Return to sport testing after ACL reconstruction is important to assure the athlete is prepared to return.
But, sometimes testing just looks at the basics and doesn’t get a clear picture of the athlete’s functional capabilities.
Here’s what we do at Champion.
To view more episodes, subscribe, and ask your questions, go to mikereinold.com/askmikereinold.
#AskMikeReinold Episode 292: Return to Sport Testing After ACL Reconstruction
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Show Notes
Transcript
Student:
All right. We’ve got Jillian from Maryland. What are your sound, reliable return to sport tests that you all utilize for post anterior cruciate ligament reconstruction athletes? Do they differ based off of the level of the athlete, whether they’re high school, college or professional? A lot of the research I have found in this area is based off of time post surgery versus validated testing for functional capacity.
Mike Reinold:
Awesome. Great job, Chappelle, welcome to the show. First question, right? Yeah. I like it. Everybody give him a virtual clap when you’re commuting in the car, don’t take your hands off the steering wheel. But good job Dan. I like it. Awesome. Sorry. So return to sport testing after ACL. Huge topic, everybody’s talking about this. It’s super complex. I’ve seen so many things out there that people are talking about from minimal things to quite comprehensive, which you could argue does is too much kind of things. I think we’re a good example for this conversation, because I think we have a blend of some scientific things. Like you said, sound reliable things with a ton of experience. Right? So there’s certain things we don’t do that I think some people do do because we just haven’t found it to be as valuable in our hands.
Mike Reinold:
So I think this would be good. We have some extra stuff that we’ve done recently over the last year or so with vault, for force plate technology that we’re really happy about and really excited about, but we also realize that not everybody has that. So there’s definitely things you can do in your clinic, no matter what. But Len, why don’t you take the lead on this and then maybe you and Diwesh can kind of tackle this episode because I know you’ve been working on kind of systemizing kind of an updated process for us at Champion, but what’s our current thoughts on this Len?
Lenny Macrina:
Always evolving, always trying to figure out what’s best. And it’s complicated because as the person said, a lot of it is time dependent. At least in the literature and still for many doctors. And so I think it’s kind of shifted now that nine months seems to be the earliest to get people back. I think that’s pretty accepted now for most. Even surgeons who tend to be a little slower in adopting some of these policies. But for us, I mean, we started out using, we still use a handheld dynamometer. Mike mentioned that we have the vault, but we still think that the handheld dynamometer is still a valuable tool. And yes, it can be expensive. They are a thousand dollars typically. But it sometimes is a really good tool to have in your clinic because I think you can use it for shoulder and knee.
Lenny Macrina:
And in this example for the knee, I’d probably recommend testing at least knee extension, but also knee flexion. And I would start that probably at about 12 weeks out of surgery. So about three months out of surgery, that’s when I would start testing and start getting some baseline stuff. Ideally if you see them pre-op, I would want to get them tested during that pre-op stage as well, because that’s when they are at their strongest. Meaning I want to test their uninvolved side because that’s going to be their gauge. That’s how you going to know with their leg symmetry index. And if they’re matching their uninvolved side. So I would try to test pre-op and I would start testing probably monthly every four to six weeks, starting at 12 weeks using at least a handheld dynamometer. And I would test it by testing into a strap, not holding a handheld dynamometer and get a quad index that way.
Lenny Macrina:
And again, you’re expecting by the time they’re nine months out, we hope that they have at least a 90% LSI. And I don’t necessarily agree with that. I think it should be a hundred plus percent LSI. Why are we settling for a 10% deficit in our athletes, especially at nine months out? So I would try to at least get that. And then for us, we are using force plates and the force deck from vault, where we’re looking at, beginning to look at 12 weeks out, roughly we’re looking at a squat assessment. We’re looking at symmetry on the squat assessment. How can they load, can they at least keep symmetry in a body weight position? So just doing body weight and then we’ll add weight to them. We’ve been doing 15% of body weight and 30% body weight holding a dumbbell and having them squat.
Lenny Macrina:
And it’s amazing to see once they start getting up into that 30% body weight, they start losing the ability to maintain symmetry early on in that testing protocol. So three, four, five months out and then they are able to hold off, be able maintain symmetry. And then we start adding kind movement jumps. We start adding isometric mid thigh poles. We’re looking at power production in that position as well.
