title: Physical Exam Risk Factors for Lower Extremity Injury in High School Athletes: A Systematic Review.
abstract: OBJECTIVE
  A stated goal of the preparticipation physical evaluation (PPE) is to reduce musculoskeletal injury, yet the musculoskeletal portion of the PPE is reportedly of questionable use in assessing lower extremity injury risk in high school-aged athletes. The objectives of this study are: (1) identify clinical assessment tools demonstrated to effectively determine lower extremity injury risk in a prospective setting, and (2) critically assess the methodological quality of prospective lower extremity risk assessment studies that use these tools.
  
  
  METHODS
  A systematic search was performed in PubMed, CINAHL, UptoDate, Google Scholar, Cochrane Reviews, and SportDiscus. Inclusion criteria were prospective injury risk assessment studies involving athletes primarily ages 13 to 19 that used screening methods that did not require highly specialized equipment. Methodological quality was evaluated with a modified physiotherapy evidence database (PEDro) scale.
  
  
  RESULTS
  Nine studies were included. The mean modified PEDro score was 6.0/10 (SD, 1.5). Multidirectional balance (odds ratio [OR], 3.0; CI, 1.5-6.1; P < 0.05) and physical maturation status (P < 0.05) were predictive of overall injury risk, knee hyperextension was predictive of anterior cruciate ligament injury (OR, 5.0; CI, 1.2-18.4; P < 0.05), hip external:internal rotator strength ratio of patellofemoral pain syndrome (P = 0.02), and foot posture index of ankle sprain (r = -0.339, P = 0.008).
  
  
  CONCLUSIONS
  Minimal prospective evidence supports or refutes the use of the functional musculoskeletal exam portion of the current PPE to assess lower extremity injury risk in high school athletes. Limited evidence does support inclusion of multidirectional balance assessment and physical maturation status in a musculoskeletal exam as both are generalizable risk factors for lower extremity injury.
authors.affiliation: *Division of Athletic Training, The Ohio State University School of Health and Rehabilitation Sciences, Columbus, Ohio; †Family Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio; ‡Sports Health and Performance Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio; and §Division of Physical Therapy, The Ohio State University School of Health and Rehabilitation Sciences, Columbus, Ohio.
authors.forename: James A
authors.initials: JA
authors.lastname: Onate
authors.forename: Joshua S
authors.initials: JS
authors.lastname: Everhart
authors.forename: Daniel R
authors.initials: DR
authors.lastname: Clifton
authors.forename: Thomas M
authors.initials: TM
authors.lastname: Best
authors.forename: James R
authors.initials: JR
authors.lastname: Borchers
authors.forename: Ajit M W
authors.initials: AM
authors.lastname: Chaudhari
mesh_terms: D000293:Adolescent; D041923:Adolescent Development; D006801:Humans; D007869:Leg Injuries; D053580:Muscle Strength; D010808:Physical Examination / Q000379:methods*; D004856:Postural Balance; D012307:Risk Factors