It is time to target psychological readiness (or lack of readiness) in return to sports after Anterior Cruciate Ligament tears
Journal of Experimental Orthopaedics volume 10, Article number: 94 (2023)
Functional recovery has for long been the focus of rehabilitation after an Anterior Cruciate Ligament (ACL) injury. It is now increasingly recognized that more attention should be given to patients` mental recovery, their psychological readiness for returning to sport, after such an injury. Within this relatively new field of science, clinicians need clarity on when and how psychological factors should be monitored and how inexpedient psychological responses may be addressed during rehabilitation. In this Expert Opinion suggestions on how targeting psychological readiness may improve rehabilitation and return-to-sport evaluations are made based on current evidence—and issues in need of further clarification are addressed.
Readiness for return to sports after ACL injury
An ACL rupture can be a devastating and potentially career-ending injury affecting young and active people. The overall aim of treatment is restoring knee stability to enable normal daily life functioning and participation at the desired activity levels—without suffering further knee injuries. Depending on the patients target activity level, concomitant injuries, and degree of knee laxity – treatment will often involve surgical reconstruction of the torn ACL. Restoration of neuromuscular function through active rehabilitation can yield acceptable function for some, but increased awareness on the importance of meniscal repair and secondary injury prevention supports a surgical approach in the majority [18, 24, 27, 46, 60].
Even though surgery and rehabilitation seem to result in normal or nearly normal functioning for most patients, many do not regain their previous levels of sports participation. Ardern et al.  reported that only 65% of patients returned to pre-injury level of sport after ACLR and no more than 55% were able to return to competitive levels. Such disappointing results are confirmed in later reports [40, 56]. In addition, the threat of subsequent surgery due to meniscal lesions, a graft rupture or a contralateral ACL injury remains significant—further adding to the risk of osteoarthritis development [25, 29, 31, 42, 52]. Therefore, improving the course of treatment and making well-founded return-to-sport decisions are crucial to support patients in reaching their goals of an active lifestyle while safeguarding long-term health and quality of life.
“Functional recovery is the key to success after surgery” has been a mantra among surgeons and therapists aiding the patients’ rehabilitation. A successful recovery has for long been associated with biological healing, restoration of native knee stability and recovery from neuromuscular deficits . Certainly, a lack of functional recovery can leave the patients vulnerable for new injuries, prevent their return to an active lifestyle and cause reduced quality of life [23, 28, 29, 38, 62]. Therefore, a close attention to patients’ progression through their phases of rehabilitation is paramount. Test batteries have been developed to identify and quantify functional deficits allowing a more targeted approach in the latter phase of rehabilitation when patients approach “return to play”. However, several studies have criticized how commonly used test batteries fail to identify patients who will struggle to return safely to sport. It has been hypothesized that some of the explanation can be found in a lack of comprehensiveness in the test batteries—focusing solely on assessment of physical readiness [12, 41, 45, 67].
New evidence emphasize how ACL injuries also have a significant psychological impact and that patients therefore need to achieve a state of “overall readiness” (including mental readiness) for returning safely to sport [8,9,10, 13, 35, 39, 65]. Yet, implementation of this knowledge to clinical practice is long overdue. The reason for this may be a lack of clarity about how the psychological aspect of readiness should be monitored and addressed in clinical care.
The impact of psychological readiness
After an ACL injury, patients may experience strong emotions of tension and anxiety, fear of new injuries, reduced confidence, and low motivation [7, 13, 26, 35, 39, 50]. These responses will inevitably affect both rehabilitation and the return-to-sport process [14, 61]. Psychological readiness has been found to be an important predictor of patients’ ability to resume sport, in fact a recent study reported it to be the most important component of a test battery when it came to predicting a return to pre-injury activity level [8, 10, 17, 22, 23, 39, 48, 67]. Further, there are indications that low psychological readiness might be associated with a higher risk of sustaining a second ACL injury upon returning to sport .
