Return to performance (RTPe), the final stage of the return to sport (RTS) continuum remains poorly defined in current soccer-related musculoskeletal (MSK) research, with limited identification and application of physical and/or psychological performance-based indicators. This scoping review aimed to systematically identify and synthesise currently used RTPe criteria, with a specific focus on facilitating return to competitive soccer at the same or higher level than pre-injury and identify gaps in relation to sport-specific demands. A scoping review was conducted in accordance with the PRISMA-ScR guidelines, using comprehensive Boolean search strategies across PubMed, CINAHL, and Web of Science databases. A total of twenty-nine peer reviewed studies met the inclusion criteria. Reported RTPe criteria encompassed the following domains: clinical examination, strength assessment, functional testing, performance-based testing, time elapsed since injury, and patient-reported outcome measures (PROMs). Most studies concentrated on the second stage of the three-stage RTS continuum, that is, 'Return to Sports', with limited integration of on-field, sport specific, or ecologically valid performance assessments. In addition, studies frequently neglect recommendations advocating a multidimensional and standardised test battery. Moreover, psychological readiness and performance-level demands-critical components of RTPe in elite soccer-were seldom addressed or often lacked standardised definitions. Female athletes were underrepresented despite higher injury incidence (6.77 vs. 5.70/1000 h in males). Anterior cruciate ligament (ACL) injuries were overrepresented, whereas more frequently occurring injuries like posterior thigh and groin injuries received less attention. More than half of the studies focused on elite athletes, limiting generalisability to recreational level. These findings underscore the urgent need for more robust, operationalized, and sport-specific RTPe criteria to support clinical decision-making and optimise outcomes following musculoskeletal injury in soccer. Existing criteria do not reliably capture readiness to pre-injury performance levels, addressing performance metrics, sport specific demands, and sex-specific considerations. Level of Evidence: N/A.

A successful return to sports (RTS) after an anterior cruciate ligament reconstruction (ACLR) is multifactorial, and therefore difficult and challenging. Unfortunately, low percentages of patients RTS, and for those who succeed, one-fifth of patients will sustain a second ACL injury. Over the past years, test batteries were developed to assess whether patients can RTS with a low risk for a second ACL injury risk. Low rates of patients who meet RTS criteria were found, coupled with the insufficiency of current RTS test batteries in predicting second ACL injuries suggesting poor sensitivity. The result of an RTS test is likely to reflect the content of a rehabilitation program, raising critical questions regarding what we are offering patients within the rehabilitation programme. Are we preparing our patients well enough for the high demands of complex situations within pivoting team sports? This narrative review offers insights from key lessons of the last 15 years on 1) RTS testing, 2) the content of rehabilitation, and 3) the RTS continuum, all from a “helicopter perspective”.

Strength data can help in guiding the return to sports (RTS) process in patients after an anterior cruciate ligament reconstruction (ACLR). There is need for a fast, cheap, and portable method to monitor muscle strength in patients after ACLR in an ambulatory stetting. Therefore, the purpose of the current study was to assess the use of a hand-held dynamometer (HHD) to monitor hamstring and quadriceps strength after ACLR and to assess the changes over time in patients tested at 3, 6 and 9 months after ACLR. It was hypothesized that patients show greater muscle strength at 6 months after ACLR compared to 3 months, and at 9 months after ACLR compared to 6 months. Forty-four amateur athletes (n = 44) after ACLR participated. Isometric hamstring and quadriceps strength were measured with a HHD at three time points during rehabilitation. Absolute isometric hamstring strength significantly progressed over time. Similar, absolute isometric quadriceps strength significantly progressed over time. This study showed that using handheld dynamometry can be a simple method to monitor the development of absolute isometric hamstring and quadriceps strength in patients after ACLR. Level of evidence III, prospective case series.

