VOLUME ELEVEN NUMBER TWO

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ORIGINAL RESEARCH

An Initial Evaluation of BTrackS™ Balance Plate and Sports Balance Software for Concussion Diagnosis

Authors:  Goble DJ, Manyak KA, Abdenour TE, Rauh MJ, Baweja HA

As recently dictated by the American Medical Society, balance testing is an important component in the clinical evaluation of concussion. Despite this, previous research on the efficacy of balance testing for concussion diagnosis suggests low sensitivity (~30%), based primarily on the use of the popular Balance Error Scoring System (BESS). The Balance Tracking System (BTrackS™, Balance Tracking Systems Inc., San Diego, CA, USA) consists of a force plate (BTrackS™ Balance Plate) and software (BTrackS™ Sport Balance) which can quickly (<2 min) perform concussion balance testing with gold standard accuracy.  Therefore, the purpose of this study was to determine the sensitivity of the BTrackS Balance Plate and Sports Balance Software for concussion diagnosis.  Preseason baseline balance testing of 519 healthy Division I college athletes playing sports with a relatively high risk for concussions was performed with the BTrackS Balance Test. Testing was administered by certified athletic training staff using the BTrackS Balance Plate and Sport Balance software. Of the baselined athletes, 25 later experienced a concussion during the ensuing sport season. Post-injury balance testing was performed on these concussed athletes within 48 of injury and the sensitivity of the BTrackS Balance Plate and Sport Balance software was estimated based on the number of athletes showing a balance decline according to the criteria specified in the Sport Balance software. This criteria is based on the minimal detectable change statistic with a 90% confidence level (i.e. 90% specificity).  The authors found that of the 25 athletes who experienced concussions, 16 had balance declines relative to baseline testing, according to the BTrackS Sport Balance software criteria. This corresponds to an estimated concussion sensitivity of 64%, which is twice as great as that reported previously when using the BESS.  Therefore, the authors concluded that the BTrackS Balance Plate and Sport Balance software has the greatest concussion sensitivity of any balance testing instrument reported to date.
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Performance of High School Football Players on Clinical Measures of Deep Cervical Flexor Endurance and Cervical Active Range of Motion: Is History of Concussion a Factor?

Authors:  Smith L, Ruediger T, Alsalaheen B

More than one million adolescent athletes participated in organized high school sanctioned football during the 2014-15 season. Football athletes are at risk for concussion.  Although cervical spine active range of motion (AROM) and deep neck flexor endurance may serve a preventative role in concussion, and widespread clinical use of measurements of these variables, reference values are not available for this population.  Cost effective, clinically relevant methods for measuring neck endurance are also well established for adolescent athletes. The purpose of this study was to report reference values for deep cervical flexor endurance and cervical AROM in adolescent football players and examine whether differences in these measures exist in high school football players with and without a history of concussion. Concussion history, cervical AROM, and deep neck flexor endurance were measured in 122 high school football players.  Reference values were calculated for AROM and endurance measures; associations were examined between various descriptive variables and concussion. The authors found no statistically significant differences between athletes with a history of concussion and those without. A modest inverse correlation was seen between body mass and AROM in the sagittal and transverse planes. Theauthors concluded that the participants with larger body mass had less cervical AROM in some directions.  While cervical AROM and endurance measurements may not be adequate to identify adolescent high school football players with a history of previous concussions, if a concussion is sustained, these results can offer a baseline to examine whether cervical AROM is affected as compared to healthy adolescents.
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SYSTEMATIC REVIEW

Effectiveness of Ultrasonography in Diagnosing Chronic Lateral Ankle Instability:  A Systematic Review

