Star Excursion Balance Test

What is the Star Excursion Balance Test?

The is a dynamic clinical assessment that aims to gauge a patient’s balance and stability when it comes to both legs. This test aims to assess a person’s physical performance, so more often than not, this is used to gauge athletes, especially when recovering from an injury. The test is also used to identify any signs of postural control deficits caused by injuries to the lower extremities, such as chronic ankle instability or any injury that affects their capability to maintain balance with their legs.

This test will be conducted on a flat surface with an asterisk marked on the floor by tape. The patient taking the test will stand in the middle of the asterisk, and they will reach for every end of the asterisk with one leg while maintaining their balance with the other. Once they are able to accomplish that (or not), they will alternate the role of their legs, so the previous one that was used to maintain balance will be the one to be used to reach for each end of the asterisk’s points, while the previous pointer leg will be used to maintain standing balance.

Check out this video to see how the assessment is performed:

How to conduct and perform the Star Excursion Balance Test

Before the test conductor begins anything, they need to prepare the following equipment:

• A flat surface (2x2 meters)
• Sticky tape
• Measuring tape
• Performance-recording sheet

Once all these are ready, make an asterisk using the sticky tape. Each strip you pull out must be six to eight feet long. Use the measuring tape to properly measure the length of each strip. Also, make sure that each strip is separated from each other by a 45-degree angle to properly form the asterisk.

Next, you need to demonstrate the instructions to the patient:

• First, pick one leg to use as your standing leg. This leg will be used to balance yourself throughout this part of the exercise.
• Get into standing position in the middle of the asterisk and place your hands on your hips.
• Once you are in standing position, you will use your other leg to reach as far as you can within the range of each direction of the asterisk but without planting your reaching foot on the ground. To reach for each direction, you will use your big toe. If you’re using your left leg as your standing leg, then you will use your right leg to reach. If that’s the case, then you will reach for each direction in clockwise order. If you’re using your left leg to reach for each direction, you will do this in counterclockwise order.
• You will repeat this three times per leg.

They will fail if:

• If they hold onto something for balance
• If they lose their balance and fall
• They remove their hands from their hips
• If they plant their reaching foot on the ground
• If their standing foot’s heel rises or moves at all

Once the instructions are clear to the patient, give them a trial run for both legs. Make sure to let them rest for 30 seconds to 1 minute, then proceed with the actual test. This isn’t timed, so they can start as soon as you tell them to start.

How to score the Star Excursion Balance Test

As the patient performs this test, you will need to observe and be ready to measure the reach for each direction using the measuring tape. You will measure in centimeters and must record to the nearest 0.5cm. For example, if their reach is 4.7cm, that counts as 4.5cm. If their reach is 4.9cm, then that counts as 5cm.

Here are the points that you need to measure:

1. Anterior
2. Anteromedial
3. Medial
4. Posteromedial
5. Posterior
6. Posterolateral
7. Lateral
8. Anterolateral

If the patient uses the right leg to reach, they will follow this in clockwise order. If they use the left leg to reach, they will follow this in counterclockwise order.

Since the first attempt for both legs are trials, you will only record the next three attempts.

Here’s the calculation:

1. (Reach 1 + Reach 2 + Reach 3) ÷ 3 = average distance in each direction (cm)
2. (Average distance in each direction ÷ leg length) x 100 = relative (normalized) distance in each direction (%)
3. (Normalized Anterior + Normalized Posteromedial + Normalized Posterolateral) ÷ 3 = Normalized Composite Score (%)

Example for 1 & 2 using Anteromedial direction:

1. (61cm + 61cm + 61cm) ÷ 3 = 61cm
2. (61cm ÷ 79cm) x 100 = 77.21%

Example for Normalized Composite Score:

3. (77% + 77% + 65%) ÷ 3 = 73%

There is not enough research to fully determine the accuracy of the results, but it is dependent on certain factors. Since this test is mostly conducted on athletes, it will depend on their sports and sex. According to Plisky et al., female high school to collegiate basketball players are 6.5 times more likely to sustain lower limb injury if their normalized composite score is below 94%, while males are three times more likely to sustain lower limb injury if they score below the same percentage.

