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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 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)

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A Comparison Between Performance on Selected Directions of the Star Excursion Balance Test and the Y Balance Test

Garrett f. coughlan.

* School of Public Health, Physiotherapy and Population Science and

† Institute for Sport and Health, University College Dublin, Ireland;

‡ Directorate of Health and Rehabilitation, St Mary's University College, London, United Kingdom;

Karl Fullam

Eamonn delahunt, conor gissane.

The Star Excursion Balance Test (SEBT) is a widely accepted method of assessing dynamic postural stability. The Y Balance Test (YBT) is a commercially available device for measuring balance that uses 3 (anterior, posteromedial, and posterolateral) of the 8 SEBT directions and has been advocated as a method for assessing dynamic balance. To date, no studies have compared reach performance in these tests in a healthy population.

To determine whether any differences exist between reach distance performance for the anterior, posteromedial, and posterolateral directions of the SEBT and the YBT.

Descriptive laboratory study.

University motion analysis laboratory.

Patients or Other Participants

A total of 20 healthy active male participants (age = 22.50 ± 3.05 years, height = 1.78 ± 0.82 m, weight = 79.48 ± 11.32 kg, body mass index = 24.96 ± 2.56 kg/m 2 ).

Intervention(s)

Participants carried out 3 trials in each reach direction on each leg on the SEBT and the YBT a minimum of 1 week apart.

Main Outcome Measure(s)

The means of the 3 trials in each direction on each leg on both tests were calculated. Data were collected after 4 practice trials in each direction. Paired t tests and Bland-Altman plots were used to compare reach distances between the SEBT and the YBT.

Participants reached farther in the anterior direction on the SEBT than on the YBT. No differences were observed in the posteromedial and posterolateral directions.

Conclusions

Differing postural-control strategies may be used to complete these tasks. This finding has implications for the implementation and interpretation of these dynamic balance tests.

• Differences in anterior reach distance were noted between the Star Excursion Balance Test and the Y Balance Test in a sample of healthy, active men.
• No differences were noted in posteromedial or posterolateral reach distances between the tests.
• Postural-control strategies for completing these tests may vary.

The perception and execution of musculoskeletal control and movement are mediated primarily by the central nervous system 1 and involve the integration of 3 main subsystems: somatosensory, vestibular, and visual. 2 Balance performance and its measurement are influenced by these subsystems. The Star Excursion Balance Test (SEBT) is a valid and reliable outcome measure of dynamic balance developed by Gray. 3 A range of indications for the clinical use of the test in athletic and pathologic populations has previously been described, including screening, 4 , 5 injury identification, 6 , 7 training, 8 – 10 and rehabilitation. 11 Most of the literature describes 8 reach directions using a grid formed by applying adhesive athletic tape or a tape measure to a level floor with lines spaced 45° apart. The directions are anterior (A), medial, lateral, posterior, anteromedial, anterolateral, posteromedial (PM), and posterolateral (PL). An individual is required to move from a starting position of 2-legged stance to single-legged stance while maximally reaching along set multidirectional lines with the opposite leg and touching down lightly on the tape with the distal end of the reach foot, without compromising equilibrium. These reaching tasks are designed to challenge postural control, strength, range of motion, and proprioceptive abilities. 12

A number of limitations are associated with the SEBT owing to the lack of a definitive published protocol outlining its administration. The touch-down aspect of the test allows for the individual to be supported by the ground, and the actual amount of pressure allowed through the foot is difficult to quantify and control. This may lead to variations in the administration and interpretation of the test protocol. In addition, for the test to be carried out in its entirety (4 practice trials and 3 test trials in each of the 8 directions on each side, giving a total of 112 reach excursions) 13 can prove time consuming for the clinician. Hertel et al 12 were the first to propose redundancy in measuring all 8 directions in a sample with chronic ankle instability and purported the use of the A, medial, and PM directions in identifying functional deficits. The clinical application of the SEBT led to the development of the Y Balance Test (YBT). Plisky et al 14 used a Y or “peace sign,” incorporating the A, PM, and PL directions in the preseason screening of high school basketball players, which in turn led to the development of the YBT. It involves the individual standing on an elevated central plastic footplate 1 in (2.54 cm) off the ground and pushing a rectangular reach indicator block with the foot along a 1.5-m length of plastic tubing in each of the 3 directions. The reach distance is recorded as the point at which the reach indicator block is pushed closest to the stance leg. The purported benefits of the YBT are that it takes less time to complete and has a standard protocol and high interrater (0.99–1.00) and intrarater reliability (0.85–0.91). 15

