ACL part3

CRITERIA, QUESTIONNAIRES AND TESTING SHEETS

PART C: TSK-11

TSK-11

CRITERIA, QUESTIONNAIRES AND TESTING SHEETS

PART D: FUNCTIONAL TESTING

Star Excursion Balance Test (SEBT)

Right Left LSI Points

Anterior % /5
Posteriomedial
Posteriolateral LSI Points
Total % /5

Test Description & Reference SEBT
Star Excursion Balance Test (Gribble et al, 2012)
- SEBT is performed in the anterior, posterolateral, and posteromedial directions.
- A composite score for all 3 directions is obtained for each leg.
- A limb symmetry index is then calculated by dividing the
mean distance (in cms) of the involved limb by the mean
distance of the noninvolved limb then multiplying by 100.

CRITERIA, QUESTIONNAIRES AND TESTING SHEETS

PART D: FUNCTIONAL TESTING

Cooper and Hughes Vestibular Balance Test

Item Outcome Points Awarded
Side to Side
Up and Down /5
Total /5
/10

Test Description & Reference
Cooper & Hughes Sports Vestibular Balance Test

Subjects stand on one leg with a small amount of flexion in the hip, knee and ankle, and place their hands on their waist.
In this position, two assessments are performed;
1. Side to side
At a rate of 60 beats per minute, subjects repeatedly turn their head from side to side (70-90 degree turn) for a period of 15 seconds. Vision needs to be inline
with head position (no visual fixing).
2. Up and down

At a rate of 60 beats per minute, subjects repeatedly tilt their head up and down (looking floor to ceiling) for a period of 15 seconds. Vision needs to be inline

with head position (no visual fixing).
The test is passed if subjects can maintain single leg stance and do not take their hands off their waist for both assessments

CRITERIA, QUESTIONNAIRES AND TESTING SHEETS

PART D: FUNCTIONAL TESTING

Single Hop Test Single Hop Test

Right Left
Trial 1
Trial 2 LSI Points
Mean % /5

Test Description & Reference
Single leg hop test (Noyes et al, 1991)
- Subjects stand on one leg and hop as far forward as possible and land on the same leg.
- The average (mean) distance of 2 valid hops is recorded with a tape measure which is fixed to the

ground. Measure from toe at take-off to heel at landing. Arms are free to swing.
- A limb symmetry index is then calculated by dividing the mean distance (in cms) of the involved limb

by the mean distance of the noninvolved limb then multiplying by 100.

CRITERIA, QUESTIONNAIRES AND TESTING SHEETS

PART D: FUNCTIONAL TESTING

Triple Hop Test Triple hop Test

Right Left
Trial 1
Trial 2 LSI Points
Mean % /5

Test Description & Reference
Triple Hop Test (Noyes et al., 1991)
- Subjects are required to hop forwards three consecutive times on one foot.
- The total distance is measured, and the average (mean) of 2 valid tests is recorded.
- Measure from toe at take off to heel at landing. Arms are free to swing.
- A limb symmetry index is then calculated by dividing the mean distance (in cms) of the

involved limb by the mean distance of the noninvolved limb then multiplying by 100.

CRITERIA, QUESTIONNAIRES AND TESTING SHEETS

PART D: FUNCTIONAL TESTING

Triple Cross Over Hop Test Triple cross over hop
Test
Right Left
Trial 1 LSI Points
Trial 2 % /5
Mean

Test Description & Reference
Triple Cross Over Hop Test (Noyes et al, 1991)
- This test is performed on a course consisting of a 15cm marking strip on the floor which is 6m long.
- Subjects are required to hop three consecutive times on one foot going in a medial to lateral to medial

direction, crossing the strip on each hop.
- The total distance is measured, and the average (mean) of 2 valid hop tests is recorded.
- Measure from toe at take-off to heel at landing. Arms are free to swing.
- A limb symmetry index is then calculated by dividing the mean distance (in cms) of the involved limb by the

mean distance of the noninvolved limb then multiplying by 100.

CRITERIA, QUESTIONNAIRES AND TESTING SHEETS

PART D: FUNCTIONAL TESTING

Side Hop Test

Right Left LSI Points
Trial 1 % /5

Test Description & Reference Side hop Test
Side Hop Test (Gustavsson et al., 2006)
- Subjects stands on test leg with hands behind the back and jumps from side to side between two

parallel strips of tape, placed 40 cm apart on the floor.
- Subject jumps as many times as possible during 30sec.
- The number of successful jumps performed, without touching the tape is recorded.

