Determinants of Psychological Readiness to Return to Sport After Anterior Cruciate Ligament Reconstruction

In the paper

“Both psychological and physical factors have an established role in ACL injury recovery, but their relative and combined contributions to psychological readiness for return to sport remain unclear.36”

What the sources say

• Partly supported

  The Background says return-to-sport decisions after ACL injury should include physical assessments and that psychological factors affect return to sport and reinjury risk. It also says factors affecting psychological readiness need further study, but it does not specifically establish that the relative and combined contributions of physical and psychological factors to readiness remain unclear. No page numbers are available in our copy. (LLM, conf=0.84)

  cites [36] Sell TC, Zerega R, King V, et al. Anterior Cruciate Ligament Return to Sport after Injury Scale (ACL-RSI) scores over time after anterior cruciate ligament reconstruction: a systematic review with meta-analysis. Sports Med Open. 2024;10(1):49. doi:10.1186/s40798-024-00712-w sourceExperimental — accuracy not yet measured

In the paper

“Clinicians use objective factors such as age, time from injury, and strength symmetry in clinical decision-making for return to sport after ACLR5–11; however, these alone do not fully explain why some athletes do not return to sport despite achieving adequate physical rehabilitation.12–15”

What the sources say

• Partly supported

  Split into 2 atoms — 1 confirmed, 1 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.

  cites [5] Feller J, Webster KE. Return to sport following anterior cruciate ligament reconstruction. Int Orthop. 2013;37(2):285–290. doi:10.1007/s00264-012-1690-7 sourceExperimental — accuracy not yet measured
• Partly supported

  Split into 2 atoms — 0 confirmed, 1 partially supported, 0 disputed, 0 misattributed, 1 unverifiable. Expand the claim to see per-atom verdicts.

  cites [6] Kaeding CC, Pedroza AD, Reinke EK, Huston LJ, Spindler KP; MOON Consortium. Risk factors and predictors of subsequent ACL injury in either knee after ACL reconstruction: prospective analysis of 2488 primary ACL reconstructions from the MOON cohort. Am J Sports Med. 2015;43(7):1583–1590. doi:10.1177/0363546515578836 sourceExperimental — accuracy not yet measured
• Partly supported

  Split into 2 atoms — 0 confirmed, 1 partially supported, 0 disputed, 0 misattributed, 1 unverifiable. Expand the claim to see per-atom verdicts.

  cites [7] Wiggins AJ, Grandhi RK, Schneider DK, Stanfield D, Webster KE, Myer GD. Risk of secondary injury in younger athletes after anterior cruciate ligament reconstruction: a systematic review and meta-analysis. Am J Sports Med. 2016;44(7):1861–1876. doi:10.1177/0363546515621554 sourceExperimental — accuracy not yet measured
• Partly supported

  Split into 2 atoms — 0 confirmed, 1 partially supported, 0 disputed, 0 misattributed, 1 unverifiable. Expand the claim to see per-atom verdicts.

  cites [8] Grindem H, Snyder-Mackler L, Moksnes H, Engebretsen L, Risberg MA. Simple decision rules can reduce reinjury risk by 84% after ACL reconstruction: the Delaware-Oslo ACL cohort study. Br J Sports Med. 2016;50(13):804–808. doi:10.1136/bjsports-2016-096031 sourceExperimental — accuracy not yet measured
• Partly supported

  Split into 2 atoms — 1 confirmed, 1 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.

  cites [9] Meredith SJ, Rauer T, Chmielewski TL, et al.; Panther Symposium ACL Injury Return to Sport Consensus Group. Return to sport after anterior cruciate ligament injury: Panther Symposium ACL Injury Return to Sport Consensus Group. Orthop J Sports Med. 2020;8(6):2325967120930829. doi:10.1177/2325967120930829 sourceExperimental — accuracy not yet measured
• ?Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  cites [10] Webster KE, Feller JA. A research update on the state of play for return to sport after anterior cruciate ligament reconstruction. J Orthop Traumatol. 2019;20(1):10. doi:10.1186/s10195-018-0516-9
• ?Not checked — no full text of the sourcecites [11] Webster KE, Feller JA, Lambros C. Development and preliminary validation of a scale to measure the psychological impact of returning to sport following anterior cruciate ligament reconstruction surgery. Phys Ther Sport. 2008;9(1):9–15. doi:10.1016/j.ptsp.2007.09.003 source
• Not checked yetcites [12] Faleide AGH, Inderhaug E. It is time to target psychological readiness (or lack of readiness) in return to sports after anterior cruciate ligament tears. J Exp Orthop. 2023;10(1):94. doi:10.1186/s40634-023-00657-1
• Partly supported

