Physical Therapy in Sport 59 (2023) 144e150

Contents lists available at ScienceDirect

Physical Therapy in Sport

journal homepage: www.elsevier.com/ptsp

A clinician-friendly test battery with a passing rate similar to a ‘gold

standard’ return-to-sport test battery 1 year after ACL reconstruction:
Results from a rehabilitation outcome registry

a, b, Eric Hamrin Senorski a, b, c, d, *
Daniel Broman a, Ramana Piussi a, b, c, Roland Thomee
a
Sportrehab Sports Medicine Clinic, Stampgatan 14, SE-411 01, Gothenburg, Sweden
b
Unit of Physiotherapy, Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of
Gothenburg, Box 455, SE-405 30, Gothenburg, Sweden
c
Sahlgrenska Sports Medicine Center, Sahlgrenska Academy, Gothenburg, Sweden
d
Swedish Olympic Committee, Sweden

a r t i c l e i n f o a b s t r a c t

Article history: Objectives: To 1) present passing rates for different clinician-friendly (CF) test batteries and 2) determine
Received 11 October 2022 the relationship between passing CF test batteries and passing gold standard (GS) return-to-sport (RTS)
Received in revised form muscle function testing, 1 year after ACL reconstruction.
16 December 2022
Study design: Cross-sectional registry study, level of evidence: 3.
Accepted 16 December 2022
Setting: Primary care.
Participants: Data from 588 patients (52% women, mean age 29.3 ± 9.8 years) were extracted from the
Keywords:
Project ACL registry.
knee
Anterior cruciate ligament
Main outcome measures: The passing rates for the different test batteries.
Evaluation Results: The passing rate for GS test battery was 28% (95% CI, 24e32%) and the passing rate for the CF test
Limb symmetry index battery with the lowest passing rate was 27% (95% CI 24e31%). The two CF test batteries with the
strongest relationships with passing GS test battery showed that 51% (95% CI 43e59%) and 49% (95% CI
44e55%) of the patients who passed the respective CF test battery also passed the GS test battery.
Conclusion: A CF test battery can be as demanding to pass as a GS test battery, 1 year after ACL recon-
struction. However, passing a CF test battery only gives patients a chance similar to a “coin flip” of also
passing a GS RTS test battery.
© 2022 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY license
(http://creativecommons.org/licenses/by/4.0/).

1. Introduction sport (RTS) following ACL reconstruction has been reported to be

important to reduce the number of second ACL injuries (Grindem
The incidence of anterior cruciate ligament (ACL) injuries re- et al., 2016). The most common tests used in RTS test batteries
mains high, where approximately 80 injuries per 100,000 in- are isokinetic knee extension and knee flexion strength tests and
dividuals occur yearly in Sweden, of which almost 50% are treated various hop tests (Abrams et al., 2014). Isokinetic strength tests are
with ACL reconstruction, followed by rehabilitation (Swedish Knee regarded as the ‘gold standard’ (GS) for assessing muscle strength
Ligament Registry [Internet], 2022). The risk of sustaining a second in patients after ACL reconstruction (Lynch et al., 2015), although
ACL injury is regarded as high after primary ACL reconstruction, without an optimal testing protocol (Undheim et al., 2015). How-
especially for young athletes (<20 years), with 29% of patients ever, this ‘gold standard’ assessment cannot be regarded as
sustaining a second ACL injury within 5 years after the primary ACL clinician-friendly (CF), since isokinetic testing systems are expen-
reconstruction (Webster et al., 2014). sive and are therefore rarely seen in clinical settings. Therefore, an
To ensure that patients pass test batteries before a return to alternative CF test battery for clinicians who does not have access to
expensive equipment would be useful. Inexpensive psychological
patient-reported outcomes (PROs) have been reported to be
* Corresponding author. Sportrehab Sports Medicine Clinic, Stampgatan 14, SE- important in predicting outcomes after ACL reconstruction (Ardern
411 01, Gothenburg, Sweden. et al., 2014; McPherson et al., 2019) and could therefore be part of a
E-mail address: [email protected] (E. Hamrin Senorski).

