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FUNCTIONAL TESTING GUIDELINES FOR ACL RECONSTRUCTION
TESTING INSTRUCTIONS FOR CLINICIANS
A number of criteria should be met before advanced functional testing of ACL reconstruction or ACL
deficient knees are tested:
-
No pain
-
No reports of instability or giving way
-
No swelling
-
Full active range of motion
Generally testing be done no earlier than 4 months with the exception of LARS ACL grafts.
TESTS:
Single Leg Squat Functional Alignment Test
Subjects stand on one leg off 20 cm box with arms crossed. 5 consecutive single leg squats are performed
in a slow and controlled manner at a rate of 2 seconds per squat. The task is rated as good, fair or poor. (
Crossley et al, 2011).
Single Leg Balance
Subjects stand on one leg with other leg raised and arms crossed over chest. The assessor uses a
stopwatch to time how long stance is maintained on one leg with eyes closed. (Springer et al, 2007).
Y Balance Test
- Place one foot in the center of the grid (stance leg denotes measure)
- While maintaining balance, reach foot forward, medial and lateral as far as possible
- Return to the starting position, no lifting stance foot or touching down
- Repeat for each of the three directions, alternating legs for direction
- 3 attempts each direction, > or equal 4cm difference denotes risk
- can express each reach as a percentage of leg length: reach distance divided by
leg length (greater trochanter to lateral malleolus) ) x100.
- Composite reach distance is sum of 3 reaches divided by 3x leg length multiplied
by 100. Less than or equal to 94% composite score is high risk. (Plisky et al, 2006,
2009)
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Single Leg Bridges
Subjects lie supine on the floor with one heel on a box or plinth 60 cm high. The knee of the test leg is
slightly bent at 20 degrees and the opposite leg is bent to 90 degrees hip and knee flexion with their arms
crossed over their chest. Hips are elevated until working leg is straight. Repeat as many times as possible
until the subject is unable to bridge to the original height. (Freckleton et al, 2013)
Calf Raises
Subjects stand on one foot on the edge of a step and perform a calf raise through full range of motion.
Calf raises are performed through full range of motion. Calf raises are performed at 1 rep every 2 sec. The
test concludes when subjects are unable to move through full range or cannot keep up with cadence
Side Bridge Endurance Test
Subjects lie on an exercise mat on their side with legs extended. The top foot is placed in front of the
lower foot, then subjects lift their hips off the mat to maintain a straight line over their full body length
for as long as able. The test ends when they cannot keep straight. (McGill et al, 1999)
Single Leg Press
Seat position at 90 degrees to the side and the foot should be placed so that the hip is flexed to 90
degrees. A valid repletion is where the weight is lowered to a depth of 90 degrees knee flexion and then
extended back to full extension. 1.8 x body weight Males, 1.5x body weight (sled + weight) Females
Carioca
Quickly side step with lead leg followed by trail leg crossing in front of the lead on the first step and then
behind on the second step for a straight distance of 30 feet and immediately reverse the direction to
cover the same distance in the shortest possible time.
Tuck Jump
Feet should be positioned shoulder width apart and the athlete will be asked to repeatedly jump for 10
seconds, pulling their thighs up parallel to the ground, while the clinician scores the quality of the
performance for each of the 8 categories by circling a number on a scale from 0 (never) to 10 (always).
The scores in each category are summed to provide the total for the assessment (out of 80). Two trials
can be performed (one viewing from front and one from side) to attain scores for all 8. A horizontal line of
tape can be used as the target for jumping and landing in the same location.
Hop Tests x 4
General: Running shoes are to be worn.
1. Perform tests in the order they appear.
2. One practice trial is given for each limb. Two measurements are taken and the average
is recorded.
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No restrictions are given on arm movement.
Begin with non-operated leg.
Two alternating trials on both limbs are measured and means for each are recorded
Start with lead toe behind marked line.
7. Measurement is taken to either the nearest 10th of a second (stopwatch) or
nearest 10th of a centimetre (measuring tape).
3.
4.
5.
6.
8. A failed jump consists of loss of balance, touching the floor with arms or opposite
leg, or an additional short hop on landing.
9. To calculate "Limb Symmetry Index" values, average the two-recorded trials on each
limb; divide the operative limb average by the non-operative limb average, and
multiply by 100 (percentage). Once "Limb Symmetry Index" values are calculated for
each of the 4 hop tests, the average of these is taken for the "Overall Combination"
score. < 85 % considered abnormal.
1. Single leg hop for distance
Stand on one limb and hop as far forward as possible, landing on the same limb.
