Welcome to the New Site!

This site was created to act as a resource to rehabilitation professionals, students, and patients alike…

Having spent nearly 5 years blogging, I have amassed a large amount of content and I have been able to see how my thought processes and beliefs have evolved over this timeframe. In doing so, I have recognized areas that needed to be updated in order to keep up with the current literature.

I have recently updated my Clinical Prediction Rule and Functional Testing resources to include updated information and to more accurately present the strength of each rule/test. This allows for the information to be more easily and accurately used in clinical practice.

I will be posting several articles detailing the improvement to my website and how each area has been updated.

Additionally, I am happy to announce that I am offering two Live courses and am in the process of scheduling for 2018-2019. If you are interested in hosting The Athlete’s Hip: Simplifying Examination, Treatment, and Return to Sport or Evaluation & Management of the Ice Hockey Athlete, feel free to Contact Me.

Thanks again for reading and for all the support you have given me and my content over the last 5+ years!

– John Snyder, PT, DPT, OCS, CSCS

Hip Pain: Return to Sport Considerations

Pre-arthritic hip pain is a common occurrence among athletes, especially those competing in ice hockey1 and field-based team sports (soccer, rugby, and football).2 While this area receives less attention than knee or shoulder injuries, current research is beginning to improve diagnosis and treatment of both intra-articular and extra-articular hip pathology. But, what about return to sport?

What the Literature Says

Determining an athlete’s readiness to return to sport is complicated. The decision with regards to hip pathology is even more convoluted due to the lack of evidence. Most literature discusses outcomes following arthroscopic surgery, and only a few studies outline the proposed benefit of conservative management.3

The available literature suggests that surgery for femoroacetabular impingement is beneficial in a symptomatic population, with 87% of patients returning to sport and 82% returning to previous level of competition.4 On the other hand, no randomized controlled studies adequately compare conservative and surgical management.5 Unfortunately, at this point the research tends to relate only to reported patient satisfaction, subjective questionnaires, and self-reported return to sport.6

How Do We Determine Return to Sport?

Unlike ACL reconstruction, hip injury lacks sufficient evidence to support return to sport guidelines. According to the 2016 Consensus Statement on Return to Sport, clinicians should combine information from a biological, psychological, and social standpoint.7 These factors include:

  • Health risk based on the athlete’s specific injury (subjective and objective measures)
  • Activity risk of returning to sport (type of sport, competition level, etc.)
  • Risk tolerance (pressure, fear of re-injury, etc.)

The StAART Framework (pictured below) proposed by Shrier and colleagues sums up this approach.8 It allows the clinician to comprehend and address all areas impacted by an individual’s readiness to return to sport.

MC020-205 Starrt Framework Chart_v03

Functional Testing Considerations

A recent systematic review conducted by Kivlan and colleagues demonstrated that several tests are reliable and valid when determining return to sport after hip injuries:9

  • Single-leg Stance
  • Deep Squat
  • Single-leg Squat
  • Star Excursion Balance Test (SEBT) / Y-Balance Test

These tests have appropriate validity and reliability but no solid cut-points, so findings should be interpreted on a patient-specific basis by considering their limb symmetry index during these tasks. Significant increase in medial–lateral sway and worse anterior–posterior control during a dynamic single-leg squat task in individuals with pre-arthric hip pain supports the use of a single-leg squat assessment.10

The modified star excursion balance test (also known as the Lower Quarter Y-Balance Test)  has been successful in identifying asymmetry and impaired proximal stability in many conditions. Recently, Johansson and colleagues performed the first study to determine the criterion and divergent validity of the SEBT in individuals with femoroacetabular impingement11. They determined that SEBT performance in the posterolateral and posteromedial directions had high to moderate criterion validity in relation to the HAGOS subscales for pain intensity and symptoms. Additionally, the posterolateral direction and ADL function showed high to moderate criterion validity. Finally and most importantly, the SEBT showed adequate divergent validity and could successfully differentiate between healthy individuals and individuals diagnosed with FAI.

Several recent studies have investigated if hop testing is appropriate in this population. Kivlan and colleagues evaluated the difference in hop testing (cross-over reach test, medial triple hop test, lateral triple hop test, and cross-over hop test) between the involved and uninvolved hip in dancers with hip pathology.12 All tests demonstrated excellent reliability (0.89 – 0.96); however, only the medial triple hop test showed significant difference between the two limbs with the non-involved limb achieving 17.8 cm more distance than the involved limb.

