Anterior Cruciate Ligament Reconstruction Return to Sport Testing Passing Rates for Healthy People: A Systematic Review

Abstract

Background:

Return to sport (RTS) is a common goal after anterior cruciate ligament (ACL) reconstruction (ACLR) but carries a relatively high risk of reinjury with up to 20% to 25% of athletes experiencing graft rupture or contralateral ACL tear. While there is increased emphasis on establishing safe RTS criteria for athletes to return to previous activity levels, studies show that even healthy individuals have difficulty passing RTS testing.

Purpose:

To synthesize data concerning whether healthy individuals can pass ACLR RTS rehabilitation tests.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

Following the established PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, the authors conducted a systematic literature search in May 2023. Three databases were used in the search (PubMed, EMBASE, and SPORTDiscus) to retrieve all studies that conducted ACLR RTS rehabilitation tests on healthy individuals. Tests included were isometric strength, isokinetic strength, hop, and balance tests. The search was performed in duplicate, and a quality assessment of all studies was included.

Results:

A total of 1724 studies were retrieved, of which 32 were included, involving 1552 controls with no history of ACL injury. From the studies analyzed, 5.3% to 42.2% of healthy participants failed 6 different hop tests, 15.2% failed the Star Excursion Balance Test, 37% failed the isometric knee flexion test, 50% failed the isometric knee extension test, and 23.7% to 28.9% failed the drop vertical jump test. An asymmetry index ≥10% was found in 6 of the 18 isokinetic tests and 2 of the 14 isometric tests. Hop testing was the most common test in the included studies (56.3%), followed by balance testing (31.3%), isometric strength testing (31.3%), isokinetic strength testing (25%), and drop vertical jump (6.3%).

Conclusion:

Many healthy individuals fail ACLR RTS tests, with some having an inherent variation from side to side that is >10%. The passing threshold for RTS testing should be a value that is practical yet helps reduce reinjury rates.

Keywords

ACL reconstruction return to sport rehabilitation ACL tear

Anterior cruciate ligament (ACL) rupture is a common knee injury among athletes that carries significant consequences including instability and inability to return to athletic activities.³ ACL reconstruction (ACLR) remains one of the most common orthopaedic surgical procedures, with nearly 350,000 performed annually in the United States alone.⁷ Return to sport (RTS) is a common goal after ACLR but carries a relatively high risk of reinjury, with up to 20% to 25% of athletes experiencing graft rupture or contralateral tear.^51,55

In attempts to reduce reinjury rates, RTS programs entail a comprehensive evaluation of functional performance using a testing battery. Common tests include limb-to-limb strength, stability, balance, postural control, technique with sport-specific tasks, and patient-reported outcomes.^13,40,46 However, there is a lack of consensus on the specific RTS testing protocol because of minimal evidence supporting the injury-predicting capacity of functional testing.^1,50,47,53

Most commonly, the limb symmetry index (LSI) has been used as a measure to assess patients at various stages in postoperative rehabilitation because of its practical clinical utility.^20,46 Traditionally, it has been widely accepted that an LSI cutoff of 90% is a satisfactory result on strength and hop tests.^8,19,21 However, its use within testing batteries remains largely variable. Despite the goal of formalizing return-to-play testing, there remains little consensus.¹³ While some test batteries incorporate as many as 15 to 20 tests, higher numbers of tests and criteria lead to significantly lower pass rates.^{17,22,34,36,53} While this shows that ACLR RTS testing is difficult to pass overall, there is a deficiency in the literature as to the number of noninjured individuals exhibiting symmetrical performances across the RTS battery.

This systematic review aimed to synthesize data on RTS testing for healthy individuals and to answer the question: Is there a high rate of healthy participants who fail ACLR RTS testing? The authors hypothesized that there would be a high rate of failure among healthy participants for tests routinely used in ACLR RTS protocols.

Methods

Following the established PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we conducted a systematic literature search in May 2023. The search was performed in 3 databases: PubMed, EMBASE, and SPORTDiscus. A unique search strategy was designed for each database. The results from each database were combined, and duplicates were removed. Two independent reviewers (A.W. and E.M.B.) then screened the results in 3 stages. The first stage screened for exclusion via abstract alone. The second stage screened the full text for exclusion. The third stage identified the ACL testing mechanisms for inclusion eligibility (Figure 1). Any disagreement was resolved by consensus or discussion with the primary investigator (A.M.M.).