Maintain the landing for a minimum of 2 seconds while the toe measurement is
recorded. (measured to the nearest cm)
2. Single leg 6 m timed hop
Perform large one-legged hops in series over 6 metres. (timed to nearest 10th of a second)
3. Triple hop for distance
Perform 3 successive hops as far as possible and land on the same leg. Maintain the
final landing for a minimum of 2 seconds while the toe measurement is recorded.
(measured to nearest 10th of a cm)
4. Crossover hop for distance
Perform 3 hops as far as possible crossing over a 15cm wide strip marking on each
hop and maintain landing after the 3rd hop for 2 seconds. The first of the 3 hops is
lateral with respect to the direction of the crossover. (measured to the nearest 10th
of a cm)
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Single Leg 8-inch Jump Landing
Stand on one leg and perform a jump landing off a 8-inch box. The landing must be
held for 5 seconds with balance maintained. The entire sequence is to be completed
with good mechanics, including proper landing stance, knees flexed and in line with
foot, level pelvis, and vertical alignment of trunk.
Single Leg Vertical Jump for Height
Stand sideways on one leg, unsupported, next to a wall. Bend your knees and jump as
high as possible, tap your hand on the wall at the maximum vertical height. One practice
trial is given for each limb. Perform two alternating trials on the unaffected and affected
sides. The vertical height is measured and the averages recorded for the L and R legs.
Single Leg Hop onto Bosu
Stand facing bosu on one leg, unsupported. Hop onto round side of bosu and hold for 5
seconds x 5 repetitions. Assess for form and technique for both L and R legs.
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Modified Vail Sports Test (strength, muscular endurance and power) – 4 components (
Garrison et al, 2012)
General:
- each component tested once
- total of 20 points , where 17/20 or 85% is a pass
- no point after 3 verbal feedbacks on incorrect patterns
- 2.5 minute break after each component
1.) Single Leg Squat (3 mins)
Perform each rep at a cadence of 1 sec up and 1 sec down between 30 - 60 degrees knee
flexion. Score 1 point per 30 seconds, comment on test ending due to form, pain or
endurance. Thick tubing on thigh perpendicular to motion.
2.) Lateral Hopping (90 sec)
Perform lateral hops, jumping from one leg to the other, leg length distance apart
(measured from greater trochanter to ground). Score 1 point per 15 seconds. Tubing
around waist.
3.) Forward and Backward Jogging (2 mins)
Perform both forward and backward jogging on the spot. Score 1 point per 30 seconds.
Tubing around waist.
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Stroke Test (effusion)
(Circle one)
(Sturgill et al, 2009)
Zero
Trace
(small wave medial
side with down
stroke)
Hold/progress
1+
(large bulge medial
side with down
stroke)
2+
(effusion spontaneously
returns to medial side)
3+
(so much fluid not
possible to move
effusion)
Leg
Circumference
3’ and 6 ‘ PFJ
Non Operative (R / L)
Operative (R /L)
Hold/progress
Knee range
Non Operative (R / L)
Operative (R / L)
Hold/progress
Flexion
Extension
Flexion
Extension
Lag (yes / No)
SLS Squat
Non Operative ( R / L)
Operative ( R / L)
Hold/Progress
Good
Good
Fair
Fair
Poor
Poor
1.) Maintain balance, while squatting to at least 60 degrees
2.) No trunk movement (lateral deviation, rotation, LF or excess forward flexion)
3.) No hip adduction or internal rotation
4.) No knee valgus and knee remains over centre of foot
5.) Smooth and controlled through whole movement
(Crossley et al, 2011)
SLS Balance
Eyes closed
(sec)
Left
1.
Right
2.
1.
Hold/progress
LSI
2.
Time ends when:
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mean
- Arms are used (uncrossed)
- Use of raised foot (touches
ground or other leg)
- Movement of stance foot
sec
sec
%
- 45 sec has elapsed
- Eyes open
Abnormal if less than 85%, normative data for 18-39 year olds 43 sec EO, 9 sec EC (Springer et al, 2007)
Hold/progress
Y Balance
Left
Right
LSI
Anterior
posteriormedial
posteriorlateral
Total:
- Best of 3 trials each
- ≥4cm L-R diff, ≤94% significant
injury risk.
Left
Right
Single Leg
Bridges
Reps:
Reps:
Calf Raises
Reps:
Reps:
Single Leg
Press
(pt. may need
to test in gym)
Weight:
Weight:
LSI
(Freckleton et al,
2013)
Bodyweight =
1.8x Male for 1RM
1.5x Female for 1RM
Calculate 1 RM from 5 RM: (5 reps x .033) + 1 x (weight in lbs lifted) = approx 1RM
Hold/progress
Carioca (Agility Drill)
Compensatory movements?
NO
YES
Adequate speed/patterning?
NO
YES
Apprehension?
