tive functional performance, and other risk factors is likely highly complex. Further investigation is ongoing and warranted. Usually, patients start being tested on the return-to-activity cri- teria when they exceed the normal time frame for graft healing and once they have resolved the postoperative knee impairments related to the knee pain, effusion, ROM, and limping (Grindem et al., 2016; Hartigan et al., 2010; Kyritsis et al., 2016; Nawasreh et al., 2016; White et al., 2013). Patients’ performance on strength and functional tests are often reported as the limb symmetry in- dex to ensure normal limb-to-limb movement symmetry. Patients’ classification on return-to-activity criteria is strict. For patients to return to sport, they must achieve a high score exceeding specific cut-off value(s) identified for passing on each individual return- to-activity criterion (Grindem et al., 2016; Hartigan et al., 2010; Kyritsis et al., 2016; Nawasreh et al., 2016; White et al., 2013). However, failing to achieve a high enough score to exceed the cut-off values on any of the criteria results in the patient being classified as failed. Patients who fail the return- to-activity criteria should be instructed on not returning to preinjury activity until they improve their knee functional performance and limb-to-limb symmetry (Grindem et al., 2016; Hartigan et al., 2010; Kyritsis et al., 2016; Nawasreh et al., 2016; White et al., 2013). Patients who pass the criteria may have limb-to-limb symmetry and functional knee performance that allow them to meet the demand of their sport activities. The cut-off value to determine patients’ readiness to return to sport based on functional per- formance and patient reported measures is debatable. A cut-off value of 90% has been used as an indication for achieving normal limb-to-limb movement symmetry and knee function to determine the moment to return-to-activity (Di Stasi et al., 2013; Grindem et al., 2016; Hartigan et al., 2010; Kyritsis et al., 2016; Nawasreh et al., 2016; Shelbourne & Klotz, 2006; Webster, Feller, & Hameis- ter, 2001; White et al., 2013; Zwolski et al., 2016). For patients who are planning to return to pivoting and cutting sport activi- ties, a cut-off of 100% on limb symmetry index is recommended (R. Thomeé et al., 2011). Postoperative performance on strength and functional measures may decrease from pre-operative levels in the contralateral (uninvolved) limb, so concurrent comparison to the contralateral limb should be interpreted cautiously (Well- sandt et al., 2017). It is important for clinicians to instruct the pa- tients who pass the criteria to avoid immediately participating in their preinjury sport activities. Instead, patients should begin with lower- level sports participation in practice and gradually build up to competition while monitoring pain, effusion, and ROM before they fully return to preinjury activities (Fitzgerald, Axe, & Snyder- Mackler, 2000c; Capin, Behrns, et al., 2017; Batteries of tests can predict the risk for musculoskeletal injuries (Kiesel, Plisky, & Voight, 2007), classify individuals early after ACL injury (Fitzgerald, Axe, & Snyder-Mackler, 2000a), and identify important limb asymmetries after ACL injury and reconstruction (Gustavsson et al., 2006; Neeter et al., 2006). A battery of seven strict return-to-activity criteria – including quadriceps strength testing, four single-legged hop tests, and two patient-reported questionnaires (see Table 6) – has been utilized to aid objective determination of return-to-sport readiness following ACL injury and reconstruction (Di Stasi et al., 2013; Fitzgerald, Axe, & Sny- der-Mackler, 2000c; Hartigan et al., 2010; Nawasreh et al., 2016). Fitzgerald and colleagues (Piva, Fitzgerald, Delitto, Wisniewski, & Delitto, 2009) found that patients who returned to their preinjury activity level without reconstruction surgery achieved, on average, > 90% on all criteria that are similar to the ones reported in Table 6. Table 6: Return-to-Sport Criteria Patients must achieve 90% or more on: • Quadriceps strength index, • All 4 single-legged hop tests, • Knee Outcome Survey – Activity of Daily Living Scale, and