  Split into 2 atoms — 1 confirmed, 1 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.

  cites [13] Kaplan Y, Witvrouw E. When is it safe to return to sport after ACL reconstruction? Reviewing the criteria. Sports Health. 2019;11(4):301–305. doi:10.1177/1941738119846502 sourceExperimental — accuracy not yet measured
• Partly supported

  Split into 2 atoms — 0 confirmed, 1 partially supported, 0 disputed, 0 misattributed, 1 unverifiable. Expand the claim to see per-atom verdicts.

  cites [14] Koca F, Stålman A, Vestberg C, Cristiani R, Fältström A. Poorer patient-reported knee function and quality of life, but not activity level, after revision ACL reconstruction compared with primary ACL reconstruction: a matched-pair analysis with a minimum 5-year follow-up. BMC Musculoskelet Disord. 2023;24(1):831. doi:10.1186/s12891-023-06954-1 sourceExperimental — accuracy not yet measured

In the paper

“These psychosocial aspects are still underused in return-to-sport decisions3,20–24 despite evidence of their effect.2,25–35”

What the sources say

• ?Not checked — no full text of the sourcecites [3] Robinson K, Kossman MK. Psychosocial factors on athlete return to sport readiness after anterior cruciate ligament reconstruction: a critically appraised topic. J Sport Rehabil. 2025;34(2):171–176. doi:10.1123/jsr.2024-0034 source
• ?Not checked — no full text of the sourcecites [20] Mir B, Vivekanantha P, Dhillon S, et al. Fear of reinjury following primary anterior cruciate ligament reconstruction: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2023;31(6):2299–2314. doi:10.1007/s00167-022-07296-6 source
• Not checked yetcites [21] Almeida GPL, Albano TR, Rodrigues CAS, Tavares MLA, de Paula Lima PO. Combining return to sport, psychological readiness, body mass, hamstring strength symmetry, and hamstring/quadriceps ratio increases the risk of a second anterior cruciate ligament injury. Knee Surg Sports Traumatol Arthrosc. 2023;31(11):5087–5095. doi:10.1007/s00167-023-07559-w
• ?Not checked — no full text of the sourcecites [22] Ross CA, Clifford A, Louw QA. Factors informing fear of reinjury after anterior cruciate ligament reconstruction. Physiother Theory Pract. 2017;33(2):103–114. doi:10.1080/09593985.2016.1271847 source
• ?Could not verify

  The Background says psychological factors influence return to sport after ACL reconstruction, and the Discussion recommends that clinicians recognise and address them. Neither passage says these factors are underused in return-to-sport decisions. Searches for underuse and for how often psychological factors are considered in such decisions found no supporting passage in our copy. (LLM, conf=0.70)

  cites [23] van Lankveld W, van Melick N, Habets B, Roelofsen E, Staal JB, van Cingel R. Measuring individual hierarchy of anxiety invoking sports related activities: development and validation of the Photographic Series of Sports Activities for Anterior Cruciate Ligament Reconstruction (PHOSA-ACLR). BMC Musculoskelet Disord. 2017;18(1):287. doi:10.1186/s12891-017-1643-9 sourceExperimental — accuracy not yet measured
• Supported

