Pronóstico de Las Pruebas Deportivas para El Riesgo de Nuevas Lesiones PDF

. . .
Published ahead of Print
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et t t ests’ st e e s
after ACL Reconstruction
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Evans Yayra Kwaku Ashigbi1,2,3 , Winfried Banzer1, Daniel Niederer2
1
Department of Preventive and Sports Medicine, Institute of Occupational, Social and
Environmental Medicine, Goethe University, Frankfurt am Main, Germany; 2Department of
Sports Medicine and Exercise Physiology, Institute of Sports Sciences, Goethe University,
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Frankfurt am Main, Germany; 3Department of Physiotherapy and Rehabilitation Sciences,
School of Allied Health Sciences, University of Health and Allied Sciences, Ghana
Accepted for Publication: 3 December 2019

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Copyright © 2019 American College of Sports Medicine

Medicine & Science in Sports & Exercise, Publish Ahead of Print
DOI: 10.1249/MSS.0000000000002246
Return to Sport Tests’ Prognostic Value for Reinjury Risk
after ACL Reconstruction
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Evans Yayra Kwaku Ashigbi1,2,3, Winfried Banzer1, Daniel Niederer2
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1
Department of Preventive and Sports Medicine, Institute of Occupational, Social and
Environmental Medicine, Goethe University, Frankfurt am Main, Germany; 2Department of
Sports Medicine and Exercise Physiology, Institute of Sports Sciences, Goethe University,
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Frankfurt am Main, Germany; 3Department of Physiotherapy and Rehabilitation Sciences,
School of Allied Health Sciences, University of Health and Allied Sciences, Ghana
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CORRESPONDENCE:
Name: Prof. Dr. Dr. Winfried Banzer

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Address: Department of Preventive and Sports Medicine, Institute Occupational, Social and
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Environmental Medicine, Theodor-Stern-Kai 7, Haus 9B,
60590 Frankfurt am Main, Germany.
E-mail: banzer@med.uni-frankfurt.de
Copyright © 2019 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
Acknowledgements: None
Conflict of interest: Authors declare no conflict of interest. The results of the study are
presented clearly, honestly, and without fabrication, falsification, or inappropriate data
manipulation. The results of the present study do not constitute endorsement by ACSM.
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ABSTRACT
Introduction: Return to sports (RTS) clearance after anterior cruciate ligament (ACL)
reconstruction typically includes multiple assessments. The ability of these tests to assess the risk
of a re-injury remains unknown. Purpose: To assess and rate RTS self-reported function and
functional tests on prognostic value for re-injury risk after ACL reconstruction and RTS. Study
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Design: Systematic review on level 2 studies. Methods: PubMed, Web of Knowledge, Cochrane
Library and Google Scholar databases were searched for articles published before March 2018.
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Original articles in English or German that examined re-injury risks/rates following primary
(index) ACL injury, ACL reconstruction, and RTS were included. All RTS functional tests used
in the included studies were analysed by retrieving an effect size with predictive value (odds
ratio, relative risk (risk ratio), positive predictive value, positive likelihood ratio or hazard rate).
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Results: A total of 276 potential studies were found; eight studies (moderate to high quality) on
6,140 patients were included in the final analysis. The re-injury incidence recorded in the
included studies ranged from 1.5% to 37.5%. Four studies reported a combination of isokinetic
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quadriceps strength at different velocities and a number of hop tests as predictive with various
effect sizes. One reported isokinetic hamstring to quadriceps ratio (HR=10.6) as predictive. Two
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studies reported functional questionnaires (KOOS and TSK-11; RR=3.7-13) and one study
showed that kinetic and kinematic measures during drop vertical jumps (DVJ) were predictive
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(OR=2.3-8.4) for re-injury and/or future revision surgery. Conclusion: Based on level 2
evidence, passing a combination of functional tests with pre-determined cut-off points used as
RTS criteria is associated with reduced re-injury rates. A combination of isokinetic strength and
hop tests are recommended during RTS testing. Keywords: return to play; graft rupture; knee
injury; hop; isokinetic; rehabilitation
INTRODUCTION
An anterior cruciate ligament (ACL) tear is the most common ligament injury in the knee (1)
with an annual incidence of between 0.9 % and 1.7% within athletic populations.(2,3) ACL
rupture is particularly high in athletes involved in sports that entail cutting and pivoting
manoeuvres.(4,5) The objectives of anterior cruciate ligament reconstruction (ACLR) and post-
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surgical rehabilitation are to restore normal knee joint stability and function,(1) as well as return
patients safely to their desired levels of activity and sport within the shortest possible time with
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an acceptably low re-injury risk. As a result, return to sports (RTS) assessments have become a
vital clinical tool in determining readiness to RTS.
These RTS criteria after ACLR often include a combination of functional tests (e.g., hop test),
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lower extremity strength tests (e.g., isokinetics of the knee extensors and flexors),
movement/landing mechanics tests (e.g., drop vertical jump), as well as self-reported (e.g., fear
of re-injury) information.(6) The use of these tests to differentiate between ACLR and ACL
intact athletes have been validated. Systematic reviews point out that, since re-injury prevention
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(7) is one of the primary aims of rehabilitation, assessments of RTS readiness using measures of
functional performance should be valid in assessing the risk of a recurrence.(8,9) Yet, only a
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relatively few RTS criteria have been evaluated for re-injury risk assessment accuracy. Both the
validated and non-validated assessments are often used as equivalents in determining an athlete’s
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RTS readiness. In a recently published meta-analyses (10) the association between passing RTS
criteria and an ACL re-injury risk were evaluated. The authors summarized studies having
dichotomized the patients based on cut-off-values of the performance in several RTS tests. The
advantage of this selection is the possibility to perform quantitative analyses (i.e. meta-analyses).
Consequently, they also included studies (11,12) which used functional RTS test-values to select
further (secondary) therapies. In contrast, this may be a source of bias because the selected post
RTS interventions will influence subsequent re-injury risk. Furthermore, the dichotomization is
artificial and does not necessarily reflect real circumstances.
In order to reduce the risk of an ACL re-injury and minimize the number of wrong RTS
clearance decisions, this important clinical decision needs to be predicated on dependable
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objective functional tests and self-reported function. In fact, the criteria on which patients are
cleared to RTS are vital to ensure a successful outcome. The objective of our review was to
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systematically screen and review the current literature on RTS self-reported function as well as
functional tests and provide an overview of evidence-based RTS assessments with an assessment
of the risk for an ACL re-injury.

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METHODS
During the conduct and reporting of this review, the Preferred Reporting Items for Systematic
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Reviews and Meta-Analysis (PRISMA) guidelines,(13) were followed and the protocol was also
registered (available at: http:www.crd.york.ac.uk/PROSPERO/display_record.php?ID=

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CRD42018088208).
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Inclusion criteria for studies
We included prospective non-randomized studies published in English or German.
Original prospective cohort research articles which were published before March 2018 were
included. The included studies investigated RTS functional tests and self-reported function as
independent and re-injury rates as dependent variables.
Exclusion criteria for studies
Case reports, letters to the editor, expert opinions, editorials, abstracts, technical reports,
protocols, systematic reviews and meta-analyses were excluded. Studies which used the
functional tests-values for further participants’ stratification into experimental or therapeutic
arms were excluded due to a potential bias of further experiments on re-injury risk.
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Inclusion criteria for participants of included studies
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Male and female adolescents and adults involved in sports who suffered a primary unilateral
ACL rupture, had subsequent reconstruction and rehabilitation.