An interesting observation is that physical and mental recovery does not always coincide [8, 17, 39, 50]. Patients might have regained sufficient function for sports participation, but still report high levels of fear and low psychological readiness . In such a situation their performance on tests of functional recovery (such as isokinetic strength tests and single-legged hop tests) will have little predictive value in whether they return to sport or not. These patients might end up never attempting a return to play [40, 56]. Conversely, other patients may display no fear and high mental readiness for returning, irrespective of how physically ready they are . These scenarios underline the importance of addressing both physical and psychological recovery—and using a test battery that includes evaluation of a combined physical and psychological readiness is therefore recommended [2, 23, 54].
Detecting erroneous psychological responses
Several tools for evaluation of psychological responses are available to help clinicians identify patients with mental issues pertaining to their injury and resumption of former athletic activities . The ACL – Return to Sports after Injury (ACL-RSI) scale was developed through literature review and identification of psychological domains hypothesized to be relevant for patients working towards returning to sport after ACLR . Three mental domains (emotions, confidence in performance and risk appraisal) were selected to constitute psychological readiness for resuming sport. The 12-item scale struck a chord with clinicians and researchers, has been translated to and validated in several languages, and is now the dominant measure for psychological readiness in this patient group [1, 11, 21, 30, 33, 36, 55, 57, 58].
There are, however, no evidence-based guidelines to inform clinicians about when psychological readiness should be assessed, how scores should be interpreted or how a low (or excessively high) readiness for returning should be addressed in the treatment course [3, 15, 35]. With regard to timing, Ardern et al.  found that psychological responses prior to, and 4 months after surgery were associated with patients ability to return to sport one year post-ACLR. Although measuring patients’ preparedness for returning to sport before surgery seems premature, it is suggested that assessment of psychological readiness should start in the relatively early phases of rehabilitation (for example at 4 months) with regular monitoring until the return-to-sport evaluation—often performed at 9 months after surgery [2, 23, 51, 54].
The uncertainty about how ACL-RSI scores should be interpreted during ACL rehabilitation relates to both which values to use for denominating patients who may struggle to return to sport (cut-off values) and to the scale`s responsiveness [51, 59, 64]. Various cut-off values have been reported with a range from 42 to 65 on the 0–100 points scale [8, 23, 48, 54, 63]. At four months, an ACL-RSI score < 56/100 is suggested to differentiate between those who may and those who may not struggle to resume pre-injury level of sports participation one year after surgery . Two studies have reported similar cut-offs at the six months assessment with a score of 60 to 62 points [54, 63]. At nine months after surgery, patients with a score of ≤ 47 may be at risk of not returning to pre-injury sport level two years after ACLR . It might seem counterintuitive that these cut-off values do not gradually increase as rehabilitation and functional performance progresses towards the return-to-sport evaluation. This phenomenon may be due to increased emotional disturbance as patients are approaching a return to sport . Further complicating matters are the indications of problems with responsiveness when the ACL-RSI is used to monitor individuals (as opposed to groups of patients) [59, 64]. At this point, the abovementioned cut-off values should therefore only be used as preliminary indicators when monitoring patients in clinical practice because their predictive value for identifying individuals in need of interventions targeting low mental preparedness needs further investigation.
Limited knowledge on interventions for low mental readiness
Although we now have the means to detect erroneous psychological responses – there is a lack of evidence on how to target these responses throughout the treatment course [3, 4, 16, 35]. Some recommendations have been made based on available knowledge; Careful information about the injury and the content and expected timeframes of rehabilitation is highlighted to reduce fear, increase motivation, and boost confidence [3, 37]. As degree of psychological readiness is associated with functional performance, clinicians may help patients feel more ready for challenging their knee by ensuring adequate physical recovery [19, 21, 32, 35, 53, 66]. In support of this, patients report that strength training and sport-specific exercises, with a graded exposure to challenging tasks, increase confidence that their knee will withstand the pressures and forces that comes with sports [34, 43]. Further, regular monitoring of functional recovery throughout rehabilitation is recommended to provide a realistic understanding of how patients are progressing and thereby promote mental recovery .
