Psychological Readiness to Return to Sport After Anterior Cruciate Ligament Reconstruction in the Adolescent Athlete

Anterior cruciate ligament (ACL) rupture is a serious injury that most often occurs during sport participation. Many athletes choose to undergo ACL reconstruction surgery with the aim of returning to their preinjury level of sport participation. However, the return-to-play rate has been estimated at only 50% to 80%.^1–3 Although many factors contribute to an athlete's return-to-sport decision, the importance of psychological recovery from such injuries is now well recognized.^4–6

An athlete's psychological readiness to return to sport, when measured during the rehabilitation period, has been strongly associated with actual return-to-sport rates and sport performance in predominantly adult populations.^7–10 Some adolescent athletes have been included in these studies, but the extent to which these relationships hold for a larger adolescent population has not been clarified. In a qualitative study, DiSanti et al¹¹ reported that psychosocial barriers were more consistently described by high school athletes aged 15–18 years than physical barriers during rehabilitation from ACL injury. Mechanisms for coping with injury and rehabilitation have also been investigated in adolescent athletes, and several have been associated with the time it takes to recover from ACL reconstruction surgery.¹² Poorer coping skills, decreased concentration, and difficulty with peaking under pressure have all been linked with a delay in recovery.¹² In adolescent athletes, less psychological readiness and greater fear of movement may also be associated with an increased risk for a second ACL injury once sport is recommenced.^13,14 These findings of psychological disturbance after athletic injury in adolescents have been explained by the idea that, because sport participation is such an important part of an adolescent athlete's identity, not being able to participate due to injury can have a significant negative effect on psychological well-being.¹¹ Therefore, psychological changes that occur after ACL injury in an adolescent athlete are likely to be of significant magnitude and may affect recovery.

The ACL-Return to Sport after Injury (ACL-RSI) scale has been used to quantify the psychological readiness to return to sport.¹⁵ However, limited information is available on its use in adolescent athletes. Kostyun et al¹⁶ recently used the ACL-RSI scale in a cohort of 93 adolescent athletes and found that scores sequentially increased over the first 6 to 7 months postsurgery and were typically higher than those reported in adult populations. Ellis et al¹² also showed that ACL-RSI scores improved over the first postoperative year in 68 adolescent athletes, and improvements were similar to those noted in adult populations. Neither group found an association between ACL-RSI scores and physician clearance to return to sport or the passing of a Y-balance test at 6 months. Unfortunately, neither study documented the actual return to sport, so any associations between ACL-RSI scores and return to play were not investigated. Therefore, we sought to examine the psychometric properties (reliability and validity) of the ACL-RSI scale in adolescent athletes at multiple time points after ACL reconstruction surgery. We also aimed to determine whether the scores for psychological readiness to return to sport could predict the return to sport in this younger cohort. We hypothesized that the scale would exhibit satisfactory psychometric properties and that scores at an earlier timepoint would predict the subsequent return to sport.

METHODS

Participants

The participants were part of a large longitudinal study of primary ACL reconstruction and were enrolled between December 2013 and June 2018. From this cohort, we selected all patients who were under 18 years at the time of surgery and had completed 6- and 12-month follow-up assessments. These time points were chosen because changes in the psychological readiness to return to sport are expected in this phase of rehabilitation, when patients begin to perform sport-specific drills and training before being cleared to return to play. This totaled 115 patients who were a highly active group pre-ACL injury (Table 1). All but 3 were full-time students.

Table 1 Patient and Preinjury Sports Characteristics

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All patients had undergone arthroscopically assisted ACL reconstruction with suspensory fixation on the femoral side and interference screw fixation on the tibial side by 1 of 3 experienced, specialized orthopaedic knee surgeons. The majority received hamstrings tendon grafts (n = 94). Medial meniscal tears were present in 28 patients (8 stable and not treated, 4 resected, 16 repaired) and lateral meniscal tears in 37 patients (15 stable and not treated, 17 resected, 5 repaired). Patients completed rehabilitation at a clinic of their choice, and standard rehabilitation protocols and guidelines were provided that encouraged immediate, full knee extension and the restoration of quadriceps function as soon as possible.¹⁷ Clearance to return to competitive sport typically occurred at 9 to 12 months postsurgery and was determined by the treating surgeon. None of the included patients had further surgery or sustained further ACL injury during the 6- to 12-month follow-up period.