CRITERIA, QUESTIONNAIRES AND TESTING SHEETS

PART D: FUNCTIONAL TESTING

Single Leg Rise Test (90° knee flexion) Points /5
%
Right Left LSI
Trial 1

Test Description & Reference
Single Leg Rise Test (Culvenor et al., 2016 & Thorstensson et al., 2004)
- Subjects sit on a chair (or a plinth) with test leg bent to 90deg, and 10cm from edge of chair.
- With hands folded across the chest, the subject aims to stand up from the sitting position and sit down as many times

as possible.

CRITERIA, QUESTIONNAIRES AND TESTING SHEETS

PART D: FUNCTIONAL TESTING

Limb Symmetry Index (LSI) Scoring

LSI is calculated by dividing the mean distance (cms), or repetitions of the involved limb by the mean of the non-involved
limb, and multiply by 100.

Limb Symmetry Index Points Awarded Limb Symmetry Index Points Awarded
(dominant leg) 10/10 or 5/5 (non dominant leg) 10/10 or 5/5
97-105 95-103

90-96 / 105-110 8/10 or 4/5 85-94 / 103-110 8/10 or 4/5

80-89 / 110-120 6/10 or 3/5 75-84 / 110-120 6/10 or 3/5

70-79 / 120-130 4/10 or 2/5 65-74 / 120-130 4/10 or 2/5

60-69 /130-140 2/10 or 1/5 55-64 / 130-140 2/10 or 1/5

< 60 / 140+ 0 points < 55 / 140+ 0 points

CRITERIA, QUESTIONNAIRES AND TESTING SHEETS

EXAMPLE

Example 1
Star Excursion Balance Test (SEBT)

Involve knee: Left
Dominant knee: Left

Right Left LSI Points

Anterior 60 58 97% 5/5

Posteriomedial 55 50

Posteriolateral 55 50 LSI Points

Total 170 158 93% 4/5

LSI (anterior) = involve/ uninvolved*100
= 58/60*100 = 97%

LSI (total) = involve/ uninvolved*100
= 158/170*100 = 93%

CRITERIA, QUESTIONNAIRES AND TESTING SHEETS

EXAMPLE

Example 2 Right Left LSI Points
Single Leg Rise Test
Trial 1 26 27 96% 4/5
Condition 1:
Involve knee: Right LSI = involve/ uninvolved*100
Dominant knee: Right = 26/27*100 = 96%

Condition 2: Trial 1 Right Left LSI Points
Involve knee: Right 26 27 96% 5/5
Dominant knee: Left

CRITERIA, QUESTIONNAIRES AND TESTING SHEETS

PART E: GENERAL FITNESS TESTING

Two sports-specific fitness tests that have previously
been performed prior to the ACL injury are to be

selected.

Such tests could include; Results Pass/Fail
• Beep Test/Shuttle/Yo-Yo Test
• Agility T-Test Test 1
• Illinois Agility Test Test 2
• Bruce Protocol
• Timed Run
• Sprint Test
• Other

CRITERIA, QUESTIONNAIRES AND TESTING SHEETS

PART F: FUNCTIONAL TESTING IN A FATIGUED STATE

Four hopping tests are to be performed in a
fatigued state. Athletes are to undertake sports-
specific exercise or game/match play until they
reach a general fatigue level of 7/10 on a VAS
scale
When athletes have reached this level of general
fatigue, the following tests are to be performed in
reasonably quick time.

• Single Hop Test
• Triple Hop Test
• Triple Cross Over Hop Test
• Side Hop Test

3 KEY CRITERIA

RETURN TO SPORT

95+ the Melbourne Return Athletes is ACL injury
to Sport Score comfortable, prevention program
confident, and eager implemented
to return to sport

Cooper & Hughes, Melbourne ACL Rehabilitation Guide 2.0

Example 1:
How do we plan treatment program from
this result?

Key criteria
- 95+ score
- Confident, mental reediness
- Prevention program implemented

Impairments

- Confident, mental reediness

Example 2:
How do we plan treatment program from
this result?