Inclusion criteria required studies with a prospective cohort of healthy, never-injured volunteers performing baseline or nonexperimental hop, movement function, strength, or balance testing. All included studies were required to have explicit statements of injury status and no previous lower extremity injury history in either extremity. The following physical tests were included in the final selection process for analysis: isometric strength tests, isokinetic strength tests, hop tests, and balance tests. Studies were excluded if (1) any of the volunteers fell outside the age limits of 16 to 45 years, (2) result values were not identified within the text, (3) the study only analyzed a test that was not utilized in another included paper, (4) the study was published >10 years ago, (5) and an English translation was unable to be obtained. Systematic reviews and meta-analyses were excluded from the study and utilized to identify additional papers meeting inclusion criteria.

An asymmetry index (AI) was calculated from all studies that reported AI or reported enough data to make the calculation. AI is calculated as the percentage difference between each limb for any given test. Failure criteria for all the tests, except the drop vertical jump, are defined as an AI >10%. There are 3 different failure definitions for the drop vertical jump: >6.5 cm of valgus in any knee, >4.1-cm side difference, and probability of high knee abduction >91%. The proportion of participants who failed each test was recorded directly from the text if the rate of failure was explicitly reported, or it was calculated using the aforementioned AI cutoff and definitions of failure for the drop vertical jump test.

Results

Literature Search

The search resulted in 32 studies meeting the inclusion and exclusion criteria. These studies included 1603 healthy controls with no history of lower extremity injury. Each study included at least one of the following RTS testing protocols: isometric strength, isokinetic strength, hop, and balance testing. Study characteristics are shown in Table 1.

Table 1

Study Characteristics^a

Study	Year	N	Mean Age, y (SD)	RTS Criteria
Bell et al²	2016	73	19.8 (1.5)	Isometric knee/hip strength
Bodkin et al⁴	2021	95	21.5 (2.9)	Isometric knee strength
Bookbinder et al⁵	2020	25	19.52 (1.64)	SLHD
Clagg et al⁹	2015	47	17.0 (2.3)	SEBT
Clark and Clacher¹⁰	2020	30	25.6 (4.5)	SLTHD, timed 6-m hop, SEBT
De Blaiser et al¹¹	2021	112	19.5 (1.5)	SEBT, isometric hip strength
Dingenen et al¹²	2019	16	22.4 (1.9)	SLHD, SLTHD, MSLTHD, MRHD
Fältström et al¹⁴	2021	119	19.0 (3.0)	SLHD, side hop, SEBT, DVJ
Fältström et al¹⁵	2017	77	19.5 (2.2)	SLHD, side hop, SEBT, DVJ
Felix et al¹⁶	2022	40	27.7 (8.16)	SLHD, isokinetic knee strength
Guney-Deniz et al¹⁸	2020	20	28.7 (3.1)	SLHD, isokinetic knee strength
Hiemstra et al²⁴	2005	15	29.6 (2.6)	Isokinetic hip strength
Hirohata et al²⁵	2022	17	19.8 (2.8)	SLHD, SLTHD, SLTCHD
Iacono et al²⁶	2018	10	19.0 (0.63)	Isokinetic knee strength
Judd and Sharp²⁸	2022	15	24 (6)	SLHD
Konstantopoulos et al²⁹	2021	24	22.0 (2.0)	SEBT, isometric hip strength
Krafft et al³⁰	2017	20	32.0 (13.3)	Isometric knee strength
Kuenze et al³¹	2015	24	21.7 (3.6)	Isometric knee strength
Kuenze et al³²	2017	10	20.8 (2.5)	Isometric knee strength
Lisee et al³³	2019	117	21.44 (2.92)	SLHD, SLTHD, SLTCHD, timed 6-m hop, isokinetic knee strength, isometric knee strength
Madsen et al³⁵	2020	275	20.16 (2.19)	SLTCHD, timed 6-m hop, side hop, medial hop, lateral hop, figure-of-8 hop
Markström et al³⁶	2023	46	22.4 (3.3)	SLHD, isometric knee strength
Mulligan and DeVahl³⁸	2020	21	23.6 (2.0)	SEBT, isometric hip strength
Murphy et al³⁹	2021	30	21.5	SLHD, SLTHD, SLTCHD, timed 6-m hop
Overmoyer and Reiser⁴¹	2013	20	21.9 (2.6)	SEBT
Pairot de Fontenay et al⁴²	2014	16	24 (6)	Single-leg squat
Peebles et al⁴³	2019	30	22.2 (3.8)	SLHD, SLTHD, SLTCHD
Rush et al⁴⁴	2020	11	23.3 (1.7)	Isokinetic knee strength
Stiffler et al⁴⁵	2017	118	20.3 (1.4)	SEBT
Vaisman et al⁴⁹	2017	51	20.8 (1.5)	Single-leg squat
		27	18.4 (0.6)
Welling et al⁵⁴	2019	30	22.8 (2.5)	Isokinetic knee strength
Xergia et al⁵⁶	2013	22	24.8 (9.1)	SLHD, SLTHD, SLTCHD, isokinetic knee strength

DVJ, drop vertical jump; MRHD, medial rotational hop for distance; MSLTHD, medial single-leg triple hop for distance; SD, standard deviation; SEBT, Star Excursion Balance Test; SLHD, single-leg hop for distance; SLTCHD, single-leg triple crossover hop for distance; SLTHD, single-leg triple hop for distance.

