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BJSM Online First, published on January 22, 2015 as 10.1136/bjsports-2014-094341
Review

Clinician-friendly lower extremity physical


performance tests in athletes: a systematic review
of measurement properties and correlation with
injury. Part 2—the tests for the hip, thigh, foot and
ankle including the star excursion balance test
Eric J Hegedus,1 Suzanne M McDonough,2 Chris Bleakley,3 David Baxter,4
Chad E Cook5

▸ Additional material is ABSTRACT physical performance tests (PPTs) were developed


published online only. To view Objective To review the quality of literature and as measures of function. A PPT is a low technology
please visit the journal online
(http://dx.doi.org/10.1136/ measurement properties of physical performance tests measure that can be performed by everyone from
bjsports-2014-094341). (PPTs) of the lower extremity in athletes. coaches to healthcare professionals to examine
Methods Using the PICOS method we established our components of sport (strength, power, agility)
For numbered affiliations see
end of article. research question as to whether individual PPTs of the through multijoint movements.2 3
lower extremity have any relationship to injury in Clinically, PPTs are used, in the lower extremity
Correspondence to competitive athletes ages 12 years to adult (no limit). especially, after injury or surgery to judge symmetry
Dr Eric J Hegedus, Department A search strategy was constructed by combining the and readiness for return to play. PPTs are also used
of Physical Therapy, High Point
University, 833 Montlieu Ave, terms ‘lower extremity’ and synonyms for ‘performance as preseason screening examinations to discern defi-
High Point, NC 27262, USA; test’ and names of performance tests with variants of ciencies that may lead to injury.
ehegedus@highpoint.edu the term ‘athlete’. After examining the knee in part 1 of However, the use of PPTs as outcome measures
this 2 part series, the current report focuses on findings and prognostic tools has at least two major issues
Accepted 30 December 2014
in the rest of the lower extremity. The Preferred that are debated.
Reporting Items for Systematic Reviews and Meta- The first issue is that the usefulness of PPTs is
Analyses (PRISMA) guidelines were followed and the not clear. For example, some authors have reported
Consensus-based Standards for the selection of health that PPTs can distinguish a deficient lower extrem-
Measurement Instruments (COSMIN) checklist was used ity from a normal lower extremity4 5 whereas
to critique the methodological quality of each paper. others dispute that claim.6 7 The same contradict-
A second measure was used to analyse the quality of ory findings exist with regard to the ability of PPTs
the measurement properties of each test. to predict injury.8 9
Results Thirty-one articles examined the measurement The second issue is that PPTs should be reliable,
properties of 14 PPTs pertaining to the lower extremity. valid and responsive and have acceptable measure-
The terminology used to name and describe the tests ment error (agreement) if they are to be clinically
and methodology by which the tests were conducted useful. For example, using a PPT as a preseason
was inconsistent. screen in an attempt to predict injury is a futile if
The star excursion balance test performed in three that PPT lacks the necessary criterion or predictive
directions (anterior, posteromedial, and posterolateral) ability. As another example, a PPT loses meaning as
appears to be the only test to be associated with an outcome measure to track progress throughout
increased injury risk. There is moderate evidence that the rehabilitation unless the agreement or the minim-
one leg hop for distance and the hexagon hop can ally important change (MIC) and the minimal
distinguish between normal and unstable ankles. There detectable change (MDC) are known. For more on
is also moderate evidence that the medial hop can critical properties of tests in sports medicine see
distinguish between painful and normal hips in dancers. Davidson and Keating.10
Conclusions Currently, there is relatively limited Our goal was to produce a series of manuscripts
research-backed information on PPTs of the lower that summarised the PPTs of the lower extremities,
extremity in athletes. We would suggest convening an and that examined the methodological quality of
international consortium comprised of experts in sports the current research and the quality of measure-
to standardise the descriptions and methodologies, and ment properties of each PPT. In our previous
to set forth a research agenda to establish definitively paper, we focused on the knee.3 We present the
the measurement properties of the most common PPTs. findings from the remaining anatomical regions of
the lower extremity.

