A set of functional lower limb tests for physiotherapists working with athletes
Tanja Hinkkanen, PT-student, Arcada UAS, E-mail: tanja.hinkkanen
Alice Vidjeskog, PT-student, Arcada UAS
Joachim Ring, PT., Master of Health Care, Degree Programme Director, Arcada UAS. E-mail: joachim.ring
The aim of this text is to introduce a set of functional lower limb tests that can be used in physiotherapy with clients that are athletes or otherwise in good physical condition. It is important to find tests that are sufficiently challenging for that target group and therefore, when testing movement or movement control impairments the tests need to be demanding. These tests are aimed to get an overview of lower extremities function during movement.
Our set of functional lower limb tests
When testing, it is extremely important that the aim of the test is clear and adequate. One should not choose a test based on how attractive or popular it appears to be nor based on the available equipment. The reliability and validity of the test must be considered regardless of the test chosen. (Bellardini et al., 2009, p. 24-25)
Based on previous literature, physiotherapists appear to evaluate lower limb function with several methods. From these methods we decided to pick out a set of six tests. The three first lower-limb tests (deep overhead squat, hurdle step and in-line lunge) are from the Functional Movement Screening (FMS™) Tool. These fundamental movements are important to manage, since they are repeatedly present in everyday life and in sports activities also. These tests are scientific proven, and results have shown that many athletes surprisingly lack optimal performance in these fundamental movements (Cook et al., 2014a). Moreover, compensatory fundamental movement patterns that may increase injury risk can be identified with the help of these tests (Chorba et al., 2010). The tests also measure the readiness for physical activity (Kramer et al., 2019). FMS™ tests work as a quick and effective screening tool. The tests help professionals to identify lower-limb functional or physical asymmetry or limitations (Kramer et al., 2019). With the help of these three movements physiotherapists can quickly evaluate movement, movement control, muscular strength, mobility, lower-limb asymmetry, balance and coordination.
The first test is the deep overhead squat. With the squat test bilateral, symmetrical and functional mobility of the hips, knees, and ankles can be assessed. Moreover, the test measures bilateral, symmetrical mobility of the shoulders and the thoracic spine, as well as stability and motor control of the core musculature when holding the dowel overhead while squatting. (Cook et al., 2014a) Luomajoki who has done a tremendous work within movement and movement control impairments has included the deep squat in his standardized tests (Luomajoki, 2018).
The second test is the hurdle step (figure 1). The test challenges the body’s proper stride mechanics throughout a stepping motion. In order to succeed in the test, coordination and stability between hips and upper body (while taking the step) and single leg stance ability is needed. The test assesses bilateral functional mobility and stability of the hips, knees, and ankles. (Cook et al., 2014a)
Figure 1. FMS™: Hurdle step (Cook et al. 2014a)
The third test is the in-line lunge test (figure 2). The body is put in a position that will focus on the stresses created during rotational, decelerating, and lateral type movements. The test challenges the trunk and extremities to resist rotation and maintain proper alignment. Hip and ankle mobility and stability, quadriceps flexibility and knee stability are also assessed in this test. (Cook et al., 2014a)
Figure 2. FMS™: In-line lunge (Cook et al. 2014a)
The fourth test is the Y-balance test also known as SEBT or modified STAR test. The Y-balance test is a quick and effective test to identify movement and balance deficiencies (Kramer et al., 2019). According to Luomajoki (2018 p. 276) the goal is to achieve a max 10 % difference between the scores of both sides based on the study made by Keller et al (Keller et al., 2016).
The Y-balance test has proven to be a reliable test (Plisky et al., 2009). It assesses primarily dynamic balance and neuromuscular control. To pass the test the tested person is required to possess strength, flexibility and proprioception. Furthermore, the test has proven to be a valid tool to evaluate an athlete’s readiness for sport participation. The performance can significantly be improved with training. (Kramer et al., 2019) The test can be performed without a special Y-Balance Test kit (Walker, 2016a) by taping a Y shaped figure on the floor.
The single leg hop test is the fifth test in our set. Hop tests have demonstrated good reliability (Sawle, 2017). Luomajoki’s (2018) athletic and more advanced tests both include single leg hop tests. With these types of tests, it is possible to evaluate dynamic balance, quality of landing, alignment, movement control and strength (Luomajoki, 2018; Physiopedia, 2020; Sawle, 2017).
We decided to include Luomajoki’s single leg hop test, where the tested person jumps on one leg forward and backward and then later from side to side (30 cm distance) while the quality of movement, balance, control etc. is assessed. The quality of movement and movement control needs to be assessed, both balance and landing plays an important role. Side differences should be noted. The test is illustrated in figure 3.
