Rehabilitation and return-to-sport after anterior cruciate ligament injury and reconstruction: Exploring physical therapists' approaches in Argentina.

OBJECTIVES: To investigate the current clinical practice regarding pre- and post-surgical rehabilitation and return to sport (RTS) criteria following anterior cruciate ligament reconstruction (ACLR). DESIGN: Cross-sectional design. Online survey. SETTING: Survey platform. PARTICIPANTS: Argentinian physical therapists (PTs). OUTCOME MEASURES: The survey consisted of a combination of 39 open- and closed-ended questions, divided across 3 sections: (1) demographic and professional information, (2) clinical practice and rehabilitation strategies, and (3) return-to-running (RTR) and RTS. RESULTS: A total of 619 PTs completed the survey. Considerable variability was observed in preoperative rehabilitation, criteria used for rehabilitation progression and RTS decision-making criteria used by PTs. From the total surveyed, 336 (54.3%) carried out RTS assessment in their clinical practice. Most of PTs (53.3%) use visual estimation to assess knee range of motion. Only 20% of the PTs reported incorporating patient-reported outcome measures in their decision-making. From PTs who use strength assessment as a criterion of RTS (68.8%), 16.6% extrapolate this from jump tests and 15.3% use manual muscle testing. Less than the 50% of the PTs recommended nine months or more to allow patients to RTS. CONCLUSIONS: Current rehabilitation practices of Argentinian PTs following ACLR are largely variable and not aligned with current evidence and scientific guidelines. To achieve better rehabilitation and RTS practices better knowledge dissemination and implementation are required.

Rehabilitation and Return to Sport Testing After Anterior Cruciate Ligament Reconstruction: Where Are We in 2022?

Athletes who sustain an anterior cruciate ligament (ACL) injury often opt for an ACL reconstruction (ACLR) with the goal and expectation to return to sports at the preinjury level. The proportion of athletes who successfully return to preinjury-level sport is low and disappointing, whereas the rate of second ACL injury in athletes under the age of 20 has been reported to be as high as 40% after return to sport (RTS). Although in recent years, new insights pertaining to RTS have been published, the lack of validity of RTS criteria after ACLR remain. The purpose of this clinical commentary is to present a critical overview of the current literature on RTS testing after ACLR.

The modifying factors that help improve anterior cruciate ligament reconstruction rehabilitation: A narrative review.

BACKGROUND: The goal of a rehabilitation programme after anterior cruciate ligament (ACL) reconstruction is to manage a patient's goals and expectations (i.e., returning to physical activities and sports) while minimizing the risk of new injury, particularly a new ACL injury. Although general rehabilitation programmes have been proposed, some factors can lead to adapting each programme to each patient. OBJECTIVE: To describe how different variables, including surgical techniques, sports participation, psycho-social and contextual factors can modify the rehabilitation programme. METHODS: We performed a narrative review with input from experts in the field (level of evidence 5). CONCLUSIONS: Modifying factors of the ACL rehabilitation programme are related to the initial lesion or surgery, to sports, or to psychological or social aspects. Regarding the type of graft, the rehabilitation is mainly different in the early postoperative phase; the other phases are not graft-based but rather goal-based rehabilitation. Depending on the meniscal or cartilage repair, the rehabilitation protocol will initially take priority over the anterior cruciate ligament reconstruction protocol. The ACL reconstruction rehabilitation programme should meet the requirements of the anticipated sports, to optimize the athlete's ability to return to the expected level and minimize the risk of reinjury. Psycho-social and contextual factors must also be considered in rehabilitation care to individualize and optimize each patient's programme.

Preliminary Evidence That Taping Does Not Optimize Joint Coupling of the Foot and Ankle Joints in Patients with Chronic Ankle Instability.

