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The Star Excursion Balance Test: An Update Review and Practical Guidelines

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The Star Excursion Balance Test (SEBT) is a reliable, responsive, and clinically relevant functional assessment of lower limbs’ dynamic postural control. However, great disparity exists regarding its methodology and the reported outcomes. Large and specific databases from various population (sport, age, and gender) are needed to help clinicians when interpreting SEBT performances in daily practice. Several contributors to SEBT performances in each direction were recently highlighted. The purpose of this clinical commentary is to (a) provide an updated review of the design, implementation, and interpretation of the SEBT and (b) propose guidelines to standardize SEBT procedures for better comparisons across studies.

• ▸ The modified Star Excursion Balance Test (mSEBT) should be used as a reliable clinical tool to assess dynamic postural control. We propose a compact version of the mSEBT for clinicians.
• ▸ All three directions as well as the composite score should be evaluated independently.
• ▸ Procedure consistency is needed (Table  1 ). Scores obtained from Y-Balance Test TM and mSEBT cannot be considered as identical.
• ▸ Key baseline characteristics should be captured among healthy athletes from various sports.
• ▸ It remains unclear whether connections exist between qualitative analysis of mSEBT performance and injury risk.
• ▸ Clinicians should refer to existing Smallest Detectable Changes scores for potentially meaningful cutoffs for injury risk estimates. Important anterior asymmetry should be reported as it might be considered as a potential risk factor for lower-extremity injury.

2021 Updated Recommendations for the SEBT Procedure

Note . ASIS = anterior and superior iliac spine; ANT = anterior; PL = posterolateral; PM = posteromedial; SEBT = Star Excursion Balance Test.

Sport injury prevention is a major goal for sports medicine and performance professionals. 1 Developing meaningful and easily implemented clinical tests to identify at-risk individuals and target them for prevention programs is therefore necessary. 2 The Star Excursion Balance Test (SEBT), initially described by Gray, 3 is a functional test originated from rehabilitation exercises of the lower limb. Since its inception, the SEBT has been frequently described in the scientific literature and evaluated for its ability to (a) assess dynamic postural control of the lower limb, 4 (b) elucidate functional deficits during return to sport phase, 5 – 8 and/or (c) identify at-risk individuals for future injuries. 9 – 11 In their systematic review, Hegedus et al. 12 revealed that across multiple functional assessments, only the SEBT has shown consistent utility for identifying increased injury risk among sport populations. Recently, evidence has emerged to suggest that the SEBT is highly reproducible. 13 The intersession reliability estimates, and smallest detectable changes (SDCs) reported suggest that the SEBT performance is stable over time with a predictable amount of error that can be accounted for in overall performance and in each direction. It is critically important that clinicians have meaningful tools for (a) capturing potential impairments in function that may increase the risk of injury and (b) charting improvements in rehabilitation function. The SEBT appears to have these qualities.

Performance rules of SEBT appear to be heterogeneous among studies. Methodological considerations regarding testing procedures may explain a large part of the observed variability in the SEBT directional values across studies. Indeed, a precise analysis of testing conditions reported in several studies revealed a critical inconsistency due to a lack of standardized procedure. 8 , 10 , 14 , 15 Thus, cutoff scores and smallest detectable differences reported in the literature are blurred, making challenging the interpretation and comparison of scores between samples or studies. 13 , 16 , 17 In 2009, an instrumented device, the Y-Balance Test ™ (YBT), was developed by Plisky et al. 18 in order to help experimenters during data collection. Several research teams have used this tool to evaluate dynamic postural control among various populations. 19 – 22 In their systematic review, Gribble et al. 7 in 2012 provided a starting point for the SEBT and YBT utility in clinical practice. The evidence since this review has substantially evolved. The aim of this commentary is to provide readers with a clinical update from recent evidence concerning SEBT procedure and interpretation with implications for clinical practice. In this commentary, we propose practical recommendations concerning the standardization of the test in order to reduce the variability of the outcomes across studies.

A careful and precise analysis of the procedures revealed important variations in (a) the methodology, (b) the data collection and analysis, and (c) the interpretation of the results. The suggested recommendations will be discussed in the next section. The practical recommendations for the SEBT standardization in order to obtain reliable and comparable results from one study to the other are reported in Table  1 .

• An Overview of Procedures

The SEBT was initially described with the individual standing in the center of eight lines forming an eight-pointed star with 45° between each of them. 23 Several studies revealed that this procedure could be simplified with only three lines (or directions, named according to the stance foot): anterior (ANT), posteromedial (PM), and posterolateral (PL). 7 , 16 , 24 This “simplified” version is now frequently but not systematically, used and named in the literature as the mSEBT. 13 , 25 The mSEBT saves time during testing by avoiding redundancy of testing directions while maintaining consistency and reliability from the original SEBT. 16 , 26 The average of the three directions is then often calculated to create a composite score (COMP). Most clinicians and researchers regularly refer to YBT when describing the test despite there being a trademarked name of a device developed by Plisky et al. 18 (see the specific section below). When carefully analyzing the literature, studies could either refer to SEBT, 10 mSEBT, 5 YBT, 27 or even the Y-Balance Test-Lower Quarter (YBT-LQ) 28 in the title or abstract although the testing procedure was similar.

Although ANT, PM, or PL refer to stance foot (Figure  1 ), some discrepancies exist in the literature when the procedure is carefully examined especially on the PL and PM directions. Indeed, recent publications switched the posterior directions in their descriptions of the procedure. 9 , 19 , 20 , 29 Those mistakes lead to potential misinterpretations of the results (see the cutoff section below). This underlines the importance and necessity for operationally defining the directions and ensuring consistency in the procedure and rigor when reading the studies.

—Setup of the mSEBT grid with three lines SEBT for left and right foot. ANT = anterior; PL = posterolateral; PM = posteromedial; mSEBT = modified Star Excursion Balance Test; SEBT = Star Excursion Balance Test.

Citation: International Journal of Athletic Therapy and Training 26, 6; 10.1123/ijatt.2020-0106

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For the testing procedure, individuals stand barefoot in double limb stance (i.e., feet together) at the center of the testing grid. Participants attempt to reach the maximal distance along each direction with the most distal portion of the reaching foot, touch the directional line, and return while keeping balance on the support. 7 When the participant regains double limb stance after the reach, the trial is over. As hand placement during the test as well as criteria for success remain different across studies, particular instructions and the exact definition of a failed trial will be discussed in specific sections. The obtained distance (typically measured in centimeters) reflects the dynamic postural performance of the stance limb.

• Number of Practice Trials

We recommend that participants should be familiar with the test to prevent any learning effect with this procedure. Several authors studied the number of trials needed to obtain a stable and reliable performance by limiting a learning effect and/or muscular fatigue. The original test was described with six practice trials in every direction for each limb. More recently, this number was lowered to four for each limb in every direction. This number (four) provides reproducible scores without additional warm-up and decreases the procedure duration because maximum performance is normally reached and the lower limb kinematics are usually stabilized. 7 , 15 , 30 , 31

• Number of Recorded Trials

Regarding the assessed parameters, the mean (in centimeters) is calculated from three trials for each direction. Some authors 10 only selected the best performance of the three trials. As reliability of both methods appears to be acceptable, no strict recommendation can be made for this criterion (mean or maximum of the three trials). It appears also relevant to switch the tested limb for each direction to reduce the onset of fatigue. 18 However, it may be worth carefully observing the evolution of performance across trials and potentially asking individuals to repeat attempts until a relative stabilization of scores during three consecutive trials. We therefore recommend that deviation between trials for the same direction on the same foot should not exceed 2 cm (based on the SE of measurement from Powden et al. 17 ).