https://doi.org/10.1016/j.ptsp.2022.12.009
1466-853X/© 2022 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
D. Broman, R. Piussi, R. Thome
e et al. Physical Therapy in Sport 59 (2023) 144e150

CF test battery, together with more CF muscle function tests. A respectively was used for analysis. Isokinetic strength testing with
recent consensus statement from the Panther Symposium ACL the Biodex System has been reported to have acceptable mechan-
Injury Return to Sport Consensus Group also recommended the ical reliability and validity for measuring muscle strength (Drouin
assessment of psychological factors before RTS (Meredith et al., et al., 2004), and it has also been reported to be reliable with test
2020). The proportion of patients who pass pre-determined cut- re-test measurements (Feiring et al., 1990).
offs (the passing rate) has not however been thoroughly investi- The hop tests were performed with the patients' hands held
gated for test batteries which only include CF muscle function tests, behind their backs. For the vertical hop, Muscle lab equipment was
such as the side-hop test and hop for distance, and psychological used (Ergotest Technology, Oslo, Norway), converting the time
PROs, such as the ACL e Return to Sport after Injury (ACL-RSI) scale spent in the air from take-off to landing into centimeters. Two
and the Knee Self-Efficacy Scale (K-SES). Furthermore, a better warm-up attempts and 3 maximum attempts were performed for
understanding of how passing or failing CF test batteries relate to each side. The highest jump achieved for each side was used for
passing GS muscle function RTS test batteries is needed. analysis. For the hop for distance, the distance from the patients’
The aim of the present study was to 1) present passing rates for toes at the starting line to the heel at landing was measured in
different CF tests and test batteries comprising hop tests and PROs centimeters. The test was approved if the landing was controlled,
and 2) determine the relationship between passing CF tests or test without the patients moving their landing foot and being able to
batteries and passing GS RTS muscle function testing, 1 year after maintain balance. Two warm-up attempts and 3 maximum at-
ACL reconstruction. tempts were performed for each side, with an optional 4th and 5th
attempt if patients failed previous attempts. The longest jump
2. Method achieved for each side was used for analysis. For the side-hop test,
the number of side hops over two lines, 40 centimeters apart,
2.1. Patient selection performed during 30 seconds was recorded. Only 1 attempt was
performed. Before the attempt, patients had familiarized with the
The data for this cross-sectional study were extracted from a test by being allowed to try 10 warm-up hops for each side. The
rehabilitation-specific registry: Project ACL, on October 1, 2021. This three hop tests have high reliability, sensitivity and accuracy for
registry has previously been described in detail (Hamrin Senorski measuring hop performance following ACL reconstruction
et al., 2017). Briefly, Project ACL has collected outcomes for pa- (Gustavsson et al., 2006).
tients after an ACL injury or reconstruction since 2014. Project ACL The results from the tests of muscle function in the present
collects data for muscle function tests and PROs prospectively at 10 study are reported as side-to-side differences, using the limb
weeks and 4, 8, 12, 18 and 24 months after baseline, i.e. an ACL symmetry index (LSI), which calculates the result for the injured leg
injury or reconstruction. Preferably, patients treated with recon- divided by the result for the non-injured leg, multiplied by 100.
struction should also perform a baseline test within 6 days prior to
reconstruction. In the present study, the demographics and data 2.3. Patient-reported outcomes