RTS Protocols

Table 2 shows the proportion of studies that evaluated individual test batteries. When looking at individual tests, hop testing was the most prevalent as 15 of the 32 studies (46.9%) included some form of hop testing. Hop tests include the following: single-leg hop for distance, single-leg triple hop for distance, single-leg triple crossover hop for distance, timed 6-m hop, side hop, single-leg squat jump, medial single-leg triple hop for distance, medial rotation hop for distance, medial hop, lateral hop, and figure-of-8 hop. The individual breakdown of studies can be found in Table 2, but the most frequently included hop tests were single-leg hop for distance (40.6%), single-leg triple hop for distance (25%), and single-leg triple crossover hop for distance (21.9%). Balance testing (Star Excursion Balance Test) was the second most common (31.3%), followed by isokinetic strength testing (25%), isometric strength testing (31.3%), and drop vertical jump (6.3%).

Table 2

Distribution of ACLR RTS Rehabilitation Tests^a

Test Category and Functional Skill	No. of Studies Using Test	Percentage of Studies Using Test
Hop
SLHD	13	40.6
SLTHD	7	21.9
SLTCHD	6	18.8
Timed 6-m hop	4	12.5
Side hop	3	9.4
Single-leg squat jump	2	6.3
MSLTHD	1	3.1
MRHD	1	3.1
Medial hop	1	3.1
Lateral hop	1	3.1
Figure-of-8 hop	1	3.1
Total hop	15	46.9
Balance
SEBT	10	31.3
Isokinetic strength
Isokinetic knee flexion	7	21.9
Isokinetic knee extension	6	18.8
Isokinetic hip extension	1	3.1
Total isokinetic	8	25.0
Isometric strength
Isometric knee extension	6	18.8
Isometric knee flexion	4	12.5
Isometric hip abduction	4	12.5
Isometric hip IR	3	9.4
Isometric hip ER	3	9.4
Isometric hip adduction	2	6.3
Isometric hip extension	2	6.3
Isometric hip flexion	1	3.1
Total isometric	10	31.3
Miscellaneous
Drop vertical jump	2	6.3

ACLR, anterior cruciate ligament reconstruction; ER, external rotation; IR, internal rotation; MRHD, medial rotational hop for distance; MSLTHD, medial single-leg triple hop for distance; RTS, return to sport; SEBT, Star Excursion Balance Test; SLHD, single-leg hop for distance; SLTCHD, single-leg triple crossover hop for distance; SLTHD, single-leg triple hop for distance.

AI Results

For hop testing, weighted means for the included studies revealed that all mean AI values were within the recommended AI guidelines for passing at <10% (Appendix Table A1, available in the online version of this article). The timed 6-m hop had the greatest mean AI (6.4%) across the 5 studies evaluating this metric.

For balance testing, all weighted mean AI values for anterior, posteromedial, posterolateral, and composite reach were <10% (Appendix Table A1, available online).

Isokinetic strength testing revealed similar results for several included metrics as found in Appendix Table A1 (available online). Notably, both studies evaluating knee flexion power at 90 deg/s and 180 deg/s reported AI >10%. In addition, all mean AI values for isokinetic hip extension were >10%. However, these specific tests were only evaluated in 1 study for hip extension angular velocity strength.

Most isometric strength testing mean AI values were <10%. However, a mean AI value >10% was found in maximal voluntary isometric contraction for knee flexion at 90° and was equal to 10% in maximum voluntary isometric contraction for knee extension at 65° (Appendix Table A1, available online).

Proportions of Individuals Failing to Meet Guidelines

Studies that explicitly stated failure rates or provided enough data to calculate the failure rate using the aforementioned AI cutoff were included to produce the results found in Table 3. Single-leg hop for distance had the greatest number of studies (n = 6) reporting a weighted mean failure rate of 11.9%. Of the functional hop testing, the side hop test had the highest failure rate of the included metrics at 42.2%. Overall, 15.2% of individuals failed the Star Excursion Balance Test, using the definitions of failure found in Table 4. Isometric testing included 1 study and found that 37% and 50% of individuals failed knee flexion and extension, respectively. There were no reported failure rates for isokinetic testing.