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Exclusion criteria for participants
Articles on participants who were not involved in sports, had no intention of RTS after
reconstruction, and have had more than one reconstruction, as well as non-isolated/multi-
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ligament injury patients whose injury was conservatively/non-operatively managed, were
excluded.
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Patients with a history of multiple ACL injuries (previous knee injuries), low back injuries or
either bilateral lower extremity injuries or surgery (beyond ACLR) requiring the care of a
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physician within the past year, or a concomitant repairable meniscus (grade III) or ligament
injury (beyond grade I medial collateral ligament injury) in the involved limb, were excluded.
Outcome measure and effect size estimator
The outcome considered for this review was a subsequent ACL re-injury. Predictive values of
self-reported function and functional tests on re-injury risk after RTS following ACLR were the
target effect estimators.
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Literature research
The literature research was performed in PubMed, Web of Knowledge, the Cochrane Library and
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Google Scholar databases. Potentially relevant published peer-reviewed original research articles
were searched for using the following search terms:
("anterior cruciate ligament") AND ("re-rupture" OR recurrence OR re-rupture OR "graft

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failure" OR re-injury OR re-injury OR secondary) AND (risk) AND ("discharge criteria" OR
function* OR “Postural control” OR balance OR Hop OR Isokinetic OR strength OR isometric
OR “limb symmetry index” OR jump OR performance)

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Unpublished and grey literatures (research that is either unpublished or has been published in
non-commercial form) were also considered using similar terms in www.guidelines.gov,

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www.opengrey.eu, www.clinicaltrials.com and www.controlled-trials.com. After study retrieval,
additional studies were identified by manually searching through the reference list of the selected
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articles.
An initial comprehensive exploratory electronic database search was conducted by two
independent reviewers to define the final search terms for the systematic research. Both
reviewers then conducted the main research independently. The identified studies were screened
for eligibility using (first) titles and (second) abstracts. Studies that did not meet the inclusion
criteria were removed. The full texts for the remaining studies were assessed to ascertain whether
they were eligible for inclusion for the purpose of this review. Consensus between the two
primary reviewers was used to address any disparities; a third reviewer was also utilized, if
necessary, to address any disparities.
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Assessment of Risk of Bias
Risk of bias assessment was done in accordance with the Cochrane Back Review Group’s
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recommendations.(14) The Cochrane tool for the assessment of risk of bias in non-randomized
studies,(15) was used to assess and rate the potential sources of bias in the included studies. The
eight-item scale with four levels assesses risk rating (‘definitely yes’, ‘probably yes’, ‘probably
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no’ and ‘definitely no’) for each item. Again, two of the reviewers independently assessed the
risk of bias associated with the selected studies and all potential disagreements were discussed
and resolved. The included studies were graded for risk of bias in the following domains:
selection, assessment of exposure, absence of outcome of interest at the beginning of the study,
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control for age, sex and other factors, prognostic factors, outcome assessment, adequacy of
follow-up as well as similarity of co-interventions. A low risk of bias was assigned to the
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assessed studies if a ‘Yes’ answer was obtained for four out of eight domains and without major
flaws,(14) (e.g., 20% or higher rate of dropout in a specific study group).

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Assessment of study quality
The Newcastle-Ottawa Scale (NOS),(16) was used to assess the methodological quality of the
included studies (eight items categorized into three). The three categories include Selection,
Comparability and Outcome. The corresponding items are as follows:
1) Selection: Representativeness of exposed cohort? -Selection of non-exposed cohort?
-Ascertainment of exposure? -Demonstration that outcome of interest was not present at start of
study? 2) Comparability: Study controls for age and sex? -Study controls for any additional
factors? 3) Outcome: Assessment of outcome? -Was follow-up long enough for outcomes to
occur? -Adequacy of follow-up of cohorts? The results of this assessment can be found in
Appendix 1 (Study quality assessment of included studies using Newcastle-Ottawa Scale).
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Assessment of level of evidence and quality of evidence rating
The 2011 level of evidence,(17) tool of the Oxford Centre for Evidence-Based Medicine
(OCEBM) was used to rate each of the studies included in the review.
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The quality of evidence was rated in accordance with GRADE guidelines.(18) Study design and
risk of bias - inconsistency of results – indirectness - imprecision - other (i.e., publication bias)
were independently rated. High quality, moderate-quality, low-quality and very low quality
evidence were used to describe the findings.

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Data extraction
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A data extraction form designed for this review was used to obtain data from each study. The
primary variables extracted were RTS criteria, functional tests or self-reported function, total re-
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injury rates, ipsilateral re-injury rates, contralateral re-injury rates (if reported) and relative re-
injury risk (predictive value). One researcher recorded all the pertinent data from the included
articles, two other authors independently reviewed the extracted data for its relevance, accuracy
and comprehensiveness.
RESULTS
Selection of included studies
Figure 1 shows a summary of the literature search and article selection. Finally, eight
articles,(19–26) met the inclusion criteria and were deemed appropriate for this review.
Synthesis and description of the included studies
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The eight studies included in this review included a total of 6,140 participants. All the eight,(19–
26) included studies adopted a prospective inception cohort study design. The included studies
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generally revealed a low risk of bias. The summary of results for study quality assessment using
a checklist is displayed in Supplemental Digital Content (see Table, Supplemental Digital
Content 1, PRISMA 2009 Checklist, http://links.lww.com/MSS/B879). The details of the study

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quality assessment criterion in the NOS,(16) are summarized in the Supplemental Digital
Content (see Appendix, Supplemental Digital Content 2, Appendix 1: Study quality assessment
of included studies using Newcastle-Ottawa Scale, http://links.lww.com/MSS/B880). One
study,(23) recruited only male participants and another study,(20) did not provide information on
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the sex distribution of the study participants. The remaining six studies,(20–22,24–26) included
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both male and female participants. The mean age of participants in the included studies ranged
from 16.2 to 29.2 years.

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Characteristics of included studies
All studies included,(19–26) reported the inclusion of participants who have suffered an isolated
unilateral primary ACL rupture (intact menisci) and who have undergone index ACLR.
Hamstring tendon grafts were used for all reconstructions in one,(22) study, whilst hamstring or
bone-patella tendon-bone (BPTB) grafts were used for reconstructions in three studies.(23–25)
Ahmed et al.,(22) involved participants from the same surgeon, while the other three,(23–25)
studies had participants from different surgeons,(23) hospitals,(24) or a national ACL
registry.(25) The type of graft used was not stated in the other four studies.(19–21,26)
All the included studies provided information on the total number of re-injuries during the study
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period and two studies,(24,25) provided additional information on the number of re-injured
participants who had revision surgery. Table 1 provides a summary of additional characteristics
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(level of evidence, number of participants, age, follow-up period, number of participants who
RTS and number of re-injuries) from the included studies.

