Knee Surgery, Sports Traumatology, Arthroscopy

, Volume 23, Issue 12, pp 3623–3631 | Cite as

Predictive parameters for return to pre-injury level of sport 6 months following anterior cruciate ligament reconstruction surgery

  • Ulrike Müller
  • Michael Krüger-Franke
  • Michael Schmidt
  • Bernd Rosemeyer



The aim of the study was to find predictive parameters for a successful resumption of pre-injury level of sport 6 months post anterior cruciate ligament (ACL) reconstruction.


In a prospective study, 40 patients with a ruptured ACL were surgically treated with semitendinosus tendon autograft. Six months after surgery, strength of knee extensors and flexors, four single-leg hop tests, Anterior Cruciate Ligament–Return to Sport after Injury Scale (ACL–RSI), subjective International Knee Documentation Committee (IKDC) 2000 and the Tampa Scale of Kinesiophobia-11 (TSK-11) were assessed. Seven months post-operatively, a standardized interview was conducted to identify “return to sport” (RS) and “non-return to sport” (nRS) patients. Logistic regression and “Receiver Operating Characteristic” (ROC) analyses were used to determine predictive parameters.


No significant differences could be detected between RS and nRS patients concerning socio-demographic data, muscle tests, square hop and TSK-11. In nRS patients, the Limb Symmetry Index (LSI) of single hop for distance (p = 0.005), crossover hop (p = 0.008) and triple hop (p = 0.001) were significantly lower, in addition to the ACL–RSI (p = 0.013) and IKDC 2000 (p = 0.037). The cut-off points for LSI single hop for distance were 75.4 % (sensitivity 0.74; specificity 0.88), and for ACL–RSI 51.3 points (sensitivity 0.97; specificity 0.63). Logistic regression distinguished between RS and nRS subjects (sensitivity 0.97; specificity 0.63).


The single hop for distance and ACL–RSI were found to be the strongest predictive parameters, assessing both the objective functional and the subjective psychological aspects of returning to sport. Both tests may help to identify patients at risk of not returning to pre-injury sport.

Level of evidence



Anterior cruciate ligament rupture Operative reconstruction Return to sport Predictors 


Conflict of interest

Authors declare that there is no conflict of interest with any organization.


