Cognitive-motor testing for ACL return to sport means adding a thinking or reaction task to the physical tests used to clear an athlete. The goal is to see how the knee performs when the athlete is also reacting, deciding, or watching something, as in real sport. Most clearance batteries today test strength and hopping with no added mental load.
Why do researchers want cognitive load in return-to-sport testing?
Chaaban (2023) pointed out that many ACL injuries happen while an athlete is doing a dual cognitive-motor task, yet most functional tests lack cognitive load. Grooms (2023) made a related point. Return-to-sport testing quantifies physical function but can fail to detect important neural compensations. Earlier brain research fits that picture. Grooms (2017) described how knee motor control shifts toward greater reliance on visual processing after ACL reconstruction.
None of these papers says a specific device is needed. They say the standard test setup leaves out a piece of what sport demands.
What does the standard battery miss?
Strength testing still carries most of the weight. Calkins (2026) reviewed 53 U.S. academic ACL reconstruction protocols and found strength requirements in 79.2% of them. Hop tests are the other common tool, and they have limits. Kotsifaki (2022) found that athletes could reach 97% symmetry in triple hop distance while knee work generation symmetry was only 51% and 66% in the two rebound phases. Fältström (2023) followed 117 female football players after reconstruction. Those who went on to a primary or second ACL injury had jumped farther and hopped more at baseline, not less.
Each of these tests asks a planned, single-task question. Cognitive-motor testing asks a different one: can the athlete move well when the next move is not known in advance.
What does a cognitive-motor test look like in a clinic?
The simplest version adds a reaction task to something the patient already does. A cue appears, the athlete picks the correct target, and the clinician records response time and accuracy for each leg. Good setups share a few features:
- The cue is unpredictable, so the athlete cannot rehearse the movement.
- The athlete stands at full body weight, not seated or on one machine.
- Left and right sides are scored separately.
- Results are saved, so the same test can be repeated across rehab.
How does QuickBoard fit?
QuickBoard is a sensor board that pairs with an iPad. The Agility Rating is a composite score from 0 to 10,000 built from four scored exercises, and it takes under two minutes. It reports reaction results for each leg, a symmetry summary, and a radar chart across five dimensions. A clinic can run it alongside strength and hop testing during the terminal phase of rehab and again before the clearance conversation. Repeating it gives a trend, not just a single reading.
The papers above support the case for adding cognitive load to testing. They did not test QuickBoard. The Agility Rating is one way to add that load and keep a record of it.
Billing: the Agility Rating bills under CPT 97750 (Physical Performance Test), in 15-minute increments, and is not billable on eval or re-eval days. Check payer rules for your clinic.
Takeaways
- Cognitive-motor testing adds a reaction or decision task to return-to-sport testing (Chaaban 2023, Grooms 2023).
- Strength requirements appear in 79.2% of reviewed U.S. academic ACL protocols (Calkins 2026).
- Hop symmetry can look normal while knee function is not (Kotsifaki 2022).
- Pick a reactive test with unpredictable cues, full body weight, per-leg scoring, and saved results.
See the Agility Rating, the Ortho Rehab and ACL Return to Sport use case, and related posts on strength-only clearance, limb symmetry and second injury, symmetry scores that rise without knee gains, force plate testing, and how ACL injury affects the brain.
Citations
- Calkins 2026
- Chaaban 2023
- Grooms 2023
- Grooms 2017
- Faltstrom 2023
- Kotsifaki 2022
See QuickBoard research for full citation details.