Systematic Review and Meta-Analysis of the Y-Balance Test Lower Quarter: Reliability, Discriminant Validity, and Predictive Validity

Abstract

Background: Deficits in dynamic neuromuscular control have been associated with post-injury sequelae and increased injury risk. The Y-Balance Test Lower Quarter (YBT-LQ) has emerged as a tool to identify these deficits.

Purpose: To review the reliability of the YBT-LQ, determine if performance on the YBT-LQ varies among populations (i.e., sex, sport/activity, and competition level), and to determine the injury risk identification validity of the YBT-LQ based on asymmetry, individual reach direction performance, or composite score.

Study design: Systematic Review.

Methods: A comprehensive search was performed of 10 online databases from inception to October 30, 2019. Only studies that tested dynamic single leg balance using the YBT-LQ were included. Studies were excluded if the Y-Balance Test kit was not utilized during testing or if there was a major deviation from the Y-Balance test procedure. For methodological quality assessment, the modified Downs and Black scale and the Newcastle-Ottawa Scale were used.

Results: Fifty-seven studies (four in multiple categories) were included with nine studies assessing reliability, 36 assessing population differences, and 16 assessing injury prediction were included. Intra-rater reliability ranged from 0.85-0.91. Sex differences were observed in the posteromedial direction (males: 109.6 [95%CI 107.4-111.8]; females: 102.3 [95%CI 97.2-107.4; p = 0.01]) and posterolateral direction (males: 107.0 [95%CI 105.0-109.1]; females: 102.0 [95%CI 97.8-106.2]). However, no difference was observed between sexes in the anterior reach direction (males: 71.9 [95%CI 69.5-74.5]; females: 70.8 [95%CI 65.7-75.9]; p=0.708). Differences in composite score were noted between soccer (97.6; 95%CI 95.9-99.3) and basketball (92.8; 95%CI 90.4-95.3; p <0.01), and baseball (97.4; 95%CI 94.6-100.2) and basketball (92.8; 95%CI 90.4-95.3; p=0.02). Given the heterogeneity of injury prediction studies, a meta-analysis of these data was not possible. Three of the 13 studies reported a relationship between anterior reach asymmetry reach and injury risk, three of 10 studies for posteromedial and posterolateral reach asymmetry, and one of 13 studies reported relationship with composite reach asymmetry.

Conclusions: There was moderate to high quality evidence demonstrating that the YBT-LQ is a reliable dynamic neuromuscular control test. Significant differences in sex and sport were observed. If general cut points (i.e., not population specific) are used, the YBT-LQ may not be predictive of injury. Clinical population specific requirements (e.g., age, sex, sport/activity) should be considered when interpreting YBT-LQ performance, particularly when used to identify risk factors for injury.

Level of evidence: 1b.

Keywords: dynamic balance; single leg balance; star excursion balance test; y-balance test lower quarter.

Figure 1.. PRISMA study selection demonstrating the systematic review of the literature for reliability, validity, and population differences for the Y-Balance Test Lower Quarter. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Figure 2:. Pooled Y-Balance Test Composite Score, Grouped by Sex. MS = Middle School, HS = High School, Col = College, Pro = Professional, ADU = Adult

Figure 3:. Pooled Y-Balance Test, Anterior Reach, Grouped by Sex. MS = Middle School, HS = High School, Col = College, Pro = Professional, ADU = Adult

Figure 4:. Pooled Y-Balance Test, Anterior Reach, Compared by Sport. MS = Middle School, HS = High School, Col = College, Pro = Professional

Figure 5:. Pooled Y-Balance Test, Posteromedial Reach, Compared by Sport. MS = Middle School, HS = High School, Col = College, Pro = Professional

Figure 6:. Pooled Y-Balance Test, Posterolateral Reach, Compared by Sport. MS = Middle School, HS = High School, Col = College, Pro = Professional