As the association between physical and psychological readiness is only small to moderate [21, 23, 32, 53], there is also a need for developing interventions that more specifically target psychological recovery [4, 16]. Preliminary evidence suggests that visual and guided imagery, goal setting, relaxation techniques, motivational interviewing, cognitive behavioural therapy, and coping modelling may reduce fear [3, 15, 16]. This evidence is, however, still limited, and inconsistent. Acknowledging the need for specific cognitive interventions also underpins how professionals with a background in neuroscience and psychology should be included both in research and treatment of these patients. With a few exceptions, physiotherapists and orthopaedic surgeons have dominated this field, but it now seems timely to expand our understanding by drawing on the experience of other professions.
Issues in need of clarification
To fully resolve the abovementioned uncertainties, it may be helpful to take a step back before moving forward. A research team including sports psychologists have pointed to ambiguities related to the concept of psychological readiness and therefore proposed the following definition: “Psychological readiness to RTS [return to sport] after injury reflects an individual’s state of mental preparedness to resume sport-specific activities and likely comprises three dimensions, including cognitive appraisals (confidence, expectations, motivations, risk appraisals, internal or external pressures), affective components (anxiety or fears about re-injury or movement, moods) and behavioural components (approach-avoidance behaviours to demonstrate physical function/neuromuscular control and engage in sport-specific tasks)(, p. 7).”
The definition undoubtedly covers many relevant aspects of feeling mentally prepared for returning to vigorous activity. However, further work is needed to clarify whether certain dimensions are more important than others, whether the psychological responses may take numerous meanings (i.e. confidence in performance and confidence in ability to withstand re-injury) and which elements to include in the construct of psychological readiness . For instance, while motivation and fear of re-injury is included in the proposed definition, others have listed these factors as separate from psychological readiness [5, 51]. A common interdisciplinary understanding of psychological readiness would enhance both researchers’ and clinicians’ ability to plan for optimal monitoring of mental recovery and to develop interventions targeting erroneous psychological responses.
Another aspect of readiness that needs to be addressed is whether fear avoidance is a rational and protective mechanism that helps patients avoid further injury when normal knee function has been disrupted. After a traumatic event, and episodes of recurrent instability, patient have painfully experienced how their knee cannot be trusted through strong and fear-provoking stimuli. Indeed, a history of previous injury makes athletes vulnerable to new injuries and being afraid of re-injury is therefore not irrational . For some, the fear and hesitation can lead to positive processes, like reorientation, where they choose to return to a lower level of sport or change to a sport involving less contact or pivoting . Such behaviour will reduce the risk of sustaining further injuries and thereby protect against future osteoarthritis [29, 40]. However, for others, fear can become irrational and thereby have a detrimental effect on the rehabilitation and long-term outcome [37, 51]. These are the individuals in need of targeted psychological interventions. Patients on the other end of the spectrum, displaying high psychological readiness irrespective of muscle strength are probably highly susceptible to new injuries and may need a different treatment approach[49, 68]. Moving forward, exploring such patient profiles would allow a more individualized and targeted rehabilitation.
Both physical and psychological readiness to return to sport need to be assessed and addressed after an ACL injury. The ACL-RSI is a validated questionnaire that can be used to evaluate psychological readiness from early phases of rehabilitation. Research on how to address inexpedient psychological readiness is underway. At current, the most important recommendations include regular monitoring to identify patients in need of particular attention. These patients should be targeted with thorough information and regular testing of physical recovery to give realistic expectations and increase motivation and confidence. Future studies should focus on achieving consensus on a psychological readiness definition, on interpretation of ACL-RSI scores, on distinguishing between helpful and inexpedient psychological responses and on how unwanted responses should be targeted.
It is time to target psychological readiness!