More recently, Kivlan and colleagues investigated the hop performance between dancers with clinically diagnosed femoroacetabular impingement and an asymptomatic control group. This study found a significant difference of approximately 50 cm when comparing the performance of the FAI group to the asymptomatic control group during both the medial triple hop test and the lateral triple hop test:13

table-remake

Further supporting the use of hop and dynamic balance activities, findings from another recent study determined that following arthroscopic hip surgery and concomitant rehabilitation, patients demonstrated > 90% limb symmetry index in the performance of a single-leg squat test, single-leg vertical jump, single-leg hop for distance, and single-leg side hop.14 While this information shows that we can achieve a LSI that is often used in return to sport of athletes post-ACL reconstruction, functional testing should be used with caution when translating it to a population of athletes with hip pain.

Continue with Caution

In the absence of definitive return to sport criteria, the clinician must focus on the tissue health (the load the tissue can absorb before injury), individual tissue stresses imposed by the athlete’s chosen sport and competition level, and any pertinent psychosocial factors (fear of re-injury).

Return to sport testing should be considered with caution as little evidence is available for this patient population.

References:

1. Lerebours F, Robertson W, Neri B, Schulz B, Youm T, Limpisvasti O. Prevalence of Cam-Type Morphology in Elite Ice Hockey Players. Am J Sports Med. 2016 Jan 28. pii: 0363546515624671. [Epub ahead of print]

2. Gerhardt MB, Romero AA, Silvers HJ, Harris DJ, Watanabe D, Mandelbaum BR. The Prevalence of Radiographic Hip Abnormalities in Elite Soccer Players. American Journal of Sports Medicine. 2012;40(3):584-588. doi:10.1177/0363546511432711.

3. Wall PD, Fernandez M, Griffin D, Foster N. Nonoperative Treatment for Femoroacetabular Impingement: A Systematic Review of the Literature. PMRJ. March 2013:1-9. doi:10.1016/j.pmrj.2013.02.005.

4. Casartelli NC, Leunig M, Maffiuletti NA, Bizzini M. Return to sport after hip surgery for femoroacetabular impingement: a systematic review. British Journal of Sports Medicine. 2015;49(12):819-824. doi:10.1136/bjsports-2014-094414.

5. Reiman MP, Thorborg K, Hölmich P. Femoroacetabular Impingement Surgery Is on the Rise—But What Is the Next Step? Journal of Orthopaedic & Sports Physical Therapy. 2016;46(6):406-408. doi:10.2519/jospt.2016.0605.

6. Sim Y, Horner NS, de SA D, Simunovic N, Karlsson J, Ayeni OR. Reporting of non-hip score outcomes following femoroacetabular impingement surgery: a systematic review. J Hip Preserv Surg. 2015;2(3):224-241. doi:10.1093/jhps/hnv048.

7. Ardern CL, Glasgow P, Schneiders A, et al. 2016 Consensus statement on return to sport from the First World Congress in Sports Physical Therapy, Bern. British Journal of Sports Medicine. May 2016. doi:10.1136/bjsports-2016-096278.

8. Shrier I. Strategic Assessment of Risk and Risk Tolerance (StARRT) framework for return-to-play decision-making. British Journal of Sports Medicine. 2015; 49: 1311–15.

9. Kivlan BR, Martin RL. Functional Performance Testing of the Hip in Athletes: A Systematic Review for Reliability and Validity. International Journal of Sports Physical Therapy. 2012;7(4):402-412.

10. Freke MD, Kemp J, svege I, Risberg MA, Semciw A, Crossley KM. Physical impairments in symptomatic femoroacetabular impingement: a systematic review of the evidence. British Journal of Sports Medicine. June 2016. doi:10.1136/bjsports-2016-096152.

11. Johnansson AC, et al. The Star Excursion Balance Test: Criterion and divergent validity on patients with femoral acetabular impingement. Manual Therapy. 2016; 26(C): 104-109. doi:10.1016/j.math.2016.07.015.

12. Kivlan BR, Carcia CR, Clemente FR, Phelps AL, Martin RL. Reliability and validity of functional performance tests in dancers with hip dysfunction. International Journal of Sports Physical Therapy. 2013 Aug;8(4):360-9.

13. Kivlan BR, et al. Comparison of Range of Motion, Strength, and Hop Test Performance of dancers with and without a Clinical Diagnosis of Femoroacetabular Impingement. International Journal of Sports Physical Therapy. 2016; 11(4): 527-535.

14. Tijssen M, van Cingel R, de Visser E, Sanden der MN-V. A clinical observational study on patient-reported outcomes, hip functional performance and return to sports activities in hip arthroscopy patients. Physical Therapy in Sport. 2016;20(C):45-55. doi:10.1016/j.ptsp.2015.12.004.