from the 1-year follow-up were extracted for analysis. Patients
were eligible for inclusion if they were aged 18e65 years, had The PROs used from Project ACL for the CF test batteries
undergone a unilateral ACL reconstruction and attended Project included the K-SES18 and the ACL-RSI.
ACL's 1-year follow-up. Patients were excluded if they had more The K-SES18 was developed to measure patients’ knee-related
than one ACL injury or if they did not complete all the muscle self-efficacy following ACL injury/reconstruction. The question-
function tests and PROs at the 1-year follow-up. The project has naire consists of 18 items divided into four sections (A-D): daily
ethical approval from the Swedish Ethical Review Authority activities (A), sporting activities (B), knee function tasks (C) and
(2020e02501). future knee self-efficacy (D). Each item produces a result from 0 to
10, with 10 indicating the highest perceived self-efficacy to perform
2.2. Muscle function tests a task (Beischer et al., 2021). The results from each question are
added together and divided by the total number of items to obtain a
The tests of muscle function in Project ACL comprise unilateral mean score. Since two strong factors have been identified in the K-
isokinetic knee extension and knee flexion muscle strength tests at SES18, A-C and D respectively (Thomee
et al., 2006), analyses were
an angular speed of 90
/second, using a Biodex isokinetic dyna- performed separately for the two subscales of A-C (K-SESpresent) and
mometer (Biodex System 4; Biodex Medical System, Shirley, NY, D (K-SESfuture). In the present study, the two respective K-SES18
USA), as well as three hop tests: vertical hop, hop for distance and subscales were regarded as separate PROs. The K-SES18 has been
side hop. This muscle function test battery will be referred to as reported to have good reliability and validity (Beischer et al., 2021;
“the GS test battery” in the present study (Abrams et al., 2014; Thomee
et al., 2006).
Lynch et al., 2015). The muscle function tests used in the CF test The ACL-RSI aims to measure patients’ emotion, confidence and
batteries in the present study included hop for distance and side risk appraisal to return to sport following an ACL injury and
hop, since these tests only require a tape measure, a stopwatch and acceptable reliability has been reported (Webster et al., 2008). In
tape as equipment. the present study, the 12-question version was used (Webster &
Before the patients were tested, they performed a standardized Feller, 2018). Each of the 12 questions is rated by patients from 1
warm-up consisting of 10 minutes on a stationary bike. For each of to 10, with 10 indicating the best perceived psychological outcome
the strength and hop tests, the test was first performed on the (i.e. highest confidence or lowest perceived risk). The results for
injured leg and then on the non-injured leg. Before patients were each item are added up to obtain a total score ranging from 0 to 120.
allowed to perform the muscle function tests, permission was
required from their responsible physical therapist and the test 2.4. Patient characteristics
leader.
The strength tests were performed with 3 maximum attempts Data for age at the time of ACL reconstruction, sex, Tegner ac-
per side with an optional 4th attempt. The rest between maximum tivity scale scores, graft choice, weight, height and body mass index
attempts was 40 seconds. The highest peak torque achieved in were extracted from Project ACL. The Tegner activity scale is a
Newton meters for each side for knee extension and knee flexion rating system used to determine how strenuous different activities
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D. Broman, R. Piussi, R. Thome
e et al. Physical Therapy in Sport 59 (2023) 144e150