Both the SEBT and YBT involve similar movements that are deemed to measure and challenge dynamic balance. Despite the similarity between the tests, no researchers to date have evaluated performance in both tests in the same group of participants. The increasing popularity of the YBT in the clinical setting for diagnosis, screening, and rehabilitation means that it is imperative to establish if any differences exist in its application and performance when compared with performance on the similar reach directions of the SEBT. Therefore, the purpose of our study was to compare the A, PM, and PL reach distance performance of healthy participants in these 2 dynamic balance tests. We hypothesized that participants would attain the same reach distance in the respective directions of the SEBT and YBT.

Participants

Ethical approval was obtained from the University College Dublin Human Research Ethics Committee. We recruited 20 healthy male participants (age = 22.50 ± 3.05 years, height = 1.78 ± 0.82 m, weight = 79.48 ± 11.32 kg, body mass index = 24.96 ± 2.56 kg/m 2 ) from the local university population. Inclusion criteria for the study required volunteers to be between 18 and 30 years of age and active participants in sporting activity 3 or more times per week with no history of lower limb injury in the past 3 months, neurologic or balance disorder, or lower limb fracture. Before formal testing began, each participant read an information leaflet and signed a consent form.

Participants reported to the laboratory in shorts and T-shirts for 2 test sessions spaced a minimum of 7 days apart. Their height, weight, and limb length in supine lying (anterosuperior iliac spine to the center of the ipsilateral medial malleolus) were measured. They were then randomized to conduct either the SEBT or YBT at the initial session and undertook the other test at the second session. The SEBT reach directions were evaluated by affixing 3 tape measures to the laboratory floor, 1 oriented anterior to the apex and 2 aligned at 135° to this in the PM and PL directions ( Figure 1 ). 16 The YBT was evaluated using a commercially available device (Y Balance Test, Move2Perform, Evansville, IN; Figure 2 ). In order to ensure comparison between the tests, the A, PM, and PL directions of the SEBT were used. Order of the test leg and direction were also randomized at each test session. All testing was conducted barefoot to eliminate additional balance and stability from the shoes. 17 As in the YBT, the anterior borders of the participant's feet were placed at the convergence of the reach direction lines of the SEBT at the second toe. The test was demonstrated by a member of the research team before the participant completed 4 practice trials in each direction on each leg. Completing these practice trials has previously been reported to decrease the learning effect without hindering an individual's ability to perform the test. 13 After the test trials were completed, each participant was given a 2-minute rest period and then conducted 3 test trials in each direction. Test sessions were undertaken at the same time of day to minimize diurnal variation in postural stability. 18 A trial was classified as invalid if the participant removed his hands from his hips, did not return to the starting position, applied sufficient weight through the reach foot so as to gain an increase in reach distance (SEBT), placed the reach foot on the ground on either side of the line or tube, raised or moved the stance foot during the test, or kicked the plate with the reach foot to gain more distance (YBT). If an invalid trial occurred, the data were discarded, and the participant repeated the trial.

Star Excursion Balance Test anterior reach direction.

Y Balance Test anterior reach direction.