Key criteria
- 95+ score
- Confident, mental reediness
- Prevention program implemented

นักกีฬาแบทมินตนั อายุ 21 ปี
s/p Rt. ACLR with hamstring graft

Impairments

- Confident, mental reediness
- Dynamic balance
- Functional stability (multidirectional)
- Functional stability in a fatigue

EXAMPLE Split Step Lunge
BASIC FOOTWORK
IN BADMINTON

Front Court Front Court Front Court
Forehand Backhand Combined

Example 2: Rehabilitation programs
How do we plan treatment
program from this result? 1. Basic footwork in badminton
2. Dynamic balance programs
ŃĆΓĆűδ Θ₧ńĿ ŘŃαĽŃΓ ŹΘř τ21 Ňδ 3. Triple crossover, side hop
s/p Rt. ACLR with hamstring graft 4. Functional stability in a fatigue

Impairments

1. Confident, mental reediness
2. Dynamic balance
3. Functional stability

(multidirectional)
4. Functional stability in a fatigue



Anterior Cruciate ligament
Reconstruction Management

for Physical Therapy

Phase V : Return to sport and prevent of re-injury

Nuttasith Petchruschatachart, PT.
Kayaphap Health Club

ACL injury prevention program

“Aim to improve the neuromuscular

control of individuals during standing, cutting,
and landing tasks.”

Cooper & Hughes, Melbourne ACL Rehabilitation Guide 2.0

Key component

• Plyometric, balance, and strengthening exercises
• Must be performed for at least 10 mins before every

training session and game.
• A program performed more than once per week,

continues for at least 6 weeks.
• It is highly recommended that athletes continue with

an ongoing ACL injury prevention program whilst they
continue to play sports.

Cooper & Hughes, Melbourne ACL Rehabilitation Guide 2.0

Five popular injury prevention programs

• Sportsmetrics Program
• The 11+ WarmUp
• The PEP Program
• The KNEE Program – Netball Australia
• The Footy First Program - AFL

Cooper & Hughes, Melbourne ACL Rehabilitation Guide 2.0



Something else ?

What really matter for ACL injury prevention ?

• 106 postoperative ACLR athletes who returned to pivoting sports
• Followed for 2 years
• Divided into 2 groups...

Quad index <90% & Quad index >90% &
<8 months since surgery >8 months since surgery

• 38% sustained a • 5% sustained a 2nd ACL

2nd ACL injury injury

Br J Sports Med. 2016 Jul;50(13):804-8. doi: 10.1136/bjsports-2016-096031. Epub 2016 May 9.
Simple decision rules can reduce reinjury risk by 84% after ACL reconstruction: the Delaware-Oslo ACL cohort study.
Grindem H, Snyder-Mackler L, Moksnes H, Engebretsen L, Risberg MA.

• Looked at double limb landing mechanics in 77 athletes
s/p ACLR who had been cleared for sport

• Those with quadriceps strength 90% or greater than
uninvolved side were no different than controls

• Those with a strength ratio of 85% or less demonstrated
hip strategy (flexion), lack of knee flexion, and dynamic
valgus

Med Sci Sports Exerc. 2015 Jul;47(7):1426-34. doi: 10.1249/MSS.0000000000000560.
Strength Asymmetry and Landing Mechanics at Return to Sport after Anterior Cruciate Ligament Reconstruction.
Schmitt LC, Paterno MV, Ford KR, Myer GD, Hewett TE.

• Similar study looking at single limb landing mechanics in
103 athletes s/p ACLR who had been cleared for sport

• Those with a strength ratio of 85% or less demonstrated
hip strategy (flexion), lack of knee flexion, and less
internal knee extension moment

Am J Sports Med. 2015 Nov;43(11):2727-37. doi: 10.1177/0363546515602016. Epub 2015 Sep 10.
Young Athletes With Quadriceps Femoris Strength Asymmetry at Return to Sport After Anterior Cruciate Ligament Reconstruction Demonstrate
Asymmetric Single-Leg Drop-Landing Mechanics.Ithurburn MP, Paterno MV, Ford KR, Hewett TE, Schmitt LC .

Known injury mechanism is
predicted by QUAD DYSFUNCTION



Make them uninjured first...

• 2017 study tracked 838 elite female athletes
• No postural control measures could predict injury (single leg

stabilization testing : static, SEBT)

• Players with a previous ACL injury had a 3-fold higher risk

of sustaining a new ACL injury compared with previously uninjured
players

No association between static and dynamic postural control and ACL injury risk among female elite handball and football
players: a prospective study of 838 players. Kathrin Steffen.Br J Sports Med. 2017 Feb;51(4):253-259.doi: 10.1136/bjsports-
2016-097068.

