Study guide
14.2 Functional Testing & Return-to-Play Criteria
BOC Certification Exam for Athletic Trainers ATC
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1 Introduction & Exam Overview
1.1 Current BOC ATC Exam Facts 1.2 Item Types, Clinical Reasoning & Study Planning
2 Screening, PPE & Risk Identification
2.1 Pre-Participation Physical Examination 2.2 Injury Surveillance, Epidemiology & Intrinsic/Extrinsic Risk 2.3 Protective Equipment Fitting & Safety Standards
3 Prevention Programs, Facility Safety & Health Literacy
3.1 Evidence-Based Injury Prevention Programs 3.2 Facility, Playing Surface & OSHA Safety 3.3 Health Literacy, Communication & Patient Advocacy
4 Environment & Wellness
4.1 Heat Illness Prevention & WBGT Monitoring 4.2 Lightning, Cold, Altitude & Air Quality 4.3 Nutrition, Hydration & Sleep 4.4 Wellness Promotion & Mental Health
5 History, Exam Framework & Neurological Screen
5.1 Patient History & Interview Techniques 5.2 Physical Examination Framework & Diagnostic Accuracy 5.3 Neurological Screening & Cranial Nerve Assessment
6 Upper Extremity & Cervical/Thoracic Spine Assessment
6.1 Shoulder Complex Assessment 6.2 Elbow, Wrist & Hand Assessment 6.3 Cervical & Thoracic Spine Assessment
7 Lumbar Spine, Hip & Knee Assessment
7.1 Lumbar Spine Assessment 7.2 Hip, Groin & Pelvis Assessment 7.3 Knee Joint Assessment
8 Foot/Ankle, Imaging, General Medical & Diagnosis
8.1 Foot & Ankle Assessment 8.2 Diagnostic Imaging & Clinical Decision Rules 8.3 Cardiovascular, Pulmonary, Abdominal & Dermatologic Assessment 8.4 Clinical Diagnosis, Differential Diagnosis, Plan of Care & Patient Education
9 Emergency Action Plans, Scene Assessment & Triage
9.1 Emergency Action Plans 9.2 Scene Assessment & Safety 9.3 Triage & Primary/Secondary Survey
10 Cardiac, Airway & Medical Collapse
10.1 Sudden Cardiac Arrest, High-Performance CPR & AED 10.2 Airway & Breathing Management 10.3 Medical Collapse: Anaphylaxis, Asthma, Diabetes, Sickle Cell & ECAST
11 Spine, Hemorrhage & Head Trauma
11.1 Cervical Spine Trauma, Equipment Removal & Spine Boarding 11.2 Hemorrhage Control, Shock, Fractures & Dislocations 11.3 Acute Head Trauma & Concussion Sideline Triage
12 Environmental Catastrophe & Mental Health Emergencies
12.1 Exertional Heat Stroke, Hyponatremia & Cold Injury Emergencies 12.2 Mental Health Emergencies, Suicide Risk & Transfer of Care
13 Rehab Design & Therapeutic Exercise
13.1 Tissue Healing Stages & Rehabilitation Plan of Care 13.2 Patient Education, Adherence & Shared Decision-Making 13.3 Therapeutic Exercise: ROM, Flexibility & Strength
14 Neuromuscular Training, Functional Testing & Return-to-Play
14.1 Neuromuscular Control, Plyometrics & Sport-Specific Training 14.2 Functional Testing & Return-to-Play Criteria 14.3 Concussion Return-to-Learn & Return-to-Sport
15 Therapeutic Modalities
15.1 Cryotherapy & Thermotherapy 15.2 Electrotherapy & Therapeutic Ultrasound 15.3 Mechanical Modalities (Traction, Compression, CPM)
16 Manual Therapy, Pharmacology & Medical Management
16.1 Manual Therapy Techniques 16.2 Taping, Bracing & Orthoses 16.3 Pharmacological Principles & Common Medications 16.4 Managing General Medical Conditions During Activity
17 Documentation, Privacy, Policy & Quality
17.1 Clinical Documentation & Medical Records 17.2 HIPAA, FERPA & Privacy 17.3 Policies, Quality Improvement & Budgeting
18 Legal, Ethics & Professional Practice
18.1 State Practice Acts, Scope of Practice & Legal Risk 18.2 BOC Standards, Ethics, EBP & Interprofessional Care
14.2 Functional Testing & Return-to-Play Criteria
Key Takeaways Explain This Topic AI
RTP is not a single hop. The classic battery is single hop, triple hop, crossover hop, and 6-m timed hop, plus Y-Balance/SEBT, strength (isokinetic if available), movement quality, and psychological readiness (ACL-RSI).
