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General Discussion1799Adding to the biological, mechanical and neurogenic consequences, ACL injury has a major impact on psychological wellbeing.42 In Chapter 8 we showed that ACL-injured patients have low knee self-efficacy, poor psychological readiness to return to sports and low subjective knee function. This is recognised by many others too. A review of literature by Bullock et al. demonstrated high levels of kinesiophobia, low knee selfefficacy and high levels of fear avoidance in ACL-injured patients.3 The results presented in this thesis emphasise that it is not just the knee we have to take into account – a more holistic approach may be needed to treat ACL-injured patients. In the treatment of ACL-injured patients it is essential to understand the above-mentioned pathways, and physicians need to be aware that ACL reconstruction is only a small part of the puzzle to enhance return to sports. As demonstrated by this thesis, the currently available reconstruction techniques seem unable to recreate a pre-injury state in many patients. With the available reconstruction techniques, the influence of biological, neuromuscular and psychological factors may be just if not as important as the actual surgical reconstruction itself to achieve pre-injury level of knee function. The power of dynamic testingDynamic rotation is a different construct than passive rotation because in the dynamic setting muscle tension, neuromuscular interaction and psychological aspects influence the range of tibial rotation. Therefore, in our view measuring rotation in a dynamic setting is more clinically relevant than measuring rotation in a passive setting. To understand why patients are unable to return to sports, it is essential to evaluate patients in sportspecific circumstances. Several tasks have been used in the past to evaluate knee kinematics after ACL reconstruction, for example a 60° cut,37 stepping off stairs32 and jumping from platforms.6 Knee flexion torques are often unreported, but some earlier studies report values varying from 0.2 to 2 Nm/kg.24,34,37 In this thesis we showed that while using a forward hop and a side jump, the knee flexion torque is up to 6 Nm/kg. This amount of force may be better Mark Zee.indd 179 03-01-2024 08:56