Knee Surg Sports Traumatol Arthrosc
DOI 10.1007/s00167-014-3261-5
Knee
Predictive parameters for return to pre‑injury level of sport
6 months following anterior cruciate ligament reconstruction
surgery
Ulrike Müller · Michael Krüger‑Franke ·
Michael Schmidt · Bernd Rosemeyer 
Received: 24 October 2013 / Accepted: 21 August 2014
© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2014
Abstract  distance (p = 0.005), crossover hop (p = 0.008) and triple
Purpose  The aim of the study was to find predictive
parameters for a successful resumption of pre-injury level
of sport 6 months post anterior cruciate ligament (ACL)
reconstruction.
Methods  In a prospective study, 40 patients with a rup-
tured ACL were surgically treated with semitendinosus
tendon autograft. Six months after surgery, strength of
knee extensors and flexors, four single-leg hop tests, Ante-
rior Cruciate Ligament–Return to Sport after Injury Scale
(ACL–RSI), subjective International Knee Documentation
Committee (IKDC) 2000 and the Tampa Scale of Kinesio-
phobia-11 (TSK-11) were assessed. Seven months post-
operatively, a standardized interview was conducted to
identify “return to sport” (RS) and “non-return to sport”
(nRS) patients. Logistic regression and “Receiver Operat-
ing Characteristic” (ROC) analyses were used to determine
predictive parameters.
Results No significant differences could be detected
between RS and nRS patients concerning socio-demo-
graphic data, muscle tests, square hop and TSK-11. In nRS
patients, the Limb Symmetry Index (LSI) of single hop for
U. Müller (*) 
Department of Orthopaedics, Physical Medicine
and Rehabilitation, University of Munich, Marchioninistrasse 15,
81377 Munich, Germany
e-mail: Ulrike.Mueller@med.uni‑muenchen.de
M. Krüger‑Franke · B. Rosemeyer 
MVZ Nordbad, Schleißheimerstrasse 130, 80797 Munich,
Germany
M. Schmidt 
Department of Medical Informatics, Biometry and Epidemiology
of the Faculty of Medicine, University of Munich,
Marchioninistrasse 15, 81377 Munich, Germany
hop (p = 0.001) were significantly lower, in addition to the
ACL–RSI (p  = 0.013) and IKDC 2000 (p  = 0.037). The
cut-off points for LSI single hop for distance were 75.4 %
(sensitivity 0.74; specificity 0.88), and for ACL–RSI 51.3
points (sensitivity 0.97; specificity 0.63). Logistic regres-
sion distinguished between RS and nRS subjects (sensitiv-
ity 0.97; specificity 0.63).
Conclusions  The single hop for distance and ACL–RSI
were found to be the strongest predictive parameters, assess-
ing both the objective functional and the subjective psycho-
logical aspects of returning to sport. Both tests may help to
identify patients at risk of not returning to pre-injury sport.
Level of evidence  II.
Keywords  Anterior cruciate ligament rupture · Operative
reconstruction · Return to sport · Predictors
Introduction
The most common ligament injury of the knee joint is the
tearing of the anterior cruciate ligament (ACL) [9, 43]. In
Germany, approximately 35,000 ACL ruptures are reported
annually (raw incidence 45:100,000), with women being
more often affected than men [6, 22]. Most patients harm
themselves without direct physical contact, particularly in
sports involving pivoting, cutting and jumping [43]. About
28,000 ACL operations are performed in Germany per year
[22]. Giving-way episodes, as well as the hope to regain
full sport activities, are reasons to consider surgical therapy
[2, 6].
With regard to the knee joint, sport activities can be
classified into four levels [17]. Level I is comprised of
sports that involve jumping, pivoting and hard cutting
13