  1. 1.
    AOSSM, The American Orthopaedic Society for Sports Medicine (2011) International Knee Documentation Committee 2000 subjective knee evaluation form. Accessed 29 Sep 2011
  2. 2.
    Ardern CL, Webster KE, Taylor NF, Feller JA (2011) Return to sport following anterior cruciate ligament reconstruction surgery: a systematic review and meta-analysis of the state of play. Br J Sports Med 45:596–606CrossRefPubMedGoogle Scholar
  3. 3.
    Ardern CL, Taylor NF, Feller JA, Webster KE (2012) Return-to-sport outcomes at 2 to 7 years after ACL reconstruction surgery. Am J Sports Med 40:41–48CrossRefPubMedGoogle Scholar
  4. 4.
    Ardern CL, Taylor NF, Feller JA, Whitehead ST, Webster KE (2013) Psychological responses matter in returning to preinjury level of sport after anterior cruciate ligament reconstruction surgery. Am J Sports Med 41:1549–1558CrossRefPubMedGoogle Scholar
  5. 5.
    Barber-Westin SD, Noyes FR (2011) Factors used to determine return to unrestricted sports activities after anterior cruciate ligament reconstruction. Arthroscopy 27:1697–1705CrossRefPubMedGoogle Scholar
  6. 6.
    Beynnon BD, Johnson RJ, Abate JA, Fleming BC, Nichols CE (2005) Treatment of anterior cruciate ligament injuries, part 1. Am J Sports Med 33:1579–1602CrossRefPubMedGoogle Scholar
  7. 7.
    Chmielewski TL, Jones D, Day T, Tillman SM, Lentz TA, George SZ (2008) The association of pain and fear of movement/reinjury with function during anterior cruciate ligament reconstruction rehabilitation. J Orthop Sports Phys Ther 38:746–753CrossRefPubMedGoogle Scholar
  8. 8.
    Chmielewski TL, Zeppieri G Jr, Lentz TA, Tillman SM, Moser MW, Indelicato PA, George SZ (2011) Longitudinal changes in psychosocial factors and their association with knee pain and function after anterior cruciate ligament reconstruction. Phys Ther 91:1355–1366PubMedCentralCrossRefPubMedGoogle Scholar
  9. 9.
    Clayton RAE, Court-Brown CM (2008) The epidemiology of musculoskeletal tendinous and ligamentous injuries. Injury 39:1338–1344CrossRefPubMedGoogle Scholar
  10. 10.
    De Carlo M, Shelbourne KD, Oneacre K (1999) Rehabilitation program for both knees when the contralateral autogenous patellar tendon graft is used for primary anterior cruciate ligament reconstruction: a case study. J Orthop Sports Phys Ther 29:144–153CrossRefPubMedGoogle Scholar
  11. 11.
    Flanigan DC, Everhart JS, Pedroza A, Smith T, Kaeding CC (2013) Fear of reinjury (kinesiophobia) and persistent knee symptoms are common factors for lack of return to sport after anterior cruciate ligament reconstruction. Arthroscopy 29:1322–1329CrossRefPubMedGoogle Scholar
  12. 12.
    George SZ, Lentz TA, Zeppieri G, Lee D, Chmielewski TL (2012) Analysis of shortened version of the Tampa scale for kinesiophobia and pain catastrophizing scale for patients after anterior cruciate ligament reconstruction. Clin J Pain 28:73–80PubMedCentralCrossRefPubMedGoogle Scholar
  13. 13.
    van Grinsven S, van Cingel RE, Holla CJ, van Loon CJ (2010) Evidence-based rehabilitation following anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 18:1128–1144CrossRefPubMedGoogle Scholar
  14. 14.
    Gustavsson A, Neeter C, Thomeé P, Silbernagel KG, Augustsson J, Thomeé R, Karlsson J (2006) A test battery for evaluating hop performance in patients with an ACL injury and patients who have undergone ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 14:778–788CrossRefPubMedGoogle Scholar
  15. 15.
    Harris JD, Abrams GD, Bach BR, Williams D, Heidloff D, Bush-Joseph CA, Verma NN, Forsythe B, Cole BJ (2014) Return to sport after ACL reconstruction. Orthopedics 37:e103–e108CrossRefPubMedGoogle Scholar
  16. 16.
    Hartigan EH, Axe MJ, Synder-Mackler L (2010) Time line for noncopers to pass return-to-sports criteria after anterior ligament reconstruction. J Orthop Sports Phys Ther 40:141–154PubMedCentralCrossRefPubMedGoogle Scholar
  17. 17.
    Hefti F, Müller W, Jakob RP, Stäubli HU (1993) Evaluation of knee ligament injuries with the IKDC form. Knee Surg Sports Traumatol Arthrosc 1:226–234CrossRefPubMedGoogle Scholar
  18. 18.