Anterior Cruciate Ligament
Anterior Cruciate Ligament Reconstruction
Anterior Cruciate Ligament - Return to Sports after Injury
Return to Sport
Alzhrani M, Alzahrani H, Alshehri YS (2022) Arabic Version of the Short Anterior Cruciate Ligament-Return to Sport After Injury Scale: Translation, Cross-cultural Adaptation, and Validation. Orthop J Sports Med 10(1):23259671211066508
Ardern CL, Glasgow P, Schneiders A, Witvrouw E, Clarsen B, Cools A et al (2016) 2016 Consensus statement on return to sport from the First World Congress in Sports Physical Therapy Bern. Br J Sports Med 50(14):853–864. https://doi.org/10.1136/bjsports-2016-096278
Ardern CL, Hooper N, O’Halloran P, Webster KE, Kvist J (2022) A Psychological Support Intervention to Help Injured Athletes “Get Back in the Game”: Design and Development Study. JMIR Form Res 6(8):e28851
Ardern CL, Kvist J (2020) BAck iN the Game (BANG) - a smartphone application to help athletes return to sport following anterior cruciate ligament reconstruction: protocol for a multi-centre, randomised controlled trial. BMC Musculoskelet Disord 21(1):523. https://doi.org/10.1186/s12891-020-03508-7
Ardern CL, Kvist J, Webster KE (2016) Psychological Aspects of Anterior Cruciate Ligament Injuries. Oper Techn Sport Med 24(1):77–83
Ardern CL, Taylor NF, Feller JA, Webster KE (2014) Fifty-five per cent return to competitive sport following anterior cruciate ligament reconstruction surgery: an updated systematic review and meta analysis including aspects of physical functioning and contextual factors. Br J Sports Med 48(21):1543–1552. https://doi.org/10.1136/bjsports-2013-093398
Ardern CL, Taylor NF, Feller JA, Webster KE (2013) A systematic review of the psychological factors associated with returning to sport following injury. Br J Sports Med 47(17):1120–1126. https://doi.org/10.1136/bjsports-2012-091203
Ardern CL, Taylor NF, Feller JA, Whitehead TS, Webster KE (2013) Psychlogical responses matter in returning to pre injury level of sport after anterior cruciate ligament reconstruction surgery. Am J Sports Med 41(7):1549–1558. https://doi.org/10.1177/0363546513489284
Ardern CL, Webster KE, Taylor NF, Feller JA (2011) Return to sport following anterior cruciate ligament reconstruction surgery: a systematic review and meta-analysis of the state of play. Br J Sports Med 45(7):596–606. https://doi.org/10.1136/bjsm.2010.076364
Ardern CL, Österberg A, Tagesson S, Gauffin H, Webster KE, Kvist J (2014) The impact of psychological readiness to return to sport and recreational activities after anterior cruciate ligament reconstruction. Br J Sports Med 48(22):1613–1619. https://doi.org/10.1136/bjsports-2014-093842
Bohu Y, Klouche S, Lefevre N, Webster K, Herman S (2015) Translation, cross-cultural adaptation and validation of the French version of the Anterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI) scale. Knee Surg Sports Traumatol Arthrosc 23(4):1192–1196. https://doi.org/10.1007/s00167-014-2942-4
Burgi CR, Peters S, Ardern CL, Magill JR, Gomez CD, Sylvain J et al (2019) Which criteria are used to clear patients to return to sport after primary ACL reconstruction? A scoping review. Br J Sports Med 53(18):1154–1161. https://doi.org/10.1136/bjsports-2018-099982
Burland JP, Toonstra J, Werner JL, Mattacola CG, Howell DM, Howard JS (2018) Decision to Return to Sport After Anterior Cruciate Ligament Reconstruction, Part I: A Qualitative Investigation of Psychosocial Factors. J Athl Train 53(5):452–463. https://doi.org/10.4085/1062-6050-313-16
Chmielewski TL, George SZ (2019) Fear avoidance and self-efficacy at 4 weeks after ACL reconstruction are associated with early impairment resolution and readiness for advanced rehabilitation. Knee Surg Sports Traumatol Arthrosc 27(2):397–404. https://doi.org/10.1007/s00167-018-5048-6
