How Much Time Is Needed Between

Serial ‘‘Return to Play’’ Assessments

to Achieve Clinically Important Strength
Gains in Patients Recovering From Anterior
Cruciate Ligament Reconstruction?
Stephan G. Bodkin,*y MEd, ATC, Margaret H. Rutherford,y BS, David R. Diduch,z MD,
Stephen F. Brockmeier,z MD, and Joe M. Hart,yz PhD, ATC
Investigation performed at the Exercise and Sport Injury Laboratory, University of Virginia,
Charlottesville, Virginia, USA

Background: Pass rates for return-to-play evaluations are alarmingly low for patients after anterior cruciate ligament reconstruc-
tion (ACLR). Since timing of return to play is a complicated decision, it is important that patients be given optimal time to realize
meaningful improvements in strength that warrant additional testing.
Purpose: To (1) compare outcomes among patients assessed at different time points after ACLR, (2) determine strength gains indic-
ative of improvements in subjective function, and (3) determine the amount of time necessary to achieve meaningful strength gains.
Study Design: Cross-sectional/case-control study; Level of evidence, 3.
Methods: A total of 293 patients participated in the study after ACLR (mean 6 SD, 23.2 6 10.1 years old; n = 142 female par-
ticipants; 6.4 6 0.9 months after ACLR). Participants were stratified on the month of their evaluation after ACLR: 5 to 6 months (n
= 122), 6 to 7 months (n = 102), 7 to 8 months (n = 43), and 8 to 9 months (n = 26). The International Knee Documentation Com-
mittee (IKDC) subjective form and knee extensor and flexor torque and symmetry, as assessed through an isokinetic dynamom-
eter, were compared among groups. Forty patients (20 female participants, 20.4 6 7.1 years old) were referred for subsequent
testing (2.14 6 0.78 months after initial visit). Subjective improvement between visits was defined as a 9-point change of the
IKDC score. Thresholds of knee extensor torque and symmetry indicative of subjective improvement and the time between as-
sessments needed to achieve these strength improvements were determined.
Results: Patients between 5 and 6 months (IKDC, 79.7; interquartile range [IQR], 70.1-88.5) had lower subjective function com-
pared to patients between 6 and 7 months (IKDC, 83.9; IQR, 74.5-92.0; P = .019) and 8 and 9 months after ACLR (IKDC, 89.1; IQR
75.8-92.3; P = .026). Patients between 5 and 6 months (1.41 N
m/kg; IQR, 1.16-1.73 N
m/kg]) had lower knee extensor torque
compared to patients 6 and 7 months (1.59 N
m/kg; IQR, 1.23-1.95 N
m/kg; P = .013) and 7 and 8 months after ACLR (1.62
N
m/kg; IQR, 1.30-1.86 N
m/kg; P = .046). Patients between 5 and 6 months (66.4%; IQR, 54.2-78.6) had lower symmetry com-
pared to patients between 6 and 7 months (71.8%; IQR,61.1-82.9; P = .019) and 8 and 9 months afterACLR (75.2%; IQR, 66.6-
87.7; P = .014). Of the 40 patients that completed follow-up assessments, an increase in knee extensor torque of 0.22 N
m/kg and
symmetry of 5.75% discriminated patients that achieved subjective improvement. A period of 1.97 months between assessments
discriminated those that achieved the established symmetry threshold.
Conclusion: Patients demonstrate increasing subjective and quadriceps function when tested at later time points from surgery;
however, the observed values are low, suggesting that at 9 months patients are demonstrating deficits that may be improving.
Approximately 2 months is needed to observe clinically meaningful improvements.
Keywords: knee ligaments; anterior cruciate ligament; limb symmetry; quadriceps; sport clearance; outcome

Injury to the anterior cruciate ligament is common among

young active individuals, with rates up to 200,000 reported
in the United States per year.22 Young active patients who
elect for anterior cruciate ligament reconstruction (ACLR)
The American Journal of Sports Medicine
with the goal of return to high levels of physical activity are
1–8
DOI: 10.1177/0363546519886291 at risk for reinjury,12 inability to return to previous levels of
Ó 2019 The Author(s) activity,2 and early onset of posttraumatic osteoarthritis.1

