Is There Value and Validity for the Use of Return to Sport Test Batteries After Anterior Cruciate Ligament Injury and Reconstruction?

Abstract

Is there value and validity for the use of return-to-sport (RTS) test batteries? With regard to RTS testing, there has been marked interest and rapid growth in studies that document RTS criteria after anterior cruciate ligament reconstruction. A set of criteria or “test-battery” is typically used to “clear” the athlete for RTS. Although most RTS testing is done with aim of assessing safety, the same measurements can be as used to determine the amount of functional capacity regained. It is suggested that RTS test batteries incorporate multiple domains of risk factors. If testing “works,” patients who pass should have a lower risk of reinjury than patients who fail but nonetheless return to sport. More recent studies have attempted to cover a broad range of risk factors, with as many as 15 to 20 RTS tests. This is possibly due to a lack of clear evidence as to what are the most important risk factors for second injury. As a result, few patients pass these combined criteria. Findings from a meta-analysis showed that there is a low rate of passing RTS testing (23%). The findings from this and a second meta-analyses are quite similar, as both showed there was no effect of passing RTS test batteries on overall subsequent anterior cruciate ligament injury. There was a 7% to 9% reduction in risk difference of graft injuries with passing of RTS; however, there was a 4% to 9% risk difference or 176% to 235% increased risk of a contralateral injury with passing of RTS criteria. There remain several problems with RTS test batteries, which include low rates of meeting thresholds, many athletes return without meeting RTS thresholds, evidence for predictive value is limited, small sample sizes in many studies (only 2 studies >100 patients), and many studies don’t document RTS rates. Additional issues include questions as to whether testing should be staged, how to monitor progression of rehabilitation, and should these RTS batteries be tailored to age groups?