[ research report ]

ALLISON R. TOOLE, PT, DPT, OCS1  •  MATTHEW P. ITHURBURN, PT, PhD, DPT, OCS2  •  MITCHELL J. RAUH, PT, PhD, MPH, FACSM3
TIMOTHY E. HEWETT, PhD, FACSM4  •  MARK V. PATERNO, PT, PhD, SCS5-7  •  LAURA C. SCHMITT, PT, PhD8-10

Young Athletes Cleared for Sports

Participation After Anterior
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Cruciate Ligament Reconstruction:

How Many Actually Meet Recommended
Return-to-Sport Criterion Cutoffs?
UUSTUDY DESIGN: Prospective cohort study.
Copyright © 2017 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

activity scale) were compared between those who

UUBACKGROUND: While meeting objective met and did not meet cutoffs.
criterion cutoffs is recommended prior to return to UURESULTS: Participants included 115 young
sports following anterior cruciate ligament (ACL) athletes (88 female). The proportions meeting

reconstruction, the number of young athletes
who meet recommended cutoffs and the impact
of cutoffs on longitudinal sports participation are
unknown.
UUOBJECTIVES: To test the hypothesis that a
higher proportion of young athletes who meet
Journal of Orthopaedic & Sports Physical Therapy®
R
individual cutoffs ranged from 43.5% to 78.3%.
The proportions meeting cutoffs for all hop tests, upture of the anterior
all strength tests, and all combined measures were cruciate ligament (ACL) is
53.0%, 27.8%, and 13.9%, respectively. A higher
a devastating injury that
proportion of participants who met cutoffs for both
strength tests maintained the same level of sports occurs with high frequency
participation over the year following return-to-

recommended cutoffs will maintain the same level
of sports participation over the year following
return-to-sport clearance compared to those who
do not meet recommended cutoffs.
UUMETHODS: At the time of return-to-sport
clearance, the International Knee Documenta-
tion Committee Subjective Knee Evaluation Form
(IKDC), quadriceps and hamstring strength limb
symmetry index (LSI), and single-leg hop test
LSI were assessed. Proportions of participants
who met individual (IKDC score of 90 or greater;
strength and hop test LSIs of 90% or greater) and
combined cutoffs were calculated. Proportions of
participants who continued at the same level of
sports participation over the year following return-
to-sport clearance (assessed using the Tegner
sport clearance than those who did not (81.3%
versus 60.2%, P = .02).
UUCONCLUSION: The proportions of young ath-
letes after ACL reconstruction recently cleared for
return to sports who met the combined criterion
cutoffs were low. Those who met the criterion cut-
offs for both strength tests maintained the same
level of sports participation at higher proportions
than those who did not.
UULEVEL OF EVIDENCE: Prognosis, level 2b. J
Orthop Sports Phys Ther 2017;47(11):825-833.
Epub 7 Oct 2017. doi:10.2519/jospt.2017.7227
UUKEY WORDS: ACL, athletic performance, knee
injury, limb symmetry, rehabilitation, return to sports
among individuals who partici-
pate in cutting and pivoting
sports.24,48 Anterior cruciate ligament
reconstruction is commonly performed
with the goal of facilitating return to
sports activities. However, recent meta-
analysis data from over 7000 participants
following ACL reconstruction demon-
strated that 65% returned to their previ-
ous level of sport and only 55% returned
to competitive sports.3 Factors associated
with a higher rate of return to preinjury
level of sport participation were younger
age, male sex, positive psychological

1
OSU Sports Medicine, The Ohio State University Wexner Medical Center, Columbus, OH. 2Department of Physical Therapy, School of Health Professions, University of Alabama
at Birmingham, Birmingham, AL. 3Doctor of Physical Therapy Program, School of Exercise and Nutritional Sciences, San Diego State University, San Diego, CA. 4Biomechanics
Laboratories and Sports Medicine, Departments of Orthopaedic Surgery, Physical Medicine and Physiology and Biomedical Engineering, Mayo Clinic, Rochester and Minneapolis,
MN. 5Division of Sports Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH. 6Division of Occupational Therapy and Physical Therapy, Cincinnati Children’s
Hospital Medical Center, Cincinnati, OH. 7Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH. 8School of Health and Rehabilitation Sciences,
The Ohio State University, Columbus, OH. 9Sports Medicine Research Institute, The Ohio State University Wexner Medical Center, Columbus, OH. 10Division of Physical Therapy,
School of Health and Rehabilitation Sciences, The Ohio State University, Columbus, OH. Investigation performed at the Cincinnati Children’s Hospital Medical Center, Cincinnati,
OH. The Cincinnati Children’s Hospital Medical Center Institutional Review Board approved the protocol for this study. This work was funded by support from National Institutes
of Health grant F32-AR055844, the National Football League Charities Medical Research grants 2007, 2008, 2009, 2011, and the Foundation for Physical Therapy. The authors
certify that they have no affiliations with or financial involvement in any organization or entity with a direct financial interest in the subject matter or materials discussed in the
article. Address correspondence to Dr Laura C. Schmitt, 453 West 10th Avenue, 516 Atwell Hall, Columbus, OH 43210. E-mail: laura.schmitt@osumc.edu t Copyright ©2017
Journal of Orthopaedic & Sports Physical Therapy®