To cite: Hegedus EJ, INTRODUCTION


McDonough SM, Bleakley C,
et al. Br J Sports Med
Measures of function, especially in an athletic METHODS
Published Online First: population where competition demands complex The Preferred Reporting Items for Systematic
[please include Day Month movements that involve multiple systems and Reviews and Meta-Analyses (PRISMA) guidelines
Year] doi:10.1136/bjsports- joints, are critical for clinical decision-making.1 To were followed.11 12 Our research question, ‘Do
2014-094341 more closely approximate function in sport, individual PPT’s of the lower extremity have any
Hegedus EJ, et al. Br J Sports Med 2015;0:1–8. doi:10.1136/bjsports-2014-094341 1
Copyright Article author (or their employer) 2015. Produced by BMJ Publishing Group Ltd under licence.
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Review

relation to injury in athletes of age 12 years and older?’, was Measurement Instruments (COSMIN) checklist,14 and the
framed using the PICOS method. quality of the measurement properties was critiqued using the
In addition, we were interested in the available research adapted quality tool of Terwee et al.16 In assessing the methodo-
reporting on the measurement qualities of PPTs. PPTs were logical quality of each accepted article, sample size was not
defined as single, low technology tests that attempt to measure taken into account. However, sample size did factor into the
constructs related to sport (strength, power and agility); lower best evidence synthesis. Data were summarised in the best evi-
extremity was defined as the region spanning from the hip prox- dence synthesis using a scoring of ‘unknown’, ‘strong’, ‘moder-
imally to the phalanges of the foot distally; and athlete as those ate’, ‘limited’, or ‘conflicting’. The scoring method was defined
participating in sports at Tegner level 5 or above.13 Level 5 and as follows:16
above athletes include a range of competitive sports from ▸ Unknown—investigated in studies of exclusively poor meth-
cycling and cross-country skiing to soccer, football, and rugby. odology or not investigated in any study
When Tegner level was not specified, we accepted studies of ▸ Strong—multiple studies of good methodological rating or at
intramural or recreational athletes as appropriate for inclusion. least 1 study of excellent methodology
Articles were excluded if authors examined the utility of a com- ▸ Moderate—multiple fair methodological studies or 1 study
bination of PPTs; if single PPTs were used but results were mea- of good methodology
sured with equipment that was either expensive or not readily ▸ Limited—one study of fair methodological quality
and widely available to the average examiner such as force ▸ Conflicting—contradictory findings
plates, motion capture cameras and timing gates; if the PPTs The quality of the measurement properties of each special test
examined impairment-level data like pain and range of motion; were graded as ‘positive’, ‘indeterminate’, or ‘negative’. Owing
if the PPTs examined tasks not related to the lower extremity; to the volume of data accumulated from this process, we pub-
or if participants were involved in Tegner activity levels 4 or lished the results in two parts: part 1—the knee, and part 2—
below. We also did not include studies where the percentage of the rest of the lower extremity. The results presented hereafter
Tegner level 5 participants comprised less than 50% of the represent our findings for the lower extremity (knee excluded).
population. Since of our interest in the measurement properties
of PPTs, we accepted studies of healthy athletes. RESULTS
Included studies, tests, and testing procedures
Search strategy Of the 169 articles read in full and the 60 that were appropriate
A search strategy (see online supplementary appendix A) was for final analysis, 31 examined PPTs of the lower extremity in
formulated using terms for sport, athletics, athletes and injuries athletes (figure 1). The one leg hop for distance8 17–23 and verti-
and combining results with terms that captured tests, perform- cal jump8 18 24–29 were most often studied. These two PPTs
