Testing in Progress

November 3, 2016

Looking to improve return-to-play outcomes, a sports medicine clinic recently introduced combines that collect baseline movement and agility data on high school athletes.

This article first appeared in the November 2016 issue of Training & Conditioning.

By Dr. Edward Ericksen, Dr. Jason Stallons, W. Andrew Middendorf, Nicole Roether, Francis Tekulve

Edward Ericksen, DPT, PT, ATC, Jason Stallons, DPT, PT, and W. Andrew Middendorf, MPT, PT, ATC, are Physical Therapists at Mercy Health Orthopaedic and Sports Medicine in Cincinnati. Nicole Roether, MEd, ATC, and Francis Tekulve, MS, ATC, CAFS, are Athletic Trainers at Mercy Health Orthopaedic and Sports Medicine. Dr. Ericksen can be reached at: ESEricksen@mercy.com.

Most everyone is familiar with the spectacle of the NFL Combine—college football’s elite coming together to showcase their strength, speed, and agility. Analysts debate athletes’ results in a number of drills and tests, and a poor showing can plummet a player’s draft stock.

At Mercy Health Orthopaedic and Sports Medicine in Cincinnati, we hold combines of our own. But instead of the best players in college football, we target high school athletes. And instead of highlighting physical prowess for potential employers, our events are geared toward collecting baseline lower-extremity movement data to assist with injury prevention and return-to-play decisions.

Our combines do share one similarity with the NFL’s, however: They keep getting bigger and better. Since our first pilot combine in March 2016, we’ve conducted more than five full-scale events, testing more than 600 local high school athletes in the process. Each one has required a high degree of planning and coordination to execute successfully.

ESTABLISHING THE NEED

It’s an all-too common scenario in sports: An athlete suffers a lower-extremity injury, proceeds through a treatment and rehab plan, and returns to activity—only to be sidelined again soon after with the same ailment. As everyone knows, return to play for lower-extremity injuries is far from a perfect science. Although experts have developed many different theories, tests, and programs to address the issue, re-injury rates remain high.

At Mercy Health, we provide outreach athletic training services to a number of local partner high schools, and we see many lower-extremity injuries each year. As part of our recent efforts to streamline our lower-extremity return-to-play procedures, we wanted to create a system that would get athletes back to activity at their pre-injury level, if not better, and keep them playing without further incident.

With this goal in mind, we formed a committee at Mercy Health made up of our athletic trainers and physical therapists. The committee’s primary goal was to develop a new lower-extremity return-to-play protocol—one that emphasized objective tests and measures to systematically progress an athlete through rehab.

To shape the protocol, our committee reviewed existing literature and talked with several experts. In doing so, we discovered an important gap: There was very little baseline or normative data that clinicians could use for comparison during return-to-play testing. This was especially true as athletes reached the end of their recovery. We looked to bridge this through our protocol and the Mercy Health Sports Medicine Combine.

Our newly established protocol is divided into stages. Each one focuses on a different area of rehabilitation, such as strength, jogging/running, plyometrics, agility, and sport-specific exercises. Injured athletes must pass tests within each stage to advance to the next step in their rehab.

The Mercy Health Sports Medicine Combine includes those same tests. By having athletes perform the tests when they are healthy, we can collect baseline data to use for comparison during their rehab, should they become injured. Then, as they would proceed through recovery, we’d continually test them and weigh the results against their pre-injury levels. When athletes would achieve functional testing scores at or near their own pre-injury marks, we’d know they were ready to return to play.

In addition, the data gathered at the combines can help us identify athletes who are at increased risk for lower-body injury. By putting them through the movement screens, we can identify and correct deficiencies before they cause an issue.

TEST IT OUT

Coming up with the idea for the Mercy Health Sports Medicine Combines was fairly easy, but we knew operating them would be more complex. We decided to start small by holding an initial pilot combine last March with roughly 50 athletes from one of the partner high schools where we provide outreach athletic training.

At the pilot event, each athlete went through four stations: lower-extremity functional test (LEFT), four single-leg hopping tests (six-meter timed, single-leg hop for distance, single-leg triple hop for distance, and single-leg triple crossover hop for distance), modified T-test, and modified pro-agility drill. We measured how long it took each athlete to complete each station.

The pilot combine taught us many lessons that helped us plan future events. For starters, we realized that we had to ensure our staff was fully versed in how to explain the tests and record the scores accurately and efficiently. This was remedied for future combines by selecting clinicians who had prior experience with the tests and by reviewing our procedures prior to each subsequent event.

To reduce error in testing performance on the athletes’ part, we decided to include the movement and agility drills as part of the combine warm-up period. This would be a better use of time, as athletes could simultaneously warm up and familiarize themselves with the drills before they got to each testing station.

We also carefully analyzed the flow of the combine. Collecting and documenting data at the LEFT and single-leg hop stations took significantly longer than the others. Therefore, at future combines, we increased the number of these stations and the staff at each one to prevent log jams. In addition, we discovered that completing the hop tests first, followed by the agility drills, and finishing with LEFT would keep the lines flowing as smoothly as possible.

COMBINE DAY

With the lessons we learned from the pilot, we felt confident going forward with the combines. Now, we have things down to a system.