movements, such as football or soccer [17]. Level II
describes activities such as tennis or skiing, level III
activities such as jogging, cycling or swimming and
level IV activities of daily life. If patients want to return
to their pre-injury sport level after surgery, the appro-
priate time point for restarting is essential. Currently,
no scientifically established time point exists. Based
on empirical data, a number of authors suggest return-
ing to level I and level II sports approximately 6 months
post-surgery [2, 13, 15, 29]. According to a review by
Barber-Westin et al. [5], one-third of the 264 analysed
studies considered the time factor as the only criterion,
while only 13 % utilized individual-based objective cri-
teria. This is in line with a recently published review by
Petersen and Zantop [39].
Objective criteria, for instance, include muscle strength
and single-leg hop tests [5, 13, 16, 24, 33, 47]. Single-leg
hop tests allow for a more comprehensive assessment of
the functional capacity of the knee joint [29]. The single
hop for distance, crossover hop for distance, triple hop for
distance and 6-m timed hop test are most often applied [5,
13, 16, 24, 33, 47]. Assessed is the Limb Symmetry Index
(LSI), the ratio of the operated leg to the non-operated leg.
As a criterion for returning to sport, LSI values of muscle
strength and/or single-leg hop tests above 85 % [5, 13, 24,
33] or 90 % [5, 16, 24, 35, 47], respectively, are recom-
mended. For participation in sport activities with frequent
pivoting movements, a value of 100 % is suggested [47].
Several authors have proposed decision criteria for return-
ing to sport using special equipment [5, 13, 16, 24, 33, 47].
However, their implementation into daily clinical routine
is not possible. Myer et al. [35] took this into account by
defining three single-leg hop tests as part of a test battery to
evaluate the operated knee.
There is strong evidence that psychological factors,
such as fear of pain, fear of re-injury and deficient confi-
dence, have a great influence on returning to sport [2, 4,
46]. A considerable number of patients do not return to
their pre-injury level of sport despite successful rehabilita-
tion and satisfactory physical recovery [2, 24, 25, 27]. To
investigate such psychological factors, various self-report
questionnaires are in use, such as the Tampa Scale of Kine-
siophobia, the Emotional Response of Athletes to Injury
Questionnaire or the Anterior Cruciate Ligament–Return to
Sport after Injury Scale [7, 8, 25, 27, 30, 49].
The aim of the study was to define parameters—func-
tional tests and/or self-report questionnaires—that can
be used to predict the successful resumption of pre-injury
level I and level II sports 6 months after ACL reconstruc-
tion. These parameters may be helpful in the clinical deci-
sion of clearing a patient to return to sport. The 6-month
time point was chosen as many surgeons decide about
clearance for returning to sport at this time.
13
Knee Surg Sports Traumatol Arthrosc
Materials and methods
The study was designed as a prospective controlled trial
with a cohort of 40 patients after ACL reconstruction sur-
gery. Patients underwent surgical treatment from July
2011 to March 2012 at Medizinisches Versorgungszentrum
(MVZ) Nordbad-Munich. All of the patients received the
same treatment and rehabilitation, according to a standard
scheme [32]. The surgical treatment consisted of an arthro-
scopic evaluation of the injured joint and the management
of the ruptured ACL in an anatomic single-bundle technique
with a fourfold semitendinosus tendon and bioabsorbable
interference screw fixation (Matryx, Linvatec–Conmed).
Inclusion criteria were an isolated rupture of ACL, age
between 18 and 65 years and the intension to return to
their pre-injury level I or level II recreational sports [17].
At the 6-month surgeon’s examination, the operated knee
joint had to be free of pain, without irritation, and had pas-
sively full range of motion. The Lachman and Pivot Shift
Test had to be positive. The patients had to be able to stand
and hop on the operated leg and did not report a subjective
feeling of instability. They had to be able to perform level
III activities without symptoms. Permission for returning to
pre-injury sport level was given by the surgeon if the above
clinical criteria were fulfilled.
Exclusion criteria were concomitant injuries, such as
injuries involving lateral ligaments or menisci, adjacent
joints (hip or foot) or the contralateral leg. Patients with
other orthopaedic, internal, neurological or psychiatric dis-
eases, as well as pregnant women, were excluded.
From a cohort of 186 operated ACL patients, 112 were
excluded due to concomitant or prior injuries or because
of age [23]. Fifty-nine of the remaining 74 patients could
be contacted for the 6-month examination. Eleven of these
patients had not performed any level I and level II sports
before surgery. The remaining 48 patients were informed
about the study and asked whether they would be willing
to participate. At the 6-month examination by the surgeon,
40 of the 48 patients fulfilled the inclusion criteria (Fig. 1).
The study was designed according to the guidelines
of the Helsinki International Conference on Harmoniza-
tion—Good Clinical Practice. The ethics committee of the
Bavarian State Chamber of Physicians (Landesaerztekam-
mer) stated that no approval for the study was required.
All patients in the study signed informed consent prior to
inclusion.
Assessment instruments and procedure
The assessment by the same physical therapist was per-
formed the same day, but subsequent to the surgeon’s
examination. The assessment instruments included 4
questionnaires, followed by six functional tests. The first
Knee Surg Sports Traumatol Arthrosc