Coronado RA, Bird ML, Van Hoy EE, Huston LJ, Spindler KP, Archer KR (2018) Do psychosocial interventions improve rehabilitation outcomes after anterior cruciate ligament reconstruction? A systematic review. Clin Rehabil 32(3):287–298. https://doi.org/10.1177/0269215517728562
Coronado RA, Sterling EK, Fenster DE, Bird ML, Heritage AJ, Woosley VL et al (2020) Cognitive-behavioral-based physical therapy to enhance return to sport after anterior cruciate ligament reconstruction: An open pilot study. Phys Ther Sport 42:82–90. https://doi.org/10.1016/j.ptsp.2020.01.004
Czuppon S, Racette BA, Klein SE, Harris-Hayes M (2014) Variables associated with return to sport following anterior cruciate ligament reconstruction: a systematic review. Br J Sports Med 48(5):356–364. https://doi.org/10.1136/bjsports-2012-091786
Diermeier T, Rothrauff BB, Engebretsen L, Lynch AD, Ayeni OR, Paterno MV et al (2020) Treatment after anterior cruciate ligament injury: Panther Symposium ACL Treatment Consensus Group. Knee Surg Sports Traumatol Arthrosc 28(8):2390–2402. https://doi.org/10.1007/s00167-020-06012-6
Ebert JR, Edwards P, Preez LD, Furzer B, Joss B (2021) Knee extensor strength, hop performance, patient-reported outcome and inter-test correlation in patients 9–12 months after anterior cruciate ligament reconstruction. Knee 30:176–184. https://doi.org/10.1016/j.knee.2021.04.012
Everhart JS, Harris K, Chafitz A, Kirven JC, Abouljoud M, Schiele S et al (2020) Psychological Assessment Tools Utilized in Sports Injury Treatment Outcomes Research: A Review. J Sports Sci Med 19(2):408–419
Faleide AGH, Inderhaug E, Vervaat W, Breivik K, Bogen BE, Mo IF et al (2020) Anterior cruciate ligament—return to sport after injury scale: validation of the Norwegian language version. Knee Surg Sports Traumatol Arthrosc 28(8):2634–2643. https://doi.org/10.1007/s00167-020-05901-0. (PMID: 32062685)
Faleide AGH, Magnussen LH, Bogen BE, Strand T, Mo IF, Vervaat W et al (2021) Association Between Psychological Readiness and Knee Laxity and Their Predictive Value for Return to Sport in Patients With Anterior Cruciate Ligament Reconstruction. Am J Sports Med 49(10):2599–2606. https://doi.org/10.1177/03635465211021831
Faleide AGH, Magnussen LH, Strand T, Bogen BE, Moe-Nilssen R, Mo IF, et al (2021) The Role of Psychological Readiness in Return to Sport Assessment After Anterior Cruciate Ligament Reconstruction. Am J Sports Med 49(5). https://doi.org/10.1177/0363546521991924363546521991924
Filbay SR, Grindem H (2019) Evidence-based recommendations for the management of anterior cruciate ligament (ACL) rupture. Best Pract Res Clin Rheumatol 33(1):33–47. https://doi.org/10.1016/j.berh.2019.01.018
Frobell RB, Roos HP, Roos EM, Roemer FW, Ranstam J, Lohmander LS (2013) Treatment for acute anterior cruciate ligament tear: five year outcome of randomised trial. BMJ 346:f232. https://doi.org/10.1136/bmj.f232
Gobbi A, Francisco R (2006) Factors affecting return to sports after anterior cruciate ligament reconstruction with patellar tendon and hamstring graft: a prospective clinical investigation. Knee Surg Sports Traumatol Arthrosc 14(10):1021–1028. https://doi.org/10.1007/s00167-006-0050-9
Grevnerts HT, Sonesson S, Gauffin H, Ardern CL, Stålman A, Kvist J (2021) Decision Making for Treatment After ACL Injury From an Orthopaedic Surgeon and Patient Perspective: Results From the NACOX Study. Orthop J Sports Med 9(4):23259671211005090
Grindem H, Engebretsen L, Axe M, Snyder-Mackler L, Risberg MA (2020) Activity and functional readiness, not age, are the critical factors for second anterior cruciate ligament injury — the Delaware-Oslo ACL cohort study. Br J Sports Med 54(18):1099–1102. https://doi.org/10.1136/bjsports-2019-100623