ance, and components of performance like strength, power, were followed in descending order of frequency by: the star
endurance, agility and function. This search was applied to excursion balance,4 5 9 30 31 shuttle run,6 24 32–34 6-meter timed
three databases: PubMed, CINAHL and SportDiscus. Results of hop,20–22 32 triple hop,20–22 35 40-yard sprint,25 34 36 triple
searches were limited to articles (not abstracts or posters) crossover hop for distance,6 17 22 6-meter timed crossover
written in the English language about humans. In addition, the hop,7 20 21 T-agility,36 37 hexagon hop,8 23 medial hop7 38 and
‘Clinical Queries’ option in PubMed was used to attempt to find the lateral hop.7 38 The PPTs and their properties were equally
systematic reviews and other articles missed by our search strat- studied in healthy populations (47% of the studies) and injured
egy, and the personal collection of one author (EJH) was populations (53% of studies). In the studies that focused on the
reviewed for pertinent articles. Finally, the reference lists of the injured, the area of injury was most often the ankle followed by
systematic reviews and of all of our final articles was searched the entire lower extremity, the hip, and the hamstrings muscle
for pertinent resources. group.
Of the PPTs studied by more than one group of authors (see
Study selection online supplementary table 1), the name given to the test and
Inclusion and exclusion criteria were applied as two authors the methodology by which it was performed and scored varied
(EJH and CB) first read all titles and abstracts. Next, all articles greatly. As an example, the vertical jump is also called a vertical
were read in full by one author (EJH) in combination with one leap, a single leg vertical, a depth vertical, a run-up jump and a
of the other authors depending on their area of expertise. If the vertical jump on two legs. The warm-up ranged from non-
two evaluating authors were in disagreement about either inclu- existent to jogging to practice trials to a dynamic warm-up. The
sion or exclusion, a third author resolved the dispute. PPT itself was described as taking off two feet, running and
jumping off of one foot and dropping 22 cm before a maximum
Data extraction, summary and analysis of quality vertical leap. The final scoring also varied from the best of two
Data were extracted by one author (EJH) with oversight by the or three trials to the mean of three trials to as many trials as
rest of the research team. We then summarised the data by first needed until a plateau in performance was reached.
gathering the names and methodologies of the PPTs to examine
them for consistency (see online supplementary table 1), produ- Summary of the methodological quality of included studies
cing a summary of all studies (see online supplementary table 2), a Reliability
summary of the methodological quality of the included studies Of the 14 tests that were studied by more than one author and
(table 1), and finally, a best evidence synthesis for each PPT had similar methodologies, all but the T agility and multistage
(table 2). We followed previously published methodology2 14 15 in fitness or ‘beep’ had reported reliability (table 1). Unfortunately,
producing this best evidence synthesis; the data on which tables 1 the methodological quality of the studies was generally poor
and 2 were based are presented in appendices B and C. due to the fact that only one measure of reliability was exam-
The methodological quality of each included article was cri- ined. Exceptions to this trend of poor methodological ratings
tiqued using the 4-point ( poor, fair, good and excellent) scoring were the medial and lateral hop tests where one group38 had
system Consensus-based Standards for the selection of health good methodological quality in a healthy subject pool.
2 Hegedus EJ, et al. Br J Sports Med 2015;0:1–8. doi:10.1136/bjsports-2014-094341
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Table 1 Summary of methodological quality by statistical property by test


