The recovery from anterior cruciate ligament (ACL) injury is well publicised to be long, and not without complications. Additionally, ACL injuries often have high re-injury rates, and a large majority of athletes unfortunately fail to complete a full recovery. Positively, there's lots of things you can do to improve your recovery after ACL injury. For …
The recovery from anterior cruciate ligament (ACL) injury is well publicised to be long, and not without complications. Additionally, ACL injuries often have high re-injury rates, and a large majority of athletes unfortunately fail to complete a full recovery. Positively, there’s lots of things you can do to improve your recovery after ACL injury. For example, high quality, systematic, evidence-based testing informs progress and enhances outcomes.. just like what we do for lower limb and ACL injuries in Melbourne out of Athletes Edge Physiotherapy.
High quality testing allows assessment of progress, modification if needed, and planning of your rehab program (van Melick et al., 2022). Testing should include a battery of different tests that are appropriate for the time and stage of your recovery (Allen et al., 2021; Angelozzi et al., 2012; Taberner et al., 2020b; Taberner et al., 2023; Stojanović et al., 2023). Testing should be completed at regular timepoints, which allows regular re-assessment and planning (Allen et al., 2021; Buckthorpe et al., 2020; Eckenrode et al., 2017; Monson et al., 2022). This article details 5 tests that athletes should master during their ACL recovery.
Remember, these are only 5 of the plethora of assessments and definitely do not constitute a complete assessment. They are not in order of importance, and should be used only as a guide. We recommend you consult with one of our highly qualified staff if you have further questions or want an individualised assessment.
Evidence recommends that formalised, high-quality, data driven regular testing every 6 weeks-3 months ideal (Kotsifaki, 2023; van Melick et al., 2022; Welling, 2024).
5 tests and movements everyone should be good at after their ACL injury
1. Single Leg Vertical Hop Test
Hop tests are common in clinical practice as methods of assessing functional performance. There are a plethora of hop tests that exist, including hop for distance, triple hop test, crossover hop test, lateral hop, vertical hops, multidirectional hops and drop jumps. Time constraints, fatigue, floor or ceiling effects, along with the similarity of data obtained means that you are unlikely to complete all of these assessments at once. So which one do you choose.. and why? A growing number of studies have recommended to use a vertical hop test, describing how it has a greater ability to assess knee and identify deficits compared to horizontal/forward hop tests (Davies et al., 2020; Ebert et al., 2018b; King et al., 2018; Kotsifaki et al., 2022; Kotsifaki et al., 2022b; Renstrom et al., 2008; Sideris et al., 2024). Additionally, use of a single leg drop jump (SLDJ) has been shown to be the preferred method to assess deficits after ACL injury (King et al., 2018; Richter et al., 2019). This was demonstrated in a study of athletes 9 months post ACL reconstruction (King et al., 2018). The majority of them “passed” the criteria (>90% LSI) for single leg hop for distance. However, when testing on a SLDJ, a high percentage failed (e.g. <80% LSI), showing greater sensitivity for performance deficits for drop jump compared to hop for distance (King et al., 2018).
GOAL: 100% limb symmetry on key measures including jump height, concentric/eccentric impulse, force at zero velocity. Speed of movement should be <0.250sec on ground contact time and reactivity (RSI) >0.5.
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2. Single Leg Sit to Stand Test
The single leg sit to stand test (SL STS) is a commonly used assessment during the early-mid stages of your ACL injury recovery (Culvenor et al., 2016; Patterson et al., 2020). It is a simple, body weight movement that can be completed anywhere, by anyone. A study by Culvenor and colleagues (2016) set a cut-off range of >22 repetitions as the minimum target to achieve. The evidence around this criteria involved evidence to show that individuals who completed <22 repetitions at 1 year had a higher likelihood of poorer quality of life up to 5 years post their ACL reconstruction (Culvenor et al., 2016). Additional research has also shown that poor performance on the SL STS test is linked with increased risk of early joint based degeneration (Patterson et al., 2020). These studies highlight the importance of achieving good single leg functional performance on longer term outcomes and joint health (Culvenor et al., 2016; Patterson et al., 2020).