Statistical Analysis

Reach distances were normalized to limb length by calculating the maximized reach distance (%MAXD) using the formula (excursion distance/limb length) × 100 = % MAXD. 13 This normalization method accounts for limb-length differences in individuals and allows comparisons between the right and left limbs and between participants. Means and standard deviations were calculated for both legs. Paired-samples t tests were conducted to compare the reach distances for each leg and between tests (version 18.0; PASW Statistics, IBM Corporation, Armonk, NY). Because 6 t tests were calculated, a Bonferroni correction was used (0.05/12), and therefore, an α level of P < .004 was set for all comparisons. Effect sizes for test differences were calculated by obtaining the difference between mean SEBT and YBT values and dividing by the pooled standard deviation. The strength of the effect sizes was interpreted using guidelines described by Cohen, 19 with values less than 0.2 interpreted as weak, 0.21 to 0.79 as moderate, and greater than 0.8 as strong. Pearson correlations and Bland-Altman assessments for agreement were used to compare SEBT and YBT performance. 20 Where heteroscedasticity (increasing differences with increasing mean difference) was observed, the data were log transformed.

Differences were observed between the SEBT and YBT in the A reach direction on both legs ( Table 1 ). Participants reached further in the SEBT than in the YBT on both the left ( P = .0002) and right legs ( P = .003). No other differences were noted in the PM and PL reach directions or between left and right legs in either test. Effect size calculations indicated that results were strong for the left leg and moderate for the right leg in the A direction and weak for both legs in the PM and PL directions. The Bland-Altman analysis showed that the 95% limit of agreement between SEBT and YBT performance in the anterior direction was 5.08 (% limb length) for the left leg (5.08 [–4.69 to 14.85]), demonstrating that SEBT reach excursions were, on average, greater than YBT values ( Figure 3 ). Log-transformed anterior-direction reaches on the right leg (4.59 [–7.41 to 16.60]) showed good agreement, with an SEBT score 3% higher than the YBT score ( Figure 4 ). Posteromedial excursions for both left (0.93 [–11.55 to 13.42]) and right (0.34 [–9.09 to 9.78]) displayed a slight bias, with SEBT scores slightly higher and scores for the right leg having less bias and variability ( Figures 5 and ​ and6). 6 ). Posterolateral excursions for both left (0.03 [–10.88 to 10.94]) and right (log transformed −0.76 [–12.70 to 11.18]) legs indicated minimal bias ( Figures 7 and ​ and8). 8 ). Paired-samples correlations are presented in Table 2 .

Ninety-five percent limits of agreement for anterior reach with left leg (5.08 [–4.69 to 14.85]).

Log-transformed 95% limits of agreement for anterior reach with right leg (4.59 [–7.41 to 16.60]).

Ninety-five percent limits of agreement for posteromedial reach with left leg (0.93 [–11.55 to 13.42]).

Ninety-five percent limits of agreement for posteromedial reach with right leg (0.34 [–9.09 to 9.78]).

Ninety-five percent limits of agreement for posterolateral reach with left leg (0.03 [–10.88 to 10.94]).

Log-transformed 95% limits of agreement for posteromedial reach with right leg (−0.76 [–12.70 to 11.18]).

Reach Distances for Star Excursion Balance Test (SEBT) and Y Balance Test (YBT) and Effect-Size (ES) Calculations

Star Excursion Balance Test and Y Balance Test: Paired-Samples Correlations (N = 20)

The principle finding in this investigation was that healthy participants achieved a longer reach distance in the A direction of the SEBT compared with the YBT. Previous authors have reported differences in SEBT reach distances similar to those of the balance tasks we observed after neuromuscular training 8 , 9 and fatigue protocols 21 and in injured groups. 7 , 21 These differences have implications for the implementation and interpretation of the YBT. We observed no differences in the other 2 reach directions. These findings may be due to differences in postural-control strategies in completing the dynamic balance tasks.

