Is return to sport testing post-ACLR a waste of time?

 2017 England’s Alex Hales is down after sustaining an injury to his knee Action Images via Reuters/Andrew Boyers

Consider why you perform return to sport (RTS) testing on athletes post anterior cruciate ligament repair (ACLR). Are you ticking a box to justify a discharge or trying to pacify a coach who wants their athlete back on the playing field? Or, do you have the intention of protecting the athlete from a repeated ACL injury? If it is the latter, how confident are you that the RTS testing you use will do that?

A multi-center study conducted a systematic review with meta-analysis to determine the association between passing RTS tests and suffering a second ACL injury(1). An ACL injury can be devastating to an athlete’s career and impacts long term functionality with an increased risk of osteoarthritis(1). A second ACL injury compounds the risk of an athlete dropping out of sports participation altogether. Therefore, RTS testing should establish assurance that the athlete assumes the lowest risk possible of reinjury. The authors defined RTS as “…the clearance of a patient for full participation in that patient’s defined sport or activity without restriction(1).”

This review found only four studies that met the stringent selection criteria. The standards the studies had to meet included:

  • Subjects between 10 and 50 years old.
  • Participants who were recovering from an ACLR.
  • Clear RTS testing protocol.
  • Reporting of those who passed and failed RTS testing.
  • Appropriate follow-up with patients.

Unfortunately, there was such a difference among the selected studies and so few of them that the evidence for establishing a relationship between RTS testing and a second ACL injury was of very low quality. The authors expressed confidence in their results as moderate.

While not significant, the researchers found a small association between passing RTS tests and suffering another ACL injury – to either the graft or the contralateral knee. The risk of a second injury for those who failed RTS testing but returned to sport anyway seems greater. In the review population, 12% of those who failed experienced a second injury, while only 5.9% of those who passed did.

Limitations and practice implications

The authors acknowledge the review’s limits, such as increased heterogeneity among just a few studies. Because the studies were so different, they could not control for the time between surgery and RTS, time between discharge and reinjury, or level of play among the subjects. Still, this review highlights the lack of standardization in RTS testing for one of the most common sports injuries. Without consistent and adhered to standards for RTS, testing becomes an obligatory action without meaning.

That the literature lacks quality studies establishing the RTS benchmarks necessary for reasonable risk assessments for a repeat injury is a disservice to our patients. Some performance levels show greater protection from reinjury, such as a difference of 10% or less in limb symmetry index scores. However, clinics and recovery programs may assign a cutoff that suits the demands of coaches and athletes who want to return to sport as soon as possible. This lack of standardization only confuses athletes and increases risk. In addition, many student-athletes receive their rehabilitation from an athletic trainer (AT) at school during their sports class time. While this approach is convenient for the athlete and their family, ATs are likely not well-versed in RTS testing and the standardized cutoffs for safely returning an athlete to the playing field.

All athletes should undergo rigorous RTS evaluations and adhere to the suggested cutoffs for play. Every clinic has the opportunity to contribute to the well-being of athletes by keeping outcome records and conducting regular follow-ups with patients to determine their program’s success. While the 2016 Consensus statement on return to sport from the First World Congress in Sports Physical Therapy, Bern outlines the Strategic Assessment of Risk and Risk Tolerance (StARRT) framework for shared decision making in RTS, it lacks specifics about implementation and standardization of testing(2). Our patients deserve more stringent and standardized clinical research to determine which RTS tests and benchmarks give them the confidence that they are ready to play, especially since psychological measures play a role in RTS readiness(1).


  1. 2019 Feb;49(2):43.
  2. British Journal of Sports Medicine 2016;50:853-864.


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