and sports are for the knees (Tegner & Lysholm, 1985). The grading 3.1. Passing rates for different tests/test batteries
system ranges from 0 to 10, where a Tegner score of 6 is regarded
as a knee-strenuous sport or activity. In the present study a Fig. 2 shows the passing rates for the different CF tests, CF test
modified version of the Tegner activity scale was used ranging from batteries and the GS test battery. The test with the highest passing
1 to 10, where sports as for example American football, rugby and rate was the K-SESpresent (90% passing [95% CI 87e92%]). The test
floorball has been added to the scale. In addition, level 0, sick leave, batteries with the lowest passing rates were the CF test battery
was excluded. including 2 muscle function tests and 3 PROs (27% passing [95% CI
24e31%]) and the GS test battery (28% passing [95% CI 24e32%]).
2.5. Data analysis
3.2. The relationship between passing or failing the CF tests or test
The primary outcomes in the present study were the proportion batteries and passing the GS test battery
of patients that passed pre-determined cut-offs in different CF tests
and test batteries at the 1-year follow-up. Pre-determined cut-offs Fig. 3 shows the proportion of patients that passed the GS test
for the CF tests were defined as: 90% Limb Symmetry Index (LSI) battery after either passing or failing a CF test or CF test battery, 1
in the different hop tests (Lynch et al., 2015), 76.6 points for ACL- year after ACL reconstruction. Patients that passed the following CF
RSI (McPherson et al., 2019) and 7 points for the K-SES18 sub- tests or test batteries: hop for distance, side-hop test, K-SESpresent, 2
scales. The cut-off of 7 used for K-SES18 in the present study is muscle function tests or 2 muscle function tests þ3 PROs had a
based on the clinical experience of 2 of the developers of the significantly higher passing rate for the GS test battery, compared
questionnaire who proposed a score of 7 or higher as “fair” knee- with patients that failed the respective CF test or test battery
related self-efficacy. One of the developers of the questionnaire is (p < 0.01). The largest proportion of patients that passed the GS test
a co-author (RT) in the present study. Pre-determined cut-offs for battery after passing a CF test or test battery was found among
tests in the GS test battery were defined as: 90% LSI for knee patients that passed the CF test batteries comprising 2 muscle
extension and knee flexion strength and 90% LSI in the different function tests þ3 PROs, 2 muscle function tests and in patients that
hop tests (Lynch et al., 2015). Table 1 presents the different com- passed the side-hop test, as 51% [95% CI 43e59%], 49% [95% CI
binations of test batteries in the present study. 44e55%] and 41% [95% CI 36e46%] of these patients also passed the
Statistical analyses were performed with the Statistical Product GS test battery respectively.
and Service Solutions (IBM Corp. Released 2017. IBM SPSS Statistics
for Windows, Version 27.0. Armonk, NY: IBM Corp.). For patient
4. Discussion
demographics, the mean value and standard deviation were used
for parametric data, while the median and minimum-maximum
The main finding in this study was that a CF test battery con-
(min-max) were used for non-parametric data. Fisher's exact test
sisting of the hop for distance, the side-hop test, ACL-RSI, K-
was performed to assess the relationship between passing or failing
SESpresent and K-SESfuture (2 muscle function tests þ 3 PROs) had a
any of the CF tests/test batteries and passing the GS test battery. A
passing rate similar to a GS muscle function test battery (27% [95%
95% confidence interval (CI) and a significance value of p < 0.01 was
CI 24e31%] versus 28% [95% CI 24e32%]), 1 year after ACL recon-
used with regard to the risk of a type I error.
struction. Furthermore, patients that passed the following CF tests
and test batteries: hop for distance, side hops, K-SESpresent, 2 muscle
3. Results function tests and 2 muscle function tests þ3 PROs had a statisti-
cally significantly higher passing rate for the GS test battery,
A total of 588 patients were included in the present study. Not compared with patients that failed the respective CF test or test
attending the 1-year follow-up or not having completed all the battery (p < 0.01). Passing the CF test batteries, 2 muscle function
muscle function tests or PROs at the 1-year follow-up were the tests or 2 muscle function tests þ3 PROs, had the strongest rela-
most common reasons for exclusion (n ¼ 1,464, 44% of the total tionship with passing the GS test battery, as 49% [95% CI 44e55%]
number of patients registered in the registry) (Fig. 1). The included and 51% [95% CI 43e59%] of the patients who passed the CF test
patients had a mean age of 29.3 (±9.8) years, a BMI of 23.6 (±2.7) battery also passed the GS test battery respectively. However, this
and 52% were women. The most commonly used graft for ACL also implies that approximately half the patients that pass these CF
reconstruction was the hamstring tendon autograft (81%). The pa- test batteries fail the GS test battery. This may indicate that passing
tients’ median pre-injury Tegner score was 8, equivalent to a CF test battery, requiring tape, a tape measure and some ques-
participating in basketball, handball, or floorball, for example. At tionnaires as materials, can be as demanding to pass as a ‘gold
the 1-year follow-up after ACL reconstruction, 60% had returned to standard’ test battery, but passing the CF test battery only gives the
a Tegner score of 6, equivalent to participating in baseball, patients a chance approximately similar to a “coin flip” of also
snowboarding or more demanding sports, for example, and 38% passing the GS test battery. It is important to acknowledge that the
had returned to their pre-injury Tegner level (Table 2). present study did not assess the relationship between passing