1
2 Bodkin et al The American Journal of Sports Medicine

After postoperative rehabilitation, performance testing is
often used to provide data that inform return-to-sports
decisions.
Postoperative guidelines for returning to sport have been
based on the patients’ time after surgery.7 To objectively
quantify patient function after ACLR, the use of return-to-
sport assessments has increased among clinicians and
researchers alike. Pass rates for return-to-play evaluations
are alarmingly low for patients after ACLR, with .81% of
patients cleared to return to activity while demonstrating
quadriceps strength asymmetries below the commonly
used limb symmetry threshold of 90%.26 At a mean 7
months after ACLR, a cohort of 88 patients with ACLR
reported a mean isokinetic quadriceps strength symmetry
of just 71%.21 These findings challenge the notion that 6
months is sufficient time to recover lower extremity
strength and highlight the importance of basing decisions
on objective data rather than postoperative time alone.
Objective assessments can be used for more than clear-
ance decisions; they can also be used for periodic determina-
tions of postoperative rehabilitation benchmarks and to
guide treatment programs and progress toward strength
and functional goals. However, the frequency of testing
should be based on the ability of patients to make clinically
meaningful improvements in function. To date, there are no
recommendations of time needed to improve quadriceps
function in patients after ACLR. Previous literature sug-
gests 20 days of training to increase the cross-sectional
area of the rectus femoris within recreationally active
healthy individuals, with increases in fascicle length occur-
ring after 10 days of training.29 However, the time needed to
increase quadriceps strength within patients after ACLR
around the time of return to sport has not been reported.
This information can help providers more effectively pre-
scribe performance tests on patients who are recovering
from ACLR by avoiding unnecessary health care resource
utilization and base recovery expectations on physiologic
response to rehabilitation after surgery. Therefore, there
were 3 aims of this study: aim 1 was to compare outcomes
from an objective testing battery at different time points
after ACLR; aim 2 was to determine strength gains indica-
tive of improvements in subjective function; and aim 3 was
to calculate the amount of time between assessments neces-
sary to achieve those meaningful strength gains.
routine return-to-sports testing in patients undergoing
ACLR. Dependent variables for aim 1 were patient-
reported knee joint function and knee extensor and flexor
peak torque and symmetry. The independent variable
was time since surgery, stratified by months. For aim 2,
dependent variables were knee extensor peak torque and
symmetry. The independent variable was a clinically
meaningful improvement in subjective function (yes/no).
For aim 3, the dependent variable was time between visits,
and the independent variable was change in quadriceps
strength/symmetry (yes/no).
Participants
A total of 293 patients participated in the study after
ACLR. All participants had a history of primary isolated
ACLR, with no surgical complications, conducted at a sin-
gle center by 1 of 5 board-certified, fellowship-trained
sports medicine orthopaedic surgeons with a mean 15.5
years of experience. Patients with meniscal repair or
meniscectomy at the time of ACLR were included because
of the high occurrence. Participants followed the same
postoperative rehabilitation guidelines. Patients were
excluded from the study if they had lower extremity joint
surgery before ACLR, a concomitant ligament reconstruc-
tion, a graft failure, a surgical complication, any lower
extremity injury within 6 months, a concussion within 6
months, or any neurological disorders. This study was
approved by our university’s institutional review board,
and all patients provided written informed consent.
Patients referred to our laboratory completed a battery of
performance assessments between 5 and 9 months after
index surgery with the intention to inform return-to-sports
decision-making timelines. Participants were stratified into
groups based on the timing of their evaluation in months
since ACLR: 5 to 6 months, n = 122; 6 to 7 months, n =
102; 7 to 8 months, n = 43; 8 to 9 months, n = 26. All patients
who achieved below a 90% limb symmetry index (LSI) for
quadriceps strength assessments were strongly encouraged
to return for subsequent testing. Of the 293 total partici-
pants, 40 (13.65%) followed up to perform a repeat test to
track progress before return to sports. These 40 patients
thus formed the cohort used to determine time-based
changes seen with continued rehabilitation.

Lower Extremity Assessment Protocol

METHODS
The Lower Extremity Assessment Protocol (LEAP) is a bat-
This was a cross-sectional descriptive laboratory study con- tery of functional assessments and subjective question-
ducted in a controlled laboratory setting where we perform naires to characterize a patient’s function after a lower

