3/12/2014

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Upper & Lower Extremity Screening
and Testing: Test, Dont Guess
Dan Lorenz, DPT, PT, ATC/L, CSCS,
USAW
GLATA Symposium
March 13, 2014
No conflicts, No
disclosures
Chicagoby way of Kansas City
Great to be back!
Objectives
Review and discuss evaluation/screening for
pathologies of the upper and lower
extremities
Outline a functional testing algorithm for the
upper and lower extremity
Review evidence-based testing measures to
help facilitate proper return to play criteria
These guys should have been
screened
A couple of thoughts
Evidence-based Medicine
The conscientious, explicit, and judicious use of
current best evidence in making decisions about
the care of an individual patient. It means
integrating clinical expertise with the best
available external evidence from systematic
research.
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Evidence-based Medicine
Evidence-based practice is the integration of (1)
clinical experience and expertise, (2) patient values,
and (3) the best evidence (research) into the decision
making process for patient care.
Sackett DL, Straus SE, Richardson WS, et al. Evidence-based
medicine. Churchill Livingstone: New York. 2004.
Notes on Screening/Testing
I encourage you to use outcome measures
Provides some objective data for both you, the
athletes, and the coaches
Special tests are a part of any screening but
we wont be covering those
Think pooled sensitivity/specificity
Medical Screening
Pain that does not vary and is present at rest,
especially if at night
Pain that doesnt vary with position
Symptoms that fluctuate with organ function,
related to eating or defecation
Changes in general health
Fever, chills, malaise
Unexplained weight loss
Nausea > 2 weeks duration
Maybe the best rule
We should be able to provoke the
pain through the exam and/or affect
it by treatment
If not, it is likely not a
musculoskeletal problem!!!
Concept Regional Interdependence
Wainner et al, JOSPT 2007
Basically, pathology or
injury can be primarily
from a different
location
Why we have to have a
total body approach to
screening/evaluation
and treatment
Concepts
Must have MOBILITY before
you have LENGTH and/or
STRENGTH
Must have PROXIMAL stability
before DISTAL
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Concept: Algorithm
A process consisting of steps, with each step
dependent on the outcome of previous one
In clinical medicine, a step-by-step protocol
for managing a health care problem
Steadmans Medical Dictionary, 2002
Algorithm
We can rehabilitate patients faster than ever
because by testing them, we always know where
the patient is in the rehab program and can
focus the interventions specifically on the
patients particular condition and status
Concept: Psychosocial
Pain
Fear
Apprehension
Kinesiophobia
History Boissonault
Pain provocation/relief
Quality of pain
Region/Radiation
Severity
Timing
**PQRST**
Subjective/History
Acute? Chronic?
Training history?
Changes in training? Surface changes?
Before, during, after training/games?
Type of sport
Repetitive symmetrical?
Repetitive asymmetrical?
Psychosocial
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Observation/Posture Key Points
Observe the feet
Heels?
Prominence of medial
aspect?
Ankle equinus?
How do they stand in
relaxed position?
Frog-eyed or Squinting
patellae?
Beighton Scale
Landmarks level
Leg length discrepancy
Creases symmetrical?
GAIT!
Beighton Scale
Beighton Scale
Score of 4 or greater is considered hypermobile
First Ray Stability Glasoe et al, PTJ 1999
Stiff interferes w/ weight acceptance, increases plantar
pressure (calluses under 1
st
met); also can have plantarflexed
first ray, which restricts medial rotation of the tibia (results in
lack of calcaneal eversion and shock absorption)
Hypermobile prolongs pronation and prevents full
supination to lock midtarsal joint, makes peroneus longus
ineffective stabilizer
Watch heel raise on single leg what does first ray do?
Upper Crossed Syndrome Janda
SICK Scapula Burkhart and Morgan
Scapula Inferior Coracoid DysKinesis
Posture/Scapular Position Upper Crossed Syndrome
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SICK Scapula
Type I
Inferior medial border prominence
Tight: pec major/minor
Weak: Low trap, serratus
Type II
Medial border prominence
Weak: Upper and lower trap, rhomboids
Type III
Superiormedial border prominence
Tight: Levator scapulae
Weak: Rhomboids
Muscles that respond w/ HYPERTONIA
(Postural)
Calves, hamstrings, piriformis, rectus femoris,
iliopsoas, TFL, hip abductors, QL, erector spinae
Muscles that respond w/ HYPOTONIA (Phasic)
Gluteii, tibialis anterior, vasti group, abdominal
muscles
Janda Approach Lower Crossed
Syndrome
Lower Crossed Syndrome
Movement Assessment: Spine Movement Assessment: Spine
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Thoracic Spine Mobility
Wall Slide
Measures ability to
extend thoracic spine for
elevation
Can they BIL shoulder
flex w/o the lumbar
spine?
