Return to Sport Testing: Lower extremity

Imagine being a recreational/competitive athlete who has undergone a career changing leg injury. You go through a surgical procedure to get repaired, and after a few months of grueling rehab, you get discharged. They clear you to return to practicing and playing sports.

You’re a bit lost because you have not done any “athletic” movements during your rehab. You have not done any jumping, or agility drills during your time in physical therapy, and yet you are now green-lighted to perform all these movements with no restrictions

This leads to a cascade of you not performing at 100% because you do not have the confidence that your leg is able to handle the demands of your sport. You lose playing time and you fear that you may never live up to your potential because of this injury. 

Introduction

This scenario is all too real and could be relatable to you, a friend, or a family member. Ever been at a party where one person is reliving their high school days saying things like “I could have gotten a full ride at U of I until I blew out my knee.” We encounter this more times than we should as sports physical therapists.

Once a rehabbing athlete goes through all the rehab phases, it is important that in the later stages they start to get reintroduced to movements that replicate the demands of their sport. Before discharging them and clearing them to return to participation, they should undergo a battery for Return to Sport testing (RTS).

Return to sport testing is a crucial step in an athlete’s rehabilitation journey to determine when an athlete is safe to return to their sport. This decision requires a combination of objective testing, clinical expertise, and an understanding of the demands of their sport. This article will describe a general overview of RTS testing for lower extremity injuries. RTS testing should be an individualized process designed to ensure that an athlete has regained adequate strength, balance, and coordination to prevent re-injury. The physical therapist should be assessing the quality of movement, pain, and overall confidence with each task. 

Strength

Strength deficits are one of the leading factors in re-injury, especially with lower extremity injuries like ACL tears, ankle sprains, or hamstring strains. Strength deficits, particularly in the quadriceps and hamstrings, are critical predictors of re-injury risk following lower extremity injuries. Grindem et al. (2020), emphasize that achieving at least 90% strength compared to the uninjured side is crucial for a safe return to sport.¹ 

Neuromuscular Control and Balance 

Balance and proprioception are often compromised after a lower extremity injury. Assessments like single-leg stance tests, or more dynamic assessments such as single-leg hops, evaluate an athlete’s neuromuscular control. Two common examples include the Star Excursion Balance Test (SEBT) and the Y-Balance Test.³

Functional Performance Testing 

In addition to strength and balance testing, a variety of functional tests can help determine an athlete’s readiness for return to sport. Research supports functional tests, such as the single-leg hop for distance and triple hop for distance offer insights on lower extremity power, symmetry, and stability.² The Vertical Jump Test should be used for athletes involved in explosive sports.⁴

Fatigue and Endurance Testing 

Testing endurance is critical for a complete RTS evaluation as evidenced by research performed by Tallard et al. (2021) which demonstrates that fatigue significantly increases injury risk.⁵ This research recommends high-repetition tests that mimic fatigue levels encountered during an athlete’s sport. By incorporating these tests, physical therapists can evaluate an athlete’s resilience to fatigue, helping to ensure that they maintain proper mechanics and stability throughout a game or match.

Sport-Specific Drills

Once an athlete passes general lower extremity testing, they should also be put through sport-specific drills that mimic game situations. For example, soccer players might perform cutting drills and multi-directional sprinting, while basketball players might work on jumping, landing, and quick directional changes.

Conclusion

Some of the above listed tests help physical therapists determine when an athlete is ready to return to sport, but there are many other important factors that influence when a PT gives their athlete the green light. These factors include: stage of recovery, time since injury, psychological readiness, a player’s position, and external stressors. In conclusion, RTS testing for lower extremity injuries is a challenging process that assesses strength, balance, functional performance, endurance, and sport-specific tasks so that physical therapists can make well-informed decisions to determine when an athlete can safely return. 

References:

1. Grindem, H., Wellsandt, E., Failla, M., Snyder-Mackler, L., & Risberg, M. A. (2020). “An Update of the Wilmington Criteria for Return to Sport after ACL Reconstruction: Evaluating Contemporary Relevance and Predictive Capacity.” Journal of Orthopaedic & Sports Physical Therapy, 50(4), 180-188.
2. Gokeler A, Dingenen B, Hewett TE. Rehabilitation and Return to Sport Testing After Anterior Cruciate Ligament Reconstruction: Where Are We in 2022? Arthrosc Sports Med Rehabil. 2022 Jan 28;4(1):e77-e82. doi: 10.1016/j.asmr.2021.10.025. PMID: 35141539; PMCID: PMC8811523.
3. Lockie RG, Schultz AB, Callaghan SJ, Jeffriess MD. The relationship between dynamic stability and multidirectional speed. Journal of Strength and Conditioning Research. 2016;30(11):3033-3043.
4. Renstrom P, Ljungqvist A, Arendt E, et al. Non-contact ACL injuries in female athletes: an International Olympic Committee current concepts statement. Br J Sports Med. 2008;42(6):394-412.
5. Tallard JC, Hedt C, Lambert BS, McCulloch PC. The Role of Fatigue in Return to Sport Testing Following Anterior Cruciate Ligament Reconstruction. IJSPT. 2021;16(4):1043-1051. doi:10.26603/001c.25687