• Participant Hand and Foot Placement During the SEBT

Another source of inconsistency was linked to both foot and hand placements of participants during SEBT testing. 14 Several investigators described testing procedures with participants maintaining hands on hips throughout the mSEBT reach, 7 , 10 , 32 – 36 while others did not control for hand placement. 6 , 16 , 22 , 23 , 34 The use of upper limbs makes balance control easier during the test, 14 , 37 and so if hands are not maintained on the hips, the participant may compensate or conceal a postural control deficit of the lower limb. 21 Moreover, dynamic postural control varies according to specific sports. Differences in SEBT performance across sports could therefore be linked to some participants using their hands during the test compared with others who did not. This would then create a spurious relationship between sport participation and SEBT performance. Thus, in order to compare several populations (or sports activities), we recommend that participants place their hands on their hips in order to standardize trunk displacement and the consistency of errors when performing the protocol 7 , 14 , 21 (Figure  2 ).

—Position of the subject for the evaluation of the right limb in the posteromedial direction.

With regard to stance foot placement, some variations were reported across studies. In the eight lines version of the SEBT, the foot (i.e., the virtual line between both malleoli) was placed at the center of the grid. 38 Several authors continue to use this alignment for the mSEBT. However, the foot can move due to loss of balance or unexpected fall during failed trials. Small changes during positioning with the ANT reach can make significant differences, therefore the foot-centered position is not recommended as it can lead to misleading results. 14 In order to improve the procedure reliability, two easily reproducible positions are proposed. The first is to position the most distal aspect of the great toe at center of the grid during the entire procedure. 10 , 23 In this case, the foot is in a more posterior position when performing the ANT reach, leading to relatively lower performances in the ANT, but higher on both PM and PL directions compared with the initial foot placement. 14 The second option consists of positioning the foot according the reached direction. 39 For the ANT, the most distal aspect of the great toe is placed at 0; but, for PM and PL directions, the most posterior aspect of the heel is placed at 0. This placement seems to minimize the influence of foot length on performance 7 but leads to significant lower PM, PL, and COMP scores 14 and requires moving the foot during the test, leading to potential errors. Similarly, reported SDCs may be different according to the position of the foot. In order to allow comparisons across studies using different foot placements, building a correction factor could be relevant, based on the foot length. For example, important results from large prospective cohort studies have used the procedure with the toe at 0, 10 , 35 , 36 revealing high PM, PL, and COMP scores. We encourage researchers to determine an accurate proportionality coefficient to account for foot placement between each procedure. Therefore, a consistent foot position should be necessarily used when evaluating various athletes and during longitudinal comparison regardless of the chosen procedure.

• A Proposed Compact Solution

For clinicians who do not have enough space for the entire Y of the mSEBT, we propose a “compact” version of the mSEBT using only a single measurement line to allow space efficiency (Figure  3a and 3b ). However, when using this procedure, the participant is required to change foot position for each direction leading to possible errors. We therefore recommend that the investigator carefully check the foot position before collecting the data. Further reliability studies are needed for this version, but it stands to reason that participants may achieve similar performance values.

—A proposed “compact” version of the mSEBT. (a) With foot position in “toe fixed” at 0 for the three directions and (b) the changing toe/heel position according to the reached direction. mSEBT = modified Star Excursion Balance Test.

• The YBT™ Device

In 2009, Plisky et al. 18 developed an instrumented device showing good to excellent intrarater and interrater reliability (intraclass correlation coefficient [ICC] = .97–1 and .85–.89, respectively). A recent study among adolescent female athletes reported that SDCs for normalized reach distance were 2.4% for the composite score, 2.4% for ANT, 3.2% for PM, and 3.2% for PL directions. 40 However, it seems that results obtained with the YBT ™ are not systematically comparable with those obtained with the standard SEBT. 25 , 28 , 32 Fullam et al. 31 recently detailed that main differences related to ANT direction with the YBT ™ leading to significant lower values compared with ANT direction of the SEBT. Similarly, Ko et al. 41 reported significant differences between mSEBT and YBT in individuals with chronic ankle instability in ANT and PM directions. In order to compare scores across studies, it is important to assess if the YBT or the mSEBT was utilized, as outcomes from these two procedures are not interchangeable.

Interpretation of Data

• Criteria for Success

Several general considerations should be applied to validate the trial. Participants have typically been asked to lightly touch the directional line while maintaining both hands on the hips (see related section). They have not been allowed to shift weight on the reaching limb, 15 , 42 lose their balance, or fall. Plisky et al. 18 allowed the stance foot to move or lift during the YBT so that the rater does not need to control it, thereby simplifying the evaluation of the test. However, it is recommended to forbid moving or lifting the heel of the stance foot 7 during the mSEBT in order to increase validity of the procedure. Specifically, during the ANT reach, participants might lift their heel to compensate for impaired weight-bearing ankle dorsiflexion. 17 , 18 There is mounting evidence that ankle dorsiflexion accounts for a significant proportion of ANT direction. 42 , 43 As a decreased range of motion in that direction is considered an important risk factor for ankle sprains, 44 we recommend not lifting the stance foot during the procedure.

• Reliability

Several investigators have reported excellent intra and interrater reliability regarding all three directions (ICC intra  = .85–.91 and ICC inter  = .99–1). 18 , 23 , 26 , 32 , 38 , 45 – 47 A recent systematic review also revealed that in healthy adults, both mSEBT and YBT have excellent intra and interrater reliability for each direction. 17 Median ICC values for interrater reliability were .88 (from .83 to .96), .87 (from .80 to 1.00), and .88 (from .73 to 1.00) for the ANT, PM, and PL directions, respectively. Concerning intrarater reliability, median ICC values were .88 (from .84 to .93), .88 (from = .85 to .94), and .90 (from .68 to .94) for the ANT, PM, and PL directions, respectively. 17 These ICC values suggest that performance measures are relatively consistent between sessions and raters. In addition, excellent reliability estimates have been reported for both mSEBT (ICC from .87 to .93) 13 and YBT (ICC from .85 to .93) 47 when comparing raters with various qualifications.

• Responsiveness: The SDC

Regarding the SDCs (the smallest amount of change, which falls outside the measurement error of the instrument) in clinical practice, a meaningful change of normalized reach distance (see below for normalization recommendations) should exceed 5.9%, 7.8%, and 7.6% for ANT, PM, and PL directions respectively 17 (Table  2 ). When using nonnormalized reach distances, a minimum of 6.4, 7.1, and 8.8 cm for ANT, PM, and PL directions is necessary to consider a clinically relevant change in healthy adults. 17 It is also suggested that there can be differences in SDC between limbs. 13 When focusing only on the COMP, van Lieshout et al. 13 calculated intrarater SDCs of 7.2% and 6.2% and interrater SDCs of 6.9% and 5% for both right and left leg, respectively, from recreational athletes between 18 and 30 years old.

SDC for Normalized Reach Distances

Note . SDC = smallest detectable changes; SEBT = Star Excursion Balance Test; YBT = Y-Balance Test ™ .

a Averaged SDCs in case of different limb values.

• Normalization With Respect to the Lower Limb

—Preferred measurement of lower limb length. From ASIS to the medial malleolus. Lateral malleolus measurement provides trivial differences. 21 ASIS = anterior and superior iliac spine.

• Composite Score Calculation

This value (in percentage) reflects the overall dynamic postural performance of the tested lower limb. 7 , 10

• Interpretation and relevant comparison

Several intrinsic factors can influence SEBT performances between participants, such as sex, 36 , 50 age, 51 level of play, 52 and injury history 6 , 53 (Table  3 ). Moreover, understanding the Specific Adaptations to Imposed Demands principle, type of sport also influences SEBT values 36 , 54 (Table  3 ). Caution should be taken when comparing outcomes across different populations. Some normative data have been established, 36 , 52 these data sets may however not be large enough to reflect accurate normative values for these different populations. Large databases from healthy participants are therefore needed to allow relevant comparison with what is considered “normal” SEBT performance within each sport. We also insist on the importance of capturing individuals baseline characteristics to identify changes over time from an injury risk or risk reduction standpoint. However, when the athlete baseline status is not available for clinicians, we recommend searching for existing databases among similar healthy individuals. 36 , 52

2021 Updated List of Intrinsic Factors Influencing SEBT Performance Between Individuals

Note . ANT = anterior; PL = posterolateral; PM = posteromedial; SEBT = Star Excursion Balance Test.

