PHYSICAL ASSESSMENT GUIDE
A guide to completing the Surf Strong Risk of Injury Screening Tool Physical Assessments
PRONE ER/IR RATIO
Instructions:
The patient should be lying in prone on a plinth for this test, with their test shoulder abducted to 90 degrees, the ipsilateral elbow flexed to 90 degrees and the arm in neutral shoulder rotation, with the upper arm supported by the plinth
The Physiotherapist should lower the plinth to an appropriate height and adopt a lunge position to adequately support the arm being tested and passively move the patient through internal and external rotation to give the patient an understanding of the required movements. The patient should then be asked to actively complete these movements.
Whilst maintaining the lunge position the Physiotherapist should hold the Hand Held Dynamometer (HHD) in their hand closest to the patient and keep their arm closely tucked into their body for support. The examiners free arm is used to support the patients elbow.
Place the HHD 2 cm proximal to the ulnar styloid on the ventral aspect for internal rotation or dorsal aspect for external rotation.
To cue the test, ask the patient to complete a maximal effort pressing into the dynamometer for 4 seconds. Verbal encouragement should not be included from the therapist.
Instruct the patient to complete a practise sub-maximal test at 50% of their maximal contraction.
Complete 2 tests for each direction on each arm, with a 10 second rest between tests.
To calculate the ratio for each shoulder, follow the formula below. Both limbs are calculated separately and same side differences between ER and IR strength as well as comparisons of strength between shoulders can then be made:
Mean ER force produced = (ER test 1 + ER test 2)/2
Mean IR force produced = (IR test 1 + IR test 2)/2
ER/IR ratio = Mean ER / Mean IR
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Norms:
An ER/IR ratio between 66% and 75% is normal (Saccol, Almeida & de Souza, 2016).
Internal rotation is commonly greater than external rotation bilaterally (Furness, Schram, Cottman-Fields, Solia & Secomb, 2018).
Reduced external rotation strength in non-dominant arm is common (Furness, Schram, Cottman-Fields, Solia & Secomb, 2018).
POSTERIOR SHOULDER ENDURANCE TEST
Instructions:
Ask the patient to lie prone on the plinth with their test arm hanging off the plinth
Place a weight equal to 2% of the patients body weight in the arm being tested
Prepare a metronome set to 30 beats per minute
Starting with the arm straight and perpendicular to the ground, the patient will abduct against resistance to 90 degrees at the set pace and hold at each end for 1 second.
Ensure the patient's arm remains straight.
Continue for as long as possible, until fatigue or elevation of the patients torso.
Repeat for the opposite shoulder
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Norms:
Patients with shoulder pain are likely to stop test by 46 seconds and 47 seconds for males and females, respectively (Evans, Konz, Nitz & Uhl, 2021).
BIERING-SORENSEN
TEST
Instructions:
Position the patient prone with their iliac crests in line with the edge of the plinth and their torso hanging off the edge.
A small chair or table can be placed under the patient which they can use their arms to support their weight with prior to the test commencing.
Hold the patients legs down for support, ask the patient to lift up their torso, cross their arms over their chest and and ensure the patient does not let their torso pass below the edge of the plinth. The patient is to hold this position for as long as possible.
Stop the test at 240 seconds
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Norms:
A time to failure below 176 seconds predicts low muscle endurance and lower back pain within the next year in males (Demoulin, Vanderthommen, Duysens & Crielaard, 2006).
A time greater than 198 seconds predicts absence of lower back pain (Demoulin, Vanderthommen, Duysens & Crielaard, 2006).
KNEE TO WALL TEST
Instructions
This test will need to be conducted against a wall and a tape measure will be used to measure the distance of the big toe to the wall
The patient may hold onto the wall for support and the back leg may rest on the ground for support also
Place some tape in a straight line along the ground, perpendicular to the wall
Ask the patient to place their test foot along the tape with their big toe touching the wall
In a split stance position and keeping their leading heel in contact with the ground, have the patient bend their knee to touch the wall with their knee
If the patient achieves contact with their knee to the wall, continue to do this whilst incrementally moving the leading foot backwards to the point where the knee can only make slight contact with the wall whilst the same side heel is touching the ground
The greatest distance achieved is marked with a pen on the tape from the point of the big toe and a tape measure is used to measure this distance from the wall in centimetres
Complete the test for the opposite leg
Norms:
Studies have sown that the knee to wall can be useful in predicting injury, where athletes with a large dorsiflexion range of motion >13cm in this test have a significantly reduced incidence of injury as opposed to those with reduced ankle dorsiflexion range > 9cm (Gabbe, Finch, Wajswelner & Bennell, 2004).
