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Saburi L, Piri E, Jafarnezhadgero A, JabarAli M. A Multidimensional Model for Return to Sport Decision-making After Anterior Cruciate Ligament Reconstruction. jrehab 2026; 27 (1) :58-71
URL: http://rehabilitationj.uswr.ac.ir/article-1-3789-en.html

Objective Return to sport (RTS) after anterior cruciate ligament reconstruction (ACLR) is commonly guided by time-based milestones and isolated functional pass/fail criteria. However, many athletes return with persistent biomechanical deficits that can increase the risk of reinjury and contribute to long-term joint degeneration. This study aims to synthesize time-specific changes in gait and running biomechanics at 6, 12, and 18 months after ACLR, and to propose an integrated, multidimensional RTS decision-making model that links rehabilitation fidelity with serial biomechanical assessment. We critically discuss whether the injury-to-surgery time (early vs delayed) may influence locomotor recovery trajectories.
Materials & Methods This is an editorial review. Evidence from the ACLR rehabilitation and biomechanics literature is reviewed narratively to summarize task-dependent recovery patterns in gait and running and to highlight the limitations of conventional RTS batteries. Based on this synthesis, two practical tools are presented: (i) a milestone-based table of gait and running biomechanical deficits at 6, 12, and 18 months post-surgery, and (ii) a multidimensional RTS decision-making framework integrating three domains of clinical, functional/neuromuscular, and biomechanical readiness.
Results Biomechanical recovery after ACLR appears nonlinear and task-specific. Gait parameters may be normal up to 12 months, whereas running mechanics, frontal-plane control, limb-loading symmetry, and neuromuscular coordination can remain impaired beyond this time. Athletes may therefore pass hop or strength symmetry thresholds while still demonstrating compensatory landing strategies, reduced knee extensor contribution, trunk/pelvic compensations, or persistent underloading of the surgical limb features associated with increased reinjury risk. Serial gait and running analyses at 6, 12, and 18 months post-surgery can help identify early protective strategies, detect deceptive recovery at mid-term follow-up, and reveal residual high-demand deficits at later stages (e.g. under speed, fatigue, and cutting). The literature on early versus delayed ACLR remains mixed, underscoring the need for more granular, time-specific evaluation of who benefits from differences in post-surgical time.
Conclusion Successful RTS after ACLR should be viewed as a continuum rather than a single clearance event. Time since surgery is necessary but insufficient. For RTS decision-making, it should integrate clinical status, psychological readiness, strength and sensorimotor recovery, movement quality, and sport-specific performance, with gait and running biomechanics serving as a clinically meaningful bridge between progression in anterior cruciate ligament rehabilitation and safer RTS decision-making.