May explain LBP in an
overhead athlete
Thoracic Spine Mobility
Quadruped thoracic
rotation
Should be at least 50 in
each direction
Spine: Cervical Cervical Flexion Supine Janda
Spine: Cervical Rolling Hoogenboom et al, NAJSPT 2009
Athlete prone and
supine
Rolling generated in
each direction with
each limb
Assesses hip, spine, and
shoulder mobility and
control
Start in supine, lead w/ both extremities, upper and lower;
repeat in prone
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Rolling
Righting reaction
As head rotates, remainder of body rotates to be
in line w/ head
PNF patterns
Neck flexion facilitates trunk flexion
Neck extension facilitates trunk extension
Neck rotation faciliates lateral flexion of the trunk
Movement Assessment
Qualitative
Visual process that focuses on quality of
movement
Postural control, tempo, rhythm
Not measured, but described
Listen to your eyes
Movement Assessment
Quantitative
Measuring the result of a specific movement
pattern
Measure amount of movement, time, accuracy of
movement
Example: Functional Testing
Single Leg Heel Raise
Atrophy?
Does calcaneus invert?
Can they stay on their great toe?
Ankle Rolling
Tandem stance, flex knees
What happens at pelvis? Knee? Ankle?
Callus Patterns Tiberio PTJ 1988
Tells you about WB v. NWB ankle/foot positions and
pressure distribution
Movement Screening Tools
Closed Chain Ankle DF ROM
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FMS
Reliable across trained raters Minick et al, 2010
FMS Composite Score can be modified w/ training Kiesel et al, 2010,
Goss et al, 2009
Injury prediction w/ composite score <14
- Firefighters Kiesel et al, 2008
- NFL football players Kiesel et al, 2007
- College athletes Chorba et al, 2010
Screening Tools Cook 1998
Deep Squat
Feet shoulder width
Dowel overhead
Assesses multiple joints
Ankle, hip, knee,
thoracic spine, and
shoulders
Ankle
Do the heels come up? Toes turn out?
Dowel rod under heel lower now?
Hips
Do they flex at the trunk?
Spine
Can they extend in thoracic spine?
Posterior or anterior tilt of pelvis?
Shoulder
Dowel rod in front of head/behind head?
What are we looking for?? Deep Squat
MOBILITY v. STABILITY problem
Provide assistance
Is it better?
Screening Tools
Y Balance
STAR Excursion
Screening Tools
Lunge Test
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Screening Tools
Step Over Test/Hurdle
Test
Lumbar spine?
Balance?
Pain?
Posture?
Rotational Stability Assessment Cook
1998
Grade III can perform
parallel to tape
II can perform diagonal
keeping torso parallel
I Unable to perform
diagonal
0 Unable to maintain
correct position
Single leg stance w/ hands on hips
Time until:
Hands off hips
Support foot moves in any direction
Other leg loses contact w/ test leg
Heel touches floor
Moderate to high reliability
High correlation w/ single leg hop test Ageberg et al, 1998
Screening Tools Stork Test Anderson et al,
2000
Stork Test/Balance Assessment
Perform
static and
dynamic
assessment
Screening Tools
Step Down Test
Single Leg Squat Analysis
Particularly useful in young females
Watch for pelvis, hip, and knee collapse
Sagittal and frontal plane analysis/view
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Screening Tools
Hip Abduction Testing
Paris
In sidelying
Palpate posterior to GT
What muscle initiates
abduction?
Normal firing order:
Gluteus medius
Palpate posterior to GT
TFL-QL
Will feel anterior to GT if TFL
Altered firing pattern:
Weak agonist=gluteus medius
Overactive synergist=TFL
QL and Opposite Hip Abd/Adductors
Vleeming
Overactive stabilizer=QL
Hip Abduction
Screening Tools
Hip Extension
Testing/Firing Sequence
Palpate medial
hamstrings
Do they flex their knee
OR can they extend hip
w/ knee extension?