Lenny Macrina:
So, so many different things that you can do. I don’t want to keep going on and on. But we’re building, we’re always building on that. So going from a squat to a counter movement jump to isometric mid thigh poles to looking at agility stuff. So using blaze pods and maybe getting a time reference. Or a 5-10-5 drill, where they have to run down and pivot on their involved leg and then sprint back and then measure for time there and then have them do it where they’re pivoting back on their uninvolved side and come sprinting back. I think Erik Meira talks about that test. That’s a nice way to isolate the involved versus the uninvolved side to see what the time difference is in a functional agility type movement. So just a few ideas that we can throw out there. But again, it’s complicated, we’re still building it, but it is a building process to get them to nine months post op.
Mike Reinold:
All right.
Lenny Macrina:
Diwe, what do you think?
Mike Reinold:
So I got a bunch of questions on that.
Lenny Macrina:
I know. I threw a lot out there.
Mike Reinold:
No, but that’s good. But so I think strength’s a big one, right? And I think that’s one of the things you say. So our friend Lane Bailey he just released a new paper in IJSPT that I’m actually about to interview him for an episode of my other new podcast that we’re going to do to talk about his article a little bit. But he talked about measuring strength of hip AB duction, abduction as well, and how it correlated to a lack in subjective and physiological readiness scores at the time to return to play that were still persisting at two years. Right? So if what he used for a threshold was one third your body weight for hip abduction, just as an example, and if you were below that, you didn’t feel good. Right? You didn’t feel ready.
Mike Reinold:
So I think the general concept of that is we measure strength. And to go back to Jillian’s question a little bit, we do this time based because we want to check strength over time. So let’s say you’re starting a strength assessment in 12 weeks, you might want to do that monthly to make sure that they’re progressing rapidly. And now you’ll have several months to pivot if somebody hasn’t. Right? And I think that’s an important concept. You don’t want to just do a return to play testing at nine months and be surprised that their strength’s not there. Right? So I think that’s an important one. So quad, hamstring ratios of that, hip abduction, those are big. We started using isometric mid thigh pull just as another variable for that. But I think to me, that’s the basis of that.
Mike Reinold:
Next up. Diwesh, let’s talk about force plates a little bit more specifically with some of the things we look at. For example, maybe like a squat jump, a counter movement jump. What does that tell you in somebody that’s coming back from a big injury in their readiness to get back to their sport based on that force plate data?
Diwesh Poudyal:
Yeah, for sure. So the battery of tests between counter movement jumps, squat jump, and then we’ll even later stage in the rehab process, maybe used like a hop test, like a repeat 10 hop test. That tests for true RSI reactive strength index. Or maybe like a drop jump where you drop off the box, then jump back up. But those battery of tests can tell us quite a bit, as far as athletically, what are you ready to do? And then also the cool thing about vault is that it also does tell a symmetry within those movements as well.
Diwesh Poudyal:
So you get an idea of not only are you symmetrical on an isometric test or a simple squat assessment where you’re looking at, are you able to load one side versus the other. But we also get an idea of, are you using fairly symmetrical forces for your legs when you’re doing a simple counter movement jump versus when you’re doing a squat jump where you pause the bottom, versus when you’re doing a repeat 10 hop test, right? So the athletic demands as they increase are you favoring a strategy where you’re avoiding that surgery side. So we have to look at that.
Diwesh Poudyal:
And then the other cool thing is we do definitely get the track a little bit more relevant power and a more relevant strength. What I mean by that is a barbell squat or your ability to squat heavy or deadlifts heavy, again, can only go so far. Right? We know that sport in nature is way more dynamic than that. It’s not just simple force production, but it’s a lot more about, can you produce force and can you produce force fast? And can you eccentrically load really fast and hit the brakes really hard and then come out out of that movement. Right? So the cool thing about the force plate technology is it tells us not only like when you do a jump, it doesn’t just tell us how high you jump.