ACL-reconstruction questionnaire assessing the psychological impact (emo-

01.07.2011-31.03.2012 tions, confidence in performance and risk appraisal) of
n=186 Concomitant injuries,
re-rupture, age returning to sport after ACL reconstruction surgery [49].
n=112 The questionnaire has high reliability, validity and test–
Isolated ACL rupture
n=74
retest reliability [26, 49], and was recently translated into
German language [31].
No contact For the functional testing, the patient warmed up using
n=15
Contacted for study stationary cycling at 50 W over 5 min. All functional clini-
n=59 cal tests were performed with the non-operated leg first.
The tests started with an isometric muscle strength meas-
Level III and IV
n=11 urement instead of an isokinetic strength measurement
[13, 16]. The Pearson correlation coefficient for the rela-
Level I and II,
Consent to participate tionship between isometric and isokinetic muscle strength
n=48 measurements in healthy subjects for knee extensors and
knee flexors is 0.74 (p < 0.0001) and 0.77 (p < 0.0001),
respectively [40]. The maximal isometric strength of the
Medical examination functional muscle groups is measured in a defined position
n=48 with a hand-held isometric strength device (Wagner Force
Inclusion criteria Dial TM model FDL) with good reliability and validity [19,
not met
Assessment n=8 44, 45]. The test was performed analogous to the method
n=40 described by Huber et al. [19]. Each patient underwent two
tests with a 20-s rest between the measurements. The bet-
ter result was recorded. The Limb Symmetry Index (LSI),
Telephone interview as well as the ratio of flexors to extensors, were calcu-
n=40
lated. Afterwards, the single-leg hop tests were performed
Scalet fever in the following order: single hop for distance, crossover
n=1
hop for distance and triple hop for distance, analogous to
Return to sport Non return the description by Myer et al. [35]. In patients with ACL
n=31 to sport reconstruction surgery, the tests show high reliability and
n=8
validity [41]. Each hop test was performed 3 times on the
respective leg with a 60-s rest in between. The longest dis-
Fig. 1  Flow chart for participants’ enrolment tance was used for calculating the LSI. The square hop test
has high reliability [14, 38] and was performed according
to the description by Gustavsson et al. [14]. It was executed
questionnaire inquired about socio-demographic data, twice on each leg with a rest of 2 min in between each. The
cause of injury and sports activities (current and before highest number of valid hops was used for evaluation.
surgery). The second questionnaire was the latest edition One month after assessment (i.e. 7 months after sur-
[1] of the International Knee Documentation Committee gery), the patient was called and in a standardized man-
(IKDC) subjective knee evaluation form, a knee-specific ner, the patient was asked about the level of sport he or she
10-item questionnaire measuring symptoms, function and had returned to, the average time spent per week and the
sport activities [20]. The IKDC subjective knee evaluation type/intensity of symptoms that might have occurred. The
form is valid and reliable for ACL injuries with a signifi- discrimination between return and non-return to sport was
cant test–retest reliability [20] and is used as criterion for made at this point. Patients who had not returned to their
returning to sport after ACL reconstruction [13, 33]. The pre-injury level of sport were asked for their reasons. In the
Tampa Scale for Kinesiophobia (TSK) is a questionnaire current study, “return to sport” is defined as the resumption
assessing pain-related fear of movement [21]. It is appro- of pre-injury level of sport, but does not imply immediate
priate for patients after ACL reconstruction [7, 8, 12]. The return to unrestricted activity.
TSK-11 was shortened from the original version by remov-
ing 6 psychometrically weak items, with a total of 11 items Statistical methods
remaining on the questionnaire [52]. The validity, reli-
ability and test–retest reliability of both questionnaires are The mean and standard deviation were calculated by using
comparable [52]. The Anterior Cruciate Ligament–Return conventional methods. The combined group of level I and
to Sport after Injury Scale (ACL–RSI) is a specific 12-item level II (return to sport) patients was compared with level

