Physical Therapy in Sport 59 (2023) 144e150

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Physical Therapy in Sport

journal homepage: www.elsevier.com/ptsp

A clinician-friendly test battery with a passing rate similar to a ‘gold

standard’ return-to-sport test battery 1 year after ACL reconstruction:
Results from a rehabilitation outcome registry

a, b, Eric Hamrin Senorski a, b, c, d, *
Daniel Broman a, Ramana Piussi a, b, c, Roland Thomee
a
Sportrehab Sports Medicine Clinic, Stampgatan 14, SE-411 01, Gothenburg, Sweden
b
Unit of Physiotherapy, Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of
Gothenburg, Box 455, SE-405 30, Gothenburg, Sweden
c
Sahlgrenska Sports Medicine Center, Sahlgrenska Academy, Gothenburg, Sweden
d
Swedish Olympic Committee, Sweden

a r t i c l e i n f o a b s t r a c t

Article history: Objectives: To 1) present passing rates for different clinician-friendly (CF) test batteries and 2) determine
Received 11 October 2022 the relationship between passing CF test batteries and passing gold standard (GS) return-to-sport (RTS)
Received in revised form muscle function testing, 1 year after ACL reconstruction.
16 December 2022
Study design: Cross-sectional registry study, level of evidence: 3.
Accepted 16 December 2022
Setting: Primary care.
Participants: Data from 588 patients (52% women, mean age 29.3 ± 9.8 years) were extracted from the
Keywords:
Project ACL registry.
knee
Anterior cruciate ligament
Main outcome measures: The passing rates for the different test batteries.
Evaluation Results: The passing rate for GS test battery was 28% (95% CI, 24e32%) and the passing rate for the CF test
Limb symmetry index battery with the lowest passing rate was 27% (95% CI 24e31%). The two CF test batteries with the
strongest relationships with passing GS test battery showed that 51% (95% CI 43e59%) and 49% (95% CI
44e55%) of the patients who passed the respective CF test battery also passed the GS test battery.
Conclusion: A CF test battery can be as demanding to pass as a GS test battery, 1 year after ACL recon-
struction. However, passing a CF test battery only gives patients a chance similar to a “coin flip” of also
passing a GS RTS test battery.
© 2022 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY license
(http://creativecommons.org/licenses/by/4.0/).

1. Introduction sport (RTS) following ACL reconstruction has been reported to be

The incidence of anterior cruciate ligament (ACL) injuries re-
mains high, where approximately 80 injuries per 100,000 in-
dividuals occur yearly in Sweden, of which almost 50% are treated
with ACL reconstruction, followed by rehabilitation (Swedish Knee
Ligament Registry [Internet], 2022). The risk of sustaining a second
ACL injury is regarded as high after primary ACL reconstruction,
especially for young athletes (<20 years), with 29% of patients
sustaining a second ACL injury within 5 years after the primary ACL
reconstruction (Webster et al., 2014).
To ensure that patients pass test batteries before a return to
* Corresponding author. Sportrehab Sports Medicine Clinic, Stampgatan 14, SE-
411 01, Gothenburg, Sweden.
E-mail address: eric.hamrin.senorski@gu.se (E. Hamrin Senorski).
important to reduce the number of second ACL injuries (Grindem
et al., 2016). The most common tests used in RTS test batteries
are isokinetic knee extension and knee flexion strength tests and
various hop tests (Abrams et al., 2014). Isokinetic strength tests are
regarded as the ‘gold standard’ (GS) for assessing muscle strength
in patients after ACL reconstruction (Lynch et al., 2015), although
without an optimal testing protocol (Undheim et al., 2015). How-
ever, this ‘gold standard’ assessment cannot be regarded as
clinician-friendly (CF), since isokinetic testing systems are expen-
sive and are therefore rarely seen in clinical settings. Therefore, an
alternative CF test battery for clinicians who does not have access to
expensive equipment would be useful. Inexpensive psychological
patient-reported outcomes (PROs) have been reported to be
important in predicting outcomes after ACL reconstruction (Ardern
et al., 2014; McPherson et al., 2019) and could therefore be part of a

