Ep 5: Return-to-sport testing

Return-to-sport testing is often treated as the final checkpoint after an ACL injury. Pass the tests, get cleared, and return to competition. But is it really that simple?

In this episode of the RX Physiotherapy Podcast, Trent Cooksley breaks down what return-to-sport (RTS) testing actually tells us — and more importantly, what it doesn’t.

You’ll learn why many athletes still experience high re-injury rates after being cleared, and why passing a battery of tests doesn’t necessarily mean the knee is ready for the demands of sport.

We explore key factors that influence safe return to sport including:

• Quadriceps strength and why it matters more than you think
• The limitations of hop tests and limb symmetry
• Why athletes can “game” common testing protocols
• How fatigue, time pressure, and real-game scenarios change movement patterns
• The psychological side of returning to sport after injury
• Why gradual exposure to training loads is critical

Rather than acting as a simple green light, return-to-sport testing should be used as a risk-management tool to prepare athletes for the demands of sport.

If you're recovering from an ACL injury, working with injured athletes, or simply want to understand how safe return-to-sport decisions are made, this episode is for you.

🎧 Tune in to learn how better testing and smarter rehab strategies can help athletes return to sport with greater confidence and lower risk of re-injury.

Disclaimer: Before making any health changes, consult with a healthcare professional.

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Transcript

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Welcome to the RX Physiotherapy Podcast, your go-to destination for all things physio, rehab, health and wellness. I'm April Patterson and tr, and each week we will dive deep into fascinating topics within the health world. From physiotherapy to nutrition and beyond. We cover it all. So sit back, relax, and enjoy the journey as we explore the exciting world of health and wellness. Let's get started. Passing tests doesn't mean you're safe. It means you've met the minimum standard. Return to sport or RTS is often treated like a finish line, pass a battery, you get cleared, you play, but re-injury rates remain stubbornly high and that tells us something important. Testing alone doesn't prevent injury or reinjury. Good day. Trent Cooksley here from RX Physiotherapy, taking you guys through yet another ACL podcast. And this episode is about what RTS testing actually tells us, what it misses and how it should be used as a risk management tool, not just as a permission to return to sport. Now at its core, RTS testing aims to answer three main questions. Can the knee. Tolerate load. Can the athlete control that load and can they do it repeatedly? Most batteries include strength testing, hop testing, and movement assessments, but the problem isn't the tests, it's how we interpret them. If we had to pick one variable that matters most, it's quadricep strength. Multiple studies by Garum and colleagues show that athletes who returned to sport with poor quadricep strength had significantly higher re-injury rates. Now, in one key paper, they demonstrated that each 1% increase in quadricep strength symmetry reduced overall reinjury risk. Here's the catch. Later work by welling etal. Showed that limb symmetry can be misleading because both limbs are often weak, especially post-injury, uh, in that first like on a zero to six weeks, where some athletes aren't training as such, training as normal, they're trying to offload their entire lower body. So if you can hatch people who have essentially just injured their ACL. Within the first week or two, you can get a good baseline of the unaffected side to get a good, um, overall baseline strength number, which tells us, which then kind of ties into absolute strength, is kind of goes in hand in hand and sometimes matters more than, um, limb symmetry alone. So the next part of kind of testing usually find, um. Hop tests, uh, they're popular because they're easy to implement, very repeatable, but the research consistently shows that they can be gamed. Studies by King and Webster demonstrated that athletes can pass hop te hopped tests using compensatory strategies, uh, adequate knee loading. So passing a hop test doesn't necessarily mean the knee's ready. Uh, it can just be that the athlete's very, very adaptable and clever. So if you are gonna implement hop tests, it's important to be very, very, um, strict on how you have the athlete perform 'em. That way they can get adequate loading through the knee and not just use other strategies to get, get their numbers up. Now movement screenings look awesome in in clinic, but real sport and kind of real life in a sense isn't controlled. Uh, work by Hewitt and Paterno highlighted that risky mechanics now often emerge under fatigue. Time, pressure and, and unpredictability. So most return to sport assessments, uh, don't really capture that. So we end up testing athletes, in least in the least dangerous environment, and yet we clear 'em to the most dangerous ones. Now, looking into a bit of the kind of psychological side of things. So fear, um, doesn't necessarily show up on the force plate or in. Some of the testing that we use, but it definitely matters. Studies by ER etal showed that the psychological readiness strongly predicts return to sport, and sometimes more than physical me measures alone. Athletes who don't trust their knee avoid certain positions, they hesitate. They try to offload it as much as they can, and that hesitation changes movements. And increases overall risk of injury. So return to sport shouldn't be a single decision. It should be return to training, return to exposure, return to competition. Research by Blanche and GABAs, uh, on trading loads showed that sudden spikes dramatically, uh, increase re re-injury risk. The same applies to post ACL. Uh, injuries. Gradual exposure is essentially protection as a whole. So let's land this. Clearly, RTS testing doesn't predict safety. It manages uncertainty. The goal isn't to clear athletes, it's to prepare them. Hopefully, you kind of took a little bit away from this one just to kind of get your thinking a little bit more. Uh, is my athlete ready to actually go back, especially when looking at the psychological side of things. Um, that can be a very big determining factor in terms of sending, you know, athletes back. Um, and it's definitely one to watch out for. Now, in the final episode, we'll tackle the most controversial question of all. Can the ACL heal on its own? And when doesn't nonsurgical rehab? Actually allow that to happen. Appreciate you listening and I'll catch you in the next one. See ya.