Semi-Professional Rugby Union: Player Proforma Capture Form

Musculoskeletal Pre-screening Questions

Personal details                                        Date: _________________________________

Name of athlete: ___________________Date of Birth: __ / __ / __ Age _____(years)

Mobile Number: ___________________Email: ________________________________

Position played: __________________________________________________________

Years in sport: ___________________________________________________________

(Please circle if yes)

Hand dominance	Foot dominance
Left	Left
Right	Right
Both	Both

 

Do you warm up prior to:	Do you cool down after:
Matches	Matches
Training	Training

 

Training habits (times per week and time per session)

 Sport specific: __________________________________________________________________

_________________________________________________________________________________

Cross training: __________________________________________________________________

_________________________________________________________________________________

 

Protection and support for training and matches (tick box)

	Training	Match	Left	Right
Ankle brace/tape
Knee brace/tape
Compression
Mouth guard
Shoulder pads
Head gear
Orthotics

 

Any perceived areas of muscular tightness, weakness and/or fatigue associated with performance or training: ____________________________________________________

__________________________________________________________________________________________________________________________________________________________________

Injury History: Current and previous (Yes/No or mark on body chart)

Region	Left/Right	Current injury	Past 12 months	Resolved	Injury details: To be filled in by physio  (inc surgery & investigations)
Head
Upper limb
Neck
Upper back
Lower back
Abdominal
Pelvis
Hip
Groin
Hamstring
Quadriceps
Knee
Calf
Shins
Ankle/foot
Other

 

Postural Assessment: (Mark with a X)                  Rating scale

Postural Component

                             Normal                      Mildly anterior                    Grossly anterior

Chin protraction                O                                 O                                             O

                             Symmetrical           Mildly asymmetrical         Grossly asymmetrical

Shoulder roundness        O                                 O                                             O

Scapular position             O                                 O                                             O        

Shoulder height                 O                                 O                                             O

Iliac crest height               O                                 O                                             O

PSIS alignment                  O                                 O                                             O

Scoliosis                              O                                 O                                             O

Rating scale

                             Normal                      Mild curve                            Grossly curved

Thoracic kyphosis            O                                 O                                             O

Lumbar lordosis                O                                 O                                             O

 

                             Normal                      Mild pronation                    Major pronation

Feet in standing      O                                 O                                             O

Flexibility tests:

Test	Left	Right
Thomas test: Hip	°	°
Thomas test: Knee	°	°
Active internal hip rotation	°	°
Active internal hip rotation	°	°
Active knee extension	°	°
Straight leg raise	°	°
Ankle dorsiflexion	cm	cm
Shoulder internal rotation	°	°
Shoulder external rotation	°	°

 

Sit and reach	cm
Lumbar spine extension	cm
Lumbar spine flexion	cm
Combined elevation test	cm

Neural mobility test:

Test	Left	Right
Active slump	°	°
ULTT (median bias):	°	°

Stability, strength and proprioception:

Test	Total time	Left	Right
Plank	min/sec
Chin tuck hold	min/sec
Single leg bridge		min/sec	min/sec
Calf raise: straight knee		reps	reps
Calf raise: bent knee		reps	reps
Multiple hop test		reps	reps

 

Functional movement screening

Max score – 15

Min score - 5

 

Deep squat:

Score

Note – 3        Upper torso parallel with tibia or towards vertical

                        Heel contact with floor

                        Femur below horizontal

                        Knees over feet

                        Bar over knees

            2          Add heel raise

                         Same criteria as 3

            1          Unable to perform movement properly with heel raise

Hurdle step:

Left	score
Right	score

 

Hurdle height          tibial tuberosity

Note - 3         Hips, knees & ankles aligned in sagittal plane

                        Erect posture maintained

            2          One or more of the scoring criteria for 3 in not performed

            1          Contact between foot & hurdle

                        Loss of balance

In-line lunge:

Left	score
Right	score

Note -            3          Body remains upright with the head, T-spine and L-spine in line

                        Tibia parallel to the sagittal plane

                        Knee touches ground

            2          One or more of the scoring criteria for 3 not performed

            1          Loss of balance

 

Findings arising from screening:

Relevance and recommendations of key findings in relation to the sport:

 

Partially adapted from:

• BokSmart - Musculoskeletal Assessment for Rugby Players
• New Zealand academy of sport – musculoskeletal screening form
• Functional Movement systems screening form