











































MANUSCRIPT TYPE


CLINICAL OUTCOMES 

 

15 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                              Volume 1 – Issue 1 – June 2018 
 

The Effect of Dynamic Balance Performance on Lower Extremity Injury 
in Division III Football Players 
Brian J. Coulombe, DAT, LAT, ATC1; Cameron J. Powden, PhD, LAT, ATC2 

1Texas Lutheran University, Seguin, TX; 2Indiana State University, Terre Haute, IN 

 

 
ABSTRACT 

Identifying and implementing evidence based prevention 
programs present a significant challenge for athletic trainers. 
Despite encouraging results in research, individual 
interventions are often specific to a setting or population and 
dependent on identifying accurate injury risk factors. This 
practice-based research is an attempt to apply current 
evidence in prevention to a population of division three 
football athletes. The clinical staff reviewed national and 
site-specific injury data and identified lower extremity (LE) 
injury as the area of focus. Evidence was searched to identify 
modifiable risk factors and valid measurement tools that 
could be addressed in our setting. Dynamic balance has been 
well documented as a risk factor for LE injury and the Y 
balance test (YBT) has been shown to be an accurate measure 
of balance and increased risk of injury. The purpose of our 
investigation was to determine if our population exhibited 
similar injury rates in those with balance deficits as 
documented in other settings. We chose the football program 
within our setting due to the high number of athletes and 
consistent injuries that occur throughout the season. All 
returning football athletes were measured for dynamic 
balance using the YBT during the annual screening process. 
Injury record keeping through electronic medical record 
(EMR) system was consistent with current procedures and non-
contact LE injuries were analyzed to remove non-modifiable 
risk factors. Comparisons were made between YBT results 
and incidence of injury in 46% of our athletes. Statistical 
analysis revealed no relationship between YBT measurements 
and LE injury. Our results are contradictory to those reported 
in recent studies from differing populations. Implementation 
difficulties and population differences are theorized reasons 
for our inability to achieve similar results. Clinically, our results 
underscore the need for clinicians to measure interventions 
within their own settings to determine usefulness and make 
the best decision for their patients. 
 

Key Phrases 
Injury Risk Reduction, Injury Surveillance, Prevention  

Correspondence 
Dr. Brian Columbe, Texas Lutheran University, 1000 W. Court 
Street, Seguin, TX 78155 
E-Mail: bcoulombe@tlu.edu 
Twitter: @BCoulATC 
 
Full Citation 
Columbe BJ, Powden CJ. The effect of dynamic balance 
performance on lower extremity injury in division III football 
players. Clin Pract Athl Train. 2018;1(1):15-20. 
https://doi.org/10.31622/2018/0001.4 
 
Submitted: May 3, 2018 Accepted: May 25, 2018 
 

INTRODUCTION 

Athletic trainers are tasked with implementing 
policies and procedures designed to prevent or 
mitigate emergent, acute, or chronic injuries and 
medical conditions1. Prevention of injuries before 
they occur (primary prevention), providing early 
identification and care (secondary prevention) to 
limit the extent of an injury, and comprehensive 
rehabilitation (tertiary prevention) after an injury 
are all areas in which athletic trainers work to 
prevent the disabling effects of injury. 
Interventions to prevent injury have historically 
focused on the individual and specific risk factors 
to which patients are exposed.2 To maximize 
primary and secondary prevention interventions it 
is important that athletic trainers focus their efforts 
on evidence-based initiatives aimed at specific 
populations of patients.2     
 
Football is a collision sport that has the highest 
injury rates of all NCAA intercollegiate athletic 
programs.3 Injuries to the lower extremity (LE) 
make up 54% of all injuries. Furthermore, the knee 
(12%), ankle (11.8%), and thigh musculature 
(10.7%) are the top 3 body parts injured in 
practice activities.3 One specific institution, a 
private, liberal arts, NCAA Division III University, 
has experienced similar injury rates for these 
types of LE injuries. Examination of electronic 
medical records (EMR) from the previous 
academic year revealed 57% of LE injuries at the 
specific institution were the result of non-contact 
mechanisms.  In an effort to improve healthcare 
services provided to our athletic population, the 
clinical athletic training staff searched recent 
evidence to identify modifiable risk factors for LE 
injury. Our evidence-based approach also 
included identifying a LE injury prevention 
program that had been evaluated for feasibility. 

