Implementing return-to-sport (RTS) testing should be an integral component of rehabilitation for young athletes who have undergone anterior cruciate ligament (ACL) reconstruction, but there are no universally accepted standards for such testing. In this article, we highlight our institution’s use of a structured and evidence-based approach to guide RTS decision-making for athletes, coaches, surgeons, therapists, and parents, with an emphasis on reducing the likelihood of reinjury after ACL reconstruction surgery.
AngelozziMMadamaMCorsicaCCalvisiVProperziGMcCawSTCacchioA.Rate of force development as an adjunctive outcome measure for return-to-sport decisions after anterior cruciate ligament reconstruction. J Orthop Sports Phys Ther. 2012;42(9):772–780. https://doi.org/10.2519/jospt.2012.3780.
2.
ArdernCLTaylorNFFellerJAWebsterKE.Return-to-sport outcomes at 2 to 7 years after anterior cruciate ligament reconstruction surgery. Am J Sports Med. 2012;40(1):41–48.
3.
Barber-WestinSDNoyesFR.Objective criteria for return to athletics after anterior cruciate ligament reconstruction and subsequent reinjury rates: a systematic review. Phys Sportsmed. 2011;39(3):100–110. https://doi.org/10.3810/psm.2011.09.1920.
4.
BeischerSGustavssonLSenorskiEH, et al. Young athletes who return to sport before 9 months after anterior cruciate ligament reconstruction have a rate of new injury 7 times that of those who delay return [published correction appears in J Orthop Sports Phys Ther. 2020;50(7):411]. J Orthop Sports Phys Ther. 2020;50(2):83–90. https://doi.org/10.2519/jospt.2020.9071.
5.
BooMEGarrisonJCHannonJP, et al. Energy absorption contribution and strength in female athletes at return to sport after anterior cruciate ligament reconstruction: comparison with healthy controls. Orthop J Sports Med. 2018;6(3):2325967118759522. https://doi.org/10.1177/2325967118759522.
BurgiCRPetersSArdernCL, et al. Which criteria are used to clear patients to return to sport after primary ACL reconstruction? a scoping review. Br J Sports Med. 2019;53(18):1154–1161. https://doi.org/10.1136/bjsports-2017-098852.
8.
CobianDGKochCMAmendolaAWilliamsGN.Knee extensor rate of torque development before and after arthroscopic partial meniscectomy, with analysis of neuromuscular mechanisms. J Orthop Sports Phys Ther. 2017;47(12):945–956. https://doi.org/10.2519/jospt.2017.7310.
9.
DautyMMenuPDaleyP, et al. Knee Strength assessment and clinical evaluation could predict return to running after anterior cruciate ligament reconstruction using patellar tendon procedure. Int J Environ Res Public Health. 2022;19(20):13396. https://doi.org/10.3390/ijerph192013396.
10.
DraovitchPPatelSMarroneW, et al. The return-to-sport clearance continuum is a novel approach toward return to sport and performance for the professional athlete. Arthrosc Sports Med Rehabil. 2022;4(1):e93–e101. https://doi.org/10.1016/j.asmr.2021.10.026.
11.
EbertJREdwardsPPreezLDFurzerBJossB.Knee extensor strength, hop performance, patient-reported outcome and inter-test correlation in patients 9-12months after anterior cruciate ligament reconstruction. Knee. 2021;30:176–184. https://doi.org/10.1016/j.knee.2021.04.012.
12.
ForelliFBarbarWKersanteG, et al. Evaluation of muscle strength and graft laxity with early open kinetic chain exercise after ACL reconstruction: a cohort study. Orthop J Sports Med. 2023;11(6):23259671231177594. https://doi.org/10.1177/23259671231177594.
13.
GrindemHSnyder-MacklerLMoksnesHEngebretsenLRisbergMA.Simple decision rules can reduce reinjury risk by 84% after ACL reconstruction: the Delaware-Oslo ACL Cohort Study. Br J Sports Med. 2016;50(13):804–808. https://doi.org/10.1136/bjsports-2016-096031.
14.
GrondinJCrennVGernigonM, et al. Relevant strength parameters to allow return to running after primary anterior cruciate ligament reconstruction with hamstring tendon autograft. Int J Environ Res Public Health. 2022;19(14):8245. https://doi.org/10.3390/ijerph19148245.