Background: Improving jump-landing technique during rehabilitation is important and may be achieved through different feedback techniques, i.e., internal focus of attention (IF) or external focus of attention using a target (EF). However, there is a lack of evidence on the most effective feedback technique after anterior cruciate ligament reconstruction (ACLR). The purpose of this study was to investigate the potential difference in jumplanding techniques between IF and EF instructions in patients after ACLR. Methods: Thirty patients (12 females, mean age 23.26 +/- 4.91 years) participated after ACLR. Patients were randomly assigned into two groups that each followed a different testing sequence. Patients performed a drop vertical jump-landing test after receiving instructions with varying types of focus of attention. The Landing Error Scoring System (LESS) assessed the jump-landing technique. Results: EF was associated with a significantly better LESS score (P < 0.001) compared with IF. Only EF instructions led to improvements in jump-landing technique. Conclusion: Using a target as EF resulted in a significantly better jump-landing technique than IF in patients after ACLR. This indicates that increased use of EF could or might result in a better treatment outcome during ACLR rehabilitation. (c) 2023 The Author(s). Published by Elsevier B.V. This is an open access article under the CC

Traumatic unidirectional instability of the glenohumeral joint occurs frequently in athletes. Treatment by surgical repair through a Bankart repair results in higher rates of successful return to sport (RTS) compared to conservative treatment. Nevertheless, one third of athletes are not able to RTS to their pre-injury level after Bankart repair and the recurrence rate of instability at 5 years after surgery is 10%. Currently only subjective factors like pain and time after surgery are used in the decision making in the RTS decision-making process. However, several factors are of importance according to literature: pain, range of motion, strength, stability, psychological factors, and proprioception. Furthermore, it is not described clearly how to measure the factors objectively. This scoping review identifies measurement instruments that are available for assessing the factors that can be of importance for RTS in athletes. A scoping literature search was conducted in Pubmed to map available measurement instruments for the factors of importance. Twenty-five articles were identified and assessed for methodological quality. The measurement instruments were rated according to the criteria for good measurement properties from the COnsensus-based Standards for the selection of health Measurement INstrument guidelines. The current scoping review provides an overview of the available measurement instruments for measuring important factors which might help in RTS decision-making after Bankart repair. Level of Evidence: 2. Eine traumatische unidirektionale Instabilität des Glenohumeralgelenks tritt häufig bei Sportlern auf. Die Behandlung durch chirurgische Reparatur durch eine Bankart-Reparatur führt im Vergleich zur konservativen Behandlung zu höheren Raten einer erfolgreichen Rückkehr zum Sport (RTS). Dennoch ist ein Drittel der Athleten nach der Bankart-Reparatur nicht in der Lage, das RTS-Niveau vor der Verletzung zu erreichen, und die Rezidivrate der Instabilität 5 Jahre nach der Operation beträgt 10 %. Derzeit werden im RTS-Entscheidungsprozess nur subjektive Faktoren wie Schmerz und Zeit nach der Operation in die Entscheidungsfindung einbezogen. Laut Literatur sind jedoch mehrere Faktoren von Bedeutung: Schmerz, Bewegungsumfang, Kraft, Stabilität, psychologische Faktoren und Propriozeption. Außerdem wird nicht klar beschrieben, wie die Faktoren objektiv zu messen sind. Dieser Scoping-Review identifiziert Messinstrumente, die zur Verfügung stehen, um die Faktoren zu beurteilen, die für RTS bei Sportlern von Bedeutung sein könnten. Eine Scoping-Literaturrecherche wurde in Pubmed durchgeführt, um verfügbare Messinstrumente für die Faktoren von Bedeutung abzubilden. 25 Artikel wurden identifiziert und hinsichtlich ihrer methodischen Qualität bewertet. Die Messinstrumente wurden nach den Kriterien für gute Messeigenschaften aus den 'COnsensus-based Standards for the selection of health Measurement INstrument guidelines' bewertet. Der aktuelle Scoping-Review gibt einen Überblick über die verfügbaren Messinstrumente zur Messung wichtiger Faktoren, die bei der RTS-Entscheidungsfindung nach der Bankart-Reparatur hilfreich sein könnten. Beweisgrad: 2.