13
 Knee Surg Sports Traumatol Arthrosc

III (non-return to sport) patients. To analyse confounding
factors in the socio-demographic data, the Mann–Whitney
U or Fisher’s exact test was applied. The assessed param-
eters of the functional tests and the scores of the question-
naires were tested for normal distribution using the Kol-
mogorov–Smirnov test. Group differences were examined
with the Mann–Whitney U test or Student’s t test, where
applicable.
The correlations were calculated using Pearson’s cor-
relation coefficient and illustrated with the respective r, R2
und p value. The cut-off points of the functional tests and
the questionnaires were determined using a ROC analysis
and area under the curve (AUC) statistics. Using the step-
wise forward method, the variables of the functional tests
and the questionnaires were simultaneously analysed in a
binary logistic regression model. The significance level was
defined as p < 0.05. The presented evaluations were carried
out using an explorative approach. The statistics were cal-
culated with Gnu R software (version 2.15.2).
Results
Socio‑demographic data
Table 1 shows the socio-demographic data of the RS group
(level I and level II) in comparison with the nRS group
(level III). There were no significant differences between
the two groups.
The time between operation and assessment was
6.2  ± 0.3 months in both the RS patients and the nRS
Table 1  Sociodemographic data of level I + II and level III patients
Level I + II Level III
patients (n.s.). The time between assessment and the tel-
ephone interview was 30.9 ± 1.2 in the RS patients and
30.0 ± 1.9 days in the nRS patients (n.s.). Due to a diag-
nosis of scarlet fever in one patient, the final study group
consisted of 39 patients.
Return to level I and II sport activities
Prior to injury, 23 patients had been active in level I sports
and 17 in level II sports. Of the 23 patients, 18 (78.3 %)
had returned to a level I sport, 4 patients had remained in
a level III sport, and one patient dropped out. Of the 17
patients in a level II sport, 13 (76.5 %) had returned to
the pre-injury level of sport and 4 remained in a level III
sport.
Functional tests
The mean LSI values of knee flexors and extensors are
shown in Table 2. The mean values of the knee flexors were
distinctly lower than those of knee extensors. The means
of the nRS patients for knee flexors and extensors were
slightly, but not significantly, lower than those of the RS
patients. Likewise, the quotient between knee flexors and
extensors did not differ significantly.
When comparing single-leg hop tests of the RS patients
(range 86 to 92 %) with the nRS patients (range 62 to
84 %), significant differences were observed for the single
hop for distance (p = 0.005), the crossover hop (p = 0.008)
and the triple hop (p = 0.001) (t test), but not for the square
hop.
With regard to age, no significant difference between
the two age groups (<30 years vs. ≥30 years) was seen for
muscle strength and hop tests. A gender-specific significant
p value

Number of patients 31 8
Table 2  Six-month LSI values and questionnaire scores
Sex male/female (%) 61.0/39.0 25.0/75.0 n.s. (2)
Age at surgery (years) 31.4 ± 10.3 33.0 ± 10.5 n.s. (1) Parameter Level I + II Level III p value
Body weight (kg) 74.3 ± 14.2 69.0 ± 14.2 n.s. (1)
LSI knee flexors (%) 76.3 ± 13.1 69.1 ± 20.3 n.s. (3)
Height (cm) 176.0 ± 9.8 173.8 ± 9.5 n.s. (1)
LSI knee extensors (%) 88.6 ± 7.9 79.7 ± 22.0 n.s. (1)
Operated leg left/right 18/13 4/4 n.s. (2)
LSI flexors/extensors (%) 86.5 ± 15.2 91.1 ± 32.6 n.s. (1)
Sport before injury (h per week) 8.6 ± 3.7 9.4 ± 4.1 n.s. (1)
LSI single hop (%) 85.6 ± 20.0 61.7 ± 20.5 0.005 (3)
Injury during sport yes/no 27/4 8/0 n.s. (2)
LSI crossover hop (%) 91.9 ± 14.3 75.1 ± 18.5 0.008 (3)
Time between injury–surgery 13.3 ± 19.2 30.6 ± 39.3 n.s. (1)
LSI triple hop (%) 88.3 ± 10.1 72.1 ± 13.1 0.001 (3)
(weeks)
LSI square hop (%) 87.5 ± 20.4 83.8 ± 44.6 n.s. (1)
Time between surgery–level III 9.2 ± 3.1 10.8 ± 4.1 n.s. (1)
sport (weeks) TSK-11 19.0 ± 4.7 21.6 ± 5.0 n.s. (3)
Sport duration level III (h per 4.4 ± 3.0 3.8 ± 1.7 n.s. (1) ACL–RSI scale 76.8 ± 15.0 48.7 ± 27.2 0.013 (1)
week) IKDC 2000 81.7 ± 9.5 74.0 ± 6.5 0.037 (3)