• Means and Cutoff Scores

Although it remains unclear what contributes to maintaining the postural control necessary to perform the SEBT, many studies have documented links between mSEBT performance and injury. 10 , 22 , 35

In order to target at-risk athletes for lower limb injuries, cutoff scores are needed. However, while the SDCs have been established, the actual predictive values for reach distances for athletes who are at risk of future injuries are widely different across studies. 10 , 35 Plisky et al. 10 were the first to establish cutoff scores among 235 high school and collegiate basketball players. Females who displayed a normalized composite score below 94% were 6.5 times more at risk of sustaining lower limb injury during the season. For males, the risk was three times higher among players who did not reached 94% of the lower limb length. When focusing on each direction, Attenborough et al., 30 revealed that a PM normalized score below 77.5% is associated with an increased risk of lateral ankle sprain in 94 netball players (odd ratio = 4.04, 95% confidence interval [1.00, 16.35]) while de Noronha et al. 9 showed that higher PL normalized scores above 80% decreased ankle sprain risk among 125 participants (hazard ratio = 0.96, 95% confidence interval [0.92, 0.99]). As previously mentioned, the description of the PL direction in the de Noronha et al. 9 , 30 studies was actually the PM direction described in the Attenborough et al. 30 study. When viewed through this lens, the findings are very similar and highlight the need for careful examination of testing procedure description. In addition, side to side asymmetry appears to be an important characteristic for the injury risk profile. Indeed, an absolute asymmetry ≥4 cm in the ANT direction was associated with a 2.5 times increased risk of lower limb injuries for both males and females. 10 More recently, Stiffler et al. 35 showed that a normalized asymmetry >4.5% in the ANT direction could identify athletes at increased risk of lower-extremity injury with 82% accuracy ( n  = 147 healthy National Collegiate Athletic Association athletes). However, side to side asymmetry did not benefit identifying at-risk individuals among 59 football players. 22 Further studies are needed to clarify the relationship between injury risk and mSEBT performances. When evaluating healthy athletes, several research teams 16 , 42 , 50 , 55 did not reveal any differences between dominant and nondominant foot on SEBT performances (Table  3 ). Those results suggest that contrary to what one might think, athletes do not perform better on their dominant limb. Clinicians therefore should check for potentially meaningful performance asymmetry during baseline screening test and return to sports evaluations.

• Contributing Factors Between SEBT Directions

The SEBT reflect the dynamic postural control of the lower limb; however, it remains somewhat unclear what contributes to the performance, whether it be the kinematics of the ankle, knee, or hip strength and coordination of the lower-extremity muscles important for maintaining postural control, or the sensorimotor elements of global postural control. 7 As previously mentioned 31 and recently confirmed by Gabriner et al., 33 weight-bearing ankle dorsiflexion is considered as the main contributor to the ANT performance. Interestingly, PL and PM were conversely influenced by frontal stabilization component, such as evertor strength, medio-lateral postural stability, and proximal function. 27 , 56 We therefore recommend investigating performance in each direction in addition to the composite score. Thus, clinicians should explore arthrokinematics alterations at the ankle for low ANT scores, and neuromuscular deficits in the frontal plane when patients exhibited low PL and PM scores.

• Qualitative Analysis

Finally, most of studies used maximum reach distance as the main quantitative parameter; while, recent findings suggest that maximal performance may not be the only relevant outcome. Indeed, qualitative analysis of the movement (i.e., excursion from sagittal plane, excessive knee valgus, trunk rotation, etc.) may play important roles when assessing individuals. 57 , 58 Further studies are needed to better understand compensations as well as kinetic and kinematic alterations among injured and at-risk athletes for musculoskeletal pathologies, such as patellofemoral or heel pain. 59 , 60 Indeed, kinetic and kinematic alterations are frequent among symptomatic patients and qualitative analysis during the test could help practitioners to identify deficits at baseline, improvements following rehabilitation, and help clinicians regarding return to sport decision. Clinicians could also further use collected qualitative information as useful feedback to improve instructions delivered to the patient during dynamic postural balance exercises. Thus, we encourage clinicians to evaluate the quality of performance of each reach direction 13 , 16 , 17 and if possible, to use one of the numerous available free software programs for further accurate kinematic analysis. Further studies are needed to evaluate the relevance of qualitative analysis for clinicians.

The SEBT is a valid and reliable functional tool to evaluate dynamic postural control of the lower limb. However, transparency in reporting of the SEBT procedures are required to ensure comparable results across studies. Key to this transparency are six recommendations:

• (a) Clinicians should utilize the three reach directions of the mSEBT (ANT, PM, and PL) for the assessment of dynamic postural control. We have proposed a compact version of the mSEBT for clinicians.
• (b) These directions should be evaluated independently as they each provide information about the postural control profile and contributors to postural performance. A composite score should not be the only variable reported.
• (c) Overall instructions need to be standardized especially regarding foot/hand position, number of practice and recorded trials as well as proper identification of posterior directions according to the tested limb. We recommend that clinicians should not use scores from YBT ™ and mSEBT interchangeably.
• (d) Normative values should be captured among heterogenous healthy populations according to sport, gender, and level of play.
• (e) Further studies are needed regarding the qualitative analysis of the test.
• (f) Individual performance should be evaluated using the established SDC scores. Important anterior asymmetry should be carefully reported and might be considered as a potential risk factor for lower-extremity injury.

Large normative databases developed from the consistent use of transparent mSEBT procedures are needed in order to help clinicians to interpret the obtained scores with peers’ samples, and to target at-risk individuals for future injuries, or to better plan the return to sport process. The mSEBT is a clinically meaningful test for assessing dynamic postural control that can be easily implemented. By encouraging clinicians to use the same performance tests with known performance estimates, SDCs, and cutoff scores for risk, it may be possible to develop more robust prevention strategies for sport injuries.

• Acknowledgments

This study did not receive any external funding. The authors have no disclosures or conflict of interest to report.

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Stiffler MR , Bell DR , Sanfilippo JL , Hetzel SJ , Pickett KA , Heiderscheit BC . Star excursion balance test anterior asymmetry is associated with injury status in division I collegiate athletes . J Orthop Sports Phys Ther . 2017 ; 47 ( 5 ): 339 – 346 . PubMed ID: 28355980 doi:10.2519/jospt.2017.6974

Stiffler MR , Sanfilippo JL , Brooks MA , Heiderscheit BC . Star excursion balance test performance varies by sport in healthy division I collegiate athletes . J Orthop Sports Phys Ther . 2015 ; 45 ( 10 ): 772 – 780 . PubMed ID: 26304643 doi:10.2519/jospt.2015.5777

Marigold DS , Bethune AJ , Patla AE . Role of the unperturbed limb and arms in the reactive recovery response to an unexpected slip during locomotion . J Neurophysiol . 2003 ; 89 ( 4 ): 1727 – 1737 . PubMed ID: 12611998 doi:10.1152/jn.00683.2002

Kinzey SJ , Armstrong CW . The reliability of the star-excursion test in assessing dynamic balance . J Orthop Sports Phys Ther . 1998 ; 27 ( 5 ): 356 – 360 . PubMed ID: 9580895 doi:10.2519/jospt.1998.27.5.356

Earl JE , Hertel J . Lower-extremity muscle activation during the star excursion balance tests . J Sport Rehabil . 2001 ; 10 ( 2 ): 93 – 104 . doi:10.1123/jsr.10.2.93

