TEST FOR SUBSTITUTION PATTERNS - Test movements 1-5
The five test movements of the TSP are performed at a pace of about 25 beats/minute: performance on beat one, return to starting position on beat two. Below: Verbal instructions given by the examiner are written in italics, starting positions = S, performance = P.
1 — Bodyweight altering test

S: Patient barefooted standing with feet a good hip-width apart. Hands placed on head. Examiner standing in front of patient.
P: Examiner: “Shift your body weight from non-injured leg to injured leg at the same time as you bend the weight bearing leg slightly at ankle, knee and hip joints. Do this alternating towards the non-injured and injured side; five times on each side. Look straight ahead.”
Substitution patterns scored:
1:1. Increased outward rotation and/or pronation on weight bearing foot
1:2. Knee moves medially in relation to the foot and hip (knee not in line with hip and foot) when weight bearing
1:3. Lateral displacement of hip–pelvis region on weight bearing side
1:4. Displacement of trunk (for instance bending trunk forward or displacing trunk laterally) on weight bearing side
1:5. Different positions of arms when comparing arm positions to trunk; look at how elbows are placed in relation to trunk, for example placed more lateral or more forward on weight bearing side as compared to when other side is weight bearing
2 — Single leg squat tip-toe standing

S: Patient barefooted facing wall, standing tip-toe on one foot. Slight support from fingertips against wall in front of patient. Examiner standing behind and then beside patient on weight bearing side.
P: Examiner: “Squat slowly about this much (demonstrating approx. 70 degrees of knee flexion) without lowering the heel. Five repetitions.”
Substitution patterns:
2:1. Knee moves medially in relation to the foot and hip (knee not in line with hip and foot) when weight bearing
2:2. Lateral displacement of hip–pelvis region on the weight bearing side
2:3. Displacement of trunk (for instance bending trunk forward or displacing laterally) on weight bearing side
3 — Single leg squat

S: Patient barefooted standing on non-injured leg beside for example a bench or wall on opposite side to weight bearing leg and fingertips (of opposite hand to weight bearing leg) providing light balance support on bench/wall. Non weight bearing leg slightly raised from the floor by slight hip and knee flexion. Examiner standing in front of and then beside patient on weight bearing side.
P: Examiner: “Squat on your leg about this much (demonstrating approx. 70 degrees of knee flexion) and rise five times. Turn around and repeat the procedure on the other leg.”
Substitution patterns:
3:1. Increased outward rotation and/or pronation on weight bearing foot
3:2. Knee moves medially in relation to the foot and hip (knee not in line with hip and foot) when weight bearing
3:3. Lateral displacement of hip–pelvis region on weight bearing side
3:4. Displacement of trunk (for instance bending trunk exaggeratedly forward or displacing trunk laterally) on weight bearing side
4 — Forward lunge from stairs

S: Patient standing with shoes, on first step of a staircase (about 15 cm high). Examiner standing in front of patient observing both the “stride” and the “return”.
P: Instructions: “Take a long stride forward to the floor (demonstrating about 80 cm from the step) with the non-injured leg and land on the foot at the same time as you bend this knee to about 90 degrees of flexion (called “stride” in scoring sheet), while the foot of the injured leg remains on the step. Remain in this position for about 2 seconds, and then return to the step (called “return” in scoring sheet). Alternate between the non-injured and injured legs. Five times on each side.”
Substitution patterns:
4:1. Shorter stride
4:2. Knee moves medially in relation to the foot and hip (knee not in line with hip and foot) when weight bearing
4:3. Displacement of trunk (for instance bending trunk forward or displacing laterally) on weight bearing side
4:4. Patient tries to help out with support from hand/hands or takes a more careful stride (sound muffled when foot meets floor)
4:5. Avoids weight-bearing on hind leg during return
5 — Double leg squat

S: Patient barefooted standing with feet a good hip-width apart. Examiner standing in front of patient.
P: Examiner: “Squat on both legs this much (demonstrating approx. 90 degrees of knee flexion), and rise up again five times”
Substitution pattern:
5:1. Displacement of bodyweight away from scored side
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