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The 6 tick boxes to return to sport from ACL rehabilitation

Anterior Cruciate Ligament (ACL) injuries can be distressing for patients and its rehabilitation is one that needs to be taken seriously. We understand that it is a timely rehabilitation, but also understand that time is not the only factor that needs to be accounted for when dealing with an ACL injury. It has been reported that 81% of individuals with an ACL injury will return to any kind of sport. Only 65% will return to their pre-injury level and merely 55% return to competitive sport.

Re-injury rates for ACL vary between 6% to 25% thus making the decision for when it is appropriate to return to sport a decision that ultimately must be made with clearance from the orthopaedic surgeons, physiotherapists and osteopaths such as those at the Injury Rehab Centre in Cheltenham.

What are the criteria to return from ACL injury safely?

One study set out to explore an objective return to sport/discharge criteria and evaluate whether strength or functional tests were risk factors for ACL graft rupture. They examined 158 professional male athletes in Qatar and followed up with the individuals 6 months after their return to sport.

The discharge criteria examined were:

  • Isokinetic Testing – Quadriceps Strength Deficit <10% at 60 Degrees/Second between legs

  • Single Hop – Limb Symmetry Index (a measure to standardise test results with lower limb length) >90%
  • Triple Hop – Limb Symmetry Index >90%
  • Triple Crossover Hop – Limb Symmetry Index >90%
  • On-Field Sports Specific Rehab
  • Running Agility T – Test (ability to run and change direction over a set of cones in a T shape set 10 metres apart) – <11 seconds

Of the 158 athletes that participated:

  • 116 (73%) fully discharged
  • 42 (27%) did not achieve

Injury Occurrence

  • 26 (16.5%) sustained graft rupture
    • 17 occurred within the first 6 months of return to sport
  • 11 (7%) sustained opposite side rupture

Was there a difference in those that were fully discharged versus not?


  • 12 out of 116 (10.3%) that were fully discharge sustained an ACL graft rupture
  • 14 out of 42 (33.3%) that did not meet the 6 criteria sustained an ACL graft rupture

Take home messages:

  • ACL re-rupture rates range from 6-25% and a high amount of individuals return to sport (81%)
  • Not meeting all 6 variables examined by the study places you at a 4x greater risk of rupture
  • For strength examined, every 10% decrease in hamstring to quad strength ratio there was a 10.6x greater risk of ACL rupture

At the Injury Rehab Centre we utilize a functional and objective measures to help mitigate your risk of injury before you return to sport. We utilize a variety of tools and combine some of the tests above with force plate technology to increase our understanding of your capability. If you’ve had an ACL injury recently or had a previous ACL injury, ensure that you are ready for your next upcoming season with the Injury Rehab Centre and book with a physiotherapist or osteopath now!

What we do at the Injury Rehab Centre

At the Injury Rehab Centre in Cheltenham we go above and beyond traditional Physiotherapy and Osteopathy clinics by using the latest assessment technology to perform tests as previously described to collect data on how you move to assess your risk of ACL injury or how your rehabilitation is progressing.

We utilise:

  • M.A.T Assessment created by the therapists of the Injury Rehab Centre to laser focus on areas of flexibility, balance and movement that identify whether your are at risk to sustain an injury.
  • Slow Motion Jumping and Running Video Analysis to IDENTIFY YOUR BAD LANDING AND CHANGING DIRECTION HABITS that maintain a risk of injury.
  • Strength Testing to identify any strength discrepancies that have a huge role in increasing your injury risk.
  • Force Plate Technology to put a number on differences in the power you can generate through each leg that can lead to compensations and can cause repetitive stress injuries and prevent return to full performance.
  •  Traditional Physiotherapy and Osteopathy examinations to identify dysfunction.

Individual management plans can then be created using baseline data to track progression of a program to address movement deficiencies and discrepancies (muscle and tendon strength, stamina, specific flexibility) as well as increasing your movement skill to make you more efficient out on the road, track or trail to bullet proof your body from injury and increase performance.

The Injury Rehab Centre is currently seeking participants for research we will be conducting into the effectiveness of treatment and rehabilitation for ACL reconstruction patients.

As part of this research participants at the Injury Rehab Centre will receive a FREE M.A.T assessment in which detailed lower limb testing will be performed to identify deficiencies and discrepancies in lower limb function to calculate risk of injury.

If this sounds like you or someone you know go click here to register your interest in being part of this study and getting a FREE assessment today.

Kyritsis P, Bahr R, Landreau P, et al Likelihood of ACL graft rupture: not meeting six clinical discharge criteria before return to sport is associated with a four times greater risk of rupture Br J Sports Med 2016;50:946-951.

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