https://doi.org/10.1016/j.ptsp.2022.12.009
1466-853X/© 2022 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
D. Broman, R. Piussi, R. Thome
e et al.
CF test battery, together with more CF muscle function tests. A
recent consensus statement from the Panther Symposium ACL
Injury Return to Sport Consensus Group also recommended the
assessment of psychological factors before RTS (Meredith et al.,
2020). The proportion of patients who pass pre-determined cut-
offs (the passing rate) has not however been thoroughly investi-
gated for test batteries which only include CF muscle function tests,
such as the side-hop test and hop for distance, and psychological
PROs, such as the ACL e Return to Sport after Injury (ACL-RSI) scale
and the Knee Self-Efficacy Scale (K-SES). Furthermore, a better
understanding of how passing or failing CF test batteries relate to
passing GS muscle function RTS test batteries is needed.
The aim of the present study was to 1) present passing rates for
different CF tests and test batteries comprising hop tests and PROs
and 2) determine the relationship between passing CF tests or test
batteries and passing GS RTS muscle function testing, 1 year after
ACL reconstruction.
2. Method
2.1. Patient selection
The data for this cross-sectional study were extracted from a
rehabilitation-specific registry: Project ACL, on October 1, 2021. This
registry has previously been described in detail (Hamrin Senorski
et al., 2017). Briefly, Project ACL has collected outcomes for pa-
tients after an ACL injury or reconstruction since 2014. Project ACL
collects data for muscle function tests and PROs prospectively at 10
weeks and 4, 8, 12, 18 and 24 months after baseline, i.e. an ACL
injury or reconstruction. Preferably, patients treated with recon-
struction should also perform a baseline test within 6 days prior to
reconstruction. In the present study, the demographics and data
from the 1-year follow-up were extracted for analysis. Patients
were eligible for inclusion if they were aged 18e65 years, had
undergone a unilateral ACL reconstruction and attended Project
ACL's 1-year follow-up. Patients were excluded if they had more
than one ACL injury or if they did not complete all the muscle
function tests and PROs at the 1-year follow-up. The project has
ethical approval from the Swedish Ethical Review Authority
(2020e02501).
2.2. Muscle function tests
The tests of muscle function in Project ACL comprise unilateral
isokinetic knee extension and knee flexion muscle strength tests at
an angular speed of 90
/second, using a Biodex isokinetic dyna-
mometer (Biodex System 4; Biodex Medical System, Shirley, NY,
USA), as well as three hop tests: vertical hop, hop for distance and
side hop. This muscle function test battery will be referred to as
“the GS test battery” in the present study (Abrams et al., 2014;
Lynch et al., 2015). The muscle function tests used in the CF test
batteries in the present study included hop for distance and side
hop, since these tests only require a tape measure, a stopwatch and
tape as equipment.
Before the patients were tested, they performed a standardized
warm-up consisting of 10 minutes on a stationary bike. For each of
the strength and hop tests, the test was first performed on the
injured leg and then on the non-injured leg. Before patients were
allowed to perform the muscle function tests, permission was
required from their responsible physical therapist and the test
leader.
The strength tests were performed with 3 maximum attempts
per side with an optional 4th attempt. The rest between maximum
attempts was 40 seconds. The highest peak torque achieved in
Newton meters for each side for knee extension and knee flexion
145
Physical Therapy in Sport 59 (2023) 144e150
respectively was used for analysis. Isokinetic strength testing with
the Biodex System has been reported to have acceptable mechan-
ical reliability and validity for measuring muscle strength (Drouin
et al., 2004), and it has also been reported to be reliable with test
re-test measurements (Feiring et al., 1990).
The hop tests were performed with the patients' hands held
behind their backs. For the vertical hop, Muscle lab equipment was
used (Ergotest Technology, Oslo, Norway), converting the time
spent in the air from take-off to landing into centimeters. Two
warm-up attempts and 3 maximum attempts were performed for
each side. The highest jump achieved for each side was used for
analysis. For the hop for distance, the distance from the patients’
toes at the starting line to the heel at landing was measured in
centimeters. The test was approved if the landing was controlled,
without the patients moving their landing foot and being able to
maintain balance. Two warm-up attempts and 3 maximum at-