Greenberg ET , Barle M , Glassmann E , Jung M-K . Interrater and test-retest reliability ofthe Y Balance Test in healthy, early adolescent female athetes . Int J Sports Phys Ther . 2019 ; 14 ( 2 ): 204 – 213 . PubMed ID: 30997273

Ko J , Wikstrom EA , Li Y , Weber M , Brown CN . Performance differences between the modified star excursion balance test and the Y-balance test in individuals with chronic ankle instability . J Sport Rehabil . 2019 ; 29 ( 6 ): 748 – 753 . doi:10.1123/jsr.2018-0078

Gribble PA , Hertel J . Considerations for normalizing measures of the star excursion balance test . Meas Phys Educ Exerc Sci . 2003 ; 7 ( 2 ): 89 – 100 . doi:10.1207/S15327841MPEE0702_3

Hoch MC , Staton GS , McKeon PO . Dorsiflexion range of motion significantly influences dynamic balance . J Sci Med Sport . 2011 ; 14 ( 1 ): 90 – 92 . PubMed ID: 20843744 doi:10.1016/j.jsams.2010.08.001

Vuurberg G , Hoorntje A , Wink LM , et al . Diagnosis, treatment and prevention of ankle sprains: update of an evidence-based clinical guideline . Br J Sports Med . 2018 ; 52 ( 15 ): 956 – 956 . PubMed ID: 29514819 doi:10.1136/bjsports-2017-098106

Hyong IH , Kim JH . Test of intrarater and interrater reliability for the star excursion balance test . J Phys Ther Sci . 2014 ; 26 ( 8 ): 1139 – 1141 . PubMed ID: 25202168 doi:10.1589/jpts.26.1139

Gribble PA , Kelly SE , Refshauge KM , Hiller CE . Interrater reliability of the star excursion balance test . J Athl Train . 2013 ; 48 ( 5 ): 621 – 626 . PubMed ID: 24067151 doi:10.4085/1062-6050-48.3.03

Shaffer SW , Teyhen DS , Lorenson CL , et al . Y-Balance test: a reliability study involving multiple raters . Mil Med . 2013 ; 178 ( 11 ): 1264 – 1270 . PubMed ID: 24183777 doi:10.7205/MILMED-D-13-00222

Neelly K , Wallmann HW , Backus CJ . Validity of measuring leg length with a tape measure compared to a computed tomography scan . Physiother Theory Pract . 2013 ; 29 ( 6 ): 487 – 492 . PubMed ID: 23289961 doi:10.3109/09593985.2012.755589

Filipa A , Byrnes R , Paterno MV , Myer GD , Hewett TE . Neuromuscular training improves performance on the star excursion balance test in young female athletes . J Orthop Sports Phys Ther . 2010 ; 40 ( 9 ): 551 – 558 . PubMed ID: 20710094 doi:10.2519/jospt.2010.3325

Cug M , Wikstrom EA , Golshaei B , Kirazci S . The effects of sex, limb dominance, and soccer participation on knee proprioception and dynamic postural control . J Sport Rehabil . 2016 ; 25 ( 1 ): 31 – 39 . PubMed ID: 26355541 doi:10-1123/jsr.2014-0250

McCann RS , Kosik KB , Beard MQ , Terada M , Pietrosimone BG , Gribble PA . Variations in star excursion balance test performance between high school and collegiate football players . J Strength Cond Res . 2015 ; 29 ( 10 ): 2765 – 2770 . PubMed ID: 25785704 doi:10.1519/JSC.0000000000000947

Vitale JA , Vitale ND , Cavaleri L , et al . Level- and sport-specific Star Excursion Balance Test performance in female volleyball players . J Sports Med Phys Fitness . 2019 ; 59 ( 5 ): 733 – 742 . PubMed ID: 30317834 doi:10.23736/S0022-4707.18.08691-7

Doherty C , Bleakley C , Hertel J , Caulfield B , Ryan J , Delahunt E . Dynamic balance deficits in individuals with chronic ankle instability compared to ankle sprain copers 1 year after a first-time lateral ankle sprain injury . Knee Surg Sports Traumatol Arthrosc . 2016 ; 24 ( 4 ): 1086 – 1095 . PubMed ID: 26254090 doi:10.1007/s00167-015-3744-z

Bressel E , Yonker JC , Kras J , Heath EM . Comparison of static and dynamic balance in female collegiate soccer, basketball, and gymnastics athletes . J Athl Train . 2007 ; 42 ( 1 ): 42 – 46 . PubMed ID: 17597942

Thorpe JL , Ebersole KT . Unilateral balance performance in female collegiate soccer athletes . J Strength Cond Res . 2008 ; 22 ( 5 ): 1429 – 1433 . PubMed ID: 18714247 doi:10.1519/JSC.0b013e31818202db

McCann RS , Crossett ID , Terada M , Kosik KB , Bolding BA , Gribble PA . Hip strength and star excursion balance test deficits of patients with chronic ankle instability . J Sci Med Sport . 2017 ; 20 ( 11 ): 992 – 996 . PubMed ID: 28595864 doi:10.1016/j.jsams.2017.05.005

Pionnier R , Découfour N , Barbier F , Popineau C , Simoneau-Buessinger E . A new approach of the Star Excursion Balance Test to assess dynamic postural control in people complaining from chronic ankle instability . Gait Posture . 2016 ; 45 : 97 – 102 . PubMed ID: 26979889 doi:10.1016/j.gaitpost.2016.01.013

de la Motte S , Arnold BL , Ross SE . Trunk-rotation differences at maximal reach of the star excursion balance test in participants with chronic ankle instability . J Athl Train . 2015 ; 50 ( 4 ): 358 – 365 . PubMed ID: 25531142 doi:10.4085/1062-6050-49.3.74

Willy RW , Hoglund LT , Barton CJ , et al . Patellofemoral pain . J Orthop Sports Phys Ther . 2019 ; 49 ( 9 ): CPG1 – CPG95 . doi:10.2519/jospt.2019.0302

Martin RL , Davenport TE , Reischl SF , et al . Heel pain—plantar fasciitis: Revision 2014 . J Orthop Sports Phys Ther . 2014 ; 44 ( 11 ): A1 – A33 . doi:10.2519/jospt.2014.0303

* Picot is with the French Handball Federation, Créteil, France. Picot, Terrier, and Fourchet are with the French Society of Sport Physiotherapist (SFMKS Lab), Pierrefitte sur Seine, France. Picot, Terrier, and Forestier are with the Savoie Mont-Blanc University, Chambéry, France. Picot, Forestier, and Fourchet are also with the Laboratoire Interuniversitaire de la Biologie et de la Motricité (LIBM), Chambéry, France. Terrier is also with the Whergo SARL, Technolac, France. Fourchet is also with the Hôpital de La Tour, Geneva, Switzerland. McKeon is with the Department of Exercise Science and Athletic Training, Ithaca College, Ithaca, NY, USA.

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Star Excursion Balance Test

The Star Excursion Balance Test (SEBT) is a simple, but time intensive, test used to measure dynamic balance/dynamic postural control.

By Owen Walker Last updated: February 29th, 2024 8 min read

Contents of Article

What is the Star Excursion Balance Test?

Why is balance important in sports, how do you conduct the star excursion balance test, what is the star excursion balance test scoring system, is the star excursion balance test valid and reliable, further reading.

• About the Author

The Star Excursion Balance Test was developed to be a reliable measure of dynamic stability. Since then, it has proven to be a sensitive indicator of lower limb injury risk in a variety of populations. To add to this, the Star Excursion Balance Test has been shown to have high levels of intra-rater test-retest reliability , though no validity coefficients have been studied.

The Star Excursion Balance Test (SEBT) is a relatively simple, but somewhat time-intensive, test used to measure dynamic balance, otherwise known as dynamic postural control (1). It measures dynamic balance by challenging athletes to balance on one leg and reach as far as possible in eight different directions (2). Though the SEBT is very similar to the Y Balance Test TM , it is important to understand that these are in fact different, with the Y Balance Test TM being a newer and condensed version of the SEBT.