BACKGROUND: Foot-ankle motion is affected by chronic ankle instability (CAI) in terms of altered kinematics. This study focuses on multisegmental foot-ankle motion and joint coupling in barefoot and taped CAI patients during the three subphases of stance at running. METHODS: Foot segmental motion data of 12 controls and 15 CAI participants during running with a heel strike pattern were collected through gait analysis. CAI participants performed running trials in three conditions: barefoot running, and running with high-dye and low-dye taping. Dependent variables were the range of motion (RoM) occurring at the different inter-segment angles as well as the cross-correlation coefficients between predetermined segments. RESULTS: There were no significant RoM differences for barefoot running between CAI patients and controls. In taped conditions, the first two subphases only showed RoM changes at the midfoot without apparent RoM reduction compared to the barefoot CAI condition. In the last subphase there was limited RoM reduction at the mid- and rearfoot. Cross-correlation coefficients highlighted a tendency towards weaker joint coupling in the barefoot CAI condition compared to the controls. Joint coupling within the taped CAI conditions did not show optimization compared to the barefoot CAI condition. CONCLUSIONS: RoM was not significantly changed for barefoot running between CAI patients and controls. In taped conditions, there was no distinct tendency towards lower mean RoM values due to the mechanical restraints of taping. Joint coupling in CAI patients was not optimized by taping.

Rehabilitation strategies of Flemish physical therapists before and after anterior cruciate ligament reconstruction: An online survey.

OBJECTIVES: The primary objective of the study was to investigate rehabilitation strategies of Flemish physical therapists before and after anterior cruciate ligament (ACL) reconstruction. Secondly, we aimed to investigate physical therapists' preferences on continuing education and evaluate their self-rated confidence and competence when treating patients before and after ACL reconstruction. DESIGN: Survey-based study. SETTING: Online survey platform. PARTICIPANTS: Flemish physical therapists (n = 283). MAIN OUTCOME MEASURES: The online survey consisted of a combination of 40 open- and closed-ended questions, divided across 5 sections: (1) participant demographics and clinical practice information, (2) patient population information, (3) continued education practices, (4) rehabilitation strategies, and (5) physical therapist self-rated confidence and competence to treat patients with ACL reconstruction. RESULTS: A wide variability in rehabilitation strategies were found across the whole ACL rehabilitation continuum, which were in general not in line with best available evidence. Nevertheless, the overall self-rated confidence and competence of physical therapists treating patients before and after ACL reconstruction were high. CONCLUSION: Our findings indicate a need to improve rehabilitation practices before and after ACL reconstruction. Advanced research dissemination and implementation are required to achieve better rehabilitation outcomes.

Subclassification of recreational runners with a running-related injury based on running kinematics evaluated with marker-based two-dimensional video analysis.

OBJECTIVES: To explore whether homogeneous subgroups could be discriminated within a population of recreational runners with a running-related injury based on running kinematics evaluated with marker-based two-dimensional video analysis. DESIGN: Cross-sectional. SETTING: Research laboratory. PARTICIPANTS: Fifty-three recreational runners (15 males, 38 females) with a running-related injury. MAIN OUTCOME MEASURES: Foot and tibia inclination at initial contact, and hip adduction and knee flexion at midstance were measured in the frontal and sagittal plane with marker-based two-dimensional video analysis during shod running on a treadmill at preferred speed. The four outcome measures were clustered using K-means cluster analysis (n = 2-10). Silhouette coefficients were used to detect optimal clustering. RESULTS: The cluster analysis led to the classification of two distinct subgroups (mean silhouette coefficient = 0.53). Subgroup 1 (n = 39) was characterized by significantly greater foot inclination and tibia inclination at initial contact compared to subgroup 2 (n = 14). CONCLUSION: The existence of different subgroups demonstrate that the same running-related injury can be represented by different kinematic presentations. A subclassification based on the kinematic presentation may help clinicians in their clinical reasoning process when evaluating runners with a running-related injury and could inform targeted intervention strategy development.

Test-retest reliability and discriminative ability of forward, medial and rotational single-leg hop tests.

BACKGROUND: Single-leg hop tests are commonly performed in the forward direction to evaluate functional performance. However, athletes move in multiple directions during pivoting sports. The first aim of this study was to examine test-retest reliability of single-leg hop tests in the forward, medial and rotational direction in non-injured athletes. Second, the discriminative ability to detect leg asymmetries with these hop tests in anterior cruciate ligament (ACL) reconstructed athletes was determined. METHODS: Sixteen recreational non-injured participants (eight females, eight males; 22.4 ±â€¯1.9 years) were tested twice (one-week interval) and performed the single hop for distance (SH), triple hop for distance (TH), medial side triple hop for distance (MSTH) and 90° medial rotation hop for distance (MRH). Intraclass correlation coefficients (ICCs), standard errors of measurement (SEM) and smallest detectable differences (SDD) were calculated. Discriminative ability was determined in 32 ACL-reconstructed participants (four females, 28 males; 24.4 ±â€¯4.6 years; six months postoperative) who performed the same hop tests once. RESULTS: The ICCs ranged between 0.93 and 0.98. The SEM and SDD were respectively 2.6-4.1% and 7.2-11.3% of the mean hop distance of the group. The proportion (%) of ACL-reconstructed participants passing the ≥90% limb symmetry cut-off was 62.5 (SH), 59.4 (TH), 40.6 (MSTH) and 46.9 (MRH). CONCLUSION: Excellent test-retest reliability of forward, medial and rotational hop tests was found. This allows clinicians to make informed interpretations of changes in hop test distances when retesting athletes. Medial and rotational hop tests are more likely to show limb asymmetries in ACL-reconstructed participants compared to forward hop tests.