Normal firing order:
Gluteus maximus
Opposite erector spinae
Ipsilateral erector spinae
Altered firing pattern:
Weak agonist=gluteus maximus
Overactive antagonist=psoas
Overactive synergist=hamstrings
Normally tested in prone
No known reliability however
Hip Extension
Supine Bridge Schellenberg et al
Raise hips from the surface, maintaining in a
straight line
Pt holds position as long as possible
If they reach 2 mins, extend the dominant LE
170.4 +/- 42.5 sec for pt w/o LBP; 76.7 +/-
48.9 sec w/ LBP
Screening Tools
Supine Bridge
Palpate medial
hamstrings first to
fire?
Can they get to full
hip extension?
What happens when
they extend one
knee?
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Prone Bridge Schellenberg et al, AJPMR 2007
Mean bridge duration
for those w/o LBP =
72.5 +/- 32.6 seconds
Mean bridge durations
for clients w/ LBP = 28.3
+/- 26.8 seconds
Trunk Endurance Testing
Strong correlation
between trunk extensor
endurance and LBP Alaranta
et al, 1995
Normative values McGill et al
1999; Reiman and Manske 2009
Side Bridge
Mean times vary from
59-96 secs
ICC=0.96-0.99 McGill et al, 1999
Glute med EMG 74 +/-
30% MVIC Ekstrom et al, 2007
Posture/Observation
Diaphragmatic
breathing assessment
TA contraction
Chest moving too?
Screening Tools
Supine trunk curl up
to long sitting
Do the hip flexors
initiate OR can they
curl their trunk
keeping the hips and
knees extended?
Trunk Flexor Endurance Test
Hold trunk at 60 as
long as possible
Mean times vary
between 147-186
sec McGill et al, APMR 1999; Chan,
APMR 2005; Reiman et al, JMMT 2006
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Double Leg Lowering Test
Lower legs until
pelvis tilts anteriorly
Athletes: 50 Reiman &
Manske 2009; Lanning et al, J Ath Train
2006
Screening Tools
Craigs Test
Anteverted vs.
Retroverted hips
Normal is 8-15
Altered static and
dynamic postures
and/or limitation of
rotation in 1 direction,
excess in another
Screening
Hip Rotation ROM
Link to knee pain, SIJ pain, and LBP
Cliborne et al, JOSPT 2007; Currier et al, Phys Ther 2007; Ellison et al, Phys Ther 1990;
Vad et al, AJSM 2004; Mellin, Spine 1988; Offierski, Spine 1983
Screening
Thomas Test
Suggest hip at 90
Have athlete support
upper leg
Two v. one joint
Does it abduct too?
Screening
Prone knee bending
Athlete prone
Passively flex heel to
buttock
Does pelvis rotate?
Do you feel increase in
lordosis?
Knee Screen - Sitting
Patellar mobility should be 2 quadrants in
each direction
Active v. passive tracking changes?
Patella alta/baja?
Check for tilt of patella
Medial/lateral and superior/inferior
Check medial tilt and glide in flexion!!
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Upper Extremity
Functional IR/ER
Total Rotational ROM
Check strength at neutral and 90/90
Supine shoulder flexion w/ legs extended and
in hook lying
Active shoulder flexion Sahrmann
Where is the inferior angle??
Apleys Scratch/Functional IR/ER
Wilk et al, CORR 2012
ER 132 +/- 9
IR 52 +/- 9
Pitchers greater ROM that position players
TROM DOM 184, Non-DOM 190
GIRD = Glenohumeral Internal Rotation Deficit
One of the causes of internal impingement
What is normal ROM for throwers?
Total Motion Concept
ER + IR = Total Motion
Wilk et al, AJSM 2002
Wilk et al, JOSPT 2009
Check IR total and isolated IR
Humeral head retroversion will change this
TROM and GIRD
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GIRD Manske et al, IJSPT 2013
Anatomical GIRD: normal in OH athletes
characterized by loss of IR <18-20
Pathological GIRD: loss of 18-20 of IR coupled
with corresponding loss of TROM >5
Problems occur if GIRD:ER Gain ratio >1
GIRD = Loss of TROM with loss of IR
compared to non-dominant
Static position
Scapulohumeral rhythm
Scapular assistance tests Kibler AJSM 2006
Active resisted scapular stability
Wall push up
Scapular Position/Mobility
Stable part of GH
articulation
Dynamically positions
glenoid
Base for muscle
attachment
Need to maintain length
tension relationship
Posture
Improper training methods
Role of the Scapula
30-35 in anterior to the
frontal plane
Why we need to do
rotator cuff exercises in
the scapular plane!!!!
