Triple hop test distance, but not asymmetry, is associated with ankle sprains in elite adolescent volleyball players

Background:Safe return to sport (RTS) after anterior cruciate ligament (ACL) reconstruction is difficult to determine in adolescent patients. Return of strength and dynamic knee stability can be assessed with functional single-leg hop testing as part of a formal RTS assessment. However, it is unclear whether performance during single-leg hop testing can predict future ACL graft rupture.Hypothesis/Purpose:To investigate differences in single-leg hop testing between adolescent patients who experienced a graft rupture after ACL reconstruction and those that did not.Methods:A retrospective review of adolescent patients whom underwent primary ACL reconstruction with a hamstring (HS) autograft identified 16 patients (10 girls, 6 boys) with single-leg hop testing data prior to graft failure. A nearest neighbor match algorithm was used to age-, sex-, surgeon-, and graft-match 16 patients without graft rupture. All patients followed a standardized rehabilitation protocol following surgery. As part of a formal RTS test, assessment of function and dynamic strength/stability was performed using 4 different single-leg hop tests: single hop for distance, triple hop for distance, triple crossover hop for distance, and timed hop. The recovery of muscle strength was defined by a limb symmetry index (LSI) ≥ 90%. Bivariate analyses were performed to compare the two groups.Results:The mean age of the entire cohort at the time of surgery was 14.6 ± 1.5 years. Patients completed their RTS test at 29.0 ± 5.4 weeks. There were no statistically significant differences in demographics, graft size, or time to RTS test between groups. There were no statistically significant differences in LSIs on the single hop (p=0.90), triple hop (p=0.36), crossover hop (p=0.41), or timed hop (p=0.48). The mean LSIs on each of the four hop tests were 92.3 ± 14.7, 95.1 ± 6.1, 95.8 ± 7.1, and 98.6 ± 7.9, respectively. Passing rates were similar between groups (p=0.54).Conclusion:Performance on single-leg hop tests 6 months after surgery is not predictive of graft rupture following ACL reconstruction with HS autograft in adolescent patients. Further investigation of alternative RTS measures and different time frames for testing in this high-risk population is needed.

Background Functional performance tests are often used in determining return to play criteria following an injury. However little research has been conducted to determine how limb dominance affects performance on many physical function tests. Objective To determine differences between the dominant and non-dominant limbs during unipedal hopping tests. Design Descriptive laboratory study. Setting Research laboratory. Participants Twenty-six physically active adults (16 females and 10 males) between 18 and 30 years of age with no history of ankle sprains or instability. Interventions Six unipedal hopping tests were investigated: Side hop, triple crossover hop, 6-metre crossover hop, lateral hop for distance, medial hop for distance, and figure-8 hop. For each test, three trials were completed on each limb. Main outcome measurements For side hop, 6-metre crossover hop, and figure-8 hop the fastest trial (sec) was used for statistical analysis. For the triple crossover hop, lateral hop for distance, and medial hop for distance the greatest distance (cm) was used for statistical analysis. Differences between the dominant and non-dominant limbs were compared for each test using a paired-samples t-test. Results No dominant versus non-dominant limb difference was identified for the side hop (p = 0.63), 6-metre crossover hop (p = 0.70), lateral hop for distance (p = 0.18), medial hop for distance (p = 0.83), and figure-8 hop (p = 0.37) tests. There was a significant difference in scores for the triple crossover hop test (p = 0.01). Performance on the dominant limb (418.35 ± 100.40 cm) was significantly better than the non-dominant limb (405.12 ± 106.57 cm). Conclusions Five of the six tests yielded no differences in performance between the dominant and non-dominant limbs. Therefore, from a rehabilitation perspective, healthcare providers can use these unipedal hopping tests to evaluate physical function following an injury without concern to whether the injury is sustained in the dominant or non-dominant side. The triple crossover hop test should be avoided since the dominant limb performed significantly better on this test.