Limb symmetry index of about 90% is a commonly cited hop/strength threshold, not a biological law. Passing 90% LSI does not reliably predict who will have a second ACL injury.
LSI caveats: the uninvolved limb may be deconditioned, so 90% of a weak side is still weak; timed-hop LSI inverts the ratio because faster is better; landing quality can fail even when distance 'passes.'
Shared decision-making includes the physician, AT, athlete, and family. In many settings the physician holds medical authority for clearance; the AT collects the battery, documents criteria, and can withhold participation.
Graduated RTP: non-contact practice → contact practice → unrestricted competition. Trap: returning because the season starts Friday with about 70% LSI and kinesiophobia.
Last updated: August 2026
Quick Answer: Return-to-play (RTP) is not a single hop. Use a battery : single hop, triple hop, crossover hop, 6-m timed hop , plus Y-Balance/SEBT , strength (isokinetic if available), movement quality , and psychological readiness ( ACL-RSI ). LSI of about 90% is a commonly cited threshold with caveats — the uninvolved limb may be deconditioned . Shared decision-making with the physician, athlete, and family ; the physician often holds medical authority ; the AT documents criteria . Trap: returning because 'the season starts Friday' with ~70% LSI and kinesiophobia.
PA8 Domain IV, task 0406 , asks the AT to determine functional status and readiness to return to activity . Functional status is a cluster , not a vibe and not a date on the protocol sheet: range of motion, effusion, strength, hop battery, movement quality, sport-specific tests, patient-reported outcomes, psychological readiness, and time from injury or surgery. The clinic hop that 'looked pretty good' on Monday is not a Friday night starting assignment.
Not a single hop: the Noyes battery and friends
The classic lower-extremity hop battery (Noyes, Barber, and Mangine, American Journal of Sports Medicine 1991) is four tests, usually the involved limb compared with the uninvolved:
Single hop for distance — one maximal hop, stick the landing (typically a controlled hold on the order of 2 seconds ). Measure from a consistent landmark (commonly the takeoff line to the landing heel ).
Triple hop for distance — three consecutive hops for maximal distance; stick the last landing.
Crossover hop for distance — three consecutive hops crossing a midline strip (often about 15 cm ), maximal distance.
6-meter timed hop — hop 6 m as fast as possible. Time is the score; lower is better.
Allow practice trials, then average or take the best of a small number of recorded trials per the clinic's protocol, and watch how they land, not only how far. A long hop with a valgus crash is a failed test even if the tape measure is flattering.
Limb symmetry index. For distance hops, LSI = (involved / uninvolved) × 100 . For the timed hop, faster is better, so LSI is typically (uninvolved time / involved time) × 100 — invert the ratio so a slower involved limb still scores below 100%. Mixing the formulas is a practical error: an involved timed hop that is slower must not be reported as 'better than the other side' because you divided the wrong way.
About 90% LSI on hop and strength tests is the commonly cited 'pass' threshold in ACL RTP literature (Reid and colleagues; Munro and Herrington; many subsequent batteries). Teach ~90% as a commonly cited threshold, not a biological law . Healthy uninjured athletes often sit near 100% . A systematic review line of work has also shown that passing LSI ≥90% on a hop battery does not reliably predict who will sustain a second ACL injury . Distance can pass while knee flexion, valgus, and trunk lean still fail. Do not invent a stricter numeric cutoff (95%, 97%) as if it were a NATA rule — some clinicians argue for higher targets because 'normal' is near 100%, but the number you must be able to source and caveat on the exam is ~90% .
LSI caveats: the uninvolved limb is not a gold standard
After ACL injury and ACLR, both limbs often decondition. Comparing a weak involved side to a deconditioned uninvolved side inflates LSI and overestimates function (Wellsandt, Schmitt, and related work). A 92% LSI on a triple hop where both distances are poor for that athlete's sport is not clearance. Better anchors when you have them: preinjury scores, age/sex/activity norms , or estimated preinjury capacity. If the 'good' leg hopped like a deconditioned teammate, 90% of that number is still a problem.
