What hop tests, step counts and PROs actually tell you after ACL surgery

You already know the RTS conversation runs on three currencies: hop-test symmetry, patient-reported outcomes and, increasingly, whatever the phone in the patient's pocket recorded this week. The honest headline is that the evidence connecting them to outcomes after ACL reconstruction is still thin — a handful of recent studies, most of it associative, and none of it yet a decision rule.

Hop symmetry is associated with RTS, not with reinjury protection

Liu et al. (2026) included 43 studies involving 17,350 participants and found that achieving a limb symmetry index ≥90% in the single-leg hop for distance (OR = 1.20, 95% CI: 1.09 to 1.33) or triple crossover hop for distance (OR = 1.18, 95% CI: 1.02 to 1.36) was associated with a higher probability of return-to-sport. That is an association, not a guarantee — the authors graded the certainty of evidence as low.

The reinjury side of the ledger is less useful. LSI ≥90% in the triple hop was associated with increased odds of reinjury in the same meta-analysis (OR 1.05, 95% CI 1.01–1.09), and the authors state plainly that distance-based hop performance alone may be insufficient to predict reinjury risk. Subgroup analyses showed stronger RTS associations in studies with >90% hamstring autografts (OR 1.64) and in individuals without meniscal injury (OR 1.39).

In that meta-analysis, hop symmetry was a return-to-sport signal but not a reinjury screen — passing a distance hop test should not be sold to the patient as protection.

The phone is measuring something real

Kandakurti et al. (2026) took a cross-sectional look at 120 adults 3–12 months after primary reconstruction and found higher daily step counts were independently associated with better KOOS-ADL scores (β = 0.48), higher ACL-QoL scores (β = 0.45) and lower pain intensity (β = −0.39), with adjustment applied. Three recovery phenotypes emerged — high-activity/low-pain, moderate/moderate, and low-activity/high-pain with greater pain catastrophizing — with significant gradients across them for pain, function and catastrophizing (all p < 0.001).

Note the direction of inference: this is simultaneous measurement, so steps tracking pain and function does not mean steps drive recovery. The authors themselves flag uncontrolled surgical factors and variable evaluation windows. Still, as a cheap concurrent signal between consultations, it is hard to ignore — a low-activity/high-pain pattern is exactly the patient who warrants an earlier call.

PROs after repair, and timing

In Egert et al. (2026), 80 of 93 patients with proximal ACL tears treated with suture augmentation were available for follow-up; after excluding the 13 who underwent revision surgery, median outcomes for the remaining 67 at a median follow-up of 79 months were: IKDC 94, Lysholm 92, and Forgotten Joint Score 86. The authors note a 16.3% revision rate remains clinically relevant. Delayed surgery was the only independent predictor of lower postoperative Tegner activity scores (β = −0.79, P = .025). That timing finding — in that repair population, not reconstruction — argues for flagging delayed presentations early.

In Few et al.'s systematic review of professional athletes, medial meniscal tears had higher failure and secondary meniscectomy rates than lateral tears, especially with all-inside repair techniques, while inside-out and suture-hook techniques appeared more favorable for medial-sided pathology. Jackson et al.'s (2026) narrative review reports return-to-sport rates of ~65% to 73% at three years, higher (83–90%) in elite and high-school athletes. And in Sheoran et al.'s (2026) randomized study of 44 patients, accelerated rehabilitation produced no significant early differences and similar functional outcomes by 9 months compared with conventional protocols. Context, not conclusions.

What this changes on Monday

Keep LSI ≥90% in the single-leg and triple crossover hops for distance as one RTS signal — but frame the reinjury question around factors the tests cannot see, since the authors conclude that distance-based hop performance alone may be insufficient to predict it. Treat daily step counts as a concurrent signal: in Kandakurti et al.'s cross-sectional study, the low-activity/high-pain phenotype had poorer outcomes. And when a proximal tear presents late, say so in the plan — in Egert et al.'s repair cohort, delayed surgery was the only independent predictor of lower activity scores.

Between consultations, PhysioSync's Smart Alerts can flag persistent high pain or low adherence for your review, so you decide when an earlier check-in is warranted.