Dr. Micah Kust
Physical Therapist
Intro:
My name is Dr. Micah Kust and I am a Physical Therapist, Athletic Trainer and Certified Strength and Conditioning Specialist currently working at Force Physical Therapy a sport performance private practice in South Florida. I have been using whiteboards to brainstorm and work through ideas pertaining to physical therapy and performance rehab for a while now. I have a voracious appetite for new knowledge and the whiteboard allows me to start refining and integrating this information into my performance rehab philosophy. The goal of this project is to bring those whiteboard thoughts together for myself and for others interested in the constant pursuit of knowledge. I believe it is very important to learn from others and integrate that knowledge into one’s own framework. Everyone has their own influences and biases, but the more continuity we have in those influences, and remove convenient biases, the better we can move the profession forward.
Lower Extremity Return to Sport Testing
The first topic I will focus on is Return to Sport (RTS) testing following lower extremity injury with knee injury being the primary emphasis. I became passionate for Return to Sport testing due to its impact on my personal and professional life. I suffered an ACL injury playing soccer as a freshman in college so I have physically and mentally gone through a return to sport process. I am thankful to have completed my collegiate playing career without a second injury but unfortunately, I sustained a reinjury of that same ACL while in PT school. At that point, I made the decision to not have another reconstructive surgery and have been ACL deficient ever since. We will save that discussion for another whiteboard Wednesday. Due to this experience, I have made it a point to stay current on return to sport evidence and continue to refine my return to sport process in order to best prepare my athletes to return to sport, performance and eventually competition.
I am the one heading the ball in neon cleats
The return to sport process is a highly debated topic so I will discuss the most current and available evidence to identify the critical aspects of RTS. One of the biggest issues with RTS testing is it is not done enough and not enough athletes pass before returning to sport. Therefore, it is important to identify the minimum requirement for appropriate return to sport testing following lower extremity injury.
The first requirement is an appropriate timetable. For example, in ACL rehab we know there is a 51% injury reduction for each month delaying return to sport up until 9 months. My answer to all my athletes about when they can return to sport following ACL injury is 9 months minimum. From there I educate them to why that is my reasoning in order to help them make the most informed decision possible about returning to sport.
The second minimum requirement is jump testing. Many different jump tests exist with some with better results than others but they must be single leg hop tests and need to be compared side to side. In a perfect world, pre-surgery measures would be used to compare however this isn’t always possible. The main tests I include in my hop tests are single leg hop for distance, triple hop for distance, lateral line hop, single leg vertical jump and single leg repeated vertical jump. Limb symmetry index (LSI) is the standard of measure for these tests and a 10% or less LSI is considered a passing result.
Another minimum requirement for RTS is strength testing. When looking at ACL injury, for every 1% improvment in quad strength LSI there is a subsequent 3% reduction in re-injury risk. In order to take advantage of this statistic we must test for it. Thankfully, there have been recent advances in equipment to make strength testing accessible to most performance therapists. The gold standard remains the isokinetic dynamometer, but other devices exist that can still give you valuable information. I use the Mark-10 force gauge which was introduced to me by Dr. Scot Morrison and his work with this device. The Mark-10 is able to measure peak force during isometric testing and can be a device to help obtain similar data to an isokinetic dynamometer without the significant price tag. The strength measurements I have started to consistently measure are knee extension, knee flexion, and hip abduction. In my opinion, any physiotherapist guiding athletes through the return to sport process must have access to a device like the Mark-10 or be willing to refer to a clinic or therapist who does.
The last piece of the RTS puzzle is physiological readiness. Although physical readiness is the primary component we focus on in performance physiotherapy, we cannot forget the physiological demand that an injury creates. The main physiological readiness test I like to use for my knee injury athletes is the ACL-RSI. This is very accessible as there is an app that can be downloaded which includes the full list of screening questions.
The return to sport process is significantly more intricate than what can be discussed in one post. There are many additional factors that I believe are significantly important to the return to sport process, which we will discuss on different whiteboards. My goal is to highlight what needs to be included as a minimum standard in order to put our athletes in the best place to succeed and improve outcomes in lower extremity return to sport rehabilitation.