Anterior Cruciate Ligament Functional Sports

Asssessment
Donna Williams, PT, MHS,* David Heidloff, ATC, PES,* Emily Haglage, PT, DPT,*
Kyle Schumacher, PT, DPT, ATC,* Brian J. Cole, MD, MBA,† and
Kirk A. Campbell, MD‡

The incidence of anterior cruciate ligament (ACL) patients has doubled in the past 5 years at
Rush University Orthopaedics. Additionally, there has been a 3-fold increase in the number of
anterior cruciate ligament injuries in patients younger than the age of 25 years of age during
this 5-year period. Fortunately, approximately 80%-90% of these patients return to their sports
at their previous level of play. However, with the increased incidence in tears, it is important for
medical providers to assist the patients in determining the risk factors they may display when
preparing to return to sport. There are very few published return to sport guidelines following
anterior cruciate ligament reconstruction. Midwest Orthopaedics at Rush has developed a
functional sports assessment (FSA) to evaluate anterior cruciate ligament injury risk factors on
postoperative patients. The FSA factors include range-of-motion, strength, endurance,
proprioception, power, core stability, ankle stability, and overall biomechanics and confidence.
Although the FSA has not been proven reliable or valid, it is based on the other commonly used
tasks in determining a patient’s ability after anterior cruciate ligament surgery. It has been
clinically relevant for the patient, therapist, athletic trainer, and physician in identifying
weaknesses and risk factors at the 5-6 month time postoperative time period. This helps to
guide the patient in what tasks he or she needs to be attentive to during the transition to return
to sport to minimize reinjury. This article provides factors that were considered when
developing the FSA, a detailed description of the FSA, and future considerations to improve
the assessment for validity and reliability.
Oper Tech Sports Med 24:59-64 C 2015 Elsevier Inc. All rights reserved.

KEYWORDS anterior cruciate ligament, functional assessment, return to sport

T he incidence of anterior cruciate ligament (ACL) injuries is

400,000-500,000 per year.1 In the United States alone,
anterior cruciate ligament reconstruction is performed in
previous level of function. The return to function often
includes sport specific activities. This consists of running,
jumping, landing, cutting, stopping, and starting and ability to
175,000 patients.2 The rehabilitation following anterior cru- tolerate any contact related to the sport they are returning to.
ciate ligament reconstruction is critical in achieving a successful For most of the patients, the procedure is successful but failure
clinical outcome. There are variations of rehabilitation proto- rates average 3% but has been reported as high as 10%-25%.3
cols but most are based in an accelerated program that Considering the cost and time spent on an anterior cruciate
facilitates early motion, recovery of strength, and return to ligament reconstruction in addition to the mental time away
from activity, a discussion about safe return to sport is a very
*Rush University Medical Center, Midwest Orthopedics PT department, 1611
important topic.
West Harrison, Suite 107, Chicago, IL 60612. The timeline in deciding when to return an athlete to sports
†Department of Orthopaedic Surgery, Division of Sports Medicine, Midwest after anterior cruciate ligament reconstruction can be contro-
Orthopaedics at Rush, Chicago, IL. versial. It is important to use standardized outcome measure in
‡Department of Orthopaedic Surgery, New York University Hospital for Joint research and clinical practice. However, objective guidelines are
Diseases, New York, NY 10003.
Address reprint requests to Donna William, PT, MHS, Rush University Medical
infrequently used to determine when an athlete is ready to safely
Center, Midwest Orthopedics PT department, 1611W, Harrison, Suite return to sport. There are few valid and reliable outcome
107, Chicago, IL 60612. E-mail: Donna.williams@rushortho.com measures in the literature. Factors to consider can include

http://dx.doi.org/10.1053/j.otsm.2015.10.002 59
1060-1872//& 2015 Elsevier Inc. All rights reserved.
60 D. Williams et al.