Should we stop blaming the glutes for everything?

Below is an article written for MikeReinold.com… 

Anterior cruciate ligament (ACL) rupture1,2 and patellofemoral pain syndrome (PFPS)3,4,5 are two of the most common lower extremity complaints that physicians or physical therapists will encounter. In addition to the high incidence of these pathologies, with regards to ACL injury, very high ipsilateral re-injury and contralateral injury have also been reported6,7,8. With the importance of treating and/or preventing these injuries, several researchers have taken it upon themselves to determine what movement patterns predispose athletes to developing these injuries. This research indicates that greater knee abduction moments9,10, peak hip internal rotation11 and hip adduction motion12 are risk factors for PFPS development. Whereas, for ACL injury, Hewett and colleagues13 conducted a prospective cohort study identifying Knee abduction angle at landing as predictive of injury status with 73% specificity and 78% sensitivity. Furthermore, as the risk factors for developing both disorders are eerily similar, Myer et al performed a similar prospective cohort study finding that athletes demonstrating >25 Nm of knee abduction load during landing are at increased risk for both PFPS and ACL injury14. With a fairly robust amount of research supporting a hip etiology in the development of these injuries, it would make sense that weakness of the hip musculature would also be a risk factor, right?

A recent systematic review found very conflicting findings on the topic. With regards to cross-sectional research, the findings were very favorable with moderate level evidence indicating lower isometric hip abduction strength with a small effect size (ES) and lower hip extension strength with a small ES15. Additionally, there was a trend toward lower isometric hip external rotation and moderate evidence indicates lower eccentric hip external rotation strength with a medium ES in individuals with PFPS15. Unfortunately, the often more influential prospective evidence told a different story. Moderate-to-strong evidence from three high quality studies found no association between lower isometric strength in hip abduction, extension, external rotation or internal rotation and the risk of developing PFPS15. The findings of this systematic review indicated hip weakness may be a potential consequence of PFPS, rather than the cause. This may be due to disuse or fear avoidance behaviors secondary to the presence of anterior knee pain. Regardless of its place as a cause or consequence, hip strengthening has proved beneficial in patients with both PFPS16,17,18 and following ACL Reconstruction19, but does it actually help to change the faulty movement patterns?

Gluteal strengthening can cause several favorable outcomes, from improved quality of life to decreased pain, unfortunately however marked changes in biomechanics is not one of the benefits. Ferber and colleagues20 performed a cohort study analyzing the impact of proximal muscle strengthening on lower extremity biomechanics and found no significant effect on two dimensional peak knee abduction angle. In slight contrast however, Earl and Hoch21 found a reduction in peak internal knee abduction moment following a rehabilitation program including proximal strengthening, but no significant change in knee abduction range of motion was found. It should be noted that this study included strengthening of all proximal musculature and balance training, so its hard to conclude that the results were due to the strengthening program. Potentially, gluteal endurance may be more influential than strength itself, so it would make sense that following isolated fatigue of this musculature, lower extremity movement patterns would deteriorate.

Once again, this belief is in contrast to the available evidence. While fatigue itself most definitely has an impact on lower extremity quality of movement, isolated fatigue of the gluteal musculature tells a different story. Following a hip abductor fatigue protocol, patients only demonstrated less than a one degree increase in hip-abduction angle at initial contact and knee-abduction angle at 60 milliseconds after contact during single-leg landings22. In agreement with these findings, Geiser and colleagues performed a similar hip abductor fatigue protocol and found very small alterations in frontal plane knee mechanics, which would likely have very little impact on injury risk23. The biomechanical explanation for why weakness or motor control deficits in the gluteal musculature SHOULD cause diminished movement quality makes complete sense, but unfortunately, the evidence at this time does not agree.

While the evidence itself does not allow the gluteal musculature to shoulder all of the blame, this does not mean we should abandon addressing these deficits in our patients. As previously stated, posterolateral hip strengthening has multiple benefits, but it is not the end-all-be-all for rehabilitation or injury prevention of lower extremity conditions. Proximal strength deficits should be assessed through validated functional testing in order to see its actual impact on lower extremity biomechanics on a patient-by-patient basis. Following this assessment, interventions should be focused on improving proximal stability, movement re-education, proprioception, fear avoidance beliefs, graded exposure, and the patient’s own values, beliefs, and expectations.

ACL Reconstruction: When Can I Play Again?

“When can I play ___________ again?”

Such a simple question. Following an anterior cruciate ligament reconstruction (ACLR), this is the answer that everyone (clinician, patient, coach, and parent) wants to know. Unfortunately, this simple question does not have a simple answer.