Performance on the SEBT has been shown to differentiate between individuals with lower limb conditions such as chronic ankle instability (3-10), patellofemoral pain (11), and anterior cruciate ligament reconstruction (12). To add to this, the SEBT is even capable of assessing improvements in dynamic balance following training interventions (13, 14).

Perhaps the SEBT’s greatest talent is its ability to identify athletes with a higher risk of lower limb injury. For example, an anterior reach asymmetry of greater than 4cm during the SEBT has been suggested to predict which individuals are at higher risk of lower limb injury (15). However, other researchers have found that only female athletes with a composite score of less than 94 % of limb length were at greater risk of injury (15). More recent research in collegiate American football players has shown that athletes with a composite score of less than 90 % are 3.5 times more likely to sustain an injury (16).

All of this information suggests that each sport and population (e.g. gender) appear to have their own injury risk cut-off point (15, 16).

Balance, otherwise known as ‘postural control’, can be defined statically as the ability to maintain a base of support with minimal movement, and dynamically as the ability to perform a task while maintaining a stable position (17, 18). In a chaotic sporting environment, the ability to maintain a stable position is vital not only for successful application of the skill but to also reduce the likelihood of injury (15, 16, 19).

As dynamic balance is an integral part of performance, and poor balance is related to a higher risk of injury (20, 21, 15), then it may be of great interest to test and monitor an athlete’s dynamic stability.

It is important to understand that whenever fitness testing is performed, it must be done so in a consistent environment (e.g. facility) so it is protected from varying weather types, and with a dependable surface that is not affected by wet or slippery conditions. If the environment is not consistent, the reliability of repeated tests at later dates can be substantially hindered and result in worthless data.

Required Equipment Before the start of the test, it is important to ensure you have the following items:

• Reliable and consistent testing facility (minimum 2×2 metres (m)).
• Test administrator(s)
• Sticky tape (minimum 8m)
• Measuring tape
• Performance recording sheet

Test Configuration Video 1 displays the test configuration for the SEBT. This setup must be adhered to if accurate and reliable data is desired. The test administrator should stick four 120 cm lengths of sticky tape onto the floor, intersecting in the middle, and with the lines placed at 45°   angles (2).

Participants should thoroughly warm up prior to the commencement of the test. Warm-ups should correspond to the biomechanical and physiological nature of the test. In addition, sufficient recovery (e.g. 3-5 minutes) should be administered following the warm-up and prior to the commencement of the test.

Conducting the test

• The athlete should be wearing lightweight clothing and remove their footwear. After doing so, they are then required to stand in the centre of the star and await further instruction.
• When using the right foot as the reaching foot, and the left leg to balance, the athlete should complete the circuit in a clockwise fashion. When balancing on the right leg, the athlete should perform the circuit in an anti-clockwise fashion.
• With their hands firmly placed on their hips, the athlete should then be instructed to reach with one foot as far as possible and lightly touch the line before returning back to the starting upright position.
• With a pencil, the test administrator should mark the spot at which the athlete touched the line with their toe. This can then be measured from the centre spot after the test to calculate the reach distance of each reach direction. Reach distances should be recorded to the nearest 0.5cm (22).
• They should then repeat this with the same foot for all reach directions before changing foot.
• After they have completed a full circuit (every reach direction) with each foot, they should then repeat this process for a total of three times per leg. For example, they should have three anterior reach performances for both their right and left leg.
• Once the athlete has performed three successful reaches with each foot in all directions, they are then permitted to step away from the testing area.
• The test administrator should have recorded the reach distance of each successful attempt, with a pencil, in order to calculate the athlete’s SEBT score after the test.

NOTE: Failed attempts include the following:

• The athlete cannot touch their foot down on the floor before returning back to the starting position. Any loss of balance will result in a failed attempt.
• The athlete cannot hold onto any implement to aid their balance.
• The athlete must keep their hands on their hips at all times throughout the test.
• The athlete must lightly touch their toe on the reach line whilst staying in full control of their body. Any loss of balance resulting in a heavy toe/foot contact with the floor should be regarded as a failed attempt.

With the test complete and all performances measured and recorded, the test administrator can then calculate the athlete’s SEBT performance scores using the following simple equations (17):

• Average distance in each direction (cm) = Reach 1 + Reach 2 + Reach 3 / 3
• Relative (normalised) distance in each direction (%) = Average distance in each direction / leg length * 100

These calculations should be performed for both the right and left leg in each direction, providing you with a total of 16 scores per athlete.

Though no validity coefficients are available for the SEBT, authors (23) have provided evidence that the SEBT is sensitive for screening various musculoskeletal injuries (17). Furthermore, high intratester reliability has been found for the SEBT (intraclass correlation coefficients = 0.78 – 0.96) (24).

We suggest you now check out this article on The Landing Error Scoring System (LESS).

All information provided in this article is for informational and educational purposes only. We do not accept any responsibility for the administration or provision of any testing conducted, whether that results in any positive or negative consequences. As an example, we do not take any responsibility for any injury or illness caused during any test administration. All information is provided on an as-is basis.

• Nelson, Brian D., “Using the Star Excursion Balance test as a predictor of lower extremity injury among high school basketball athletes” (2012).Theses and Dissertations. Paper 389. [Link]
• Gribble PA, Kelly SE, Refshauge KM, Hiller CE. Interrater Reliability of the Star Excursion Balance Test. Journal of Athletic Training 2013;48(5):621–626. [PubMed]
• Akbari M, Karimi H, Farahini H, Faghihzadeh S. Balance problems after unilateral lateral ankle sprains. J Rehabil Res Dev. 2006;43(7): 819–824. [PubMed]
• Gribble PA, Hertel J, Denegar CR. Chronic ankle instability and fatigue create proximal joint alterations during performance of the Star Excursion Balance Test. Int J Sports Med. 2007;28(3):236–242. [PubMed]
• Gribble PA, Hertel J, Denegar CR, Buckley WE. The effects of fatigue and chronic ankle instability on dynamic postural control. J Athl Train. 2004;39(4):321–329. [PubMed]
• Hale SA, Hertel J, Olmsted-Kramer LC. The effect of a 4-week comprehensive rehabilitation program on postural control and lower extremity function in individuals with chronic ankle instability. J Orthop Sport Phys Ther. 2007;37(6):303–311. [PubMed]
• Hertel J, Braham RA, Hale SA, Olmsted-Kramer LC. Simplifying the Star Excursion Balance Test: analyses of subjects with and without chronic ankle instability. J Orthop Sport Phys Ther. 2006;36(3):131– 137. [PubMed]
• Martinez-Ramirez A, Lecumberri P, Gomez M, Izquierdo M. Wavelet analysis based on time-frequency information discriminate chronic ankle instability. Clin Biomech (Bristol, Avon). 2010;25(3): 256–264. [PubMed]
• Nakagawa L, Hoffman M. Performance in static, dynamic, and clinical tests of postural control in individuals with recurrent ankle sprains. J Sport Rehabil. 2004;13(3):255–268. [Link]
• Olmsted LC, Carcia CR, Hertel J, Shultz SJ. Efficacy of the Star Excursion Balance Tests in detecting reach deficits in subjects with chronic ankle instability. J Athl Train. 2002;37(4):501–506. [PubMed]
• Aminaka N, Gribble PA. Patellar taping, patellofemoral pain syndrome, lower extremity kinematics, and dynamic postural control. J Athl Train. 2008;43(1):21–28. [PubMed]
• Herrington L, Hatcher J, Hatcher A, McNicholas M. A comparison of Star Excursion Balance Test reach distances between ACL deficient patients and asymptomatic controls. Knee. 2009;16(2):149–152. [PubMed]
• McKeon PO, Ingersoll CD, Kerrigan DC, Saliba E, Bennett BC, Hertel J. Balance training improves function and postural control in those with chronic ankle instability. Med Sci Sports Exerc. 2008; 40(10):1810–1819. [PubMed]
• McLeod TC, Armstrong T, Miller M, Sauers JL. Balance improvements in female high school basketball players after a 6- week neuromuscular-training program. J Sport Rehabil. 2009;18(4): 465–481. [PubMed]
• Plisky PJ, Rauh MJ, Kaminski TW, Underwood FB. Star Excursion Balance Test as a predictor of lower extremity injury in high school basketball players. J Orthop Sports Phys Ther. 2006;36(12):911–919. [PubMed]
• Butler RJ, Lehr ME, Fink ML, Kiesel KB, Plisky PJ. Dynamic balance performance and noncontact lower extremity injury in college football players: an initial study. Sports Health. 2013;5(5): 417–422. [PubMed]
• Bressel E, Yonker JC, Kras J, Heath EM. Comparison of Static and Dynamic Balance in Female Collegiate Soccer, Basketball, and Gymnastics Athletes. Journal of Athletic Training 2007;42(1):42–46. [PubMed]
• Winter DA, Patla AE, Frank JS. Assessment of balance control in humans. Med Prog Technol. 1990;16:31–51. [PubMed]
• Zazulak B, Cholewicki J, and Reeves NP. Neuromuscular control of trunk stability: Clinical implications for sports injury prevention. J Am Acad Orthop Surg 16: 497–505, 2008. [PubMed]
• de Noronha M, Franca LC, Haupenthal A, Nunes GS. Intrinsic predictive factors for ankle sprain in active university students: a prospective study [published online January 20, 2012]. Scan J Med Sci Sports. doi:10.1111/j.1600-0838.2011.01434. [PubMed]
• McGuine T. Sports injuries in high school athletes: a review of injury-risk and injury-prevention research. Clin J Sports Med. 2006;16:488-499. [PubMed]
• Shaffer SW, Teyhen DS, Lorenson CL, Warren RL, Koreerat CM, Straseske CA, Childs JD. Y-Balance Test: a reliability study involving multiple raters. Mil Med. 2013;178(11):1264-70. [PubMed]
• Olmstead L, Carcia C, Hertel J, Shultz S. Efficacy of star excursion balance test in detecting reach deficits in subjects with chronic ankle instability. Journal of Athletic Training. 2002;37(4):501-507. [PubMed]
• Hertel J, Miller S, Denegar C. Intratester and intertester reliability during the star excursion balance test. Journal of Sport Rehabilitation. 2000;9(1):104-116. [Link]