Mean, standard deviation, (1) Mann–Whitney U test, (2) Fisher’s Mean, standard deviation, (1) Mann–Whitney U test, (3) Student’s t
exact t test test
Level I and II return to sport patients, level III non-return to sport Level I and II return to sport patients, level III non-return to sport
patients patients

13
Knee Surg Sports Traumatol Arthrosc

difference was found only in the LSI score of the single hop
for distance (men 88.3 ± 17.3 %/women 72.3 ± 23.6 %;
p = 0.022; Mann–Whitney U test).
Questionnaires
The mean values of the ACL–RSI, the TSK-11 and the
IKDC 2000 are shown in Table 2. The RS patients scored
significantly higher on the ACL–RSI scale (p  = 0.013;
Mann–Whitney U test) and the IKDC 2000 (p  = 0.037; t
test). The values of the TSK-11 showed a slightly higher
score in the nRS patients (n.s.). No significant gender or
age-specific differences were observed.
Correlation between functional parameters
and questionnaires
No significant correlation was found between muscle
strength and the scores of the 3 questionnaires (Table 3).
A minor correlation existed between the ACL–RSI and
the IKDC 2000 with regard to the single hop for distance
(r = 0.36, p = 0.023; r = 0.35, p = 0.028) and the triple
hop (r = 0.41, p = 0.009; r = 0.47, p = 0.002). Also, there
was a small correlation between the IKDC 2000 and square
hop by r = 0.32, p = 0.046.
Cut‑off points as predictive parameters

Complaints and return to pre‑injury level of sport
In the telephone interviews, 18 of the 39 patients com-
plained of symptoms on the operated knee that were related
to their sport activities during the previous 4 weeks (pain,
swelling, feeling of instability); 21 patients had no symp-
toms. The symptoms occurred mostly during or shortly
after sport activity. Symptoms were found to be nearly
equal between the RS and nRS patients, and further analy-
sis of the subgroups with and without symptoms showed no
relationship between the symptoms and the results of mus-
cle strength and single-leg hop tests, except for the crosso-
ver hop (symptoms yes/no p  = 0.044; Mann–Whitney U
test).
The AUC and the cut-off points, indicating the threshold
for inclusion into either the RS or the nRS patient group,
together with sensitivity, specificity and accuracy, are pre-
sented in Table 4. Only parameters with significant p values
are listed. The AUC revealed moderate-to-good discrimina-
tive accuracy for the single hop for distance, crossover hop,
triple hop as well as the ACL–RSI and IKDC 2000 ques-
tionnaires (Table 4).
The single hop for distance had a high specificity (0.88)
and high sensitivity (0.74), while the ACL–RSI had a very
high sensitivity (0.97) and moderate specificity (0.63).
When both cut-off points were applied together, all eight
nRS patients could be assigned correctly, and of the 31 RS
patients, 23 were assigned correctly.

Table 3  Correlations between Parameter ACL–RSI TSK-11 IKDC 2000

LSI values and scores of
questionnaires r p value r p value r p value

LSI knee flexors 0.24 n.s. −0.20 n.s. 0.21 n.s.

LSI knee extensors −0.02 n.s. 0.02 n.s. 0.12 n.s.
LSI flexors/extensors 0.25 n.s. −0.26 n.s. 0.11 n.s.
LSI single hop 0.36 0.023 −0.05 n.s. 0.35 0.028
LSI crossover hop 0.19 n.s. −0.10 n.s. 0.25 n.s.
LSI triple hop 0.41 0.009 −0.08 n.s. 0.47 0.002
Presented are Pearson’s r with LSI square hop −0.03 n.s. 0.07 n.s. 0.32 n.s.
corresponding p values

Table 4  AUC values and cut-off points

Parameter p (I + II/III) AUC Cut-off Sensitivity Specificity Accuracy

LSI single hop 0.005 (3) 0.823 75.4 % 0.74 0.88 0.77
LSI crossover hop 0.008 (3) 0.762 77.2 % 0.87 0.75 0.85
LSI triple hop 0.001 (3) 0.839 90.2 % 0.55 1.00 0.64
ACL–RSI scale 0.013 (1) 0.790 51.3 0.97 0.63 0.90
IKDC 2000 0.037 (3) 0.712 78.7 0.58 0.88 0.64