  This source supports the clause about evidence of psychosocial factors’ effect, not the separate claim that they are underused in return-to-sport decisions. Its Results report that female athletes who sustained a second ACL injury had significantly higher psychological-readiness and risk-appraisal scores; its clinical recommendations say psychological readiness should be considered in return-to-sport decisions. The findings show an association, not a proven causal effect. (LLM, conf=0.89)

  cites [24] Zarzycki R, Cummer K, Arhos E, et al. Female athletes with better psychological readiness are at higher risk for second ACL injury after primary ACL reconstruction. Sports Health. 2024;16(1):149–154. doi:10.1177/19417381231155120 source
• ?Not checked — no full text of the sourcecites [2] Hopper HM, Bruce Leicht AS, Thompson XD, et al. The effect of factors from different time points on psychological readiness following ACL reconstruction. Phys Ther Sport. 2024;67:161–166. doi:10.1016/j.ptsp.2024.05.002 source
• Supported

  This source is cited for evidence of psychosocial aspects’ effect, not for the separate assertion that they are underused in return-to-sport decisions. The introductory passage in our copy says psychological readiness contributes to return to sport after ACL reconstruction and that readiness scores are related to whether athletes return to their preinjury sport. (LLM, conf=0.89)

  cites [25] Aizawa J, Hirohata K, Ohji S, Ohmi T, Koga H, Yagishita K. Factors associated with psychological readiness to return to sports with cutting, pivoting, and jump-landings after primary ACL reconstruction. Orthop J Sports Med. 2020;8(11):2325967120964484. doi:10.1177/2325967120964484 source
• ?Not checked — no full text of the sourcecites [26] Baez SE, Hoch JM, Cormier M. The Stress and Injury Model and Cognitive Appraisal Model: implications for patients after anterior cruciate ligament reconstruction. Athl Train Sports Health Care. 2020;12(4):181–187. doi:10.3928/19425864-20190924-02 source
• Partly supported

  The introductory passage following Level of Evidence (page not provided) says that depression and anxiety affect orthopaedic outcomes and that mental-health screening is not yet standard musculoskeletal care. It does not address whether psychosocial factors are underused specifically in return-to-sport decisions. (LLM, conf=0.84)

  cites [27] Cheng AL, Downs DL, Brady BK, et al. Interpretation of PROMIS depression and anxiety measures compared with DSM-5 diagnostic criteria in musculoskeletal patients. JBJS Open Access. 2023;8(1):e22.00110. doi:10.2106/JBJS.OA.22.00110 sourceExperimental — accuracy not yet measured

In the paper

“Objective functional measures did not meaningfully improve model performance (quadriceps strength symmetry = −0.6%, single-legged hop symmetry = 0.6%).”

In the paper

“overall variance decomposition revealed that the KOOS-QoL (18.8%), the KOOS-Sport (14.8%), and kinesiophobia (13.3%) were the strongest contributors to psychological readiness, followed by the KOOS-Pain/Symptoms (9.3%), hop-distance symmetry (5.2%), and generalized anxiety (5.0%).”

In the paper

“The overall model accounted for 70.5% of total variance in ACL-RSI scores (adjusted R2 = 0.64, P < .001), with a cross-validated R2 of 0.61 supporting model stability and minimal overfitting.”

In the paper

“The largest unique contributors were the KOOS-Sport (4.9%), kinesiophobia (3.6%), and the KOOS-QoL (3.3%), with all other predictors explaining <1.5% of additional variance.”

In the paper

“Notably, the KOOS-Pain/Symptoms contributed to the overall explained variance (9.3%) but demonstrated no meaningful unique contribution after we considered psychological and perceived function variables.”

In the paper

“Importantly, cross-validation analyses yielded comparable performance estimates, supporting model stability and minimizing concerns about overfitting.”

In the paper

“We assessed the primary outcome of psychological readiness for return to sport using the ACL-RSI scale.17”

What the sources say

• ?Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  cites [17] Webster KE, Feller JA. Development and validation of a short version of the Anterior Cruciate Ligament Return to Sport After Injury (ACL-RSI) scale. Orthop J Sports Med. 2018;6(4):2325967118763763. doi:10.1177/2325967118763763

In the paper

“In contrast, unique (semipartial) effects were smaller, indicating substantial shared variance among psychological and patient-reported factors.”

In the paper

“Given that the KOOS-Pain and KOOS-Symptoms were highly correlated (r = 0.86), we averaged results to form a composite indicator, KOOS-Pain/Symptoms, representing perceived knee symptoms and discomfort. This approach minimized multicollinearity while preserving the shared construct of symptomatic knee status.”