Postural control may be classified as either static (attempting to maintain a base of support with minimal movement) or dynamic (attempting to maintain a stable base of support while completing a prescribed movement). 21 This is a complex process that requires central processing of sensory inputs from visual, vestibular, and somatosensory pathways, as well as a resultant efferent response that controls the precise recruitment of specific motor units. 22 The central nervous system generates a “blueprint for movement,” which is delivered to pattern generators at a spinal level, resulting in the patterned activation of α and γ motoneuron systems. 23 Feedback and feed-forward control mechanisms play vital roles in the control of movement and the execution of tasks such as the SEBT and YBT. The stimulation of mechanoreceptors located in the periphery (ie, skin, ligaments, muscles, and joints) provides afferent feedback via spinal pathways regarding joint movement and position in various body segments during movement. 24 , 25 The pattern of motoneuron activation is fine tuned by feedback from these mechanoreceptors, which act either monosynaptically or via inhibitory interneurons and provide a corrective response to the action. 26 In contrast, feed-forward controls have previously been described as anticipatory actions occurring before the sensory detection occurs. 27 , 28 The mechanism of feedback and feed-forward control may vary between the SEBT and YBT, resulting in differences in reach distances in the A direction. The YBT requires the participant to stand in an elevated position on a central footplate while pushing a sliding block. He or she receives constant proprioceptive feedback throughout the reach excursion from the plantar surface of the reach foot. In the SEBT, the participant places downward pressure through the reach foot only at the end of the reach excursion and, therefore, does not receive a similar level of afferent information throughout the movement, potentially relying on a feed-forward control strategy until contact is made with the tape measure. The postural-control strategy used during the SEBT may mean that the individual does not have the same level of inhibition throughout the movement and, thus, reaches further. An external focus of attention facilitates automaticity in motor control and promotes movement efficiency compared with an internal focus. 29 Contact with the sliding block may have induced a more internal focus, thereby resulting in a negative influence on the A direction. In addition, pressure is allowed with the ground by the reach leg, albeit minimally, and actually provides a point of support. In the YBT, the individual may remain in a narrower stance as a result of the feedback received throughout the movement and therefore not reach as far. In upright stance, a stiffening strategy, characterized by decreased amplitude and increased frequency of postural adjustments and leaning back away from the direction of the postural threat, has previously been reported, 30 , 31 resulting in a feeling of less stability when standing on an elevated surface. 32 Sabin et al 33 recently reported reduced reach distances when performing the SEBT on an unstable surface. The elevated stance-leg position of the YBT, although at a relatively low height, may be perceived as a barrier to reaching further.

Several possible explanations for A reach differences are based on feedback mechanisms. The visual system provides the body with visual cues for use as reference points in orienting the body in space. It is generally agreed that, under normal conditions, the somatosensory and visual subsystems are the primary mediators of balance and postural awareness. 25 In the A reach direction, participants receive visual feedback from the reach leg as they move and can observe the scored reach distance on each trial. In the PM and PL directions, visual awareness is reduced, and therefore, the inability of the participants to see their scores may not limit their reach as in the A direction. However, this places an increased demand on somatosensory feedback strategies, meaning that, during the YBT, participants were able to reach similar distances as on the SEBT owing to their contact with the sliding block. Another potential reason for similar reach distances observed in the PM and PL directions relates to the placement of the reach foot on the sliding block of the YBT. Participants were instructed to not place the foot on top of the tubing and in all cases placed the plantar surface of the reach foot on the medial side of the sliding block. This may have resulted in their maintaining support closer to their center of gravity during the YBT than when they reached along the tape measures of the SEBT, again allowing them to reach similar distances in the PM and PL directions. In the A direction, the foot was placed on the lateral side of the sliding block, thus displacing the center of gravity and subsequently reducing reach distances compared with the SEBT.