Authors:  Radwan A, Bakowski J, Dew S, Greenwald B, Hyde E, Webber N

Chronic ankle instability (CAI) is a condition that often develops after repeated ankle sprains, increasing the susceptibility of the ankle to move into excessive inversion when walking on unstable surfaces. Treatment for CAI costs approximately three billion health care dollars annually. Currently, common diagnostic tools used to identify ankle instability are arthroscopy, imaging, manual laxity testing, and self-reported questionnaires. The purpose of this systematic review was to investigate the effectiveness of ultrasonography in diagnosing CAI, in comparison with other diagnostic tools.   Six high quality articles were included in this systematic review, as indicated by high scores on the QUADAS scale, ranging from 10 to 13. Sensitivity of US ranged from: 84.6 % -100%, specificity of US ranged from: 90.9% – 100% and accuracy ranged from: 87% – 90.9%. The results of the included studies suggest that US is able to accurately differentiate between the grades of ankle sprains and between a lax ligament, torn ligament, thick ligament, absorbed ligament, and a non-union avulsion fracture. These findings indicate that US is a reliable method for diagnosing CAI, and that US is able to classify the degree of instability. Therefore the researchers found that US is effective, reliable, and accurate in the diagnosis of CAI.  The clinical implication is that US could allow for earlier diagnosis, which could increase the quality of care as well as decrease the number of outpatient visits. This could lead to improvement in treatment plans, goals and rehabilitation outcomes.
Abstract
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ORIGINAL RESEARCH

An Electromyographic Analysis of the Shoulder Complex Musculature While Performing Exercises Using the BodyBlade® Classic and BodyBlade™ Pro.

Authors: Escamilla R, Yamashiro K, Dunning R, Mikla, T, Grover M, Kenniston M, Loera J, Tanasse T, Andrews J

In spite of the Bodyblade® (BB) being used in clinical settings during shoulder and trunk rehabilitation and training for 24 years, there are only five known scientific papers that have described muscle recruitment patterns using the BB.  Moreover, there are no known studies that have examined muscle activity differences between males and females or between different BB devices. Therefore, the primary purposes of this investigation were to compare glenohumeral and scapular muscle activity between the Bodyblade® Pro (BBP) and Bodyblade® Classic (BBC) devices while performing a variety of exercises, as well as to compare muscle activity between males and females. Twenty young adults, 10 males and 10 females, performed seven BB exercises using the BBC and BBP. EMG data were collected from anterior and posterior deltoids, sternal pectoralis major, latissimus dorsi, infraspinatus, upper and lower trapezius, and serratus anterior during 10 seconds of continuous motion for each exercise, and then normalized using maximum voluntary isometric contractions (MVIC).  A two-factor repeated measures Analysis of Variance (p < 0.05) was employed to assess differences in EMG activity between BB devices (BBC and BBP) and genders. As hypothesized, for numerous exercises and muscles glenohumeral and scapular EMG activity was significantly greater in females compared to males and was significantly greater in the BBP compared to BBC. There were generally no significant interactions between BB devices and gender. Overall glenohumeral and scapular muscle activity was not significantly different between using one hand and using two hands, but was greater in some conditions. The authors concluded that it may be appropriate to employ BB exercises during shoulder rehabilitation earlier for males compared to females and earlier for the BBC compared to the BBP given less overall muscle activation in males and BBC compared to in females and BBP. Differences in muscle activity between exercises generally was the similar regardless if the BBC or the BBP was employed.
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Comparison of Trunk and Lower Extremity Muscle Activity Among Four Stationary Equipment Devices: Upright Bike, Recumbent Bike, Treadmill, and ElliptiGO®

Authors: Bouillon L, Baker R, Gibson C, Kearney A, Busemeyer T

Stationary equipment devices are often used to improve fitness. The ElliptiGO® was recently developed that blends the elements of an elliptical trainer and bicycle, allowing reciprocal lower limb pedaling in an upright position. However, it is unknown whether the muscle activity used for the ElliptiGO® is similar to walking or cycling. To date, there is no information comparing muscle activity during exercise on the treadmill, stationary upright and recumbent bikes, and the ElliptiGO®. Therefore, the purpose of this study was to assess trunk and lower extremity muscle activity among treadmill walking, cycling (recumbent and upright) and the ElliptiGO® cycling. It was hypothesized that the ElliptiGO® and treadmill would elicit similar electromyographic muscle activity responses compared to the stationary bike and recumbent bike during an exercise session. Twelve recreationally active volunteers participated in the study and were assigned a random order of exercise for each of the four devices (ElliptiGO®, stationary upright cycle ergometer, recumbent ergometer, and a treadmill). Two-dimensional video was used to monitor the start and stop of exercise and surface electromyography (SEMG) were used to assess muscle activity during two minutes of cycling or treadmill walking at 40-50% heart rate reserve (HRR). Eight muscles on the dominant limb were used for analysis:  gluteus maximus (Gmax), gluteus medius (Gmed), biceps femoris (BF), lateral head of the gastrocnemius (LG), tibialis anterior (TA), rectus femoris (RF).  Two trunk muscles were assessed on the same side; lumbar erector spinae at L3-4 level (LES) and rectus abdominus (RA).  Maximal voluntary isometric contractions (MVIC) were determined for each muscle and SEMG data were expressed as %MVIC in order to normalize outputs. The authors found that percent MVIC for RF during ElliptiGO® cycling was higher than recumbent cycling. The LG muscle activity was highest during upright cycling. The TA was higher during walking compared to recumbent cycling and ElliptiGO® cycling. No differences were found among the the LES and remaining lower limb musculature across devices.  Therefore, the authors concluded that ElliptiGO® cycling was found to elicit sufficient muscle activity to provide a strengthening stimulus for the RF muscle. The LES, RA, Gmax, Gmed, and BF activity were similar across all devices and ranged from low to moderate strength levels of muscle activation.
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Not All Single Leg Squats Are Equal: A Biomechanical Comparison of Three Variations

