This document summarizes key findings related to return to sport after ACL reconstruction. It finds that the risk of contralateral ACL injury is higher than ipsilateral injury, and about half of athletes return to competitive sport. A comprehensive battery of tests is needed before clearance, including absence of effusion, >90% quad strength, hop tests ≥90% bilateral symmetry, quality movement screens, and ≥12 months from surgery. Functional milestones are more important than time milestones alone. Multiple measures are needed due to significant re-injury risk and low return to sport rates.

1. Tina Postrel, SPT
University of Central Florida
Spring 2015 Inservice

2.  Incidence: re-injury & return to sport
 Risk factors
 Key concepts of rehab
 Early phase
 Late phase
 Return to sport outcome measures
 Objective measures
 Subjective/psychosocial
 Biomechanical screens
 Time vs. functional tests
 Return to practice
 Clinical Recommendation
 Summary

3.  @ 2 yrs:
 Study overview:
 return to pivoting/cutting sport
 N=78
 C=47
 LOE=2 cohort study
 Overall: 30% of athletes sustained 2nd ACL injury
 21% contralateral
 9% ipsilateral
 Females: 2x more likely for contralateral injury
vs ipsilateral

4.  @ 10 yrs:
 Study overview:
 systematic review
 N=2682
 LOE=2
 Overall: 20.5%
 8% ipsilateral, 12.5% contralateral
 contralateral tear 1.63x greater

5. 20113 2014 4 20115
Achieve successful knee function 90% ----- ------
Return to ANY sport 82% 81% 67%
Return to PRE injury level 63% 65% ------
Return to COMPETITVE sport 44% 55% 33%
Study size N=5,770 N=7,556 N=503
(athletes)
Study design MA & SR MA & SR Case
series
Mean F/U time 3.5 yrs N/A 12 mo

6.  Effusion
 Extension

7.  Proprioception
 Stability
 Hip & glut strength
 control medial collapse
 Power
 Contralateral limb training too!

8.  Running Progression
 Trace or less effusion, >80% strength, >8-16wks

10.  Quad Strength
 MVIC: Max Voluntary Isometric
Contraction
 >90% contralateral strength
 similar hop test scores compared to
uninjured athletes
 <85% = ↓ self reported fxn,
impaired performance (hop tests)
 Hamstring/Quad Ratio
 >60% H:Q ratio
 Clinical Application:
 Biodex Isokinetic machine OR
Dynamometer @ 60° Flex

11.  Hop Testing
 >16-22 weeks
 Test dynamic knee stability, agility
 ≥ 90% limb symmetry index
 Instructions:
 2 practice trials ea LE→2 measured trials →avg & compare involved to
uninvolved

12.  Subjective /psychosocial
 IKDC
 International Knee Documentation Subjective Knee Form
 High Specificity (SP= 84.8% @ 6mo, 91.9% @ 12mo)
 Athlete low score = indicative of failing fxnal tests
 Low Sensitivity (SN= 62% @ 6mo, 37% @ 12mo)
 High/normal score = better symmetry on hop test, but
doesn’t correlate w/passing
 IKDC > KOOS
 Knee Injury & OA Outcome Score
 TSK
 Tampa Scale for Kinesiophobia
 good to ID fear of reinjury

13.  Biomechanical Screens
 Drop Vertical Jump
 Tuck Jump
 Y balance Test
 Quality of Movement SL
step down

14.  Rate of Force Development (RFD)
 Way to compare neuromuscular control vs max strength
 RFD: Measures quick accelerations & power
 RFD vs MVIC: Max Voluntary Isometric Contraction (@ 60° Flex)
• MVIC 97% pre-injury level
@ 6 mo
• RFD≥ 90% pre-injury level
@ 12 mo
• Subjects required +20wks
rehab c power focus

15.  Time vs Functional Measures?
 Most recommendations ≥ 6 months
 However… time does not correlate c functional
abilities
20149 201011
Pass Fxnal outcomes @ 6 mo 30% 48%
Pass Fxnal outcomes @ 12 mo 52% 78%
Fxnal outcomes tested: Quadriceps
index, hop tests
Quadriceps index, hop
tests, KOS-ADLS,
Global Rating Scale of
Overall Knee Function
Study design Prospective
Cohort
RCT
cohort N=141 N=40

17.  Objective Tests:
 Absence of knee effusion and pain
 Full knee AROM/PROM
 Quad Strength
 ≥ 90% contralateral quad strength
 Subjective:
 Athlete Perception via IKDC
 Functional & Biomechanical Screens:
 ≥ 90% bilat symmetry c SL hop tests
 Quality test: Vertical drop jump test (consider contralateral too)
 Overall Time:≥ 12 mo
 0-6 mo: strength, balance, proprioception
 6-12 mo: power/explosive strength, sport specific, return to
practice
 *risk of re-injury is significant and return to sport % is low so
multiple measures needed. Single measures may be
inadequate to ID deficiencies.