(1) Mann–Whitney U test, (3) Student’s t test

Level I and II return to sport patients, level III non-return to sport patients

13

Logistic regression analysis
A logistic regression analysis with binary outcome “return
to pre-injury sport level YES/NO” was applied to the
parameters. Age and gender were not introduced into the
model since they were not significant (age p = 0.477; gen-
der p = 0.872). The final model consisted of the parameters
ACL–RSI (OR for an increase of 10 units 1.83; p = 0.018)
and LSI single hop for distance (OR for an increase of 10
units 1.78; p = 0.042), which leaded to an AUC of 0.91 and
an accuracy of 0.90.
Using the logistic model, 35 out of the 39 patients could
be assigned correctly. Of the 31 RS patients, 30 could be
identified as such, which corresponded to a sensitivity of
0.97. Of the eight nRS patients, five could be identified,
which corresponded to a specificity of 0.63.
Discussion
The important findings of the present study are that RS and
nRS patients differ significantly regarding single-leg hop
tests and the ACL–RSI score. The single hop for distance
and ACL–RSI scale were the strongest predictive param-
eters for assessing return to sport.
Out of the 39 patients, 31 (79.5 %) successfully resumed
their pre-injury level of sport, while 8 patients remained
in a level III sport. A number of authors consider the time
point of 6 months to be appropriate for a return to level I
and II sports [2, 5, 13, 14, 29], while others permit return-
ing after 4 months [10, 18]. It appears that women take
longer to return, but finally reach the same rate as men [3].
In our cohort, 6 women and 2 men did not return to their
sport. Age seems to play a role, and patients older than
32 years of age returned to sport significantly less often
than did patients younger than 32 years [3].
Differences between RS and nRS patients
In the nRS patients, LSI values of knee extensors and knee
flexors were slightly, but not significantly, lower than in
the RS patients. The LSI mean values of knee extensors in
RS patients were in the range of 88.6 ± 7.9 %, which is
consistent with the results of most other authors [37, 48,
51]. The LSI mean values of knee flexors reported by other
investigators are often higher than the values in this study
(76.3  ± 13.1 %) [16, 37, 48, 51]. It is documented, how-
ever, that LSI for knee flexors in patients with a semiten-
dinosus tendon graft, as used in this study, was distinctly
lower than in patients with patellar tendon graft, 6 months
after surgery [29, 48]. It is known that the LSI values of
knee flexors and extensors improve continuously from 3 to
6 and 12 months post-surgery [16, 48, 51].
13
Knee Surg Sports Traumatol Arthrosc
Similar to muscle strength, hop tests improve continu-
ously at 3, 6 and 12 months post-surgery [16, 48, 51]. In
the nRS patients, LSI values of the single-leg hops for
distance were significantly lower (62–75 %) than those of
the RS patients. The LSI means for the single-leg hops for
distance of the RS patients ranged between 86 and 92 %,
which corresponds to ranges reported by other authors [42,
48, 51]. The LSI mean of the square hop of the RS patients
was 87.5 ± 20.4 % and thus was higher than the value
reported by Thomeé et al. [48]. In contrast, the square hop
did not differ significantly. Although the patients performed
the square hop as the last test, the aspect of endurance and
fatigue in the present collective did not seem to be an issue.
Several authors recommended LSI values of muscle
strength and/or single-leg hops above 85 % [5, 13, 24, 33]
or 90 % [5, 16, 24, 35, 47], respectively, as criterion for
returning to sport. According to Thomeé et al. however,
at 6 months post-surgery, only 70 % of the patients had
reached an individual LSI value of ≥85 % of the knee flex-
ors and only 25 % of the knee extensors [48]. Even after
12 months, a large number of patients would not have met
the recommended criterion of 85 % [48]. The same applies
to the single-leg hop tests [48]. Wells et al. described a sim-
ilar finding regarding the muscle strength of knee extensors
in an investigation with juvenile athletes [50]. The crite-
rion of ≥85 % for returning to sport was met, irrespective
of gender, after 6 months by 59 % and after 10 months by
78 % of the participants. However, 18 % of the participants
had not achieved the required criterion, even after 1 year
[50].
The criteria quoted in the literature are purely empirical
values [24]. In a study on healthy athletes, the strength of
the strongest and the weakest leg was compared and a max-
imum difference of 4–16 % was found [24, 44]. Therefore,
it was proposed to accept about 15 % as greatest deficiency
in muscle strength before allowing the patient to return to
sport [24]. For the single-leg hop tests, by contrast, no dif-
ference could be established [38].
The most common reasons for not returning to sport
according to Kvist et al. [25] were “problems with knee
function”, as well as “fear of re-injury”. This is consistent