NO
YES
Complaints of pain?
NO
YES
(hip hike, knee F in air, altered weight bearing)
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Comments:
10 Second Tuck Jump (plyometric drill) (Myer, 2006)
Knee and Thigh Motion
1. knees neutrally aligned at landing
0 1 2 3 4 5 6 7 8 9 10
2. thighs reach parallel (observed at highest
point of jump)
0 1 2 3 4 5 6 7 8 9 10
3. Thighs equal side-side (throughout
sequence)
0 1 2 3 4 5 6 7 8 9 10
Hold/Progress
SCORE
Foot Position
4. Foot placement shoulder width apart
0 1 2 3 4 5 6 7 8 9 10
5. Foot placement not staggered (side view)
0 1 2 3 4 5 6 7 8 9 10
6. Toe to mid foot rocker utilized (no heel
strike)
0 1 2 3 4 5 6 7 8 9 10
Plyometric Technique
7. Rapid rebound between jumps (no visible
delay)
0 1 2 3 4 5 6 7 8 9 10
8. Lands same footprint (from point of take
off)
0 1 2 3 4 5 6 7 8 9 10
Total For Assessment
Hop Testing (Reid, 2007)
/80
Hold/progress
Single Hop For Distance
Non Operative limb
(cm)
Operative (cm)
1.
1.
2.
LSI
2.
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6 m Timed Hop
Non Operative limb
(cm)
Operative (cm)
1.
1.
2.
LSI
2.
Triple Hop For Distance
Non Operative limb
(cm)
Operative (cm)
1.
1.
2.
LSI
2.
Cross Over Hop For Distance
Non Operative limb
(cm)
Operative (cm)
1.
1.
2.
LSI
2.
Single Leg 8 inch Jump Landing
Able to land with 5 sec hold
Yes
No
Good body mechanics? (ball-midfoot landing,
knees flexed, pelvic level, trunk midline
Yes
No
Complaints of pain?
Yes
No
Vertical Jump For height (cm)
Trial 1 / 2
Trial 1 / 2
Non-operative limb (R / L)
/
/
Operative Limb (R / L)
/
/
Single Leg Bosu Hop
Yes
Average height
Progress/Hold
No
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Able to land with 5 sec hold
Good Body Mechanics/Position
No complaints of pain?
Comments:
Modified Vail Sports Test
If patient repeats error on 3 consecutive repetitions after correction, they do not receive a point for
that particular segment/time frame. Test ends when patient cannot continue or form is incorrect.
1 point for every 30s for SL squat, 1 point every 15 s for lateral bound. 1 point every 30 s for running
tests.
Single Leg Endurance Squats (goal: 3 min)
1.) Knee Flexion angle between 30 and 60
Yes
No
2.) Patient performs without dynamic knee valgus
Yes
No
3.) Patient avoids locking knee during extension
Yes
No
4.) Patient avoids patella extending past the toe during knee
flexion
Yes
No
5.) Patient maintains upright trunk during knee flexion
Yes
No
30 s
Total Points
30s-60s
1’-1’30’’
1’30-2”
2’-2’30”
2’30”-3’
/6
Lateral Bounding (goal: 90 sec) - Length of bound is half of body height
1.) Knee flexion angle is 30 or greater when landing
Yes
No
2.) Patient performs without dynamic knee valgus
Yes
No
3.) patient performs within landing boundaries
Yes
No
4.) Landing phase does not exceed 1 second in duration
Yes
No
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5.) Patient maintains upright trunk during knee flexion
Yes
0-15”
Total Score /6
15”-30”
30”-45”
45”-60”
60”-75”
75”-90”
No
Forward Jogging (goal: 2 mins)
1.) Knee flexion angle between 30 and 60
Yes
No
2.) patient performs within landing boundaries
Yes
No
3.) Patient performs without dynamic knee valgus
Yes
No
4.) Patient avoids locking knee during extension
Yes
No
5.) Landing phase does not exceed 1 second in duration
Yes
No
6.) Patient maintains upright trunk during knee flexion
Yes
No
30”
30”-60”
60”-1’30”
1’30”-2’
Total points
/4
Backward Jogging (goal: 2 min)
1.) Knee flexion angle between 30 and 60
Yes
No
2.) patient performs within landing boundaries
Yes
No
3.) Patient performs without dynamic knee valgus
Yes
No
4.) Patient avoids locking knee during extension
Yes
No
5.) Landing phase does not exceed 1 second in duration
Yes
No
6.) Patient maintains upright trunk during knee flexion
Yes
No
30”
Total points
30”-1’
TOTAL OVERALL
1’-1’30”
/20
1’30”-2’
/4
(17/20 is 85%)
Physiotherapist/Assessor Comments:
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