Diwesh Poudyal:
It tells us how much force are you creating on the eccentric on the descent. Right? How hard and how fast are you hitting the brakes to stop your momentum so that you get to zero velocity? And then how much force are you having to put into the ground to overcome that entire movement to get back up into a concentric phase, and then eventually, how much force are you putting at takeoff to leave the ground. Right? So all those in depth metrics can give us a ton of insight. And if we start tracking that, let’s say, I know Len and I had talked about introducing a counter movement jump at week 16. Right? When the athlete had started to do some hopping and do a little bit of jumping.
Diwesh Poudyal:
But if we look at the metrics of week 16, we compare again at nine months, do they make appreciable progress in that, right? Or was it just the force production that went up right? Is their RSI still really low? If their reactive strength index really low, I mean, chances are that you’re not that ready for your sport. Right? Especially for a contact sport or an impact sport like basketball or volleyball or something like that. So I think all these metrics and having the in depth understanding of what’s happening within a simple counter movement jump can give you a ton of insight that you can relate back to the actual sport and say, all right, the athlete is strong, but maybe they’re not actually reactively strong to actually withstand the forces of the sport. That’s kind what we’re looking at right now.
Mike Reinold:
And I hope Jillian, I hope that answers a little bit of like your functional capacity question a little bit, because I think that’s how we look at that. And notice how we talked about strength, power, but then breaking down those types of functional capabilities, the quantitative type assessment of looking at their ability to jump and their symmetry and how reactive they are, that type thing. Now there’s a whole ‘nother side of that that’s probably more qualitative than quantitative that we often don’t talk about here. But it’s how well do they jump. It’s not just what’s their force output, but what’s maybe their kinematics that they do it. And I think that’s something that we probably don’t do enough, anybody really. Because it’s really hard to scrutinize that.
Mike Reinold:
So I think the future’s coming with some of the abilities to track biomechanics with just using the cameras on our phones and stuff like that. I think we’re going to get better with that. There’s a couple of devices that are out there that try to do it, that’s out there. But I think to me, that’s a big basis. So force output, strength, agility type things, their speed. These are the types of things we kind of look at.
Mike Reinold:
One question I wanted to throw out to anybody and then we’ll kind of open it up for more discussion. But one thing we haven’t talked about is hop tests, for example. Which are… I was going to say gold standard, but gold standard applies that they’re awesome. Right? But we don’t really hop test that much. We hop test probably when the physician ask us to, to give us the thing. But it’s not like something that we necessarily put in our battery of tests. Right? So, I mean, Len you want to jump in and why… Unless I’m wrong, maybe you do more hop tests than I do but-
Lenny Macrina:
No, I mean, I also want to clarify, because Diwe did mention a hop test, but it’s not the hop test that PTs know.
Mike Reinold:
Good point.
Lenny Macrina:
It’s not the hop for distance or the side to side hop. It’s literally doing 10 hops in a row on the force plate to get repetitive jumping and landing to see how much force they can produce and how quickly they can produce it. So different than the hop test in the literature. And going back to that question, Mike, that hop test maybe has some value to give you kind of a qualitative look to see how they can do a jump and landing techniques. But I think what we’re seeing in literature, it’s not the horizontal hopping that we’re most concerned with, it’s vertical hopping that most concerned. Because that’s the best way to quantify quad involvement in a functional dynamic, powerful pattern is a vertical hop.
Lenny Macrina:
When you do a horizontal hop, like a hop test, there are many substitution patterns that you can utilize in being able to jump and land and you can kind of cheat your way through it. And so I think we’re seeing that with some of the research that’s out there, is that vertical hopping is the best way to do it. Which is kind of the hopping that Diwe talked about, is just basically straight up and down and looking at the amount of force they produce. But then also maybe a slo-mo camera on your iPhone and looking to see how much valgus they get and how much internal rotation they’re getting and comparing side to side, if they’re still getting that and trying to kind of adjust for that. Because we know that’s a high risk pattern for a future injury is if they get into too much valgus. So I think more it’s the vertical hopping that we’re more concerned with the horizontal hopping.
Mike Reinold:
It’s pretty rare, at least in my experience that somebody knocks every test out of the park. Like the strength test, the power test, they look completely amazing and then have the worst hop tests in the world. Right? It’s almost like when you don’t feel good, you don’t look good. You don’t have confidence in your limb and your strength’s down, then you’re going to hop poorly. Yeah.