RESULTS

The ACL-RSI scores recorded at the 6- and 12-month follow-ups are shown in Table 2. No floor or ceiling effects were present; 1 patient scored the maximum 100 at 6 months, as did 8 patients at 12 months. Scores for female patients were lower than for male patients at both time points; however, the same increase in scores was seen between the time points (mean difference for both male and female patients was 15.8 points, P < .0001, effect size = 0.98).

Table 2 Descriptive Statistics for Anterior Cruciate Ligament-Return to Sport after Injury Scale Scores at 6 and 12 Months

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The scale displayed high internal consistency, with a Cronbach α of 0.91 at 6 months and 0.94 at 12 months. At both time points, principal component analysis indicated the presence of 2 underlying factors, which accounted for 64% (33% by factor 1, 31% by factor 2) of the variance at 6 months and 73% (38% by factor 1, 35% by factor 2) of the variance at 12 months. The 7 items associated with factor 1 were all from the confidence in performance and risk appraisal domains of the scale, whereas the 5 items that were associated with factor 2 were the emotions items (Table 3). Therefore, we calculated scores for these 2 factors (confidence and risk appraisal subscale and emotions subscale), as well as the overall scale. Mean values were higher for confidence in performance and risk appraisal items than for emotions items. The item on which the patients scored lowest was “Do you find it frustrating to have to consider your knee with respect to your sport?” with a mean value of only 30 out of 100 at the 6-month follow-up (Table 3).

Table 3 Anterior Cruciate Ligament-Return to Sport after Injury Scale Scores at 6 and 12 Months for the 2 Identified Factors (Mean ± SD)

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At 6 months, no patient had returned to play; 76% (87/115) of patients had not attempted any form of sport and 24% (28/115) had recommenced training. At 12 months, 30% (34/115) of patients had not attempted any form of sport, 37% (43/115) had recommenced training, and 33% (38/115) had recommenced play at any level of competition (27 at the same or a higher level than preinjury and 11 at a lower level). The ACL-RSI scores at 6 months were higher for patients who had returned to play at 12 months (Table 4). Of the 2 subscales, scores on the emotions subscale were higher at 6 months for patients who returned to play at 12 months, but there was no difference between the scores of those who did and those who did not return to play on the confidence and risk appraisal subscale (Table 4). The ROC analysis showed the same pattern of results: 6-month ACL-RSI scores and scores on the emotions subscale had fair to good predictive ability for a return to play at 12 months (full scale: area under the ROC curve = 0.7, P = .03; emotions subscale: area under ROC curve = 0.73, P = .009; Figure), whereas no significant association was seen for the confidence and risk appraisal subscale (area under the ROC curve = 0.59, P = .09).

Table 4 Comparison of Anterior Cruciate Ligament-Return to Sport after Injury Scale Scores at 6 Months With Return-to-Play Status at 12 Months Postreconstruction

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DISCUSSION

We explored the use of the ACL-RSI scale to measure psychological readiness to return to sport in adolescent athletes after ACL reconstruction. Our results suggest that the scale has value for use in this population. The scale was not subject to floor or ceiling effects, and scores at a 6-month postoperative assessment subsequently improved. Recent work¹⁹ has shown that a change score of 13.4 points reflects a minimally important change in psychological readiness at a group level. Thus, the magnitude of change (15.8 points) seen in this adolescent cohort was of sufficient magnitude to be clinically meaningful. The scale also had good ability to predict return-to-sport status at 12 months. This is consistent with and complements previous findings in adult populations.^20,21

Similar to adults, the scale had high internal consistency in adolescents, indicating that the items were measuring the same construct, that of psychological readiness. However, an interesting point of difference between the current adolescent cohort and previous adult populations was the factor structure of the scale. The ACL-RSI scale was designed around 3 domains (emotions, confidence in performance, and risk appraisal), and although it was initially thought that this might result in 3 underlying factors, most prior adult population samples have revealed that only 1 underlying factor was present.^{15,20,22–25} Yet in the current adolescent cohort, 2 underlying factors were found at both time points. The first factor included all 7 items from the confidence in performance and risk appraisal domains, whereas the second included all 5 items from the emotions domain. From a user perspective, this means that a total score for the scale can be calculated, as can separate scores for each of these factors. It is interesting that 2 similar factors were identified during the Spanish translation of the ACL-RSI scale in which the mean age of the sample was 21 years.²⁶ This cohort was older than ours but younger than the participants in most of the earlier studies, in which the typical mean age was 28 to 30 years.^15,23–25