    Howell S, Taylor M (1996) Brace-free rehabilitation, with early return to activity, for knees reconstructed with a double-looped semitendinosus and gracilis graft. J Bone Joint Surg Am 78:814–825PubMedGoogle Scholar
  19. 19.
    Huber E, Stoll T, Ehrat B, Wäckerlin B, Hofer HO, Seifert B, Stucki G (1997) Zuverlässigkeit und Normperzentilen einer neuen isometrischen Muskelkraftmessmethode. Schweizer Ztschr Physiotherap 5:29–39Google Scholar
  20. 20.
    Irrgang JJ, Anderson AF, Boland AL, Harner CD, Kurosaka M, Neyret P, Richmond JC, Shelborne KD (2001) Development and validation of the International Knee Documentation Committee subjective knee form. Am J Sports Med 29:600–613PubMedGoogle Scholar
  21. 21.
    Kori SH, Miller RP, Todd DD (1990) Kinesiophobia: a new view of chronic pain behaviour. Pain Manag 3:35–43Google Scholar
  22. 22.
    Krudwig WK (2000) Situation der Arthroskopie in Deutschland. Arthroskopie 13:191–193CrossRefGoogle Scholar
  23. 23.
    Krüger-Franke M, Reinmuth S, Kugler A, Rosemeyer B (1995) Concomitant injuries with anterior cruciate ligament rupture. A retrospective study. Unfallchirurg 98:328–332PubMedGoogle Scholar
  24. 24.
    Kvist J (2004) Rehabilitation following anterior cruciate ligament injury: current recommendations for sports participation. Sports Med 34:269–280CrossRefPubMedGoogle Scholar
  25. 25.
    Kvist J, Ek A, Sporrstedt K, Good L (2005) Fear of re-injury: a hindrance for returning to sports after ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 13:393–397CrossRefPubMedGoogle Scholar
  26. 26.
    Kvist J, Österberg A, Gauffin H, Tagesson S, Webster K, Ardern C (2012) Translation and measurement properties in the Swedish version of ACL-Return to Sports after Injury questionnaire. Scand J Med Sci Sports 23:568–575PubMedGoogle Scholar
  27. 27.
    Langford JL, Webster KE, Feller JA (2009) A prospective longitudinal study to assess psychological changes following anterior cruciate ligament reconstruction surgery. Brit J Sports Med 43:377–381CrossRefGoogle Scholar
  28. 28.
    Lee DYH, Karim SA, Chang HC (2008) Return to sport after anterior cruciate ligament reconstruction—a review of patients with minimum 5-year follow-up. Ann Acad Med Singapore 37:273–278PubMedGoogle Scholar
  29. 29.
    Logerstedt DS, Snyder-Mackler L, Ritter RC, Axe MJ, Godges JJ (2010) Knee stability and movement coordination impairments: knee ligament sprain. J Orthop Sports Phys Ther 40:A1–A37Google Scholar
  30. 30.
    Morrey MA (1999) A longitudinal examination of athletes emotional and cognitive responses to ACL injury. Clin J Sport Med 9:63–69CrossRefPubMedGoogle Scholar
  31. 31.
    Müller U, Schmidt M, Krüger-Franke M, Rosemeyer B (2014) Die ACL–Return to Sport after Injury Skala als wichtiger Parameter bei der Beurteilung Rückkehr zum Sport Level I und II nach Rekonstruktion des vorderen Kreuzbands (deutsche Version). Sport Orthop Traumatol 30:135–144Google Scholar
  32. 32.
    MVZ (2011) Einheitliches Nachbehandlungsschema für vordere Kreuzbandplastik ohne BegleitverletzungenGoogle Scholar
  33. 33.
    Myer GD, Paterno MV, Ford KR, Quatman CE, Hewett TE (2006) Rehabilitation after anterior cruciate ligament reconstruction: criteria-based progression through the return-to-sport phase. J Orthop Sports Phys Ther 36:385–402CrossRefPubMedGoogle Scholar
  34. 34.
    Myer GD, Paterno MV, Ford KR, Hewett TE (2008) Neuromuscular training techniques to target deficits before return to sport after anterior cruciate ligament reconstruction. J Strength Cond Res 22:987–1014CrossRefPubMedGoogle Scholar
  35. 35.
    Myer GD, Schmitt LC, Brent JL, Ford KR, Foss KDB, Scherer BJ, Heidt RS Jr, Divine JG, Hewett TE (2011) Utilization of modified NLF combine testing to identify functional deficits in athletes following ACL reconstruction. J Orthop Sports Phys Ther 41:377–388PubMedCentralCrossRefPubMedGoogle Scholar
  36. 36.
    Myer GD, Martin L, Ford KR, Paterno MV, Schmitt LC, Heidt RS, Colosimo A, Hewett TE (2012) No association of time from surgery with functional deficits in athletes after ACL-reconstruction: evidence for objective return-to-sport criteria. Am J Sports Med 40:2256–2263PubMedCentralCrossRefPubMedGoogle Scholar
  37. 37.