Table 1
The different combinations of test batteries.

Test batteries PROs Muscle function tests

3 PROs ACL-RSI; K-SESpresent; e

K-SESfuture
2 Muscle function tests e Hop for distance; side hop
2 Muscle function tests þ ACL-RSI; K-SESpresent; Hop for distance; side hop
3 PROs K-SESfuture
GS test battery Isokinetic strength for knee extension and knee flexion; vertical hop; hop for distance; side hop

PROs ¼ Patient reported outcomes, GS ¼ gold standard, ACL-RSI ¼ Anterior Cruciate Ligament e Return to Sport after Injury scale, K-SESpresent ¼ Knee e Self-Efficacy Sca-
lepresent, K-SESfuture ¼ Knee e Self-Efficacy Scalefuture.

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Fig. 1. Flowchart of inclusion and exclusion of the study population.

ACL ¼ Anterior Cruciate Ligament; n ¼ number; PRO ¼ Patient Reported Outcome.

Table 2
Patient demographics.

Total Women Men

Number of patients (%) 588 (100%) 303 (52%) 285 (48%)

Age at ACL reconstruction, years 29.3 ± 9.8 27.8 ± 9.0 30.9 ± 9.3
Weight, kg 72.0 ± 12.2 64.6 ± 8.4 79.9 ± 10.5
Height, cm 174.2 ± 8.9 168.2 ± 5.9 180.8 ± 6.9
BMI, kg/m2 23.6 ± 2.7 22.8 ± 2.4 24.1 ± 2.7
Hamstring tendon graft, n (%) 479 (81%) 247 (82%) 232 (81%)
Patellar tendon graft, n (%) 98 (17%) 50 (17%) 48 (17%)
Other graft, n (%) 11 (2%) 6 (2%) 5 (2%)
Pre-injury Tegner, median (min-max) 8 (1e10) 8 (1e10) 8 (1e10)
Returned to Tegner 6 at 1-year follow-up, yes (%) 351 (60%) 169 (56%) 182 (64%)
Returned to  pre-injury Tegner at 1-year follow-up, yes (%) 221 (38%) 110 (36%) 111 (39%)

Kg ¼ kilograms, cm ¼ centimeters, BMI ¼ Body Mass Index, n ¼ number, min ¼ minimum, max ¼ maximum, Tegner ¼ Tegner activity scale score.

different CF tests or test batteries and subsequent knee injuries. As battery comprising 2 muscle function tests þ3 PROs to 57% for the
a result, no conclusions can be drawn with regard to whether test battery comprising only 2 muscle function tests. However, the
passing these test batteries is able to reduce the risk of sustaining proportion of patients that passed the GS test battery after
subsequent knee injuries. achieving pass in the CF test battery comprising 2 muscle function
Our results suggest that relatively few patients pass a GS test tests þ3 PROs and the CF test battery comprising only 2 muscle
battery and a CF test battery comprising 2 muscle function tests and function tests (the same muscle function tests) was similar (51% vs
3 PROs respectively, 1 year after ACL reconstruction, which is in line 49% and the confidence intervals overlapped). This means that the
with previous research on different RTS test batteries (Thomee
addition of the 3 PROs to a CF test battery that already comprised
et al., 2012; Welling et al., 2018). This indicates that the vast ma- the 2 muscle function tests did not add much value in terms of
jority of patients are not physically or mentally ready to RTS 1 year increasing the proportion of patients who pass the GS test battery,
after ACL reconstruction, as achieving both symmetrical muscle despite making the CF test battery more demanding to pass.
function and acceptable psychological readiness before RTS is rec- Furthermore, caution should be taken when using the CF test bat-
ommended in the current literature (Meredith et al., 2020). It is teries as an RTS assessment following ACL reconstruction, as the
therefore reasonable to suggest that either a rehabilitation period proportion of patients who achieve pass in GS RTS testing is rela-
longer than 1 year after ACL reconstruction, or a rehabilitation tively low after achieving pass in a CF test battery (51% at best). This
period with higher quality (e.g. optimal strength training, hop indicates that patients might not be ready to RTS despite being
training and mental preparation) might be necessary for most cleared with a CF test battery. However, whether passing these CF
patients. test batteries might reduce the risk of an ACL re-injury is yet to be
There were considerable differences in passing rates for the determined and it is therefore not clear which test battery is
different stand-alone CF tests, ranging from 48% for ACL-RSI to 90% superior.
for K-SESpresent. Considerable differences in passing rates were also Interestingly, achieving an acceptable score for ACL-RSI had a
found in the different CF test batteries, ranging from 27% for the test lower passing rate (48% [95% CI 44e52%]) than passing the CF test