Progressive strength training restores quadriceps and hamstring muscle strength within 7 months after ACL reconstruction in amateur male soccer players.

OBJECTIVES: The purpose of the current study was to compare the results of a progressive strength training protocol for soccer players after anterior cruciate ligament reconstruction (ACLR) with healthy controls, and to investigate the effects of the strength training protocol on peak quadriceps and hamstring muscle strength. DESIGN: Between subjects design. SETTING: Outpatient physical therapy facility. PARTICIPANTS: Thirty-eight amateur male soccer players after ACLR were included. Thirty age-matched amateur male soccer players served as control group. MAIN OUTCOME MEASURES: Quadriceps and hamstring muscle strength was measured at three time points during the rehabilitation. Limb symmetry index (LSI) > 90% was used as cut-off criteria. RESULTS: Soccer players after ACLR had no significant differences in peak quadriceps and hamstring muscle strength in the injured leg at 7 months after ACLR compared to the dominant leg of the control group. Furthermore, 65.8% of soccer players after ACLR passed LSI >90% at 10 months for quadriceps muscle strength. CONCLUSION: Amateur male soccer players after ACLR can achieve similar quadriceps and hamstring muscle strength at 7 months compared to healthy controls. These findings highlight the potential of progressive strength training in rehabilitation after ACLR that may mitigate commonly reported strength deficits.

Two-dimensional video analysis can discriminate differences in running kinematics between recreational runners with and without running-related knee injury.

OBJECTIVES: To determine whether two-dimensional video analysis could discriminate running kinematics between recreational runners with and without a running-related knee injury. DESIGN: Case-control. SETTING: Research laboratory. PARTICIPANTS: Forty-two recreational runners (5 male-13 female injured; 7 male-17 female non-injured). Running-related knee injury was defined as the presence of anterior or lateral knee pain, resulting in altered running activity for at least one week. MAIN OUTCOME MEASURES: Foot and tibia inclination at initial contact, and lateral trunk position, contralateral pelvic drop, femoral adduction, hip adduction, knee flexion and ankle dorsiflexion at midstance were measured with two-dimensional video analysis during running. Participant characteristics (sex, age, body weight, body length, body mass index, running volume before injury, running speed) and two-dimensional measured angles were compared between groups. RESULTS: No significant differences in participant characteristics between groups were identified (P > .05). The injured group ran with greater contralateral pelvic drop (P = .035), femoral adduction (P = .021) and hip adduction (P = .001) at midstance, and significantly smaller foot inclination at initial contact (P = .031). CONCLUSION: Two-dimensional video analysis can discriminate kinematics between runners with and without running-related knee injury. Greater contralateral pelvic drop, femoral adduction and hip adduction at midstance may provide running retraining targets for runners with running-related knee injury.

Biomechanical Risk Factors Associated with Running-Related Injuries: A Systematic Review.

