Multidimensional Criteria For Return-To-Sport Decision-Making Following Anterior Cruciate Ligament Reconstruction: A Systematic Review Of Functional Performance, Psychological Readiness, And RTS Assessment Strategies

Abstract

Background:
Return-to-sport decision-making after anterior cruciate ligament reconstruction remains challenging, as successful surgery does not always indicate complete functional recovery or readiness for sports participation. Time-based progression alone may fail to identify persistent deficits in physical performance, psychological readiness, and movement quality.

Objective:
This systematic review aimed to evaluate multidimensional criteria used for RTS decision-making following ACL reconstruction, focusing on functional performance, psychological readiness, and clinical assessment strategies.

Methods:
A systematic review was conducted according to PRISMA 2020 guidelines. PubMed/MEDLINE, Scopus, Web of Science, Cochrane Library, and PEDro databases were searched from January 2000 to March 2026. Studies evaluating RTS assessment criteria after primary ACL reconstruction were included. Data regarding functional tests, psychological measures, RTS criteria, and reinjury outcomes were extracted and synthesized narratively due to methodological heterogeneity.

Results:
A total of 500 records were identified, and 50 studies were included in the qualitative synthesis. Functional assessments commonly included isokinetic strength testing, hop tests, Limb Symmetry Index (LSI), dynamic balance, and movement quality analysis. Although LSI ≥90% was frequently used, evidence suggested that symmetry-based criteria alone may not accurately represent complete recovery. Psychological readiness, primarily assessed using the ACL-Return to Sport after Injury (ACL-RSI) scale, was consistently associated with successful RTS and return to pre-injury activity levels. Combined RTS assessment batteries integrating physical performance, psychological readiness, patient-reported outcomes, and sport-specific demands demonstrated greater clinical relevance.

Conclusion:
RTS decision-making after ACL reconstruction should follow a multidimensional approach rather than relying on time or single assessment criteria. Integrating functional performance, psychological readiness, and sport-specific evaluation may improve RTS decisions and reduce secondary injury risk.