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Psychological Readiness to Return to Sport Is Associated With Second Anterior Cruciate Ligament Injuries
Abstract
Background: Psychological responses after anterior cruciate ligament (ACL) injury and ACL reconstruction (ACLR) have been identified as predictors of return to sport but have not been investigated in relation to further injury. Purpose/Hypothesis: To determine whether psychological readiness to return to sport is associated with second ACL injury. It was hypothesized a priori that at both preoperative and 12-month postoperative time points, patients who sustained a second ACL injury would have lower psychological readiness than patients who did not have a second injury. Study Design: Cohort study; Level of evidence, 2. Methods: Patients who had a primary ACLR procedure between June 2014 and June 2016 completed the ACL–Return to Sport after Injury (ACL-RSI) (short version) scale before their ACLR and repeated the scale at 12 months after surgery to assess psychological readiness to return to sport. Patients were followed for a minimum of 2 years (range, 2-4 years) after surgery to determine further injury. The primary outcome was the relationship between ACL-RSI scores and the incidence of second ACL injury. Results: In 329 patients who returned to sport after ACLR, 52 (16%) sustained a second ACL injury. No difference in psychological readiness was observed at the preoperative time point, but patients who sustained a second injury trended toward lower psychological readiness at 12 months compared with noninjured patients (60.9 vs 67.2 points; P = .11). Younger (≤20 years) patients with injury had significantly lower psychological readiness to return to sport than young noninjured patients (60.8 vs 71.5 points; P = .02), but no difference was found in older patients (60.9 vs 64.6 points; P = .58). In younger patients, receiver operating characteristic curve analysis revealed a cutoff score of 76.7 points with 90% sensitivity to identify younger patients who sustained a second ACL injury. Conclusion: Younger patients with lower psychological readiness are at higher risk for a second ACL injury after return to sport.
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48% of participants had unacceptable ACL-RSI scores based on the cutoff of 77.
“Overall, nearly half (48%) of participants indicated unacceptable ACL-RSI scores based on the cutoff of 77 reported by McPherson et al.”
From The relationship between psychological readiness to return to sport and kinesiophobia in teens and young adults after anterior cruciate ligament reconstruction (2025) · cites this paper as McPherson et al., 2019
The ACL-RSI cutoff of 77 was chosen because a score of 77 demonstrated 90% sensitivity in identifying those who went on to suffer a second ACL injury.
“This cutoff was chosen by the work of Mcpherson et al. who reported that a score of 77 points on the ACL-RSI demonstrated 90% sensitivity in identifying those who went on to suffer a second ACL injury (McPherson et al., 2019).”
From The relationship between psychological readiness to return to sport and kinesiophobia in teens and young adults after anterior cruciate ligament reconstruction (2025) · cites this paper as McPherson et al., 2019
Lower psychological readiness at the time of return to sport is associated with a higher risk of recurrent ACL injuries in athletes aged 20 years and younger, while no such relationship has been reported in athletes over the age of 20.
“Moreover, lower psychological readiness at the time of RTS has been associated with a higher risk of recurrent ACL injuries in athletes aged 20 years and younger, while no such relationship has been reported in athletes over the age of 20 (McPherson et al., 2019).”
From The relationship between psychological readiness to return to sport and kinesiophobia in teens and young adults after anterior cruciate ligament reconstruction (2025) · cites this paper as McPherson et al., 2019
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Cited by
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Butler, L., Baez, S., Walker, C., Roman, D., Douthit, T., Kuenze, C., Ulman, S., & ARROW (2025) · Frontiers in Psychology · doi:10.3389/fpsyg.2025.1623398 · Cited by 9
Petushek, E., Harkey, M. S., Santiago, K., Stamm, A., Baez, S., Diekfuss, J. A., Myer, G. D., & Kuenze, C. (2025) · Physical Therapy in Sport · doi:10.1016/j.ptsp.2025.08.004 · Cited by 5
Metadata
- Authors
- McPherson, A. L., Feller, J. A., Hewett, T. E., & Webster, K. E.
- Affiliations
- Mayo Clinic (US)
- Epworth Hospital (AU)
- La Trobe University (AU)
- Corresponding author
- Webster, Kate E.
- Venue
- The American Journal of Sports Medicine
- Publisher
- SAGE Publications
- Published
- 2019-02-12
- Volume
- 47
- Issue
- 4
- Pages
- 857-862
- ISSN
- 0363-5465 (ISSN-L)
- 1552-3365
- OpenAlex
- W2914883240
- Cited by
- 269
- References
- 0
- Citations by year
- 2026: 34 · 2025: 45 · 2024: 37 · 2023: 40 · 2022: 40 · 2021: 33 · 2020: 29 · 2019: 10
- FWCI
- 26.41
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- The American Journal of Sports Medicine (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Surgery › Knee injuries and reconstruction techniques
- Health Sciences › Medicine › Orthopedics and Sports Medicine › Sports injuries and prevention
- Social Sciences › Psychology › Developmental and Educational Psychology › Sport Psychology and Performance
- Keywords
- anterior cruciate ligament injury, second ACL injury, psychological readiness, return to sport, anterior cruciate ligament reconstruction, ACL-RSI scale, youth athletes, injury prediction, age as risk factor
- MeSH terms
- Return to Sport, Anterior Cruciate Ligament Injuries, Adolescent, Adult, Fear, Female, Follow-Up Studies, Humans, Male, Prospective Studies, Recurrence, Young Adult, Anterior Cruciate Ligament Reconstruction
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