Time and criteria together. Grindem and colleagues (Delaware-Oslo ACL cohort, British Journal of Sports Medicine 2016) associated earlier return to level-1 sport , especially in the window before about 9 months , with higher reinjury risk , and associated passing strength, hop, and patient-reported criteria with lower risk. Kyritsis and colleagues ( BJSM 2016) found athletes who failed a discharge battery (including isokinetic strength and hop tests) had a substantially higher graft-rupture rate (on the order of four times in that cohort). Neither paper makes '90% at 6 months' a license to play. Time is not a criterion by itself ; criteria without enough healing time are also incomplete. Graft biology, sport demand, and age (adolescents returning to pivoting sport) all argue against calendar-only clearance.
Strength, Y-Balance/SEBT, and movement quality
Isokinetic testing , when available, remains a useful quadriceps and hamstring snapshot. Quadriceps peak-torque LSI is commonly targeted at ≥90% ; a lingering quad deficit is a persistent ACL problem and a reason hops can look better than the knee is. Hamstring capacity and the hamstring-to-quadriceps relationship matter for ACL strain, but do not reduce the whole decision to one ratio. When isokinetics are absent, use handheld dynamometry , repetition-max estimates, or closed-chain strength tests — do not skip strength because hops 'looked fine.' Hops can hide a quad that will not last a second half.
Y-Balance Test / Star Excursion Balance Test (SEBT): dynamic single-leg reach in anterior, posteromedial, and posterolateral directions (Y-Balance) or the fuller SEBT star. Normalize to limb length. Anterior reach asymmetry of more than about 4 cm has been associated with higher lower-extremity injury risk in some basketball cohorts (Plisky and colleagues). Teach that as a research signal , not a universal BOC cutoff. Use the test to find reach deficits and poor control, not to rubber-stamp RTP.
Movement quality is part of the battery even when it is not a numbered LSI: drop vertical jump, tuck jump, lateral shuffle, and cutting video. Dynamic valgus on a drop vertical jump is a classic ACL-prevention and RTP observation (Hewett / Myer line of work). An athlete can hop far with a stiff, upright strategy that will not survive a crowd. Sport-specific tests finish the picture: kicking distance and accuracy, throwing velocity and pain, skating starts, swimming turns — match the sport, the position, and the energy system.
Psychological readiness: ACL-RSI and kinesiophobia
The ACL-Return to Sport after Injury (ACL-RSI) scale (Webster, Feller, and colleagues) asks about emotions, confidence in performance, and risk appraisal . Low scores associate with not returning to sport and with poorer outcomes; they are data , not softness. Kinesiophobia (often sampled with the Tampa Scale of Kinesiophobia) shows up as a stiff, tentative plant — a functional finding. Graded exposure, honest education about risk, and referral when anxiety or depression is in play are part of RTP, not extras. Do not invent a single ACL-RSI cutoff as a NATA number; use the concept and the trend , and combine it with the physical battery.
Shared decision-making, authority, documentation, graduated RTP
The RTP decision is not the coach's . Shared decision-making includes the physician, AT, athlete, and family (the coach may contribute logistics — practice schedule, position demand — but does not hold a medical veto). In many secondary-school and college settings the team physician has medical authority for clearance. The AT implements the protocol , collects the battery, documents , communicates, and can withhold participation under standing orders, the injury policy, and the emergency action plan even when a coach is loud. Document: date, tests used, raw scores and LSI values, landing/movement notes, patient-reported and ACL-RSI results, who cleared, and the graduated plan.
Graduated RTP after a lower-extremity reconstructive or high-demand injury is not clinic → championship. Typical steps: controlled non-contact practice (individual skill, no opponent) → contact practice or scrimmage → unrestricted competition . Passing a hop battery on Monday does not mean starting in the state final on Friday. Volume, intensity, and opposition are separate progressions. The athlete who 'passed' in sneakers on a clean floor still has to survive sport footwear, a live defender, and fatigue.
Exam trap: returning because 'the season starts Friday' with about 70% LSI and kinesiophobia . Calendar pressure is not a criterion. Seventy percent LSI is not 'close enough.' Fear that makes the athlete hesitate on a plant is a reason to delay and treat , not a reason to tape and hope. Ninety percent of a deconditioned uninvolved limb plus a pretty single hop plus a coach's deadline is still not a battery.