Lenny Macrina:
Right.
Mike Reinold:
You’re like, “Duh, of course.” We get that. Right? So-
Lenny Macrina:
And I think actually, if we can, just so we don’t get exposed for not mentioning it, doing an ACL RSI or some kind of functional questionnaire can pull that out. I don’t use it a lot. I’ve used it in the past and I’ve found my athletes tend to cheat it through it because they wanted to get passable numbers. But if you use it to kind of subjective questionnaire where somebody is truly not confident in their movements and you give this questionnaire, it’ll come out and then they won’t do well in some of these functional tests or you just don’t test them. Because they’re just not ready for it mentally because they know they’re not strong enough. So using some of these subjective questionnaires has been shown to kind of give you a little guidance into how they feel they’re doing.
Mike Reinold:
Yeah. And again, the psychological readiness I think is an emerging thing that we’ve learned a lot about over the last several years. Hey, Dan. What else, what have you done in your experience? What do you think about some of these tests?
Dan Pope:
Sure. Yeah. I guess to go back on your point of the hop test, I think you have to be a little careful with it. And also talking about, Lenny was saying, is filming folks while they’re doing their jumping. And I think this is really an ongoing thing. So if you’re working with your athlete and you’re doing jumping, you’re constantly going to be queuing. You’re going to be looking at the way they move a little bit. But what I’ve found a lot is you’ll see athletes that have symmetry with jumping side to side on a variety of tests. But if you actually look at the video, they tend to use much more of a hip strategy. Right? So when they jump and land, they’re going to land with the hips pretty far back with minimal knee flexion. Maybe they’re going to get a lot of hip drop from a compensation standpoint.
Dan Pope:
So you will potentially see some valgus, which maybe is putting them at higher risk for re-injury. But you’re probably finding that quad weakness or that fear or whatever it is of loading the knee. So if you’re using that index as a barometer of whether or not they’re safe to go back and you’re seeing a lot of compensation, I think that’s probably not accurate. Right? You’re probably still sending some of them back with the compensation strategy, despite passing those tests on paper. So I think that’s something you have to be a little bit cautious with.
Mike Reinold:
Yeah. And probably something that happens quite a bit. And I think going back to what we talked before, about the psychological readiness score. That’s an emerging science that we’re learning more and more about, but again, it comes down to making sure that the person has confidence in their limb. And if you’re working them through this and they’re passing these tests and they’re doing these jump tests, they’re using force plate data, they’re doing their strength. That in and of itself has a huge ability for them to build confidence in their limb. But if we’re just throwing them at like a return to sport testing protocol at the nine month mark, you wonder if that has something to do with it where it’s just like fear of a test out of the blue. Right? Where it’s not something like, oh, no, I’ve been testing since week 12, essentially going through things.
Mike Reinold:
So it interesting to kind of put it all together, but I think too, like Lenny was really worried about this too, again. The point of this podcast today, isn’t to talk about this is the comprehensive step A through Z on return to sport testing. For me, it’s more about going back to Jillian’s question is capacity. Right? And how do we look at more functional capacities during our ACL return to sport testing versus a comprehensive program. And I think that’s the future and that’s one of the reasons why we upgraded to force plate data was I think we can get more out of that than just doing things like simple hop test or balance tests.
Mike Reinold:
So I think that’s a little bit of the future. Not everybody has access to that, of course, but this is the type of things we need to do over time. So strength, power development, the ability to produce for both concentrically and eccentrically, absorb it during repeated hops. And there’s so much to it that I think really relates to it. But if that’s the type of thing we’re running our athletes through, and we’re doing that sequentially over time, I think we’re putting our athletes in a really good position to succeed when we get to that point. Right? Makes sense?
Mike Reinold:
So, awesome. All right. So great question. Thanks, Jillian. Hopefully that kind of helps a little bit kind of talking some of the specifics about capabilities that we can develop. If you have a question like that head to mikereinold.com, click on that podcast link, and we’ll be sure to keep answering as much as we can. So in the meantime, please subscribe, Apple podcast, Spotify. We’ll see you on the next episode. Thanks so much.