BACKGROUND:After anterior cruciate ligament reconstruction (ACLR), a patient's physical capacities, such as (repeated) sprint performance, agility performance, and intermittent endurance performance, are often reduced because of detraining effects. Monitoring the progression of these physical capacities is essential for specific training goals before patients return to complex team sports. PURPOSE:To map the existing literature regarding on-field tests for (repeated) sprint performance, agility performance, and intermittent endurance performance in patients after ACLR. STUDY DESIGN:Scoping review; Level of evidence, 4. METHODS:A search was performed in 4 electronic databases, PubMed, Embase, CINAHL, and PsycInfo, following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines for scoping reviews. RESULTS:There were 11 studies that met the inclusion criteria and described a total of 14 on-field tests for patients after ACLR. Overall, 2 tests were described for sprint performance, 11 tests were related to agility performance, and 1 test was performed for intermittent endurance performance. CONCLUSION:The results of this scoping review provide an overview of on-field tests to monitor sport-specific progression and to set performance-specific training goals for patients after ACLR before returning to complex team sports.

Background: Limited information is available on the experiences of patients during rehabilitation after anterior cruciate ligament reconstruction (ACLR). Aim: The current study aimed to identify factors that differentiated positive and negative patient experiences during rehabilitation after ACLR. Method and Design: A survey-based study with an online platform was used to identify factors that differentiated positive and negative patient experiences during rehabilitation after ACLR. Seventy-two patients (age 27.8 [8.8] y) after ACLR participated. Data were analyzed and themes were identified by comparing categories and subcategories on similarity. Main Findings: Positive patient experiences were room for own input, supervision, attention, knowledge, honesty, and professionalism of the physiotherapist. Additionally, a varied and structured rehabilitation program, adequate facilities, and contact with other patients were identified as positive patient experiences. Negative experiences were a lack of attention, lack of professionalism of the physiotherapists, a lack of sport-specific field training, a lack of goal setting, a lack of adequate facilities, and health insurance costs. Conclusions: The current study identified factors that differentiated positive and negative patient experiences during rehabilitation after ACLR. These findings can help physiotherapists in understanding the patient experiences during rehabilitation after ACLR.

Despite the development of return to sport (RTS) guidelines over recent years, there is a lack of a scientific consensus on the RTS criteria used to release a patient to unrestricted sport activity after ACL reconstruction (ACLR). A proportional meta-analysis, showed that only 23% of patients after ACLR passed RTS test batteries before RTS. Although passing RTS criteria reduce the risk of subsequent graft rupture by 60%, it increases the risk of a contralateral ACL rupture by 235%. These equivocal findings in terms of validity of RTS tests after ACLR leaves clinicians with high level of uncertainty in clinical decision-making. Dingenen & Gokeler proposed that RTS should be viewed as continuum after ACL injury and ACLR. Moreover, one of the possible solutions why patients do not meet the RTS criteria is simply due to the lack of implementation of evidence- based rehabilitation in terms of specificity and training load. Too often, the end phase of the rehabilitation is not extensive or specific enough, thereby exposing athletes to specific training loads and training characteristics that they cannot handle from a physical, neurocognitive as well as from a psychological perspective. Della Villa et al. introduced the concept of an On Field Rehabilitation (OFR) model to bridge the gap between standard rehabilitation and return to training. This allows for a gradual progression of each part and thus ensures correct function and that no adverse knee reaction is noted before moving on to the next level. Returning an athlete to full participation should be a graduated continuum and not based on a set of tests at one single point in time. The above findings pertaining to the high incidence of recurrent injuries, question whether the current RTS tests provide relevant information for guiding the decision making. There is a need for more ecological valid research approaches to test an athlete returning to sports after an ACLR in more complex sports-specific demanding tests, which are more reflective of the demands while on the field. Based on a RTS continuum approach, training and tests should include physical, cognitive and psychological loads in a gradual fashion that prepare the athlete for a safer RTS

