The Psychology of Return to Sport in Youth Athletes After ACL Reconstruction

Introduction
Approximately 25% of all anterior cruciate ligament (ACL) injuries in the United States occur in adolescent patients.¹ Sustaining an ACL tear significantly impacts a young athlete’s career with between approximately 89% of pediatric and adolescent athletes able to return sport after ACL reconstruction (ACLR), and 68% to 74%  able to return to their previous level.^2,3 Adolescent athletes are especially vulnerable to long term consequences of ACL injuries as they require substantial time away from sport at a crucial time in precollegiate years and if not rehabilitated correctly, can lead to sequelae such as reinjury, additional surgeries, and extra time away from sport.

Return to sport (RTS) metrics have traditionally involved physical measures such as strength, symmetry, and range of motion, but an increase in recent evidence suggests a clear need to incorporate psychological readiness into RTS decisions. The importance of a multidisciplinary approach is emphasized by the findings that young athletes who experience high levels of kinesiophobia (i.e., fear of painful movement and/or reinjury), low psychological readiness, and altered knee confidence are at increased risk of sustaining a second ACL injury.^4–6 This article synthesizes recent evidence on the psychology of RTS in young athletes after ACLR, with a focus on practical assessment and intervention strategies. 

Assessing Psychological Burden
The psychological burden of ACL injury is commonly measured using two validated tools: the ACL Return to Sport after Injury (ACL-RSI) scale, a 12-item questionnaire of psychological readiness encompassing emotion, confidence, and risk appraisal scored 0 to 100, and the Tampa Scale for Kinesiophobia (TSK-11), an 11-item questionnaire of fear of movement and reinjury.^7–9 The TSK has several versions including the TSK-17 and TSK-13 that are longer than the TSK-11; however, the TSK-11 is most frequently used in this setting and has been validated specifically in the ACLR population.¹⁰ Butler et al found that 47.9% of 315 participants aged 13 to 30 scored below the validated ACL-RSI pass threshold of 77 at an average of 8.2 months post-surgery, and identified a moderate inverse correlation between ACL-RSI and TSK-11 scores in both teens (r = −0.59) and adults (r = −0.45), with every one-point increase in TSK-11 associated with 28% higher odds of unacceptable psychological readiness.¹¹ Baez et al similarly found that among 101 ACLR patients aged 13 to 25 who were assessed at six to 12 months post-surgery, lower ACL-RSI scores were associated with 2.1 times greater odds of persistent knee symptoms, and higher TSK-11 scores with 1.9 times greater odds, independent of age, sex, body mass index, and graft type.¹²   

Demographic Considerations
Psychological readiness can vary by age and sex. Previous studies have shown that younger athletes report higher psychological readiness scores than adults.⁷ In a study of 154 ACLR patients aged 14 to 30 by Roman et al, teens reported significantly higher ACL-RSI total scores and confidence subscale scores compared with adults at 6 to 12 months post-surgery.¹³ Butler et al found similar results with adults being twice as likely as teens to report unacceptable psychological readiness.¹¹ These findings suggest that different thresholds for psychological readiness should be considered by age. Neither study observed a difference in ACL-RSI scores by sex. 
However, there are known significant differences in male and female recovery patterns post-ACLR. Amongst adolescent ACL injuries, females were 1.4 times less likely to return to their preinjury level of sport after ACLR than their male counterparts, with 24% to 30% of adolescent female athletes who did return to sport experiencing a second ACL injury within two years of ACLR.^14–16 In a study examining female athletes who sustained a second ACL injury within two years of their initial ACLR, it was shown that those who sustained a second injury actually had higher psychological readiness scores at RTS testing than those without reinjury.⁴ This finding may suggest that high self-reported readiness that is incongruent with functional readiness could paradoxically increase reinjury risk.

In a study of male and female high school athletes with a history of ACLR, overall psychological readiness and fear of reinjury did not differ by sex, but male and female athletes described distinct psychological experiences during recovery. Qualitative analysis showed that males described distress related to perceived poor physical performance and slow pace of recovery. Females emphasized a greater external locus of control and valued social support and relationships with their health care team as a positive factor in recovery, whereas a perceived lack of attention from health care professionals was seen as a barrier.¹⁷ While objective ACL-RSI scores may suggest no differences between sexes in psychological readiness, these qualitative data suggest that the psychological factors contributing to these calculated scores may differ between sexes.

Who Needs Intervention?  
A systematic review and meta-analysis by Bullock et al of 73 studies with over 7,000 patients found that kinesiophobia and knee self-efficacy improve substantially from preoperatively to three to six months post-ACLR but then typically plateau after.⁵ With most patients returning to sport after nine months, this plateau in psychological readiness earlier than the average time to RTS means that significant improvement in metrics like ACL-RSI and TSK-11 should be seen prior to clearance to RTS.

Knowledge of a patient’s specific fears driving kinesiophobia may also provide insights on how to prepare a patient psychologically to RTS. A multisite latent class analysis of 134 ACLR patients (mean age 20.2 years) identified two distinct subgroups among less-active patients: a fear/symptom-limited group (71%), driven by fear of reinjury, concern that activity would worsen knee health, and fear of symptoms with movement, and a symptom-limited group (29%), whose primary barrier was physical knee symptoms such as pain, swelling, and locking. Despite reporting similar physical symptoms and performance-based function, the fear/symptom-limited group had the lowest psychological readiness and highest kinesiophobia, anxiety, and depression of all groups, underscoring the value of distinguishing fear-driven from symptom-driven barriers when tailoring intervention.¹⁸

Psychological Intervention Strategies
Both the ACL-RSI and TSK-11 take less than 10 minutes to administer and require no additional equipment or clinic visits, making them practical for routine screening. For athletes with greater fear or reduced psychological readiness, graded exposure therapy (GET) has the most evidence of the psychological interventions. GET involves progressive, systematic exposure to sport-specific movements or situations that provoke fear such as cutting, landing, or player contact. These situations are presented to the patient in a hierarchy of increasing intensity. A systematic review and meta-analysis of psychological interventions for patients undergoing ACLR, which included graded exposure approaches, found that such interventions improve psychological readiness and reduce fear of reinjury.¹⁹

Baez et al demonstrated feasibility and early efficacy of GET in females with a history of ACLR, showing reductions in injury-related fear and improvement in physical function.²⁰ A randomized controlled trial comparing GET, cognitive restructuring, and standard care in athletes ages 16 to 25 at three to six months post-ACLR reported that the GET group had significantly greater reductions in TSK-11 scores, and improved biomechanics, functional metrics, and improved RTS rates compared with cognitive restructuring and standard care.²¹

Clinical Takeaways for Practice

Psychological readiness should be incorporated into clearance for return to sport and should be interpreted in the context of objective physical testing. ACL-RSI and TSK-11 are easily administered in the clinic setting and would be most beneficial to administer over several time points, such as three, six, and nine months post-ACLR in young athletes. Attention should be paid to subscales rather than total scores alone, since subscales can reveal important nuances that total scores may mask. Preparation for RTS should be tailored to whether a lack of readiness is driven by psychological or functional barriers. For example, kinesiophobia-driven patients may benefit from graded exposure and psychologically informed rehabilitation, while symptom-driven patients may benefit more from functional progression and strengthening. Clinicians should refer to mental performance consultants and sport psychologists when appropriate to support a multidisciplinary approach to rehabilitation.

References

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