Table 3

Proportion of Healthy Participants Who Fail ACLR RTS Testing^a

ACLR RTS Tests	Study Count	n	Mean, %
Hop tests
SLHD	6	303	11.9
SLTHD	3	76	5.3
MSLTHD	1	16	31.2
Timed 6-m hop	2	60	21.7
Side hop	2	196	42.2
MRHD	1	16	31.2
Balance testing
SEBT	2	196	15.2
Isometric testing
Knee flexion	1	46	37.0
Knee extension	1	46	50.0

ACLR, anterior cruciate ligament reconstruction; MRHD, medial rotational hop for distance; MSLTHD, medial single-leg triple hop for distance; RTS, return to sport; SEBT, Star Excursion Balance Test; SLHD, single-leg hop for distance; SLTHD, single-leg triple hop for distance.

Table 4

Percentage of Healthy Participants Who Fail the Drop Vertical Jump According to 3 Different Criteria

Failure Definition	Study Count	n	Mean, %
>6.5 cm of valgus in any knee	2	196	28.9
>4.1-cm side difference	2	196	23.7
Probability of high knee abduction moment >91	2	196	28.1

Discussion

The most important finding of this study is that a substantial proportion of healthy individuals fail several tests routinely used in testing batteries for RTS after ACLR.

There is a lack of evidence in the literature to validate the passing values for ACLR RTS testing. A recent systematic review and meta-analysis found that only 23% of patients pass RTS testing batteries after ACLR.⁵³ Our study found that many healthy individuals do not pass RTS tests even though the mean AI across all studies was within 10% for most of the tests. This indicates that while the mean AI across the population may be within a passing range, there is still a large number of individuals who have an inherent asymmetry >10%.

The high proportion of healthy individuals who fail ACLR RTS testing indicates that the passing threshold may be impractical. Given that healthy individuals have a hard time passing ACLR RTS tests, clinicians should be cautious when requiring their patients who underwent ACLR to pass such tests before they return to play. Although lowering the passing threshold may be met with caution, there is a lack of consensus on the ability of ACLR RTS tests to prevent reinjury in the first place.^1,50,47,53 One may argue, however, that it is of greater importance for a patient who underwent ACLR to pass the test with symmetry as he or she is at increased risk for an ACL graft tear compared with the healthy, uninjured patient.

Hop testing was the most prevalent test used in our review. The rate of healthy individuals failing different hop tests ranged from 5.3% for the SLTHD to 42.2% for the side hop test. This high degree of variability shows that hop tests are far from equal in their ability to assess asymmetries, even among healthy participants. We were unable to perform comparative statistics between hop tests given the heterogeneity of studies and small sample sizes.

Limb dominance has been proposed to influence limb symmetry when performing ACLR RTS testing. Zumstein et al⁵⁷ observed this effect when evaluating asymmetries for quadriceps strength testing; however, there was no significant effect of limb dominance on hop testing, drop jump testing, or knee flexor strength. Furthermore, Morishige et al³⁷ found that leg dominance influences knee valgus and internal rotation during the landing phase of the drop vertical jump test, suggesting an increased risk of ACL injury in participants’ nondominant leg.

The ability of ACL RTS testing to predict injury is debatable. While we found the rates of healthy participant failure to be low in some forms of hop testing, there is conflicting evidence concerning its ability to predict injury.^6,52,57 The drop vertical jump test assesses knee valgus and internal rotation during the landing phase, and increases in these measures are associated with an increased risk of ACL injury.^9,14,23 However, failure rates among healthy participants range from 23.7% to 28.9% for the drop vertical jump test. With a failure rate of around 1 in 4 among healthy participants, this is a difficult test to rely on the readiness of patients who underwent ACLR to RTS as it would cause many participants to have delayed RTS.

Test batteries for determining RTS present an additional challenge for athletes attempting to return to previous activity levels. Studies have shown that the proportion of individuals passing an RTS test battery decreases with the addition of each test.^17,22,36 We found that 42.2% of healthy patients fail the side hop test. Therefore, if the side hop test were included in an ACLR RTS battery, up to 42.2% of participants who had no ACL injury would fail based on this test alone. With failure rates this high, additional testing could severely hamper participants who might otherwise be able to RTS safely.

This study is not without limitations. The largest limitation of this review is the heterogeneity of included studies and the small sample sizes of healthy people performing functional tests. This resulted in an inability to account for confounding variables. We were unable to perform comparative statistics or provide significant values for healthy participants’ ability to pass ACLR RTS testing. Furthermore, there continues to be a lack of evidence for which RTS testing accurately predicts future ACL injury.