tempts were performed for each side, with an optional 4th and 5th
attempt if patients failed previous attempts. The longest jump
achieved for each side was used for analysis. For the side-hop test,
the number of side hops over two lines, 40 centimeters apart,
performed during 30 seconds was recorded. Only 1 attempt was
performed. Before the attempt, patients had familiarized with the
test by being allowed to try 10 warm-up hops for each side. The
three hop tests have high reliability, sensitivity and accuracy for
measuring hop performance following ACL reconstruction
(Gustavsson et al., 2006).
The results from the tests of muscle function in the present
study are reported as side-to-side differences, using the limb
symmetry index (LSI), which calculates the result for the injured leg
divided by the result for the non-injured leg, multiplied by 100.
2.3. Patient-reported outcomes
The PROs used from Project ACL for the CF test batteries
included the K-SES18 and the ACL-RSI.
The K-SES18 was developed to measure patients’ knee-related
self-efficacy following ACL injury/reconstruction. The question-
naire consists of 18 items divided into four sections (A-D): daily
activities (A), sporting activities (B), knee function tasks (C) and
future knee self-efficacy (D). Each item produces a result from 0 to
10, with 10 indicating the highest perceived self-efficacy to perform
a task (Beischer et al., 2021). The results from each question are
added together and divided by the total number of items to obtain a
mean score. Since two strong factors have been identified in the K-
SES18, A-C and D respectively (Thomee
et al., 2006), analyses were
performed separately for the two subscales of A-C (K-SESpresent) and
D (K-SESfuture). In the present study, the two respective K-SES18
subscales were regarded as separate PROs. The K-SES18 has been
reported to have good reliability and validity (Beischer et al., 2021;
Thomee
et al., 2006).
The ACL-RSI aims to measure patients’ emotion, confidence and
risk appraisal to return to sport following an ACL injury and
acceptable reliability has been reported (Webster et al., 2008). In
the present study, the 12-question version was used (Webster &
Feller, 2018). Each of the 12 questions is rated by patients from 1
to 10, with 10 indicating the best perceived psychological outcome
(i.e. highest confidence or lowest perceived risk). The results for
each item are added up to obtain a total score ranging from 0 to 120.
2.4. Patient characteristics
Data for age at the time of ACL reconstruction, sex, Tegner ac-
tivity scale scores, graft choice, weight, height and body mass index
were extracted from Project ACL. The Tegner activity scale is a
rating system used to determine how strenuous different activities
D. Broman, R. Piussi, R. Thome
e et al.
and sports are for the knees (Tegner & Lysholm, 1985). The grading
system ranges from 0 to 10, where a Tegner score of 6 is regarded
as a knee-strenuous sport or activity. In the present study a
modified version of the Tegner activity scale was used ranging from
1 to 10, where sports as for example American football, rugby and
floorball has been added to the scale. In addition, level 0, sick leave,
was excluded.
2.5. Data analysis
The primary outcomes in the present study were the proportion
of patients that passed pre-determined cut-offs in different CF tests
and test batteries at the 1-year follow-up. Pre-determined cut-offs
for the CF tests were defined as: 90% Limb Symmetry Index (LSI)
in the different hop tests (Lynch et al., 2015), 76.6 points for ACL-
RSI (McPherson et al., 2019) and 7 points for the K-SES18 sub-
scales. The cut-off of 7 used for K-SES18 in the present study is
based on the clinical experience of 2 of the developers of the
questionnaire who proposed a score of 7 or higher as “fair” knee-
related self-efficacy. One of the developers of the questionnaire is
a co-author (RT) in the present study. Pre-determined cut-offs for
tests in the GS test battery were defined as: 90% LSI for knee
extension and knee flexion strength and 90% LSI in the different
hop tests (Lynch et al., 2015). Table 1 presents the different com-
binations of test batteries in the present study.
Statistical analyses were performed with the Statistical Product
and Service Solutions (IBM Corp. Released 2017. IBM SPSS Statistics
for Windows, Version 27.0. Armonk, NY: IBM Corp.). For patient
demographics, the mean value and standard deviation were used
for parametric data, while the median and minimum-maximum
(min-max) were used for non-parametric data. Fisher's exact test
was performed to assess the relationship between passing or failing
any of the CF tests/test batteries and passing the GS test battery. A