Authors:  Khuu A, Foch E, Lewis CL

The single leg squat (SLS) is a functional task used by practitioners to evaluate and treat multiple pathologies of the lower extremity. Variations of the SLS may have different neuromuscular and biomechanical demands. The effect of altering the non-stance leg position during the SLS on trunk, pelvis, and lower extremity mechanics has not been reported. Therefore, the purpose of this study was to compare trunk, pelvis, hip, knee, and ankle kinematics and hip, knee, and ankle kinetics of three variations of the SLS using different non-stance leg positions: SLS-Front, SLS-Middle, and SLS-Back.  Sixteen healthy women performed the three SLS tasks while data were collected using a motion capture system and force plates. Joint mechanics in the sagittal, frontal, and transverse planes were compared for the SLS tasks using a separate repeated-measures analysis of variance (ANOVA) for each variable at two analysis points: peak knee flexion (PKF) and 60 degrees of knee flexion (60KF). The authors found that different non-stance leg positions during the SLS resulted in distinct movement patterns and moments at the trunk, pelvis, and lower extremity. At PKF, SLS-Back exhibited the greatest kinematic differences (p < 0.05) from SLS-Front and SLS-Middle with greater ipsilateral trunk flexion, pelvic anterior tilt and drop, hip flexion, adduction, and external rotation as well as less knee flexion and abduction. SLS-Back also showed the greatest kinetic differences (p < 0.05) from SLS-Front and SLS-Middle with greater hip external rotator moment and knee extensor moment as well as less hip extensor moment and knee adductor moment at PKF. At 60KF, the findings were similar except at the knee.  Therefore, the authors concluded that the mechanics of the trunk, pelvis, and lower extremity during the SLS were affected by the position of the non-stance leg in healthy females. Practitioners can use these findings to distinguish between SLS variations and to select the appropriate SLS for assessment and rehabilitation.
Abstract
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Kinematic Analysis of Knee Valgus During Drop Vertical Jump and Forward Step-up in Young Basketball Players

Authors:  Paz GA, de Freitas Maia M, Farias D, Santana H, Miranda H, Lima V, Herrington L

Lower limb asymmetry between dominant and nondominant limbs is often associated with lower extremity injuries. However, there is a lack of detailed evidence about frontal plane projection angle (FPPA) of the knee joint (knee valgus) during drop vertical jump (DVJ) and forward step-up tasks (FSUP) in young basketball players. Therefore, the purpose of this study was to assess the FPPA (i.e., dynamic knee valgus) via 2D video analysis during DVJ and FSUP tasks between dominant and nondominant limbs of young male basketball players.  Twenty seven young male basketball players (age 14.5 ± 1.3 y, height 161.1 ± 4.1 cm, weight 64.2 ± 10.2 kg) participated in this study. The participants were asked to perform a bilateral DVJ and unilateral FSUP tasks. Kinematic analysis of FPPA was completed via a two-dimensional (2D) examination in order to evaluate the knee valgus alignment during the beginning of the concentric phase of each task. Knee valgus alignment was computed considering the angle between the line formed between the markers at the anterior superior iliac spine and middle of the tibiofemoral joint and the line formed from the markers on the middle of the tibiofemoral joint to the middle of the ankle mortise. Paired t-tests were used to evaluate differences in tasks. Standard error of measurement (SEM) was calculated to establish random error scores. There was no difference on knee valgus angle during the DVJ task between dominant (20.2 ± 4.4º) and nondominant legs (20 ± 4.1º; p = 0.067). However, a significant difference was noted during FSUP between the non-dominant limb (18.7 ± 3.4º) when compared to the dominant (21.7 ± 3.5º; p = 0.001) limb.  Therefore, the authors concluded that two dimensional kinematic analysis of knee FPPA may help coaches and other professionals to detect asymmetries between dominant and nondominant limbs, and to develop training programs with the goal of reducing overall lower extremity injury risk.
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Lower Extremity Hypermobility, But Not Core Muscle Endurance Influences Balance in Female Collegiate Dancers