While our study shows that there are many individuals with >10% side-to-side difference for various RTS tests, it is difficult to make any recommendations on a new passing threshold for ACLR RTS tests from this systematic review. Future investigations should aim to elucidate the injury-predicting capacity of functional tests used in ACLR RTS criteria and identify more reliable cutoff values in different populations and contexts. This will contribute to the continued efforts to produce individualized, patient-centered prevention and rehabilitation as the field continues investigating strategies to reduce ACL injury burden.^27,48

Conclusion

Supplemental Material

sj-pdf-1-ajs-10.1177_03635465241313194 – Supplemental material for Anterior Cruciate Ligament Reconstruction Return to Sport Testing Passing Rates for Healthy People: A Systematic Review

Supplemental material, sj-pdf-1-ajs-10.1177_03635465241313194 for Anterior Cruciate Ligament Reconstruction Return to Sport Testing Passing Rates for Healthy People: A Systematic Review by Audria Wood, Mathew Hargreaves, John N. Manfredi, Maxwell Harrell, Elizabeth Marks Benson, Clay Rahaman, Dev Dayal, Eugene W. Brabston, Thomas Evely, Aaron Casp and Amit M. Momaya in The American Journal of Sports Medicine

Footnotes

Submitted August 29, 2024; accepted November 14, 2024.

One or more of the authors has declared the following potential conflict of interest or source of funding: E.B. has received hospitality payments from Smith & Nephew, Prime Surgical, Stryker Corporation, Arthrex, LinkBio Corp, Zimmer Biomet Holdings, IlluminOss Medical Inc, Next Science, and Orthofix; and consulting fees from LinkBio Corp. T.E. has received support for education from Smith & Nephew, Arthrex, and Gentleman Orthopedic Solutions; and hospitality payments from Exatech Inc, Pacira Pharmaceuticals Inc, IlliminOss Medical Inc, Stryker Corp, Prime Surgical, Next Science, Zimmer Biomet Holdings, Encore Medical, LinkBio Corp, Linvatec Corporation, and Ossio Inc. A.C. has received support for education from Supreme Orthopedic Systems, Arthrex, and Prime Surgical; consulting fees, grants, and speaking fees from Arthrex; and hospitality payments from Vericel Corporation, Stryker Corporation, IlliminOss Medical Inc, Prime Surgical, Exactech Inc, DePuy Synthes Sales Inc, Zimmer Biomet Holdings, Linvatec Corporation, and Orthofix Medical Inc. A.M.M. has received support for education from Prime Surgical; honoraria from Fidia Pharma USA; consulting fees from Miach Orthopaedics Inc and Stryker Corp; and hospitality payments from Smith & Nephew, Ethicon, Arthrex, Flexion Therapeutics, Pacira Therapeutics Inc, Innovation Technologies Inc, IlliminOss Medical, Bioventus, Exatech Inc, DePuy Synthes Sales Inc, Zimmer Biomet Holdings, Next Science, Linvatec Corporation, and Orthofix. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

ORCID iDs

Audria Wood

Maxwell Harrell

Elizabeth Marks Benson

Clay Rahaman

Dev Dayal

Aaron Casp

An online CME course associated with this article is available for 1 AMA PRA Category 1 Credit™ at https://education.sportsmed.org/Public/Catalog/Home.aspx?CourseSearch=1&Criteria=9&Option=25. In accordance with the standards of the Accreditation Council for Continuing Medical Education (ACCME), it is the policy of The American Orthopaedic Society for Sports Medicine that authors, editors, and planners disclose to the learners all financial relationships during the past 12 months with any commercial interest (A ‘commercial interest’ is any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients). Any and all disclosures are provided in the online journal CME area which is provided to all participants before they actually take the CME activity. In accordance with AOSSM policy, authors, editors, and planners’ participation in this educational activity will be predicated upon timely submission and review of AOSSM disclosure. Noncompliance will result in an author/editor or planner to be stricken from participating in this CME activity.

References

Andrade

Pereira

van Cingel

Staal

Espregueira-Mendes

How should clinicians rehabilitate patients after ACL reconstruction? A systematic review of clinical practice guidelines (CPGs) with a focus on quality appraisal (AGREE II). Br J Sports Med. 2020;54(9):512-519. doi:10.1136/bjsports-2018-100310

Bell

Trigsted

Post

Walden

CE.

Hip strength in patients with quadriceps strength deficits after ACL reconstruction. Med Sci Sports Exerc. 2016;48(10):1886-1892. doi:10.1249/MSS.0000000000000999

Beynnon

Vacek

Newell

, et al. The effects of level of competition, sport, and sex on the incidence of first-time noncontact anterior cruciate ligament injury. Am J Sports Med. 2014;42(8):1806-1812. doi:10.1177/0363546514540862

Bodkin

Weltman

Hart

JM.