BACKGROUND: Running is a popular form of physical activity with many health benefits. However, the incidence and prevalence of running-related injuries (RRIs) is high. Biomechanical factors may be related to the development of RRIs. OBJECTIVE: This systematic review synthesizes biomechanical risk factors related to the development of RRIs in non-injured runners. METHODS: PubMed, Web of Science, CINAHL, Embase, and SPORTDiscus were searched in July 2018 for original peer-reviewed prospective studies evaluating potential biomechanical factors associated with the development of RRIs. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Two reviewers independently assessed articles for inclusion and methodological quality. Due to methodological heterogeneity across studies, a narrative synthesis of findings was conducted, rather than a meta-analysis. RESULTS: Sixteen studies, including 13 of high quality and three of moderate quality, were included. A large number of biomechanical variables were evaluated, producing inconsistent evidence overall. Limited evidence indicated greater peak hip adduction in female runners developing patellofemoral pain and iliotibial band syndrome, but not for a mixed-sex population of cross-country runners sustaining an RRI. The relationship between vertical loading rate and RRIs was inconsistent. Other kinematic, kinetic and spatiotemporal factors were only studied to a limited extent. CONCLUSIONS: Current prospective evidence relating biomechanical variables to RRI risk is sparse and inconsistent, with findings largely dependent on the population and injuries being studied. Future research is needed to confirm these biomechanical risk factors and determine whether modification of these variables may assist in running injury prevention and management.

Between-session and inter-rater reliability of the modified tuck jump assessment in healthy adult athletes.

OBJECTIVES: This study aimed to determine the between-session and inter-rater reliability of the modified tuck jump assessment (TJA). DESIGN: Reliability study. SETTING: Human movement laboratory. PARTICIPANTS: Sixteen recreational participants (8 females, 8 males; mean age: 22.4 years) participated in the study. Participants performed the modified TJA in two sessions separated by one week. MAIN OUTCOME MEASURES: Between-session and inter-rater reliability were determined by two independent raters. The standard error of measurement (SEM) and smallest detectable difference (SDD) were calculated. RESULTS: The between-session reliability for the total scores was excellent for rater 1 (ICC = 0.93, 95% CI = 0.78-0.98) and rater 2 (ICC = 0.96, 95% CI = 0.89-0.99), with SEM's and SDD's ranging between 0.5-0.7 and 1.3-2.1 respectively. The inter-rater reliability for the total scores was good for session 1 (ICC = 0.85, 95% CI = 0.58-0.95) and session 2 (ICC = 0.88, 95% CI = 0.66-0.96). In general, there was poor agreement for item analysis for both raters between sessions as well as between raters. CONCLUSION: The modified TJA revealed excellent between-session and good inter-rater reliability for the total score. Reliability for the between-session was poor for the individual items. The relatively poor reliability for the individual items imply that caution is warranted when solely interpreting the total score.

The relationship between hip muscle strength and dynamic knee valgus in asymptomatic females: A systematic review.

OBJECTIVE: To systematically review literature investigating the relationship between hip muscle strength and dynamic lower extremity valgus during movement tasks in asymptomatic females. METHODS: Four databases (CINAHL, SPORTDiscus, Embase and Ovid MEDLINE) were searched in February 2017. Studies investigating the relationship between hip muscle strength and dynamic knee or lower extremity valgus during movement tasks among asymptomatic females over 18 years old were included. Meta-analyses were performed where two or more studies used similar tasks. RESULTS: Five studies reported no relationship between hip strength and dynamic lower extremity valgus. Greater peak lower extremity valgus was associated with reduced hip strength in eight studies, and greater hip strength in three studies. In the meta-analysis, a relationship between weaker hip strength and greater dynamic lower extremity valgus was found for ballistic single leg landing, but not double leg landing or single leg squat tasks. CONCLUSIONS: Although the relationship between hip strength and dynamic lower extremity valgus is conflicting, meta-analysis revealed lower extremity dynamic valgus was consistently associated with hip strength in single leg ballistic tasks, but not double leg ballistic or single leg squat tasks. The relationship between hip strength and dynamic lower extremity valgus may be conditional to task demand.

Is knee neuromuscular activity related to anterior cruciate ligament injury risk? A pilot study.

BACKGROUND: There is limited evidence on neuromuscular risk factors for anterior cruciate ligament (ACL) injuries, with most work mainly focusing on hamstrings and quadriceps muscle strength. This prospective pilot study explored if neuromuscular activation patterns of the quadriceps and hamstrings during a drop vertical jump influence ACL injury risk. METHODS: Forty-six female athletes performed a drop vertical jump at baseline. Injuries were monitored throughout a one-year follow-up. Neuromuscular activation patterns of the vastus medialis, vastus lateralis, hamstrings medialis and hamstrings lateralis, and selected landing kinematic and kinetic profiles (knee flexion, knee abduction and hip flexion angles, and knee abduction moments), were compared between athletes who sustained a non-contact ACL injury and those who remained injury free. Electromyogram vector fields were created to represent neuromuscular activation patterns of muscle pairs around the knee joint rather than only considering individual muscle activations, and compared using Statistical Parametric Mapping. RESULTS: Four athletes sustained an ACL injury. Significantly greater {hamstrings medials, hamstrings lateralis}, {vastus lateralis, hamstrings lateralis} and {hamstrings lateralis, vastus medialis} activations, mainly due to greater hamstrings lateralis activation, were found in the injured group around peak loading and just before take-off (P < 0.001). No group differences were found in knee flexion, knee abduction and hip flexion angles, or knee abduction moments. CONCLUSIONS: This pilot study revealed initial evidence that athletes already showed altered neuromuscular activation patterns prior to sustaining an ACL injury, namely increased lateral and posterior muscle activations.

