High Yield Overview

RETURN TO SPORT CRITERIA

Criteria-Based | Psychological Readiness | Re-injury Prevention

LSI greater than 90%Limb Symmetry Index target

Criteria-BasedSuperior to time-alone

25%Re-injury rate in young athletes

ACL-RSIPsychological readiness scale

RTS Phases

Phase 1

PatternInjury/Surgery

TreatmentTissue healing, pain control

Phase 2

PatternRehabilitation

TreatmentRestore ROM, strength, proprioception

Phase 3

PatternReturn to Training

TreatmentSport-specific drills, conditioning

Phase 4

PatternReturn to Competition

TreatmentFull unrestricted sport participation

Phase 5

PatternReturn to Performance

TreatmentPre-injury performance level

Critical Must-Knows

Criteria-based RTS associated with 84% reduction in re-injury vs time-based alone
Limb Symmetry Index (LSI) greater than 90% on hop tests and strength
Hop test battery: single hop, triple hop, crossover hop, 6-meter timed hop
Psychological readiness: ACL-RSI score greater than 70 associated with successful RTS
Re-injury risk: Up to 25% in young athletes returning to high-level pivoting sport

Examiner's Pearls

"
Time alone is insufficient - criteria must be met
"
Fear of re-injury is major barrier to RTS
"
Quadriceps strength is most predictive single factor
"
ACL re-injury peak occurs 6-12 months post-RTS

Clinical Imaging

Imaging Gallery

A young athlete performing a single-leg hop test with 100% limb symmetry but with poor quality (genu valgum on landing, hip drop, and trunk lean).Credit: Open-i / NIH via Open-i (NIH) (Open Access (CC BY))

Criteria-based rehabilitation progression. QMA, quality of movement assessment; ROM, range of motion.Credit: Open-i / NIH via Open-i (NIH) (Open Access (CC BY))

A young athlete performing a squat with (A) a knee strategy and (B) a hip strategy.8Credit: Open-i / NIH via Open-i (NIH) (Open Access (CC BY))

Critical Return to Sport Exam Points

Criteria-Based Approach

Time alone is insufficient - Grindem 2016 showed 84% reduction in re-injury with criteria-based RTS. Must achieve LSI greater than 90% on strength and hop tests. Psychological readiness equally important as physical criteria.

Limb Symmetry Index

LSI = Involved/Uninvolved x 100. Target greater than 90% (ideally greater than 95%). Apply to hop tests (single, triple, crossover, timed) and isokinetic strength (quadriceps/hamstrings). Low LSI predicts re-injury.

Psychological Readiness

ACL-RSI scale (0-100) - score greater than 70 associated with successful RTS. Fear of re-injury is major barrier - 50% cite as reason for not returning. Tampa Scale of Kinesiophobia also used. Address early in rehabilitation.

Re-injury Risk Factors

Young age (less than 20 years) - highest risk. Early RTS (less than 9 months post-ACL reconstruction). Returning to pivoting sports. LSI less than 90%. Not meeting criteria - 4x increased re-injury rate.

At a Glance

Return to sport (RTS) after orthopedic injury or surgery is a critical decision point that significantly impacts re-injury risk and long-term outcomes. The paradigm has shifted from time-based decisions to criteria-based approaches. Evidence demonstrates that athletes who meet specific objective criteria before returning to sport have significantly lower re-injury rates. The ACL reconstruction model is the most extensively studied and serves as the template for RTS protocols across orthopedic injuries.

Key elements of modern RTS include: Limb Symmetry Index (LSI) greater than 90% on functional hop tests and isokinetic strength testing, full range of motion, absence of pain and effusion, and critically, psychological readiness assessed via validated tools such as the ACL-RSI scale. Re-injury rates remain concerning, with up to 25% of young athletes sustaining re-injury (ipsilateral or contralateral ACL rupture) when returning to high-level pivoting sports. This underscores the importance of comprehensive assessment and realistic patient counseling.