range-of-motion (ROM), strength, pain, outcome scores, and

functional performance. It is imperative that the dynamic
component of the performance is considered to decrease the
possibility of reinjury.
The objective of this article is to review the return to sport
protocols in the literature as it relates to the Midwest
Orthopaedics at Rush Functional Sports Assessment (FSA).
The assessment was developed to assist the orthopedic
physicians and physical therapists in determining the deficits
and strengths of postoperative anterior cruciate ligament
patients, as they are preparing to return to sport. It is used to
clarify what tasks the athlete needs to focus on, to perform
sport specific activities with minimal risk.
Our objective in creating the FSA was to evaluate as many
modifiable ACL injury risk factors as possible whereas adher-
ing to constraints that limit most physical therapy clinics. For Figure 1 Single Leg Squat Front View (Color version of figure is
the purpose of the FSA, the modifiable ACL injury risk factors available online.)
were ROM in the lower extremities, strength and power
symmetry of the lower extremities, quadriceps dominance, purpose of this ROM testing in the FSA is to identify significant
proprioception, endurance, core stability, ankle stability, over- ROM restrictions that would inhibit progressing with the
all quality of biomechanics with high-risk athletic movements, remainder of the test. For the purposes of the FSA, the patient
and confidence in the knee. Constraints placed on our is expected to achieve 201 of ankle dorsiflexion bilaterally,
approach to testing protocols were that the FSA needed to symmetric knee extension, and 1201 of knee flexion bilaterally.
take 60 minutes or less to complete, use common equipment
found in a PT clinic, be able to be performed in a small area
(6 m  3 m), use the movements in all 3 planes, be relevant, be
reliable, provide immediate feedback that the patient can use to Single Leg Hop
reduce their injury risk factors, and provide data that the The single leg hop assessment requires the patient to stand on
patient’s physician can use as a component in the return to play 1 leg and hop as far as possible, land on the same limb, and
decision. maintain their balance for 2 seconds. Inability to maintain
Patients are strongly encouraged to have met the criteria balance invalidates that attempt. Measurements are then taken
described below performing the FSA. Patients should allow at from the patient’s heel to the nearest centimeter. This process is
least 20 weeks since their date of surgery, have experience with repeated, alternating between the unaffected and affected side
lateral movement, pivoting, and plyometrics, report pain levels until 3 measurements are taken on each leg.
less than a 3/10 with activities of daily living and current Single-leg performance-based measures used to assess the
exercises, be prepared to begin the transition back to their sport combination of muscle strength and power, neuromuscular
in the next month, and have a physician’s clearance specifically control, confidence in the repair knee, and the ability to
for the FSA. tolerate loads related to sports-specific activities following
The FSA consists of 9 different sections—a knee and ankle surgical and rehabilitative interventions.4-7 In our opinion,
ROM assessment, single leg hop, triple hop, crossover triple the 4 hop tests progress from the least difficult to the most
hop, 6 m timed hop, single leg squatting, lateral jumping, and
pivoting, 6 m straight line run with a change in direction, and a
plyometric box jump assessment. The patient’s test is recorded
with 1-2 video cameras and the video is analyzed afterwards
with the patient present to discuss deficits noted. Video footage
is also analyzed by the test administrator afterwards for more
comprehensive identification of deficits.
Patients are instructed to wear athletic clothing and shoes
that they wear for their regular athletic activity and training.
Patients that would be utilizing a brace when they return to
their sport are instructed to wear their brace during testing.
Patients are allowed to warm up utilizing any method with
which they are comfortable and familiar.

ROM Assessment
The FSA ROM assessment consists of goniometric assessment Figure 2 Single Leg Squat Side View (Color version of figure is available
of ankle dorsiflexion, knee flexion, and knee extension. The online.)
Anterior cruciate ligament functional sports asssessment 61

Figure 3 Lateral Bounding. Figure 5 Decleration.

difficult. If an athlete is unable to perform the single hop for We believe, the triple hop is the next most difficult regarding
distance safely, they may not be able to continue with the rest the 4 hop tests. Hamilton et al8 found that the triple hop for
of the FSA. Even though it is the least difficult portion of the distance was a strong positive predictor of performance on
test, it still requires adequate lower extremity strength, neuro- clinical power and strength tests. These findings demonstrate
muscular control, and balance to avoid knee valgus and that the triple hop is a strong predictor of lower limb muscular
compromising knee positions. strength and power The triple hop has been shown to be a
strong predictive test for strength and power symmetry when
compared with the results of a Biodex System 3 Pro Dyna-
Triple Hop mometer (Biodex Medical Systems, Shirley, NY) at angular
velocities of 601/s and 1801/s.8
The triple hop assessment requires the patient to stand on 1 leg
and hop 3 consecutive times on the same leg as far as possible,
maintaining their balance for 2 seconds after the final jump. Crossover Hop Test
The patient is expected to maintain constant motion between
the second and third jumps. Pausing for more than half of a The crossover hop assessment requires the patient to stand on
second between the second and third jumps or demonstrating 1 leg and hop 3 consecutive times on the same leg as far as
an inability to maintain balance invalidates that attempt. possible, maintaining their balance for 2 seconds after the final
Measurements are then taken from the patient’s heel to the jump. The patient is expected to jump medially over a line on
nearest centimeter. This process is repeated, alternating the floor on their first jump, laterally over the line on their
between the unaffected and affected side until 3 measurements second jump, and medially over the line for their third jump.
are taken on each leg. The patient is expected to maintain constant motion between
The triple hop assesses strength and power symmetry, the second and third jumps. Pausing for more than half of a
proprioception, ankle stability, and confidence in the knee. second between the second and third jumps or demonstrating

Figure 4 Lateral Bounding. Figure 6 Box Jump Starting Position.