95% confidence interval (CI) and a significance value of p < 0.01 was
used with regard to the risk of a type I error.
3. Results
A total of 588 patients were included in the present study. Not
attending the 1-year follow-up or not having completed all the
muscle function tests or PROs at the 1-year follow-up were the
most common reasons for exclusion (n ¼ 1,464, 44% of the total
number of patients registered in the registry) (Fig. 1). The included
patients had a mean age of 29.3 (±9.8) years, a BMI of 23.6 (±2.7)
and 52% were women. The most commonly used graft for ACL
reconstruction was the hamstring tendon autograft (81%). The pa-
tients’ median pre-injury Tegner score was 8, equivalent to
participating in basketball, handball, or floorball, for example. At
the 1-year follow-up after ACL reconstruction, 60% had returned to
a Tegner score of 6, equivalent to participating in baseball,
snowboarding or more demanding sports, for example, and 38%
had returned to their pre-injury Tegner level (Table 2).
Table 1
The different combinations of test batteries.
Test batteries PROs
3 PROs ACL-RSI; K-SESpresent;
K-SESfuture
2 Muscle function tests e Hop for distance; side hop
2 Muscle function tests þ ACL-RSI; K-SESpresent;
3 PROs K-SESfuture
GS test battery
PROs ¼ Patient reported outcomes, GS ¼ gold standard, ACL-RSI ¼ Anterior Cruciate Ligament e Return to Sport after Injury scale, K-SESpresent ¼ Knee e Self-Efficacy Sca-
lepresent, K-SESfuture ¼ Knee e Self-Efficacy Scalefuture.
Physical Therapy in Sport 59 (2023) 144e150
3.1. Passing rates for different tests/test batteries
Fig. 2 shows the passing rates for the different CF tests, CF test
batteries and the GS test battery. The test with the highest passing
rate was the K-SESpresent (90% passing [95% CI 87e92%]). The test
batteries with the lowest passing rates were the CF test battery
including 2 muscle function tests and 3 PROs (27% passing [95% CI
24e31%]) and the GS test battery (28% passing [95% CI 24e32%]).
3.2. The relationship between passing or failing the CF tests or test
batteries and passing the GS test battery
Fig. 3 shows the proportion of patients that passed the GS test
battery after either passing or failing a CF test or CF test battery, 1
year after ACL reconstruction. Patients that passed the following CF
tests or test batteries: hop for distance, side-hop test, K-SESpresent, 2
muscle function tests or 2 muscle function tests þ3 PROs had a
significantly higher passing rate for the GS test battery, compared
with patients that failed the respective CF test or test battery
(p < 0.01). The largest proportion of patients that passed the GS test
battery after passing a CF test or test battery was found among
patients that passed the CF test batteries comprising 2 muscle
function tests þ3 PROs, 2 muscle function tests and in patients that
passed the side-hop test, as 51% [95% CI 43e59%], 49% [95% CI
44e55%] and 41% [95% CI 36e46%] of these patients also passed the
GS test battery respectively.
4. Discussion
The main finding in this study was that a CF test battery con-
sisting of the hop for distance, the side-hop test, ACL-RSI, K-
SESpresent and K-SESfuture (2 muscle function tests þ 3 PROs) had a
passing rate similar to a GS muscle function test battery (27% [95%
CI 24e31%] versus 28% [95% CI 24e32%]), 1 year after ACL recon-
struction. Furthermore, patients that passed the following CF tests
and test batteries: hop for distance, side hops, K-SESpresent, 2 muscle
function tests and 2 muscle function tests þ3 PROs had a statisti-
cally significantly higher passing rate for the GS test battery,
compared with patients that failed the respective CF test or test
battery (p < 0.01). Passing the CF test batteries, 2 muscle function
tests or 2 muscle function tests þ3 PROs, had the strongest rela-
tionship with passing the GS test battery, as 49% [95% CI 44e55%]
and 51% [95% CI 43e59%] of the patients who passed the CF test
battery also passed the GS test battery respectively. However, this
also implies that approximately half the patients that pass these CF
test batteries fail the GS test battery. This may indicate that passing
a CF test battery, requiring tape, a tape measure and some ques-
tionnaires as materials, can be as demanding to pass as a ‘gold
standard’ test battery, but passing the CF test battery only gives the
patients a chance approximately similar to a “coin flip” of also
passing the GS test battery. It is important to acknowledge that the
present study did not assess the relationship between passing
Muscle function tests
e
Hop for distance; side hop
Isokinetic strength for knee extension and knee flexion; vertical hop; hop for distance; side hop
146
D. Broman, R. Piussi, R. Thome
e et al. Physical Therapy in Sport 59 (2023) 144e150