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Fig. 2. Passing rates for different test batteries, 1 year after ACL reconstruction.
CF ¼ clinician-friendly test battery, GS ¼ gold standard test battery, K-SESpresent ¼ Knee e Self-Efficacy Scalepresent, K-SESfuture ¼ Knee e Self-Efficacy Scalefuture, ACL-RSI ¼ Anterior
Cruciate Ligament e Return to Sport after Injury scale, 2 MF test ¼ unilateral hop for distance þ side hops, 3 PROs ¼ ACL e Return to Sport Index (ACL-RSI) þ Knee e Self-Efficacy
Scalepresent (K-SESpresent) þ Knee e Self-Efficacy Scalefuture (K-SESfuture), 95% confidence interval inside square brackets.

Fig. 3. Proportion of patients that passed the gold standard (GS) test battery after passing or failing a clinician-friendly (CF) test or CF test battery, 1 year after ACL reconstruction.
GS ¼ gold standard test battery, K-SESpresent ¼ Knee e Self-Efficacy Scalepresent, K-SESfuture ¼ Knee e Self-Efficacy Scalefuture, ACL-RSI ¼ Anterior Cruciate Ligament e Return to Sport
Index, 2 MF test ¼ unilateral hop for distance þ unilateral side hops, 3 PROs ¼ ACL e Return to Sport after Injury scale (ACL-RSI) þ Knee e Self-Efficacy Scalepresent (K-
SESpresent) þ Knee e Self-Efficacy Scalefuture (K-SESfuture), * ¼ statistically significant difference in passing rates for the GS test battery between patients that pass a clinician-friendly
test/test battery and patients who fail a clinician-friendly test/test battery p < 0.01, 95% confidence interval inside square brackets.

battery comprising hop for distance and side hops (57% [95% CI demanding than recovering muscle function. This underlines the
53e61%]), indicating that recovering psychological factors before a importance of focusing on the psychological aspect throughout the
return to sport following ACL reconstruction can be more rehabilitation period, as well as recovering muscle function, which