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Return to Sport criteria
Patient reported outcome questionnaires were used to evaluate knee function and monitor
progress as part of the RTS criteria in six of the included studies.(19–22,24,25) The knee
outcome survey activities of daily living (KOOS-ADL), together with the Global Rating Scale
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(GRS), were used as part of the RTS criteria in two studies,(21,24) whilst the International Knee
Documentation Committee (IKDC), was utilized in two of the studies.(22,25) The KOOS-QoL
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questionnaire was used in two studies,(19,25) to aid the RTS decision-making. One,(26) of the
selected studies used drop vertical jump (DVJ) as a functional biomechanical measure for the
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assessment of the risk of an ACL re-injury. Kyritsis et al.,(23) utilized on-field sports specific
rehabilitation as well as the running t-test as part of six clinical discharge (RTS) criteria. The
details of these criteria are summarized in Table 2.
Re-injury incidence
The re-injury incidence (both ipsilateral and contralateral injuries) recorded in the selected
studies ranged from a minimum of 1.5 % in Granan et al.,(25) to 37.5 % in Paterno et al.(19)
Two studies,(22,25) did not differentiate ipsilateral re-injuries from contralateral injuries and
ipsilateral re-injuries were relatively higher in four studies,(19,21,23,24). The reported rates of
re-injury associated with RTS functional tests/self-reported function as well as their reported
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predictive values are as organised in Table 2.
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Risk assessment value of the functional assessments
All variables used for assessing the re-injury predictive values and the respective effect
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estimators are displayed in Table 2. Paterno et al.,(19) observed that patients who sustained a re-
injury had a greater Tampa Scale of Kinesiophobia (TSK-11) score at the time of RTS (mean,
19.8 ± 4.0, p=0.03) than those who did not suffer a re-injury (mean, 16.4 ± 3.6, p = 0.03).
Another study,(20) by the same working group using a clinical prediction model (described as
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high or low risk), the validation step identified the high-risk group as being more likely to suffer
re-injury with a sensitivity of 0.67 and specificity of 0.72. Wellsandt et al.,(21) published results
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from a secondarily analysed dataset within a completed randomized controlled trial (RCT) from
an on-going RCT on athletes who were active in cutting and pivoting activities prior to a primary
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ACL injury. Here, LSIs were able to predict an ACL re-injury (sensitivity, 0.273; 95% CI;
0.010-0.566). Ahmed et al.,(22) published a study of 200 cases from a single surgeon, and
participants who sustained a graft rupture had a significantly poor IKDC functional and
radiological outcomes than the control group, which did not suffer a re-injury after primary
ACLR. Kyritsis et al.,(23) published data from the Aspetar National Sports Medicine Programme
based in Qatar. The authors reported that not meeting six discharge criteria and a decreased
hamstring to quadriceps ratio in the injured limb before RTS was associated with increased risk
of re-injury. Grindem et al.,(24) published data from the Norwegian arm of the Delaware-Oslo
ACL study which concluded that return to level 1 sports leads to a 4.32 (p=0.048) increase in re-
injury rates over two years. Granan et al.,(25) published a prospective cohort prognostic study
using data from the Norwegian National Knee Ligament Registry (NKLR) and observed an
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increased risk of graft failure in patients who had a knee injury and osteoarthritis outcome score
quality of life (KOOS-QoL) <44 at two years post index ACLR. This study further reported that
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every 10-point reduction in the KOOS-QoL increases the risk of ACLR revisions by 33.6 % (95
% CI 21.2–47.5). Paterno et al.,(26) again conducted a prognostic biomechanical screening study
on athletes after ACLR using 3D motion analysis during a DVJ and postural stability assessment
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before their return to pivoting and cutting sports. Participants who sustained a re-injury
demonstrated a 4.1-fold greater asymmetry in internal knee extensor moment at initial contact
when compared with the cohort of patients who did not suffer an additional injury.
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DISCUSSION
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The results of this systematic review demonstrate that knee neuromuscular function measures of
quadriceps strength, hop tests, sub-scales of the knee injury and the osteoarthritis outcome score
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(KOOS) and biomechanical measures of DVJ all assesed the risk for a re-injury and/or future
revision surgery in patients following an ACL reconstruction. This review collected and
summarized the evidence that passing a combination of functional tests and self-reported
function with pre-determined cut-off points used as RTS criteria is associated with reduced re-
injury rates. The moderate- to high- quality of evidence and level II evidence of the studies
included shows that a combination of quadriceps strength tests, hop tests (single, triple, crossover
and 6-meter timed), as well as other self-reported measures, may be used as a re-injury predictive
RTS criteria.(19–21,23,24)
Objective functional criteria
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Previous systematic reviews have synthesised published articles on functional performance
testing and objective criteria for RTS after ACLR. Abram et al.,(27) reported that even with the
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large number of published investigations regarding all aspects of ACLR, few clinicians utilize
objective data in determining RTS. Harris et al.,(28) reported that objective criteria for RTS were
cited in only 10% (5 out of 49) of studies. Barber-Westin and Noyes,[24] also earlier observed
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that, out of 264 studies that investigated RTS following ACLR, only 13%,(29) cited objective
criteria for RTS. Overall, our review expanded the current knowledge on this topic, and our
results may help researchers to select valid, objective, and (most importantly) tests that are able
to assess re-injury risk.

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Limb symmetry index of strength and hop tests

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Based on the available literature, over the past 10-15 years isokinetic/quadriceps strength and
hop testing expressed as limb symmetry indexes (LSI) have been the most commonly cited
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objective tests used as part of most of the RTS decision-making in assessing an athlete’s
readiness to return to unrestricted sport after ACLR. In our review, between-leg symmetry of
functional strength and the four standard hop tests (single-leg, cross-over, triple and 6-meter
timed hops) after ACLR were the most commonly used RTS functional tests in the included
studies. These studies required the study participants to be able to hop on the reconstructed leg at
least 90% of the distance hopped on the contralateral (uninvolved) leg,(30) to confirm RTS
readiness. Although achievement of LSIs in quadriceps strength and hop tests after ACLR is not
a confirmation that pre-injury functional levels have been achieved, several studies,(19–
21,23,24) have shown that achieving these pre-determined functional performance thresholds
before RTS significantly reduces the re-injury incidence and its attendant revision surgeries.
Despite these promising findings, LSI may overestimate knee function since the resulting
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reduction in sports participation that follows the injury, reconstruction and rehabilitation leads to
bilateral muscle strength deficits. (31) Yet, the LSI of 90 % is generally used. We agree that no
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strong rationale for the < 90% LSI cut point is available. Beyond EPIC values, absolute
performance values (e.g., peak torque, peak torque to body mass ratio, hop distance) provide a
better means to estimate re-injury risk when they are compared to re-injury or reference values.
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In one of the studies included in this review, estimated pre-injury capacity (EPIC), i.e. the level
which is an evaluation of the degree of limb symmetry obtained by comparing the involved-limb
measures to uninvolved limb measures before ACLR, was investigated. Preliminary evidence
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from this study showed that using 90% EPIC levels as a reference standard is even more
sensitive than LSI in assessing the risk of an ACL re-injury. Since the use of 90 % EPIC levels
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have been proven by Wellsandt et al.,(21) as being even more sensitive than 90% LSIs at
assessing the risk of ACL re-injuries, the use of LSIs needs to be re-examined and its
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inadequacies addressed to help improve its sensitivity for predicting ACL re-injuries. The
potential benefit of using the uninvolved-limb function prior to, instead of after ACLR to
determine RTS readiness, is thus evident. This may indicate that the use of LSIs does not give a
true reflection of knee function after ACLR and may therefore also play a role in the occurrence
of an ACL re-injury. Beyond EPIC levels, absolute performance values (e.g., peak torque, peak
torque to body mass ratio, hop distance) provide a better means to estimate re-injury risk when
they are compared to re-injury or reference values.
Self-reported function
In 2010, Frobell et al.,(32) investigated a hypothesis that pointed to the fact that the results of
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KOOS-QoL can be used as an indicator of risk of clinical graft failure. Granan et al. also
revealed an association between inadequate knee function measured with the QoL subscale of
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KOOS and a subsequent ACL re-injury. This study observed an increased risk of graft failure in
patients who had a KOOS-QoL < 44 at 2 years post index ACLR. This shows that KOOS-QoL
readings can be used to identify patients who are at high risk of re-injury prior to RTS.
Webb et al.,(33) reported that an increase in PTS elevates the odds of both ACL injury and graft
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rupture by a factor of five. Ahmed et al.,(22) published a study of 200 case series from a single
surgeon and participants who sustained a graft rupture had a significantly worse IKDC
radiological grade than the control group, which did not suffer a re-injury after the primary
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ACLR. This study concluded that patients who suffer recurrent injuries after ACLR have poorer
functional and radiological outcomes compared to sex- and age-matched counterparts who suffer
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a single injury and underwent only primary reconstruction. A PTS of >12° increased the odds of
a further ACL injury.