Orientation
Scapular Assistance Test
Pt elevates indep
Clinician fixes scapula
and assists w/ upward
rotation
Flip Sign
Resist ER and watch for
the scapula to
reposition or the medial
border become more
prominent
Indicative of scapular
weakness
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Retraction Test
Pt seated, elevates
indep
Clinician retracts
scapula and then
repeats
Could try in standing as
well
Functional Testing Algorithm - LE
Davies
Basic measurements
Stability testing (i.e Lachmans)
Balance/Proprioception
Strength testing
Jump/Hop Tests
LE functional tests
Sport-specific tests
Discharge/Return to Sport
Dont forget kinesiophobia!
Functional Testing Algorithm UE
Davies 1998, 2011
Visual Analog Scale
Basic measurements <10% BIL
Kinesthetic/Proprioceptive
Testing
Isokinetic testing
Y Balance Test
Closed Kinetic Chain Upper
Extremity Stability Test
Males 23 touches, Females 21
touches
1-Arm Seated Shot Put
Functional Throwers Performance
Index
Males 17-41%, Females 33-
60%
Underkoeffer Overhand Softball
Throw
One Arm Hop Test Falsone et al, JOSPT
2002
Sport Specific Testing
Basic Measurements
Time/Soft tissue healing
VAS
Anthropometric measures
AROM <10% difference
PROM
Core testing?
ROM need PASSIVE knee flexion too!
Strength
Knee Extension Angle (KEA)
Davis et al, JSCR 2008
Davis et al, JSCR 2005 - >20 degs = tight hamstrings
Anthropometric Measures
Ankle Figure 8
Quads Joint line, 10 cm and 20 cm prox to joint line
Calf 15 cm distal to joint line
Basic Measurements
Make no assumptions!!
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Balance/Proprioceptive Testing
Could use SEBT on wall
Davies et al, JOSPT 1993
Measure angular joint
replication
For LE:
CTSIB
SEBT
Time to stabilization
Measure amount of
errors in given time
frame
Balance Testing STAR Excursion
Balance Test Plisky et al, 2006
Athletes w/ anterior
right/left reach distance
> than 4 cm were 2.5x
more likely to sustain a
lower extremity injuries
Girls with a composite
reach distance < 94% of
their limb length were
6.5x more likely to have
a lower extremity injury
Strength Testing
Manual muscle test
Hand held dynamometry
Leg press test (10 RM)
Single leg step down test
Crossley et al, AJSM 2011
Good, Fair, Poor quality
Suggest <4 point difference
before progression
Performance Tests
10 yd dash
Acceleration
40 yd dash
Pro Agility
ACL Hop Tests
Single leg hop v. Triple
Hop
6 M timed hop
LEFT
Stairs Hopple Test
Single leg hop up/down
flight of stairs
Figure of 8 Test
Two circles, ea 4m in
diameter
Lephart et al, J Ath Train
1991
Unilateral deficits not present in bilateral tasks need
single limb tests Myer et al, JOSPT 2011
Jump/Hop Testing
Vertical Jump
Double Leg Broad Jump
Males 100% of ht, Females 90%
Single leg hop for distance
Males 90% of ht, Females 80%
Triple Hop for Distance
Medial/Lateral or Crossover Hop
6 M Timed Hop
Hop and Stop Juris et al, JOSPT 1997
What do they MEAN??
Single hop v. Triple hop
Triple hop v. 6M timed hop
Time to stabilization difference/Double-
clutching
Hip strategy/Ankle strategy v. Triple extension
Accuracy and Precision??