Individual hop analysis and reactive strength ratios provide better discrimination of ACL reconstructed limb deficits than triple hop for distance scores in athletes returning to sport

The objective of this study was to examine the predictive value of the Triple Hop for Distance (THD) physical performance test to assess lower extremity (LE) strength and power in individuals donning firefighter personal protective equipment (PPE). Thirty-one healthy participants completed the THD in firefighter PPE on both the dominant and non-dominant limb. Dependent variables included LE power (vertical jump height [cm]) on a jump mat, and LE strength of the quadriceps and hamstrings (peak torque [Nm]) on an isokinetic dynamometer. THD was a strong predictor of LE power on the dominant (p<0.01) and non-dominant (p<0.01) limbs. THD was also a moderate predictor of LE strength on both the dominant limb (Ham60 [p<0.01]), Quad60 [p<0.01]), and the non-dominant limb (Ham60 [p<0.01]), (Quad60 [p<0.01]). The THD was found to be a strong and valid predictor for clinical measures of LE power and strength in firefighter PPE.

Background: The incidence of contralateral anterior cruciate ligament (ACL) injury after ACL reconstruction (ACLR) is high. Often, return-to-sport (RTS) tests of strength and functional hopping rely on limb symmetry indices (LSIs) to identify deficits, although the utility of these measures in athletes with bilateral ACL injuries is unknown. Purpose/Hypothesis: The aim of this study was to investigate if LSIs used as RTS criteria in female patients after unilateral ACLR were appropriate for female patients with bilateral ACL involvement. The hypothesis tested was that asymmetries with traditional LSI measures would be present in a population after unilateral ACLR but would not be present in a population with bilateral ACLR due to the lack of a healthy internal control limb. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A total of 45 female subjects were classified into 3 groups: after second (contralateral) ACLR (ACLR-B; n = 15); after primary unilateral ACLR (ACLR-U; n = 15); and uninjured controls (CTRL; n = 15). After being cleared for RTS, each subject completed a single-legged hop for distance (SLHD), triple hop for distance (THD), and triple-crossover hop for distance (CHD) test, in addition to an isometric quadriceps strength test on both limbs. Means and LSI ([involved limb/uninvolved limb] × 100) were calculated for each test. Limb symmetry deficits were defined by LSI <90%. Results: Analysis of functional hop testing revealed a side × group interaction for SLHD (P = .001), THD (P = .019), and CHD (P = .04). Side-to-side differences were found in the ACLR-U group for all hop tests (P = .001-.003) and in the ACLR-B group for SLHD (P = .002) and THD tests (P = .024). No side-to side differences were seen in the CTRL group (P > .05). A side × group interaction was found for isometric quadriceps strength (P = .006), with lower LSI seen in the ACLR-U group (81% ± 17.6%) compared with the CTRL group (102.2% ± 10.8%) and the ACLR-B group (95.6% ± 24.9%). Although no interaction was seen, side-to-side differences were noted in the THD in the ACLR-U group (P = .013) and ACLR-B group (P = .024) and in the CHD in the ACLR-U group (P = .001). Despite absence of an LSI deficit, bilateral peak quadriceps strength in the ACLR-B group was comparable to the involved limb of the ACLR-U group and less than in the CTRL group (P = .012). Conclusion: Both the ACLR-U and the ACLR-B groups demonstrated side-to-side deficits during functional hop tests; however, these deficits were not identified according to the clinically accepted LSI values of ≥90%, calling into question the efficacy of current RTS criteria. At the time of RTS, only individuals in the ACLR-U group demonstrated an altered LSI in quadriceps strength. Significantly lower quadriceps strength of both limbs in the ACLR-B group was seen compared with the CTRL group, despite no LSI deficits in quadriceps strength. Current use of LSIs during strength and performance tests may not be an appropriate means of identifying residual deficits in female patients after bilateral ACLR at time of RTS. Furthermore, a better indicator of strength performance in this population may need to include a comparison of strength performance values to the normative values of healthy controls.