Authors: Ambegaonkar JP, Cortes N, Caswell SV, Ambegaonkar GP, Wyon M

Dance is a physically demanding activity, with almost 70 percent of all injuries in dancers occurring in the lower extremity (LE). Prior researchers report that muscle function (e.g. muscle endurance) and anatomical factors (e.g. hypermobility) affect physical performance (e.g. balance) and can subsequently influence LE injury risk. Specifically, lesser core muscle endurance, balance deficits, and greater hypermobility are related to increased LE injury risk. However, the potential interrelationships among these factors in dancers remain unclear. The purposes of this study were to examine the relationships among core muscle endurance, balance, and LE hypermobility and determine the relative contributions of core muscle endurance and LE hypermobility as predictors of balance in female collegiate dancers. Core muscle endurance was evaluated using the combined average anterior, left, and right lateral plank test time scores(s). LE hypermobility was measured using the LE-specific Beighton hypermobility measure, defining hypermobility if both legs had greater than 10 degree knee hyperextension. Balance was measured via the composite anterior, posterolateral, and posteromedial Star Excursion Balance Test (SEBT) reach distances (normalized to leg length) in 15 female healthy collegiate dancers (18.3+0.5yrs, 165.5+6.9cm, 63.7+12.1kg). Point-biserial-correlation-coefficients examined relationships and a linear regression examined whether core endurance and hypermobility predicted balance (p<.05). The authors found that LE hypermobility (Yes; n=3, No; n=12) and balance (87.2+8.3% leg length) were positively correlated r(14)=.67, (p=.01). However, core endurance (103.9+50.6 s) and balance were not correlated r(14)=.32, (p=.26).  LE hypermobility status predicted 36.9% of the variance in balance scores (p=.01). Therefore, the authors concluded that LE hypermobility, but not core muscle endurance may be related to balance in female collegiate dancers. While LE hypermobility status influenced balance in the female collegiate dancers, how this LE hypermobility status affects their longitudinal injury risk as their careers progress needs further study. Overall, the current findings suggest that rather than using isolated core endurance-centric training, clinicians may encourage dancers to use training programs that incorporate multiple muscles – in order to improve their balance, and possibly reduce their LE injury risk.
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Acute Changes in Passive Glenohumeral Rotation Following Tennis Play Exposure in Elite Female Players

Authors: Moore-Reed SD, Kibler WB, Myers NL, Smith BJ

Alterations in glenohumeral (GH) rotation especially internal rotation and total range of motion have been associated with altered GH kinematics and susceptibility to injury. Researchers have evaluated long-term change in baseball and tennis players, and short-term changes in baseball players. However, acute (short-term) changes in GH rotation have not been evaluated in tennis players. Therefore, the purpose of this study was to quantify short-term glenohumeral rotational changes within a group of professional women’s tennis players following competitive play. It was hypothesized that there would be acute alterations in passive glenohumeral internal rotation and total range of motion following episodes of tennis play. Passive glenohumeral external rotation (GER), glenohumeral internal rotation (GIR), and total range of motion (TROM) were evaluated in a cohort of 79 professional adult female tennis players.  Measurements were taken at three different time points (TP): baseline before match play (TP1), immediately after match play (TP2), and 24-hours after baseline (TP3).  The authors found that there was a statistically significant decrease in the mean GIR from TP1 (43 ± 11 degrees) to TP2 (39 ± 9 degrees) (p=0.002) and from TP1 to TP3 (38 ± 10°) (p=0.001). All measures were at the level of minimal detectable change (MDC) (4 degrees) indicating clinical significance. There was a decrease in mean TROM from TP1 (146 ± 11 degrees) to TP2 (142 ± 12 degrees) (p=0.04), which was not above MDC (7 degrees). Subgroup analysis showed that 47 percent of the players demonstrated a decrease in GIR beyond MDC, and 37 percent demonstrated a decrease in TROM beyond MDC.  GER remained unchanged across all time points (p>0.05). Therefore, the authors concluded that both GIR and TROM were reduced after acute exposure to tennis play. In a large subgroup of the cohort, the changes were clinically significant and approached values previously demonstrated to be associated with increased injury risk. Given the changes in glenohumeral motion following acute exposure to tennis play in a substantial group of players, evaluation of players for significant motion alterations following overhead activity and intervention strategies to minimize such alterations in these players are recommended.
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Static Stretching Does Not Reduce Variability, Jump and Speed Performance