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47-11 RR Toole 5.indd 825 10/18/2017 2:27:41 PM

 [ research report
response, symmetrical hopping perfor-
mance, and being an elite athlete prior
to surgery.3
Despite previous work that reported
return-to-sport rates following ACL
reconstruction, there is an absence of
consistent use or agreement in the lit-
erature regarding the factors that guide
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return-to-sport decision making.6,10 In
a recent report of factors used to deter-
mine clearance for return to sports after
ACL reconstruction, Barber-Westin and
Noyes10 reported that 32% of studies only
considered the postoperative timeline to
guide return-to-sport decision making,
and that only 13% of the studies used
objective measures and criteria to deter-
mine of when an athlete could return to
sports participation.10 Among the stud-
Copyright © 2017 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
ies that reported use of objective criteria
for return-to-sport decision making, the
most commonly used assessments were
strength testing, performance-based
functional testing, and self-reported knee
function; although specific criterion val-
ues varied widely among studies.10,23
Strength tests of the quadriceps and
hamstrings10,11,15-18,26,41,47,59,60 and the sin-
Journal of Orthopaedic & Sports Physical Therapy®
gle-leg hop test1,10,25 are among the most
commonly used to objectively determine
patient readiness for return to sports after
ACL reconstruction and are associated
with several indicators of return-to-sport
success. Typically, limb symmetry indices
(LSIs) are used to assess whether muscle
strength and functional performance are
restored after ACL reconstruction com-
pared to the uninvolved limb.42 Kvist33
proposed that the greatest acceptable
deficiency in isokinetic muscle strength
before allowing individuals to return
to sports following ACL reconstruc-
tion should be 15%. However, previous
studies have reported that a difference
of greater than 10% between limbs fol-
lowing ACL reconstruction is regarded
as unsatisfactory for both strength and
hop test performance.25,38,39,51,53,57 While
recommendations for strength prior to
return to sports often involve LSIs, pre-
vious work examining the relationship
between strength and return to sports
826 | november 2017 | volume 47 | number 11 | journal of orthopaedic & sports physical therapy
47-11 RR Toole 5.indd 826
has primarily found that involved-limb
peak torque is related to return to sports.
At 1 year post ACL reconstruction, Lentz
et al36 reported that those with higher
involved-limb quadriceps torque were
more likely to return to preinjury level
of sports participation than those who
had lower-involved limb quadriceps
torque values. Similarly, at 1.5 to 2 years
following ACL reconstruction, higher
hamstring peak torque was found to be
correlated with a higher Tegner activity
score.8 Hop test performance has also
been evaluated to determine its relation-
ship to successful return to sports, and
individuals 1 year post ACL reconstruc-
tion with an LSI of greater than 85% on
single-leg hop tests were more likely to
have attempted return to the preinjury
level of sport than those with an LSI of
less than 85%.6
In addition to use of objective strength
and physical performance measures to
inform return-to-sport decisions after
ACL reconstruction, the literature rec-
ommends the use of patient-reported
measures of function.10 The International
Knee Documentation Committee Subjec-
tive Knee Evaluation Form (IKDC) is a
commonly used measure of self-reported
knee function in return-to-sport decision
making after ACL reconstruction.15 Im-
portantly, previous work has found that
individuals who returned to their pre-
injury level of sports participation after
ACL reconstruction had a higher IKDC
score (93.8 ± 6.3) than those who did not
return to their preinjury level of sports
participation (78.0 ± 15.6).36
While previous studies have reported
proportions of individuals after ACL re-
construction who meet cutoffs for vari-
ous measures,23,57 the number of young
athletes meeting recommended criterion
cutoffs at the specific time of return-to-
sport clearance and the impact of meet-
ing criterion cutoffs on longitudinal
sports participation remain unreported.
This is particularly important, given
suboptimal return-to-sport outcomes
over time following ACL reconstruction.
Therefore, the objective of this study was
]
to describe the proportion of athletes af-
ter ACL reconstruction cleared for sports
participation who met individual and
combined recommended return-to-sport
criterion cutoffs, and to test the hypoth-
esis that a higher proportion of athletes
who met recommended return-to-sport
criterion cutoffs would maintain the
