from clearing patients with physical and functional deficits to return high-demand activities, as patients who meet objective functional criteria are at lower risk of subsequent injury (Capin, Snyder-Mackler, et al., 2019; Grindem et al., 2016; Kyritsis et al., 2016). The overall rate of return to preinjury activity level is low and does not meet the expectation after surgery. Only 65% of patients return to their pre- injury sport and only 55% return to their pre-injury level of sport (Ardern et al., 2014). Among those who do return to sport, up to 30% incur a second ACL injury to either the ipsilateral graft or the intact contralateral ACL (Ardern, Taylor, et al., 2014; Hui et al., 2011; Kamath et al., 2014; Leys, Salmon, Waller, Linklater, & Pinczewski, 2012; Paterno et al., 2010; Salmon, Russell, Musgrove, Pinczewski, & Refshauge, 2005; Shelbourne & Muthukaruppan, 2005; Wright, Magnussen, Dunn, & Spindler, 2011(Paterno et al., 2014). Failure to determine patients’ readiness at the time of clearing them to return to sport may contribute to the low rate of return to preinjury level of activities and the high rate of second ACL injury. Using a comprehensive set of objective measures as return-to-activity criteria to assess patients’ readiness is crucial for successful outcomes after ACL injury and reconstruction surgery (Capin, Snyder-Mackler, et al., 2019; Grindem et al., 2016; Kyritsis et al., 2016). One of the approaches to determine patients’ readiness to return to sport is based on the time frame from surgery. Time from surgery may account for the graft healing process but not the resolution of knee impairments, functional deficits, or limb-to-limb movement asymmetry. Therefore, allowing patients with knee impairments and functional deficits to return to participate in high-demand physical activities solely based upon the time from surgery may result in a negative effect on patients’ outcomes and increase the risk for subsequent injuries. Clinicians may consider both the time from surgery and the resolution of patients’ impairments, functional deficits, and movement asymmetry prior to return to activities (Petersen et al., 2014). Recent evidence suggests waiting at least 9 months after ACL reconstruction, and upwards of 12 months or perhaps longer, prior to full participation in jumping, cutting, and pivoting sports (Grindem et al., 2016; Nagelli & Hewett, 2017). When patients have a revision or contralateral ACL reconstruction or other high-risk factors for re-injury, clinicians should consider advising an even longer timeframe for return to sport and council the athletes on the relative risks of returning to various types of sports (i.e., level I vs. level II vs. level III). Assessing patients’ readiness after reconstruction surgery is challenging (Ardern, Österberg, et al., 2014). Returning to a preinjury level of activity is a multifactorial in nature and requires multiple aspects of patients’ readiness consideration including the physical, functional, skill-specific, and psychological status. Furthermore, it is challenging to identify a set of objective measures that are capable of assessing different aspects of patients’ readiness. Currently, there is no consensus on which set of objective measures constitutes “satisfactory” return-to- activity criteria after surgery. Moreover, determining patients’ readiness to return to preinjury level of activity is not commonly done. In a systemic review study to determine the criteria that have been used to return to unrestricted sport activities after surgery, time from surgery and subjective measures were used in 15% of studies, and objective criteria such as lower extremity muscle strength, limb movement symmetry, knee ROM, and joint effusion were used in only 13% of the studies (Barber-Westin & Noyes, 2011a). Other systematic review studies indicate that there is a lack of objective criteria used to determine return to preinjury sport activity (Ardern et al., 2011b; Barber-Westin & Noyes, 2011b; Harris et al., 2014; Narducci, Waltz, Gorski, Leppla, & Donaldson, 2011; van Melick et al., 2016). Incorporating a comprehensive testing battery using objective measures as criteria may help determine when a patient can more safely return to participate in preinjury activities (van
Melick et al., 2016), although no consensus exists on precisely what tests and measures should be included. The commonly used return-to-activity criteria are composed of performance- based tests and patient-reported knee function measures. The combined criteria are used in clinical settings with the attempt to quantitatively assess the limb-to-limb movement, strength, and function performance symmetries and global knee function to determine a patient’s readiness to return to sport after ACL injury and reconstruction surgery (Ardern, Taylor, Feller, & Webster, 2012; Barber-Westin & Noyes, 2011a; Feller & Webster, 2003; Kobayashi et al., 2004; Nawasreh et al., 2016; Petersen et al., 2014; Undheim et al., 2015; Zwolski, Schmitt, Thomas, Hewett, & Paterno, 2016). Using video analysis is also recommended to be used at the time of clearing patients to return to activity for assessing movement quality (Paterno 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, Zaffagnini, 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). Restoring 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 injury and reconstruction surgery (Benjaminse et al., 2006; Jonsson, 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 testing 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 during functional activities (Hurd, Axe, & Snyder-Mackler, 2008a; Kocher 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 surgery (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 suggested 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 criteria because they provide information about patients’ perception of their knee function during participation in simple daily living activities after injury and surgery. These measures
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