Think outside the box: Incorporating secondary cognitive tasks into return to sport testing after ACL reconstruction

Chaaban, Courtney R.; Turner, Jeffrey A.; Padua, Darin A. · 2023 · DOAJ

DOI: 10.3389/fspor.2022.1089882

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Summary

This mini-review addresses the limitations of current return-to-sport (RTS) testing protocols following anterior cruciate ligament reconstruction (ACLR). The authors highlight a critical disconnect: while RTS test batteries are widely used to determine athlete readiness, they fail to replicate the cognitive demands inherent in sport, such as dividing attention between motor tasks and environmental stimuli. Consequently, many athletes who pass these tests still sustain secondary ACL injuries or fail to return to their pre-injury level of play. The paper argues that incorporating secondary cognitive tasks into functional RTS testing is necessary to better simulate sport-specific scenarios and identify athletes at risk for re-injury. The authors review literature on three common functional RTS tests: the drop vertical jump, single-leg hop tests, and cutting tasks. They critique current assessments for focusing primarily on motor performance metrics (e.g., distance, time) which have limited correlation with injury-related biomechanics. Instead, the review advocates for assessing movement quality using tools like the Landing Error Scoring System (LESS) and the Cutting Movement Assessment Score (CMAS), which evaluate high-risk biomechanical patterns such as knee valgus and abduction moments. The authors propose a framework where RTS testing integrates cognitive dual-tasks, requiring athletes to perform motor skills while engaged in cognitive challenges, such as virtual reality simulations or attentional tasks like the Stroop test. Key findings indicate that worse cognitive performance, including slower reaction times and processing speed, is associated with higher-risk biomechanical loading patterns consistent with ACL injury mechanisms. Studies cited show that adding cognitive loads or virtual reality environments to jump and landing tasks results in increased vertical ground reaction forces, reduced knee flexion at initial contact, and increased knee abduction angles. These alterations mimic the biomechanics observed during actual ACL injuries. Furthermore, the review notes that current RTS batteries do not significantly reduce the risk of secondary ACL injury, suggesting that standard tests lack the specificity to discriminate safe from unsafe movement strategies under sport-like conditions. The significance of this work lies in its recommendation to shift RTS testing from purely physical performance assessments to comprehensive evaluations that include cognitive-motor dual tasks. By integrating cognitive demands, clinicians can better replicate the sport-specific environments that load the ACL to failure. The authors conclude that future RTS protocols should measure cognitive performance, movement quality, and motor performance concurrently. This approach aims to identify athletes who may compensate for physical deficits with altered, high-risk biomechanics when distracted, thereby improving the predictive validity of RTS testing and potentially reducing secondary injury rates.

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