Time-Based vs Criteria-Based Return to Sport

Factor	Time-Based Approach	Criteria-Based Approach
Decision basis	Calendar time since surgery (e.g., 9 months post-ACL)	Objective criteria met regardless of time
Re-injury risk	Higher re-injury rates (up to 25%)	84% reduction in re-injury (Grindem 2016)
Assessment tools	Clinical assessment, time elapsed	LSI, hop tests, isokinetic strength, ACL-RSI
Psychological factors	Often ignored or underemphasized	Formally assessed with validated scales
Individualization	Same timeline for all patients	Tailored to individual recovery trajectory
Evidence support	Historical practice, weak evidence	Strong evidence from prospective studies

Mnemonic

SHARPRTS Criteria Components

Strength

Isokinetic quad/hamstring LSI greater than 90%

Hop tests

Single, triple, crossover, timed - all LSI greater than 90%

Absence of symptoms

No pain, swelling, or instability

Range of motion

Full extension, symmetric flexion

Psychological readiness

ACL-RSI greater than 70, low kinesiophobia

Memory Hook:SHARP criteria = SHARP return to sport without re-injury!

Mnemonic

STCTHop Test Battery

Single hop for distance

Maximum single-leg hop length

Triple hop for distance

Three consecutive single-leg hops

Crossover hop for distance

Three hops crossing midline

Timed 6-meter hop

Time to complete 6 meters hopping

Memory Hook:STCT - Standard Test battery for Clearing athletes To compete!

Mnemonic

IRTCPRTS Phases

Injury phase

Acute management, tissue healing

Rehabilitation phase

Restore ROM, strength, proprioception

Training return

Sport-specific drills, conditioning

Competition return

Full unrestricted sport participation

Performance return

Pre-injury performance level

Memory Hook:IRTCP - Injury, Rehab, Training, Competition, Performance - the complete RTS journey!

Principles of Return to Sport

The philosophy of return to sport has evolved significantly over the past two decades. The traditional approach of clearing athletes based purely on time elapsed since injury or surgery has been replaced by evidence-based, criteria-driven protocols.

The Continuum Model

Return to sport is not a single event but a continuum with distinct phases:

Return to Participation: Athlete can participate in rehabilitation and modified training
Return to Sport: Athlete can return to sport activities but may be at reduced level
Return to Performance: Athlete performs at or above pre-injury level

Why Time Alone is Insufficient

Multiple studies demonstrate that time since surgery does not correlate with readiness:

Athletes may achieve criteria at different rates
Tissue healing does not guarantee functional recovery
Psychological readiness often lags behind physical recovery
Graft maturation in ACL reconstruction continues beyond 12 months

Risk Stratification

Athletes returning to sport should be stratified by risk:

High-risk activities: Pivoting sports (football, netball, basketball, skiing)
Moderate-risk activities: Running, tennis, golf
Low-risk activities: Swimming, cycling, gym work

Risk stratification guides the stringency of criteria required before clearance and helps set realistic expectations with athletes.

ACL Reconstruction - The Paradigm

ACL reconstruction serves as the most extensively studied model for return to sport criteria. The principles established from ACL research apply broadly across orthopedic injuries.

Hop Test Battery:

The four-hop test battery is the gold standard functional assessment:

Single Hop for Distance: Maximum distance on single-leg hop
Triple Hop for Distance: Total distance of three consecutive hops
Crossover Hop for Distance: Three hops crossing midline alternately
6-Meter Timed Hop: Time to complete 6 meters hopping

Interpretation:

Calculate Limb Symmetry Index (LSI) = Involved leg/Uninvolved leg x 100
Target: LSI greater than 90% on all four tests
Ideal: LSI greater than 95% associated with lower re-injury rates
All four tests should be passed - not averaged

Limitations:

Hop tests assess quantity but not quality. Movement quality assessment (landing mechanics, valgus control) should supplement hop testing. Video analysis of hop performance provides additional information about movement patterns.

Psychological Readiness

Psychological factors are increasingly recognized as critical determinants of successful return to sport. Fear of re-injury is the most commonly cited barrier to RTS.