62 D. Williams et al.

Figure 7 Box Jump Landing (Color version of figure is available Figure 9 Box Jump Rebound Landing (Color version of figure is
online.) available online.)

an inability to maintain balance invalidates that attempt. analysis software (Dartfish USA Inc), with timing beginning
Measurements are then taken from the patient’s heel to the when the patient’s toe is no longer in contact with the ground
nearest centimeter. This process is repeated, alternating and ending when the foot lands over the 6 m mark. This
between the unaffected and affected side until 3 measurements process is repeated, alternating between the unaffected and
are taken on each leg. affected side until 3 measurements are taken on each leg.
The last 2 hop tests performed are arguably the most Logerstedt et al10 demonstrates that the 6 m timed hop was
apprehensive for the participant to perform.9 The crossover the strongest independent predictor and had the highest
hop is the most demanding hop test as it imposes forces in discriminatory accuracy for self reported knee function 1 year
frontal and transverse planes, combined with multiple hops in after ACL reconstruction.10 With a specificity of 90%, the 6 m
the sagittal plane.10 Side-to-side differences are minimized in timed hop test was the most useful test for identifying patients
these patients, likely indicating superior neuromuscular con- with self reported knee function below normal ranges at
trol, therefore increasing the probability of knee function 1 year.11 Previous work by Fitzgerald et al5 has shown that
within normal ranges at 1 year.10 The crossover hop test most the 6 m timed hop along with other variables can identify those
accurately identified patients with knee function within normal with poor dynamic knee stability from those with good knee
ranges.10 stability early after ACL injury. In those individuals with good
dynamic knee stability, this test can also discriminate among
those who did not successfully return to high-level sports from
those who did.11 Those individuals who can perform these
The 6-m Hop for Time hops tests with high limb symmetry demonstrate more
The 6 m hop for time assessment requires the patient to stand confidence and less favoring of the un-involved limb during
on 1 leg and hop along a 6 m line, utilizing only the leg being return to sport activities.
tested. Time for completion is done with Dartfish motion

Single Leg Squat

The single leg squat assessment requires the patient to perform
unilateral squatting from 01 of extension to 601 of flexion while
holding the 15% of their body weight with their ipsilateral
upper extremity. The patient is allowed to use a balance assist
with 2 fingers of the contralateral upper extremity. 601 of knee
flexion is measured with a goniometer with the patient in a
squatted position and a chair with padding is set to make
contact with the patient when 601 of flexion is achieved.
Instructions are then given to the patient outlining expectations
and potential cuing they may receive to address common
deficits. Expectations are that the patient would perform the
single leg squatting task for 2 minutes, bearing the weight on 1
leg, maintain constant motion, avoid hyperextension of the
Figure 8 Box Jump Rebound (Color version of figure is available knee, avoid transferring weight to the chair behind them,
online.) maintain a position void of lateral trunk flexion, maintain a
Anterior cruciate ligament functional sports asssessment 63