19.  Incidence of Re-injury
 Contralateral ACL tear 1.6x > ipsilateral
 Athletic population > general
 Women > men
 Incidence of Return to Sport
 Only ½ return to competitive sport
 Comprehensive testing needed before clearance for return
to sport
 Subjective, objective, functional & biomechanical screens
 Don’t forget about power!
 “Gold Standard” for return to sport
 No effusion
 >90% quad MVIC
 SL hop test
 IKDC
 Quality of Movement: Vertical Drop Jump
 Functional Milestones > Time Milestones

20. 1. Paterno M, Rauh M, Schmitt L, Ford K, Hewett T. Incidence of second ACL injuries 2 years after primary acl reconstruction and return to
sport. The American Journal Of Sports Medicine. 2014;(7):1567.
2. Magnussen R, Meschbach N, Kaeding C, Wright R, Spindler K. ACL graft and contralateral ACL tear risk within ten years following
reconstruction: a systematic review. JBJS Reviews. 2015; 3(1):e3.
3. Ardern C, Webster K, Taylor N, Feller J. Return to sport following anterior cruciate ligament reconstruction surgery: a systematic review and
meta-analysis of the state of play. British Journal Of Sports Medicine. 2011;45(7):596-606.
4. Ardern C, Taylor N, Feller J, Webster K. Fifty-five per cent return to competitive sport following anterior cruciate ligament reconstruction
surgery: an updated systematic review and meta-analysis including aspects of physical functioning and contextual factors. British Journal Of
Sports Medicine. November 2014;48(21):1543-1553.
5. Ardern C, Webster K, Taylor N, Feller J. Return to the Preinjury Level of Competitive Sport After Anterior Cruciate Ligament Reconstruction
Surgery. American Journal Of Sports Medicine. March 2011;39(3):538-543.
6. Adams D, Logerstedt DS, Hunter-Giordano A, Axe MJ, Snyder-Mackler L. Current concepts for anterior cruciate ligament reconstruction: a
criterion-based rehabilitation progression. J Orthop Sports Phys Ther. 2012 Jul;42(7):601-14. doi: 10.2519/jospt.2012.3871.
7. Schmitt L, Paterno M, Hewett T. The impact of quadriceps femoris strength asymmetry on functional performance at return to sport following
ACL recostruction. JOPST. 2012; 42(9):750-759.
8. Reid A, Birmingham B, Stratford P, Alcock G, Giffin R. Hop testing provides a reliable and valid outcome measure during rehabilitation after
anterior cruciate ligament reconstruction. Phys Ther. 2007; 87:337-349.
9. LOGERSTEDT D, Dl STASI S, SNYDER-MACKLER L, et al. Self-Reported Knee Function Can Identify Athletes Who Fail Return-to-Activity Criteria
up to 1 Year After Anterior Cruciate Ligament Reconstruction: A Delaware-Oslo ACL Cohort Study. Journal Of Orthopaedic & Sports Physical
Therapy. December 2014;44(12):914-923.
10. Angelozzi M, Madama M, Cacchio A, et al. Rate of Force Development as an Adjunctive Outcome Measure for Return-to-Sport Decisions After
Anterior Cruciate Ligament Reconstruction. Journal Of Orthopaedic & Sports Physical Therapy. Sept 2012 ;42(9):772-780.
11. Hartigan E, Axe M, Snyder-Mackler L. Time Line for Noncopers to Pass Return-to-Sports Criteria After Anterior Cruciate Ligament
Reconstruction. JOSPT. 2010;40(3):141-154.
12. Hu F, Chmieleski T, Spindler K, Wilk K, Swiontkowski M, Marx R. Return to Sport after ACL Reconstruction. JOSPT & JBJS Webinar. Nov 2014.
13. Mueller L, Bloomer B, Durall C. Which Outcome Measures Should Be Used to Determine Readiness to Play After ACL Reconstruction?. Journal
Of Sport Rehabilitation. May 2014;23(2):158-164.