Background: A limited number of patients return to sport (RTS) after an anterior cruciate ligament reconstruction (ACLR) and patients who RTS have a relatively high risk for second ACL injury. The purpose of the current study was to compare the results of a test battery between patients who returned to the pre-injury level of sport (RTS group) and patients who did not (NO-RTS group). It was hypothesized that the RTS group showed better test results. Methods: Sixty-four patients (age 27.8 +/- 8.8 years) were included. The results of a multicomponent test battery (jump-landing task assessed with the Landing Error Scoring System (LESS), three hop tests, isokinetic strength test for quadriceps and hamstring) were compared between groups with a 2 x 2 ANOVA. Results: The RTS group showed a significantly lower LESS score (p = 0.010), significantly higher absolute scores on hop tests with both legs (injured leg: single leg hop test p = 0.013, triple leg hop test p = 0.024, side hop test p = 0.021: non-injured leg: single leg hop test p 0.011, triple leg hop test p = 0.023, side hop test p = 0.032) and significantly greater hamstring strength in the injured leg (p = 0.009 at 60 degrees/s, p = 0.012 at 180 degrees/s and p - 0.013 at 300 degrees/s). No differences in test results were identified between patients who sustained a second ACL injury and patients who did not. Conclusion: Patients after ACLR with better jump-landing patterns, hop performance and greater hamstring strength have greater likelihood for RTS. However, our findings show that RTS criteria fail to identify patients who are at risk for a second ACL injury. (C) 2020 The Author(s). Published by Elsevier B.V.

OBJECTIVES:The purpose of the current study was to compare the results of a progressive strength training protocol for soccer players after anterior cruciate ligament reconstruction (ACLR) with healthy controls, and to investigate the effects of the strength training protocol on peak quadriceps and hamstring muscle strength.DESIGN:Between subjects design.SETTING:Outpatient physical therapy facility.PARTICIPANTS:Thirty-eight amateur male soccer players after ACLR were included. Thirty age-matched amateur male soccer players served as control group.MAIN OUTCOME MEASURES:Quadriceps and hamstring muscle strength was measured at three time points during the rehabilitation. Limb symmetry index (LSI) > 90% was used as cut-off criteria.RESULTS:Soccer players after ACLR had no significant differences in peak quadriceps and hamstring muscle strength in the injured leg at 7 months after ACLR compared to the dominant leg of the control group. Furthermore, 65.8% of soccer players after ACLR passed LSI >90% at 10 months for quadriceps muscle strength.CONCLUSION:Amateur male soccer players after ACLR can achieve similar quadriceps and hamstring muscle strength at 7 months compared to healthy controls. These findings highlight the potential of progressive strength training in rehabilitation after ACLR that may mitigate commonly reported strength deficits.

The purpose of the current prospective study was to assess the changes over time in patients tested at 6 months and 9 months after anterior cruciate ligament reconstruction (ACLR) with a return to sport (RTS) test battery. It was hypothesized that more patients passed RTS criteria at 9 months compared to 6 months.

BACKGROUND:Strength deficits, muscle imbalances, and quadriceps inhibition are common after the surgical reconstruction of the anterior cruciate ligament (ACL), even after the patient's returned-to-sport. Typically, asymmetries between the operated and non-operated leg as well as the hamstring/quadriceps (HQ) ratio are calculated using maximum isokinetic torque values. Moreover, the knee flexion angles, which correspond to the measured torque values, were not considered. Therefore, the aim of the study was to evaluate the usage of an angle-specific approach for the analysis of isokinetic data in patients after an ACL-reconstruction. METHODS:A cross-sectional laboratory study design was used to investigate the influence of leg (operated vs. non-operated) and two velocities on angle-specific isokinetic data. Concentric quadriceps and hamstring torques and ratios of 38 patients were assessed 6.6 months after ACL-reconstruction with a hamstring tendon graft. At a velocity of 60°/s and 180°/s, angle-specific torques and HQ-ratios were analyzed with conventional discrete parameters and a Statistical Parametric Mapping procedure, which evaluates continuous data. The relationship between angle-specific and conventional HQ-ratios was evaluated with Pearson correlation coefficients. RESULTS:Angle-specific torques and HQ-ratios were different between the operated and non-operated leg and between velocities. In the operated leg, the quadriceps deficit was higher at 60°/s in knee flexion angles > 50°. The HQ-ratios decreased with greater knee flexion at both velocities, but with a different magnitude. Around 30°, the HQ-ratios reached 1.0 and did not differ between the velocities, while leg differences were present from 40 to 60°. At the higher testing velocity, the maximum flexion torque occurred at greater knee flexion, whereas the maximum extension torque were present at a similar joint angle. The correlation coefficients between conventional and angle-specific HQ-ratios were low in knee angles < 35° and > 65° and varied according to leg and velocity. CONCLUSIONS:The angle specific approach is recommended for future ACL-research, as it reveals strength deficits and imbalances, which were not captured by conventional parameters. The results provide a rationale for more specific joint angle and/or velocity based training and may help for return-to-sport decisions.