ISB clinical biomechanics award winner 2019: knee extensor fatigue resistance in individuals following anterior cruciate ligament reconstruction. Clin Biomech (Bristol, Avon). 2021;81:105242. doi:10.1016/j.clinbiomech.2020.105242

Bookbinder

Slater

Simpson

Hertel

Hart

JM.

Single-leg jump performance before and after exercise in healthy and anterior cruciate ligament reconstructed individuals. J Sport Rehabil. 2020;29(7):879-885. doi:10.1123/jsr.2019-0159

Brumitt

Heiderscheit

Manske

Niemuth

Rauh

MJ.

Lower extremity functional tests and risk of injury in Division III collegiate athletes. Int J Sports Phys Ther. 2013;8(3):216.

Buller

Best

Baraga

Kaplan

LD.

Trends in anterior cruciate ligament reconstruction in the United States. Orthop J Sports Med. 2015;3(1):2325967114563664. doi:10.1177/2325967114563664

Burgi

Peters

Ardern

, 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. doi:10.1136/bjsports-2018-099982

Clagg

Paterno

Hewett

Schmitt

LC.

Performance on the modified Star Excursion Balance Test at the time of return to sport following anterior cruciate ligament reconstruction. J Orthop Sports Phys Ther. 2015;45(6):444-452. doi:10.2519/jospt.2015.5040

10.

Clark

Clacher

LH.

Lower-limb motor-performance asymmetries in English community-level female field hockey players: implications for knee and ankle injury prevention. Phys Ther Sport. 2020;43:43-51. doi:10.1016/j.ptsp.2020.02.001

11.

De Blaiser

Roosen

Willems

, et al. The role of core stability in the development of non-contact acute lower extremity injuries in an athletic population: a prospective study. Phys Ther Sport. 2021;47:165-172. doi:10.1016/j.ptsp.2020.11.035

12.

Dingenen

Truijen

Bellemans

Gokeler

Test-retest reliability and discriminative ability of forward, medial and rotational single-leg hop tests. Knee. 2019;26(5):978-987. doi:10.1016/j.knee.2019.06.010

13.

Ellman

Sherman

Forsythe

LaPrade

Cole

Bach

BR.

Return to play following anterior cruciate ligament reconstruction. J Am Acad Orthop Surg. 2015;23(5):283-296. doi:10.5435/JAAOS-D-13-00183

14.

Fältström

Hägglund

Hedevik

Kvist

Poor validity of functional performance tests to predict knee injury in female soccer players with or without anterior cruciate ligament reconstruction. Am J Sports Med. 2021;49(6):1441-1450. doi:10.1177/03635465211002541

15.

Fältström

Hägglund

Kvist

Functional performance among active female soccer players after unilateral primary anterior cruciate ligament reconstruction compared with knee-healthy controls. Am J Sports Med. 2017;45(2):377-385. doi:10.1177/0363546516667266

16.

Felix

ECR

Alonso

Brech

, et al. Is 12 months enough to reach function after athletes’ ACL reconstruction: a prospective longitudinal study. Clinics (Sao Paulo). 2022;77:100092. doi:10.1016/j.clinsp.2022 .100092

17.

Gokeler

Welling

Zaffagnini

Seil

Padua

Development of a test battery to enhance safe return to sports after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2017;25(1):192-199. doi:10.1007/s00167-016-4246-3

18.

Guney-Deniz

Harput

Kaya

Nyland

Doral

MN.

Quadriceps tendon autograft ACL reconstructed subjects overshoot target knee extension angle during active proprioception testing. Knee Surg Sports Traumatol Arthrosc. 2020;28(2):645-652. doi:10.1007/s00167-019-05795-7

19.

Gustavsson

Neeter

Thomeé

, et al. A test battery for evaluating hop performance in patients with an ACL injury and patients who have undergone ACL reconstruction. Knee Surg Sports Traumatol Arthrosc. 2006;14(8):778-788. doi:10.1007/s00167-006-0045-6

20.

Harput

Tunay

Ithurburn

MP.

Quadriceps and hamstring strength symmetry after anterior cruciate ligament reconstruction: a prospective study. J Sport Rehabil. 2020;30(1):1-8. doi:10.1123/jsr.2019-0271

21.

Hegedus

McDonough

Bleakley

Cook

Baxter

GD.

Clinician-friendly lower extremity physical performance measures in athletes: a systematic review of measurement properties and correlation with injury, part 1. The tests for knee function including the hop tests. Br J Sports Med. 2015;49(10):642-648. doi:10.1136/bjsports-2014-094094

22.

Herbst

Hoser

Hildebrandt

, et al. Functional assessments for decision-making regarding return to sports following ACL reconstruction. Part II: Clinical application of a new test battery. Knee Surg Sports Traumatol Arthrosc. 2015;23(5):1283-1291. doi:10.1007/s00167-015-3546-3

23.