same level of sports participation from
the time of return-to-sport clearance to 1
year following return-to-sport clearance
compared to athletes who did not meet
criterion cutoffs.
METHODS
Participants
T
his study included a cohort of
the longitudinal ACL REconstruc-
tion Long-term outcomes in Ado-
lescents and Young adults (ACL-RELAY)
Study at Cincinnati Children’s Hospital
Medical Center. Participants were re-
cruited from local orthopaedic practices
and physical therapy clinics in the greater
Cincinnati and northern Kentucky areas
from 2007 to 2015. All participants were
recruited following ACL reconstruction
and were enrolled in the study imme-
diately after clearance to return to un-
restricted sports participation by their
surgeon and rehabilitation specialist.
Specific inclusion criteria included (1)
primary, unilateral ACL reconstruction,
(2) completed rehabilitation program
after ACL reconstruction, (3) cleared for
unrestricted sports participation by a sur-
geon and treating rehabilitation special-
ist, and (4) planned to return to cutting
and pivoting sports on a regular basis (50
hours or more per year). The decision to
allow return-to-sport clearance, the crite-
ria used in return-to-sport decision mak-
ing, and the rehabilitation program after
ACL reconstruction, were not monitored
or controlled by the current study. All
baseline data for this study were collected
within 4 weeks of return-to-sport clear-
ance. Participants with all graft types
(bone-patellar tendon-bone autograft,
hamstring tendon autograft, allograft) as
well as those with meniscus repair or par-
10/18/2017 2:27:41 PM
 tial meniscectomy at the time of ACL re-
construction were included in the study.
Exclusion criteria consisted of (1) a his-
tory of low back pain requiring the care
of a physician in the past year, (2) lower
extremity injury or surgery (beyond pri-
mary ACL injury) requiring the care of a
physician in the past year, (3) a concomi-
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tant ligament injury during ACL injury
(beyond grade 1 medial collateral liga-
ment injury), and (4) skeletal immaturity,
as identified by an ACL reconstruction
procedure that was modified due to open
epiphyseal plates in the tibia or femur.
This study was approved by the Cincin-
nati Children’s Hospital Medical Center
internal Institutional Review Board, and
written informed consent and/or paren-
tal permission were obtained prior to
Copyright © 2017 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
testing from all participants and/or the
parent/guardian, when required.
Objective Criteria Measures
Objective criterion cutoffs used in this
study were based on recommendations
in the literature, and included quadriceps
strength, hamstring strength, single-leg
hop tests (single hop, triple hop, crossover
Journal of Orthopaedic & Sports Physical Therapy®
hop for distance, 6-meter timed hop),
and the IKDC score.1,11,15-18,25,26,33,41,47,59,60
Quadriceps and Hamstring Strength
Testing  Strength of the quadriceps and
hamstring muscles was quantified as
peak torque output from an isokinetic
dynamometer (Biodex Medical Systems,
Inc, Shirley, NY). Participants were seat-
ed in the dynamometer with their trunk
fully supported and their hips flexed to
approximately 90°. The knee joint was
aligned with the dynamometer axis, and
the dynamometer resistance arm was se-
cured to the distal shank. The trunk, pel-
vis, and thigh were stabilized with straps.
Following 3 practice trials, participants
performed 5 maximum-effort repetitions
of knee extension and flexion at 180°/s
through the knee range of motion from
90° of flexion through full knee exten-
sion. The peak torque output, normal-
ized to body weight (Newton meters per
kilogram), during the extension phase
was recorded as quadriceps strength and
journal of orthopaedic & sports physical therapy | volume 47 | number 11 | november 2017 | 827
47-11 RR Toole 5.indd 827
during the flexion phase was recorded as
hamstring strength. The normalized peak
torque value for each limb was used to
calculate the quadriceps and hamstring
LSI values: LSI = (involved peak torque/
uninvolved peak torque) × 100%, with an
LSI less than 100% indicating a deficit on
the involved limb). This method has been
used to reliably quantify quadriceps and
hamstring torque in healthy individu-
als and individuals with ACL injury and
reconstruction.19,21,31,32,37,40,50,55
Single-Leg Hop Tests  Participants per-
formed the 4 single-leg hop tests in the
following order: single hop for distance,
triple hop for distance, crossover hop for
distance, and 6-meter timed hop.42 These
hop tests are commonly used clinically
and have good measurement reliability
in noninjured individuals and in those
following ACL reconstruction.12,14,20,32,49
Each participant completed a practice