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Star Excursion Balance Test

The Star Excursion Balance Test (SEBT) is a dynamic test that requires strength, flexibility, and proprioception. It is a measure of dynamic balance that provides a significant challenge to athletes and physically active individuals.

The test can be used to assess physical performance, but can also be used to screen deficits in dynamic postural control due to musculoskeletal injuries (e.g. chronic ankle instability), to identify athletes at greater risk for lower extremity injury, as well as during the rehabilitation of orthopedic injuries in healthy active adults (1)

Research has suggested to use this test as a screening tool for sport participation as well as a post-rehabilitation test to ensure dynamic functional symmetry. 

Figure (physiopedia)

How to perform The SEBT:

Conducting the Test (science for sport)

• The athlete should be wearing lightweight clothing and remove their footwear. After doing so, they are the required to stand in the centre of the star, and await further instruction.
• When using the right foot as the reaching foot, and the left leg to balance, the athlete should complete the circuit in a clockwise fashion. When balancing on the right leg, the athlete should perform the circuit in an anti-clockwise fashion.
• With their hands firmly placed on their hips, the athlete should then be instructed to reach with one foot as far as possible and lightly touch the line before returning back to the starting upright position.
• With a pencil, the test administrator should mark the spot at which the athlete touched the line with their toe. This can then be measured from the centre spot after the test to calculate the reach distance of each reach direction. Reach distances should be recorded to the nearest 0.5cm (22).
• They should then repeat this with the same foot for all reach directions before changing foot.
• After they have completed a full circuit (every reach direction) with each foot, they should then repeat this process for a total of three times per leg. For example, they should have three anterior reach performances for both their right and left leg.
• Once the athlete has performed 3 successful reaches with each foot in all directions, they are then permitted to step away from the testing area.
• The test administrator should have recorded the reach distance of each successful attempt, with a pencil, in order to calculate the athlete’s SEBT score after the test.

Scoring System

With the test complete and all performances measured and recorded, the test administrator can then calculate the athlete’s SEBT performance scores using the following simple equations:

• Average distance in each direction (cm) = Reach 1 + Reach 2 + Reach 3 / 3
• Relative (normalised) distance in each direction (%) = Average distance in each direction / leg length * 100

These calculations should be performed for both the right and left leg in each direction, providing you with a total of 16 scores per athlete.

 Normative data

Figure ( Miller, T., 2012).

• According to Hertel, Miller, and Deneger (2000), the reliability of the SEBT ranges between r = 0.85-0.96
• According to Plisky et al (2006), the reliability of this test ranges between 0.82-0.87 and scores 0.99 for the measurement of limb length
• Chaiwanichsiri et al (2005) concluded that the Star Excursion Balance training was more effective than a conventional therapy program in improving functional stability of a sprained ankle
• Plisky et al (2009) concluded that the intra-rater reliability of the SEBT as being moderate to good (ICC 0.67- 0.97) and inter-rater reliability as being poor to good (0.35-0.93) [2]

Supporting Articles/text

Advanced fitness assessment and exercise prescription. Heyward V. Human kinetics, 6th edition: 303 (5)

Miller, T. (2012). National Strength and Conditioning Association. Test and Assessment. Human Kinetics. Champagne, IL.

Bressel E, Yonker JC, Kras J, Heath EM. Comparison of Static and Dynamic Balance in Female Collegiate Soccer, Basketball, and Gymnastics Athletes. Journal of Athletic Training 2007;42(1):42–46.

Chaiwanichsiri D., Lorprayoon E., Noomanoch L. (2005). Star Excursion Balance Training : Effects on Ankle Functional Stability after Ankle Sprain. Journal of Medical Association Thailand 88(4): 90-94 (1B)

Plisky P., Rauh M., Kaminski T., Underwood F (2006) Star Excursion Balance Test as a Predictor of Lower Extremity Injury in High School Basketball Players. Journal of Orthopaedic and Sports Physical Therapy. 36 (12) (1B)

Plisky P et al. (2009). The Reliability of an Instrumented Device for Measuring Components of the Star Excursion Balance Test.  American Journal of Sports Physical Therapy. 4(2): 92–99. (2B)

Validity and reliability of upper extremity star excursion balance test in adolescent swimmers

Affiliations.

• 1 Department of Sport Rehabilitation, Shanghai University of Sport, Shanghai, China.
• 2 Graduate School, Xi'an Physical Education University, Xi'an, China.
• 3 Shanghai Changning Youth Amateur Sports School, Shanghai, China.
• 4 Department of Rehabilitation Medicine, Shanghai Shangti Orthopaedic Hospital, Shanghai, China.
• PMID: 36923209
• PMCID: PMC10009542
• DOI: 10.1016/j.jesf.2023.02.003

Background: Upper limb balance is one of the important physical fitness parameters for all populations, especially overhead athletes like swimmers. Upper extremity star excursion balance test (UESEBT) is a comprehensive dynamic balance assessment, this study aims to explore the reliability and validity of UESEBT among adolescent swimmers.

Methods: This cross-sectional study recruited 70 adolescent swimmers. All participants were required to complete UESEBT, upper quarter Y-balance test (UQYBT), maximal isometric strength (MIS) tests in upper limb, closed kinetic chain upper extremity stability test (CKCUEST), trunk flexor endurance test (TFET) and lateral trunk endurance test (LTET). The intra- and inter-operator reliability and the correlation of UESEBT with other physical performances were conducted.