ACL Return to Sport after Injury (ACL-RSI) Scale:

The ACL-RSI is a 12-item validated questionnaire assessing psychological readiness:

Domains Assessed:

Emotions (confidence, fear, frustration)
Confidence in performance
Risk appraisal (perceived re-injury risk)

Scoring:

Range: 0-100
Higher scores indicate better psychological readiness
Score greater than 70: Associated with successful RTS
Score less than 56: Associated with failure to return to sport

Clinical Use:

Administer at rehabilitation milestones
Track progress longitudinally
Identify athletes needing psychological intervention
Include in RTS decision-making alongside physical criteria

Athletes with low ACL-RSI scores despite meeting physical criteria should be considered for psychology referral and may benefit from delayed RTS.

Other Injuries - RTS Criteria

While ACL reconstruction is the paradigm, RTS principles apply across orthopedic injuries with condition-specific modifications.

Return to Sport After Shoulder Stabilization:

Surgical vs Non-operative:

Surgical stabilization in athletes has lower recurrence (10-15% vs 50-70%)
RTS typically 4-6 months post-Latarjet, 5-6 months post-Bankart

Criteria for RTS:

Range of Motion: Full symmetric ROM, especially external rotation
Strength: Isokinetic strength LSI greater than 90% (rotator cuff, deltoid)
Apprehension Testing: Negative apprehension test critical
Functional Testing: Sport-specific overhead or contact activities

Outcome Measures:

Rowe Score: 100-point scale for shoulder instability outcomes
WOSI (Western Ontario Shoulder Instability Index): Quality of life measure
Athletic Shoulder Outcome Score (ASES)

Sport-Specific Considerations:

Overhead athletes (swimmers, throwers): Focus on external rotation and overhead stability
Contact athletes (rugby, football): Focus on impact tolerance
Collision sports may require bracing initially

Psychological readiness is less studied in shoulder instability but fear of apprehension position should be addressed during rehabilitation.

Evidence Base

📚 Grindem et al (Delaware-Oslo ACL Cohort)

Key Findings:

Athletes meeting RTS criteria had 84% lower re-injury rate
Each 10% increase in quadriceps strength index reduced re-injury by 3%
Passing RTS criteria reduced knee re-injury regardless of when they returned
Criteria-based approach superior to time-based approach

Clinical Implication: Criteria-based RTS decisions significantly reduce re-injury - key evidence to cite in exam.

Source: BJSM 2016

📚 Ardern et al (Systematic Review)

Key Findings:

Only 63% of athletes returned to pre-injury sport level
81% returned to some form of sport participation
Younger athletes had higher return rates
Fear of re-injury major barrier - 50% cited as reason for not returning

Clinical Implication: Realistic counseling - only 63% return to pre-injury level despite successful surgery.

Source: BJSM 2014

📚 Ardern et al (Psychological Factors)

Key Findings:

Psychological response is strongest predictor of RTS
ACL-RSI score greater than 70 associated with successful return
Fear and low confidence predict failure to return
Psychological readiness should be formally assessed

Clinical Implication: Must assess psychological readiness - not just physical criteria.

Source: BJSM 2013

📚 Kyritsis et al

Key Findings:

Athletes not meeting all 6 RTS criteria had 4x higher re-injury rate
Criteria: hop tests, strength, running, agility
All criteria must be passed - not averaged or traded off
Professional footballers studied (high-demand population)

Clinical Implication: All criteria must be met - failing any single test predicts increased re-injury risk.

Source: BJSM 2016

📚 Wiggins et al

Key Findings:

LSI greater than 90% on hop tests associated with lower re-injury
LSI greater than 95% ideal target
Quadriceps strength most predictive single factor
Hop test battery should be used rather than single test

Clinical Implication: Target LSI greater than 90% minimum, ideally greater than 95%.

Source: Am J Sports Med 2016

📚 Paterno et al

Key Findings:

15% ipsilateral re-injury rate, 11% contralateral ACL injury
Young age (less than 20 years) strongest risk factor
Female athletes at higher risk
Second ACL injury rate 6x higher than primary injury

Clinical Implication: Young athletes must be counseled about significant re-injury risk.