Authors:  de Oliveira FCL, Rama LMPL

Stretching is often part of the warm-up routine prior to athletic participation; however, controversial evidence exists on the effects of stretching on countermovement jump (CMJ) and sprint performance. Additionally, analysis of variability between repeated tasks is useful for monitoring players, in order to analyze factors that could affect performance, and to guide clinical decisions for training strategies.  Therefore, the purpose of this study was to examine whether static stretching (SS) prior to CMJ and 20-meter (20-m) sprint would affect performance, and to investigate whether SS affects an athlete’s ability to perform these tasks consistently.  Twenty-two trained healthy athletes (23.2 ± 5.0 years) attended, randomly, two testing sessions, separated by 48 hours. At session one, all participants underwent 10 minutes of dynamic running warm-up followed by the experimental tasks (three CMJ and three 20-m sprint), whereas five minutes of stretching was added after the warm-up routine at session two. All participants performed the same experimental tasks in both sessions. The stretching protocol consisted of five stretching exercises for each lower limb.  The paired-samples t-test revealed no significant differences between the stretching protocol condition and no stretching condition for the 20-m sprint (t(21)=.920; p=.368) and CMJ (t(21)=.709; p=.486). There were no significant differences in trial-by-trial variability on 20-m sprint (t(21)=1.934;  p=.067) and CMJ scores (t(21)=.793; p=.437) as result of SS.  Therefore, the authors concluded that the SS protocol did not modify jumping and running ability in trained healthy athletes. The SS prior to training or competition may not cause detrimental effects to athletic performance.
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The Immediate and Long-term Effects of Kinesiotape® on  Balance and Functional Performance

Authors: Wilson V, Douris P, Fukuroku T, Kuzniewski M, Dias J, Figueiredo P

The application of Kinesio Tex® tape (KT) results, in theory, in the improvement of muscle contractibility by supporting weakened muscles. The effect of KT on muscle strength has been investigated by numerous researchers who have theorized that KT facilitates an immediate increase in muscle strength by generating a concentric pull on the fascia. The effect of KT on balance and functional performance has been controversial because of the inconsistencies of tension and direction of pull required during application of KT and whether its use on healthy individuals provides therapeutic benefits. Therefore, the purpose of the present study was to investigate the immediate and long-term effects of the prescribed application (for facilitation) of KT when applied to the dominant lower extremity of healthy individuals. The hypothesis was that balance and functional performance would improve with the prescribed application of KT versus the sham application.  Seventeen healthy subjects (9 males; 8 females) ranging from 18-35 years of age (mean age 23.3±0.72), volunteered to participate in this study. KT was applied to the gastrocnemius of the participant’s dominant leg using a prescribed application to facilitate muscle performance for the experimental group versus a sham application for the control group. The Biodex Balance System and four hop tests were utilized to assess balance, proprioception, and functional performance beginning on the first day including pre- and immediately post-KT application measurements. Subsequent measurements were performed 24, 72, and 120 hours after tape application. Repeated measures ANOVA’s were performed for each individual dependent variable.  The authors found that there were no significant differences for main and interaction effects between KT and sham groups for the balance and four hop tests.  Therefore, the results of the present study did not indicate any significant differences in balance and functional performance when KT was applied to the gastrocnemius muscle of the lower extremity.
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CASE REPORT

Acute Effects of Dry Needling on Posterior Shoulder Tightness: A Case Report

Authors: Passigli S, Plebani G, Poser A

Posterior shoulder tightness has been associated with numerous shoulder disorders. The purpose of this case report was to report the outcomes of a subject with posterior shoulder tightness treated with dry needling as a primary intervention strategy. The subject was a 46-year-old man who was referred to physical therapy with primary symptoms of shoulder pain and loss of motion consistent with subacromial impingement syndrome. Clinical findings upon examination revealed glenohumeral internal rotation and horizontal adduction losses of motion and reproduction of pain symptoms upon palpation of the infraspinatus, teres minor, and posterior deltoid. A single treatment of trigger point dry needling was used to decrease pain and improve range of motion.  Following the intervention, clinically meaningful improvements were seen in pain and shoulder range of motion. The immediate improvement seen in this subject following the dry needling to the infraspinatus, teres minor, and posterior deltoid muscles suggests that muscles may be a significant source of pain and range of motion limitation in this condition.
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CLINICAL COMMENTARY

