Lower extremity return to play testing protocols

The athlete has had a lower extremity injury that required either surgery, extensive rehab and reconditioning and is cleared to participate. But are they ready to return to play without hesitation? Are they trained to competent levels of starting, elastic and stopping strength? 

These questions always concerned me when one of my athletes sustained a major injury. The solution was a series of tests that assessed closed-chain, multiple-direction, single-leg movement and allowed a percentage system of scoring, so the deficiency in elastic, starting, and stopping strength could be quantified, and any test anxiety could be noted.

The return to play protocol starts at a low level and progresses to a more complex level of movement. It takes an hour to warm up, test and score the events. Filming is a good idea since it creates a tool for the doctor to observe the movements and compare them to the scores. 

Test 1 – Cross hop and stick 

First thing is to have the athlete go through a good dynamic multiple-direction warm-up and observe the athlete as they move. Are they limping? Are they favoring a leg? Are they starting and stopping exclusively on one leg? 

Athletic tape is laid out in a cross pattern, and the athlete begins in the middle of the crossed tape. With a moderate level hop forward, backward, lateral right and left, the athlete will hop and stick the landing, attempting to hold for three seconds. The test is scored +, 0, or –. A score of + is a balanced landing that was stable immediately. A score of 0 means the athlete was a bit unstable but able to maintain a single-leg stance with balance. A score of – is recorded if the athlete uses the non-weight-bearing leg to touch to achieve balance. The score should be recorded for both legs and should be a + in all directions. If not, more stability training is indicated.

Test 2 – Single-leg vertical hop

This is a single-leg hop off each leg. Landing on two feet is fine. Make sure and reach with the opposite arm of the jumping leg. Yes, it is awkward to do the non-dominant leg, but the comparative score will indicate the first hint of a performance deficit. The score of the right and left leg is divided by one into the other, then multiplied by 100 to get a percentage score. For example:

• 17 inches divided by 18 inches = .94 x 100 = 94% 
• This score should be the highest in the series of tests. 

Test 3 — 40-yard circle test 

Two cones are set out 10 yards apart. The athlete will go from the starting line around the cones either clockwise or counterclockwise for two laps (forty yards), sprinting through the finish. The rehabbed leg will either be constantly on the outside or inside of the laps. Note which way the athlete chose to go first. In the case of an ACL, the rehabbed leg being on the outside of the lap begins to more closely mimic the internal rotation action that, combined with a loss of stability, can lead to an ACL injury. Time each lap, then divide and multiply to get a score. This is a competitive speed test.

Test 4 – 40-yard shuttle 

The athlete will do four 10-yard legs of sprinting at full speed. Every time they change direction, it must be on the same foot/leg. The test compares the high-speed ability to absorb and produce force with a two-foot change of direction. Any anxiety on the part of the athlete should be noted. This is also a full-speed drill. Again, score the percentage.

Test 5 – Linear 5-hop test 

Set up a tape measure and from the starting line, direct the athlete to hop on one leg five times and run through the landing. The test administrator should follow along with a dowel rod and mark the heel of the foot on the last hop landing. These hops are executed at a good effort with power and control — not all out, where control is lost. On the last landing, the distance from the heel to the start is recorded and scored. 

Test 6 – Lateral 5 hop test 

This drill is to measure the ability to absorb and produce force on one leg in a series of lateral hops akin to a single-leg change of direction in competition. This drill mimics the mechanism of injury in a non-contact ACL rupture. The athlete stands on the starting line and hops laterally toward the non-weight-bearing, bent-kneed leg. The administrator will score the foot that lands on the fifth hop and note the distance. The athlete should NOT stick the landing, just run it out.

Test 7 – Backwards hop x5 

This is a test of stopping strength and is usually the lowest-scoring test since stopping strength is the last ability to return to 100%. The athlete will hop backward on one leg for five reps, and the administrator will mark from the toes of the fifth hop to score this test.

» ALSO SEE: Navigating NIL in education-based athletics

Here is an actual scoring of an ACL repair for a D1 athlete who was cleared to practice.

As the scores indicate, the lack of stopping strength above 90% would preclude this athlete from full participation. This was agreed upon, and after two more weeks of rehab focusing on absorbing force, the athlete was retested and scored above 90% and was cleared for full go.

This is an excellent test battery to help an athlete return to play for practice and have the numbers to back the decision.

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