Source: Am J Sports Med 2010

Exam Viva Scenarios

Practice these scenarios to excel in your viva examination

VIVA SCENARIOStandard

Scenario 1: ACL RTS Clearance

EXAMINER

"A 22-year-old netball player is 9 months post-ACL reconstruction with hamstring autograft. She wants to return to competitive netball. How do you assess if she is ready?"

EXCEPTIONAL ANSWER

Returning to competitive netball after ACL reconstruction requires comprehensive assessment across physical and psychological domains. I would not clear her based on time alone - the 9-month mark is a minimum, not a clearance criterion. First, I would assess clinical criteria: full range of motion (especially full extension), no effusion, negative Lachman and pivot shift confirming graft integrity, and no pain with daily activities. Second, I would perform a hop test battery - single hop, triple hop, crossover hop, and 6-meter timed hop - calculating Limb Symmetry Index for each. She needs LSI greater than 90% on all four tests, ideally greater than 95% for high-level pivoting sport like netball. Third, I would assess isokinetic strength - quadriceps and hamstring peak torque compared to the contralateral limb. Quadriceps LSI greater than 90% is critical as quadriceps strength is the most predictive factor for successful return and re-injury prevention. Fourth, I would assess psychological readiness using the ACL-RSI scale. A score greater than 70 is associated with successful return to sport. Fear of re-injury is the most common reason for not returning, and low psychological readiness despite passing physical criteria is a reason to delay clearance. Fifth, I would confirm she has completed a graduated return to training program including running, cutting, pivoting, and sport-specific netball drills at match intensity without symptoms. I would counsel her about re-injury risk - young female netball players have up to 25% risk of second ACL injury (either knee) when returning to pivoting sport. The STABILITY study suggests lateral tenodesis may reduce this in high-risk patients, though this should have been considered at the time of primary reconstruction.

KEY POINTS TO SCORE

Criteria-based not time-based decision

Hop test battery with LSI greater than 90% on all tests

Isokinetic quadriceps strength LSI greater than 90%

ACL-RSI psychological readiness greater than 70

Counsel about significant re-injury risk in young pivoting athletes

COMMON TRAPS

✗Clearing based on 9 months elapsed alone

✗Not knowing the hop test battery components

✗Forgetting psychological readiness assessment

✗Not mentioning re-injury risk counseling

LIKELY FOLLOW-UPS

"What is the ACL-RSI scale and what score indicates readiness?"

"What is the re-injury rate in young athletes returning to pivoting sport?"

VIVA SCENARIOChallenging

Scenario 2: Failed to Meet Criteria

EXAMINER

"The same netball player has hop test LSI of 85% and quadriceps LSI of 82% at 9 months. She is frustrated and says her friend returned at 6 months. How do you counsel her?"

EXCEPTIONAL ANSWER

This is a common and challenging counseling scenario. I would validate her frustration while explaining the evidence behind our approach. First, I would explain why criteria matter: The Grindem study showed that athletes meeting return to sport criteria had an 84% reduction in re-injury compared to those who did not. The Kyritsis study showed athletes not meeting criteria had a 4-fold increased re-injury rate. With her current LSI values of 85% and 82%, she has significantly elevated re-injury risk if she returns now. Second, I would put this in personal terms: A second ACL injury would mean another surgery, another 9-12 months of rehabilitation, and worse long-term outcomes. Young athletes have up to 25% risk of second ACL injury even when meeting criteria - her risk is higher without meeting them. Third, I would address her friend's example: Every athlete recovers at their own rate. Some reach criteria earlier, some later. Clearing based on time rather than readiness may explain why some athletes re-injure. Her friend may have been fortunate, but this does not change what the evidence tells us about her risk. Fourth, I would provide a concrete plan: She needs targeted quadriceps strengthening - heavy resistance training, eccentric loading, and potentially blood flow restriction training if available. I would retest in 6-8 weeks. Most athletes who are close at 9 months can achieve criteria by 11-12 months with focused training. Fifth, I would maintain her engagement by allowing modified training - she can continue sport-specific drills, non-contact team training, and conditioning while we address her strength deficit. Complete removal from all activity is counterproductive. The goal is to return her to sport safely and sustainably - a few extra weeks of rehabilitation is minimal compared to another year lost to re-injury.

