RETURN TO SPORT
Functional evaluation, such as the hop test, may be considered as one factor to determine return to sport after ACL reconstruction.

Rationale

Two low quality studies (Nawasreh 2018, Toole 2017) show that application of hop test criteria for return to sport results in better return to preinjury quality of exercise and maintenance of level of sports participation for one year. There is little evidence regarding other criteria, including muscle function, timing of return to play, kinesiophobia, and other rating scales. Specifically, the optimal timing of functional testing and return to sport is unclear based on the literature. Nawasreh (2018) performed hop testing 6 months after surgery, while the timing was more variable in the study by Toole (2017) (mean 8.1 months after surgery). One low quality study (Beischer 2020) suggests that using 9 months as a criterion from return to sport results in a lower rate of graft failure/rupture while another (Webster 2021) finds no difference when 12-month criteria are applied. 

Benefits/Harms of Implementation

Hop testing criteria for return to sport presents little direct risk of harm. However, it is unclear whether there is a risk of adverse events if a patient were to meet hop test criteria but not others, including temporal parameters.

Outcome Importance

Outcomes like return to sport and graft failure are important after ACL reconstruction. Therefore, establishing criteria for safe return to sport is crucial.

Cost Effectiveness/Resource Utilization

Hop testing requires a competent tester and space for the testing. Many physical therapy or athletic training facilities are currently capable of performing such assessments. Other testing, such as muscular function, may require more expensive or space-prohibitive equipment.

Acceptability

Hop testing has been described for quite some time, so the recommendation will be acceptable to clinicians.

Feasibility

Implementation of hop testing criteria is reasonable but requires personnel and space to perform the testing.

Future Research

Future research should strive for higher study quality and focus on the impact of various criteria (time from surgery, functional testing, strength testing, psychological readiness, etc.) on safe return to activity after ACL reconstruction in order to establish better evidence-based guidelines.