Hewett

Myer

Ford

, et al. Biomechanical measures of neuromuscular control and valgus loading of the knee predict anterior cruciate ligament injury risk in female athletes: a prospective study. Am J Sports Med. 2005;33(4):492-501. doi:10.1177/0363546504269591

24.

Hiemstra

Gofton

Kriellaars

DJ.

Hip strength following hamstring tendon anterior cruciate ligament reconstruction. Clin J Sport Med. 2005;15(3):180-182. doi:10.1097/01.jsm.0000157795.93004.ea

25.

Hirohata

Aizawa

Ohmi

, 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. doi:10.1186/s13102-022-00542-x

26.

Iacono

Buksbaum

Padulo

Hetsroni

Ben-Sira

Ayalon

Isokinetic moment curve abnormalities are associated with articular knee lesions. Biol Sport. 2018;35(1):83-91. doi:10.5114/biolsport .2018.71486

27.

Jenkins

Guzman

Gardner

, et al. Rehabilitation after anterior cruciate ligament injury: review of current literature and recommendations. Curr Rev Musculoskelet Med. 2022;15(3):170-179. doi:10.1007/s12178-022-09752-9

28.

Judd

Sharp

The single hop for distance test: reviewing the methodology to measure maximum and repeated performance. J Sport Rehabil. 2022;31(5):657-663. doi:10.1123/jsr.2021-0242

29.

Konstantopoulos

Kafetzakis

Chatziilias

Mandalidis

Fatigue-induced inter-limb asymmetries in strength of the hip stabilizers, postural control and gait following a unilateral countermovement vertical jump protocol. Sports (Basel). 2021;9(3):33. doi:10.3390/sports 9030033

30.

Krafft

Stetter

Stein

, et al. How does functionality proceed in ACL reconstructed subjects? Proceeding of functional performance from pre- to six months post-ACL reconstruction. PLoS One. 2017;12(5):e0178430. doi:10.1371/journal.pone.0178430

31.

Kuenze

Hertel

Saliba

Diduch

Weltman

Hart

JM.

Clinical thresholds for quadriceps assessment after anterior cruciate ligament reconstruction. J Sport Rehabil. 2015;24(1):36-46. doi:10.1123/jsr.2013-0110

32.

Kuenze

Kelly

Jun

Eltoukhy

Unilateral quadriceps strengthening with disinhibitory cryotherapy and quadriceps symmetry after anterior cruciate ligament reconstruction. J Athl Train. 2017;52(11):1010-1018. doi:10.4085/1062-6050-52.10.13

33.

Lisee

Slater

Hertel

Hart

JM.

Effect of sex and level of activity on lower-extremity strength, functional performance, and limb symmetry. J Sport Rehabil. 2019;28(5):413-420. doi:10.1123/jsr.2017-0132

34.

Losciale

Zdeb

Ledbetter

Reiman

Sell

TC.

The association between passing return-to-sport criteria and second anterior cruciate ligament injury risk: a systematic review with meta-analysis. J Orthop Sports Phys Ther. 2019;49(2):43-54. doi:10.2519/jospt .2019.8190

35.

Madsen

Booth

Volz

Docherty

CL.

Using normative data and unilateral hopping tests to reduce ambiguity in return-to-play decisions. J Athl Train. 2020;55(7):699-706. doi:10.4085/1062-6050-0050.19

36.

Markström

Naili

Häger

CK.

A minority of athletes pass symmetry criteria in a series of hop and strength tests irrespective of having an ACL reconstructed knee or being noninjured. Sports Health. 2023;15(1):45-51. doi:10.1177/19417381221097949

37.

Morishige

Harato

Kobayashi

, et al. Difference in leg asymmetry between female collegiate athletes and recreational athletes during drop vertical jump. J Orthop Surg Res. 2019;14(1):424. doi:10.1186/s13018-019-1490-5

38.

Mulligan

DeVahl

Can proximal hip strength and dynamic control differentiate functional ankle stability classifications?

Int J Sports Phys Ther. 2020;15(6):1061-1072. doi:10.26603/ijspt20201061

39.

Murphy

Louw

Moloney

Leibbrandt

Clifford

AM.

Hop performance after return to sport in anterior cruciate ligament-reconstructed Gaelic football and hurling athletes. J Sport Rehabil. 2021;30(5):707-716. doi:10.1123/jsr.2019-0488

40.

Myer

Paterno

Ford

Quatman

Hewett

TE.

Rehabilitation after anterior cruciate ligament reconstruction: criteria-based progression through the return-to-sport phase. J Orthop Sports Phys Ther. 2006;36(6):385-402. doi:10.2519/jospt.2006.2222

41.