Results: For reliability, the intra- and inter-operator reliability of all directions and composite score were high-to-excellent (ICC = 0.706-1.000) among all participants. For validity, the UESEBT has a moderate-to-strong correlation with UQYBT ( r = 0.42-0.72, p < 0.001), and a weak-to moderate one with CKCUEST ( r = 0.25-0.42, p < 0.05). Furthermore, the UESEBT performance showed weak-to-moderate correlations with MIS ( r = 0.24-0.44, p < 0.05). UESEBT was correlated to LTET ( r = 0.24-0.33, p < 0.05) whereas no relationship was found with TFET.

Conclusions: UESEBT was a reliable and valid tool to screen upper extremity dynamic balance among adolescent swimmers. UESEBT provides more detailed information in eight directions to assess the upper limb sport performance. Further study should explore the prediction ability of UESEBT for injury.

Keywords: Adolescent; CKC, closed kinetic chain; CKCUEST, closed kinetic chain upper extremity stability test; D, dominant limb as stance limb; Dynamic balance; ICC, intraclass correlation coefficients; LQYBT, lower quarter Y-balance test; LTET, lateral trunk endurance test; MDC, minimum detectable change; MIS, maximal isometric strength; ND, non-dominant limb as stance limb; Reliability; SEM, standard error of measurement; Swim; TFET, trunk flexor endurance test; UESEBT, upper extremity star excursion balance test; UQYBT, upper quarter Y-balance test; Validity.

© 2023 The Society of Chinese Scholars on Exercise Physiology and Fitness. Published by Elsevier (Singapore) Pte Ltd.

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The Reliability of an Instrumented Device for Measuring Components of the Star Excursion Balance Test

Phillip j. plisky.

a ProRehab, PC, Evansville, IN

Paul P. Gorman

Robert j. butler.

b University of Evansville, Evansville, IN

Kyle B. Kiesel

Frank b. underwood, bryant elkins.

The Star Excursion Balance Test (SEBT) is a dynamic test that requires strength, flexibility, and proprioception and has been used to assess physical performance, identify chronic ankle instability, and identify athletes at greater risk for lower extremity injury. In order to improve the repeatability in measuring components of the SEBT, the Y Balance Test™ has been developed.

The purpose of this paper is to report the development and reliability of the Y Balance Test™.

Single limb stance excursion distances were measured using the Y Balance Test™ on a sample of 15 male collegiate soccer players. Intraclass Correlation Coefficients (ICC) were used to determine the reliability of the test.

The ICC for intrarater reliability ranged from 0.85 to 0.91 and for interrater reliability ranged from 0.99 to 1.00. Composite reach score reliability was 0.91 for intrarater and 0.99 for interrater reliability.

This study demonstrated that the Y Balance Test™ has good to excellent intrarater and interrater reliability. The device and protocol attempted to address the common sources of error and method variation in the SEBT including whether touch down is allowed with the reach foot, where the stance foot is aligned, movement allowed of the stance foot, instantaneous measurement of furthest reach distance, standard reach height from the ground, standard testing order, and well defined pass/fail criteria.

The Y Balance Test™ is a reliable test for measuring single limb stance excursion distances while performing dynamic balance testing in collegiate soccer players.

Unilateral balance and dynamic neuromuscular control are required for sport. Dysfunctional unilateral stance has been prospectively identified as a risk for injury in sport. 1 – 6 Recent discussion in the literature has occurred regarding the importance of assessing dynamic neuromuscular control for injury prediction using body relative movement testing. 7 The Star Excursion Balance Test (SEBT) is a dynamic test that requires strength, flexibility, and proprioception. The goal of the SEBT is to maintain single leg stance on one leg while reaching as far as possible with the contralateral leg. 8 , 9 The SEBT has been used to measure physical performance, compare balance ability among different sports, and identify individuals who have chronic ankle instability. 10 – 13 Recently, the test has been used to identify athletes at greater risk for lower extremity injury. 1 Researchers have suggested using the SEBT as a screening tool for sport participation and as a post-rehabilitation test to ensure dynamic functional symmetry. 11 Further, researchers have shown that SEBT performance improves after training. 10 , 14

The test originally incorporated reaching in eight directions while standing on each foot, 9 but factor analysis indicated that one reach direction (posteromedial) was able to accurately identify individuals with chronic ankle instability as well as performing all eight directions. 15 Further, Plisky et al 1 reported that the sum of three reach directions (anterior, posteromedial, and posterolateral), as well as asymmetry between legs in anterior reach distance, were predictive of lower extremity injury in high school basketball players. Hubbard et al 12 reported that the anterior and posteromedial reach directions identified persons with chronic ankle instability. In a second study, these same authors found that hip abduction strength was correlated with the posteromedial reach distance, and hip extension strength correlated with posterolateral reach distance on the SEBT. 16

For clinical use and screening purposes, the test needs to capture the greatest amount of information in the shortest amount of time. Thus, the anterior, posteromedial, and posterolateral directions appear to be important to identify individuals with chronic ankle instability and those at greater risk of lower extremity injury.

The intrarater reliability of the SEBT has been reported as moderate to good (ICC 0.67- 0.97), 8 , 11 , 17 and interrater reliability has been reported as poor to good (0.35-0.93). 17

Because this balance test is dynamic, difficulty can occur in attempting to accurately assess the farthest reach point and what criteria constitutes a successful reach (e.g. how much movement of the stance foot is allowed or if the reach foot is allowed to touch down). Thus, there have been many protocols utilized for the test ( Table 1 ) with the primary variations in protocol being whether the reach foot touches the floor. Touching down with the reach foot introduces error by making it difficult to quantify the amount of support gained from that touchdown. If touchdown is not allowed, standardizing the distance from the ground that the person reaches is difficult, as well as instantaneously marking the farthest reach point. In addition, it is difficult for examiners to determine how much movement of the stance foot is allowed. Precise determination of the heel or forefoot lift off from the surface is difficult due to the contours of the foot and the rapid position changes due to co-contraction of the lower limb muscles during unilateral stance.

Comparison of Methods Used in Previous Studies

Another disparity in SEBT protocols is where the stance foot is aligned to determine starting position. The starting point has been reported to be at the bisection of the lateral malleolus, 18 – 21 most distal aspect of the toes, 22 center of the foot, 11 , 18 , 23 – 32 and varied according to reach direction. 9 , 33

The Y Balance Test™ (FunctionalMovement.com, Danville, VA) is an instrumented version of components of the SEBT developed to improve the repeatability of measurement and standardize performance of the test. The device utilizes the anterior, posteromedial, and posterolateral components of the SEBT. Therefore, a testing protocol was developed to address potential sources of error and to describe standard testing procedure so that results can be compared among studies as well as among clinicians. This device and protocol attempt to address the common sources of error and method variation including whether touchdown is allowed with the reach foot, where the stance foot is aligned, movement allowed of the stance foot, instantaneous measurement of furthest reach distance, standard reach height from the ground, standard testing order, and well defined pass/fail criteria.

Fifteen male collegiate soccer players (mean 19.7 ± 0.81 years) participated in the study. Subjects were excluded from participation in the study for lower extremity amputation; vestibular disorder; lack of medical clearance for participation; injury; current or undergoing treatment for inner ear, sinus, upper respiratory infection, or head cold; or cerebral concussion within the previous three months. Prior to participation all subjects read and signed an informed consent form approved by the University of Evansville's Institutional Review Board.

Testing Device

The Y Balance Test Kit™ consists of a stance platform to which three pieces of PVC pipe are attached in the anterior, posteromedial, and posterolateral reach directions ( Figure 1 ). The posterior pipes are positioned 135 degrees from the anterior pipe with 45 degrees between the posterior pipes. Each pipe is marked in 5 millimeter increments for measurement. The subject pushes a target (reach indicator) along the pipe which standardizes the reach height (i.e. how far off the ground the reach foot is), and the target remains over the tape measure after performance of the test, making the determination of reach distance more precise.