Test-retest reliability of two-dimensional video analysis during running.

OBJECTIVES: To examine test-retest reliability of two-dimensional measured frontal and sagittal plane kinematics during running, and to determine how many steps to include to reach and maintain a stable mean. DESIGN: Reliability study. SETTING: Research laboratory. PARTICIPANTS: Twenty-one recreational runners. MAIN OUTCOME MEASURES: Lateral trunk position, contralateral pelvic drop, femoral adduction, hip adduction, knee flexion and ankle dorsiflexion during midstance, and foot and tibia inclination at initial contact were measured with two-dimensional video analysis during running for 10 consecutive steps for both legs. All participants were tested twice one week apart. A sequential estimation method was used to determine the number of steps needed to reach a stable mean. Intraclass correlation coefficients (ICC) and smallest detectable differences (SDD) were calculated. RESULTS: The minimal number of steps was 6.3 ±â€¯0.3. Lateral trunk position, femoral adduction and foot inclination showed excellent reliability (ICC 0.90-0.99; SDD 1.3°-2.3°). Tibia inclination and ankle dorsiflexion showed good to excellent reliability (ICC 0.73-0.92; SDD 2.2°-4.8°). Hip adduction and knee flexion showed good reliability (ICC 0.82-0.89; SDD 2.3°-3.8°). Contralateral pelvic drop showed moderate to good reliability (ICC 0.59-0.77; SDD 2.7°-2.8°). CONCLUSION: Two-dimensional video analysis is reliable to assess running kinematics on different days. The mean of at least 7 steps should be included.

The assessment of movement health in clinical practice: A multidimensional perspective.

This masterclass takes a multidimensional approach to movement assessment in clinical practice. It seeks to provide innovative views on both emerging and more established methods of assessing movement within the world of movement health, injury prevention and rehabilitation. A historical perspective of the value and complexity of human movement, the role of a physical therapist in function of movement health evaluation across the entire lifespan and a critical appraisal of the current evidence-based approach to identify individual relevant movement patterns is presented. To assist a physical therapist in their role as a movement system specialist, a clinical-oriented overview of current movement-based approaches is proposed within this multidimensional perspective to facilitate the translation of science into practice and vice versa. A Movement Evaluation Model is presented and focuses on the measurable movement outcome of resultants on numerous interactions of individual, environmental and task constraints. The model blends the analysis of preferred movement strategies with a battery of cognitive movement control tests to assist clinical judgement as to how to optimize movement health across an individual lifespan.

A novel approach for the detection and exploration of joint coupling patterns in the lower limb kinetic chain.

BACKGROUND: A comprehensive perspective on foot and lower limb joint coupling is lacking since previous studies did not consider the multi-articular nature of the foot and lower limb neither accounted for biomechanical heterogeneity. RESEARCH QUESTION: The current manuscript describes a novel methodological process for detection and exploration of joint coupling patterns in the lower limb kinetic chain. METHODS: The first stage of the methodological process encompasses the measurement of 3D joint kinematics of the foot and lower limb kinetic chain during dynamic activities. The second stage consists of selecting the kinematic waveforms of interest. In the third stage, cross-correlation coefficients are calculated across the selected one-dimensional continua of each subject. In the fourth stage, all cross-correlation coefficients per subject are used as input variable in a cluster algorithm. Algorithm specific qualitative metrics are subsequently considered to determine the most robust clustering. Finally, in the fifth stage the process of biomechanical interpretation is initiated and further exploration is recommended by triangulating with other biomechanical variables. RESULTS: A first clinical illustration of the novel method was provided using data of fourteen young elite athletes. Cross-correlation coefficients for each leg were calculated across continua of the pelvis, hip, knee, rear foot and midfoot. A hierarchical clustering approach stratified the coefficients into two distinct clusters which was mainly guided by the frontal plane knee kinematics. Both clustered differed significantly from each other with respect to their frontal plane ankle, knee and hip kinetics. SIGNIFICANCE: The presented method seems to provide a valuable approach to gain insight into foot and lower joint coupling.