Statistical property

Test Reliability Agreement Hypothesis testing Criterion validity Responsiveness

Star excursion balance test Good No studies Poor to good Excellent No studies
Sprint test: 40 yards Poor No studies No studies No studies Poor
Shuttle run Poor No studies Poor to fair No studies Poor to good
Vertical jump Poor No studies No studies Poor to excellent Good to excellent
One leg hop for distance Poor No studies Poor to good Poor to excellent Fair
One leg hop for distance: three hops Poor No studies No studies No studies Fair
Triple crossover hop for distance Poor No studies Poor No studies No studies
6-meter timed hop Poor No studies Poor No studies Poor to fair
6-meter timed crossover hop Poor Poor Good No studies No studies
Hexagon hop Poor No studies Good Poor No studies
Medial hop Poor to good Poor Good Poor No studies
Lateral hop Poor to good Poor Good Poor No studies
T-agility No studies No studies No studies No studies Fair to good
Multistage fitness No studies No studies No studies Excellent Good
Summary quality ratings above are based on the most frequent quality rating in each category. If there were two or fewer studies examining the statistical property, a range was given.
The reach test was not summarised since one of the two studies had no description of how to perform the test.

Agreement/measurement error Responsiveness


Three of the 14 PPTs were studied for agreement: The 6-meter With regard to the responsiveness of PPTs of the lower extrem-
timed crossover hop, the medial hop test, and the lateral hop ity, the vertical jump and beep tests were the only tests to be
test. The one study7 to examine these three PPTs was found to examined in studies of good or excellent methodological
have poor methodological quality based on the fact that only quality.27 28 In both of these studies the vertical jump improved
one measurement, the MDC, was reported. Reporting on the with sport-specific training in female volleyball players and male
MIC in addition to the MDC would have improved the meth- rugby players. The beep test also improved with sport-specific
odological rating to good. training. In two studies of healthy athletes, one of good
quality36 and one of fair quality,37 the T-agility test was
unaffected by bracing of ankles and was significantly improved
Hypothesis testing/construct validity after 6 weeks of plyometric training, respectively. In two studies
The methodological quality for the construct validity of the of fair methodological quality,19 20 athletes who received, in
6-meter timed crossover hop, hexagon hop, medial hop and one case, a hamstring stretching programme, and in another
lateral hop were all rated good. Of these tests, the medial hop case, a 6-week isokinetic strengthening programme, showed
test demonstrated the ability to detect a difference in a painful improvement in the single hop and triple hop.
compared to a non-painful hip, and the hexagon hop, the
ability to differentiate a lax from a stable ankle in the same par- Summary of the quality of the measurement properties
ticipant or between participants. Two other tests, the star excur- Reliability
sion balance test (SEBT) and the single leg hop, had a range of Reliability was graded positive for all 14 PPTs except for the
ratings from poor to good. For the star excursion balance test, hexagon hop test, which was found to have an intraclass correl-
the study of good methodological quality5 showed this PPT to ation (ICC) of 0.64.8 The 6-meter timed hop was found reliable
differentiate a chronically unstable ankle from a normal, within in two20 21 of three32 articles.
the same participant and between participants. For the single leg
hop, one study23 of good methodological quality demonstrated Agreement/measurement error
the ability of this test to differentiate between subjects with Of the 31 articles included in this review, only one group of
ankle laxity and those without. Finally, there were no studies authors7 investigated the measurement error of just 3 PPTs. The
examining the construct validity of the 40-yard sprint, the verti- 6-meter timed crossover hop had an MDC of 0.42 s, the medial
cal jump or the T-agility test. hop had an MDC of 20.81 cm, and the lateral hop had an
MDC of 22.62 cm. However, because the MIC was not calcu-
lated, the grade assigned was indeterminate.
Criterion validity
In contrast to the other statistical properties, criterion validity of Hypothesis testing/construct validity
some PPTs was examined in studies of excellent methodological The quality rating for the measurement property construct val-
quality. Poor performance (less than 94% of the opposite limb idity is positive almost without exception. The dominant themes
for total reach distance) on the SEBT was associated with a are that our studied PPTs correlate well with return to activity,
three-fold increase in lower extremity injury risk, and an anter- and are able to differentiate between an injured lower extremity
ior reach difference of greater than 4 cm was associated with a and a healthy one: within an athlete and between athletes.
2.7-fold increase in injury risk.9 The vertical jump, single leg Exceptions to these chief themes are the shuttle run and the
hop and beep tests were examined in the same study18 and triple crossover hop for distance which may not be able to dis-
none found to be a risk factor for lower extremity injury. tinguish between an injured and uninjured ankle,6 and the
Hegedus EJ, et al. Br J Sports Med 2015;0:1–8. doi:10.1136/bjsports-2014-094341 3
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Table 2 Synthesis of evidence by test


Strong (+++) Moderate (++) Limited (+)
Measurement property Unknown (???) (---) (--) (−) Conflicting (±)

Star excursion balance test Reliability ???