15.
HerringtonLGhulamHComfortP.Quadriceps strength and functional performance after anterior cruciate ligament reconstruction in professional soccer players at time of return to sport. J Strength Cond Res. 2021;35(3):769–775. https://doi.org/10.1519/JSC.0000000000002749.
16.
HirohataKAizawaJOhmiT, et al. Reactive strength index during single-limb vertical continuous jumps after anterior cruciate ligament reconstruction: cross-sectional study. BMC Sports Sci Med Rehabil. 2022;14(1):150. https://doi.org/10.1186/s13102-022-00542-x.
17.
IthurburnMPThomasSPaternoMVSchmittLC.Young athletes after ACL reconstruction with asymmetric quadriceps strength at the time of return-to-sport clearance demonstrate drop-landing asymmetries two years later. Knee. 2021;29:520–529. https://doi.org/10.1016/j.knee.2021.02.036.
18.
JordanMJAagaardPHerzogW.Lower limb asymmetry in mechanical muscle function: a comparison between ski racers with and without ACL reconstruction. Scand J Med Sci Sports. 2015;25(3):e301–e309. https://doi.org/10.1111/sms.12314.
19.
JordanMJMorrisNNimphiusSAagaardPHerzogW.Attenuated lower limb stretch-shorten-cycle capacity in ACL injured vs. non-injured female alpine ski racers: not just a matter of between-limb asymmetry. Front Sports Act Living. 2022;4:853701. https://doi.org/10.3389/fspor.2022.853701.
20.
KingERichterCDanielsKA, et al. Biomechanical but not strength or performance measures differentiate male athletes who experience ACL reinjury on return to level 1 sports. Am J Sports Med. 2021;49(4):918–927. https://doi.org/10.1177/0363546520988018.
21.
KingERichterCFranklyn-MillerA, et al. Whole-body biomechanical differences between limbs exist 9 months after ACL reconstruction across jump/landing tasks. Scand J Med Sci Sports. 2018;28(12):2567–2578. https://doi.org/10.1111/sms.13271.
22.
KingERichterCFranklyn-MillerAWadeyRMoranRStrikeS.Back to normal symmetry? biomechanical variables remain more asymmetrical than normal during jump and change-of-direction testing 9 months after anterior cruciate ligament reconstruction. Am J Sports Med. 2019;47(5):1175–1185. https://doi.org/10.1177/0363546519828419.
23.
KingERichterCJacksonM, et al. Factors influencing return to play and second anterior cruciate ligament injury rates in level 1 athletes after primary anterior cruciate ligament reconstruction: 2-year follow-up on 1432 reconstructions at a single center. Am J Sports Med. 2020;49(4):918–927. https://doi.org/10.1177/0363546520988018.
24.
KnurrKAKliethermesSAStiffler-JoachimMRCobianDGBaerGSHeiderscheitBC.Running biomechanics before injury and 1 year after anterior cruciate ligament reconstruction in division I collegiate athletes. Am J Sports Med. 2021;49(10):2607–2614. https://doi.org/10.1177/03635465211026665.
25.
KotsifakiAVan RossomSWhiteleyRKorakakisVBahrRSiderisVJonkersI.Single leg vertical jump performance identifies knee function deficits at return to sport after ACL reconstruction in male athletes. Br J Sports Med. 2022;56(9):490–498. https://doi.org/10.1136/bjsports-2021-104692.
26.
KotsifakiRSiderisVKingEBahrRWhiteleyR.Performance and symmetry measures during vertical jump testing at return to sport after ACL reconstruction. Br J Sports Med. 2023;57:1304–1310. https://doi.org/10.1136/bjsports-2022-106588.
27.
KuenzeCWeaverAGrindstaffTL, et al. Age-, sex-, and graft-specific reference values from 783 adolescent patients at 5 to 7 months after ACL reconstruction: IKDC, Pedi-IKDC, KOOS, ACL-RSI, single-leg hop, and thigh strength. J Orthop Sports Phys Ther. 2023;53(4):1–8. https://doi.org/10.2519/jospt.2023.11389.
28.
