Everyone knows that the #1 predictor of injury is previous injury. As physical therapists, this hits very close to home because it basically means that we’re not doing our job! And working in high-level athletics just makes this all the more common.
One piece of the puzzle is, of course, good treatment. This includes the entire plan of care: manual techniques, corrective exercises, return to function/sport. The other piece, however, is discharge. When do we give the green light to return? What is it based on? Discharge criteria has always involved an idea of symmetry. Historically, this may have been isolated to manual muscle testing and range of motion; however, better understanding and research have given rise to widely used functional tests and measures.
We as practitioners pick and choose testing measures based on research, logistics, and setting (e.g. hospital vs. sports team). Most importantly, we want to choose a test that has been shown through evidence based practice to be a good marker of successful rehabilitation. Many functional tests out there do a great job addressing performance and function, with the goal of achieving pre-injury levels at discharge. However, some of these metrics fall short when considering risk for re-injury. Given what we know about injury predictors, this could be an area where we are failing our patients and athletes.
Together with movement assessments and observation, I use a cluster of testing to determine readiness for return to sport / discharge. These include, but are not limited to: FMS, Triple Hop Test, Closed Kinetic Chain Upper Extremity Stability Test, squat tests (e.g. single leg, drop), and the Star Excursion Balance Test (SEBT)/Y-Balance Test (YBT). Today, I want to briefly talk about the SEBT/YBT.
The SEBT has been well documented as an effective way to assess motor control deficits and lower extremity injury outcome. The YBT takes 3 of the reach directions (anterior, posteromedial, posteriolateral) and creates an easy way to assess a person’s risk for injury. What’s interesting to note is that leg dominance, including sport specificity, has not been shown to result in a significant difference side to side. This means that even without baseline testing, the YBT can still be an effective tool to assess readiness for discharge.
Okay, so in planning for discharge, you do a YBT with your patient but you find that they are still scoring in a range that indicates heightened injury risk. Now what? Well the YBT is predictive of risk, but it is modifiable risk. This is important because it means that we can change things – mitigate this risk. That’s exactly what was shown in an article published in 2013 in the British Journal of Sports Medicine: High adherence to a neuromuscular injury prevention program improves functional balance and reduces injury risk in Canadian youth female football players: a cluster randomized trial. Authors Steffen et al found that not only are functional balance / YBT scores able to be modified, but modifying them actually does decrease injury risk! Not an athlete? No problem. Studies have shown similar improvements in the 65-85 age group as well.
There is no one answer to solve the re-injury risk riddle. But good discharge testing is a big step toward helping identify those who are not yet ready to run out the door. You can have surpassed your goals for strength and range of motion – performance, even. But it’s about looking at the whole continuum of care to make sure you don’t miss something and spin around the revolving door right back into the clinic. Stop the cycle!