Agreement ???
Hypothesis testing ++
Criterion validity +++
Responsiveness ???
Sprint test: 40 yards Reliability ???
Agreement ???
Hypothesis testing ???
Criterion validity ???
Responsiveness ???
Shuttle run Reliability ???
Agreement ???
Hypothesis testing ±
Criterion validity ???
Responsiveness ???
Vertical leap Reliability ???
Agreement ???
Hypothesis testing ???
Criterion validity ---
Responsiveness ±
One leg hop for distance Reliability ???
Agreement ???
Hypothesis testing ++
Criterion validity ---
Responsiveness −
One leg hop for distance: three hops Reliability ???
Agreement ???
Hypothesis testing ???
Criterion validity ???
Responsiveness −
Triple crossover hop for distance Reliability ???
Agreement ???
Hypothesis testing ???
Criterion validity ???
Responsiveness ???
6-meter timed hop Reliability ???
Agreement ???
Hypothesis testing ???
Criterion validity ???
Responsiveness ???
6-meter timed crossover hop Reliability ???
Agreement ???
Hypothesis testing --
Criterion validity ???
Responsiveness −
Hexagon hop Reliability ???
Agreement ???
Hypothesis testing ++
Criterion validity ???
Responsiveness ???
Medial hop Reliability ???
Agreement ???
Hypothesis testing ++
Criterion validity ???
Responsiveness ???
Lateral hop Reliability ???
Agreement ???
Hypothesis testing --
Criterion validity ???
Responsiveness ???
T-agility Reliability ???
Agreement ???
Hypothesis testing ???
Criterion validity ???
Responsiveness ???
Multistage fitness or “beep” test Reliability ???
Agreement ???
Hypothesis testing ???
Continued

4 Hegedus EJ, et al. Br J Sports Med 2015;0:1–8. doi:10.1136/bjsports-2014-094341


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Table 2 Continued
Strong (+++) Moderate (++) Limited (+)
Measurement property Unknown (???) (---) (--) (−) Conflicting (±)

Criterion validity --−


Responsiveness ++
Grading key
Unknown: investigated in studies of exclusively poor methodology or not investigated in any study.
Strong: multiple studies of good methodological rating or at least 1 study of excellent methodology.
Moderate: multiple fair methodological studies or 1 study of good methodology.
Limited: one study of fair methodological quality.
Conflicting: contradictory findings.

6-meter timed crossover hop and lateral hop which may not be areas of sample size and methodological quality. Studies of
able to distinguish between a painful and non-painful hip within sample size 30 or less, or that had a ‘poor’ methodological
the same athlete.7 quality rating, were eliminated as we pooled the results from all
articles for each PPT.
Criterion validity
The quality rating of almost all PPTs in this review for criterion
validity was negatively biased largely on the inability of the tests Star excursion balance test
to predict injury.8 18 Also, the medial and lateral hop tests The reliability of the SEBT was examined in two studies of good
demonstrated no correlation with isokinetic testing results.7 The methodological quality30 31 but small sample sizes caused them
exception was the modified SEBT which had a positive rating to be eliminated from consideration leaving the reliability of the
based on the association of deficits from side-to-side with SEBT unknown. Also in question is the responsiveness and the
increased risk of lower extremity injury.9 agreement of the SEBT since no studies of fair or better quality
involving athletes have been conducted to the best of our
knowledge. However, there is moderate evidence that the SEBT
Responsiveness can detect differences between unstable and normal ankles
The quality of the responsiveness of the PPTs was generally within and between participants.5 There is strong evidence that
positive due largely to the fact that their performance decreased the modified 3-direction SEBT can predict injury. Both a com-
with restrictive braces or tape and with ice application, and posite reach score difference of less than 94% and an anterior
increased with sport-specific training27 and plyometrics37 (but reach difference of 4 cm or greater is associated with increased
the effect of combining these two interventions may not be injury risk.9
cumulative).28

Best evidence synthesis by PPT Sprint test: 40 yards


The best evidence synthesis (table 2) combines considerations There was one study of better than poor quality and this study
from the methodological quality of the included articles and the examined responsiveness of the 40-yard sprint.36 However, the
quality of the measurement properties of each PPT. The add- study examined only 20 healthy individuals and so the evidence
itional scrutiny provided at this highest level summary is in the in total for the 40-yard dash leaves us to conclude that we know

Figure 1 Process for selecting


studies.