Postural control and dynamic balance are two 
modifiable risk factors that have been related to 
LE injury.4,5 Recent evidence indicates that 

https://doi.org/10.31622/2018/0001.4


The Effect of Dynamic Balance Performance on Lower Extremity Injury in Division III Football Players 
 

 

16 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                              Volume 1 – Issue 1 – June 2018  

impaired balance increases an athlete’s risk of 
injury.6-10 Furthermore, prophylactic balance 
training programs have demonstrated the ability 
to decrease injury risk.5,11,12 Together these 
findings highlight the importance of identifying 
balance deficits during the prevention process. 
Single leg balance tests, like the Star Excursion 
Balance Test (SEBT) and the newer Y-Balance Test 
(YBT), are frequently used tools in lab-based and 
practical research studies that use single leg reach 
distance to evaluate dynamic balance and 
postural control.4-7,13-15 Evidence for using the YBT 
as an injury prediction tool has been encouraging 
with multiple studies identifying anterior reach 
asymmetries of over 4cm and composite scores of 
under 89.9% as strong predictors of injury.7,8,11,15  

As our clinical staff reviewed current evidence on 
the YBT, concerns of replicating results found in 
previous studies within our own patient population 
became evident.  It was important for us to 
establish measures at which our athletes 
experience increased injury before implementing 
interventions to prevent those injuries.  We 
determined that our first step in improving quality 
of care in the area of injury prevention started 
with the collection and analysis of data within a 
specified population to determine what, if any, 
interventions may be appropriate.  Although the 
YBT has performed well as a predictive measure 
of injury in NCAA Division 1 football, basketball, 
and soccer athletes, its utility to identify at-risk 
individuals is unclear within the football 
population at the specific NCAA Division III 
institution. The purpose of this practice-based 
research project was to determine the relationship 
between the YBT and LE injury in football athletes 
at the institution. Our hypothesis was that those 
experiencing non-contact LE injuries would 
demonstrate significantly greater asymmetries 
and lower composite scores than the uninjured 
population. 
 
PATIENTS 

One hundred thirty-nine football student-athletes 
from the same NCAA Division III institution 
participated in this screening and monitoring 
program. Prior to the start of the 2016 football 
season, all athletes completed an annual medical 
screening process of which YBT measurements 
were included. Athletes were given brief 
information on the purpose of balance assessment 

as a means to identify risk of LE injury before 
completing measurements. Athletes with a LE injury 
at the time of YBT evaluation were excluded from 
this study. Athletes who were included in this study 
were then monitored throughout the competitive 
season for LE injuries.  

INTERVENTION 

The FMS Y Balance Test (Perform Better, West 
Warwick, RI) was used to measure balance in 
athletes. The YBT tool consists of a center platform 
and three PVC pipes attached in anterior, 
posteromedial, and posterolateral directions. 
Each directional pipe is labeled in centimeters (cm) 
and includes a sliding block that an athlete pushes 
as they reach in a specific direction (Figure1).  
Reliability assessments of YBT measurements in 
multiple studies suggest strong intrarater 
reliability between ICC=0.85-0.93 and interrater 
reliability between ICC=0.91-1.0.5,8,15 The 
measurement protocol utilized was based on a 
previous protocol.15 Athletes were instructed to 
stand barefoot on the center platform and reach 
out in each direction, with the contralateral limb, 
to slide a block down the directional pipe. Trials 
were repeated if athletes removed hands from 
hips, failed to return to the start, threw the block, 
or placed excess weight on the block. Athletes 
completed four practice trials followed by three 
measurement trials in each direction. The furthest 
reach in each direction was recorded, normalized 
to leg length and used for analysis. Two 
examiners monitored the trials to ensure correct 
procedure and two others recorded reach 
distances. YBT examiners completed educational 
sessions to ensure that those measuring YBT 
understood the process and could obtain reliable 
measurements.  Leg length was measured 
following YBT. Leg length was measured from the 
anterior superior iliac spine to the distal tip of the 
medial malleolus on both limbs after athletes 
lifted their hips off of the table and returning to a 
supine position. All YBT and leg length 
measurements were completed by the clinical 
athletic training staff (< 8 years BOC certified) or 
senior level professional athletic training students 
who completed a training module with 
measurement practice at the institution. The 
information was stored in a Microsoft® Excel 
spreadsheet to be analyzed with injury data to 
determine the, if any, relationship exists between 
balance and LE injury. This was an important first 



The Effect of Dynamic Balance Performance on Lower Extremity Injury in Division III Football Players 
 

 

17 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                              Volume 1 – Issue 1 – June 2018  

step in determining the necessity of possible 
prevention programming. 