*Address correspondence to Stephan G. Bodkin, MEd, ATC, Department of Kinesiology, University of Virginia, Box 400407, Charlottesville, VA 22904,
USA (email: sgb3d@virginia.edu).
y
Department of Kinesiology, University of Virginia, Charlottesville, Virginia, USA.
z
Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA.
Submitted April 9, 2019; accepted September 18, 2019.
One or more of the authors has declared the following potential conflict of interest or source of funding: D.R.D. receives royalties from Smith & Nephew,
is a consultant for DePuy Mitek and Medical Device Business, and receives hospitality payments from Osteocentric Technologies. S.F.B. receives consul-
tant and education fees from Arthrex Inc; consulting fees from Exactech, DePuy Synthes, Zimmer Biomet Holdings, Medical Device Business, and Micro-
Aire Surgical Instruments; and compensation from Tornier and Supreme Orthopedics Systems. AOSSM checks author disclosures against the Open
Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.
AJSM Vol. XX, No. X, XXXX
Figure 1. CONSORT (Consolidated Standards of Reporting
Trials) flowchart of study patients and procedures.
extremity injury. All assessments were performed by test-
ers trained by the principal investigator (J.M.H.). To stan-
dardize the administration of the assessments, all
assessors followed a procedure operation manual. Patients
are referred to perform the LEAP from their treating phys-
ical therapist or athletic trainer as early as 6 months after
surgery to provide objective information to guide return-to-
play decision making. Patients are then seen by their
treating surgeon to discuss their results and manage the
return-to-sports progression. Our goal for patients is 90%
symmetry for quadriceps peak torque before return to
sports.21 Patients discuss LEAP results with referring pro-
viders and are often scheduled for repeat visits to track
progress. A CONSORT (Consolidated Standards of Report-
ing Trials) chart of patients included in the current study
is available in Figure 1.
Patient-Reported Outcomes
After enrollment, all participants completed the Interna-
tional Knee Documentation Committee (IKDC) subjective
questionnaire to evaluate knee function. This measure
has been shown to be valid and reliable within patients
after ACLR.8,10 Physical activity was quantified through
the Tegner Activity Scale.6
Knee Extension and Flexion Strength
Isokinetic, concentric knee extension and flexion strength
were measured bilaterally with a Biodex System IV dyna-
mometer at a speed of 90 deg/s. All testing was performed
on the uninvolved limb, followed by testing of the involved
limb. The participants completed practice trials on each
limb for practice and familiarization. The participants pro-
vided maximal effort through their full range of motion for
8 trials. All isokinetic data were reviewed for precision
(\15% coefficient of variation). Measures of mean peak
torque for knee extension and flexion were exported from
the multimode System IV dynamometer.
Time Needed Between RTP Assessments 3
Data Processing
Involved Limb and Symmetry Calculations. Unilateral
measures of peak torque were normalized to the partici-
pant’s body weight (N
m/kg). Symmetry measures were
calculated with the following equation: limb symmetry =
involved limb / uninvolved limb.
Statistical Analysis
Aim 1: Time From Surgery. Demographic variables were
compared among groups with 1-way analyses of variance
(groups: 5-6, 6-7, 7-8, and 8-9 months after ACLR) with
post hoc Tukey least significant difference for continuous
data and chi-square tests for categorical variables. The
assumption of normality was assessed with the Shapiro-
Wilk test. The Levene test was used to assess homogeneity
of the data. Measures of subjective and muscular function
were compared among groups through Kruskal-Wallis
tests with the post hoc Dunn test.
Aim 2: Repeat Assessments. A previously defined mini-
mal clinically important difference for the IKDC in
patients after ACLR was defined as a 9-point increase of
the total 100-point scale, as established by Nwachukwu
et al.25 In the current study, ‘‘subjective improvement’’
was operationally defined as an increase in IKDC score
9 points between visits.
Receiver operator characteristic (ROC) curve analyses
were used to establish thresholds of mass-normalized
strength and symmetry needed between assessments to
discriminate between patients who did and did not
improve their subjective function. The independent varia-
bles in this analysis were mass-normalized peak knee
extensor torque and knee extensor symmetry. The depen-
dent variable was the dichotomous variable of subjective
improvement. The thresholds selected for the cutoff value
maximized the sensitivity and specificity. We operationally
defined strength and symmetry over these thresholds as
an ‘‘increase in strength’’ or ‘‘increase in symmetry.’’
Aim 3: Time Necessary for Strength Improvements. A
second ROC curve analysis was then used to establish
a threshold for time needed between visits to discriminate
patients who did or did not increase their strength/
symmetry above the previously established thresholds.
The independent variable for this analysis was time
between visits. The dependent measures were the dichoto-
mous variables of strength and symmetry.
The area under the curve (AUC) for each ROC curve
analysis was used to quantify the ability of the test (inde-
pendent variable) to separate the participants above and
below a defined threshold. An AUC value of 1.0 indicates
a test with perfect predictive ability, and a value of 0.5
indicates predictive ability that is no better than a coin flip.
Positive and negative predictive values were used to cal-
culate the proportion of accurately classified patients who
had either a positive test (ie, increase in IKDC score) or neg-
ative test (ie, decrease or no change in IKDC score). These
values were calculated for each established threshold.
Likelihood ratios (LRs) were used to estimate how much
the test (ie, quadriceps strength symmetry) would change
4 Bodkin et al The American Journal of Sports Medicine

TABLE 1
Patient Characteristics: Aim 1a

Months After ACLR

5-6 6-7 7-8 8-9 P Value All

Patients, n 122 102 43 26 293

Female:male, n 61:61 50:52 20:23 13:13 .96 144:149
Age, y 23.1 6 10.7 23.2 6 10.0 22.9 6 8.9 23.9 6 9.3 .99 23.8 6 10.0
Height, cm 172.1 6 10.7 173.2 6 10.6 173.2 6 9.0 172.2 6 10.4 .85 172.7 6 10.4
Mass, kg 75.8 6 18.2 75.9 6 18.2 76.4 6 20.6 72.9 6 14.9 .87 75.7 6 18.3
Time since surgery, mo 5.62 6 0.27 6.37 6 0.26 7.40 6 0.29 8.44 6 0.29 \.001b 6.39 6 0.92
Tegner
Preinjury 8.4 6 1.4 8.37 6 1.4 8.63 6 1.2 7.58 6 1.9 .024c,d 8.35 6 1.42
Current 5.61 6 1.6 5.97 6 1.8 5.95 6 1.7 5.48 6 2.5 .35 5.77 6 1.81

a
Values are presented as mean 6 SD unless noted otherwise. ACLR, anterior cruciate ligament reconstruction.
b
All groups are significantly different from one another.
c
A greater preinjury activity level for the 5- to 6-month group than the 8- to 9-month group.
d
A greater preinjury activity level for the 7- to 8-month group than the 8- to 9-month group.