• Estimated Pre-Injury Capacity (EPIC)
• Tested 70 subjects prior to ACLR
• Tested again at 6-months postop
• 57% had quad index >90% when compared involved at 6 months to

uninvolved at 6 months
• 29% had quad index >90% when compared involved at 6 months to

uninvolved at preop (EPIC QI)
• EPIC QI was more sensitive to 2nd injury

J Orthop Sports Phys Ther. 2017 May;47(5):334-338. doi: 10.2519/jospt.2017.7285. Epub 2017 Mar 29.
Limb Symmetry Indexes Can Overestimate Knee Function After Anterior Cruciate Ligament Injury.
Wellsandt E, Failla MJ, Snyder-Mackler L.

• Knee-extension maximum-voluntary-isometric-con-
traction (MVIC) torque was measured bilaterally
using a Biodex multimodal dynamometer with knee
flexed to 90°

• we found that unilateral normalized knee-extension
torque greater than 3.00 Nm/kg and quadriceps CAR
symmetry greater than 99.4% were indicative of
positive patient-reported outcomes as measured by
total KOOS score after ACLR

Quadriceps function and symmetry were both indicative of good self-
reported knee function after ACLR. Clinicians should consider quadriceps strength
exceeding 3.00 Nm/kg and nearly complete CAR symmetry when developing
rehabilitation goals for patients with ACLR.

Journal of Sport Rehabilitation, 2015, 24, 36-46 http://dx.doi.org/10.1123/jsr.2013-0110

Injury prevention

= Strength training

Injury prevention

Key component of phase V

Plyometric >> RFD

Strengthening exercises >> Peak torque (force generation)

Balance >> Control

“Improve and maintain impulse”

Programming

1. Need analysis
2. Exercise selection
3. Training frequency
4. Exercise order
5. Training load, volume & reps
6. Rest periods

Essentials strength training and conditioning. fourth edition

Strength training

1. Need analysis

Evaluation of the sport

• Body and limb movement patterns and muscular involvement (movement analysis)
• Strength, power, hypertrophy, and muscular endurance priorities (physiological analysis)
• Common sites for joint and muscle injury and causative factors (injury analysis)

Assessment of athlete

• Training and Injury status
• Training background, exercise history

Primary training goal

• Typically, this goal is to improve strength, power, hypertrophy, or muscular endurance.

Essentials strength training and conditioning. fourth edition

Strength training

1. Need analysis

Strength training

2. Exercise selection

Sport specific exercise type

• The more similar the training activity is to the actual sport movement, the
greater the likelihood that there will be a positive transfer to that sport.

• Core and assistance exercise – Multi joint/large area, Single joint/smaller
area

Ball kicking - Unilateral hip adduction and abduction, single-leg squat, forward
step lunge, leg (knee) extension, leg raise

Vertical jumping - Snatch, power clean, push jerk, back squat, front squat,
standing calf (heel) raise

Running, sprinting - Snatch, clean, front squat, forward step lunge, step-up, leg
(knee) extension, leg (knee) curl, toe raise (dorsiflexion)

Essentials strength training and conditioning. fourth edition

2. Exercise selection

2. Exercise selection

Strength training

3. Training frequency

Training status

• Beginner to advance
• Split routine

Sport season

• Off, pre, in, post season

Training Body Mon Tue wed Thu Fri sat sun
day part or
muscle rest rest
rest rest
Total Total Total Total

3 lower lower rest lower rest lower

body body body body

4 Push & push pull rest push pull
pull

Essentials strength training and conditioning. fourth edition

Strength training

4. Exercise order

• Decisions are invariably based on how one exercise affects the
quality of effort or the technique of another exercise

• Power > non-power core > Assistance Exercises
• Higher skill & concentration, most effected by fatigue first

Example
Power clean > push jerk > back squat > single leg squat > quad
extension

Essentials strength training and conditioning. fourth edition

Strength training

5. Training load, volume and reps

• Percentage of 1RM (repetition maximum)
• RPE (rated of perceived exertion) – RIR (reps in reserved)

Strength training

5. Training load, volume and reps

Strength training

5. Training load, volume and reps

Strength training

Percentage of 1RM (repetition maximum)

Strength training

RPE (rated of perceived exertion) – RIR (rep in reserved)

Application of the Repetitions in Reserve-Based Rating of Perceived Exertion Scale for Resistance Training. Erik R.helms
Strength Cond J. 2016 Aug; 38(4): 42–49. Published online 2016 Aug 3. doi: 10.1519/SSC.0000000000000218

Strength training

RPE (rated of perceived exertion) – RIR (rep in reserved)