Patient-Specific and Surgery-Specific Factors That Affect Return to Sport After ACL Reconstruction

Authors: Joreitz R, Lynch A, Rabuck S, Lynch B, Davin S, Irrgang J

Anterior cruciate ligament (ACL) reconstruction is frequently performed to allow individuals to return to their pre-injury levels of sports participation, however, return to pre-injury level of sport is poor and re-injury rates are unacceptably high. Re-injury is likely associated with the timeframe and guidelines for return to sport (RTS). It is imperative for clinicians to recognize risk factors for re-injury and to ensure that modifiable risk factors are addressed prior to RTS. The purpose of this commentary is to summarize the current literature on the outcomes following return to sport after ACL reconstruction and to outline the biologic and patient-specific factors that should be considered when counseling an athlete on their progression through rehabilitation. A comprehensive literature search was performed to identify RTS criteria and RTS rates after ACL reconstruction with consideration paid to graft healing, anatomic reconstruction, and risk factors for re-injury and revision. Results were screened for relevant original research articles and review articles, from which results were summarized. Variable RTS rates are presented in the literature due to variable definitions of RTS ranging from a high threshold (return to competition) to low threshold (physician clearance for return to play). Re-injury and contralateral injury rates are greater than the risk for primary ACL injury, which may be related to insufficient RTS guidelines based on time from surgery, which do not allow for proper healing or resolution of post-operative impairments and elimination of risk factors associated with both primary and secondary ACL injuries. The authors concluded that RTS rates to pre-injury level of activity after ACLR are poor and the risk for graft injury or contralateral injury requiring an additional surgery is substantial.  Resolving impairments while eliminating movement patterns associated with injury and allowing sufficient time for graft healing likely gives the athlete the best chance to RTS without further injury. Additional research is needed to identify objective imaging and functional testing criteria to improve clinical decision making for RTS after ACLR.
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Exercise Rehabilitation in the Non-Operative Management of Rotator Cuff Tears: A Review of the Literature

Authors:  Edwards P, Ebert J, Joss B, Bhabra G, Ackland T, Wand A

The incidence of rotator cuff tears increases with age, with full-thickness rotator cuff tears present in approximately 25 percent of individuals in their sixties, and more than 50 percent of those in their eighties. While surgery is considered an effective treatment, recurrent tears at the insertion site are common, especially with degenerative tears, which are frequent in the older population. More recently, there has been increasing interest in exercise rehabilitation and physical therapy as a means to manage partial and full thickness tears of the rotator cuff by addressing weakness and functional deficits. Recent studies have suggested that patients opting for physical therapy have demonstrated high satisfaction, an improvement in function, and success in avoiding surgery. When considering the increasing rate of shoulder surgery and the associated economic and social burden rotator cuff surgery places on both the patient and the health care system, non-surgical management such as physical therapy and exercise may, in selected cases, be a treatment alternative to surgical repair. The purpose of this clinical commentary is to provide an overview of rotator cuff pathology and pathogenesis, and to present an evidence-based case for the role of conservative rehabilitation in the management of rotator cuff injuries.
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Return to Play Progression for Rugby Following Injury to the Lower Extremity: A Clinical Commentary and Review of the Literature

Authors:  Sclafani MP, Davis CC

Rugby requires unique demands from its players. Those involved in rehabilitation and care of these athletes must possess an understanding of both the game and various positions. There have been numerous reports focusing on the physiological demands and biomechanical analyses of various components of gameplay, but no specific progression has been developed to assist clinicians assess the readiness to return of a player after injury. The purpose of this clinical commentary is to outline testing components, general gameplay guidelines, movement progressions, and sport and position-specific progressions related to rugby gameplay following a lower extremity injury.  This progression also includes testing parameters for each phase and guidance for clinicians regarding the ability to gauge readiness to return to sport.  It is essential that an athlete returning to the sport of rugby undergo a guided, graduated return to sport progression to ensure safety and to decrease the risk of re-injury. This proposed return to sport progression outlines key parameters for both the sport as a whole and for specific positions.
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