    Neeter C, Gustavsson A, Thomeé P, Augustsson J, Thomeé R, Karlsson J (2006) Development of a strength test battery for evaluating leg muscle power after ACL injury and reconstruction. Knee Surg Sports Traumatol Arthrosc 14:571–580CrossRefPubMedGoogle Scholar
  38. 38.
    Östenberg A, Roos E, Ekdahl C, Roos H (1998) Isokinetic knee extensor strength and functional performance in healthy female soccer players. Scand J Med Sci Sports 8:257–264CrossRefPubMedGoogle Scholar
  39. 39.
    Petersen W, Zantop T (2013) Return to play following ACL reconstruction: survey among experienced arthroscopic surgeons (AGA instructors). Arch Orthop Trauma Surg 133:969–977CrossRefPubMedGoogle Scholar
  40. 40.
    Reed RL, Den Hartog R, Yochum K, Pearlmutter L, Ruttinger AC, Mooradian AD (1993) A comparison of hand-held isometric strength measurement with isokinetic strength measurement in the elderly. J Am Geriatr Soc 41:53–56CrossRefPubMedGoogle Scholar
  41. 41.
    Reid A, Birmingham TB, Stratford PW, Alcock GK, Giffin JR (2007) Hop testing provides a reliable and valid outcome measure during rehabilitation after anterior cruciate ligament reconstruction. Phys Ther 87:337–349CrossRefPubMedGoogle Scholar
  42. 42.
    Shaw T, Williams MT, Chipchase LS (2005) Do early quadriceps exercises affect the outcome of ACL reconstruction? A randomised controlled trial. Aust J Physiother 51:9–17CrossRefPubMedGoogle Scholar
  43. 43.
    Spindler KP, Wright RW (2008) Anterior cruciate ligament tear. N Engl J Med 359:2135–2142PubMedCentralCrossRefPubMedGoogle Scholar
  44. 44.
    Stoll T, Huber E, Seifert B, Michel A, Stucki G (2000) Maximal isometric muscle strength: normative values and gender-specific relation to age. Clin Rheumatol 19:105–113CrossRefPubMedGoogle Scholar
  45. 45.
    Stoll T, Huber E, Seifert B, Stucki G, Michel BA (2002) Isometric muscle strength measurement. Thieme, StuttgartGoogle Scholar
  46. 46.
    te Wierike SCM, van der Sluis A, van den Akker-Scheck I, Elferink-Gemser MT, Visscher C (2013) Psychosocial factors influencing the recovery of athletes with anterior cruciate ligament injury: a systematic review. Scand J Med Sci Sports 23:527–540Google Scholar
  47. 47.
    Thomeé R, Kaplan Y, Kvist J, Myklebust G, Risberg MA, Theisen D, Tsepis E, Werner S, Wondrasch B, Witvrouw E (2011) Muscle strength and hop performance criteria prior to return to sports after ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 19:1798–1805CrossRefPubMedGoogle Scholar
  48. 48.
    Thomeé R, Neeter C, Gustavsson A, Thomeé P, Augustsson J, Eriksson B, Karlsson J (2012) Variability in leg power and hop performance after ACL-reconstruction. Knee Surg Sports Traumatol Arthrosc 20:1143–1151CrossRefPubMedGoogle Scholar
  49. 49.
    Webster KE, Feller JA, Lambros C (2008) Development and preliminary validation of a scale to measure the psychological impact of returning to sport following anterior cruciate ligament reconstruction surgery. Phys Ther Sport 9:9–15CrossRefPubMedGoogle Scholar
  50. 50.
    Wells L, Dyke JA, Albaugh J, Ganley T (2009) Adolescent anterior cruciate ligament reconstruction: a retrospective analysis of quadriceps strength recovery and return to full activity after surgery. J Pediatr Orthop 29:486–489CrossRefPubMedGoogle Scholar
  51. 51.
    Wilk KE, Romaniello WT, Soscia SM, Arrigo CA, Andrews JR (1994) The relationship between subjective knee scores, isokinetic testing, and functional testing in the ACL-reconstructed knee. J Orthop Sports Phys Ther 20:60–73CrossRefPubMedGoogle Scholar
  52. 52.
    Woby SR, Roach NK, Urmston M, Watson PJ (2005) Psychometric properties of the TSK-11: a shortened version of the Tampa Scale for Kinesiophobia. Pain 117:137–144CrossRefPubMedGoogle Scholar

Copyright information

© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2014

Authors and Affiliations

  • Ulrike Müller
    • 1
  • Michael Krüger-Franke
    • 2
  • Michael Schmidt
    • 3
  • Bernd Rosemeyer
    • 2
  1. 1.Department of Orthopaedics, Physical Medicine and RehabilitationUniversity of MunichMunichGermany
  2. 2.MVZ NordbadMunichGermany
  3. 3.Department of Medical Informatics, Biometry and Epidemiology of the Faculty of MedicineUniversity of MunichMunichGermany

Personalised recommendations