Return to Sport Testing After ACL Reconstruction

How to know if you are ready to return to play/sport after ACL surgery - and what criteria do we use with our patients in ACL rehab?

A guide to return to sport testing post ACL surgery, by expert physical therapists.

Return to sport (RTS) Testing in ACL rehab

After ACL reconstruction surgery, there are specific criteria that athletes must meet before we clear them to RTS. We assess these with specific return to sport testing in ACL rehab.

What is the criteria for returning to sport after ACL surgery?

Time-based criteria:

• At least 9-12 months post-ACL reconstruction surgery

• 12+ months for allografts

9 months post-op is the earliest we would recommend for an athlete to RTS due to the significant increased risk of reinjury observed in young athletes returning to knee-strenuous sport before 9 months. This time-based criteria accounts for the biological healing time frame of the ACL graft.

We also use an assessment-based criteria that includes clinical, strength, and performance-based criteria to measure physical readiness for RTS.

Assessment-based Criteria:

Clinical

• No effusion or pain with running, sprinting or agility exercises

This is to ensure that the knee is ready to tolerate the high load demands of RTS.

Strength

• Isometric quadriceps Limb Symmetry Index (LSI) ≥ 90-100%

  • 100% for level I sports: this constitutes sports that involve jumping, cutting, and pivoting for 50 hours or more per year (eg, soccer, football, basketball)

  • We use force transducer technology to measure this

• Isokinetic quadriceps LSI ≥ 90% (we do not provide this specific type of testing in-clinic, as the equipment is not readily available within the profession)

• LSI is calculated by dividing the affected limb score by the unaffected limb score

Force transducer technology being used to assess quad strength

If there is one muscle that is the most important predictor of RTS, it is the quadriceps! Make sure to strengthen the quad through knee dominant movements and test isolated quad strength through open chain knee extension. This is to ensure that the hip muscles don’t help to perform the movement. Athletes after ACL injury often use their hip muscles more to offload a weak quad in movements such as leg press, squat, lunge, hop test, etc.

Performance-based

• Hop testing ≥ 90% compared to uninjured side

• Single Leg Hop (distance)

• Cross-over hop (distance)

• Triple hop (distance)

• Timed hop (6 meters)

Here, we are looking for symmetry between affected and unaffected sides. In addition, we are also looking for movement quality. Specifically, we want controlled and balanced landings with minimal to no dynamic knee valgus with jumping and landing.

Return to Competition Progression after ACL Surgery

• Non-contact practice

• Small sided contact practices (1v1, 2v2, 3v3)

• Full Practice

• Return to competition with restricted workload (reduced minutes)

• Return to competition unrestricted

• *All without apprehension, pain, instability, effusion or compensations

This is done gradually over months to avoid overloading the knee and preventing any new injuries. We don’t simply return to full competition right away.

What is the difference between “Return to Play” vs “Return to Sport” vs “Return to Performance?”

Return to play is when an athlete gradually progresses sport-specific workload until returning to full competition with unrestricted minutes.

Return to sport is when the athlete returns to the preinjury level of sport but not necessarily at the previous intensity level.

Return to performance is when the athlete returns to both the preinjury level of sport and preinjury intensity level and unrestricted minutes.

What are additional consideration when returning to sport after ACL surgery?

• No effusion (swelling), pain or apprehension with sport specific training and practice progressions

• Return to pre-injury conditioning level

• Assess psychological readiness for RTS

  • Using subjective, patient reported outcome measures

  • Fear of retear and reinjury are common barriers preventing athletes to RTS at their preinjury intensity level

How to prevent ACL re-injury | ACL Secondary Prevention Program:

Sports requiring cutting and pivoting have high rates of retear and reinjury. ACL prevention programs typically consist of progressive strengthening, sport specific agilities, and plyometrics.

The combination of the following done 2x per week is optimal for ACL injury prevention:

• Include multi-planar movements

  • Front-back, side-to-side, and rotational movements

  • Sports and functional activities require movements in multiple planes of motion

• Include both single-leg and double-leg activities

• Since more ACL injuries occur in single-leg stance

• Incorporate unanticipated or reaction type movements

• To simulate game scenarios

• Since more ACL injuries occur in game compared to practice

• Emphasize correct foot positioning and muscle coordination during cutting and dynamic movements

• Jumping, landing, acceleration & deceleration movements, etc.

• Since most ACL injuries are noncontact and occur when changing directions, decelerating or landing from a jump

• Maintain quadriceps strength and periodically assess with 1-RM knee extension strength test (pre/post season)

• Consider including copenhagen planks and Nordic hamstring curls

If you would like to work with us, contact us below to speak with a physical therapist.

Dr. Vincent Liu PT, DPT

Doctor of Physical Therapy

The Game Plan Physical Therapy