Redefining the Paradigm: Advancing Evidence-Based Return-to-Sport Criteria Following Isolated Posterior Cruciate...

Acute posterior cruciate ligament (PCL) injuries occur during high-impact sports including American Football, soccer, and skiing. While many of these injuries can be managed nonsurgically, surgery is necessary in some cases, particularly in cases of instability. Clear and standardized return-to-sport (RTS) criteria during rehabilitation following PCL reconstruction (PCL-R) are lacking.

This scoping review aims to identify and analyze existing RTS guidelines for PCL-R and propose improvements on the basis of frameworks from anterior cruciate ligament reconstruction, laying the groundwork for future research.

Following the PRISMA-ScR guidelines, studies were included if they evaluated RTS criteria after isolated PCL-R in adult athletes. The search strategy involved a three-step approach, including initially limited searches, keyword identification, and a final comprehensive search of five electronic databases (MEDLINE, Embase, CINAHL, SCOPUS, and PEDro). The inclusion criteria encompassed studies involving athletes aged > 18 with isolated PCL-R. Exclusion criteria were studies involving multi-ligament injuries, revision surgeries, or nonEnglish publications.

A total of 13 studies met the inclusion criteria, reporting diverse RTS criteria. RTS timelines were mentioned in four studies (31%), generally ranging from less than 6 up to 12 months. Clinical criteria, including range of motion (ROM) and pain, were reported in eight studies (63%). Full knee extension and near-complete flexion recovery were generally required before RTS, although specific flexion thresholds were not consistently defined. In addition, the absence of pain or the presence of only minimal pain was commonly expected before clearance. Strength assessments were included in five studies (38%), and were frequently assessed via isokinetic testing, with only one study adopting a limb symmetry index (LSI) ≥ 90% as a clearance criterion. Performance criteria, such as hop tests, were used in four studies (31%), often employing a LSI threshold of over 90%. Patient-reported outcome measures (PROMs) were assessed in 11 studies (85%). Scores such as the IKDC and Lysholm demonstrated significant postsurgical improvements, often exceeding 90 and 85, respectively, at the time of RTS.

This review highlights the absence of standardized RTS criteria following PCL-R. Clinicians should consider integrating objective criteria when assessing RTS, including full ROM recovery, minimal or no pain, quadriceps and hamstring strength symmetry of ≥ 90% LSI, performance-based tests such as hop tests (commonly using an LSI > 90%), and PROMs (e.g., IKDC > 90, Lysholm > 85).