Grindem H, Snyder-Mackler L, Moksnes H, Engebretsen L, Risberg MA (2016) Simple Decision rules can reduce reinjury risk by 84% after ACL reconstruction: the Delaware Oslo ACL Cohort study. Br J Sports Med 50(13):804–808. https://doi.org/10.1136/bjsports-2016-096031
Harput G, Tok D, Ulusoy B, Eraslan L, Yildiz TI, Turgut E et al (2017) Translation and cross-cultural adaptation of the anterior cruciate ligament-return to sport after injury (ACL-RSI) scale into Turkish. Knee Surg Sports Traumatol Arthrosc 25(1):159–164. https://doi.org/10.1007/s00167-016-4288-6
Harris KP, Driban JB, Sitler MR, Cattano NM, Balasubramanian E, Hootman JM (2017) Tibiofemoral Osteoarthritis After Surgical or Nonsurgical Treatment of Anterior Cruciate Ligament Rupture: A Systematic Review. J Athl Train 52(6):507–517. https://doi.org/10.4085/1062-6050-49.3.89
Hart HF, Culvenor AG, Guermazi A, Crossley KM (2020) Worse knee confidence, fear of movement, psychological readiness to return-to-sport and pain are associated with worse function after ACL reconstruction. Phys Ther Sport 41:1–8. https://doi.org/10.1016/j.ptsp.2019.10.006
Jia ZY, Cui J, Wang W, Xue CC, Liu TZ, Huang X et al (2018) Translation and validation of the simplified Chinese version of the anterior cruciate ligament-return to sport after injury (ACL-RSI). Knee Surg Sports Traumatol Arthrosc 26(10):2997–3003. https://doi.org/10.1007/s00167-018-4850-5
Kvist J, Bengtsson J, Lundqvist C (2023) The experience and influence of fear after anterior cruciate ligament reconstruction: an interview study with young athletes. BMC Sports Sci Med Rehab 15(1):50. https://doi.org/10.1186/s13102-023-00659-7
Kvist J, Ek A, Sporrstedt K, Good L (2005) Fear of re-injury: a hindrance for returning to sports after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 13(5):393–397. https://doi.org/10.1007/s00167-004-0591-8
Kvist J, Osterberg A, Gauffin H, Tagesson S, Webster K, Ardern C (2013) Translation and measurement properties of the Swedish version of ACL-Return to Sports after Injury questionnaire. Scand J Med Sci Sports 23(5):568–575. https://doi.org/10.1111/j.1600-0838.2011.01438.x
Kvist J, Silbernagel KG (2022) Fear of Movement and Reinjury in Sports Medicine: Relevance for Rehabilitation and Return to Sport. Phys Ther 102(2):pzab272. https://doi.org/10.1093/ptj/pzab272
Kyritsis P, Bahr R, Landreau P, Miladi R, Witvrouw E (2016) Likelihood of ACL graft rupture: not meeting six clinical discharge criteria before return to sport is associated with a four times greater risk of rupture. Br J Sports Med 50(15):946–951. https://doi.org/10.1136/bjsports-2015-095908
Langford JL, Webster KE, Feller JA (2009) A prospective longitudinal study to assess psychological changes following anterior cruciate ligament reconstruction surgery. Br J Sports Med 43(5):377–381. https://doi.org/10.1136/bjsm.2007.044818
Lindanger L, Strand T, Mølster AO, Solheim E, Inderhaug E (2019) Return to Play and Long-term Participation in Pivoting Sports After Anterior Cruciate Ligament Reconstruction. Am J Sports Med 47(14):3339–3346. https://doi.org/10.1177/0363546519878159
Losciale JM, Zdeb RM, Ledbetter L, Reiman MP, Sell TC (2019) The Association Between Passing Return-to-Sport Criteria and Second Anterior Cruciate Ligament Injury Risk: A Systematic Review With Meta-analysis. J Orthop Sports Phys Ther 49(2):43–54. https://doi.org/10.2519/jospt.2019.8190
Luc B, Gribble PA, Pietrosimone BG (2014) Osteoarthritis prevalence following anterior cruciate ligament reconstruction: a systematic review and numbers-needed-to-treat analysis. J Athl Train 49(6):806–819. https://doi.org/10.4085/1062-6050-49.3.35