BackgroundOutcomes after anterior cruciate ligament reconstruction (ACLR) may not be optimal, with poor physical and psychological function potentially affecting return to sport (RTS) ability. Understanding the relationship between commonly used hop tests and the Anterior Cruciate Ligament – Return to Sport Index (ACL-RSI) may improve rehabilitation strategies and optimize patient outcomes.Hypothesis/PurposeThe purpose of this study was to examine the relationship between ACL-RSI scores and limb symmetry index (LSI) for the single hop for distance (SHD), triple hop for distance (THD), crossover hop for distance (CHD), timed 6-meter hop (T6H), and single leg vertical hop (SLVH) in a cohort of National Collegiate Athletic Association (NCAA) Division 1 collegiate athletes after ACLR. The hypothesis was that SLVH LSI would be more highly correlated with ACL-RSI score than all horizontal hop tests.Study designCross-Sectional StudyMethodsTwenty-one National Collegiate Athletic Association (NCAA) Division 1 collegiate athletes (7 males, 14 females) at 6.62 ± 1.69 months after ACLR were included in this retrospective study. Primary outcomes were ACL-RSI score and LSI for SHD, THD, CHD, T6H, and SLVH. The relationship between ACL-RSI scores and performance on hop tests (LSIs) was evaluated using correlation analysis and step-wise linear regression (p ≤ 0.05).ResultsThere were significant correlations found when comparing ACL-RSI and the LSI for SHD (rs = 0.704, p < 0.001), THD (rs = 0.617, p = 0.003), CHD (rs = 0.580, p = 0.006), and SLVH (rs = 0.582, p = 0.006). The CHD explained 66% (R2 value of 0.660) of the variance in the ACL-RSI, while the other hop tests did not add to the predictive model.ConclusionsPhysical function has the capacity to influence psychological status after ACLR. Clinicians should recognize that SLVH, SHD, THD, and CHD are correlated with ACL-RSI and improvements in physical function during rehabilitation may improve psychological status and optimize RTS after ACLR.Level of evidenceLevel 3

BackgroundKnee function deficits may persist after anterior cruciate ligament reconstruction (ACLR). Return to sport (RTS) testing batteries assess recovery after ACLR and can guide RTS progression, but the ideal test components are debatable. The single leg vertical hop for height (SLVH) test using a commercially available jump mat may provide a valuable assessment of knee function.Hypothesis/PurposeThe purpose of this study was to compare the limb symmetry index (LSI) of SLVH to horizontal hop testing in a cohort of National Collegiate Athletic Association (NCAA) Division 1 collegiate athletes after ACLR. The hypothesis was the SLVH would elicit significantly lower LSI than horizontal hop tests.Study designCross-Sectional StudyMethodsEighteen National Collegiate Athletic Association (NCAA) Division 1 collegiate athletes (7 males, 11 females) at 7.33 ± 2.05 months after ACLR were included in this retrospective study. LSI was calculated for single hop for distance (SHD), triple hop for distance (THD), cross-over hop for distance (CHD), timed 6-meter hop (T6H), and SLVH. A repeated measures ANOVA was performed to identify differences in LSI for each test. Spearman’s Rho correlation coefficient was calculated to examine the relationship between LSIs for each test.ResultsThe LSI for SLVH (84.48% ± 11.41%) was significantly lower than LSI for SHD (95.48 ± 8.02%, p = 0.003), THD (94.40 ± 3.70%, p = 0.002), CHD (95.85 ± 7.00, p = 0.007), and T6H (97.69 ± 6.60%, p = 0.001). The correlation of LSI between SLVH and the horizontal hop tests was weak and non-significant for SHD (rs = 0.166, p = 0.509), CHD (rs = 0.199, p = 0.428), and T6H (rs = 0.211, p = 0.401) and moderate and non-significant for THD (rs = 0.405, p = 0.096).ConclusionsIndividuals after ACLR had lower LSI on the SLVH than on horizontal hop tests and weak to moderate correlations between the tests suggest SLVH detects performance deficits not identified by the horizontal hop tests.Level of evidence3

Safe return to sport (RTS) after anterior cruciate ligament reconstruction (ACLR) surgery is important. Core stabilization is common within rehabilitation, but its influence on hopping performance and single-leg landing kinetics among athletes post-ACLR is unclear. Twenty-four male professional athletes who had ACL reconstruction surgery (time since surgery = 11.47 ± 1.55 months) were recruited and randomly assigned to exercise (n = 12) and control (n = 12) groups. Exercise group received an 8-week core stability exercise program. Limb symmetry index (LSI) for single-leg hop for distance (SLH) and triple hop (TRH) tests, and single-leg landing kinetics (multidirectional ground reaction forces) were measured pre- and post-intervention. In post-test, the participants in exercise group were more symmetrical in SLH (P = .04, CI = 0.01–7.68) and TRH (P = .01, CI = 0.28–11.1) distances. They also improved their LSI values for vertical ground reaction force (vGRF), though not significantly (P < .05). LSI for anteroposterior (a-p) and mediolateral (m-l) GRFs remained unchanged for participants of both groups. Our findings indicate the positive effect of core exercise on decreasing between-limb asymmetries during SLH and TRH tests. Our results demonstrate that despite lack of change in kinetics, functional performance is more symmetrical following core stability training.