Y BALANCE TEST
The Y balance test is used to assess physical performance, identify chronic ankle instability, and identify athletes at greater risk for lower extremity injury. It is a reduced form of the star excursion balance test to include only the anterior, posteromedial and posterolateral directions.
The angle of each arm of the Y shaped tape is 135 degrees between the anterior strip and both posterior strips and 90 degrees between both posterior strips.
For this test the non-weight bearing foot cannot touch the ground to maintain balance and the stance foot must not change position although heel lift is acceptable.
The patient should have 6 practise trials for each limb in each direction as the learning effect can impact results.
The patient should be barefoot for this test.
For the anterior reach, instruct the patient to place their toes at the centre of the three strips of tape for the test. For both posterior reaches, the heel is placed on the centre marker.
A mark should be made on the tape for the furthest distance each limb achieves in each direction.
Instruct the patient to stand on 1 foot with hands on hips and to reach as far as possible along the tape, lightly touching the tape with their toe at this point. Complete this for one leg with 3 consecutive attempts.
Once anterior is completed for 1 leg, swap to anterior direction for the opposite leg.
Follow the process as above for the posterolateral and posteromedial directions.
To calculate a composite score, a measurement for both left and right leg length in centimetres will be required. To calculate this, use a measuring tape to measure the distance between the test limb anterior superior iliac spine (ASIS) and the ipsilateral medial malleolus.
Calculating results:
- To gain objective results from the Y balance test, the maximal distance (cm) in each direction for each limb is used.
- A composite score, which is used to predict injury is then calculated for each limb using the following formula:
((Anterior + Posteromedial + Posterolateral) / (3 x Limb Length)) x 100
Norms:
A composite score of below 89% shows an increased risk of injury (Butler, Lehr, Fink, Kiesel & Plisky, 2013).
Anterior reach asymmetries over 4cm between legs may indicate an increased risk of lower limb injury (Freeman, Bird & Sheppard, 2013).
Composite scores below 80% increased patient risk of ankle sprain by 48% whereas patients who achieved a composite score of greater than 90% had a significantly reduced incidence of ankle sprains (Lehr et al., 2013).
SINGLE LEG SQUAT TEST
Instructions
The patient must be barefoot to conduct this test
Cue the patient to place their hands on their hips, stand on one leg and lift up their opposite leg to 90 degrees hip flexion
The patient should then slowly bend their weight bearing knee to 30 degrees and then stand up tall
This should be performed 3 times on each leg
Repeat on the opposite side, following the above instructions
Results:
Physiotherapists should observe for flailing arms, collapsing of the weight bearing knee into valgus (kneecap medial to 1st toe) and Trendelenburg sign. A positive test is where the patient shows 2 or more of the above abnormal responses which would indicate increased risk of lower limb injury (Ugalde, Brockman, Bailowitz & Pollard, 2014).
HAMSTRINGS / QUADRICEPS RATIO
Instructions:
Use a hand held dynamometer to measure force production of the hamstrings and quadriceps unilaterally
Hamstring force should be measured with the patient in prone and the knee bent to 90 degrees with the HHD placed on the dorsal aspect of the heel
Quadriceps force should be measured with the patient in sitting with the plinth height not allowing the feet to touch the ground and the HHD placed on the ventral aspect of the leg 2cm proximal to the medial/lateral malleolus
Allow 1 sub-maxiamal practise test at 50% of maximal contraction to allow the patient to gain familiarity with the test
For each test, conduct 2 trials for each limb in each movement
Allow for 10 seconds between trials
To calculate the hamstrings to quadriceps ratio, use the following formula for each leg individually:
Mean hamstring force = (Hamstring test 1 + Hamstring test 2)/2
Mean Quadriceps force = (Quadriceps test 1 + Quadriceps test 2)/2
H/Q ratio = Mean Hamstring force / Mean Quadriceps force
Norms:
A H/Q ratio of 50%-80% is considered normal (Rosene, Fogarty & Mahaffey, 2001).
THE DROP JUMP TEST
Instructions:
Have the patient stand on a 31cm high box or step
Cue the patient to step off the elevated platform landing with both feet on the ground at once, and in one motion upon landing from the drop, jump as high as possible and land on both feet again.
3 practise trials of the drop jump are allowed
3 consecutive jumps are then completed for the test
The patient should rest for 10 seconds in-between each trial
The above steps can then also be followed to complete the single leg drop jump test do observe unilateral landing mechanics if deemed safe for the patient. For this test, the patient should drop onto one leg and then jump, landing on both legs. This should be repeated for both legs.
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Assessment:
The jumps should be reviewed with slow motion footage.
High risk patients will display valgus where the patella moves inward beyond the 1st toe, ipsiliateral trunk motion as well as any reduced hip, knee or ankle range of motion.