Fig. 1. Flowchart of inclusion and exclusion of the study population.

ACL ¼ Anterior Cruciate Ligament; n ¼ number; PRO ¼ Patient Reported Outcome.

Table 2
Patient demographics.

Total Women Men

Number of patients (%) 588 (100%) 303 (52%) 285 (48%)

Age at ACL reconstruction, years 29.3 ± 9.8 27.8 ± 9.0 30.9 ± 9.3
Weight, kg 72.0 ± 12.2 64.6 ± 8.4 79.9 ± 10.5
Height, cm 174.2 ± 8.9 168.2 ± 5.9 180.8 ± 6.9
BMI, kg/m2 23.6 ± 2.7 22.8 ± 2.4 24.1 ± 2.7
Hamstring tendon graft, n (%) 479 (81%) 247 (82%) 232 (81%)
Patellar tendon graft, n (%) 98 (17%) 50 (17%) 48 (17%)
Other graft, n (%) 11 (2%) 6 (2%) 5 (2%)
Pre-injury Tegner, median (min-max) 8 (1e10) 8 (1e10) 8 (1e10)
Returned to Tegner 6 at 1-year follow-up, yes (%) 351 (60%) 169 (56%) 182 (64%)
Returned to  pre-injury Tegner at 1-year follow-up, yes (%) 221 (38%) 110 (36%) 111 (39%)

Kg ¼ kilograms, cm ¼ centimeters, BMI ¼ Body Mass Index, n ¼ number, min ¼ minimum, max ¼ maximum, Tegner ¼ Tegner activity scale score.

different CF tests or test batteries and subsequent knee injuries. As
a result, no conclusions can be drawn with regard to whether
passing these test batteries is able to reduce the risk of sustaining
subsequent knee injuries.
Our results suggest that relatively few patients pass a GS test
battery and a CF test battery comprising 2 muscle function tests and
3 PROs respectively, 1 year after ACL reconstruction, which is in line
with previous research on different RTS test batteries (Thomee
addition of the 3 PROs to a CF test battery that already comprised
et al., 2012; Welling et al., 2018). This indicates that the vast ma-
jority of patients are not physically or mentally ready to RTS 1 year
after ACL reconstruction, as achieving both symmetrical muscle
function and acceptable psychological readiness before RTS is rec-
ommended in the current literature (Meredith et al., 2020). It is
therefore reasonable to suggest that either a rehabilitation period
longer than 1 year after ACL reconstruction, or a rehabilitation
period with higher quality (e.g. optimal strength training, hop
training and mental preparation) might be necessary for most
patients.
There were considerable differences in passing rates for the
different stand-alone CF tests, ranging from 48% for ACL-RSI to 90%
for K-SESpresent. Considerable differences in passing rates were also
found in the different CF test batteries, ranging from 27% for the test
battery comprising 2 muscle function tests þ3 PROs to 57% for the
test battery comprising only 2 muscle function tests. However, the
proportion of patients that passed the GS test battery after
achieving pass in the CF test battery comprising 2 muscle function
tests þ3 PROs and the CF test battery comprising only 2 muscle
function tests (the same muscle function tests) was similar (51% vs
49% and the confidence intervals overlapped). This means that the
the 2 muscle function tests did not add much value in terms of
increasing the proportion of patients who pass the GS test battery,
despite making the CF test battery more demanding to pass.
Furthermore, caution should be taken when using the CF test bat-
teries as an RTS assessment following ACL reconstruction, as the
proportion of patients who achieve pass in GS RTS testing is rela-
tively low after achieving pass in a CF test battery (51% at best). This
indicates that patients might not be ready to RTS despite being
cleared with a CF test battery. However, whether passing these CF
test batteries might reduce the risk of an ACL re-injury is yet to be
determined and it is therefore not clear which test battery is
superior.
Interestingly, achieving an acceptable score for ACL-RSI had a
lower passing rate (48% [95% CI 44e52%]) than passing the CF test