These factors may also account for the significant differences and relatively large limits of agreement in the A direction, which indicate poor agreement between the tests in this study. Although this poor agreement would have practical implications for the use of these tests together as part of a screening protocol or clinical assessment outcome, it is unlikely that the tests would be used concurrently in these situations. Similarly, previous investigators measuring SEBT performance have indicated that side-to-side differences like those we observed between the SEBT and YBT in the A direction predict lower limb injury 4 and indicate deficiency in conditions such as chronic ankle instability 6 and anterior cruciate ligament injury. 7 Therefore, caution should be exerted when interpreting reach distances from both tests in the A direction in the same individual or group. Based on our findings, the posterolateral direction is the test with the least bias, which may make it more feasible for comparison between the tests. There is a paucity in the literature of studies investigating the relationship between the YBT and injury screening and assessment. Owing to its practicality and ease of use in a clinical setting, further research is warranted.

Finally, the differentiation between the levels of the elevated stance foot on the central footplate and the lower reach foot during the YBT compared with the level base for the SEBT may influence the individual's postural-control strategy. However, the former may be more applicable to everyday situations in which postural control is required on uneven surfaces. The role this strategy may have in the completion of these tests warrants further investigation.

CONCLUSIONS

A difference in A reach-direction distance was observed between the SEBT and YBT, with no differences noted in the PM and PL directions. Postural-control strategies used in completing the tests appear to influence reach performance. The results of this study have implications for both researchers and clinicians in interpreting and implementing these dynamic balance tests. Reach values and research established for the SEBT in athletic, healthy, and injured populations may not be transferrable to YBT performance. We are also the first to report on such values for the YBT in a healthy athletic male group. It is important to note that differences exist between these assessment tools; however, we did not establish if one test is more clinically appropriate than the other. Further research on the postural-control strategies and kinematic demands associated with these tests may indicate which conditions may be best screened or diagnosed using which test and therefore have implications for assessment and rehabilitation.

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Star Excursion Balance Test & Dynamic Postural Control

• Anterior (ANT), posteromedial (PM) and posterolateral (PL) lines.
• Stand on the central point.
• Hands on hips. 
• Reach as far as you can along the line and gently tap the line.
• Do not come to rest on the line.
• Do not transfer your body weight onto the reaching leg.

FACTORS AFFECTING PERFORMANCE 

• Vastus medialis is most active in anterior reach. 
• Vastus lateralis is least active in lateral reach.
• Medial hamstring is most active during anterolateral reach.
• Bicep femoris was most active during posterior and posterolateral reach. 

WHAT DOES THE SEBT TELL US?

Chronic ankle instability (cai):.

• In CAI, all three directions have the ability to identify reach deficits in participants compared to healthy controls, however, the PM is the most representative of the overall performance (Hertel, Braham, Hale & Olmsted-Kramer., 2006). 
• Anterior reach is more impacted by dorsiflexion ROM and plantar cutaneous sensation, meaning that mechanical restrictions and sensory deficits impact this movement.
• DF ROM is best evaluated with the knee to wall weight bearing lunge test compared to non weight bearing AROM (Dill et al., 2014). 
• Posteromedial and posterolateral reach is more impacted by eversion strength and balance control. 
• De la Motte, Arnold & Ross (2015) studied the movement pattern differences in trunk rotation and found that patients with CAI are more likely to use increased trunk flexion during anterior reach which suggests a compensation strategy for reduced ankle control is to manipulate the pelvis and trunk. 

ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION (ACLR):

• The same authors (De la Motte, Arnold & Ross., 2015, p.358) also studied trunk movements in ACL patients and found that following an ACLR, when reaching forward, patients are more likely to rotate their trunk away (backwards) from the reach leg and externally rotate the pelvis on the stance leg. 
• In a different study following ACLR, researchers found that when looking above the ankle and at the knee, patients with reduced quadricep strength have reduced reach capacity in the anterior directions (Clagg, Daterno, Hewett & Schmitt., 2015). 
• These same authors also found that hip abductions strength impacts all 3 directions, telling us that dynamic balance has contributions from the foot, ankle, knee, hip and trunk and our assessment of movement patterns should try consider all these areas too. 

PATELLOFEMORAL PAIN SYNDROME (PFPS):

IMPLEMENTATION INTO REHAB

REFERENCES:

Erson Religioso III, DPT, FAAOMPT

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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.