Combining neurocognitive and functional tests to improve return-to-sport decisions following ACL reconstruction

Review written by Dr Christina Le info

Key Points

  1. Similar to changes in physical function, changes to the central nervous system also occur after an ACL injury or surgery.
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At the end of every athlete’s recovery journey following an anterior cruciate ligament (ACL) reconstruction, is a battery of return to sport (RTS) testing. Typically, these RTS tests evaluate criteria like muscle strength, function (e.g., hop tests), and self-reported function (e.g., knee confidence). The objective of these RTS tests is to identify individuals who may be at increased risk of a second ACL injury. Pass the tests and gradually resume full sports participation or don’t pass the tests and work on improving those weaknesses.

But just as the quadriceps muscles change after an ACL injury or surgery, so does the brain! Individuals who undergo ACL reconstruction have been shown to shift toward using more visual-motor rather than sensory-motor strategies to engage in knee movement (1). It is quite common to observe patients thinking hard about movement patterns (e.g., walking, squatting, jumping) that were previously automatic.

The authors of this viewpoint describe this concept of spending more attention on movements as “neurocognitive reliance” and argue that clinicians should integrate neurocognitive tasks into RTS testing.

The objective of these return to play tests is to identify individuals who may be at increased risk of a second ACL injury.
Dual tasks are meant to distract from or challenge proprioception while asking a patient to make task-relevant decisions.


In theory, every individual has a motor reserve and cognitive reserve, and these reserves work together when executing physical tasks. Following ACL reconstruction, patients exhibit decreased motor reserves (e.g., reduced quadriceps torque) which subsequently places higher demands on cognitive reserves

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