Knowing just when to put an athlete back on the field after ACL reconstruction is a difficult proposition. Surgeons often look at swelling , graft stability and quad girth. In the past, we have relied on isokinetic testing and hop testing measures in the clinic as guidelines as well.

As a sports performance specialist and clinician, I am keenly interested in not only fully rehabbing this injury, but also preventing it form happening again in the future. Observing quality of movement in cutting, jumping, running and drills offers good insight in this process, but I think we need more.


The FMS and Y-Balance test are things I use in my equation as well. I often see clients ace the YBT, but struggle to obtain a passing score on the FMS based on issues in core stability and the deep squat.  Current literature reports that any score less than a 14 carries a 4-fold increase for non-contact injury risk in female collegiate athletes.  Click here to read that study.

In addition, I look at the following for return to play decision making:

  • Single leg squat depth
  • Single leg broad jump
  • Single leg impact mechanics
  • Deceleration and cutting form
  • Cross-over hop test
  • Single leg triple hop
  • 6 M timed hop test

Below is a video of the single leg broad jumps, the triple hop, cross-over hop test and 6 M timed hop test.

What does research have to say?  I think we have a vacuum where athletes get “cleared” or released from PT and they wonder back to sport too soon.  Here are some recent studies examining hop testing, quad strength and the rate of quadriceps force development relative to this topic.

Single leg hop testing and its correlation to self reported functional outcome – AJSM

Modified NFL combine style testing to identify deficits after ACL reconstruction – JOSPT

Impact of quad strength asymmetry and functional performance at return to sport – JOSPT

Rate of quad force development after ACL surgery – JOSPT

In my experience, most of these patients really do not make it back to premorbid levels until at least 9-12 months.

As we search for answers to the best return to play criteria, we also lack answers about what makes an injury prevention program successful. Padua et al has shown that it may take up to 9 months of training to maintain a positive learning effect from a prevention program when assessed 3 months later.  Click here to read more on this.

My colleagues and I are meeting with Dr. Padua next week to learn more about his research and prevention program.  I believe based on my experience with the FMS, Y-Balance test, hop testing and movement assessment, not to mention 15 years of experience in the clinic, that faulty movement patterns, asymmetry and poor motor control have a lot to do with injury risk for ACL non-contact injuries.  Perhaps movement screening can help us head some of these injuries off before they happen.

Risk for re-tear is always a concern.  Should we send an athlete back to play who aces the hop testing, has great stability, no swelling, good running/cutting form but a poor deep squat pattern?  What does it mean if they are a 13 on the FMS at 6 months post-op and all else looks good?  Should we wait until 9-12 months to send athletes back?  Or should symmetrical movement be the leading indicator for readiness?

We have questions left to answer and more work to do in this arena.  Given the rate of re-injury and current non-contact injury stats, we need to keep searching for better standards and stricter criteria for clearing our athletes to return to play.  I look forward to participating in this process and hopefully we can build a better model as we go!