position void of excessive forward trunk flexion (beyond insight for potential factors that may be hindering an ability to
parallel plane of tibia when viewed laterally), avoid the knee perform this task with correct form. This test is performed
passing a vertical plane in anterior to their toes, maintain level bilaterally (Figs. 3,4).
hips when viewed anteriorly, and avoid a valgus knee angle. The purpose of this test is to assess the patient’s ability to
Cuing is given to correct form during testing to assess the maintain stable core, hip, and knee with push-off and landing
patient’s ability to perform this task correctly and gain insight during lateral movements such as changing directions when
for potential factors that may be hindering an ability to perform side-stepping or defending a player during a game. Sell et al13
this task with correct form. This test is performed bilaterally demonstrated, “jump direction significantly influenced knee
(Figs. 1,2). biomechanics, suggesting that lateral jumps are the most
The purpose of the single leg squat test is to challenge the dangerous of the stop-jumps.” Therefore, anterolateral, lateral,
patient’s endurance toward the beginning of the test to fatigue and posterolateral jumps are included in our FSA to assess a
the quadriceps to properly assess what the patient’s form might risky movement that requires significant gluteal and quad-
look like when the leg is tired (ie, the end of the game). In riceps control to maintain proper knee stability without knee
addition, the “single leg squat component is for the patient to valgus. In addition, Queen et al’s14 research suggests that, “the
demonstrate quadriceps and hip muscle endurance to main- crossover cut places an increased load on the lateral portion of
taining the appropriate movement strategies.”11 The single leg the forefoot, whereas the side-cut task places an increased load
squat test has been shown to be a reliable test per Ageberg et on the medial portion of the forefoot and the acceleration task
al,“medio-lateral knee motion assessed by visual inspection places increased load on the middle forefoot, the differences in
during the single-limb mini-squat was valid in 2-dimensional, loading patterns based on athletic task are important for
showing a medially placed tibia and thigh, and knee valgus in understanding potential injury mechanisms” Therefore, with
individuals with a knee-medial-to-foot position compared with this information videotaped it allows the testers to provide
those with a knee-over-foot position. The actual movement, in patients with their specific risks and alternative ways of moving
3-dimensional, was mainly exhibited as increased internal hip to avoid high-risk knee movement patterns that could cause
rotation. The inter-rater reliability of the observational clinical another injury or ACL tear.
test was high. These results suggest that the single-limb mini-
squat test provides a valid and reliable clinical method.”12
Deceleration and Change
in Direction
Lateral Agility and Pivoting The deceleration test requires the patient to take 4-5 steps
The lateral agility and pivoting test requires the patient to jump anteriorly, accelerating with each step, come to a sudden stop,
laterally, anterolaterally, and posterolaterally against resistance and change direction to a backpedal. Expectations are that the
for 90 seconds. A rectangle is outlined on the floor where the patient would build speed with each step until the change in
foot of patient’s lower extremity being tested is outlined. This direction. At the change in direction, the patient is to land and
rectangle is used as a landing target for testing. A rectangle is push-off with the tested lower extremity when transitioning
used to encourage the patient to maintain a neutral foot and from an anterior run to a backpedal without any assistance
tibial rotation position regarding the camera being used to film from the contralateral lower extremity. When the patient
the test and discourage premature rotation of the body as a returns to the starting point, they transition back to an anterior
whole before pivoting jumps. The rectangle is positioned at a run, repeating this process until 5 trials have been completed
distance from the wall equal to the amount of slack in the on each lower extremity. The patient is instructed to run at a
resistance bands used for testing. Lines are then placed directly speed that is as fast as they are comfortable with, building
lateral, 451 anterolateral, and 451 posterolateral to the landing speed with each repetition. Expectations are that the patient
goal at a distance equal to the patient’s length from greater would maintain constant motion during testing, change
trochanter to the floor. A belt is placed around the patient’s direction unilaterally, display knee flexion during their change
waist at anterior superior iliac spine level and resistance is of direction, maintain level hips when viewed anteriorly, and
attached equal to 15% of their of body weight. If exactly 15% is maintain a neutral hip, knee, and ankle alignment during their
not possible because of the gaps in resistance cord resistance transition from anterior to posterior movement. Cuing is given
tiers, the closest weight to 5 lb (rounding down) is used. to correct form during testing to assess the patient’s ability to
Expectations are that the patient would jump laterally, pivot perform this task correctly and gain insight for potential factors
posterolaterally, jump laterally, then pivot anterolaterally, that may be hindering an ability to perform this task with
repeating this process for 90 continuous seconds without correct form (Fig. 5).
stopping. The patient is expected to maintain constant motion, This test is performed to assess hip and knee stability during
have at most one foot in contact with the ground at any given quick direction changes which frequently occur in a sports
point of testing, rotate their body as a whole for pivoting tasks, setting. The test is videotaped to slowly assess patients’
avoid a valgus knee angle, display at least 301 of knee flexion neuromuscular control of hip internal rotation, knee valgus,
with landings, and keep their foot in line with the landing trendelenburg, trunk flexion (lateral or forward), and patients’
target. Cuing is given to correct form during testing to assess confidence when asked to change direction while only placing
the patient’s ability to perform this task correctly and gain weight on postsurgical leg. Research has suggested that poor
64 D. Williams et al.

single leg landing mechanics correlate with poor knee mechan- literature. Although the validity and reliability of these proto-
ics and increased risk for noncontact anterior cruciate ligament cols are limited, they have been found to be strong predictors
injuries.15 Additional research is required to test the validity and of strength, performance, neuromuscular control, power, and
reliability of deceleration testing in the ACLR patient. high-risk or low-risk for re-tears.
Despite limited evidence to fully support the FSA as a
reliable and valid tool, it has been clinically relevant in
Box Jump Landing to Vertical identifying risk factors and weaknesses for the patient, physical
Jump therapist, athletic trainer, and physician to concentrate on,
when preparing to return to sport.
The box jump landing to vertical jump test requires the Additional studies would be beneficial to standardize the
patient to jump anterior from a 12 in plyometric box to a line FSA and other similar assessments to develop a valid and
that is set one half of their height away, land, immediately reliable tool for postoperative anterior cruciate ligament return
jump vertically with a maximum effort vertical jump, and to sport testing.
land. Expectations are that the patient would make ground
contact at the same time with both lower extremities, display
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