The role of objective high performance testing, with appropriate technology and high quality equipment, for athletes following an ACL injury or surgery, cannot be overstated! Passing a comprehensive, objective, return to sport testing battery has been consistently shown to increase the likelihood of returning to sport and, perhaps more importantly, significantly decrease the risk of a future ACL injury (Maestroni et al., 2023; O’Dowd et al., 2024).
But, not all objective measures and tests are created equal of course! There are a number of measures that consistently correlate to the likelihood of returning to sport, an athlete’s level of performance, and the likelihood of re-injury. These measures can be most accurately assessed using the fixed dynamometry and force plate systems utilised at Complete Physio in our High Performance Testing service..
These measures can not be accurately assessed with lower budget or lower equipment demand testing protocols. These measures can be broadly split into two groups:
- Maximal strength
- Plyometric ability.
Maximal Strength
Why is it Important?
It is common for athletes to have remaining quadriceps strength deficits late in their ACL rehabilitation process. Athletes with residual quadriceps strength deficits have been shown to have poorer athletic performance upon returning to sport and biomechanical deficits which predispose them to future ACL injury. Athletes with residual hamstring strength deficits have also been shown to have decreased athletic performance when they return to sport (Gill et al., 2024; Högberg et al.,2024; Ithurburn et al., 2018; Read et al., 2023).
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Whilst a number of low cost, low equipment options exist for assessing muscular strength, they significantly lack reliability and validity. The muscles of the thigh are too powerful to be accurately assessed using a dynamometer stabilised by a clinician, functional testing (such as squat, lunge or deadlift strength) lack the required specificity to assess the muscle of interest, and repetition maximum testing (such as seeing how much weight you can lift 5 times on a leg extension machine) does not perfectly correlate with the maximal strength of the muscle. Maximal quadriceps and hamstring strength can most accurately be assessed with an externally fixated dynamometry system, which we utilise during our High Performance Testing service.
Patient Testimonial: Steve, 32, Semi-Pro Footballer from Essex
“After my first ACL surgery, I worked with a physio, but we didn’t have access to the kind of advanced technology I needed. I felt like I went back to playing a bit too soon and ended up re-injuring my knee. This time, I wanted to make sure I got everything right, and that’s when I came across the High Performance Testing Service at Complete Physio.
They used special equipment like force plates and fixed dynamometry to measure my strength, balance, and how my body was moving. It wasn’t just about how I felt, but I could actually see real numbers showing my progress. They found some weaknesses and imbalances I didn’t even know I had, which helped them put together a rehab plan that was totally personalised for me.
Seeing the results on the force plates really helped – I could tell how much power each leg was producing, and the fixed dynamometry gave me detailed info on how strong my muscles were, like my quads and hamstrings. Having this data made me feel a lot more confident that when I returned to football, I was ready and not rushing things.
Thanks to the team at Complete Physio, I’ve come back stronger and with peace of mind knowing I’m not risking another injury. I couldn’t have asked for better support!”
Plyometric Ability
Why is it Important?
It has been proven time and time again that measures of vertical hop performance are the last physical performance measures to normalise in athletes rehabilitating from an ACL injury or surgery. These measures include maximal hop height in various circumstances, and what is known as reactive strength index (RSI) which is a measure of plyometric ability. Such ongoing deficits, in athletes who return to sport following ACL rehabilitation, correlate with poorer athletic performance and biomechanical deficits which could predispose them to future injury (Hirohata et al., 2022; Kotsifaki et al., 2022; Kotsifaki et al., 2023; Maestroni et al., 2023; Read et al., 2023; Taylor et al., 2020; Wang et al., 2023; Zarro et al., 2021).
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It is still common to see physiotherapists use measures of horizontal hopping performance, such as distance hopped or time taken to hop a certain distance, as a low budget and minimal equipment approach to testing plyometric ability following ACL injury or surgery. Unfortunately, these tests alone may not be enough when looking to return to higher level activities, such as, football. All of the evidence quoted above shows that horizontal hop performance measures normalise significantly sooner than vertical hop measures, and therefore miss a big part of the picture! This is because hopping vertically requires a significantly higher contribution from the knee joint compared to horizontal hopping, which is predominantly powered by the ankle and the hip (Kotsifaki et al., 2021).
There are also a number of lower budget options to measure vertical hop height, but these alternatives miss out on a great deal of the accuracy, reliability, and breadth of important data that can be gained by using the force plate technology that we use as part of our Complete Physiotherapy High Performance Testing assessment (Kotsifaki et al., 2023; Labban et al., 2024).
In summary, High Performance Testing at Complete Physio ensures that you can receive the high quality data that you need to make informed decisions regarding your rehabilitation and return to sport following an ACL injury or surgery. This type of comprehensive testing is most advisable from 3 months into your rehabilitation, when you feel that you are less limited by pain, and making good progress. These tests are especially relevant late in the rehabilitation process, when you feel that you are close to returning to sport.
Ask your physiotherapist, or reach out to the team at Complete Physio to help you decide whether this comprehensive assessment is right for you, your injury, and your performance goals.
Don’t delay, book today and begin your road to complete recovery.
If you’re unsure whether this service is right for you, we offer a free 10-15 minute consultation call to discuss the process and how it can benefit you.