the probability of having the condition (ie, gain in IKDC
score). A positive LR is indicative of the effect of a positive
test (ie, quadriceps strength symmetry) on the probability
that the condition in question is present (ie, increase in
IKDC score). A negative LR is indicative of the effect of
a negative test on the probability that the condition in
question is present. LRs were calculated for each estab-
lished threshold. LRs were used to estimate the shift in
probability of having the condition (ie, gain in IKDC score)
if the patient received a positive test (ie, high quadriceps
strength symmetry).
An a priori alpha was set .05 for all analyses. All anal-
yses were conducted through R Studio (v 1.1.383).
Positive predictive value = Pr (number of true
positive cases | number of total positive tests)
Equation 1
Negative predictive value = Pr (number of true
negative cases | number of total negative tests)
Equation 2
and symmetry (P \ .001); therefore, nonparametric sta-
tistics were performed. Subjective function was signifi-
cantly different when compared among months after
surgery (H = 8.31; P = .04). Patients assessed between 5
and 6 months after ACLR demonstrated significantly
worse subjective function than patients assessed between
7 and 8 months and 8 and 9 months after ACLR (Table 2).
Knee extensor peak torque was significantly different
when compared among months after surgery (H = 8.14;
P = .04). Patients assessed between 5 and 6 months after
ACLR demonstrated lower knee extensor peak torque
than patients assessed between 6 and 7 months and 7
and 8 months (Table 2). Knee extensor symmetry was sig-
nificantly different when compared among months after
surgery (H = 8.88; P = .03). Patients assessed between 5
and 6 months after ACLR demonstrated lower knee exten-
sor symmetry than patients assessed between 6 and 7
months and 8 and 9 months. There were no statistical dif-
ferences between knee flexor peak torque (H = 0.58; P =
.90) or symmetry (H = 1.04; P = .79) among the groups.

1LR = sensitivity / (1 – specificity)

Equation 3 Aim 2: Repeat Assessments
Demographics for patients completing a secondary LEAP
–LR = (1 – sensitivity) / specificity can be found in Table 3. Descriptive statistics for func-
Equation 4 tional measures are presented in Table 4. The ROC curve
analysis indicated that an increase in involved limb exten-
LSI = (involved limb / uninvolved limb) 3 100 sor peak torque 0.22 N
m/kg (AUC = 0.760; P = .005) and
Equation 5 extensor torque symmetry 5.75% (AUC = 0.775; P = .003)
was able to discriminate patients who increased subjective
function between visits. Table 5 presents the sensitivity,
RESULTS specificity, and positive and negative predictive values
for these thresholds.
Aim 1: Time From Surgery Of the 40 patients who completed follow-up assess-
ments, a finding of a peak knee extensor torque increase
Patient characteristics among groups are available in Table 0.22 N
m/kg (1LR = 2.62) increased the probability of
1. The assumption of normality was violated for dependent having an increase in subjective function from 45% (n =
variables of subjective function and knee extensor torque 18 of 40) to 68.3% for a total probability shift of 23.3%. A
AJSM Vol. XX, No. X, XXXX Time Needed Between RTP Assessments 5

TABLE 2
Between-Group Differencesa

Months After ACLR

5-6 6-7 7-8 8-9 P Value Effect Size, h2

IKDC 79.7b,c (70.1-88.5) 83.9b (74.5-92.0) 79.3 (73.6-88.8) 89.1c (75.8-92.3) .019,b .026d .04,b .04d
Peak knee torque, N
m/kg
Extensor 1.41b,d (1.16-1.73) 1.59b (1.27-1.95) 1.62d (1.30-1.86) 1.53 (1.27-1.97) .013,b .046d .03,b .02d
Flexor 0.837 (0.676-1.06) 0.897 (0.729-1.05) 0.915 (0.676-1.01) 0.885 (0.632-1.12) — —
Knee LSI, %
Extensor 66.4b,c (54.2-78.6) 71.8b (61.1-82.9) 67.5 (59.4-78.1) 75.2c (66.6-87.7) .019,b .014c .02,b .02c
Flexor 92.7 (81.4-102.3) 94.3 (81.4-104.8) 91.3 (81.1-102.6) 90.5 (81.1-102.6) — —

a
Values are presented as median (interquartile range) unless noted otherwise. ACLR, anterior cruciate ligament reconstruction; IKDC,
International Knee Documentation Committee; LSI, limb symmetry index.
b
Significant difference between groups: 5-6 vs 6-7 months.
c
Significant difference between groups: 5-6 vs 8-9 months.
d
Significant difference between groups: 5-6 vs 7-8 months.