trial before performing 2 measured trials
for each limb, with limbs being tested in
random order. The averages of the 2 tri-
als for the involved and uninvolved limbs
were used to calculate an LSI for distance
measures as (involved score/uninvolved
score) × 100%, and for the 6-meter timed
hop as (uninvolved score/involved score)
× 100%. For all LSI scores, an LSI less
than 100% indicated a deficit of the in-
volved limb.
The IKDC  To assess self-reported knee
function, participants completed the
IKDC. The IKDC is a knee-specific mea-
sure of symptoms, function, and sports
activity.27 The IKDC contains 10 items
related to knee symptoms and physi-
cal function, and has been shown to be
both a reliable and responsive measure of
function in individuals following ACL in-
jury and reconstruction.27,28 Scores range
from 0 to 100, with higher scores indicat-
ing less disability.27
Measurement of Sports Participation
From Time of Return to Sports to 1 Year
Post Return to Sports  Sports participa-
tion was assessed with the Tegner activity
scale.56 The Tegner activity scale ranges
from 0 to 10, with each value indicating
the ability to perform specific activities.56
An activity level of 10 corresponds to
participation in competitive sports at a
national level, an activity level of 6 cor-
responds to participation in recreational
sports, and an activity level of 0 indicates
that a person is on sick leave or disability
due to knee problems.56 The Tegner activ-
ity scale has shown acceptable test-retest
reliability and validity in individuals with
ACL injury and other knee injuries.13,56
For the current study, participants com-
pleted the Tegner activity scale at the
time of return-to-sport clearance and
at 1 year post return-to-sport clearance.
Performance at the same level of sport
from time of return-to-sport clearance to
1 year post return-to-sport clearance was
defined as maintaining the same or high-
er Tegner score at 1 year post return-to-
sport clearance compared with the time
of return-to-sport clearance. Participants
who sustained a second ACL injury prior
to 1 year post return to sports were cat-
egorized as failing to maintain the same
Tegner score from the time of return-to-
sport clearance to 1 year post return-to-
sport clearance.
Statistical Analysis
The LSI has been the most frequently
used and reported criterion for whether
strength and single-leg hop performance
are normal or abnormal in the involved
limb compared to the uninjured limb af-
ter ACL reconstruction.33,38,42 An LSI of
less than 90%, or more than a 10% defi-
cit in the involved limb compared to the
uninvolved limb, has been regarded as
unsatisfactory for both strength and sin-
gle-leg hop test performance after ACL
reconstruction.23,33,38,39,53,57 Therefore,
the criterion cutoff used in this study for
strength measures (quadriceps and ham-
strings) and single-leg hop testing was an
LSI of 90% or greater.23 Similarly, when
using the IKDC, studies have shown
that higher proportions of athletes have
returned to sport following ACL recon-
struction when their IKDC scores were
greater than 90.36 Therefore, the criterion
cutoff used in this study for the IKDC was
a score of 90 or greater.
10/18/2017 2:27:42 PM
 [ research report ]
Participant demographic data were
collected and compared between sexes Participant Characteristics at the Time
TABLE 1
using independent t-tests and chi-square of Return to Sports Participation*
tests for continuous and categorical data,
respectively. If cell counts were less than Male Female P Value
5, Fisher exact tests were used to com- Participants, n (%) 27 (23.5) 88 (76.5)
pare categorical data between sexes. De- Age, y 18.8 ± 3.1 16.6 ± 2.1 .01
mographic data were compared between Height, cm 179.3 ± 7.1 164.4 ± 6.5 <.01
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sexes due to the relatively large differ- Weight, kg 85.9 ± 15.9 62.4 ± 8.4 <.01
ence in group numbers between males Time from surgery to return to sport, mo 8.1 ± 2.5 8.2 ± 2.4 .82
and females. Proportions of participants Graft type, n (%)
meeting individual criterion cutoffs Patellar tendon autograft 14 (51.9) 36 (40.9) .29†
(quadriceps strength LSI, hamstring Hamstring tendon autograft 11 (40.7) 46 (52.3) .86‡
strength LSI, single hop LSI, triple hop Allograft 2 (7.4) 6 (6.8) .66§
LSI, crossover hop LSI, 6-meter timed IKDC score 87.3 ± 8.2 87.7 ± 11.2 .83
hop LSI, IKDC), meeting both strength Single-leg hop LSI 93.7 ± 6.4 94.2 ± 6.3 .73
test criterion cutoffs, meeting all hop Triple hop LSI 94.9 ± 7.6 95.2 ± 6.1 .90
test criterion cutoffs, and meeting all Crossover hop LSI 92.8 ± 12.3 95.1 ± 7.5 .39
objective criterion cutoffs (strength, hop 6-meter timed hop LSI 96.3 ± 8.0 96.8 ± 7.6 .78
Copyright © 2017 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