CSM 2014 Sports Physical Therapy Section Platform Presentations (Abstracts SPL1–SPL66)

Background: Patient-reported outcome (PROs) instruments of knee function quality of life are routinely administered to patients after anterior cruciate ligament reconstruction (ACLR). The Patient Acceptable Symptom State (PASS), an evidence-based threshold defining perceived outcomes, may be a useful indicator of strength and functional performance. Purpose: To compare strength and functional performance between patients recovering from ACLR who did and did not meet PASS thresholds on associated PROs. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A total of 223 patients who had undergone ACLR (106 women, 117 men; 7.62 ± 1.71 months after ACLR) completed isokinetic knee extensor and flexor strength at 90 deg/s, hop performance (single-limb hop for distance [SLHD], triple hop for distance [THD], 6-m timed hop [6MH]), and PROs (International Knee Documentation Committee Subjective Form [IKDC], Knee injury and Osteoarthritis Outcome Score [KOOS], and Anterior Cruciate Ligament Return to Sport After Injury [ACL-RSI]) assessments in a controlled laboratory setting at an academic institution. Independent-samples t tests compared strength and hop measures between patients who did and did not achieve a PASS on the PROs. Limb symmetry index (LSI) was calculated as (ACLR Limb ÷ Contralateral Limb) × 100%. Strength and hop performance LSI outcomes were converted into indicator variables, categorized as either a “pass” or “fail” based on the operational definition of having an LSI value ≥90%. Chi-square tests compared strength and hop LSI PASS status measures to PRO PASS status. Results: Patients who achieved IKDCPASS were significantly stronger and had more symmetric limbs than those who did not achieve IKDCPASS. Values for IKDCPASS were as follows: knee extension ACLR limb 1.72 ± 0.47 N·m/kg, contralateral limb 2.40 ± 0.45 N·m/kg, LSI 71.64% ± 15.23%; knee flexion ACLR limb 1.04 ± 0.29 N·m/kg, contralateral limb 1.05 ± 0.26 N·m/kg, LSI 99.12% ± 17.22%. Values for IKDCFAIL were knee extension ACLR limb 1.47 ± 0.52 N·m/kg, contralateral limb 2.25 ± 0.47 N·m/kg, LSI 64.66% ± 17.07%; knee flexion ACLR limb 0.88 ± 0.28 N·m/kg, contralateral limb 0.97 ± 0.28 N·m/kg, LSI 90.46% ± 17.41%. Effect sizes ranged from small to moderate (P < .001; d = 0.3-0.55). IKDCPASS status was significantly associated with an LSI ≥90% for knee flexion peak torque (χ2 = 9.66; P = .002), SLHD (χ2 = 9.61; P = .002), and THD (χ2 = 3.97; P = .02), with a moderate effect size (P < .05; d = 0.41-0.73). Significant relationships were found with KOOSPASS (Pain, Activities of Daily Living [ADL], and Sport) and LSI ≥90% for peak knee flexion torque with a moderate effect size (Pain and ADL, P < .001; Sport, P = .04; d = 0.59-0.72) and SLHD with a strong effect size for the Symptom subscale (Symptom, P < .01, d = 1.21; Pain, P = .003; ADL, P = .04; Sport, P = .001). No differences were found in strength outcomes for patients who achieved ACL-RSIPASS versus those who did not (P > .05). Patients who achieved ACL-RSIPASS had more symmetric SLHD and THD LSI scores and jumped farther on their contralateral limb for the THD compared with ACL-RSIFAIL patients (P < .05; d = 0.50-0.64). Conclusion: Patients meeting thresholds for the IKDCPASS and KOOSPASS (Pain, ADL, and Sport subscales) demonstrated greater knee strength bilaterally, and hopped farther and more symmetrically, compared with patients who scored below the PASS threshold on the same PROs. Using PASS thresholds for PROs can aid clinicians when considering when patients can safely return to activities after ACLR.