Foot and ankle kinematics in chronic ankle instability subjects using a midfoot strike pattern when running, including influence of taping.

BACKGROUND: Investigate differences in multi-segment foot kinematics between controls and participants with chronic ankle instability during running with a midfoot striking pattern and to evaluate the effect of Low-Dye and High-Dye taping. METHODS: Three-dimensional multi-segment foot kinematics of 12 controls and 15 participants with chronic ankle instability were collected while running barefoot, and in both taping conditions. Ranges of motion occurring at each joint, each sub phase of stance, were compared between groups and between taping conditions (0-dimensional inference). Kinematic data were also compared using one-dimensional statistical parametric mapping. FINDINGS: The symptomatic group demonstrated while barefoot running a significantly decreased rearfoot dorsiflexion range of motion during the peak impact phase as well as a less dorsiflexed position from 6 to 12% of the running cycle. During the absorption and generation phase, the symptomatic group also showed a significantly increased rearfoot dorsiflexion and adduction motion as well as an increased midfoot inversion motion. In the peak impact phase of both taping conditions, a decreased midfoot inversion motion was found. The High-Dye taping resulted in a decreased rearfoot plantarflexion motion whereas the Low-Dye caused a decreased midfoot inversion motion. INTERPRETATION: Persons with chronic ankle instability seem to have altered rearfoot and midfoot kinematics while running with a midfoot striking index. High-Dye taping seems to have better therapeutic features than Low-Dye taping.

Are two-dimensional measured frontal plane angles related to three-dimensional measured kinematic profiles during running?

OBJECTIVES: To investigate the temporal relationship between two-dimensional measured frontal plane joint angles and three-dimensional measured kinematic profiles during the stance phase of running, and to assess the intra- and intertester reliability of the two-dimensional angles. DESIGN: Observational study. SETTING: Research laboratory. PARTICIPANTS: Fifteen injury-free elite athletes. MAIN OUTCOME MEASURES: Contralateral pelvic drop (CPD), femoral adduction (FA), hip adduction (HA) and knee valgus (KV) were measured at the deepest landing position during midstance with two-dimensional video analysis during running. CPD, HA and knee abduction were measured continuously during the entire stance phase through three-dimensional motion analysis. One-dimensional statistical parametric mapping was used to examine the temporal relationships between the two-dimensional angles and three-dimensional kinematic profiles. In addition, intra-class correlation coefficients (ICC) were calculated to assess the intra- and intertester reliability of the two-dimensional angles. RESULTS: Two-dimensional CPD, FA and HA were significantly related to the three-dimensional HA kinematic profile. Two-dimensional CPD was significantly related to the three-dimensional CPD kinematic profile. No significant relationship was found between two-dimensional KV and three-dimensional knee abduction. Excellent intra- and intertester reliability was found for the two-dimensional angles (ICC 0.90-0.99). CONCLUSIONS: These findings support implementing two-dimensional video analysis to evaluate CPD and HA during running.

Clinical course and recommendations for patients after anterior cruciate ligament injury and subsequent reconstruction: A narrative review.

Almost all athletes who have suffered an anterior cruciate ligament (ACL) injury expect a full return to sports at the same pre-injury level after ACL reconstruction (ACLR). Detailed patient information on the reasonable outcomes of the surgery may be essential to improve patient satisfaction.Pre-operative rehabilitation before ACLR should be considered as an addition to the standard of care to maximise functional outcomes after ACLR.We propose an optimised criterion-based rehabilitation programme within a biopsychosocial framework.No benchmark exists for evaluating return-to-sport (RTS) readiness after ACLR. Therefore, the authors propose a multi-factorial RTS test battery. A combination of both physical and psychological elements should be included in the RTS test battery.There is need for shared decision-making regarding RTS. Cite this article: EFORT Open Rev 2017;2:410-420. DOI: 10.1302/2058-5241.2.170011.