test, IKDC) were calculated. Proportions Quadriceps femoris strength LSI 88.6 ± 13.8 88.3 ± 11.6 .92
of participants who continued at the Hamstring strength LSI 92.4 ± 19.1 97.6 ± 18.1 .22
same level of sports participation from Abbreviations: IKDC, International Knee Documentation Committee Subjective Knee Evaluation
Form; LSI, limb symmetry index.
the time of return-to-sport clearance to *Values are mean ± SD unless otherwise indicated.
1 year after return-to-sport clearance †
Chi-square comparison of distribution of patellar tendon autografts and hamstring autografts
were compared between those who met between sexes.
‡
Fisher exact test comparison (small cell count) of distribution of patellar tendon autografts and
and did not meet criterion cutoffs using allografts between sexes.
chi-square tests. Statistical significance §
Fisher exact test comparison (small cell count) of distribution of hamstring autografts and allografts
for all comparisons was determined a between sexes.
Journal of Orthopaedic & Sports Physical Therapy®

priori as P<.05. All statistical analyses

were performed using Minitab software
(Version 16.2; Minitab Inc, State Col-
lege, PA).
RESULTS
clearance or graft type used during ACL
reconstruction (P>.05) (TABLE 1).
Across the entire cohort, the propor-
tions of participants meeting individual
criterion cutoffs for quadriceps strength
LSI and hamstring strength LSI, as well
SD Tegner score at 1 year post return to
sports, 8.42 ± 1.56), while 33.9% (n = 39)
did not maintain the same level of sports
participation due to a decreased Tegner
score (n = 16) (mean ± SD Tegner score
at return to sports, 9.0 ± 0.63; mean ±

P
articipants included 115 young
athletes (mean ± SD age at return-
to-sport clearance, 17.1 ± 2.5 years;
88 female, 27 male; mean ± SD time from
ACL reconstruction to baseline testing
at return-to-sport clearance, 8.2 ± 2.4
months). Graft types used in ACL recon-
struction for the entire cohort included
57 (49.5%) hamstring tendon autografts,
50 (43.5%) patellar tendon autografts,
and 8 (7%) allografts. Male participants
were older (P = .01), taller (P<.01), and
weighed more (P<.01) on average than fe-
male participants (TABLE 1). There were no
observed differences between males and
females in time from surgery to time of
baseline testing at time of return-to-sport
as cutoffs for both strength tests, are
shown in FIGURE 1. The proportions of
participants meeting individual crite-
rion cutoffs for each single-leg hop test
LSI as well as cutoffs for all hop tests are
shown in FIGURE 2. The proportion of par-
ticipants meeting the criterion cutoff for
the IKDC was 46.9%. The proportion of
participants meeting all criterion cutoffs
(both strength test LSIs, all hop test LSIs,
IKDC) was 13.9%.
Of the 115 participants, 66.1% (n =
76) maintained or increased their level
of sports participation from return-to-
sport clearance to 1 year post return-to-
sport clearance (mean ± SD Tegner score
at return to sports, 8.34 ± 1.54; mean ±
SD Tegner score at 1 year post return to
sports, 6.13 ± 1.31) or due to a second
ACL injury prior to 1 year after return-to-
sport clearance (n = 23) (mean ± SD Teg-
ner score at return to sports, 8.57 ± 0.90).
A higher proportion of participants who
met the cutoffs for both strength tests at
time of return-to-sport clearance main-
tained the same level of sports participa-
tion from return-to-sport clearance to 1
year post return-to-sport clearance com-
pared to those who did not meet these
cutoffs (met cutoffs for both strength
tests and maintained sports participa-
tion, 81.3% versus did not meet cutoffs
for both strength tests and maintained
sports participation, 60.2%, respectively;

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47-11 RR Toole 5.indd 828 10/18/2017 2:27:42 PM

 100% 100%
90% 90%
Proportion of Entire Sample (n = 115)

Proportion of Entire Sample (n = 115)

80% 80%
70% 70%
60% 60%
50% 50%
40% 40%
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30% 30%
20% 20%
10% 10%
0% 0%
Quadriceps Hamstring Quadriceps Single Hop Triple Hop Crossover Hop 6-meter Timed Hop All Hop Tests
and Hamstring for Distance