Background: After anterior cruciate ligament reconstruction (ACLR), a battery of strength and hop tests is frequently used to determine the readiness of an athlete to successfully return to sports. However, the anterior cruciate ligament reinjury rate remains alarmingly high. Purpose: To evaluate the lower limb function of athletes after ACLR at the time when they had been cleared to return to sports (RTS). We aimed to evaluate if passing discharge criteria ensures restoration of normal lower limb biomechanics in terms of kinematics, kinetics, work, and percentage work contribution during a triple hop for distance. Study Design: Controlled laboratory study. Methods: Integrated 3-dimensional motion analysis was performed in 24 male athletes after ACLR when cleared to RTS and 23 healthy male controls during the triple-hop test. The criteria for RTS were (1) clearance by the surgeon and the physical therapist, (2) completion of a sports-specific on-field rehabilitation program, and (3) limb symmetry index >90% after quadriceps strength and hop battery tests. Lower limb and trunk kinematics, as well as knee joint moments and work, were calculated. Between-limb differences (within athletes after ACLR) and between-group differences (between ACLR and control groups) were evaluated using mixed linear models. Results: Although achieving 97% limb symmetry in distance hopped and displaying almost 80% symmetry for knee work absorption in the second rebound and third landing, the ACLR cohorts demonstrated only 51% and 66% limb symmetry for knee work generation in the first and second rebound phases, respectively. During both work generation phases of the triple hop, the relative contribution of the involved knee was significantly smaller, with a prominent compensation from the hip joint (P < .001, for all phases) as compared with the uninvolved limb and the controls. In addition, patients deployed a whole body compensatory strategy to account for the between-limb differences in knee function, mainly at the hip, pelvis, and trunk. Conclusion: Symmetry in the triple hop for distance masked important deficits in the knee joint work. These differences were more prominent during work generation (concentric-propulsive) than work absorption (eccentric-landing). Clinical Relevance: Symmetry in hop distance during the triple hop test masked significant asymmetries in knee function after ACLR and might not be the appropriate outcome to use as a discharge criterion. Differences between limbs in athletes after ACLR were more prominent during the power generation than the absorption phase.

ObjectivesTo assess the associations between the single leg hop tests at two premises; baseline and the change after 12 months, and change in patient reported outcome measures and persistent instability...

Objectives:Bone-patellar tendon-bone (BPTB) autograft has been considered the gold standard graft source for young patients who wish to return to cutting or pivoting sports after anterior cruciate ligament reconstruction (ACLR). In the past decade, quadriceps tendon (QT) autografts have become increasingly popular due to the graft’s large cross-sectional area and potential for reduced graft site morbidity. However, current evidence on patient-reported outcome measures (PROMs), functional outcomes, and second ACL injury prevalence in patients who undergo ACLR with QT autograft is limited. In particular, there is a lack of large multi-site clinical studies comparing outcomes after ACLR with QT and BPTB autografts in young patients. Therefore, the purpose of this study was to compare PROMs, functional outcomes, and second ACL injury after ACLR with QT and BPTB autograft in patients from 13 to 30 years of age using available data from a large, multi-site patient registry.Methods:Data for this study were obtained from the ACL Reconstruction Rehabilitation Outcomes Workgroup (ARROW) multi-site registry, which includes data from 9 medical and academic center sites. Patients were 13-30 years of age, had undergone primary, unilateral ACLR, and had PROMs and functional outcome data collected 5-7 months after ACLR. Second injury data was collected at least 2 years after primary ACLR. PROMs included International Knee Documentation Committee (IKDC) score and ACL Return to Sport After Injury (ACL-RSI) score. The pediatric version of the IKDC was used for patients under 19 years of age. Functional outcome data was assessed bilaterally for isokinetic knee extension torque, isokinetic knee flexion torque, single leg hop distance, and triple hop distance. Limb symmetry indices (LSIs, %) were calculated for all functional outcomes. The association between graft source and prevalence of second injury was assessed using a binomial logistic regression while accounting for age and sex. Functional outcomes and PROMs were compared between graft sources using a one-way ANOVA.Results:730 patients (661 BPTB, 69 QT) were included in the analysis. QT and BPTB autograft cohorts did not differ in age (p = 0.392) or time since surgery (p = 0.598) (Table 1). Cohorts did not differ in IKDC score (p = 0.094), but QT autograft patients did report significantly lower ACL-RSI scores than BPTB autograft patients (p = 0.036) (Table 1). Isokinetic knee extension torque LSI (p = 0.272) and triple hop LSI (p = 0.074) did not differ between graft cohorts, but QT autograft patients reported significantly lower isokinetic knee flexion torque LSI (p = 0.042) and lower single hop LSI (p = 0.049) when compared to patients with BPTB autograft (Table 1). 91 BPTB autograft patients (13.8%) and 8 QT autograft patients (11.6%) experienced second ACL injury. When controlling for age and sex, graft source was not significantly associated with second ACL injury (p = 0.647, OR = 1.198, CI = 0.553-2.592).Conclusions:The current study was conducted using data from the ARROW registry and therefore included patients from multiple surgeons and multiple sites across the continental United States, making this study as representative as possible of the general young population. Graft source does not appear to be associated with second ACL injury at least two years after ACLR among patients 13 to 30 years of age with extensor mechanism grafts. However, patients with BPTB autograft reported better psychological readiness, hamstring strength, and single hop distance when compared to QT autograft patients. Future work should investigate the mechanisms by which BPTB autograft patients may be exhibiting improved ACL-RSI scores, flexion strength, and single hop distance, and how these differences 6 months post-ACLR may or may not impact long-term second ACL injury risk.