LogerstedtDGrindemHLynchA, et al. Single-legged hop tests as predictors of self-reported knee function after anterior cruciate ligament reconstruction. Am J Sports Med. 2012;40(10):2348–2356. https://doi.org/10.1177/0363546512457551.
29.
MaestroniLReadPTurnerAKorakakisVPapadopoulosK.Strength, rate of force development, power and reactive strength in adult male athletic populations post anterior cruciate ligament reconstruction—a systematic review and meta-analysis. Phys Ther Sport. 2021;47:91–104. https://doi.org/10.1016/j.ptsp.2020.11.024.
30.
MyerGDFordKRHewettTE.New method to identify athletes at high risk of ACL injury using clinic-based measurements and freeware computer analysis. Br J Sports Med. 2011;45(4):238–244. https://doi.org/10.1136/bjsm.2010.072843.
31.
MyerGDSchmittLCBrentJL, et al. Utilization of modified NFL combine testing to identify functional deficits in athletes following ACL reconstruction. J Orthop Sports Phys Ther. 2011;41(6):377–387.
32.
O’MalleyERichterCKingEStrikeSMoranKFranklyn-MillerAMoranR.Countermovement jump and isokinetic dynamometry as measures of rehabilitation status after Anterior Cruciate Ligament Reconstruction. J Athl Train. 2018;53(7):687–695. https://doi.org/10.4085/1062-6050-480-16.
33.
Pairot de FontenayBVan CantJGokelerARoyJS.Reintroduction of running after anterior cruciate ligament reconstruction with a hamstrings graft: can we predict short-term success?J Athl Train. 2022;57(6):540–546. https://doi.org/10.4085/1062-6050-0407.21.
34.
Palmieri-SmithRMLepleyLK.Quadriceps strength asymmetry after anterior cruciate ligament reconstruction alters knee joint biomechanics and functional performance at time of return to activity. Am J Sports Med. 2015;43(7):1662–1669. https://doi.org/10.1177/0363546515578252.
35.
ReadPJDaviesWTBishopCMc AuliffeSWilsonMGTurnerAN. Residual deficits in reactive strength indicate incomplete restoration of athletic qualities following anterior cruciate ligament reconstruction in professional soccer players. J Athl Train. 2020;58(5):423–429. https://doi.org/10.4085/169-20.
36.
SchmittLCPaternoMVHewettTE.The impact of quadriceps femoris strength asymmetry on functional performance at return to sport following anterior cruciate ligament reconstruction. J Orthop Sports Phys Ther. 2012;42(9):750–759. https://doi.org/10.2519/jospt.2012.4194.
37.
SchweryNAKielyMTLarsonCM, et al. Quadriceps strength following anterior cruciate ligament reconstruction: normative values based on sex, graft type and meniscal status at 3, 6 & 9 months. Int J Sports Phys Ther. 2022;17(3):434–444. https://doi.org/10.26603/001c.32378.
38.
ThomasCDos’SantosTComfortPJonesP.Between-session reliability of common strength- and power-related measures in adolescent athletes. Sports. 2017;5(1):15. https://doi.org/10.3390/sports5010015.
39.
WainnerRSWhitmanJMClelandJAFlynnTW.Regional interdependence: a musculoskeletal examination model whose time has come. J Orthop Sports Phys Ther. 2007;37(11):658–660. https://doi.org/10.2519/jospt.2007.0110.
40.
WebsterKEFellerJA.Exploring the high reinjury rate in younger patients undergoing anterior cruciate ligament reconstruction. Am J Sports Med. 2016;44(11):2827–2832. https://doi.org/10.1177/0363546516651845.
41.
WellsandtEFaillaMJSnyder-MacklerL.Limb symmetry indexes can overestimate knee function after anterior cruciate ligament injury. J Orthop Sports Phys Ther. 2017;47(5):334–338. https://doi.org/10.2519/jospt.2017.7285.
42.
WigginsAJGrandhiRKSchneiderDKStanfieldDWebsterKEMyerGD.Risk of secondary injury in younger athletes after anterior cruciate ligament reconstruction: a systematic review and meta-analysis. Am J Sports Med. 2016;44(7):1861–1876. https://doi.org/10.1177/0363546515621554.
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