Y Balance Test Kit™

Y Balance Test™ Protocol

The subjects viewed an instructional video which demonstrated the test and testing procedure as explained by Plisky et al. 1 Hertel et al 17 found a significant learning effect with the SEBT where the longest reach distances occurred after six trials followed by a plateau. Therefore, the subjects practiced six trials on each leg in each of the three reach directions prior to formal testing. The subjects were tested within 20 minutes of practicing. All subjects wore athletic shoes during the performance of the test. The subject stood on one leg on the center foot plate with the most distal aspect of the athletic shoe at the starting line. While maintaining single leg stance, the subject was asked to reach with the free limb in the anterior ( Figure 2 ), posteromedial ( Figure 3 ), and posterolateral ( Figure 4 ) directions in relation to the stance foot. In order to improve the reproducibility of the test and establish a consistent testing protocol, a standard testing order was developed and utilized. The testing order was three trials standing on the right foot reaching in the anterior direction (right anterior reach) followed by three trials standing on the left foot reaching in the anterior direction. This procedure was repeated for the posteromedial and the posterolateral reach directions.

Anterior reach using the Y Balance Test Kit™

Posteromedial reach using the Y Balance Test Kit™

Posterolateral reach using the Y Balance Test Kit™

The subject was instructed by one rater (PPG) to stand on the platform with toes behind the line and to push the reach indicator in the red target area in the direction being test. These were the only instructions given to the subject during testing. All testing was observed and scored by two raters (inter-rater reliability) simultaneously that were blinded to each others scoring. Rater #1 was a physical therapist assistant and certified athletic trainer with with 10 years of experience, and Rater #2 (BE) was a physical therapist with 7 years of experience. The raters independently determined if a successful trial was completed (i.e. that the foot was positioned correctly behind the line and that all of the criteria were met for a successful trial). To reduce bias, the rater recorded the reach distance regardless whether he thought the trial was successful. After three trials in one reach direction, the raters were asked if they had a least one successful trial. If they did not, the subject was asked to perform an additional trial until a successful reach was completed. If the subject was unable to perform the test according to the above criteria in six attempts, the subject failed that direction.

The maximal reach distance was measured by reading the tape measure at the edge of the reach indicator, at the point where the most distal part of the foot reached. The trial was discarded and repeated if the subject: 1) failed to maintain unilateral stance on the platform (e.g. touched down to the floor with the reach foot or fell off the stance platform), 2) failed to maintain reach foot contact with the reach indicator on the target area while it was in motion (e.g. kicked the reach indicator), 3) used the reach indicator for stance support (e.g. placed foot on top of reach indicator), or 4) failed to return the reach foot to the starting position under control. The starting position for the reach foot is defined by the area immediately between the standing platform and the pipe opposite the stance foot. The process was repeated while standing on the other leg.

The specific testing order was right anterior, left anterior, right posteromedial, left posteromedial, right posterolateral, and left posterolateral. The greatest successful reach for each direction for each rater was used for analysis of the reach distance in each direction. Also, the greatest reach distance from each direction was summed to yield a composite reach distance for analysis of overall performance on the test. The testing procedure was repeated approximately 20 minutes later using a single rater (PPG) and measuring the same subjects right stance limb (to measure intra-rater reliability).

Lower Limb Length

On a mat table with the subject supine, the subject lifted the hips off the table and returned them to starting position. Then, the examiner passively straightened the legs to equalize the pelvis. The subject's right limb length was then measured in centimeters from the anterior superior iliac spine to the most distal portion of the medial malleolus with a cloth tape measure.

Data Analysis

The data were analyzed for each subject for the right limb in the anterior, posterolateral, and posteromedial reach directions. Means and standard deviations were calculated for the reach distance in each direction and limb length. Paired sample t-test was used to determine if there was a difference between the performance of the right and left limb. Since reach distance is related to limb length, reach distance was normalized to limb length to allow future comparison among studies. To express reach distance as a percentage of limb length, the normalized value was calculated as reach distance divided by limb length then multiplied by 100. 22 Composite reach distance was the sum of the three reach directions divided by three times limb length, and then multiplied by 100. 22 An ICC (3,1) was used to evaluate intrarater reliability and ICC (2,1) was used to evaluate interrater reliability for each of the normalized reach distances.

Mean, standard deviation, median, and range of the average performance of the two limbs are reported in Table 2 . Intrarater reliability for the one tester ranged from 0.85 to 0.91 with anterior reach 0.91, posteromedial of 0.85, and posterolateral 0.90, and composite 0.91 ( Table 3 ). Inter-rater reliability between the two testers ranged from 0.99 to 1.0 with anterior 1.0, posteromedial 0.99, posterolateral 0.99, and composite reach 0.99 ( Table 4 ).

Results of Y Balance Test

Intrarater reliability (one rater) for the right stance limb for the Y Balance Test ™

Interrater reliability for the Y Balance Test ™

The intrarater reliability of the SEBT has been reported as moderate to good (ICC 0.67-0.97), 8 , 11 , 17 and interrater reliability has been reported as poor to good (0.35-0.93). 17 The variability in the ranges of previously reported reliability of the SEBT suggests the need to improve the accuracy of the testing methods and importance of a standardized testing protocol. The interrater reliability improved over the traditional SEBT testing methods when using the Y Balance Test™. Because the interrater reliability exceeds the intrarater reliability, the variability in subject performance on the test likely exceeds the variability in the measurement recorded by different raters (i.e. the precision in the device is greater than the precision in subject performance). This occurrence can be attributed to a more standardized scoring criteria and a more precise measurement device that also standardizes performance. Further, a standard testing order (i.e. right anterior, left anterior, right posteromedial, left posteromedial, right posterolateral, left posterolateral) allows for consistent performance of the test and attempts to minimize fatigue by alternating stance limbs.

The Y Balance Test™ was developed to address some of the limitations of the traditional SEBT testing methods. A reach indicator, standard reach height from the ground, well defined pass/fail criteria, and the ability of the reach indicator to remain over the tape measure after performance improve the reproducibility of the reach measurement. These features also allow the rater to focus more attention on observing the subject, and, therefore, better assess the subject's movement quality ( Table 5 ). If examiners focused on monitoring stance foot movement, it was nearly impossible to simultaneously mark reach distance. In addition, during the development of the testing protocol for the device, it was difficult for examiners to determine how much movement of the stance foot was allowed in a successful trial (i.e. it was difficult to determine if/when the heel or forefoot actually lifted from the surface). Thus, the athlete was allowed to lift the heel off the ground to improve repeatability and standardize the testing procedures so that results can be compared among studies as long as the toe remained aligned with the start stripe at the front of the stance platform.

Recommendations for standardized protocol with the provided rationale for the recommendation.

Some limitations to this study should be noted. Error could have been introduced by fatigue, 30 practice effect, 17 and remeasurement on the same day of initial testing. Future studies should be conducted with shoes off as many athletes attend pre-participation physicals and rehabilitation sessions with a large variety of footwear, often not appropriate for sport. Future studies should utilize a similar, standardized testing protocol so that results may be compared across studies. In addition, only one limb (right) was measured twice by the first rater.

A need exists to collect normative data using the Y Balance Test™ on varied populations (e.g. collegiate, high school, basketball, hockey, elderly, firefighters, etc). With normative data and prospective studies, the Y Balance Test™ could be evaluated for prediction of injury in different populations and establish acceptable reach distances for each population.

The Y Balance Test™ has shown good to excellent reliability with the standardized equipment and methods. By establishing the reliability of the Y Balance Test™, sports medicine clinicians can better determine deficits and asymmetries in individuals, as well as assist in the return to play decision-making process.

Financial Disclosure: The primary author of this study is the inventor of the Y Balance Test Kit™ used in this study.