Psychological Readiness is the Main Barrier to Return to Play After Revision Anterior Cruciate Ligament...

Despite advances in modern surgical techniques, return-to-play (RTP) rates after revision anterior cruciate ligament reconstruction (R-ACLR) often fall short of patients' expectations. There is growing awareness that a patient's psychological recovery is as important as the functional recovery of their knee.

The primary purpose of this study was to determine the RTP rate and identify the barriers to RTP after R-ACLR. Secondarily, we compared the progression of psychological readiness (using the Anterior Cruciate Ligament-Return to Sport after Injury [ACL-RSI] scale) throughout rehabilitation between those who achieved RTP and those who did not. Finally, we assessed if RTP could be predicted for patients aged <23 years and patients aged ≥23 years based on their ACL-RSI scores at different time points during rehabilitation.

Case-control study; Level of evidence, 3.

This investigation included 301 patients who underwent R-ACLR at our institution. Preoperatively, patients completed a questionnaire detailing their demographic characteristics and target level of RTP. The ACL-RSI scale was also administered preoperatively and at 3 months, 6 months, and 9 months. At 2 years postoperatively, patients indicated whether or not they had returned to play. Those who did not return provided their reasons for not doing so.

The mean age was 25.4 ± 6.3 years, and 84.5% of patients were male. Although 95.1% of patients undergoing R-ACLR intended to return to play before surgery, only 63.4% achieved this goal at 2-year follow-up. The main barriers to RTP were a fear of reinjury (44%), a lack of confidence in performance (13%), and ongoing knee pain (11%). The mean preoperative ACL-RSI score was significantly higher in patients who returned to play than in those who did not (51.2 ± 23.4 vs 42.6 ± 23.3, respectively; P = .027), indicating greater psychological readiness to RTP. The mean ACL-RSI score was also significantly higher in those who achieved RTP at 3 months, 6 months, and 9 months. A preoperative ACL-RSI score of 42.9 points predicted RTP in patients aged <23 years, with a sensitivity of 76% and a specificity of 77% (area under the curve = 0.73). The ACL-RSI score was able to predict RTP at all time points, demonstrating the most accuracy preoperatively and at 6 months postoperatively. At 6 months, a cut-off score of 60.4 points predicted RTP in patients aged <23 years (sensitivity = 62%; specificity = 81%), and a cut-off score of 56.7 points predicted RTP in patients aged ≥23 years (sensitivity = 54%; specificity = 77%).

Psychological readiness, especially fear of reinjury, was a significant barrier to RTP after R-ACLR. Patients with lower psychological readiness who were less likely to return to play could be detected using the ACL-RSI scale.