Rehabilitation Assessment, Outcome Measurement, and Progression

injury evals intend to answer what question?

what is the problem?

primary focus of injury evals

• identify red flags

• perform special tests

• assess acute impairments (swelling, deformity, bleeding, loss of function)

immediate decision making in injury evals

• determine whether athlete can safely return to play or needs removal.

  
  

• Guide initial first aid and emergency care (splinting, immobilization, transport).

  
  

• Provide communication to the healthcare team, coaches, and family.

  
  

rehab evals intend to answer what question

“Where are we now, and how do we get better?”

ongoing systematic assessments performed in rehab evals

• pain

• ROM

• strength

• functional performance

• patient reported outcomes

purpose of rehab evals

• Identify barriers to healing (pain, stiffness, weakness, poor adherence).

• Set short- and long-term goals with measurable benchmarks.

• Progress exercise prescription safely (e.g., increase load, complexity).

why are rehab evals repeated regularly?

Track improvements or setbacks over time.

Support clinical decisions on return-to-play readiness.

Communicate progress with the patient, physician, and healthcare team.

Numeric Pain Rating Scale (NPRS, 0–10)

patient rates average, worst, or current pain.

Visual Analog Scale (VAS, 0–100 mm)

patient marks pain intensity on a continuous line

meaningful change in NPRS

2-point reduction

Tampa Scale of Kinesiophobia (TSK)

• Assesses fear of movement or reinjury.

• Higher scores may reflect greater movement avoidance or hesitation.

• Findings may support graded exposure to feared activities, setting progressive achievable goals, and providing education and confidence-building strategies

Pain Catastrophizing Scale (PCS)

Assesses pain-related thoughts:

• Rumination: difficulty shifting attention away from the pain

• Magnification: perceiving the pain or its potential consequences as especially threatening

• Helplessness: feeling that there is little they can do to control or improve the situation

Higher scores may indicate that pain is having a greater cognitive or emotional impact.

Findings may support pain education, reassurance, graded activity, and interdisciplinary referral when appropriate.

Patient Health Questionnaire-9 (PHQ-9)

screens for symptoms associated with depression

Generalized Anxiety Disorder-7 (GAD-7)

screens for symptoms associated with anxiety

LEFS

general lower-extremity function

FAAM

foot/ankle function — ADL + Sport

IKDC

knee symptoms and function

KOOS

knee symptoms, ADLs, sport/recreation, quality of life

DASH / QuickDASH

upper-extremity function

SPADI

shoulder pain and disability

role of PROMs in rehab

Establish a patient-reported baseline.

Track meaningful change throughout recovery.

Help identify differences between objective performance and perceived function.

Support goal setting, progression, and return-to-activity decisions.

Minimal Clinically Important Difference (MCID)

Smallest change considered meaningful to the patient.

Helps determine whether a change in score reflects a meaningful improvement in symptoms or function.

“Does this change matter to the patient?”

Minimal Detectable Change (MDC)

Smallest change that exceeds expected measurement error.

Helps determine whether an observed difference is likely a true change rather than normal measurement variability.

“Is this change greater than measurement error?”

soft end-feel

soft-tissue compression

firm end-feel

muscle/capsule/ligament stretch

hard end-feel

bone-to-bone contact

empty end-feel

pain stops motion before endpoint

injury eval ROM

What does motion tell us about the injury and safety?

rehab eval ROM

What remains limited, is it improving, and is the patient ready to progress?

Universal goniometer

• Most common and versatile clinical instrument

• Large protractor with measurements in degrees

inclinometer

• More precise measurement with high reliability often used in research settings.

• Uses gravity to determine joint or segment position

• Particularly useful for spinal motion

selection of measurement tool depends on

Joint being measured

Required precision

Clinical setting

Ability to reproduce the measurement

why use goniometery?

• Provides objective, quantifiable measurement of joint angles.

• Enhances reliability beyond visual estimates.

• Standardized tool for documentation and communication.

goniometry standard measurement procedure

Align:

Fulcrum: near joint axis

Stationary arm: longitudinal axis of proximal segment

Moving arm: longitudinal axis of distal segment

limitations of goniometry

requires consistency in placement and patient positioning for accuracy

purpose of girth and circumference measurements

Assesses swelling (edema) and muscle atrophy/hypertrophy.

Provides objective data to support clinical decisions.

methods for girth and circumference measurements

• Use a flexible tape measure; measure in centimeters.

• Take at consistent landmarks (e.g., 10 cm above patella, mid-biceps).

• Compare to contralateral limb.

circumference and swelling

helps monitor resolution of acute injury and guide progression.

circumference and atrophy

identifies disuse or weakness; helps justify strengthening emphasis.

circumference and hypertrophy

tracks gains in rehab, especially in return-to-play protocols.

girth measurement reliability

• Use the same anatomical landmark every time.

• Apply a consistent amount of tape tension.

• Maintain the same patient position and muscle state.

• When possible, have the same clinician repeat measurements.