TABLE 3 the probability of having a meaningful increase in knee

Patient Characteristics: Aims 2 and 3 extensor torque (0.22 N
m/kg) from 45% (n = 18 of 40)
to 28.2% for a total probability shift of 16.8%.
n or Mean 6 SD A time between visits 1.97 months (1LR = 4.20)
Patients 40 increased the probability of having a meaningful increase
Female:male 20:20 in knee extensor LSI (5.75% LSI) from 57.5% (n = 23 of
Age, y 20.4 6 7.1 40) to 85.1% for a total probability shift of 27.6%. A time
Height, cm 173.9 6 10.2 between visits \1.97 months (–LR = 0.32) decreased the
Mass, kg 78.1 6 20.1 probability of having a meaningful increase in knee exten-
Subjective improvement, yes:no 18:22 sor LSI (5.75%) from 42.5% (n = 17 of 40) to 19.1% for a total
Increase in quadriceps, yes:no probability shift of 23.4%.
Strength 22:18
Symmetry 23:17

peak knee extensor torque change \0.22 N
m/kg (–LR =
0.24) decreased the probability of having satisfactory
knee function from 45% (n = 18 of 40) to 16.4% for a total
shift of 28.6%. A knee extensor symmetry increase
5.75% (1LR = 2.29) increased the probability of having
an increase in subjective function from 45% (n = 18 of 40)
to 68.3% for a total probability shift of 23.3%. A knee exten-
sor symmetry change \5.75% (–LR = 0.26) decreased the
probability of having satisfactory knee function from 45%
(n = 18 of 40) to 16.4% for a total shift of 28.6%.
Aim 3: Time Necessary for Strength Improvements
We found that 1.97 months between visits was the time nec-
essary to achieve an increase of extensor knee strength of
0.22 N
m/kg (AUC = 0.646; P = .115). We also found that
1.97 months between visits was necessary to achieve an
increase in knee extensor LSI of 5.75% (AUC = 0.801; P =
.001). Sensitivity, specificity, and positive and negative pre-
dictive values for these thresholds are available in Table 5.
A time between visits 1.97 months (1LR = 2.04)
increased the probability of having a meaningful increase
in knee extensor torque (0.22 N
m/kg) from 55% (n = 22
of 40) to 71.4% for a total probability shift of 16.4%. A
time between visits \1.97 months (–LR = 0.48) decreased
DISCUSSION
Patients stratified by the month of return-to-sport assess-
ments demonstrated greater subjective function and knee
extension symmetry when tested at later time points. How-
ever, the observed values were low when compared with the
commonly sought 90% thresholds,14 suggesting that
patients continued to show strength deficits within 9
months after ACLR. Of the 40 patients who completed
follow-up assessments, an increase in knee extensor
strength of 0.22 N
m/kg and a knee extensor limb symmetry
of 5.75% indicated a clinically meaningful improvement of
subjective function. A time of approximately 2 months
between visits was found to be necessary for patients to
achieve this increase in quadriceps strength and symmetry.
Patients within this cohort demonstrated greater sub-
jective function and higher knee extensor LSI values
when assessed between 8 and 9 months after ACLR
when compared with the patients assessed between 5
and 6 months after ACLR. Time since surgery has been
shown to be the most common factor used when making
decisions for return to sport after ACLR.3,7 Time following
any injury should be considered, given the healing pro-
cesses of involved tissues11; however, it is often the only
criterion used,3 ignoring the symptomatic state of the
patient or objective measures of strength and performance.
Research continues to show that patients around this 6-
6 Bodkin et al The American Journal of Sports Medicine

TABLE 4
Functional Differences Between Visits: Aims 2 and 3a

Mean 6 SD

Visit 1 Visit 2 Mean Difference (95% CI) P Value

Months after ACLR 5.62 6 0.27 8.11 6 0.79 2.16 (1.91 to 2.40) \.001
IKDC 79.1 6 13.5 86.8 6 12.8 7.66 (4.87 to 10.44) \.001
Knee extensor peak torque
Normalized, N
m/kg 1.45 6 0.37 1.72 6 0.39 0.28 (0.20 to 0.35) \.001
Symmetry, % 63.5 6 13.2 72.3 6 12.5 8.75 (5.08 to 12.42) \.001
Knee flexor peak torque
Normalized, N
m/kg 0.92 6 0.29 1.03 6 0.29 0.12 (0.06 to 0.17) \.001
Symmetry, % 97.0 6 19.8 99.5 6 16.9 2.52 (–2.80 to 7.84) .34

a
ACLR, anterior cruciate ligament reconstruction; IKDC, International Knee Documentation Committee.

