spoken into this system of approaching Return To Play. I am anxious to present the next post which will elaborate more of these thoughts…until then, keep improving!
Recommended List (based on sport demands) – Things that I feel are also valuable, but require more equipment/set-up/training/etc.
- Running Form Analysis
- 1-Rep Max Leg Press
- Functional Movement Screen (FMS)
- Landing Error Scoring System (LESS)