Met Did not meet Met Did not meet

FIGURE 1. Proportion of participants meeting and not FIGURE 2. Proportion of participants meeting and not meeting recommended return-to-sport single-leg hop test
meeting the recommended return-to-sport strength criterion cutoff of a limb symmetry index of 90% or greater.
criterion cutoff of a limb symmetry index of 90% or
greater.
participation at 1 year following return- study43 (average age of approximately 21
Copyright © 2017 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

P = .02) (TABLE 2). No differences were ob- to-sport clearance, compared to 60.2% years and at an average of 7 months fol-
served in continuing at the same level of who did not meet the cutoffs for both lowing ACL reconstruction), which may
sports participation from time of return- strength tests. account for differences in the propor-
to-sport clearance to 1 year post return- In the present study, at the time of tion of participants who demonstrated
to-sport clearance between those who return-to-sport clearance, a range in the a quadriceps strength LSI at or above
met individual criterion cutoffs, cutoffs proportion of individuals who met indi- 90%. Additionally, rehabilitation and
for all hop tests, or cutoffs for all criteria vidual criterion cutoffs (43.5%-78.3%) return-to-sport decision making were
(all, P>.05) (TABLE 2). was observed. Approximately 70% to not controlled in our study, as they were
80% of participants met the criterion in the Palmieri-Smith and Lepley study,43
Journal of Orthopaedic & Sports Physical Therapy®

DISCUSSION cutoffs for each individual single-leg which might have further impacted the
hop test, and less than half of partici- proportion of individuals after ACL re-

T
he purpose of this study was to pants met the criterion cutoff for the construction who met the quadriceps
describe the proportions of athletes IKDC score (46.9%) and the individual strength LSI criterion of 90% or greater.
after ACL reconstruction cleared criterion cutoff for quadriceps strength To our knowledge, there are no published
for sports participation who met indi- LSI (43.5%). Regarding the quadriceps data regarding the proportions of young,
vidual and combined recommended strength LSI, the current findings are active individuals after ACL reconstruc-
return-to-sport criterion cutoffs, and to consistent with previous studies exam- tion meeting hamstring strength LSI,
examine the impact of meeting recom- ining young, active individuals after IKDC, or hop test LSI criterion cutoffs
mended return-to-sport criterion cutoffs ACL reconstruction at the time of return specifically at the time of return to sports
on successful longitudinal maintenance to sports, which reported that between for comparison. Despite this, the current
of level of sports participation at 1 year 40% and 44% of participants demon- study shows that young athletes after
post return to sports. The proportions of strated a quadriceps strength LSI at or ACL reconstruction are being cleared to
participants who met individual recom- above 90%.29,52,53 However, these pro- return to sports despite deficits in muscle
mended return-to-sport criterion cutoffs portions are higher than those reported strength and function.
ranged from 43.5% to 78.3%. However, by Palmieri-Smith and Lepley,43 who Although the proportions of par-
only 13.9% of participants met the cutoffs reported that only 20% of participants ticipants meeting individual criterion
for all criteria for recommended return demonstrated a quadriceps strength LSI cutoffs were variable, they were higher
to sports (strength tests, hop tests, and at or above 90% at return to sports. The than the proportions of participants
IKDC). In addition, the findings par- average age of participants in the cur- who met the cutoffs for combinations
tially supported the study hypothesis, as rent study (17.5 years) was younger and of objective criteria. Fifty-three per-
81.3% of participants who met the cut- participants had a longer average time cent of our sample met the cutoffs for
offs for both strength tests maintained from surgery (8.2 months) compared to all hop tests, 27.8% met the cutoffs for
or participated at a higher level of sports those in the Palmieri-Smith and Lepley both strength tests, and only 13.9% met

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 [ research report ]

Proportions of Participants Who Maintained the Same Level
TABLE 2 of Sports Participation From Return-to-Sport Clearance to 1 Year Post
Return-to-Sport Clearance Based on Criterion Cutoffs*

Met Cutoff Did Not Meet Cutoff

Criterion Cutoffs Continued Did Not Continue Continued Did Not Continue P Value
IKDC score ≥90 66.7 33.3 65.6 34.4 .90
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Single-leg hop LSI ≥90% 64.3 35.7 70.9 29.1 .49