• Do not assume changes in circumference directly represent equivalent changes in muscle size or strength.

inclinometer uses

• measure the angle of a body segment relative to gravity

  • Uses gravity as the reference rather than requiring alignment of two arms across a joint

** spinal ROM and movements where traditional goniometer alignment is difficult

inclinometer basic procedure

• Position patient consistently

• Place device at the specified anatomical landmark

• Establish/record starting position

• Have patient perform the desired movement

• Record the change in angle

dual inclinometry

Two inclinometers may be used to isolate motion occurring between body segments

recording goniometry measurements

0°–180° system

Anatomic neutral is recorded as 0°

Movement away from neutral is recorded in degrees.

goniometer documentation

Joint and motion

Right/left side

AROM or PROM

Degrees achieved

Pain or symptoms

Compensation when present

ex. Right knee AROM: 0°–125°, pain-free

strength assessment in rehab

• Identifies strength deficits that may limit function or delay return to activity.

• Provides objective benchmarks for progression and return-to-sport decisions

purpose of MMT

Quick, practical gross strength screen. Useful early in rehabilitation. Limited sensitivity for smaller strength deficits, especially in stronger patients

purpose of HHD

Quantifies force output in lbs or Newtons. More sensitive than MMT for detecting side-to-side deficits and change over time. Useful for calculating limb symmetry.

purpose of isokinetic testing

Measures force/torque through a controlled range at a constant angular velocity.

Can assess variables such as peak torque, work, and agonist–antagonist relationships.

Commonly used in later-stage rehabilitation and return-to-sport testing.

limb symmetry index

Compares performance of the involved limb with the uninvolved limb.

LSI = involved ÷ uninvolved × 100

Used with strength and functional tests to quantify side-to-side symmetry. ≥90% symmetry is a commonly used return-to-sport benchmark, but should not be used as the sole clearance criterion.

best practice for reording strength assessments

Record absolute values and symmetry percentages.

Interpret strength alongside movement quality, ROM, symptoms, functional testing, and sport demands.

purpose of functional capacity testing

Assesses the ability to perform integrated, higher-level movement.

Progresses from controlled tasks → activity/sport-specific demands.

Helps evaluate readiness for progression and return to activity/sport.

Y-Balance / Star Excursion

Lower extremity: single-leg balance + multidirectional reach.

Assesses dynamic balance, control, reach performance, and symmetry.

Upper Quarter Y-Balance: closed-chain UE stability, mobility, and control.

hop testing

• Single, triple, crossover, and timed hop tests.

• Assesses lower-extremity power, control, endurance, and symmetry.

• Can calculate LSI between limbs.

jump measures

vertical jump, countermovement jump, drop jump

speed/agility measures

sprint, shuttle, change-of-direction tests

endurance/capacity measures

repeated-sprint, step, running, or work-capacity tests

sport/ task sepcific measures

throwing, cutting, lifting, occupational or position-specific tasks

quantitative factors in functional testing

distance, time, force/power, repetitions, LSI

qualitative factors in functional testing

movement strategy, control, landing mechanics, compensation

SMART goals

specific

measurable

achievable

relevant

time-bound

match load to

Tissue irritability

Stage of healing

Current capacity

Response to loading

Condition/procedure precautions

higher irritability

symptoms easily provoked/slow to settle

→ lower-load, controlled exercise; protected ROM; gradual exposure

lower irritability

symptoms less reactive, recover predictably

→ progress load, ROM, speed, volume, complexity, task specificity

responses to monitor with rehab prorgession

• Pain during/after exercise

• Swelling/effusion

• ROM

• Strength/fatigue

• Movement quality/function

• Next-day response

post op rehab considerations

Protocol and tissue-healing restrictions may override symptoms.

Progression may depend on:

• Procedure/fixation

• Weight-bearing status

• ROM restrictions

• Surgeon criteria/time from surgery

Low pain ≠ tissue readiness

ongoing reassessment

Monitor response to treatment

Identify progress, plateaus, or regression

Modify interventions and goals

Determine readiness for progression

quick clinical reassessment

• Current symptoms/pain

• Response to previous treatment & HEP

• Swelling, ROM, or other relevant key marker(s)

• Readiness for planned activity

periodic reassessment

Repeat relevant measures from the baseline evaluation:

• PROMs

• ROM

• Strength

• Functional performance

Frequency depends on the condition, phase of rehabilitation, goals, and expected rate of change

reasses sooner when…

• New or worsening symptoms

• Unexpected regression or change in function

• Poor response to treatment

• Approaching a progression or return-to-activity decision

• Documentation

• Document measurable progress at appropriate intervals and according to practice-setting, payer, and organizational requirements.

post op patient education

• Procedure and expected recovery course

• Weight-bearing/ROM restrictions

• Precautions and potential complications

• Early mobility, gait, and equipment needs

home exercise program (HEP) components

• Individualized

• Clearly demonstrated

• Appropriately dosed

• Progressed as the patient changes

• Realistic for the patient’s environment and schedule

how to promote adherance to HEP

• Explain why each exercise matters.

• Provide clear verbal + written/visual instructions.

• Confirm understanding and technique.

• Address barriers and involve the patient in goal setting.

• Reassess adherence, response, and difficulty at follow-up visits.

components of “subjective”

Pain/symptoms

Tolerance to activity and HEP

Confidence and perceived progress

Changes in daily or sport function

components of “objective”

ROM

Strength

Balance/functional performance

Relevant PROM scores

components of “assessment”

What is improving?

What remains limited?

What may be contributing?

components of “plan”

Update treatment priorities and exercise progression.

Modify HEP as needed.

Identify what will be reassessed next.