Hegedus EJ, et al. Br J Sports Med 2015;0:1–8. doi:10.1136/bjsports-2014-094341 5


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nothing about the measurement properties of the 40-yard dash Medial hop test
in athletes. The medial hop test has moderate evidence to support that this
PPT can discriminate between a painful and non-painful hip in
Shuttle run dancers.7
The shuttle run, based on one study of fair methodological
quality,33 has limited and conflicting evidence with regard to Lateral hop test
construct validity. College freshman with previous injury have The lateral hop test has moderate evidence that it cannot dis-
slower times than freshmen without a prior injury. This relation- criminate between a painful and non-painful hip in dancers.7
ship did not hold true for sophomores, juniors or seniors.
Because of sample size and methodological quality issues, the
T-agility test
reliability, agreement, criterion validity and responsiveness of
Although two studies36 37 reported on the responsiveness of the
the 20 m shuttle run are unknown.
T-agility test in soccer players, both were of a small sample size
and therefore, there is no evidence to support the use of this PPT.
Vertical jump
There is no evidence as to the reliability, agreement or construct
validity of the vertical leap. There is strong evidence based on Multistage fitness or beep test
one excellent study that the vertical jump does not predict Although there is no evidence with regard to the reliability, agree-
injury in female soccer players.18 There is also strong but con- ment or construct validity of the beep test, there is moderate evi-
flicting evidence that the vertical jump is responsive. The verti- dence that the test is responsive to sport-specific training.27 There
cal jump increases with sport-specific training in female is also strong evidence that the beep test cannot predict injury.18
volleyball players27 but does not respond to plyometric training
beyond sport-specific training in male rugby players.28 DISCUSSION
PPTs are used by coaches, strength and conditioning experts,
One leg hop for distance and healthcare professionals to estimate function, gauge pro-
There is moderate evidence of the construct (discriminant) val- gress after surgery or injury, predict which athletes are at a
idity of the one leg hop for distance which provides different greater risk for injury, and also in the return to play decision.
results between athletes who have ankle instability and those We evaluated 31 studies pertaining to 14 PPTs of the lower
who do not.23 There is strong evidence that this PPT is not a extremity in athletes.
predictor of injury based on one high quality study.18 There is
limited evidence of the responsiveness of the one leg hop for How do our findings add value to the sports medicine
distance. This PPT does not change in athletes with functional community?
ankle instability with changes in isokinetic strength.20 There is The naming of PPTs, how they are performed, their warm-up,
no evidence as to the reliability or agreement of the one leg and their final scoring vary enough to cause confusion and to
hop. limit generalisability. We found similar problems in our review
of PPTs in the knee.3 Thus, a primary conclusion from our
One leg hop for distance: 3 hops/triple hop study is to call for an international consortium to develop con-
Similar to the one leg hop for distance test, there is limited evi- sistency in terminology and methodology of commonly used
dence that the triple hop is not responsive to a change in isokin- PPTs.
etic strength of the ankle.20 There is no evidence of the The most frequent rating of study methods was ‘poor’. The
reliability, agreement, construct validity or criterion validity of most immediate and achievable need is for adequately powered
the triple hop. studies that examine the validity and both the intra-rater and
inter-rater reliability of PPTs.
Triple crossover hop for distance There are gaps in the current knowledge base about PPTs for
There is no evidence for the use of this PPT in the lower athletes that might make these tests unhelpful for practical use.
extremity with an athletic population. Tests that lack validity should be dropped.10 The National
