# Decision‐making in return to sport clearance after ACL reconstruction is primarily based on objective criteria: Insights from AGA knee experts

## TL;DR

Experts prioritize objective criteria like time since surgery and clinical exams when deciding when athletes can return to sports after ACL reconstruction.

## Contribution

This study identifies the most valued objective criteria for return to sport clearance after ACL surgery based on expert opinions.

## Key findings

- Time since surgery and clinical exams are top criteria for RTS clearance.
- Hop tests and movement quality assessments are commonly used RTS tests.
- Psychological assessments are rarely used in RTS decisions.

## Abstract

To identify current surgical strategies and objective criteria used for return to sport (RTS) clearance after primary isolated anterior cruciate ligament (ACL) reconstruction, based on a survey of knee surgery experts.

An online survey was developed by the ‘Knee Ligament’ committee of the German‐speaking Arthroscopy Society (AGA) and distributed to certified ‘AGA Knee Experts’ in November and December 2023. The final questionnaire consisted of 26 questions covering surgical strategies, postoperative evaluation, and RTS clearance after primary isolated ACL reconstruction. Participants were asked to rank objective RTS criteria, and weighted mean ranks were calculated to assess their relative importance (1 = most important, 8 = least important). Data were analysed descriptively to reflect current expert practices.

A total of 113 board‐certified knee surgeons from Germany, Austria, and Switzerland participated in this survey. Hamstring tendon autografts were the preferred graft choice for primary isolated ACL reconstruction (87%), with over half of the respondents (58%) adapting graft selection based on the patient's activity level. RTS testing is routinely performed by 64% of participants. The most frequently used RTS tests are hop tests (93%), assessment of movement quality (59%), and postural stability (56%). The most important objective criteria for RTS clearance were time since ACL reconstruction (mean rank, 2.7), manual clinical examination (mean rank, 2.7), and RTS assessment tools (mean rank, 3.2). Concomitant surgical procedures such as cartilage treatment, meniscus repair, and osteotomies affect RTS clearance. Sport psychological assessment is rarely used (12%).

This study found that knee experts prioritised time since surgery, clinical examination, and RTS assessment tools as the most important criteria for unrestricted RTS clearance after primary isolated ACL reconstruction. RTS clearance is affected by concomitant surgical procedures, whereas psychological assessment remains uncommon.

Level V.