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A combination of the TSK-11 result of ≥19 with LSIs as RTS criteria in Paterno et al.,(20)
recorded a very high re-injury relative risk (risk ratio) of 13. This shows that fear affects an
athlete’s functional test performance and contributes to the occurrence of a re-injury. Several
studies,(34–37) on return to play after ACLR have therefore strongly pointed to fear of re-injury
as a major reason cited by patients who decide not to RTS. Arden et al.,(38) also cited
psychological readiness including low kinesiophobia as a factor most associated with successful
RTS.
Kinematics and kinetics during drop jump landings
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Several authors,(39–42) have recommended advanced neuromuscular training as a requirement
for patients who plan to RTS following ACLR. Findings from Paterno et al.,(26) support the fact
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that altered neuromuscular control patterns during a dynamic landing task and deficits in postural
stability are assessors of the risk of an ACL graft failure on RTS. This study reported that the net
hip rotation moment impulse in isolation is a good assessor of an ACL re-injury risk with a
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moderate to high measure of sensitivity (0.78) and specificity (0.81). This shows that
biomechanical and neuromuscular factors such as hip and knee kinematics which can be
measured using DVJ, may be able to assess the re-injury risk. These findings are in line with
other studies,(43,44) which have identified changes in movement patterns demonstrated by

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patients after initial ACLR as possible assessors of an ACL re-injury risk.

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Clinical practice implications

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Even though passing a set of RTS tests minimizes the risk of re-injury, it is evident that
knowledge of the associated residual risk on RTS and the added ability to predict the same based
on the functional tests and self-reported function employed is a vital clinical skill that is needed
by clinicians. The use of a battery of tests for RTS clearance for assessment of re-injury risk has
been documented. Added information on the ability of the included functional tests to assess the
risk for re-injury is equally essential in the quest to standardize RTS clearance and reduce ACL
re-injuries. Final RTS clearance decisions need to positively balance the need to clear patients
with their risk of re-injury and RTS functional tests can be used to assess the risk for a re-injury.
Even though this review showed that KOOS-QoL subscale and DVJ tests may be able to assess
the risk for an ACL re-injury, our findings also point to the fact that using a combination of
strength and hop tests can also be used to ascertain the risk of an ACL re-injury following
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ACLR. Instead of only performing one single assessment at the hypothetical end of the RTS
process, multiple measurements, aiming to monitor and verify the course of the RTS process,
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may be more promising. (45) A stepwise processing of functional testing is thus indicated, for
example following the stepwise/gradual progressing recommended in Logerstedt et al. (46) ,
Davies et al. (47) , and Wilk and Arrigo. (39) Self-reported outcomes can be assessed earlier
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than isokinetics and hop tests. Knee extension (isokinetic) strength/torque and hop tests were the
most commonly used functional tests (and those with the highest value in assessing the re-injury
risk. We thus recommend the use of (in this order and as a stepwise process) self-reported
outcomes – isokinetics – single leg hop for distance – triple hop and triple crossover hop for
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distance as RTS battery of tests.

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Limitations of this review

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Even though all the selected studies recorded low risk of bias and are of good quality in overall
grading, one of the main limitations associated with this review is the lack of standardized data
across the selected studies regarding age, sex, rehabilitation protocol, follow-up time, RTS
criteria and functional tests used. The use of sub-standard RTS criteria may allow participants to
RTS participation ahead of biological, as well as functional recovery. This may have contributed
to an increased risk of re-injury on RTS. Also, the large number of participants in Granan et al.
and the reported relatively low incidence of re-injury had a larger influence on our conclusions
than the findings of studies that involved much smaller cohorts. Irrespective of these
methodological variations, we believe that the high level of evidence presented in the included
studies provides clinicians and patients with evidence-based scientific information on RTS
functional tests and re-injury risk.
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Limitations of the included studies
The lack of standardized data across the included studies regarding age, sex, follow-up time and
RTS criteria are potential limitations. A recent meta-analysis by Wiggins et al.,(48) indicates
younger age (< 25 years) is a risk factor for an ACL graft rupture. Also, females have a greater
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knee laxity and lower Lysholm and Tegner activity scores compared with males.(49)
Furthermore, most of the functional tests were combined with other RTS tests, making it
impossible to determine their individual re-injury risks. In addition, the differences in sources of
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research data used, as well as the varying skills level of health professionals involved with the
participants may also play a role in the recorded re-injury rates. Some of the studies relied on
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data from a national registry, whilst others depended on data from a single surgeon and other
sources. The authors of most of the included studies had no control over the RTS criteria used
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since study participants were already cleared to return to unrestricted sports. Graft type and
surgical techniques were also different among the selected studies and, even though these factors
play a role in ACL re-injury, they were beyond the scope of our review.
Conclusion
This systematic review provides information on published RTS functional tests and self-reported
function used to assess re-injury risk following primary ACLR. Return to sports clearance is a
multi-dimensional clinical decision that requires consideration of pre-, intra- (graft choice,
anatomic graft position and graft tensioning) and post-operative factors. Moderate- to high-
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quality evidence supports the finding that a combination of functional tests assesses the risk for a
subsequent re-injury after ACLR and RTS. Knee extension strength and hop tests were the most
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commonly used functional tests (and those with the highest predictive value). Moderate quality
evidence further shows that the KOOS-QoL subscale, as well as drop jump biomechanics may be
used to assess the risk for ACL re-injuries. This review highlights the need for a rigorous
examination of objective RTS tests on their ability to provide information on graft rupture risk in
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the continued quest for an evidence-based standardized safe RTS clearance protocol.
Summary
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What is known about the subject:

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 RTS clearance after ACLR and rehabilitation typically includes a multiple of functional
assessments.
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 The prognostic value for re-injury risk of these assessments remain relatively unknown.
What this study adds to existing knowledge:
 Neuromuscular function measures of quadriceps strength, hop tests, KOOS-QoL sub-
scale and biomechanical measures of DVJ may be used to assess the risk for a re-injury
and/or future revision surgery after ACLR.
 Passing a combination of objective functional tests with pre-determined cut-off points
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used as RTS criteria is associated with a reduced re-injury risk.
 Self-reported functional measures may be used to estimate re-injury risk prior to RTS
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after ACLR. EP
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Acknowledgements
None
Conflict of interest
Authors declare no conflict of interest.
The results of the study are presented clearly, honestly, and without fabrication, falsification, or
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inappropriate data manipulation. The results of the present study do not constitute endorsement
by ACSM.
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Ethical approval
This article does not contain studies on human participants performed by any of the authors.
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Informed consent
Not applicable
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Author contributions
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The authors contributed equally to this work by making substantial contributions to the
conception, design, acquisition of data, analysis and interpretation of data, drafting of the article,
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revising the draft article critically for important intellectual content and final approval of the
version to be published.
References
1. Barber-Westin SD, Noyes FR. Objective criteria for return to athletics after anterior
cruciate ligament reconstruction and subsequent reinjury rates: a systematic review. Phys
Sportsmed. 2011;39(3):100–10. doi:10.3810/psm.2011.09.1926
2. Salmon L, Russell V, Musgrove T, Pinczewski L, Refshauge K. Incidence and risk
D
factors for graft rupture and contralateral rupture after anterior cruciate ligament
reconstruction. Arthroscopy. 2005;21(8):948–57. doi:10.1016/j.arthro.2005.04.110
TE
3. Niederer D, Engeroff T, Wilke J, Vogt L, Banzer W. Return to play, performance, and
career duration after anterior cruciate ligament rupture: A case-control study in the five
biggest football nations in Europe. Scand J Med Sci Sports. 2018. doi:10.1111/sms.13245
EP
4. Andernord D, Desai N, Björnsson H, Ylander M, Karlsson J, Samuelsson K. Patient
predictors of early revision surgery after anterior cruciate ligament reconstruction: a
cohort study of 16,930 patients with 2-year follow-up. Am J Sports Med.
2015;43(1):121–7. doi:10.1177/0363546514552788
C
5. Brophy RH, Stepan JG, Silvers HJ, Mandelbaum BR. Defending Puts the Anterior
C
Cruciate Ligament at Risk During Soccer: A Gender-Based Analysis. Sports Health.
2015;7(3):244–9. doi:10.1177/1941738114535184
A
6. van Melick N, van Cingel REH, Brooijmans F, Neeter C, van Tienen T, Hullegie W,
Nijhuis-van der Sanden MWG. 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):1506–15.
doi:10.1136/bjsports-2015-095898
7. Webster KE, 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):917–29. doi:10.1007/s40279-019-01093-x
8. Czuppon S, Racette BA, Klein SE, Harris-Hayes M. Variables Associated With Return to
Sport Following Anterior Cruciate Ligament Reconstruction: A Systematic Review. Br J
Sports Med. 2013;48(5):356–64. doi:10.1136/bjsports-2012-091786
D
9. Wilk KE, Arrigo CA. Rehabilitation Principles of the Anterior Cruciate Ligament
TE
Reconstructed Knee: Twelve Steps for Successful Progression and Return to Play. Clin
Sports Med. 2017;36(1):189–232. doi:10.1016/j.csm.2016.08.012
10. Losciale JM, Zdeb RM, Ledbetter L, Reiman MP, Sell TC. The Association Between
EP
Passing Return-to-Sport Criteria and Second Anterior Cruciate Ligament Injury Risk: A
Systematic Review With Meta-Analysis. J Orthop Sports Phys Ther. 2018;1–52.
doi:10.2519/jospt.2019.8190
11. Sousa PL, Krych AJ, Cates RA, Levy BA, Stuart MJ, Dahm DL. Return to sport: Does
C
excellent 6-month strength and function following ACL reconstruction predict midterm
outcomes? Knee Surg Sports Traumatol Arthrosc. 2017;25(5):1356–63.

C
doi:10.1007/s00167-015-3697-2
A
12. Nawasreh Z, Logerstedt D, Cummer K, Axe M, Risberg MA, Snyder-Mackler L.
Functional performance 6 months after ACL reconstruction can predict return to
participation in the same preinjury activity level 12 and 24 months after surgery. Br J
Sports Med. 2018;52(6):375. doi:10.1136/bjsports-2016-097095
13. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic
reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6(7):e1000097.
doi:10.1371/journal.pmed.1000097
14. Furlan AD, Pennick V, Bombardier C, van Tulder M. 2009 updated method guidelines
for systematic reviews in the Cochrane Back Review Group. Spine. 2009;34(18):1929–
41. doi:10.1097/BRS.0b013e3181b1c99f
D
15. Reeves BC, Deeks JJ, Higgins JPT, Wells GA. Chapter 13: Including non-randomized
TE
studies. In: Higgins JPT, Green S (editors), Cochrane Handbook for Systematic Reviews
of Interventions Version 5.1.0 (updated March 2011). The Cochrane Collaboration, 2011.
[Internet]. 2011. Available from: www.handbook.cochrane.org.

EP
16. Wells GA, Shea B, O'Connell D, Peterson J, Welch V, Losos M, Tugwell P. The
Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in
meta-analyses [Internet]. 2013. Available from:
http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp
C
17. Howick J, Chalmers I, Glasziou P, Greenhalgh T, Heneghan C, Liberati A, Moschetti I,
Phillips B, Thornton H. Oxford Centre for Evidence-Based Medicine (OCEBM) Levels

C
of Evidence [Internet]. 2011. Available from: https://www.cebm.net/2016/05/ocebm-
levels-of-evidence/
A
18. Atkins D, Best D, Briss PA, Eccles M, Falck-Ytter Y, Flottorp S, Guyatt GH, Harbour
RT, Haugh MC, Henry D, Hill S, Jaeschke R, Leng G, Liberati A, Magrini N, Mason J,
Middleton P, Mrukowicz J, O'Connell D, Oxman AD, Phillips B, Schünemann HJ,
Edejer TT-T, Varonen H, Vist GE, Williams JW, Zaza S. Grading quality of evidence
and strength of recommendations. BMJ. 2004;328(7454):1490.
doi:10.1136/bmj.328.7454.1490
19. Paterno MV, Huang B, Thomas S, Hewett TE, Schmitt LC. Clinical Factors That Predict
a Second ACL Injury After ACL Reconstruction and Return to Sport: Preliminary
Development of a Clinical Decision Algorithm. Orthop J Sports Med.
2017;5(12):2325967117745279. doi:10.1177/2325967117745279
D
20. Paterno MV, Flynn K, Thomas S, Schmitt LC. Self-Reported Fear Predicts Functional
TE
Performance and Second ACL Injury After ACL Reconstruction and Return to Sport: A
Pilot Study. Sports Health. 2018;10(3):228–33. doi:10.1177/1941738117745806
21. Wellsandt E, Failla MJ, Snyder-Mackler L. Limb Symmetry Indexes Can Overestimate
EP
Knee Function After Anterior Cruciate Ligament Injury. J Orthop Sports Phys Ther.
2017;47(5):334–8. doi:10.2519/jospt.2017.7285
22. Ahmed I, Salmon L, Roe J, Pinczewski L. The long-term clinical and radiological
outcomes in patients who suffer recurrent injuries to the anterior cruciate ligament after
C
reconstruction. Bone Joint J. 2017;99-B(3):337–43. doi:10.1302/0301-620X.99B3.37863