with the findings of Ardern et al. [2], Flanigan et al. [11]
and Lee et al. [28]. In the present study, all 8 nRS patients
indicated fear of re-injury and 3 patients indicated feel-
ing of joint unsteadiness as reasons for not returning to
sport. Correspondingly, the ACL–RSI scores of the 8 nRS
patients were significantly lower (48.7 ± 27.2) than the
scores of the RS patients (76.8 ± 15.0; p  = 0.013), sug-
gesting that in the nRS group, psychological aspects have
an important impact on athletes’ return to sport, which is
consistent with the previous studies [4, 27, 49]. In a follow-
up of 3, 6 and 12 months following ACL reconstruction,
the ACL–RSI score improved continuously in both the RS
Knee Surg Sports Traumatol Arthrosc
and the nRS group (p < 0.001) [27], which suggests that
patients developed an increasingly positive attitude towards
returning to sport during rehabilitation. However, an impor-
tant fact was that the ACL–RSI scores of nRS patients after
6 and 12 months remained significantly lower (p = 0.005)
than did those of the RS subjects [27]. When comparing
various psychological variables, Ardern et al. [4] demon-
strated that the ACL–RSI is the variable with the best dis-
criminative capabilities for returning to sport. In summary,
results in the literature and also in this study suggest that
the ACL–RSI scale can be applied during an early stage of
rehabilitation to identify patients that are psychologically
insufficiently prepared to return to their sport. In those
patients, an appropriate treatment may be considered in
order to develop more confidence in the performance of the
operated knee [4, 25, 27].
Predictive parameters for return to sport
Two approaches were used in the attempt to develop a pre-
diction model for returning to pre-injury sport. In the logis-
tic regression analysis, the two strongest parameters were
the single hop test for distance and the ACL–RSI scale.
The two tests consider both the objective functional and
the subjective psychological aspects of returning to sport.
The model allowed to identify 30 of the 31 RS patients cor-
rectly, but only 5 of the 8 nRS patients, corresponding to a
specificity of 0.63, which is not convincing.
The second model provided a higher specificity. In this
approach, the cut-off points of the two strongest param-
eters were used to predict the likelihood of returning to
sport. If the two threshold values were applied to the indi-
vidual data of the patients, all 8 nRS patients were clas-
sified correctly, corresponding to a specificity of 1. Five
of these patients had an ACL–RSI score below the cut-off
point. On the other hand, the model only recognized 23
of 31 patients who in fact returned to sport. Eight patients
returned, although their LSI values of the single hop test
for distance were below the cut-off point. This observa-
tion is in line with the several reports stating that patients
had successfully returned to sport although the subsequent
assessment revealed individual values below the recom-
mended criteria of single-leg hop tests and/or quadriceps
strength [27, 35, 36, 51]. Thus, at the time of clinical
assessment, the model recognized all patients (100 %) who
did not resume their sport and about 74 % of the patients
that resumed their pre-injury sport. There was, however,
a remaining group of patients who successfully returned,
but on the basis of their LSI levels, and according to the
model, would not have been recommended to return at that
point of time. This interesting group needs to be observed
carefully with a longer follow-up to register any adverse
events.
The cut-off model described offers a promising and prac-
ticable instrument to predict the return to sport 6 months
after reconstruction of the ACL. Both tests—the single hop
for distance and ACL–RSI scale—are easy to apply and
may help to identify (a) patients at risk of not returning to
pre-injury sport and (b) the underlying reason—functional,
psychological, or both. However, the instrument needs to
be validated in a larger number of patients before it can be
implemented into routine clinical practice. A larger patient
sample would allow for more precise calculation of the cut-
off points for both variables, as well as their combination.
The results are valid only for patients with isolated ACL
ruptures and cannot be generalized to patients with con-
comitant injuries.
Conclusions
In this study, the single hop for distance and the ACL–RSI
scale were found to be the strongest parameters in predict-
ing the return to pre-injury sport 6 months after ACL recon-
struction. The two parameters consider both the objective
functional and the subjective psychological aspects of
returning to sport. The results of our study encourage an
intensified use of the single hop for distance and the ACL–
RSI scale in decision-making.
Conflict of interest  Authors declare that there is no conflict of
interest with any organization.
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