Figure 3. Single leg hop test. Higher up: forward and backward. Underneath: side to side (Luomajoki 2018 p. 279)
When examining functional movement, movement control and when evaluating readiness for physical activity and ability to return to sports after injury, one of the main things is to examine contralateral muscular imbalances. Imbalance and asymmetry might cause injuries (Chorba et al., 2010). Thereby it is important to measure differences in strength and what comes to lower limbs, it seems to be crucial to compare side differences. According to Dohoney et al. (2002), one can predict one-repetition maximum (1RM) strength with a 4-6 RM submaximal strength assessment. This is a safer way to measure strength versus going for 1RM.
The sixth and last test is a strength test. Squat with weights is part of Luomajoki’s (2018 p. 312) more advanced tests and it was also stated as a good muscle strength test by Bellardini (2009 p. 165). However, a normal squat does not consider lower-limbs muscle strength asymmetry. Therefore, we didn’t include it into our chosen set. According to Walker (2016b), leg press is also used to measure maximal muscle strength. Leg press allows to test the strength of one leg at a time in a safe way. Therefore, we decided to select single leg press to our set. Each lower limb will be tested separately by predicting 1RM strength with a 4-6 RM submaximal strength assessment.
Discussion
Physiotherapists use several functional lower limb tests but unfortunately, in many cases the validity of these tests is still unknown in terms of suitability for different target groups. It is good to remember that there is no “one test set” that fits all. Our functional lower-limb test battery is suitable to test athletes and other physically active people.
References
Bellardini, H., Henriksson, A. och Tonkonogi, M. 2009. Tester och mätmetoder för idrott och hälsa, 1 edition, SISU Idrottsböcker, Stockholm
Chorba, R.S., Chorba, D.J., Bouillon, L.E., Overmyer, C.A. and Landis J.A., 2010. Use of a functional movement screening tool to determine injury risk in female collegiate athletes, North American Journal of Sports Physical Therapy: NAJSPT, 5(2), p.47.
Cook, G., Burton, L., Hoogenboom, B.J. and Voight, M., 2014a. Functional Movement Screening: the use of fundamental movements as an assessment of function-Part 1, International Journal of Sports Physical Therapy: IJSPT, 9(3), 396-409.
Dohoney, P., Chromiak, J.A., Lemire, D., Abadie, B.R. and Kovacs, C. 2002. Prediction of one repetition maximum (1-RM) strength from A 4-6 RM and A 7-10 RM submaximal strength test in healthy young adult males, Journal of Exercise Physiology Online, 5(3), 54-59.
Keller, M., Kurz, E., Schmidtlein O., Welsch, G. und Anders C., 2016. Interdisziplinäre Beurteilungskriterien für die Rehabilitationnach Verletzungen an der unteren Extremität: Ein funktions-basierter Return to Activity Algorithmus, Sportverletzung Sportschaden: Organ der Gesellschaft fur Orthopadisch-Traumatologische Sportmedizin; 30 (1), 38-49.
Kramer, T.A., Sacko, R.S., Pfeifer, C.E., Gatens, D.R., Goins, J.M. and Stodden, D.F. 2019. The association between functional movement Screen TM, Y-Balance test, and physical performance tests in male and female high school athletes, International Journal of Sports Physical Therapy: IJSPT, 14(6), 911-919.
Luomajoki, H. 2018, Liikkeen ja Liikekontrollin Häiriöt, Testit ja harjoitteet selän, niskan, olkapään sekä alaraajan toiminnallisiin ongelmiin, 1 edition, VK-Kustannus Oy, Lahti
Physiopedia., 2020. Hop test Available: https://www.physio-pedia.com/Hop_Test (External link), Accessed: 17.03.2020
Plisky, P.J., Gorman, P.P., Butler, R.J., Kiesel, K.B., Underwood, F.B. and Elkins, B. 2009. The reliability of an instrumented device for measuring components of the star excursion balance test, North American Journal of Sports Physical Therapy: NAJSPT, 4(2), 92-99.
Sawle, L., Freeman, J. and Marsden, J. 2017. Intra-rater reliability of the multiple single-leg hop-stabilization test and relationship with age, leg dominance and training, International Journal of Sports Physical Therapy: IJSPT, 12(2): 190-198.
Walker, O., 2016a. The Y Balance Test™ (YBT) is a simple, yet reliable, test used to measure dynamic balance, Science for Sport, 18.9.2016, Available: www.scienceforsport.com/y-balance-test (External link) , Accessed: 18.3.2020
Walker, O., 2016b. 1 RM Testing, Science for Sport, 5.6.2016, Available: https://www.scienceforsport.com/1rm-testing/, Accessed: 18.3.2020