C
23. Kyritsis P, Bahr R, Landreau P, Miladi R, Witvrouw E. Likelihood of ACL graft rupture:
not meeting six clinical discharge criteria before return to sport is associated with a four
A
times greater risk of rupture. Br J Sports Med. 2016;50(15):946–51. doi:10.1136/bjsports-
2015-095908
24. Grindem H, Snyder-Mackler L, Moksnes H, Engebretsen L, Risberg MA. 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):804–8. doi:10.1136/bjsports-
2016-096031
25. Granan L-P, Baste V, Engebretsen L, Inacio MCS. Associations between inadequate knee
function detected by KOOS and prospective graft failure in an anterior cruciate ligament-
reconstructed knee. Knee Surg Sports Traumatol Arthrosc. 2015;23(4):1135–40.
doi:10.1007/s00167-014-2925-5
D
26. Paterno MV, Schmitt LC, Ford KR, Rauh MJ, Myer GD, Huang B, Hewett TE.
TE
Biomechanical measures during landing and postural stability predict second anterior
cruciate ligament injury after anterior cruciate ligament reconstruction and return to sport.
Am J Sports Med. 2010;38(10):1968–78. doi:10.1177/0363546510376053

EP
27. Abrams GD, Harris JD, Gupta AK, McCormick FM, Bush-Joseph CA, Verma NN, Cole
BJ, Bach BR. Functional Performance Testing After Anterior Cruciate Ligament
Reconstruction: A Systematic Review. Orthop J Sports Med.
2014;2(1):2325967113518305. doi:10.1177/2325967113518305
C
28. Harris JD, Abrams GD, Bach BR, Williams D, Heidloff D, Bush-Joseph CA, Verma NN,
Forsythe B, Cole BJ. Return to sport after ACL reconstruction. Orthopedics.

C
2014;37(2):e103-8. doi:10.3928/01477447-20140124-10
A
29. Barber-Westin SD, Noyes FR. Factors used to determine return to unrestricted sports
activities after anterior cruciate ligament reconstruction. Arthroscopy. 2011;27(12):1697–
705. doi:10.1016/j.arthro.2011.09.009
30. 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;42(7):601–14.
doi:10.2519/jospt.2012.3871
31. Palmieri-Smith RM, Thomas AC, Wojtys EM. Maximizing Quadriceps Strength After
ACL Reconstruction. Clin Sports Med. 2008;27(3):405–24.
doi:10.1016/j.csm.2008.02.001
D
32. Frobell RB, Roos EM, Roos HP, Ranstam J, Lohmander LS. A randomized trial of
treatment for acute anterior cruciate ligament tears. N Engl J Med. 2010;363(4):331–42.
TE
doi:10.1056/NEJMoa0907797
33. Webb JM, Salmon LJ, Leclerc E, Pinczewski LA, Roe JP. Posterior tibial slope and
further anterior cruciate ligament injuries in the anterior cruciate ligament-reconstructed

EP
patient. Am J Sports Med. 2013;41(12):2800–4. doi:10.1177/0363546513503288
34. Ardern CL, Österberg A, Tagesson S, Gauffin H, Webster KE, Kvist J. The impact of
psychological readiness to return to sport and recreational activities after anterior cruciate
ligament reconstruction. Br J Sports Med. 2014;48(22):1613–9. doi:10.1136/bjsports-

C
2014-093842
C
35. Ardern CL, Webster KE, Taylor NF, Feller JA. Return to sport following anterior
cruciate ligament reconstruction surgery: a systematic review and meta-analysis of the

A
state of play. Br J Sports Med. 2011;45(7):596–606. doi:10.1136/bjsm.2010.076364
36. Kvist J, Ek A, Sporrstedt K, Good L. Fear of re-injury: a hindrance for returning to sports
after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc.
2005;13(5):393–7. doi:10.1007/s00167-004-0591-8
37. Ross MD. The relationship between functional levels and fear-avoidance beliefs
following anterior cruciate ligament reconstruction. J Orthop Traumatol. 2010;11(4):237–
43. doi:10.1007/s10195-010-0118-7
38. Ardern CL, Taylor NF, Feller JA, Webster KE. Fear of re-injury in people who have
returned to sport following anterior cruciate ligament reconstruction surgery. J Sci Med
Sport. 2012;15(6):488–95. doi:10.1016/j.jsams.2012.03.015
D
39. Wilk KE, Arrigo CA. Rehabilitation Principles of the Anterior Cruciate Ligament
TE
Reconstructed Knee: Twelve Steps for Successful Progression and Return to Play. Clin
Sports Med. 2017;36(1):189–232. doi:10.1016/j.csm.2016.08.012
40. van Grinsven S, van Cingel REH, Holla CJM, van Loon CJM. Evidence-based
EP
rehabilitation following anterior cruciate ligament reconstruction. Knee Surg Sports
Traumatol Arthrosc. 2010;18(8):1128–44. doi:10.1007/s00167-009-1027-2
41. Wilk KE, Reinold MM, Hooks TR. Recent advances in the rehabilitation of isolated and
combined anterior cruciate ligament injuries. Orthop Clin North Am. 2003;34(1):107–37.
C
42. Risberg MA, Mørk M, Jenssen HK, Holm I. Design and implementation of a
C
neuromuscular training program following anterior cruciate ligament reconstruction. J
Orthop Sports Phys Ther. 2001;31(11):620–31. doi:10.2519/jospt.2001.31.11.620

A
43. Gokeler A, Dingenen B, Mouton C, Seil R. Clinical course and recommendations for
patients after anterior cruciate ligament injury and subsequent reconstruction: A narrative
review. EFORT Open Rev. 2017;2(10):410–20. doi:10.1302/2058-5241.2.170011
44. Goerger BM, Marshall SW, Beutler AI, Blackburn JT, Wilckens JH, Padua DA. Anterior
cruciate ligament injury alters preinjury lower extremity biomechanics in the injured and
uninjured leg: the JUMP-ACL study. Br J Sports Med. 2015;49(3):188–95.
doi:10.1136/bjsports-2013-092982
45. Dingenen B, Gokeler A. Optimization of the Return-to-Sport Paradigm After Anterior
Cruciate Ligament Reconstruction: A Critical Step Back to Move Forward. Sports Med.
2017;47(8):1487–500. doi:10.1007/s40279-017-0674-6
D
46. Logerstedt D, Arundale A, Lynch A, Snyder-Mackler L. A conceptual framework for a
sports knee injury performance profile (SKIPP) and return to activity criteria (RTAC).
TE
Braz J Phys Ther. 2015;19(5):340–59. doi:10.1590/bjpt-rbf.2014.0116
47. Davies GJ, McCarty E, Provencher M, Manske RC. ACL Return to Sport Guidelines and
Criteria. Curr Rev Musculoskelet Med. 2017;10(3):307–14. doi:10.1007/s12178-017-

EP
9420-9
48. Wiggins AJ, Grandhi RK, Schneider DK, Stanfield D, Webster KE, 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):1861–76.