This study compared the effects of plyometric training (PT) and virtual training (VT) on physical and functional performance. Fifty-five moderately-trained women participated in this randomized, controlled, prospective study. The subjects were randomly assigned to VT (N.=20), PT (N.=18), and control (CG, N.=17) groups. The VT was performed using the Your Body Shape Fitness Evolved 2012™ exergame in an Xbox360/Kinetic™ environment. The PT was based on the methods used in previous studies. Both interventions were performed 3 times per week for 8 weeks. Participants in the CG were not submitted to any type of intervention. Physical performance (fitness and athleticism levels) was assessed using the Nike+ Kinetic Training™ exergame in an Xbox360/Kinetic™ environment. Functional performance was assessed using the shuttle run (SR), triple hop test (THT), and six-meter timed hop test (STHT). Postintervention fitness and athleticism levels were significantly greater in VT (P<0.001 and P=0.009) and in PT (P<0.001 and P=0.003) than baselines values. Only VT postintervention fitness level was significantly greater compared to CG (P=0.03). Postintervention SR values were significantly lower than baselines values in all groups (P<0.001). VT (P=0.08) and PT (P=0.006) postintervention values were significantly lower compared to CG. Postintervention THT values were significantly greater than baselines values in VT and PT (P<0.001). VT (P=0.04 - dominant limb) and PT (P=0.003 - dominant limb; and P=0.03 - non-dominant limb) postintervention values were significantly greater compared to CG. Postintervention STHT values were significantly lower than baselines values in VT (P<0.001), PT (P<0.001) and CG (P=0.01-0.02). PT postintervention dominant (P=0.01) and non-dominant (P=0.03) limb values were significantly lower compared to CG. Both VT and PT are beneficial for improving physical and functional performance. Therefore, VT might be a new tool that can be used for physical exercise practice and conditioning training in moderately-trained women.

Functionality testing following anterior cruciate ligament (ACL) reconstruction can benefit clinicians and patients in determining readiness for return to sport. While a component of a multifactorial decision, inability to perform well on these tests predicts increased risk of reinjury. As of 2013, only 41% of orthopaedic surgeons report using strength or functionality testing in evaluating patients for return to sport (RTS). In the intermediate to late stages of their rehabilitation program, patients may undergo these tests to determine readiness and safety to return to sport. The tests described in this video include the single and triple hop for distance, triple crossover hop, single and double vertical leg jump tasks, drop jump landing task, and isokinetic and isometric strength testing. Clinicians who incorporate these tests into patient rehabilitation programs may reduce patient risk of ACL reinjury by 75% to 84%. The limb symmetry index (LSI) is a reliable calculated measure for these tests, with a strong reliability for the hop tests. The limb symmetry index can be calculated for each test and represents the ratio of measured performance of the involved, or post-ACL reconstruction, leg when compared against the uninvolved leg. The commonly used limb symmetry index threshold for passing each hop test is 90%. Patients who score 90% or greater on each of these tests are less likely to experience knee reinjury. The ability of knee strength and functionality tests in determining RTS following ACL reconstruction has been highlighted as a tool in potentially reducing risk of knee reinjury. Other isometric and isokinetic testing can be used in addition to the described functionality tests but may not be possible in certain practices due to equipment and funding limitations. Usage of these strength and functionality tests, in conjunction with clinician evaluation, may lead to more optimal outcomes for patients and lower rates of reinjury. Psychological assessment may aid in evaluating patient readiness for return to sport. Importantly, further sport-specific testing is still recommended and will optimize patient outcomes.