OUTCOME MEASURES 

Injury EMR surveillance occurred via SportsWare© 
(Computer Sports Medicine Inc. 
Stoughton, MA.) database and lasted the entire 
fall 2017 season.  Injuries to the LE that resulted 
from any non-contact mechanism were included if 
the event required medical care and resulted in 
time-loss of one or more days of normal football 
activities. A report was generated through the 
EMR for the stated conditions and YBT values for 
those injured were matched in Microsoft® Excel 
database for analysis. Athletes sustaining multiple 
injuries were included for their first injury only. 
 
Analyses were conducted using a statistical 
software program (IBM Corp. Released 2015. 
IBM SPSS Statistics for Windows, Version 23.0. 
Armonk, NY: IBM Corp). Means and standard 
deviations were calculated for all reach distances 
and asymmetries in each leg for injured and 
uninjured athletes.  Limb asymmetries were 
calculated by taking the absolute difference 
between limbs for each reach direction and 
composite score.  Receiver operator characteristic 
(ROC) curves were created to establish a cut-off 
point at which a difference in scores correlated 
with an increased chance of LE injury.  This was 
done for each reach and composite score 
asymmetry to determine risk of injury in this 
population. The P value was set at P < 0.05 a 
priori. 
 
RESULTS 
 
Non-contact LE injuries occurred in 62 of 136 
athletes who completed the 2017 football season 
(Table 1).  The normalized reach distances and 
composite scores are presented in Table 2 for 
injured and uninjured athletes. Non-significant 
asymmetries (Table 3) were noted among injured 
and uninjured populations (P = 0.382) with mean 
asymmetries for each direction and composite 
being within 1% except for the posteromedial 
reach direction (2%).  ROC data failed to reach 
significance in establishing cut off points for reach 
or composite score asymmetries.    

Table 1. Sustaining Non-Contact LE Injuries. 
 Number Percentage 
No Injury 74 54.4 
Injury 62 45.6 

Total 136 100.0 
 
 

 
 
 

 

 



The Effect of Dynamic Balance Performance on Lower Extremity Injury in Division III Football Players 
 

 

18 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                              Volume 1 – Issue 1 – June 2018  

 
Table 3. YBT Asymmetry Values for each direction  
Group (n) Anterior Posteromedial Posterolateral Composite 

Uninjured (74) 5.8 ± 4.8%  7.5 ± 6.7% 9.1 ± 7.4% 4.3 ± 4.2% 

Injured (62) 6.4 ± 5.6%    9.5 ± 14.1%   9.0 ± 11.7% 5.2 ± 6.2% 

Average (136) 6.1 ± 5.2%    8.4 ± 10.8% 9.1 ± 9.6% 4.7 ± 5.2% 

Note: Values are expressed as a percentage difference between limbs 

 
Table 4.  Receiver Operator Characteristic Findings 

 
DISCUSSION 
 
The purpose of this study was to determine if a 
relationship exists between YBT performance and 
the incidence of LE injury in NCAA Division III 
football players.  Our results did not find any YBT 
reach direction that was predictive of LE injury.  
This is in contrast to recent investigations of YBT 
performance in other populations. Using the star 
excursion balance test (SEBT), Plisky6 found that 
high school basketball players with anterior reach 
asymmetries greater than 4 cm demonstrated a 
2.5 times greater injury risk.  Additionally, female 
athletes were 6.5 times more likely to sustain 
injury if their composite reach score was less than 
94% of their limb length.6  The relation of anterior 
reach asymmetry to increased injury risk was 
corroborated using the YBT in a population of 
NCAA Division 1 athletes from various sports in a 
2015 investigation by Smith et al. which found 
that participants with anterior reach differences 
of over 4 cm were almost 4 times more likely to 
sustain a LE during their competitive season.9  
Similar YBT procedures have been applied 
among amateur and professional soccer players 
finding a 4 cm difference in the posteromedial 
direction as a risk factor for injury.16   In contrast, 
another investigation using the YBT among NCAA 
Division I football players was unable to 
corroborate injury risk in those with anterior reach  