147
D. Broman, R. Piussi, R. Thome
e et al. Physical Therapy in Sport 59 (2023) 144e150

Fig. 2. Passing rates for different test batteries, 1 year after ACL reconstruction.
CF ¼ clinician-friendly test battery, GS ¼ gold standard test battery, K-SESpresent ¼ Knee e Self-Efficacy Scalepresent, K-SESfuture ¼ Knee e Self-Efficacy Scalefuture, ACL-RSI ¼ Anterior
Cruciate Ligament e Return to Sport after Injury scale, 2 MF test ¼ unilateral hop for distance þ side hops, 3 PROs ¼ ACL e Return to Sport Index (ACL-RSI) þ Knee e Self-Efficacy
Scalepresent (K-SESpresent) þ Knee e Self-Efficacy Scalefuture (K-SESfuture), 95% confidence interval inside square brackets.

Fig. 3. Proportion of patients that passed the gold standard (GS) test battery after passing or failing a clinician-friendly (CF) test or CF test battery, 1 year after ACL reconstruction.
GS ¼ gold standard test battery, K-SESpresent ¼ Knee e Self-Efficacy Scalepresent, K-SESfuture ¼ Knee e Self-Efficacy Scalefuture, ACL-RSI ¼ Anterior Cruciate Ligament e Return to Sport
Index, 2 MF test ¼ unilateral hop for distance þ unilateral side hops, 3 PROs ¼ ACL e Return to Sport after Injury scale (ACL-RSI) þ Knee e Self-Efficacy Scalepresent (K-
SESpresent) þ Knee e Self-Efficacy Scalefuture (K-SESfuture), * ¼ statistically significant difference in passing rates for the GS test battery between patients that pass a clinician-friendly
test/test battery and patients who fail a clinician-friendly test/test battery p < 0.01, 95% confidence interval inside square brackets.

battery comprising hop for distance and side hops (57% [95% CI demanding than recovering muscle function. This underlines the
53e61%]), indicating that recovering psychological factors before a importance of focusing on the psychological aspect throughout the
return to sport following ACL reconstruction can be more rehabilitation period, as well as recovering muscle function, which