There is a lack of objective factors which can be used in guiding the return to sport (RTS) decision after an anterior cruciate ligament reconstruction (ACLR). The purpose of the current study was to conduct qualitative analysis of the single leg hop (SLH) in patients after ACLR with a simple and clinical friendly method and to compare the possible difference in movement pattern between male and female patients.

It is unknown how movement patterns that are learned carry over to the field. The objective was to determine whether training during a jump-landing task would transfer to lower extremity kinematics and kinetics during sidestep cutting.

Background: Hop tests are frequently used to determine return to sports (RTS) after anterior cruciate ligament reconstruction (ACLR). Given that bilateral deficits are present after ACLR, this may result in a falsely high limb symmetry index (LSI), since LSI is calculated as a ratio between the values of the limbs. Hypothesis: Athletes after ACLR would achieve LSI > 90% for the hop test. Secondly, athletes after ACLR demonstrate decreased jump distance on the single hop for distance (SLH) and triple leg hop for distance (TLH) and decreased number of hops for the side hop (SH) for both involved and uninvolved limbs compared to normative data of sex, age and type of sports matched healthy athletes. Materials and methods: Fifty-two patients (38 males mean age 23.9 +/- 3.5 years; 14 females mean age 21.7 +/- 3.5 years) who had undergone an ACLR participated in this study. Patients performed the 3 hop tests at a mean time of 7 months after ACLR. Hop distance, number of side hops and LSI were compared with normative data of 188 healthy athletes. Results: The differences between the involved limb and the uninvolved limb were significant in all hop tests (SLH P = 0.003, TLH P = 0.003, SH P = 0.018). For females, only significant between limb differences were found in the SLH (P = 0.049). For both the SLH and the TLH, significant differences were found between the involved limb and the normative data (males; SLH P < 0.001, TLH P < 0.001; females; SLH P < 0.001, TLH P = 0.006) and between the uninvolved limb and the normative data for both males and females (males; SLH P < 0.001, TLH P < 0.001; females; SLH P = 0.003, TLH P = 0.038). For the SH, only significant differences were found between the involved limb and the normative values in males (P = 0.033). Conclusion: Athletes who have undergone an ACLR demonstrate bilateral deficits on hop tests in comparison to age and sex matched normative data of healthy controls. Using the LSI may underestimate performance deficits and should therefore be analyzed with caution when used as a criterion for RTS after ACLR. (C) 2017 Elsevier Masson SAS. All rights reserved.

Background: Retention of movement technique is crucial in anterior cruciate ligament (ACL) injury prevention programs. It is unknown if specific instructions or video instructions result in changes in kinematic and kinetic measures during a relatively short training session, and in a retention test one week later. Hypothesis/Purpose: The purpose was to determine the effects of verbal external focus (EF), verbal internal focus (IF) and video instructions (VI) on landing technique (i.e. kinematics and kinetics) during training and retention. Study Design: Randomized Controlled Trial. Methods: This study compared verbal EF, verbal IF, VI and CTRL group. Forty healthy athletes were assigned to the IF (n=10), EF (n=10), VI (n=10) or CTRL group (n=10). A jump-landing task was performed as a baseline, followed by two training blocks (TR1 and TR2) and a post test. Group specific instructions were offered in TR1 and TR2. In addition, subjects in the IF, EF and VI groups were free to ask for feedback after every jump in TR1 and TR2. One week later, a retention test was conducted without specific instructions or feedback. Kinematics and kinetics were captured using an 8-camera motion analysis system. Results: Males and females in the EF and VI instruction group showed beneficial results during and after the training session, in terms of improved landing technique. Retention was achieved after only a short training session. Conclusion: ACL injury prevention programs should include EF and/or VI instructions to improve kinematics and kinetics and achieve retention. Level of Evidence: 3b.