Triple hop LSI ≥90% 67.8 32.2 60.0 40.0 .48
Crossover hop LSI ≥90% 67.1 32.9 63.9 36.1 .74
6-meter timed hop LSI ≥90% 67.4 32.6 61.5 38.5 .59
Quadriceps LSI ≥90% 74.0 26.0 60.0 40.0 .11
Hamstring LSI ≥90% 70.3 29.7 58.5 41.5 .21
All hop tests LSI ≥90% 68.9 31.1 62.9 37.1 .51
Quadriceps and hamstring LSI ≥90% 81.3 18.7 60.2 39.8 .02
Met all combined criterion cutoffs 81.3 18.7 63.6 36.4 .11
Abbreviations: IKDC, International Knee Documentation Committee Subjective Knee Evaluation Form; LSI, limb symmetry index.
*Values are percent unless otherwise indicated.
Copyright © 2017 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

the cutoffs for all criteria. The present
findings are similar to those reported by
Thomeé and colleagues,57 who examined
the proportions of individuals meet-
ing muscle strength and performance-
based functional criterion cutoffs at 6
months following ACL reconstruction.
While approximately 15% to 60% of in-
Journal of Orthopaedic & Sports Physical Therapy®
of muscle strength and knee function
as did the current study.23,57 However,
the current study builds on the work of
these studies by examining proportions
of individuals meeting the most com-
monly recommended return-to-sport
objective criterion cutoffs at the specific
time of return-to-sport clearance. It
at the time of return-to-sport clearance
(60.2%). To our knowledge, this is the
first study to evaluate sports participa-
tion at 1 year that considered both quad-
riceps and hamstrings strength criteria.
A recent systematic review15 reported
that higher quadriceps muscle strength
was a factor associated with successful

dividuals met the 90% criterion cutoff
for individual muscle strength and per-
formance-based function measures, 0%
met cutoffs for all combined measures.57
In another similar recent study, Gokeler
et al23 found that only 7% of participants
at 6 months after ACL reconstruction
passed all objective criterion cutoffs,
including strength, functional, self-re-
ported, and movement assessment mea-
sures.23 The current study found slightly
higher proportions of participants who
met cutoffs for all criteria (13.9% ver-
sus 0%57 and 7%23) compared to these
studies, which may be accounted for by
our study sample being younger (17.5
years versus 28 years57 and 25 years23)
and active in high-level cutting and piv-
oting sports. Thus, our sample might
have had more exposure to single-leg
plyometric activities, potentially im-
pacting their performance during these
tasks. In addition, these previous stud-
ies did not use the exact same measures
is unclear whether participants in the
Thomeé et al57 study or Gokeler et al23
study were cleared for, or participat-
ing in, sports activity at 6 months after
ACL reconstruction. In addition, despite
moderate correlations among strength,
self-reported, and performance-based
measures of function after ACL recon-
struction,9,30,34,42,46,53,54,58,61 taken together,
these findings indicate that performance
on one test does not reflect a similar suc-
cessful performance on other tests.
Understanding factors related to
successful return to and maintenance
of sports participation is critical given
poor return-to-sport outcomes after
ACL reconstruction.3,7 The present find-
ings illustrate that a higher proportion
of participants who met the cutoffs for
both strength tests at the time of re-
turn-to-sport clearance maintained or
participated at a higher sports participa-
tion level (81.3%) 1 year later than those
who did not meet both strength cutoffs
sports participation following ACL re-
construction (defined as return to any
sport at the preinjury level at any post-
surgical time point; findings ranged from
6 months to 7.9 years following ACL re-
construction). Further work is needed to
broaden understanding of the potential
role of individual and combined strength
criteria in successful return to sports,
as well as long-term activity participa-
tion following ACL reconstruction. In
addition, other studies have reported
that factors associated with successful
return-to-sport status have included an
IKDC score of greater than 93,36 objec-
tive knee function classified as “normal”
(IKDC category A),3 and symmetrical
single-leg hopping performance.3 In the
current study, neither meeting the cutoff
for IKDC score nor meeting the cutoffs
for single-leg hop test performance was
related to maintaining sports participa-
tion level over the year after return-to-
sport clearance. While the current study

830 | november 2017 | volume 47 | number 11 | journal of orthopaedic & sports physical therapy