Football League (NFL) uses the vertical jump and 40-yard sprint
Six-meter timed hop as part of the NFL combine/predraft testing, and the National
There is no evidence for the use of this PPT in the lower Basketball Association (NBA) uses the vertical jump as part of
extremity with an athletic population. the NBA combine/predraft testing. These tests lack proven valid-
ity. The vertical leap is unable to predict injury and there is con-
Six-meter timed crossover hop flicting evidence of its responsiveness, casting doubt on the
This PPT, a combination of the triple crossover hop and the ability of the vertical leap to provide valuable information as an
6-meter timed hop, has moderate evidence that it cannot dis- outcome measure. Some contend that the goal of the combine
criminate between a painful and non-painful hip in dancers.7 tests is to predict performance but the NFL combine tests do
There is limited evidence that changes in the 6-meter timed not appear to possess this ability either.39
crossover hop do not correlate with changes in isokinetic What we appear to know currently about PPTs of the lower
strength.20 There is no evidence as to the reliability, agreement extremity for athletes is:
or criterion validity of this PPT. ▸ There is strong evidence that the vertical leap and single leg
hop are NOT predictors of injury.
Hexagon hop ▸ Normalised composite right reach distance of 94% or less
There is no evidence of the reliability, agreement, criterion validity and an anterior right/left reach distance difference of 4 cm
or responsiveness of the hexagon hop test, but there is moderate or more of the SEBT performed in three directions (anterior,
evidence of the ability of this PPT to discriminate between military posteromedial, and posterolateral) appears to be the only test
athletes with ankle instability and those without. to be associated with increased injury risk.
6 Hegedus EJ, et al. Br J Sports Med 2015;0:1–8. doi:10.1136/bjsports-2014-094341
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▸ There is moderate evidence that the one leg hop for distance
Table 3 Recommendations to advance research on PPTs in sports
provides different results between athletes who have ankle
medicine
instability and those who do not, which strengthens the argu-
ment for this test as an outcome measure in the rehabilitation Number Recommendation
of athletes with ankle instability.
1 Convene an international consortium to standardise terminology and
▸ There is moderate evidence that the 6-meter timed crossover methodology
hop has no ability to discern between a painful and non- 2 Conduct adequately powered studies of inter-rater and intra-rater
painful hip in dancers. reliability
▸ There is moderate evidence that the hexagon hop can distin- 3 Conduct adequately powered studies of validity including:
guish between normal and unstable ankles in military ▸ Construct—PPTs should address distinct constructs that are key
academy athletes. to return to play like power, agility, motor control, and stability.
PPTs should be able to detect asymmetry in these constructs in a
▸ There is moderate evidence that the medial hop can distin-
recovering lower extremity
guish between painful and normal hips in dancers. ▸ Criterion/Predictive—PPTs should contribute to models that
▸ There is strong evidence that the beep test has no ability to predict injury or performance
predict injury and moderate evidence that this test is respon- 4 Closely examine PPTs as clinical outcome measures:
sive to sport-specific training ▸ Establish the MDC and minimally important change
The current body of knowledge should leave the clinician- ▸ Establish the responsiveness of PPTs to changes in athlete status
with injury and recovery
scientist sceptical about the use of these tests for preseason
5 Review the literature on PPTs of the upper extremity leading to:
screening, as predictors of injury, and as outcome measures after ▸ Establishment of an upper extremity research agenda
injury or surgery. There is both an opportunity, and an urgent ▸ Development of new throwing sport-specific PPTs
need, for further research on all of these tests. ▸ Studies of validity, reliability, responsiveness