C
doi:10.1177/0363546515621554
C
49. Tan SHS, Lau BPH, Khin LW, Lingaraj K. The Importance of Patient Sex in the
Outcomes of Anterior Cruciate Ligament Reconstructions: A Systematic Review and

A
Meta-analysis. Am J Sports Med. 2016;44(1):242–54. doi:10.1177/0363546515573008
Figure 1: Article selection using the PRISMA 2009 flow diagram.
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Figure 1
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Table 1: Characteristics of included studies
α
M, male; F, female; mo, months; RTS, return to sports; SD, standard deviation; n, number; * revision
Literature source Level of Number of Quality Age Follow- RTS (n) Second ACL/other knee injuries
(authors and year) Evidenc Participants Checklis (years) up time Ipsilate- Contralate- Unclassified Total n
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e t Score mean (SD) (mo) ral ral (%)
Paterno et al. (2018) 2 40 6 16.2 (3.4) 24 40 8 7 - 15 (37.5)
Paterno et al. (2017) 2 163 (58 M, 105 9 16.7 (3.0) 24 163 8 15 9 32 (19.6)
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F)
Wellsandt et al. 2 70 (47 M, 23 F) 8 26.6 (10) 24 70 7 4 - 11 (15.7)

(2017) (Initially 182)
Ahmed et al. (2017) 2 36 (20 M, 16 F) 7 21.6 240 Not - - 36 36 (18)
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(Initially 200) reported
Kyritsis et al. 2 158 (158 M) 7 22 (5) 12 158 15 11 - 26 (16.5)

(2016) (Initially 377)
Grindem et al. 2 100 (46 M, 54 F) 9 24.3 (7.3) 24 100 8 2 14 (other 24 (24)

(2016) (Initially 106 knee injuries) *4
from 150)
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Granan et al. (2015) 2 5,517 (2,887 M, 8 29.2 (10.8) 24 Not - - 83 *83 (1.5)
2,630 F) reported
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(Initially 8,944)
Paterno et al. (2010) 2 56 (21 M, 35 F) 7 16.4 (2.97) 12 56 3 10 - 13 (23.2)

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Table 2: RTS Criteria, Functional tests, Rate of re-injury, Re-injury predictive values, Reported effect estimator and Clinical meaning of the effect.
α
RTS, return to sports; TSK, Tampa Scale of Kinesiophobia; OR, odds Ratio; RR, relative risk (risk ratio); PPV+, positive predictive value; LR+, positive
likelihood ratio; HR, hazard rate; KOOS-QoL, Knee injury and Osteoarthritis Outcome Score Quality of Life subscale; IKDC, International Knee
Documentation Committee; LSI, Limb Symmetry Index; KOS-ADL, Knee Outcome Survey Activities of Daily Living; GRS, Global Rating Scale; PTS,
Posterior Tibial Slope; DVJ, Drop Vertical Jump.
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Literature Variable(s) At RTS tests/criteria with cut Functional test / Value/Score/Criteria Reported effect Clinical meaning
source (authors investigated off points (if stated) measure component of used to determine estimator of the effect: re-
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and year) RTS criteria / study OR/RR/LR+/HR (Predictive value) injury risk
OR/RR/PPV+/LR+ increased /
/HR decreased
Paterno et al. Self-reported TSK-11 (≥17); Marx Activity Rating TSK-11 ≥19 RR=13.0; 95% CI: Risk increased
(2018) kinesiophobia Marx Activity Rating Scale Scale; 2.1, 81.0 ; p=0.03 when the
(≤15); Quadriceps strength test; kinesiophobia is
Quadriceps strength test; Hop test (single, triple, ≥19 points
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Hop tests triple crossover and 6-m
timed)
Paterno et al. Limb symmetry Isometric quadriceps strength Quadriceps strength test; High risk profile OR=5.14; 95% CI: Risk is decreased
(2017) index of test at 60° knee flexion; participants (age<19, 1.00, 26.46 when the LSI is ≥
functional Isokinetic quadriceps and Hop tests (single, triple, Triple hop LSI<98.5 90 % in isokinetics
discharge hamstring strength test at 180 triple crossover and 6-m OR >98.5 for females PPV+=46.15% and hop tests
criteria deg/s and 300 deg/s; 4 hop tests timed); with high knee related
(90% and 95%); KOOS-QoL confidence from
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score; IKDC score;
Dynamic clinical assessment
KOOS-QoL subscale; KOOS QoL subscale)
compared to low risk
(e.g., Anterior-posterior knee IKDC score group.
laxity using CompuKT
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arthrometer at 20° knee flexion).
Wellsandt et al. Limb symmetry Quadriceps strength (LSI 90%); Quadriceps strength test; LSIs ≥90% for LR+=0.596; 95% Risk is decreased
(2017) index of 4 hop tests (LSI 90%); Hop test (single, triple, quadriceps strength CI: 0.218, 1.627 when the LSI is ≥
functional KOS-ADL (90%); triple crossover and 6-m and all 4 single leg 90 % in isokinetics
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discharge GRS (90%) timed); hop tests. and hop tests