TABLE 5
Thresholds for Strength and Symmetry Needed to Improve Subjective Function
and the Time Needed Between Visits to Achieve Such Measuresa

Threshold AUC P Value Sensitivity Specificity 1LR –LR

Increase of (a) strength and (b) symmetry needed to improve IKDC score 9 points
a Mass-normalized extensor torque 0.22 N
m/kg .760 .005 .833 .682 2.62 .24
b Symmetry extensor torque 5.75% .775 .003 .833 .637 2.29 .26
Time between visits needed to achieve (c) strength and (d) symmetry thresholds
c Time needed to reach 0.22 N
m/kg 1.97 mo .646 .115 .682 .667 2.04 .48
d Time needed to reach 5.75% 1.97 mo .801 .001 .739 .824 4.20 .32

a
AUC, area under the curve; IKDC, International Knee Documentation Committee; LR, likelihood ratio.

month time point show adaptations in strength and biome-
chanical movement patterns that may predispose them to
high risk of subsequent ACL injury.14,19 Although patients
assessed at later time points demonstrated greater subjective
function and knee extensor limb symmetry, the observed
median quadriceps strength (1.65 N
m/kg) and symmetry
(76.7%) were low as compared with the previously estab-
lished strength threshold of 3.0 N
m/kg and clinical LSI
goal of 90%.14,26,27 Even at 9 months after ACLR, patients
were demonstrating muscular and subjective deficits that
may continue to improve—stressing the importance of objec-
tive assessments for progressing patients to sport.
An increase in knee extensor strength of 0.22 N
m/kg and
symmetry of 5.75% was found to discriminate patients able to
increase their subjective function between assessments.
Within this cohort, 0.22 N
m/kg is about a 15%
(0.22 N
m/kg / 1.45 N
m/kg) increase in strength. At 1 year
after ACLR, patients had greater quadriceps and biomechan-
ical symmetry from their return-to-play assessment at 6
months, suggesting that the natural recovery of strength
within this population may not occur within the initial 6
months.9 Patients and clinicians alike are frustrated with
the marginal strength gains that occur late within the reha-
bilitation process and the inability to confidently return to
activity as a result.18,20 The results from this study may be
used as a clinical target for patients and clinicians seeking
an improvement in patient function to manage expectations
and guide progressions after ACLR.
All patients were advised to return for repeat testing
after seeking additional therapy. Patients in this study
who returned for subsequent testing (n = 40) all sought
additional therapy after receiving the results from their
initial assessment. As seen in Figure 2, not all patients
responded the same. Only 55% (22 of 40) of the study’s par-
ticipants were able to increase their strength above
a threshold indicative of subjective improvement. Of the
18 patients who failed to reach this strength threshold, 5
patients had lower knee extensor strength than their ini-
tial assessment. It is indeed daunting that almost half of
patients failed to demonstrate clinically meaningful
improvements after a mean 2 months of additional rehabil-
itation. Many factors could contribute to the 45% (18 of 40)
who were unable to increase their strength above this
value, such as differences of rehabilitation protocols
(type, volume, intensity),13 psychological barriers,4 or
underlying muscular inhibition.16 Defined as the inability
to increase strength, persistent muscle weakness has
been shown within patients after ACLR. Although most
often used to describe patients presenting with strength
and activation deficits years from surgery,17 serial assess-
ments were used in the current study to identify patients
who showed resistance to traditional rehabilitation within
the time of return to sport. Patients with lower quadriceps
strength have been shown to demonstrate neural adapta-
tions after ACLR.5,28 It is unknown if these underlying
neurophysiologic adaptations influence the ability to
AJSM Vol. XX, No. X, XXXX
Figure 2. Quadriceps strength assessed at the (1) initial and
(2) follow-up visits. Gray box plots represent the group mean
and interquartile ranges of strength at each visit. Lines with
solid markers indicate patients who increased their strength
indicative of satisfactory improvement. Lines with white
markers indicate patients who did not increase their strength
indicative of satisfactory improvement.
regain muscle strength during the time of return to sport
after ACLR.
A duration of 2 months between visits was able to
acceptably discriminate patients who were able to increase
their knee extensor LSI by 5.75%. To date, there is little
agreement on the time frame of releasing patients to sport,
with many current programs structured to provide assess-
ments at 6 months after surgery and with evidence sug-
gesting that it takes as long as 2 years for patients to
reach their baseline joint health and function.9,23,30 What
is agreed on is the use of objective measures to individual-