In the paper

“with a cross-validated R2 of 0.61 supporting model stability and minimal overfitting.”

In the paper

“To assess model stability and potential overfitting, we conducted repeated 10-fold, cross-validation (50 repeats) and reported the cross-validated R2 as an index of generalizability.”

In the paper

“In previous work, researchers often examined these domains in isolation, which limits clinical insight into how subjective perceptions, psychological variables, and objective measures of function interact during recovery.16,20”

What the sources say

• ?Not checked — no full text of the sourcecites [16] Xiao M, van Niekerk M, Trivedi NN, et al. Patients who return to sport after primary anterior cruciate ligament reconstruction have significantly higher psychological readiness: a systematic review and meta-analysis of 3744 patients. Am J Sports Med. 2023;51(10):2774–2783. doi:10.1177/03635465221102420 source
• ?Not checked — no full text of the sourcecites [20] Mir B, Vivekanantha P, Dhillon S, et al. Fear of reinjury following primary anterior cruciate ligament reconstruction: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2023;31(6):2299–2314. doi:10.1007/s00167-022-07296-6 source

In the paper

“Second, the relatively modest sample size (n = 58) reduced statistical power and limited the ability to detect smaller but clinically meaningful effects.”

In the paper

“Additionally, given the number of predictors considered, the subject-to-variable ratio was modest; however, predictors were entered hierarchically based on conceptual domains rather than simultaneously reducing model complexity at each step.”

In the paper

“We assessed model assumptions using standard residual diagnostics for linearity, homoscedasticity, and normality.”

In the paper

“First, we collected data from a single clinical site, which may limit generalizability to broader ACLR populations with different rehabilitation practices, demographics, or competitive sport demands.”

In the paper

“Our results highlighted that readiness reflects how athletes think about and perceive their recovery, not simply how they perform on physical tests.”

In the paper

“Generalized anxiety initially explained a notable share of variance in ACL-RSI scores (18.1%), highlighting its importance in early hierarchical models. However, when all predictors were considered together through variance decomposition (Lindeman, Merenda, and Gold method and semipartial R2), the influence of the variable was reduced markedly.”

In the paper

“In the current literature, <65% of athletes who undergo ACLR return to their previous competitive level, with psychological factors, especially fear of reinjury, representing key barriers.4”

What the sources say

• ?Not checked — no full text of the sourcecites [4] Ardern CL, Webster KE, Taylor NF, Feller JA. Return to sport following anterior cruciate ligament reconstruction surgery: a systematic review and meta-analysis of the state of play. Br J Sports Med. 2011;45(7):596–606. doi:10.1136/bjsm.2010.076364 source

In the paper

“For our analysis, we used data from each participant’s first visit when the return-to-sport readiness assessment was administered to ensure consistency and minimize potential bias from repeated measures.”

In the paper

“Accordingly, the relatively large contributions from generalized anxiety, kinesiophobia, the KOOS-QoL, and the KOOS-Sport appear robust, whereas the smaller ΔR2 values for the KOOS-Pain/Symptoms and objective measures should be interpreted cautiously, as they may reflect limited power rather than true absence of association.”

In the paper

“Although the modest sample size limited sensitivity to small effects (ΔR2 < 0.05), the study was better positioned to detect moderate-to-large incremental effects.”

In the paper

“Inspection of the residuals-versus-fitted diagnostic plot of the overall model (including all predictors) indicated no severe violations of linearity or homoscedasticity. The Q-Q plot showed residuals with approximately normal distribution, which was supported by the Shapiro-Wilk test (W = 0.96, P = .06), indicating no deviation from normality.”

In the paper

“We evaluated multicollinearity using variance inflation factors (VIFs) for the full regression model (including all predictors), with a VIF of <5 indicating acceptable collinearity.”

In the paper

“Some unexplained variance also may reflect measurement error or random variability; however, the use of established measures with supporting validity evidence and stable cross-validation results suggest it is unlikely to be attributable solely to error and likely reflects meaningful unmeasured factors, with effects that may be conservative.”

In the paper

“All VIF values were <3, indicating acceptable levels of collinearity.”