KEY POINTS TO SCORE

Validate frustration while explaining evidence

Cite specific studies (Grindem - 84% reduction, Kyritsis - 4x risk)

Personalize the risk (second injury consequences)

Provide concrete rehabilitation plan with retest timeline

Allow continued training while addressing deficits

COMMON TRAPS

✗Clearing her because she is frustrated

✗Being dismissive of her concerns

✗Not having specific data to support the recommendation

✗Not providing a concrete plan forward

LIKELY FOLLOW-UPS

"What specific exercises would you recommend for quadriceps strengthening?"

"How do you address the psychological impact of delayed clearance?"

VIVA SCENARIOChallenging

Scenario 3: Psychological Barriers to RTS

EXAMINER

"A 25-year-old footballer has passed all physical criteria at 10 months post-ACL reconstruction but says he is terrified of re-injury and does not feel ready. His ACL-RSI score is 48. How do you manage this?"

EXCEPTIONAL ANSWER

This scenario highlights the critical importance of psychological readiness in return to sport decision-making. Despite meeting all physical criteria, I would not clear this athlete to return to competitive football. An ACL-RSI score of 48 is well below the threshold of 70 associated with successful return, and scores below 56 are associated with failure to return to sport. First, I would validate his concerns and explain that fear of re-injury is extremely common - 50% of athletes cite it as a barrier to return. This is not weakness or lack of commitment; it is a normal psychological response to a significant injury. Second, I would explain the consequences of returning before psychologically ready: Athletes with high fear may alter their movement patterns protectively, which can actually increase re-injury risk. Additionally, returning to competition in a fearful state will likely confirm his fears rather than build confidence, potentially ending his career prematurely. Third, I would refer to a sports psychologist for targeted intervention including cognitive behavioral therapy, graded exposure to fear-provoking situations, visualization and mental rehearsal, and addressing catastrophic thinking about re-injury. Fourth, I would implement a gradual return program: start with training situations that provoke less anxiety (non-contact drills, training with teammates he trusts), progressively increase intensity and contact, celebrate successful exposure without re-injury, and build confidence through graduated challenges. Fifth, I would retest his ACL-RSI score at regular intervals, targeting score greater than 70 before competition return. The timeline is guided by his psychological recovery, not a calendar. His physical preparation will be maintained during this process. I would also explore any specific triggers - perhaps witnessing a teammate's ACL injury, or a near-miss during training - that may require targeted intervention.

KEY POINTS TO SCORE

ACL-RSI less than 56 associated with failure to RTS - do not clear despite physical readiness

Fear of re-injury is normal and common (50% cite as barrier)

Sports psychology referral for targeted intervention

Graded exposure program to build confidence

Psychological readiness must be achieved before competition return

COMMON TRAPS

✗Clearing him because physical criteria are met

✗Dismissing his fear as irrational or weak

✗Not knowing the ACL-RSI score thresholds

✗Not involving sports psychology

LIKELY FOLLOW-UPS

"What interventions does sports psychology offer for fear of re-injury?"

"What is the Tampa Scale of Kinesiophobia?"

Australian Context

Australian Sports Medicine Context

ACL Injury in Australian Sport:

Australia has one of the highest rates of ACL injury globally, driven by the popularity of high-risk pivoting sports:

AFL (Australian Football League): 0.8 ACL injuries per club per season
Netball: One of the highest ACL injury rates in female sport worldwide
Rugby League/Union: Significant ACL injury burden
Soccer: Increasing participation leading to increased ACL injuries

Annual ACL Reconstruction Volume:

Approximately 17,000 ACL reconstructions performed annually in Australia
Peak age group: 15-25 years
Female athletes have 2-3x higher injury rate in equivalent sports

The high incidence drives significant investment in both prevention programs and return to sport research from Australian centers.

Prevention Focus

FIFA 11+, Netball Australia KNEE Program, and AFL-specific programs actively promoted in Australian sport with demonstrated efficacy.

Research Leadership

La Trobe Sport and Exercise Medicine Research Centre and other Australian centers contribute significantly to RTS evidence base.