ize patient care and guide postsurgical decision making.
The use of return-to-sport programs should then shift
from tests providing outcomes such as ‘‘pass’’ and ‘‘fail’’ to
assessments administered to identify impairments to prop-
erly guide and progress patients to sport. To accomplish
this, serial assessments should be considered. A single
assessment may provide a snapshot of the patient’s recov-
ery and not inform clinicians of how the patient is pro-
gressing and responding to current therapies. Given the
results of this study, when patients exhibit low strength
or symmetry values during objective testing, clinicians
should counsel them to return no sooner than another 2
months to allow adequate time to meet or exceed clinically
meaningful strength gains. Failure to experience clinically
meaningful strength gains after shorter bouts of rehabili-
tation may yield disappointing and misleading results.
Within healthy individuals, 20 days of training was found
Time Needed Between RTP Assessments 7
to increase quadriceps strength by 35% and cross-sectional
area by 7%.29 It is unknown whether increases in strength
in this study were due to (1) an increase in muscle size, as
there is evidence that quadriceps atrophy persists at and
beyond this time point,24 or (2) neural adaptations shown
to precede muscle hypertrophy.15
This study is not without its limitations. LEAP is set up
to enroll patients through referral networks from local
orthopaedic and physical therapy clinics. The current study
did not randomize patients to a month for initial assess-
ments. The current study represents clinical cases after
ACLR where patients are referred to return-to-sport assess-
ments at a time when they feel ready. Of the patients who
returned for subsequent testing, the amount or type of ther-
apy that the patient received was not controlled for. The
amount and type of rehabilitation to provide the greatest
patient improvements are an area for future research.
Patients assessed between 8 and 9 months after ACLR
had higher measures of subjective function and knee
extensor LSI when compared with those assessed approxi-
mately 6 months after ACLR. Although greater measures
were observed at later time points after surgery, the
observed values were below common clinical goals,14 and
even at 9 months after ACLR, patients were demonstrating
deficits that may be improving. For patients who do not
achieve desirable outcomes with return-to-sport assess-
ments, approximately 2 months may be the minimum
time needed to achieve clinically meaningful improve-
ments in patient-reported outcomes, strength, and symme-
try. This suggested guideline can be helpful to the
clinician. Athletes are often eager to return to sport and
desire repeat testing as soon as possible. However, when
they still do not meet the criteria for release to sport, frus-
tration can develop that may affect motivation and drive
throughout rehabilitation. By informing patients that 2
months has been shown to be the interval needed to
make a clinically meaningful change in testing outcomes,
patients and clinicians can have a realistic target.
REFERENCES
1. Ajuied A, Wong F, Smith C, et al. Anterior cruciate ligament injury and
radiologic progression of knee osteoarthritis: a systematic review and
meta-analysis. Am J Sports Med. 2014;42(9):2242-2252.
2. Ardern CL, Taylor NF, Feller JA, Webster KE. Return-to-sport out-
comes at 2 to 7 years after anterior cruciate ligament reconstruction
surgery. Am J Sports Med. 2012;40(1):41-48.
3. Barber-Westin SD, Noyes FR. Factors used to determine return to
unrestricted sports activities after anterior cruciate ligament recon-
struction. Arthroscopy. 2011;27(12):1697-1705.
4. Beischer S, Senorski EH, Thomeé C, Samuelsson K, Thomeé R. How
is psychological outcome related to knee function and return to sport
among adolescent athletes after anterior cruciate ligament recon-
struction? Am J Sports Med. 2019;47(7):1567-1575.
5. Bodkin SG, Norte GE, Hart JM. Corticospinal excitability can discrim-
inate quadriceps strength indicative of knee function after ACL-
reconstruction. Scand J Med Sci Sports. 2019;29(5):716-724.
6. Briggs KK, Lysholm J, Tegner Y, Rodkey WG, Kocher MS, Steadman
JR. The reliability, validity, and responsiveness of the Lysholm score
and Tegner Activity Scale for anterior cruciate ligament injuries of the
knee: 25 years later. Am J Sports Med. 2009;37(5):890-897.
8 Bodkin et al
7. Burgi CR, Peters S, Ardern CL, et al. Which criteria are used to clear
patients to return to sport after primary ACL reconstruction? A scop-
ing review. Br J Sports Med. 2019;53(18):1154-1161.
8. Collins NJ, Misra D, Felson DT, Crossley KM, Roos EM. Measures of
Knee Function International Knee Documentation Committee (IKDC)
Subjective Knee Evaluation Form, Knee injury and Osteoarthritis Out-
come Score (KOOS), Knee injury and Osteoarthritis Outcome Score
Physical Function Short Form (KOOS-PS), Knee Outcome Survey