Given this, it’s best to use this in conjunction with other balance-related tests as well as lower extremity-related tests as part of a comprehensive examination. You will get more accurate results that way.

When is it best to conduct the Star Excursion Balance Test?

Most of the time, the Star Excursion Balance Test is taken by athletes, especially if they are coming from an injury or when they are training.

Athletes who take this test are usually part of basketball or soccer teams. Their respective sports require balance and dynamic postural control, so this test is usually conducted during the early stages of training to properly gauge the players' balance and potential balance deficits. The results will then be used to construct a training program to help them attain a benchmark and minimize the risk of injury if the results point towards a risk of sustaining injury.

If an athlete gets injured and sustains a knee or ankle injury, this test can be used during the recovery or rehabilitation phase to assess the current level of postural control they have and develop a rehabilitation program.

In clinical settings besides athlete rehabilitation, the Star Excursion Balance Test can be included as part of a comprehensive examination of a patient with neurological conditions that are likely to affect their balance. It can also be used as a screening test for elderly patients who are suspected to be at risk of falling.

Who can conduct the Star Excursion Balance Test?

Since the Star Excursion Balance Test is a dynamic physical examination that involves balance, it is best conducted by the following healthcare professionals:

• Athlete trainers and coaches
• Athlete physicians
• Physical therapists
• Occupational therapists
• Rehabilitation specialists

Given that there is a lack of research when it comes to how scores should be interpreted, it is best if these professionals, or professionals who have been highly trained to deal with and treat patients when it comes to their balance and lower extremities, to be the ones who conduct this so you can trust their judgment regarding scores and what they decide to do with the patient.

To reiterate, this test is best when included as part of a comprehensive examination, and we recommend that you include it so you can get results from other assessments, some of which have already been established to be reliable. Some balance tests that you use are the ones that are part of the Short Physical Performance Battery (SPPB), which all have something to do with balance. This is to account for the lack of research regarding the results. While it’s best to have experts conduct it, it’s also best to conduct other similar tests to get the best picture possible when it comes to the patient's balance.

What are the benefits of the Star Excursion Balance Test?

It’s an inexpensive test to conduct.

One of the best things about the Star Excursion Balance Test is that it’s a non-invasive test that doesn’t require anything big from the conductor or the patient. The patient just needs to be in comfortable, lightweight or fitness clothing. The conductor just needs the necessary space to conduct it, marking tape to make the asterisk on the floor, and a measuring tape to measure the patient’s leg length and the reach of each leg.

The instructions are also easy to explain, demonstrate, and follow, so patients taking it should know what to do. Whatever difficulties arise will depend on their balance, and if they have a hard time keeping themselves together during the test, that’s an indication of a balancing deficit.

It can guide treatment decisions when results are confirmed.

Speaking of the test identifying balancing deficits, this can be used on numerous populations. While it is primarily used to assess athletes, it can be used to assess those with neurological conditions and elderly patients since they are at risk of falling. By properly interpreting the results based on observations and their scores, healthcare professionals can combine them with results from other balance or lower extremity-related tests to check for any conditions like sprained ankles or knee problems, plus, determine what goes into their respective treatment plans.

It can be used to monitor patients down the line.

Earlier, we mentioned that the Star Excursion Balance Test is often used on athletes, especially those who are in the middle of recovering from an injury. At that point, the test becomes a monitoring method for professionals to see how fast they are recovering and if they are improving when it comes to their reach and balance. This is not exclusive to athletes, of course.

Let’s say you implemented a treatment plan that involves rehabilitation. You can conduct this test from time to time to see if doing so will help improve your patient’s balance. If they are getting better, then it’s likely that recovery is still possible for the patient and your treatment plan is working. If not, there might be a chance that their balance has been permanently impacted (more likely for elderly patients or those with neurological conditions), or your treatment plan might just need a few adjustments (or should be overhauled).