The presence of subfactors does not change the overall scale validity, and scores on the full ACL-RSI scale at 6 months adequately predicted the return to sport at 12 months. Nonetheless and of potential benefit is that exploration of subscale scores may enable a more thorough understanding of which specific aspects of psychological readiness might be important or relevant in adolescent athletes. In this regard, it was clear that our sample's emotional response seemed to be the most influential determinant of psychological readiness to return to sport. At 6 months, our cohort showed relatively high levels of frustration followed by fear, and scores on the emotions subscale had good predictive ability for the return to sport at 12 months. It is not surprising that adolescent athletes, particularly those who are eager to resume sport, might be frustrated at this point in their rehabilitation, because adolescents who strongly identify with the athletic role (ie, have a high degree of athletic identity) are known to display higher levels of emotional disturbance after injury.²⁷ This is thought to be due to a loss of identity when they are unable to participate in sport and, for those who play team sports, the loss of involvement with their team.^28,29 Frustration may also be related to the athlete's coping style; evidence suggests this differs according to the athlete's age, with younger athletes less able to identify ways in which a stressor may be beneficial (positive reframing).³⁰ Although it is unclear whether a strong desire to return to sport, a loss of athletic identity, or coping style contributed to the feelings of frustration and emotional responses expressed by the adolescent athletes in this study, our results indicate that addressing such frustrations may be beneficial. This should be explored in future research.

Fear of reinjury has been one of the most common reasons cited by athletes who do not resume sport after ACL injury.³¹ Consistent with prior work, the current cohort of adolescent athletes was moderately fearful at both time points. Fear of movement has also been studied in young athletes returning to sport after ACL reconstruction.¹⁴ This pilot work showed that athletes (aged 10–25 years) with high levels of fear were 4 times more likely to report lower levels of activity and 6 to 7 times more likely to score worse on tests of functional performance.¹⁴ They were also 13 times more likely to have a graft rupture within 2 years after returning to sport. However, some degree of imprecision exists regarding this estimate due to the relatively small sample size of 40 athletes. Nonetheless, it clearly highlights the potential negative effect such emotions may have on recovery and even the future risk of injury. Adolescent athletes' emotional responses recorded using the short version of the ACL-RSI were similarly shown to be lower at 12 months postsurgery in adolescent athletes who went on to sustain a further ACL injury, whereas confidence in performance and risk appraisal items were not different.³² Confidence did not seem to be a significant concern in our cohort of younger athletes, who by 12 months were highly confident about their ability to perform well (mean scores >80/100).

Limited additional data exist with which to compare our findings. Fones et al³³ surveyed a group of young athletes (mean age = 16 years at surgery) at a mean of 4 years after surgery and reported that ACL-RSI scores were lower for patients who did not successfully return to their primary sport. Yet because the measures were only obtained at 1 time point, it is unclear whether the higher scores in the group that returned were simply because they were already participating in sport. Still, the strong association between ACL-RSI scores and sporting status is consistent with our current results.

Our study was not without limitations. Patients were from a single private metropolitan clinic and were a relatively homogeneous population. Responses were measured at only 2 time points 6 months apart, and further work is needed to investigate longer-term outcomes. Most of the patients were at the upper end of the adolescent age range (15–17 years), and thus, the current data may be less generalizable to the early adolescent years. In our prediction analysis, we did not differentiate between patients who had returned to the same level of sport as before injury and those who returned to a lower level. We felt that 12 months was too early for all patients to have an adequate opportunity to return to their prior level of participation, and as such, future researchers should explore the relationship between psychological readiness and the level of sport to which adolescent athletes return over a longer follow-up period. Male patients scored higher on the ACL-RSI than female patients, although the absolute change in scores over time was the same. The current study was insufficiently powered to further investigate sex differences, and this is also an area worthy of examination.

CONCLUSIONS

We confirmed that the ACL-RSI scale can be used without modification in adolescent athletes. The psychometric properties are sound, and the scores at 6 months were associated with subsequent return to sport. We also found that the adolescent athletes' emotional response appeared to be more influential than their confidence or appraisal of risk in predicting a return to sport.