Activities of Daily Living Scale (KOS-ADL), Lysholm Knee Scoring
Scale, Oxford Knee Score (OKS), Western Ontario and McMaster
Universities Osteoarthritis Index (WOMAC), Activity Rating Scale
(ARS), and Tegner Activity Score (TAS). Arthritis Care Research.
2011;63:S208-S228.
9. Curran MT, Lepley LK, Palmieri-Smith RM. Continued improvements
in quadriceps strength and biomechanical symmetry of the knee after
postoperative anterior cruciate ligament reconstruction rehabilitation:
is it time to reconsider the 6-month return-to-activity criteria? J Athl
Train. 2018;53(6):535-544.
10. Ebrahimzadeh MH, Makhmalbaf H, Golhasani-Keshtan F, Rabani S,
Birjandinejad A. The International Knee Documentation Committee
(IKDC) subjective short form: a validity and reliability study. Knee
Surg Sports Traumatol Arthrosc. 2015;23(11):3163-3167.
11. Ekdahl M, Wang JHC, Ronga M, Fu FH. Graft healing in anterior cru-
ciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc.
2008;16(10):935-947.
12. Faltstrom A, Kvist J, Gauffin H, Hagglund M. Female soccer players
with anterior cruciate ligament reconstruction have a higher risk of
new knee injuries and quit soccer to a higher degree than knee-
healthy controls. Am J Sports Med. 2019;47(1):31-40.
13. Gokeler A, Bisschop M, Benjaminse A, Myer GD, Eppinga P, Otten E.
Quadriceps function following ACL reconstruction and rehabilitation:
implications for optimisation of current practices. Knee Surg Sports
Traumatol Arthrosc. 2014;22(5):1163-1174.
14. 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):804-808.
15. Hakkinen K, Komi PV. Electromyographic changes during strength
training and detraining. Med Sci Sports Exerc. 1983;15(6):455-460.
16. Harkey MS, Luc-Harkey BA, Lepley AS, et al. Persistent muscle inhi-
bition after anterior cruciate ligament reconstruction: role of reflex
excitability. Med Sci Sports Exerc. 2016;48(12):2370-2377.
17. Hart JM, Kuenze CM, Diduch DR, Ingersoll CD. Quadriceps muscle
function after rehabilitation with cryotherapy in patients with anterior
cruciate ligament reconstruction. J Athl Train. 2014;49(6):733-739.
For reprints and permission queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav.
The American Journal of Sports Medicine
18. Heijne A, Axelsson K, Werner S, Biguet G. Rehabilitation and recov-
ery after anterior cruciate ligament reconstruction: patients’ experi-
ences. Scand J Med Sci Sports. 2008;18(3):325-335.
19. Hewett TE, Myer GD, Ford KR, et al. Biomechanical measures of
neuromuscular control and valgus loading of the knee predict ante-
rior cruciate ligament injury risk in female athletes: a prospective
study. Am J Sports Med. 2005;33(4):492-501.
20. Langford JL, Webster KE, Feller JA. A prospective longitudinal study
to assess psychological changes following anterior cruciate ligament
reconstruction surgery. Br J Sports Med. 2009;43(5):377-381.
21. Menzer H, Slater LV, Diduch D, et al. The utility of objective strength
and functional performance to predict subjective outcomes after
anterior cruciate ligament reconstruction. Orthop J Sports Med.
2017;5(12):2325967117744758.
22. Moses B, Orchard J. Systematic review: annual incidence of ACL
injury and surgery in various populations. Res Sports Med.
2012;20(3-4):157-179.
23. Nagelli CV, Hewett TE. Should return to sport be delayed until 2 years
after anterior cruciate ligament reconstruction? Biological and func-
tional considerations. Sports Med. 2017;47(2):221-232.
24. Norte GE, Knaus KR, Kuenze C, et al. MRI-based assessment of
lower-extremity muscle volumes in patients before and after ACL
reconstruction. J Sport Rehabil. 2018;27(3):201-212.
25. Nwachukwu BU, Chang B, Voleti PB, et al. Preoperative Short Form
Health Survey score is predictive of return to play and minimal clini-
cally important difference at a minimum 2-year follow-up after ante-
rior cruciate ligament reconstruction. Am J Sports Med.
2017;45(12):2784-2790.
26. Palmieri-Smith RM, Lepley LK. Quadriceps strength asymmetry after
anterior cruciate ligament reconstruction alters knee joint biome-
chanics and functional performance at time of return to activity.
Am J Sports Med. 2015;43(7):1662-1669.
27. Pietrosimone B, Lepley AS, Harkey MS, et al. Quadriceps strength
predicts self-reported function post-ACL reconstruction. Med Sci
Sports Exerc. 2016;48(9):1671-1677.
28. Pietrosimone BG, Lepley AS, Ericksen HM, Gribble PA, Levine J.
Quadriceps strength and corticospinal excitability as predictors of
disability after anterior cruciate ligament reconstruction. J Sport
Rehabil. 2013;22(1):1-6.
29. Seynnes OR, de Boer M, Narici MV. Early skeletal muscle hypertro-
phy and architectural changes in response to high-intensity resis-
tance training. J Appl Physiol. 2007;102(1):368-373.
30. Wellsandt E, Failla MJ, Snyder-Mackler L. Limb symmetry indexes
can overestimate knee function after anterior cruciate ligament injury.
J Orthop Sports Phys Ther. 2017;47(5):334-338.