LIMITATIONS MDC, minimal detectable change; PPTs, physical performance tests.


As with any systematic review, we were limited in our findings by
the quantity and quality of the original articles. There is very limited
information about the use of PPTs in patients with hip and thigh
pathologies. Because many of the original articles were of a small are, at best, variant and, at worst, thoroughly confusing. The one
sample size, much of the information gained in examining meth- leg hop for distance was the single test of use at the knee and
odological quality was lost in the production of the synthesis of evi- ankle since it is responsive to rehabilitation after ACL reconstruc-
dence. We may have overlooked some articles because we excluded tion and discriminant in cases of ankle instability. Further, only
those not written in English, and because there is no accepted one test, the modified SEBT, has strong evidence of the ability to
search strategy for PPTs. Further, focus on individual PPTs that predict injury in the lower extremity.9 Finally, only the medial
required little technology eliminated the examination of clusters of hop has shown utility at the hip, a vastly understudied region.
PPTs and those tests that take advantage of more advanced technol- We call for an international consortium comprised of experts
ogy like three-dimensional motion capture and force plates. in sports to standardise the descriptions and methodologies of
However, this limitation increased the generalisability and clinical PPTs, and pursue a research agenda (table 3) to establish the
utility of our findings. Finally, our use of the COSMIN as the tool psychometric properties of the most common PPTs so that
to judge methodological quality, a vital component of the overall healthcare professionals, coaches, trainers and sporting organisa-
evidence synthesis, can be questioned since the measurement prop- tions can discover whether these tests may be used with confi-
erties of the COSMIN itself are not well understood.15 dence as measures of function, as outcome measures, or as
predictive factors, or whether—alternatively—they are simply a
CONCLUSIONS waste of time and resources.
PPTs of the lower extremity
There are a plethora of PPTs used as assessments of function, mea-
sures of symmetry or in an effort to predict which athletes might
become injured. In the lower extremity, only the modified SEBT What are new findings
has the ability to predict injury in high school basketball players.
There is moderate evidence that the one leg hop for distance and
▸ There are 14 physical performance tests (PPTs) pertinent to
the hexagon hop tests provide different results between athletes
the lower extremity and 6 to the knee that have been
who have ankle instability and those who do not. Also, there is
substantially studied so that we have some idea of their
moderate evidence that the medial hop can distinguish between
measurement properties in an athletic population.
painful and normal hips in dancers. Finally, there is moderate evi-
▸ The naming and methodology of PPTs in the entire lower
dence that the beep test is responsive to sport-specific training.
extremity are not consistent.
▸ The one leg hop for distance was the single test of use at
PPTs of the knee
the knee and ankle since it is responsive to rehabilitation
From part 1 of our systematic review, the only finding of moder-
after anterior cruciate ligament reconstruction and
ate evidence or better is that the one leg hop for distance is
discriminant in cases of ankle instability.
responsive in that test results improve as rehabilitation after
▸ Only one test, the modified star excursion balance test
anterior cruciate ligament (ACL) reconstruction progresses,
(SEBT), has shown strong evidence of the ability to predict
strengthening the use of this PPT as an outcome measure.
injury in the lower extremity.
▸ The hip region is understudied. Only the medial hop has
Overall
shown utility at the hip where this test can discriminate
In our review and summary of 60 articles pertaining to the lower
between a painful and non-painful hip in dancers.
extremity in athletes, test naming, description and methodology
Hegedus EJ, et al. Br J Sports Med 2015;0:1–8. doi:10.1136/bjsports-2014-094341 7
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Review
11 Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA statement for reporting
systematic reviews and meta-analyses of studies that evaluate healthcare
How might it impact on clinical practice interventions: explanation and elaboration. BMJ 2009;339:b2700.
12 Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items for systematic reviews
and meta-analyses: the PRISMA statement. BMJ 2009;339:b2535.
▸ Caution is urged in making any firm clinical conclusions
13 Tegner Y, Lysholm J. Rating systems in the evaluation of knee ligament injuries. Clin
based on the results of PPTs when testing the lower Orthop Relat Res 1985;(198):43–9.
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Centre for Health and Rehabilitation Technologies, School of Health Sciences, 19 Ross MD. Effect of a 15-day pragmatic hamstring stretching program on hamstring
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Division of Physical Therapy, Duke University, Durham, North Carolina, USA 21 Sekir U, Yildiz Y, Hazneci B, et al. Reliability of a functional test battery evaluating
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for quality, and edited the final manuscript. DB and CEC examined articles for 24 Bocchinfuso C, Sitler M, Kimura I. Effects of Two Semirigid Prophylactic Ankle
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Provenance and peer review Not commissioned; externally peer reviewed. 26 Macpherson K, Sitler M, Kimura I, et al. Effects of a semirigid and softshell
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Clinician-friendly lower extremity physical


performance tests in athletes: a systematic
review of measurement properties and
correlation with injury. Part 2−−the tests for
the hip, thigh, foot and ankle including the
star excursion balance test
Eric J Hegedus, Suzanne M McDonough, Chris Bleakley, David Baxter
and Chad E Cook

Br J Sports Med published online January 22, 2015

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