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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

screenedA 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 1st 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

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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 LBPCliborne 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 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

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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

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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, AJSM 2009 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

StepModified 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

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Rehabilitation

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