terno et al., 2010; van Melick et al., 2016). Isometric and isokinetic strength tests are used to determine the strength performance of the quadriceps and hamstrings muscles (Gokeler, Welling, Zaffag- nini, Seil, & Padua, 2016; Harris et al., 2014; Kyritsis et al., 2016; Petersen et al., 2014; Arundale et al., 2017; Capin, Failla, et al., 2019; Capin, Khandha, et al., 2017; Grindem et al., 2016). Restor- ing high and balanced strength for the quadriceps and hamstrings contribute to successful outcomes after surgery (Eitzen, Holm, & Risberg, 2009; Kyritsis et al., 2016). Instrumented, clinical, and functional knee stability tests are commonly used after ACL in- jury and reconstruction surgery (Benjaminse et al., 2006; Jons- son, Riklund-Ahlström, & Lind, 2004; Kocher, Steadman, Briggs, Sterett, & Hawkins, 2004; Rudolph et al., 2000; Sato et al., 2013; Seto, Orofino, Morrissey, Medeiros, & Mason, 1988; Shelbourne & Davis, 1999; Zaffagnini, Bignozzi, Martelli, Lopomo, & Marcacci, 2007). Joint laxity identified by using instruments and clinical test- ing is a measure for joint integrity and the possible risk for future joint injury (Kocher et al., 2002, 2004; Lynch et al., 2013); however, the level of laxity does not contribute to patient performance dur- ing functional activities (Hurd, Axe, & Snyder-Mackler, 2008a; Ko- cher et al., 2004; Snyder- Mackler et al., 1997). Single-legged hop tests for distance and time are also among the commonly used objective return-to-activity criteria (Myer, Schmitt, et al., 2011; Nawasreh et al., 2016; R. Thomeé et al., 2012). Hop tests are performance-based tests that measure dynamic knee stability, and they are predictable of the postoperative knee function and can detect changes in knee function after surgery (Grindem et al., 2011; Logerstedt et al., 2012; Myer, Schmitt, et al., 2011). Moreover, they are sensitive to differentiate between healthy individuals and patients with functional deficits after sur- gery (Logerstedt et al., 2012, 2013b; Myer, Schmitt, et al., 2011). Other tests that include quickly changing directions and speed of movement that is relevant to sport participation are also sug- gested to be used during the process of determining a patient’s readiness to return to sports. They could include running T test, sprinting, shuttle run test, carioca test, counter movement jumps, speedy jumps, plyometric jumps, quick feet test, and a vertical hop test (Gokeler et al., 2016; Herbst et al., 2015; Keays, Bullock- Saxton, & Keays, 2000; Kong et al., 2012; Lephart et al., 1992; Lephart, Kocher, Harner, & Fu, 1993; Tegner & Lysholm, 1985; Wilk, Romaniello, Soscia, Arrigo, & Andrews, 1994). Evaluating the quality of movement during functional activity is suggested to determine patients’ readiness (Aerts et al., 2015; Bell, Smith, Pennuto, Stiffler, & Olson, 2014; Padua et al., 2015; H. C. Smith et al., 2012). Limited data support the efficacy of using a specific type of movement quality test (i.e., the hop-and-hold test) to identify those at greater risk for second ACL injury (van Melick et al., 2021). Patient-reported measures of knee function have been used as cri- teria because they provide information about patients’ perception of their knee function during participation in simple daily living activities after injury and surgery. These measures include KOS- ADLS and GRS (Irrgang et al., 1998; Marx et al., 2001; Nyland, Cottrell, Harreld, & Caborn, 2006). Sport-specific patient-report- ed measures that assess the patients’ perception during participa- tion in sport activities have been used as return-to-activity criteria after injury and surgery. Examples include IKDC 2000 and ACL- RSI (Gokeler et al., 2016; Hartigan, Zeni, Di Stasi, Axe, & Snyder- Mackler, 2012; Kong et al., 2012; Lentz et al., 2012; Nawasreh et al., 2016). Over the last decade, studies have highlighted the importance of the patients’ psychological readiness on functional recovery and decision to return to preinjury level of sport activities (Ardern, Taylor, Feller, & Webster, 2013; Everhart, Best, & Flani- gan, 2013; te Wierike, et al., 2013). Approximately one-third of patients cite fear as a reason for not returning to sport (van Melick et al., 2021) and higher levels of fear are associated with second injury risk among those who do not necessarily meet objective functional criteria prior to returning to sport (Paterno et al., 2018). The interplay of psychological readiness to return to sport, objec-
• Global rating score of knee function. Note . From Western Schools, © 2018.
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