 
asymmetries, but did find a 3.5 times higher injury 
rate in those with composite scores of less than 
89% of limb length.8 The combination of these 
findings highlight the variation in the predictive 
ability of the YBT/SEBT and underscores the 
importance of continued investigations within 
multiple populations.  Before adopting quality 
improvement interventions, athletic trainers should 
incorporate evidence from their own patient 
population along with current research evidence 
to ensure the usefulness of those interventions.  
Practice-based research and analysis of such data 
can help focus efforts on the needs of our patients 
and improve overall outcomes. Despite our results, 
the YBT can still be a useful marker of 
neuromuscular control in patients after specific 
injuries.  Investigations among patients with lateral 
ankle sprains, chronic ankle instability, anterior 
cruciate injury, and patellofemoral pain syndrome 
consistently exhibit significant reach deficits in the 
directions used in the YBT.4  Additionally, 
rehabilitation focusing on improving balance while 
reaching in anterior, posteromedial, 
posterolateral directions has shown improvement 
within injured populations.4  One such study 
among those with chronic ankle instability found 
significant improvement in reach distances after 4 
weeks of balance exercise focused on the 
anterior, posteromedial, and posterolateral 
directions.10  Within our application, baseline 

Asymmetry 
Measure 

Area Std. Error P value Cut Off 
Score 

Sensitivity Specificity 

Anterior .519 .050 .702 0.1% 61.3% 47.3% 
Posteromedial .532 .050 .526 7.2% 43.5% 67.6% 
Posterolateral .456 .050 .382 1.0% 98.0% 11.0% 
Composite .513 .051 .800 8.4% 19.4% 91.9% 



The Effect of Dynamic Balance Performance on Lower Extremity Injury in Division III Football Players 
 

 

19 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                              Volume 1 – Issue 1 – June 2018  

measurements were used as objective return to 
play criteria for those injured throughout the 
season.  Evidence has established the YBT as an 
appropriate measure of dynamic postural control, 
and that interventions focusing on balance and 
neuromuscular control exercises lead to improved 
reach scores.17-20  
 
There were a number of challenges experienced 
in the implementation of the YBT testing 
procedures, which may have affected 
measurements collected.  A large number of 
football athletes (139) reported for the pre-
participation exam that was scheduled for a 3-
hour time period.  The addition of a balance 
testing station increased the time required to 
complete all components of the exam, which 
created a sense of fatigue in athletes and 
clinicians.  The YBT was a new procedure for staff 
and professional level students who were 
conducting measurements.  Training and practice 
sessions were employed, but unforeseen 
challenges during a time-sensitive exam may have 
compromised the ability to record accurate 
measurements.  Additionally, returning players 
may not have provided maximal effort as this was 
a new and unexpected task that was seen as a 
burden.  Lessons learned through unsuccessful 
experiences provide valuable information on how 
to improve procedures and must be addressed in 
future investigations of the YBT as a predictive 
assessment of injury.  Educational sessions for 
athletes and coaching stakeholders can lead to 
buy-in and commitment to gathering accurate 
measurements.  Further training and experience 
among those conducting measurements will 
increase efficiency and accuracy of the 
measurement process.  Finally, procedures to limit 
the number of athletes measured in one session 
may help with the impatience of athletes and the 
fatigue of clinicians.   

The results of this practice-based research did not 
identify YBT measurements predictive of lower 
extremity injury.  Adjustments to implementation 
policies will be necessary if the YBT will be 
continued to be used as a predictor of lower 
extremity injury or an objective rehabilitation 
measure.  One of the benefits that resulted from 
our investigation was an additional clinical 
outcome measure to assess return to activity status 
for those that incur lower extremity injury.  
Comparisons to YBT baseline measures of 

dynamic balance will be useful information to 
assist clinical decision making regardless of injury 
predictive ability.  

CLINICAL APPLICATION   

While identifying and using current evidence to 
guide clinical practice is an important function of 
an athletic trainer, implementation of specific 
interventions designed to prevent injury should be 
tailored to the individual setting and population 
being treated.  Practice based research provides 
information on potential usefulness of interventions 
and can provide additional clinician-rated 
outcomes to improve clinical decision-making.  
Continuous data collection and assessment of 
interventions is crucial for clinicians to make the 
best decisions for their patients. 

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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                              Volume 1 – Issue 1 – June 2018  

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