Mahood C, Perry M, Gallagher P, Sole G (2020) Chaos and confusion with confidence: Managing fear of Re-Injury after anterior cruciate ligament reconstruction. Phys Ther Sport 45:145–154. https://doi.org/10.1016/j.ptsp.2020.07.002
McPherson AL, Feller JA, Hewett TE, Webster KE (2019) Psychological Readiness to Return to Sport Is Associated With Second Anterior Cruciate Ligament Injuries. Am J Sports Med 47(4):857–862. https://doi.org/10.1177/0363546518825258
Meredith SJ, Rauer T, Chmielewski TL, Fink C, Diermeier T, Rothrauff BB et al (2020) Return to sport after anterior cruciate ligament injury: Panther Symposium ACL Injury Return to Sport Consensus Group. Knee Surg Sports Traumatol Arthrosc 28(8):2403–2414. https://doi.org/10.1007/s00167-020-06009-1
Meuffels DE, Favejee MM, Vissers MM, Heijboer MP, Reijman M, Verhaar JA (2009) Ten year follow-up study comparing conservative versus operative treatment of anterior cruciate ligament ruptures. A matched-pair analysis of high level athletes. Br J Sports Med 43(5):347–351. https://doi.org/10.1136/bjsm.2008.049403
Morrey MA, Stuart MJ, Smith AM, Wiese-Bjornstal DM (1999) A longitudinal examination of athletes’ emotional and cognitive responses to anterior cruciate ligament injury. Clin J Sport Med 9(2):63–69. https://doi.org/10.1097/00042752-199904000-00004
Muller U, Kruger-Franke M, Schmidt M, Rosemeyer B (2015) Predictive parameters for return to pre-injury level of sport 6 months following anterior cruciate ligament reconstruction surgery. Knee Surg Sports Traumatol Arthrosc 23(12):3623–3631. https://doi.org/10.1007/s00167-014-3261-5
Piussi R, Beischer S, Thomeé R, Thomeé C, Sansone M, Samuelsson K et al (2022) Greater Psychological Readiness to Return to Sport, as Well as Greater Present and Future Knee-Related Self-Efficacy, Can Increase the Risk for an Anterior Cruciate Ligament Re-Rupture: A Matched Cohort Study. Arthroscopy 38(4):1267-1276.e1261. https://doi.org/10.1016/j.arthro.2021.08.040
Podlog L, Eklund RC (2007) The psychosocial aspects of a return to sport following serious injury: A review of the literature from a self-determination perspective. Psychol Sport Exerc 8(4):535–566. https://doi.org/10.1016/j.psychsport.2006.07.008
Podlog L, Wadey R, Caron J, Fraser JJ, Ivarsson A, Heil J, et al (2022) Psychological readiness to return to sport following injury: a state-of-the-art review. Int Rev Sport Exerc Psychol. https://doi.org/10.1080/1750984X.2022.20819291-20
Randsborg P-H, Cepeda N, Adamec D, Rodeo SA, Ranawat A, Pearle AD (2022) Patient-Reported Outcome, Return to Sport, and Revision Rates 7–9 Years After Anterior Cruciate Ligament Reconstruction: Results From a Cohort of 2042 Patients. Am J Sports Med 50(2):423–432. https://doi.org/10.1177/03635465211060333
Raoul T, Klouche S, Guerrier B, El-Hariri B, Herman S, Gerometta A et al (2019) Are athletes able to resume sport at six-month mean follow-up after anterior cruciate ligament reconstruction? Prospective functional and psychological assessment from the French Anterior Cruciate Ligament Study (FAST) cohort. Knee 26(1):155–164. https://doi.org/10.1016/j.knee.2018.11.006
Sadeqi M, Klouche S, Bohu Y, Herman S, Lefevre N, Gerometta A (2018) Progression of the Psychological ACL-RSI Score and Return to Sport After Anterior Cruciate Ligament Reconstruction: A Prospective 2-Year Follow-up Study From the French Prospective Anterior Cruciate Ligament Reconstruction Cohort Study (FAST). Orthop J Sports Med 6(12):2325967118812819
Sala-Barat E, Alvarez-Diaz P, Alentorn-Geli E, Webster KE, Cugat R, Tomas-Sabado J (2019) Translation, cross-cultural adaptation, validation, and measurement properties of the Spanish version of the anterior cruciate ligament-return to sport after injury (ACL-RSI-Sp) scale. Knee Surg Sports Traumatol Arthrosc 28(3):833–839. https://doi.org/10.1007/s00167-019-05517-z