With copious amounts of research devoted to this pathology, it would seem like an easy question to answer, but that is far from the reality. In a study of 100 soccer athletes, only 72% returned to sport following ACLR and at 7 year follow-up, only 36% were still playing (Brophy et al). This low return to sport percentage is not isolated to soccer players, as a similar study (McCullough et al) found that only 63% of high school and 67% of college-level american football players were able to return to sport. Even more concerning, there is a substantial number of patients that will have a revision or additional surgery. According to Hettrich et al, at a 6 year follow-up for 980 patients, 18.9% had additional surgical procedures performed on the same knee that initially underwent ACLR. That same study showed that 7.7% had a revision ACLR, while 6.4% had an ACLR on the opposite knee. A study published by Paterno et al, identified a significant injury rate in subjects who had previously suffered an ACL tear. This is especially evident in young females who have greater than a 25% incidence of ACL rupture in their first year back to competition. Why is this the current state of affairs with this injury, and what can we do to improve these outcomes?

Before determining when a patient is ready to return to their sports, it is first necessary to understand which biomechanical factors and faulty movement patterns may have contributed to their initial injury. In 2005, Hewett et al published a landmark study identifying biomechanical factors that can help predict initial rupture of the ACL. dynamic valgus In this study, 205 female athletes performed a jump-landing task, and 9 of these went on to rupture their ACL during the following season. During the jump-landing task, these nine female athletes demonstrated increased knee abduction at landing (8°), which translated to 2.5 times more than all the others who did not sustain an injury. Those who injured their ACL also produced 20% higher ground reaction force upon landing, which was potentially influenced by a decreased knee flexion angle upon landing. All these factors considered, individuals who are at risk for rupturing or re-rupturing their ACL demonstrate landing patterns that coincide with the typical dynamic valgus mechanism of injury. This work led to the refinement of recommended ACL rehabilitation protocols (Hewett et al). This thorough criterion-based protocol placed a major emphasis on the need for “ACL Prevention Programs” to serve as a model for the last phase of ACL reconstruction rehabilitation.

All this being said, how can we assess these risk factors in our patients? In general, there are two classes of functional testing that should be utilized prior to clearing someone to return to sport; proprioceptive/dynamic postural control and functional hop testing. Both of which play an integral role in assessing a patient’s ability to control dynamic valgus. This valgus is often associated with the development of lower extremity pathology (patellofemoral pain syndrome, iliotibial band syndrome, ACLR, ect.). These tests challenge patients to a threshold that can identify motor control, proprioception, and muscular strength/endurance deficits. These are factors that cannot be assessed accurately with the typical range of motion, manual muscle test, and Lachman testing that seems to be common practice with regards to return to play criteria.

There are many proprioceptive tests that can be utilized in the clinical setting, however there are two that should be included in any ACLR rehabilitation program. The first, and probably most well-known, is the star excursion balance test (SEBT). This test originally involved the subject balancing on one leg while reaching with the opposite limb in 8 different directions. The test has since been modified and aptly renamed the Y-Balance Test (YBT), as the only directions included are anterior, posterolateral, and posteromedial. These two variations of the test were examined in a systematic review by Gribble et al and were both found to have excellent reliability (YBT: intra-rater reliability = 0.85-0.89 and inter-rater-reliability = 0.97-1.00, SEBT: 0.78-0.96 and 0.81-0.93). In addition to being a reliable test, it is also very applicable to ACLR patients. Delahunt et al evaluated the difference between limbs of female athletes who have undergone ACLR with regards to the performance of the SEBT. These subjects were, on average, 2.9 years removed from surgery and still demonstrated significant asymmetry. Significant deficits were seen in both the posterolateral and posteromedial directions, while altered hip frontal, sagittal, and transverse plane kinematics were also evident during testing. To reinforce the significance of this asymmetry in performance and kinematic profile, Plisky et al found that basketball players with anterior right-to-left reach differences of more than 4 cm were 2.5 times more likely to sustain lower extremity injuries. More importantly 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. Regardless of whether you utilize the full SEBT or the shortened YBT, quantifying the potential faulty movement patterns that likely predisposed this individual to their initial injury is paramount to a successful return to sport.