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Lower Extremity Functional Testing
LEFT (Lower Extremity
Functional Test)
Reliable measure of LE
function Tabor et al, J Sport Rehab 2002
Comparable reliability w/
other LE tests Negrete et al, J Sport
Rehab 2002
Norms
Males 90-125 seconds
Females 120-150 seconds
Sprint-Front
Sprint - Retro Run
Side Shuffles Both Ways
Cariocas Both Ways
Figure 8s Both Ways
45 Angle Cuts Both Ways
90% Angle Cuts Both Way
Cross-Over Steps Both
Ways
Sprint - Front
Sprint Retro Run
LE Performance Tests
Padua et al, AJSM2009
Landing Error Scoring
System (LESS)
Valid, reliable assessment
of overall jump landing
biomechanics
Involves sagittal and frontal
plane analysis
Provides targeted
treatment for those at risk
for ACL injury Myer et al, IJSPT
2008
Pilot data reliability
= 0.84
LE Performance Test Tuck Jump
Assessment
Tuck Jump
Assessment Myer et al,
IJSPT 2008
Predictor of ACL injury
risk
Hop and Stop Juris et al, JOSPT 1997
Force absorption might be better indicator of
function than force production for
determination of functional capacity
Hop Test
Stop Test
Stop:Hop Ratio for symmetry
LE Performance Test T Drill/Test
Numerous % ranks
for various
populations Harmon et al 2008,
Reiman and Manske 2009, Hoffman, 2006
ICC= 0.94-0.98 Paoale et al
2000
Pro-Agility Test
Used at NFL Combine
% ranks for various
populations Reiman and Manske 2009,
Hoffman 2006
No known reliability
data
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LE Performance Test Edgren Side
Step
Modified Agility T-Test Hickey et al, JSCR 2009
Modified T-Agility Test Hickey et al, 2009
Traditional T test +
cuts/shuffles to one
side
Objective, quantitative,
reliable functional
assessment
ICC = 0.825
Recommend < 10%
difference
Illinois Agility Test Reiman and Manske
Passing for males is < 18.4 seconds
What about FATIGUE?
Functional Agility Short-term Fatigue Protocol
(FAST-FP)
Step downs 20 secs off 30 cm box
1RM of L Drill
5 consecutive countermovement jumps
Run back/forth on agility ladder
No rest, complete 4 sets
Quammen et al, J Ath Train 2012; Cortes et al, J Sport
Sci 2012
UE Functional Tests
Y Balance Test Westrick et al,
IJSPT 2012
Reliable test of UE closed
chain function
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Seated Shot Put Negrete et al, JSCR 2010
Has become the 1 leg hop test of the UE
Minimum Detectable Change (MDC)
DOM 17 inches, NDOM 18 inches
Reliable and valid
Gillespie et al, J Human Mvmt Studies 1987
Negrete et al, JSCR 2010
Good for older adults too! Harris et al, JSCR 2011
Seated Shot Put
CKC UE Stability Test Goldbeck & Davies, J Sport Rehab 2000
Line 3 feet apart
Males push up position; Females on knees
Touch both hands to each line as many times as
possible in 15 seconds
3 tests, average score
Norms: Females 21, Males 23
Collegiate males 26, females 21 Pontillo et al, JOSPT 2011
Correlates w/ HHD strength of elevation and IR Pontillo et al,
JOSPT 2010
Clinically useful test for UE function
Rousch et al, IJSPT 2007
CKC UE Stability Test
Functional Throwers Performance
Index (FTPI) Davies et al, JOSPT 1993
Line on floor 15 from wall, 1x1 square, 4
from floor
4 submax controlled warmups
Controlled max number of accurate throws in
30 seconds
3 sets
Divide total number/accurate throws x 100%
FTPI Davies et al, JOSPT 1993
Norms Males Females
Throws 15 13
Accuracy 7 4
FTPI 47% 29%
Range 33-60% 17-41%
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UE Performance Tests
Medicine ball chest pass
Davis et al, J Strength Cond Res 2008
Backward medicine ball throw
Clemons et al, J Strength Cond Res 2010
One Arm Hop Test Falsone et al, JOSPT 2002
Complete 5 reps as fast as possible, compare times to
other extremity; NDOM avg about 5% slower
Upper Extremity/Trunk
Strength/Power Ellenbecker & Roetert, MSSE 2004; Ikeda et al, Eur J Appl Physiol
2007
Overhand, Backward, and Rotational medicine
ball throws using 6 lb ball
Normative values established for males and
females
Power Tests
Seated Medicine Ball Throw, 12 lb for distance
BOMB (Backward Overhead Medicine Ball), 15
lb for distance
Plyometric push up onto force plate, 27 drop
Discharge/Return to Play Decisions
Creighton et al, CJSM 2010
Step 1: Evaluation of Health Status
Demographics
Symptoms
PMH
Signs/Physical Exam
Labs
Functional Tests
Psychological State
Potential seriousness of injury/release to play
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RTP
Step 2: Evaluation of Participation Risk
Type of sport (contact v. non-contact)
Position
Limb dominance
Competitive level
Ability to protect
Padding?
RTP
Step 3: Decision Modifiers
Timing of season (playoffs)
Pressure from athlete
External pressure
Masking the injury
Conflict of interest (financial)
Fear of litigation
Kinesiophobia
Thank you!! Thank you!
danielslorenz@gmail.com
Twitter: @kcrehabexpert
Facebook: Specialists in Sports and Orthopedic
Rehabilitation
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