GOAL: >22 repetitions and 100% limb symmetry (and ideally >25-30)
3. Soleus Strength Test
There a numerous lower limb muscles that should be assessed during your ACL injury recovery. However, one of the most important is arguably the soleus muscle. The soleus muscle is one of your calf muscles, shown to be a key contributor to running at all speeds (Dorn et al., 2012) and high activity during landing and change of direction (COD) movements (Maniar et al., 2018; Maniar et al., 2020; Mokhtarzadeh et al., 2013). Studies have shown that the soleus muscle is vital at mitigating the loads on the ACL, and consider “protective” of the ACL during landing and COD, due to the posterior force it provides during these movements (Maniar et al., 2018; Maniar et al., 2020; Mokhtarzadeh et al., 2013). There are numerous ways to assess the solues, however it is recommended to find a test with appropriate sensitivity to determine differences between sides, and that allows you to measure maximum strength. We recommend the seated, isometric soleus test, utilizing force plates, as detailed below.
GOAL: 100% limb symmetry and ideally >3-4 x bodyweight in kg (or 30-40N/kg)
4. Knee Control Assessments
Along with measuring functional performance, the ability to control dynamic movement is considered a critical part of your ACL injury testing (Buckthorpe et al., 2020; Buckthorpe, 2021; Draovitch et al., 2022; Ford et al., 2003). A variety of movements should be assess for movement control, including but not limited to running, change of direction, landing, hopping, contact movements, unanticipated movements, along with skill and sport based assessments. One of the key components of an ACL injury test battery is looking at the quality of your hopping and landing movements (Davies et al., 2020; Ekizos & Santuz, 2023; Hewitt et al., 2005; Hewitt et al., 2018; King et al., 2021; Kotsifaki et al., 2022; Mathieu-Kälin et al., 2023; Renstrom et al., 2008; Sas, 2014; Welling, 2024). Typically, assessing the landing during a single leg drop jump, and a forward hop landing, is recommended (King et al., 2019; Kotsifaki et al., 2022; Kotsifaki, 2023). While there are a variety of things to assess with landing control, key considerations include the degree of knee flexion, knee valgus or internal rotation, pelvic and trunk control, and foot position (King et al., 2019; King et al., 2021; Kotsifaki et al., 2022; Mathieu-Kälin et al., 2023; Sas, 2014). Generally, a slow motion video assessment should be completed with an experience lower limb rehab physiotherapist to ensure adequate technique and movement control (Bisciotti et al., 2016; Buckthorpe, 2021; Driban et al., 2023; Forelli et al., 2023; Prelaz, 2013; Sas, 2014; Van Melick et al., 2016; Welling, 2024)
GOAL: excellent knee, trunk and pelvis control on slow motion video.
5. Quadriceps Strength Testing
Achieving excellent quadriceps strength after an ACL injury is arguably one of the most important components of your recovery. Significantly quadriceps strength has been shown to be one of the most important criterion for predicting re-injury risk (Driban et al., 2023). Additionally, for every 1% increase in quadriceps symmetry between legs (e.g. injury vs non-injured), there was a subsequent 3% reduction in knee re-injury risk (Grindem et al., 2016; Meredith et al., 2020). Furthermore, poor quadriceps symmetry between legs has been shown to have poor influences on functional and hopping performance during return to sport testing (Schmitt et al., 2012).
There are numerous methods to assess quadriceps strength, including highly accurate isokinetic testing, isometric dynamometers and repetition maximum testing (Brinlee et al., 2022; Eckenrode et al., 2017; Khayambashi et al., 2016; Monson et al., 2022; Sinacore et al., 2017; van Melick et al., 2022). While all tests methods have pros and cons, the isokinetic testing is the recommended where access and finances allow due to its high accuracy. Secondly, isometric dynamometry is considered a valid alternative, provided the test is standardised and a belt is used to fix the dynamometer during testing (Sinacore et al., 2017; van Melick et al., 2022).
GOAL: 100% limb symmetry on knee extension strength (on force dynamometer or isokinetic testing) and 8 x BW / 8N/kg
Want to know more or get assessed?
Please note that this is by no means an exhaustive list. This is just a guide to illustrate 5 parts of what is a comprehensive, multifaceted assessment process. As mentioned above, testing should occur every 4-6 weeks, be criteria based, and look to measure important metrics like strength, movement control power, functional performance, dynamic skills and psychological readiness. Key timepoints like returning to running, commencing field-based rehabilitation, and a return to sport, all require comprehensive batteries of tests and checklists of criteria. If you are interested in getting evidence-based, expert testing for your ACL injury, please get in touch with us at Athletes Edge Physiotherapy or book your specialist rehab and performance testing appointment at our inner Melbourne facility.
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This article is written by Director and senior physio Ky Wynne, who has clinical interest and expertise in running injuries and lower limb rehabilitation (including ACL injuries).
What’s Your Next Step?
Value yourself and start your journey with Athletes Edge Physiotherapy today.