Overmoyer

Reiser

RF.

Relationships between asymmetries in functional movements and the Star Excursion Balance Test. J Strength Cond Res. 2013;27(7):2013-2024. doi:10.1519/JSC.0b013e 3182779962

42.

Pairot de Fontenay

Argaud

Blache

Monteil

Asymmetries in joint work during multi-joint movement after anterior cruciate ligament reconstruction: a pilot study. Scand J Med Sci Sports. 2014;24(6):e471-e476. doi:10.1111/sms.12207

43.

Peebles

Renner

Miller

Moskal

Queen

RM.

Associations between distance and loading symmetry during return to sport hop testing. Med Sci Sports Exerc. 2019;51(4):624-629. doi:10.1249/MSS.0000000000001830

44.

Rush

Norte

Lepley

AS.

Limb differences in hamstring muscle function and morphology after anterior cruciate ligament reconstruction. Phys Ther Sport. 2020;45:168-175. doi:10.1016/j.ptsp.2020.06.012

45.

Stiffler

Bell

Sanfilippo

Hetzel

Pickett

Heiderscheit

BC.

Star Excursion Balance Test anterior asymmetry is associated with injury status in Division I collegiate athletes. J Orthop Sports Phys Ther. 2017;47(5):339-346. doi:10.2519/jospt.2017.6974

46.

Thomeé

Kaplan

Kvist

, et al. Muscle strength and hop performance criteria prior to return to sports after ACL reconstruction. Knee Surg Sports Traumatol Arthrosc. 2011;19(11):1798-1805. doi:10.1007/s00167-011-1669-8

47.

Toole

Ithurburn

Rauh

Hewett

Paterno

Schmitt

LC.

Young athletes cleared for sports participation after anterior cruciate ligament reconstruction: how many actually meet recommended return-to-sport criterion cutoffs?

J Orthop Sports Phys Ther. 2017;47(11):825-833. doi:10.2519/jospt.2017.7227

48.

Truong

Mosewich

Holt

Miciak

Whittaker

JL.

Psychological, social and contextual factors across recovery stages following a sport-related knee injury: a scoping review. Br J Sports Med. 2020;54(19):1149-1156. doi:10.1136/bjsports-2019-101206

49.

Vaisman

Guiloff

Rojas

Delgado

Figueroa

Calvo

Lower limb symmetry: comparison of muscular power between dominant and nondominant legs in healthy young adults associated with single-leg-dominant sports. Orthop J Sports Med. 2017;5(12):23259 67117744240. doi:10.1177/2325967117744240

50.

van Melick

van Cingel

REH

Brooijmans

, et al. Evidence-based clinical practice update: practice guidelines for anterior cruciate ligament rehabilitation based on a systematic review and multidisciplinary consensus. Br J Sports Med. 2016;50(24):1506-1515. doi:10.1136/bjsports-2015-095898

51.

Waldén

Hägglund

Ekstrand

High risk of new knee injury in elite footballers with previous anterior cruciate ligament injury. Br J Sports Med. 2006;40(2):158-162. doi:10.1136/bjsm.2005.021055

52.

Warren

Lininger

Smith

Copp

Chimera

NJ.

Association of functional screening tests and noncontact injuries in Division I women student-athletes. J Strength Cond Res. 2020;34(8):2302-2311. doi:10.1519/JSC.0000000000003004

53.

Webster

Hewett

TE.

What is the evidence for and validity of return-to-sport testing after anterior cruciate ligament reconstruction surgery? A systematic review and meta-analysis. Sports Med. 2019;49(6):917-929. doi:10.1007/s40279-019-01093-x

54.

Welling

Benjaminse

Lemmink

Dingenen

Gokeler

Progressive strength training restores quadriceps and hamstring muscle strength within 7 months after ACL reconstruction in amateur male soccer players. Phys Ther Sport. 2019;40:10-18. doi:10.1016/j.ptsp.2019.08.004

55.

Wiggins

Grandhi

Schneider

Stanfield

Webster

Myer

GD.

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. doi:10.1177/0363546515621554

56.

Xergia

Pappas

Zampeli

Georgiou

Georgoulis

AD.

Asymmetries in functional hop tests, lower extremity kinematics, and isokinetic strength persist 6 to 9 months following anterior cruciate ligament reconstruction. J Orthop Sports Phys Ther. 2013;43(3):154-162. doi:10.2519/jospt.2013.3967

57.

Zumstein

Centner

Ritzmann

How limb dominance influences limb symmetry in ACL patients: effects on functional performance. BMC Sports Sci Med Rehabil. 2022;14(1):206. doi:10.1186/s13102-022-00579-y

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.

0.00 MB

0.13 MB