Sandon A, Engström B, Forssblad M (2020) High Risk of Further Anterior Cruciate Ligament Injury in a 10-Year Follow-up Study of Anterior Cruciate Ligament-Reconstructed Soccer Players in the Swedish National Knee Ligament Registry. Arthroscopy 36(1):189–195. https://doi.org/10.1016/j.arthro.2019.05.052
Silva LO, Mendes LMR, Lima POP, Almeida GPL (2018) Translation, cross-adaptation and measurement properties of the Brazilian version of the ACL-RSI Scale and ACL-QoL Questionnaire in patients with anterior cruciate ligament reconstruction. Braz J Phys Ther 22(2):127–134. https://doi.org/10.1016/j.bjpt.2017.09.006
Slagers A, Reininga I, van den Akker-Scheek I (2017) The Dutch language anterior cruciate ligament return to sport after injury scale (ACL-RSI) - validity and reliability. J Sports Sci 35(4):393–401. https://doi.org/10.1080/02640414.2016.1167230
Slagers AJ, van den Akker-Scheek I, Geertzen JHB, Zwerver J, Reininga IHF (2019) Responsiveness of the anterior cruciate ligament - Return to Sports after Injury (ACL-RSI) and Injury - Psychological Readiness to Return to Sport (I-PRRS) scales. J Sports Sci 37(21):2499–2505. https://doi.org/10.1080/02640414.2019.16460231-7
Sommerfeldt M, Raheem A, Whittaker J, Hui C, Otto D (2018) Recurrent Instability Episodes and Meniscal or Cartilage Damage After Anterior Cruciate Ligament Injury: A Systematic Review. Orthop J Sports Med 6(7):2325967118786507. https://doi.org/10.1177/2325967118786507
te Wierike SC, van der Sluis A, van den Akker-Scheek I, Elferink-Gemser MT, Visscher C (2013) Psychosocial factors influencing the recovery of athletes with anterior cruciate ligament injury: a systematic review. Scand J Med Sci Sports 23(5):527–540. https://doi.org/10.1111/sms.12010
van Melick N, Pronk Y, Nijhuis-van der Sanden M, Rutten S, van Tienen T, Hoogeboom T (2022) Meeting movement quantity or quality return to sport criteria is associated with reduced second ACL injury rate. J Orthop Res 40(1):117–128. https://doi.org/10.1002/jor.25017
Webster KE, Feller JA (2018) Development and Validation of a Short Version of the Anterior Cruciate Ligament Return to Sport After Injury (ACL-RSI) Scale. Orthop J Sports Med 6(4):2325967118763763
Webster KE, Feller JA (2021) Evaluation of the Responsiveness of the Anterior Cruciate Ligament Return to Sport After Injury (ACL-RSI) Scale. Orthop J Sports Med 9(8):23259671211031240
Webster KE, Feller JA, Lambros C (2008) 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 9(1):9–15. https://doi.org/10.1016/j.ptsp.2007.09.003
Webster KE, Nagelli CV, Hewett TE, Feller JA (2018) Factors Associated With Psychological Readiness to Return to Sport After Anterior Cruciate Ligament Reconstruction Surgery. Am J Sports Med 46(7):1545–1550. https://doi.org/10.1177/0363546518773757
Welling W, Benjaminse A, Lemmink K, Gokeler A (2020) Passing return to sports tests after ACL reconstruction is associated with greater likelihood for return to sport but fail to identify second injury risk. Knee 27(3):949–957. https://doi.org/10.1016/j.knee.2020.03.007
Zarzycki R, Cummer K, Arhos E, Failla M, Capin JJ, Smith AH, et al (2023) Female Athletes With Better Psychological Readiness Are at Higher Risk for Second ACL Injury After Primary ACL Reconstruction. Sports Health. 19417381231155120. https://doi.org/10.1177/1941738123115512019417381231155120
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Faleide, A.G.H., Inderhaug, E. It is time to target psychological readiness (or lack of readiness) in return to sports after Anterior Cruciate Ligament tears. J EXP ORTOP 10, 94 (2023). https://doi.org/10.1186/s40634-023-00657-1