Contact Us:
If you would like to book an appointment, or would like further information, please contact us on 020 7482 3875 or email info@complete-physio.co.uk
References:
- Gill, V. S., Tummala, S. V., Han, W., Boddu, S. P., Verhey, J. T., Marks, L., & Chhabra, A. (2024). Athletes Continue to Show Functional Performance Deficits at Return to Sport After Anterior Cruciate Ligament Reconstruction: A Systematic Review. Arthroscopy: The Journal of Arthroscopic & Related Surgery, S0749-8063(24)00011-2.
- Hirohata, K., Aizawa, J., Ohmi, T., Ohji, S., Mitomo, S., Ohara, T., Koga, H., Yagishita, K., Jinno, T., & Okawa, A. (2022). Reactive strength index during single-limb vertical continuous jumps after anterior cruciate ligament reconstruction: cross-sectional study. BMC Sports Science, Medicine & Rehabilitation, 14(1), 150.
- Högberg, J., Lindskog, J., Sundberg, A., Piussi, R., Simonsson, R., Samuelsson, K., Thomeé, R., & Hamrin Senorski, E. (2024). Relationship between hamstring strength and hop performance at 8 and 12 months after ACL reconstruction with hamstring tendon autografts. BMC Sports Science, Medicine & Rehabilitation, 16(1), 134.
- Ithurburn, M. P., Altenburger, A. R., Thomas, S., Hewett, T. E., Paterno, M. V., & Schmitt, L. C. (2018). Young athletes after ACL reconstruction with quadriceps strength asymmetry at the time of return-to-sport demonstrate decreased knee function 1 year later. Knee Surgery, Sports Traumatology, Arthroscopy, 26(2), 426–433.
- Kotsifaki, A., Korakakis, V., Graham-Smith, P., Sideris, V., & Whiteley, R. (2021). Vertical and Horizontal Hop Performance: Contributions of the Hip, Knee, and Ankle. Sports Health, 13(2), 128–135.
- Kotsifaki, A., Van Rossom, S., Whiteley, R., Korakakis, V., Bahr, R., Sideris, V., & Jonkers, I. (2022). Single leg vertical jump performance identifies knee function deficits at return to sport after ACL reconstruction in male athletes. British Journal of Sports Medicine, 56(9), 490–498.
- Kotsifaki, R., Sideris, V., King, E., Bahr, R., & Whiteley, R. (2023). Performance and symmetry measures during vertical jump testing at return to sport after ACL reconstruction. British Journal of Sports Medicine, 57(20), 1304–1310.
- Labban, W., Manaseer, T., Golberg, E., Sommerfeldt, M., Nathanail, S., Dennett, L., Westover, L, & Beaupre, L. (2024). Jumping into recovery: A systematic review and meta-analysis of discriminatory and responsive force plate parameters in individuals following anterior cruciate ligament reconstruction during countermovement and drop jumps. Journal of Experimental Orthopaedics, 11(2), e12018.
10, Maestroni, L., Turner, A., Papadopoulos, K., Sideris, V., & Read, P. (2023). Total Score of Athleticism: Profiling Strength and Power Characteristics in Professional Soccer Players After Anterior Cruciate Ligament Reconstruction to Assess Readiness to Return to Sport. The American Journal of Sports Medicine, 51(12), 3121–3130.
11. Maestroni, L., Turner, A., Papadopoulos, K., Cohen, D., Sideris, V., Graham-Smith, P., & Read, P. (2023). Comparison of Strength and Power Characteristics Before ACL Rupture and at the End of Rehabilitation Before Return to Sport in Professional Soccer Players. Sports Health, 15(6), 814–823.
12. O’Dowd, D. P., Stanley, J., Rosenfeldt, M. P., Walsh, S., Twaddle, B., De Ruiter, L., Crua, E., Monk, A. P., & Walsh, S. (2024). Reduction in re-rupture rates following implementation of return-to-sport testing after anterior cruciate ligament reconstruction in 313 patients with a mean follow-up of 50 months. Journal of ISAKOS: Joint Disorders & Orthopaedic Sports Medicine, 9(3), 264–271.
13. Read, P. J., Davies, W. T., Bishop, C., McAuliffe, S., Wilson, M. G., & Turner, A. N. (2023). Residual Deficits in Reactive Strength After Anterior Cruciate Ligament Reconstruction in Soccer Players. Journal of Athletic Training, 58(5), 423–429.
14. Taylor, J. B., Westbrook, A. E., Head, P. L., Glover, K. M., Paquette, M. R., & Ford, K. R. (2020). The single-leg vertical hop provides unique asymmetry information in individuals after anterior cruciate ligament reconstruction. Clinical Biomechanics (Bristol, Avon), 80, 105107.
15. Wang, L., Xia, Q., Li, T., Wang, Z., & Li, J. (2023). Limb Symmetry Index of Single-Leg Vertical Jump vs. Single-Leg Hop for Distance After ACL Reconstruction: A Systematic Review and Meta-analysis. Sports Health, 19417381231205267.
16. Zarro, M. J., Stitzlein, M. G., Lee, J. S., Rowland, R. W., Gray, V. L., Taylor, J. B., Meredith, S. J., Packer, J. D., & Nelson, C. M. (2021). Single-Leg Vertical Hop Test Detects Greater Limb Asymmetries Than Horizontal Hop Tests After Anterior Cruciate Ligament Reconstruction in NCAA Division 1 Collegiate Athletes. International Journal of Sports Physical Therapy, 16(6), 1405–1414.
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