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has previously been described (Sonesson et al., 2017). The lower the south-west of Sweden, but patients from all over Sweden are
passing rate for the ACL-RSI, combined with the fact that both too registered in the project. As a result, some of the patients registered
low and too high scores for the ACL-RSI have been associated with a in Project ACL only attend a few selected follow-ups and some
higher risk of a second ACL injury (McPherson et al., 2019; Piussi patients are enrolled with the aim of only completing the PROs
et al., 2022), supports the importance of incorporating psycholog- regularly, which is done digitally.
ical PROs in an RTS test battery. We therefore recommend the use of Despite the fact that included patients’ pre-injury activity levels
psychological PROs in an RTS test battery, despite the fact that had a large min-max range (Tegner score 1e10), most included
adding PROs to a test battery did not appear to strengthen the patients participated in sports with high knee-strenuous demands
relationship to passing a GS test battery, although it helped to make before their ACL injury, with a median Tegner score of 8 (equivalent
the test battery more demanding to pass. to participating in basketball, handball or floorball, for example).
A large proportion of patients (90% [95% CI 87e92%]) passed the Only 30 out of the included 588 patients had pre-injury activity
pre-determined cut-off score of 7 for the K-SESpresent. However, levels with low knee-strenous demands (Tegner score <6). The
including the K-SESpresent in a test battery with the aim of assessing results in the present study can therefore be generalizable for pa-
readiness to RTS warrants discussion. Only 3 of the 14 questions are tients participating in sporting activities with high knee-strenuous
related to self-efficacy regarding knee-strenuous activities, while demands, but they might not be generalizable for populations with
the remaining items assess knee self-efficacy in daily life or less a lower physical activity level.
knee-demanding physical activities, which might partly explain the In the present study, several analyses were performed,
high passing rate in this cohort. Furthermore, there are no recom- increasing the risk of type I error. To account for this risk, the p-
mendations in the literature for an adequate cut-off score for the K- value was set at p < 0.01.
SES18. The cut-off of 7 points used in the present study is based on
the clinical experience of 2 of the developers of the questionnaire, 6. Conclusion
who proposed a score of 7 or higher as “fair” knee-related self-ef-
ficacy. This might also be a factor when it comes to the high passing A clinician-friendly test battery comprising muscle function
rate for the K-SESpresent in this cohort. In retrospect, using the tests and psychological PROs can be as demanding to pass as a ‘gold
validated Quality-of-Life subscale from the Knee injury and Oste- standard’ RTS muscle function test battery, 1 year after ACL
oarthritis Outcome score (KOOS QoL) (Roos & Lohmander, 2003), reconstruction. However, passing a clinician-friendly test battery
with the cut-off of 62.5 points suggested by Muller et al. (Muller consisting of the side-hop test, hop for distance and three psy-
et al., 2016), for the CF test batteries might have been an alterna- chological PROs only gives patients a chance approximately similar
tive to using K-SESpresent. to a “coin flip” of also passing a gold standard RTS muscle function
test battery. Future research is needed to study to which extent
5. Limitations patients who pass clinician-friendly test batteries return to sport
and what proportion go on to suffer a subsequent ACL injury.
None of the studied CF test batteries included strength tests for
knee extension or knee flexion. As this was a cross-sectional reg- Ethical approval
istry study, we were limited to the data available in the registry.
Since Project ACL uses isokinetic strength testing, not regarded as Ethical approval was obtained from the Swedish Ethical Review
clinician-friendly in terms of pricing, we were not able to include Authority (registration number: 2020e02501).
any strength tests in the CF test batteries. However, we still
recommend including some type of strength test for knee exten-
Financial disclosures
sion and knee flexion before RTS, if possible, as it is recommended
in the literature and symmetrical knee extension strength has been
The study was funded by grants from the Local Research and
shown to be an important factor in reducing the risk of knee €dra Bohusla €n
Development Board for Gothenburg and So
reinjuries (Grindem et al., 2016; Meredith et al., 2020). The use of a
(VGFOUGSB-970705).
portable fixed dynamometer, which can be regarded as more
clinician-friendly in terms of pricing, for knee extension and knee
Ethical statement
flexion strength has been shown to produce reliable strength
measurements and might therefore be suitable for use in the
Data for this study is based on a rehabilitation registry project
absence of an isokinetic system (Toonstra & Mattacola, 2013).
(Project ACL), where all patients have received written information
Another option for assessing muscle strength could be by having
and have given their informed consent to participate in the
patients performing a 1RM or a 3RM in a knee extension or knee
research project. The principles of the Helsinki declaration have
flexion machine. However, the relationship between muscle
been used as guidance in this study.
strength assessment using a Biodex (peak torque) or a knee
extension/knee flexion machine is unknown. We do not recom-
mend using the hop for distance or the side hop test as a proxy for Declaration of competing interests
assessing muscle strength.
One limitation in the present study is the patients’ adherence to None.
attending the follow-ups and completing all the muscle function
tests and PROs at the time of the follow-ups. Of the 3332 patients Declaration of competing interest
enrolled in Project ACL at the time of data extraction, 1464 (44%)
had not completed all the muscle function tests or PROs at the 1- None declared.
year follow-up, or had not participated at the follow-up at all. We
do not know whether these patients differ from the study cohort in Acknowledgements
terms of patient characteristics or if they would have produced
different results in the test batteries. The relatively low adherence We would like to thank Jeanette Kliger for help with English
could be partially explained by the fact that Project ACL is located in language editing.
149
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e et al. Physical Therapy in Sport 59 (2023) 144e150

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