Y-Balance Test

In addition to the use of the SEBT or YBT, the use of the lateral step-down test (LSDT) is integral to assessing each individual patient’s movement quality and resulting strength, range of motion, and/or motor control deficits. While there is not as much literature to support this specific test, it still provides a snapshot into the athlete’s ability to control stability at the knee in both the frontal and transverse planes. As diminished strength of the hip abductors and external rotators frequently accompany pathology of the lower extremity, this test provides information to help individualize a patient’s program. While the efficacy of this test’s ability to predict future injury has not been assessed, its reliability has. In a study conducted by Piva et al, the reliability of the LSDT was moderate (ICC= 0.67, Percent Agreement= 80%). Additionally, a more recent study by Boden et al determined that the interrater reliability of the LSDT was equal to 0.59 (fair agreement) and the percent agreement was 83%. While this test is not as well known as the previously mentioned proprioceptive tests, it still provides a simple, reliable way to qualitatively assess your patient’s postural control early in the rehabilitation process.

As your patient continues to progress through their rehabilitation, more functionally appropriate and demanding tests and measures should be implemented. Of particular interest, regardless of your patient’s sport, are four functional jump tests (single hop, X-hop, triple hop, and timed hop). Xergia et al found significant asymmetries in terms of performance on the functional hop test, lower extremity kinematics, and isokinetic strength testing when comparing individuals following ACLR to asymptomatic control subjects. The ACLR group demonstrated greater isokinetic knee extension deficits and greater performance asymmetry during all three functional hop tests in comparison to the control group at 6 and 9 months post-operatively. Hop Testing In agreement with these findings, Myers et al evaluated the percent asymmetry between the four different hop tests in subjects who had undergone ACLR and normal uninjured control subjects. Predictably, the ACLR group demonstrated statistically significant symmetry deficits in comparison to the control group. Average symmetries for the ACLR group only approached 92% for the single-leg hop, 91% for the triple-hop, 92% for the crossover hop, and 96% for the timed hop test, whereas the only test that did not reach 100% symmetry for the control group was the crossover hop test (97%). In addition to these studies, Schmitt et al found that individuals who demonstrated a greater level of quadriceps femoris strength also performed superiorly on hop testing and actually performed at the same level as uninjured control subjects. While these seem like excellent procedures to assess in the clinic, how do these functional tests translate to our patient’s ability to perform everyday functional activities? Di Stasi et al evaluated gait asymmetries between individuals who passed their return to sport criteria (isometric quadriceps strength test, 4 single-legged hop tests, and 2 self-report questionnaires) and those who failed at 6 months status-post ACLR. They found that athletes who demonstrate superior functional performance 6 months after ACL reconstruction may have fewer abnormal and asymmetrical gait behaviors than those who could not pass the testing battery.

The need to ensure our patient’s ability to return to play at a level that does not compromise their safety should be our primary goal as clinicians, but are we actually using this information? The short answer is no. Barber-Westin et al conducted a systematic review of the return to sport criteria within the current research literature. Of the 264 studies included, 105 (40%) provided no criteria of any kind to release patients, 84 (32%) only relied on time since surgery, and 40 (15%) relied on time since surgery and subjective criteria. All in all, only 35% of studies included objective measures in their rationale for releasing their patients to their sport. This past year, a survey and subsequent analysis was conducted by Peterson et al in order to determine the current practice patterns of orthopedic surgeons with regards to return to sport. Unfortunately, this study yielded similar results. Of the 221 experienced arthroscopic surgeons surveyed, only ~40% utilized some sort of proprioceptive test, muscular strength analysis, or even the single-leg hop test.

“Only 35% of studies provided objective criteria to determine release of patients back to sport!”

Rehabilitation following ACLR should not be based upon specific time frames, but instead upon the achievement of specific criteria. This should dictate progression to the next stage. Time does not heal all wounds. These wounds must be treated with an efficacious program structured towards the specific demands of his/her sport and the underlying deficits that resulted in the initial injury. Terry Malone’s course, “ACL and PCL Injuries, Surgeries, and Rehabilitation” and Phil Plisky’s course, “Return to Sport and Discharge Planning”, provide many excellent clinical pearls that clinicians should look to implement within their treatment plans and eventual discharge planning.

While we cannot control all of the factors that affect a patient’s rehabilitation (psychological profile, concomitant injuries, level of competition, ect.), we can provide them with a safe, reliable, and effective plan guided by the use of specific and relevant tests and measures. We need to embrace the need to appropriately assess how each patient moves and any deficits that need to be addressed prior to releasing them to their respective sport. We only provide a disservice if they are released to play at 6 months only to re-injure themselves at 9 months. It is our responsibility to release them only when they can appropriately handle the stresses of their sport, rather than on a specific time frame or when they have a 5/5 grade on a manual muscle test.

So, do you agree or disagree? I would love to hear some feedback as to what you need to see before releasing an athlete to their sport…