Background It is unknown if learned motor skills as practiced in ACL injury prevention training carry over to other tasks. Objective Determine if training of a jump-landing task results in transfer of improvement in lower extremity biomechanics during sidestep cutting. Design Randomized controlled trial. Setting Controlled laboratory setting, recreational athletes. Participants Twenty male and twenty female healthy team ball sport athletes were randomly assigned to a verbal internal focus (IF, n=10), verbal external focus (EF, n=10), video (VI, n=10) or control group (CTRL, n=10). Interventions A jump-landing task was performed at baseline followed by training blocks (TR1 and TR2), an immediate post-test and an one-week retention test. Subjects in the IF, EF and VI groups received group specific instructions in TR1 and TR2. Transfer was determined after one week with a 45° unanticipated sidestep cutting task. Main Outcome Measurements Hip and knee flexion range of motion (ROM). Results During sidestep cutting, males in the VI (5.1°±1.0) and CTRL (5.1°±1.0) group showed greater hip flexion ROM compared to the IF (3.7°±0.0) and EF (3.0°±1.5) groups (p<0.05). For females, the VI group (7.0°±1.0) showed greater hip flexion ROM compared to the IF (0.6°±0.0), EF (1.3°±0.7) and CTRL (2.7°±0.0) groups (p<0.05). The EF (males −15.8°±3.9, females −11.0°±3.0) and VI (males −15.1°±2.6, females −16.7°±1.8) groups showed greater knee flexion ROM compared to the IF (males −6.6°±3.9, females −6.0°±1.3) group (p<0.05). Conclusions Athletes who received VI instructions demonstrated transfer of improved movement technique from jump-landing to sidestep cutting. Adding visual instruction to ACL injury prevention programs seems promising for transfer to sport specific situations.

Purpose There is a lack of consensus regarding the appropriate criteria for releasing patients to return to sports (RTS) after anterior cruciate ligament reconstruction (ACLR). A test battery was developed to support decision-making. Methods Twenty-eight patients (22 males and 6 females) with a mean age of 25.4 ± 8.2 years participated and were 6.5 ± 1.0 months post-ACLR. All patients followed the same rehabilitation protocol. The test battery used consisted of the following: isokinetic test, 3 hop tests and the jump-landing task assessed with the LESS. The isokinetic tests and single-leg hop tests were expressed as a LSI (involved limb/uninvolved limb × 100 %). In addition, patients filled out the IKDC and ACL-Return to Sport after Injury (ACL-RSI) scale. RTS criteria to pass were defined as a LSI > 90 % on isokinetic and hop tests, LESS < 5, ACL-RSI > 56 and a IKDC within 15th percentile of healthy subjects. Results Two out of 28 patients passed all criteria of the test protocol. The pass criterion for the LESS < 5 was reached by 67.9 % of all patients. For the hop tests, 78.5 % of patients passed LSI > 90 % for SLH, 85.7 % for TLH and 50 % for the SH. For the isokinetic test, 39.3 % of patients passed criteria for LSI peak torque quadriceps at 60°/s, 46.4 % at 180°/s and 42.9 at 300°/s. In total, 35.7 % of the patients passed criterion for the peak torque at 60°/s normalized to BW (>3.0 Nm) for the involved limb. The H/Q ratio at 300°/s > 55 % for females was achieved by 4 out of 6 female patients, and the >62.5 % criterion for males was achieved by 75 %. At 6 months post-ACLR, 85.7 % of the patients passed the IKDC score and 75 % the ACL-RSI score >56 criteria. Conclusion The evidence emerging from this study suggests that the majority of patients who are 6 months after ACLR require additional rehabilitation to pass RTS criteria. The RTS battery described in this study may serve as a framework for future studies to implement multivariate models in order to optimize the decision-making regarding RTS after ACLR with the aim to reduce incidence of second ACL injuries. Level of evidence III.