The Role of Psychological Readiness in Return to Sport Assessment After Anterior Cruciate Ligament Reconstruction

Abstract

Background: Knowledge about the predictive value of return to sport (RTS) test batteries applied after anterior cruciate ligament reconstruction (ACLR) is limited. Adding assessment of psychological readiness has been recommended, but knowledge of how this affects the predictive ability of test batteries is lacking. Purpose: To examine the predictive ability of a RTS test battery on return to preinjury level of sport and reinjury when evaluation of psychological readiness was incorporated. Study Design: Cohort study; Level of evidence, 2. Methods: A total of 129 patients were recruited 9 months after ACLR. Inclusion criteria were age ≥16 years and engagement in sports before injury. Patients with concomitant ligamentous surgery or ACL revision surgery were excluded. Baseline testing included single-leg hop tests, isokinetic strength tests, the International Knee Documentation Committee (IKDC) Subjective Knee Form 2000, a custom-made RTS questionnaire, and the Anterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI) scale. The RTS criteria were IKDC 2000 score ≥85% and ≥85% leg symmetry index on hop and strength test. At a 2-year follow-up evaluation, further knee surgery and reinjuries were registered and the RTS questionnaire was completed again. Regression analyses and receiver operating characteristic analyses were performed to study the predictive ability of the test battery. Results: Out of the 103 patients who completed the 2-year follow-up, 42% returned to their preinjury level of sport. ACL-RSI 9 months after surgery (odds ratio [OR], 1.03) and age (OR, 1.05) predicted RTS. An ACL-RSI score <47 indicated that a patient was at risk of not returning to sport (area under the curve 0.69; 95% CI, 0.58-0.79), with 85% sensitivity and 45% specificity. The functional tests did not predict RTS. Six patients sustained ACL reinjuries and 7 underwent surgery for other knee complaints/injuries after RTS testing. None of the 29 patients who passed all RTS criteria, and were therefore cleared for RTS, sustained a second knee injury. Conclusion: ACL-RSI and age were predictors of 2-year RTS, while functional tests were not informative. Another main finding was that none of the patients who passed the 85% RTS criteria sustained another knee injury.

Association Between Psychological Readiness and Knee Laxity and Their Predictive Value for Return to Sport in Patients With Anterior Cruciate Ligament Reconstruction

“…As previous studies have presented a lack of predictive value of commonly used functional tests on sports resumption, there is a need for further research to explore other possible factors that may affect ability to RTS. 22 Our results suggest that measurements of knee laxity and psychological readiness have a place in RTS assessments. So far, monitoring of psychological responses does not seem to be an integrated part of today's rehabilitation programs.…”

“…6,32 The explanation for this difference might lie in the relatively large proportion of middle-aged patients returning to recreational sports in the current cohort, as returning to leisure activity may be more feasible than returning to competitive sports. 22 No association between knee laxity and sports resumption has been reported in previous cross-sectional studies, and the overall evidence for the predictive value of knee laxity testing has been sparse. 6,7,31,32 The IKDC 2000 knee evaluation system includes assessment of several domains to describe knee impairment, and categorizes function from category A (normal) to D (abnormal).…”

“…The project-specific activity questionnaire registers the type and level of preinjury activity/sport and the RTS goals. 22 Furthermore, the status on returning to sport and achieving goals is reported. Level of participation is categorized as elite, high, or medium level of competition, low level of competition, or recreational level.…”

Relationships Between Physical Function and Psychological Readiness to Return to Sport After Anterior Cruciate Ligament Reconstruction

“…Only ACL-RSI score at 6 months was included in the nal model, and an ACL-RSI score ≥60 out of 100 at the 6-month follow-up was the most in uential predictor of a return to the preinjury sport as of the 2-year follow-up 51 . In recent years, inclusion of the ACL-RSI score in criteria for the return to sport has been recommended [2][3][4]12,44,51,58 .…”

“…Only ACL-RSI score at 6 months was included in the nal model, and an ACL-RSI score ≥60 out of 100 at the 6-month follow-up was the most in uential predictor of a return to the preinjury sport as of the 2-year follow-up 51 . In recent years, inclusion of the ACL-RSI score in criteria for the return to sport has been recommended [2][3][4]12,44,51,58 .Information about speci c factors of physical function that contribute to psychological readiness is needed to plan the rehabilitation for returning to sports. Two previous studies have revealed factors of psychological readiness from objective variables of physical function 1,61 .…”