Female Athletes With Better Psychological Readiness Are at Higher Risk for Second ACL Injury After Primary ACL Reconstruction

Abstract

Background: Approximately 1 in 4 athletes returning to sports will sustain a second anterior cruciate ligament (ACL) injury. Psychological factors related to kinesiophobia, confidence, and psychological readiness are associated with second ACL injury; however, the evidence is conflicting. Hypothesis: Athletes who sustain a second ACL injury (ie, graft rupture or contralateral ACL rupture) within 2 years of ACL reconstruction (ACLR) would have greater kinesiophobia, less confidence, and lower psychological readiness prior to return to sport (RTS) compared with athletes who do not sustain a second ACL injury. Study Design: Secondary analysis of a prospective randomized trial. Level of Evidence: Level 3. Methods: A total of 39 female Level I/II athletes completed the following measures after postoperative rehabilitation and a 10-session RTS and second ACL injury prevention program: ACL Return to Sport after Injury (ACL-RSI) scale, the 11-item Tampa Scale of Kinesiophobia (TSK-11), and question 3 on the Knee injury and Osteoarthritis Outcome Score (KOOS) quality of life (QoL) subscale. Athletes were dichotomized based on whether they sustained a second ACL injury within 2 years of ACLR or not. Independent t tests determined group differences in TSK-11, KOOS-QoL, ACL-RSI, and the 3 individual components of the ACL-RSI (ie, emotions, confidence, risk appraisal). Results: Nine athletes sustained a second ACL injury (4 graft ruptures and 5 contralateral ACL ruptures). The group that sustained a second ACL injury had higher scores on the ACL-RSI ( P = 0.03), higher on the risk appraisal questions of the ACL-RSI ( P < 0.01), and met RTS criteria sooner than athletes who did not ( P = 0.04). All second ACL injuries occurred in athletes who underwent primary ACLR with hamstring tendon autografts. Conclusion: Athletes who sustained a second ACL within 2 years of ACLR had a more positive psychological outlook, higher scores on the specific questions related to the risk appraisal construct of the ACL-RSI, and met RTS criteria sooner than athletes who did not sustain a second ACL injury. Clinical Relevance: Counseling athletes about delaying RTS to reduce the risk of second ACL injury may be especially important in athletes who display high psychological readiness and meet RTS criteria sooner.

Anterior Cruciate Ligament‐Return to Sport after Injury (ACL‐RSI) subcategories are affected by subjective running ability and medial single‐leg hop distance in postreconstruction patients at 6 months

“…These results suggest that 6 months after reconstruction, increasing the ability to run and SLH distances in both the anterior and lateral directions will lead to improved results in risk appraisals. On the other hand, a recent study in female patients 7 months after reconstruction reported that higher Risk Appraisal scores were associated with a second injury [ 10 ]. Younger age was associated with higher Risk Appraisal score [ 34 ].…”

“…Therefore, the ability to interpret the contribution of the involved limb variable to the overall ACL‐RSI value remains limited. Subcategory scores are affected by age and gender, so these must be taken into account when generalizing the findings [ 10 , 34 ]. In addition, the focus on hamstring tendon reconstruction limits the generalizability of findings to broader populations and different types of reconstructions.…”

“…Lower ACL‐RSI total score has been associated with the occurrence of secondary injuries after reconstruction [ 9 ]. On the other hand, the Risk Appraisal subcategory score of ACL‐RSI at 7 months after reconstruction has been reported to be higher for those who sustained a second injury within 2 years after surgery than for those who did not experience reinjury [ 10 ]. In recent years, inclusion of the ACL‐RSI score in criteria for the return to sport has been recommended [ 3 , 7 ].…”

Differences in psychological readiness for return to sport after anterior cruciate ligament injury is evident in thigh musculature motor unit characteristics

“…13 Contrarily, another study with a smaller sample size has also demonstrated that females with higher ACL-RSI scores were more likely to have a second ACL injury. 35 Thus, with the discrepancy of ACL-RSI scores with re-injury, this study was uniquely designed to differentiate objective MU characteristics of thigh musculature between those with disparate ACL-RSI scores (RSI-high and RSI-low) at 6 months and 12 months post-injury and healthy CTRLs. 31 36 This study aimed to determine the relationship of a subjective psychological readiness metric to RTS to objective measures of bilateral motor CTRL.…”