148
D. Broman, R. Piussi, R. Thome
e et al.
has previously been described (Sonesson et al., 2017). The lower
passing rate for the ACL-RSI, combined with the fact that both too
low and too high scores for the ACL-RSI have been associated with a
higher risk of a second ACL injury (McPherson et al., 2019; Piussi
et al., 2022), supports the importance of incorporating psycholog-
ical PROs in an RTS test battery. We therefore recommend the use of
psychological PROs in an RTS test battery, despite the fact that
adding PROs to a test battery did not appear to strengthen the
relationship to passing a GS test battery, although it helped to make
the test battery more demanding to pass.
A large proportion of patients (90% [95% CI 87e92%]) passed the
pre-determined cut-off score of 7 for the K-SESpresent. However,
including the K-SESpresent in a test battery with the aim of assessing
readiness to RTS warrants discussion. Only 3 of the 14 questions are
related to self-efficacy regarding knee-strenuous activities, while
the remaining items assess knee self-efficacy in daily life or less
knee-demanding physical activities, which might partly explain the
high passing rate in this cohort. Furthermore, there are no recom-
mendations in the literature for an adequate cut-off score for the K-
SES18. The cut-off of 7 points used in the present study is based on
the clinical experience of 2 of the developers of the questionnaire,
who proposed a score of 7 or higher as “fair” knee-related self-ef-
ficacy. This might also be a factor when it comes to the high passing
rate for the K-SESpresent in this cohort. In retrospect, using the
validated Quality-of-Life subscale from the Knee injury and Oste-
oarthritis Outcome score (KOOS QoL) (Roos & Lohmander, 2003),
with the cut-off of 62.5 points suggested by Muller et al. (Muller
et al., 2016), for the CF test batteries might have been an alterna-
tive to using K-SESpresent.
5. Limitations
None of the studied CF test batteries included strength tests for
knee extension or knee flexion. As this was a cross-sectional reg-
istry study, we were limited to the data available in the registry.
Since Project ACL uses isokinetic strength testing, not regarded as
clinician-friendly in terms of pricing, we were not able to include
any strength tests in the CF test batteries. However, we still
recommend including some type of strength test for knee exten-
sion and knee flexion before RTS, if possible, as it is recommended
in the literature and symmetrical knee extension strength has been
shown to be an important factor in reducing the risk of knee
reinjuries (Grindem et al., 2016; Meredith et al., 2020). The use of a
portable fixed dynamometer, which can be regarded as more
clinician-friendly in terms of pricing, for knee extension and knee
flexion strength has been shown to produce reliable strength
measurements and might therefore be suitable for use in the
absence of an isokinetic system (Toonstra & Mattacola, 2013).
Another option for assessing muscle strength could be by having
patients performing a 1RM or a 3RM in a knee extension or knee
flexion machine. However, the relationship between muscle
strength assessment using a Biodex (peak torque) or a knee
extension/knee flexion machine is unknown. We do not recom-
mend using the hop for distance or the side hop test as a proxy for
assessing muscle strength.
One limitation in the present study is the patients’ adherence to
attending the follow-ups and completing all the muscle function
tests and PROs at the time of the follow-ups. Of the 3332 patients
enrolled in Project ACL at the time of data extraction, 1464 (44%)
had not completed all the muscle function tests or PROs at the 1-
year follow-up, or had not participated at the follow-up at all. We
do not know whether these patients differ from the study cohort in
terms of patient characteristics or if they would have produced
different results in the test batteries. The relatively low adherence
could be partially explained by the fact that Project ACL is located in
149
Physical Therapy in Sport 59 (2023) 144e150
the south-west of Sweden, but patients from all over Sweden are
registered in the project. As a result, some of the patients registered
in Project ACL only attend a few selected follow-ups and some
patients are enrolled with the aim of only completing the PROs
regularly, which is done digitally.
Despite the fact that included patients’ pre-injury activity levels
had a large min-max range (Tegner score 1e10), most included
patients participated in sports with high knee-strenuous demands
before their ACL injury, with a median Tegner score of 8 (equivalent
to participating in basketball, handball or floorball, for example).
Only 30 out of the included 588 patients had pre-injury activity
levels with low knee-strenous demands (Tegner score <6). The
results in the present study can therefore be generalizable for pa-
tients participating in sporting activities with high knee-strenuous
demands, but they might not be generalizable for populations with
a lower physical activity level.
In the present study, several analyses were performed,
increasing the risk of type I error. To account for this risk, the p-
value was set at p < 0.01.
6. Conclusion
A clinician-friendly test battery comprising muscle function
tests and psychological PROs can be as demanding to pass as a ‘gold
standard’ RTS muscle function test battery, 1 year after ACL
reconstruction. However, passing a clinician-friendly test battery
consisting of the side-hop test, hop for distance and three psy-
chological PROs only gives patients a chance approximately similar
to a “coin flip” of also passing a gold standard RTS muscle function
test battery. Future research is needed to study to which extent
patients who pass clinician-friendly test batteries return to sport
and what proportion go on to suffer a subsequent ACL injury.
Ethical approval
Ethical approval was obtained from the Swedish Ethical Review
Authority (registration number: 2020e02501).
Financial disclosures
The study was funded by grants from the Local Research and
€dra Bohusla €n
Development Board for Gothenburg and So
(VGFOUGSB-970705).
Ethical statement
Data for this study is based on a rehabilitation registry project
(Project ACL), where all patients have received written information
and have given their informed consent to participate in the
research project. The principles of the Helsinki declaration have
been used as guidance in this study.
Declaration of competing interests
None.
Declaration of competing interest
None declared.
Acknowledgements
We would like to thank Jeanette Kliger for help with English
language editing.
D. Broman, R. Piussi, R. Thome
e et al. Physical Therapy in Sport 59 (2023) 144e150

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