The combines are offered as part of the outreach athletic training services we provide to our partner schools, and we hold them at any school that expresses an interest in having one. However, we require the school to have at least 50 athletes scheduled to attend before we commit. This makes it worth the time and personnel we must dedicate to organize the event.

Any athlete from one of our partner schools can participate in a combine at no cost. A wide variety of sports have already been represented, including water polo, volleyball, football, basketball, cross country, soccer, and lacrosse.

On the day of a combine, Mercy Health staffers arrive early to set up tables, organize stations, and delegate duties. Our combine personnel includes many different Mercy Health employees, such as athletic trainers, physical therapists, supervisors, and registrars. The number of workers needed depends on the size of the combine. For instance, we use more than 20 staffers on larger days.

To start the event, we have athletes warm up with dynamic stretching and a run-through of the hop tests, agility drills, and LEFT. After this, we split the athletes into even groups and send them to separate stations. Depending on the volume of athletes, the combine can take two to three hours to complete.

We record both quantitative and qualitative metrics during the combines, as neither can be solely relied upon for accuracy when considering safe return to play. Naturally, it is easier to focus on quantitative metrics like time and distance. Some of the tests have preexisting normative data that we measure against, such as the hop tests and LEFT, and we use the limb symmetry index to compare individual athletes’ lower extremities.

For qualitative measures, we note either success or failure for each test to help control interrater reliability. To be successful at a test, an athlete has to complete it without aberrant movement and stick the landing with minimal sway.

We then document any observed movement deficits, so we can recall them in the future for comparison. Athletes with deficits are made aware of these limitations, and we create remedial programs to address them. Although we prefer to do this on the same day as the combine, we often do it on another day if there isn’t enough time.

All the combine data is stored in a spreadsheet on a secure Mercy Health server for future reference so we can easily access it, should we see one of the athletes for rehabilitation services. We also share all test data with the participants’ athletic trainers—who are Mercy Health employees—strength and conditioning coaches, and sport coaches.

PROMISING RESULTS

The benefits we’ve seen from hosting the Mercy Health Sports Medicine Combines have come in many different forms. The athletes love the competitive element of the testing, and they view it as a fun alternative to their normal summer conditioning.

However, we’ve discovered that the competitive side can also be a detriment, as athletes try to beat each other’s scores at the expense of using good form. To combat this, we educate them on proper technique and give them a lot of feedback before and during the tests.

It was a challenge at first to educate coaches and parents on why the combines were important. To spread the word about our events and further the public’s understanding of them, we’ve promoted them to local media outlets, who have run a handful of stories on TV, print, and radio.

The publicity has proved beneficial, and we’ve received positive feedback from coaches and parents who have attended the combines and seen what opportunities they provide. Specifically, coaches have been excited to use the data from the combines to create athlete-specific training programs to improve strength, agility, and form. In addition, parents appreciate that we are taking steps to prevent injuries that could potentially sideline their children.

Strength coaches and athletic trainers from our partner schools are on board with the combines, as well. They understand the gap that remains in returning athletes to sport and welcome our proactive approach. We view athletic trainers and strength coaches as the driving forces to implement change in an athlete’s routine, and we hope they will utilize our combine data to create athlete-specific plans to improve movement deficits.

Because the Mercy Health Sports Medicine Combines are so new, we haven’t had the chance to use data from them to help an injured athlete return to play. However, we look forward to utilizing the data at the appropriate time.

Furthermore, data collected at the combines is only relevant for the specific athletes tested at this time. In the future, we hope to use it to create normative data for comparing athletes to peers of the same age and sport. Measuring an athlete’s performance against a set of norms, as well as their own pre-injury data, will enable us to see whether pre-existing deficits were a factor in their injury and if they need to exceed their own pre-injury performance before they return to play.

We have high aspirations for the continued improvement of the combines. More and more schools have asked for them, and we are currently expanding them to include upper-extremity testing for overhead athletes. We also hope to grow the combines so we can test all incoming freshmen annually and repeat the process again prior to their junior years. As the combines advance, we feel confident they will help us achieve our long-term goal of streamlining lower-extremity return to play.

Sidebar:

NEED TO KNOW

From our experience hosting Mercy Health Sports Medicine Combines in greater Cincinnati, we have a few tips for athletic trainers and strength coaches who want to develop and plan a combine at their school. They are:

• Focus on communication. Talk with your school’s athletic director, sport coaches, athletes, and parents beforehand. You need all parties to buy in to the importance of the combine for it to be successful.

• Start small. Hosting a pilot combine first with a smaller, predetermined number of athletes will help you identify any issues that need to be addressed prior to staging a large testing session.

• Choose the right location. Select an appropriately sized facility. You will need a big space to run a battery of tests for a large number of athletes. Our combines are usually held in high school gymnasiums to ensure we have enough room.

• Group athletes. We found it beneficial to have athletes remain in the same groups for the whole combine. This keeps things organized and efficient for the staffers directing the tests and recording the results.

• Recruit an ample staff. It’s important to have enough personnel present. We employ an “all hands on deck” approach to our combines to ensure they run smoothly.

• Have a plan for the data. Recording different measurements is great, but make sure you have a strategy in place for using the data toward athlete improvement.

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