criteria KOS-ADL;
GRS
/HR decreased
Ahmed et al. Clinical and Instrumented tests of laxity IKDC score Mean PTS ≥ 110, Not reported Not reported
(2017) radiological using KT 1000; p < 0.001
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outcomes IKDC scores (knee function and Mean time between
radiographic assessment); primary
Measures of PTS using OsiRix reconstruction and
software (PTS ≤12°) failure: 5.8 years
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(2months-20.5years)
Kyritsis et al. Limb symmetry Quadriceps strength test (90%); Quadriceps strength test LSIs < 90% HR=4.1, 95% CI: Risk is increased
(2016) index of 6 3 hop tests (90%); quadriceps strength 1.9, 9.2; p≤0.001 when the LSI is <
functional On-field sports specific Hop test (single, triple and all 3 single leg 90 % in isokinetics
discharge rehabilitation; and triple crossover) hop tests. and hop tests
criteria Running-t test On-field sports specific
rehabilitation tests; Hamstring to HR=10.6, 95% CI: Risk is increased
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Quadriceps ratio in 10.2, 11; p=0.005 when the
Running-t test involved leg at 60°/s Hamstring to
(per 10% difference) Quadriceps ratio is
decreased at 60°/s
Grindem et al. Limb symmetry Isometric strength test (90%) Isometric strength test; Scores > 90% on all HR=0.16; 95 % CI: Risk is decreased
(2016) index of 4 hop test (90%) Hop test (single, triple, tests 0.02, 1.20; p=0.075 when the LSI is ≥
functional KOS-ADL (90%) triple crossover and 6-m 90 % in isokinetics
discharge
criteria
GRS (90%)
C timed);
KOS-ADL;
GRS
and hop tests
Granan et al. Knee function KOOS QoL (< 44) KOOS QoL KOOS QoL< 44 RR=3.7; 95 % CI: Risk is increased
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(2015) 2.2, 6.0 when the KOOS
value is < 44 points
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Paterno et al. Biomechanical Not reported DVJ (full 3-D motion Hip extension rotator OR=8.4; 95% CI: Risk is increased
(2010) measures (participants have already been analysis); moment (initial 10% 2.1, 33.3; p<0.01 when net hip
cleared to RTS and were already of landing) < 1.1×10-3 extension rotator
active) Postural stability Nm/kg moment during the
assessment initial 10% of
/HR decreased
stance is < 1.1×10-3
Nm/kg
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Frontal plane (valgus) OR=3.5; 95% CI: Risk is increased
ROM > 12.1µ 1.3, 9.9; p=0.03 when the frontal
plane motion value
is > 12.1µ
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Side-to-side OR=3.3; 95% CI: Risk is increased
difference 1.2, 8.8; p=0.03 when side-to-side
(asymmetry) in asymmetry is >
sagittal plane knee 2.8×10-2 Nm/kg
moments at the point
of initial contact >
2.8×10-2 Nm/kg
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Postural stability on OR=2.3; 95% CI: Risk is increased
involved limb; mean 1.1, 4.7; p=0.03 when mean degree
degree of deflection of deflection is <
score < 4.07°±2.06° 4.07±2.06°
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Appendix 1: Study quality assessment of included studies using Newcastle-Ottawa Scale
*represents the individual criterion within the sub-group was full-filled
-means the individual criterion within the sub-group was not full-filled
Quality Assessment Criteria Acceptable (*) Paterno et al. Paterno et al. Wellsandt et Ahmed et al. Kyritsis et Grindem et al. Granan et al. Paterno et al.
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Not acceptable (-) (2018) (2017) al. (2017) (2017) al. (2016) (2016) (2015) (2010)
Selection
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Representativeness of exposed Representativeness of average in - * - - - * * -
cohort? communinty (age/sex/primary
ACLR/completed rehabilitation/RTS
clearance/risk of ACL reinjury)
Selection of non- exposed cohort? Selected from the same community * * * * * * * *
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as exposed cohort
Ascertainment of exposure? Secured records, Structured * * * * * * * *
interview
Demonstration that outcome of Clearance to return to high-level * * * * * * * *
interest was not present at start of (level 1 or 2) sports/play/athletic

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study? activity by physician and
rehabilitation team
Comparability
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Study controls for age and sex? Yes Age + Age + Age + Age + Age + Age + Age + Age +
Sex – Sex + Sex + Sex + Sex – Sex + Sex + Sex +
(-) (*) (*) (*) (-) (*) (*) (*)

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Study controls for any additional Type of graft, Time since surgery, * * * * * * * *
factors? Time to reinjury/graft failure, Cause
of re-injury, Height, Weight, BMI,
Quality Assessment Criteria Acceptable (*) Paterno et al. Paterno et al. Wellsandt et Ahmed et al. Kyritsis et Grindem et al. Granan et al. Paterno et al.
Not acceptable (-) (2018) (2017) al. (2017) (2017) al. (2016) (2016) (2015) (2010)
Objective functional meaures
(Isokinetic quadriceps strength test,
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Hop tets: single leg hop for distance,
triple hop for distance, crossover
hop for distance, 6m timed hop,
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runnign t test), Postural stability
(balance test), S
ubjective/self report
outcomes:Psychological measures
(TSK-11, ACL-RSI); KOOS, IKDC,
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GRS and KOS-ADLS;
Biomechanical measures, A-P knee
laxity etc
Outcome
Assessment of outcome? Independent blind assessment - * * * * * * *
Was follow-up long enough for

record linkage
Follow-up ≥ 2 years
C * * * * * * * -
outcomes to occur?
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Adequacy of follow-up of cohorts? Complete follow-up, or participants * * * - * * - *
lost to follow-up unlikely to

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introduce bias
Overall Quality Score (Maximum = 9) 6 9 8 7 7 9 8 7

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Accepted for Publication: 3 December 2019

Copyright © 2019 American College of Sports Medicine

Return to Sport Tests’ Prognostic Value for Reinjury Risk

after ACL Reconstruction

Environmental Medicine, Goethe University, Frankfurt am Main, Germany; 2Department of

Name: Prof. Dr. Dr. Winfried Banzer

Environmental Medicine, Theodor-Stern-Kai 7, Haus 9B,

60590 Frankfurt am Main, Germany.

presented clearly, honestly, and without fabrication, falsification, or inappropriate data

injury; hop; isokinetic; rehabilitation

vital clinical tool in determining readiness to RTS.

artificial and does not necessarily reflect real circumstances.

clearance decisions, this important clinical decision needs to be predicated on dependable

of the risk for an ACL re-injury.

registered (available at: http:www.crd.york.ac.uk/PROSPERO/display_record.php?ID=

Inclusion criteria for studies

We included prospective non-randomized studies published in English or German.

independent and re-injury rates as dependent variables.

functional tests-values for further participants’ stratification into experimental or therapeutic

ACL rupture, had subsequent reconstruction and rehabilitation.

ligament injury patients whose injury was conservatively/non-operatively managed, were

target effect estimators.

were searched for using the following search terms:

("anterior cruciate ligament") AND ("re-rupture" OR recurrence OR re-rupture OR "graft

function* OR “Postural control” OR balance OR Hop OR Isokinetic OR strength OR isometric

OR “limb symmetry index” OR jump OR performance)

non-commercial form) were also considered using similar terms in www.guidelines.gov,

www.opengrey.eu, www.clinicaltrials.com and www.controlled-trials.com. After study retrieval,

An initial comprehensive exploratory electronic database search was conducted by two

necessary, to address any disparities.

flaws,(14) (e.g., 20% or higher rate of dropout in a specific study group).

Assessment of study quality

Comparability and Outcome. The corresponding items are as follows:

Appendix 1 (Study quality assessment of included studies using Newcastle-Ottawa Scale).

evidence were used to describe the findings.

Selection of included studies

Synthesis and description of the included studies

a checklist is displayed in Supplemental Digital Content (see Table, Supplemental Digital

Content 1, PRISMA 2009 Checklist, http://links.lww.com/MSS/B879). The details of the study

of included studies using Newcastle-Ottawa Scale, http://links.lww.com/MSS/B880). One

from 16.2 to 29.2 years.

Characteristics of included studies

studies had participants from different surgeons,(23) hospitals,(24) or a national ACL

RTS and number of re-injuries) from the included studies.

details of these criteria are summarized in Table 2.

% CI 21.2–47.5). Paterno et al.,(26) again conducted a prognostic biomechanical screening study

Objective functional criteria

to assess re-injury risk.

Limb symmetry index of strength and hop tests

they are compared to re-injury or reference values.

a further ACL injury.

Kinematics and kinetics during drop jump landings

other studies,(43,44) which have identified changes in movement patterns demonstrated by

patients after initial ACLR as possible assessors of an ACL re-injury risk.

Clinical practice implications

example following the stepwise/gradual progressing recommended in Logerstedt et al. (46) ,

distance as RTS battery of tests.

Limitations of this review

functional tests and re-injury risk.

What is known about the subject:

 Neuromuscular function measures of quadriceps strength, hop tests, KOOS-QoL sub-