A Guideline for Validated Return-to-Sport Testing in Everyday Clinical Practice: A Focused Review on the Validity, Reliability, and Feasibility of Tests Estimating the Risk of Reinjury After ACL Reconstruction

Abstract

Background: Information derived from functional return-to-sport (RTS) tests after primary anterior cruciate ligament (ACL) reconstruction (ACLR) can have a significant impact on the risk reduction of ACL reruptures. However, due to space, time, and financial limitations, few clinicians utilize objective data to assess their patients' functional abilities after ACLR.

Purpose: To identify validated and feasible RTS tests that could reliably estimate the risk of reinjury after ACLR in everyday clinical practice beyond the highly sophisticated laboratory setting.

Study design: Systematic review; Level of evidence, 4.

Methods: A focused review was performed by experts of the committees for Ligament Injuries and Prevention/Rehabilitation of the German Knee Society. RTS functional tests, their reinjury prognostic values (if known), their reliabilities, and their implementation capacities were extracted from the original studies on the described RTS test setup, as well as from studies on potential test alternatives. These alternatives were required to be less resource-consuming yet still validated and thus able to be implemented into everyday practice. All tests were categorized according to their relevant target objective: isokinetic or isometric strength, functional (hopping and jumping) ability, or self-reported readiness.

Results: In the final analysis, 19 studies involving 7513 patients were included. From these, a total of 21 RTS tests were retrieved, and 13 tests were included. For strength testing, 2 dynamic tests and 1 static test were found to be eligible. Functional ability was represented by 8 different jump, hop, and agility tests. Tests for self-reported readiness included the ACL-Return to Sport after Injury scale and the Knee injury and Osteoarthritis Outcome Score Sport and Recreation subscore. Alternative tests included the 8-repetition maximum test, handheld/portable dynamometer, single-leg vertical (countermovement) hop with inertial sensor or smartphone app, and the drop jump with knee displacement or normalized knee distance measurement.

Conclusion: For most of the strength and functional abilities assessed by RTS tests, validated and less resource-consuming alternatives do exist. Therapists and clinicians working in nonlaboratory settings may find it helpful to select from a menu of established RTS tests and test alternatives for each relevant target objective, depending on their individual requirements.

Keywords: ACL; knee; ligaments; physical therapy; rehabilitation; return to sport; sports trauma.

Figure 1.

Flowchart for test selection regarding the different resources of time, money, and space The development from the most time-, money- and space-efficient test alternatives to the most standardized tests is indicated with the arrows. The different colors of the text boxes correspond to the quality criteria outlined in Tables 2–4. ACL-RSI, Anterior Cruciate Ligament–Return to Sport after Injury; KOOS, Knee injury and Osteoarthritis Outcome Score; RM, repetition maximum; Sport/Rec, Sport and Recreation.

Figure 2.

Flowchart to create a return-to-sport test battery tailored to the individual needs of clinicians and patients. ACL-RSI, Anterior Cruciate Ligament–Return to Sport after Injury; IKDC, International Knee Documentation Committee; RTS, return to sport.