47-11 RR Toole 5.indd 830 10/18/2017 2:27:43 PM

 included only high-level athletes plan-
ning on returning to cutting and pivoting
sports (mean Tegner score at return to
sports of 8.5) and may have been unique
compared to previous studies, additional
work is needed to evaluate what return-
to-sport objective criteria and cutoffs are
most important to promote successful
Downloaded from www.jospt.org at Marquette University on November 28, 2017. For personal use only. No other uses without permission.
sports participation over time after ACL
reconstruction.
There are several limitations of the
present study to consider. First, the cur-
rent cohort was young, athletic, and
female dominant; given the high rates
of ACL injury and ACL reconstruction
in this subpopulation, this limits the
generalizability of the findings to all
individuals after ACL reconstruction.
Second, though we evaluated commonly
Copyright © 2017 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
reported return-to-sport criteria (thigh
muscle strength, self-reported func-
tion, hop tests), there are other factors
beyond those included in this study that
are associated with return to sports af-
ter ACL reconstruction. A number of
studies have found associations between
return to sports and psychosocial/psy-
chological variables (kinesiophobia/fear
Journal of Orthopaedic & Sports Physical Therapy®
of reinjury, knee-related self-efficacy,
confidence).2,4,5,15,22,35,36 Further evalu-
ation of the impact of these factors,
along with that of strength, function,
and performance, on return to sports
is warranted. Third, only one criterion
value (90%) was evaluated in this study,
based on what is commonly regarded as
acceptable for return-to-sport participa-
tion after ACL reconstruction.25,38,39 Fur-
ther evaluation of other criterion cutoffs
and raw values (versus symmetry) may
provide additional information regard-
ing successful return to and mainte-
nance of sports participation after ACL
reconstruction. Fourth, we compared
self-reported activity levels just after re-
turn-to-sport clearance and 1 year later.
We did not evaluate activity levels per-
taining to return to preinjury level of ac-
tivity. Several studies have reported that
contextual factors (eg, family commit-
ments, non–knee-related life events) are
among the most commonly cited reasons
journal of orthopaedic & sports physical therapy | volume 47 | number 11 | november 2017 | 831
47-11 RR Toole 5.indd 831
for individuals to postoperatively change
or reduce activity levels.7,22 The present
study evaluated activity levels from af-
ter return-to-sport clearance to 1 year
later to minimize the potential impact
of contextual factors regarding postop-
erative sports participation on the find-
ings, but did not exclude participants
due to decreased sports participation for
social reasons. Fifth, the current study
did not evaluate strength or function at
1 year post return-to-sport clearance.
It is possible that a decline in sports
participation level over this year might
have been accompanied by a decline in
strength or function at this same time.
Consistent with prior work,44,45 20% of
the sample sustained a second ACL in-
jury prior to 1 year post return-to-sport
clearance and were classified as failing
to maintain sports participation over
the year post return to sports. While dif-
ferent return-to-sport criterion cutoffs
might have been met by those who sus-
tained second ACL injuries versus those
whose sports participation declined due
to other reasons, this was not evaluated
by the current study. Finally, subjects
were enrolled within 4 weeks of return-
to-sport clearance and were planning on
returning to cutting and pivoting sports
regularly. However, because of this,
some participants might have gradu-
ally increased their sports participa-
tion over the year after return-to-sport
clearance, potentially leading to higher
proportions of participants reporting an
increased Tegner score from baseline to
1 year later.
CONCLUSION
T
he results of this study pro-
vide insights into clinical return-
to-sport decision making for the
young, active individual after ACL recon-
struction. In young, active individuals
at the time of return-to-sport clearance
following ACL reconstruction, 43.5%
to 78.3% of participants met individual
quadriceps and hamstring strength, hop
test, and IKDC criterion cutoffs, while
only 13.9% to 53.0% met cutoffs for
combinations of criteria. A higher pro-
portion of athletes who met cutoffs for
both strength tests were able to main-
tain or improve their level of sports par-
ticipation at 1 year post return-to-sport
clearance compared to those who did
not meet these cutoffs. These data may
support the particular consideration for
meeting cutoffs for both quadriceps and
hamstring muscle strength. Future work
is warranted to examine the impact of
meeting recommended return-to-sport
criterion cutoffs on other outcomes af-
ter ACL reconstruction, including lon-
gitudinal knee function and the risk of
second ACL injury. t
KEY POINTS
FINDINGS: At the time of return-to-sport
clearance after anterior cruciate liga-
ment (ACL) reconstruction, only 13.9%
of participants met combined cutoffs for
strength, function, and performance.
Young athletes after ACL reconstruction
who met recommended cutoffs for both
strength tests (limb symmetry index
of 90% or greater) at return to sports
continued in sports participation at 1
year post return to sports at higher pro-
portions than those who did not meet
recommended cutoffs.
IMPLICATIONS: Despite being cleared
for return to sports, deficits in muscle
strength, function, and performance
are observed in a substantial proportion
of young, active individuals after ACL
reconstruction. Those with deficits at re-
turn to sports are less likely to maintain
their level of sports participation.
CAUTION: Specific recommendations for
return-to-sport criterion cutoffs that
optimize activity level following ACL
reconstruction cannot be made.
ACKNOWLEDGMENTS: The authors thank the
staff at the Sports Medicine Biodynamics
Center, particularly Staci Thomas, and the
Sports and Orthopaedic Team in the Divi-
sion of Occupational and Physical Therapy
at Cincinnati Children’s Hospital Medical
Center for their contribution to this work.
10/18/2017 2:27:44 PM
 [ research report
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