The Ankle Ligament Reconstruction-Return to Sport after Injury (ALR-RSI) is a valid and reliable measure to assess psychological readiness before returning to sport following peroneal tendon pathology surgery.

PURPOSE: The objective of this study was to validate a scale that could help surgeons evaluate patients' psychological readiness to return to sport (RTS) after peroneal tendon pathology surgery. METHODS: The Ankle Ligament Reconstruction-Return to Sport after Injury (ALR-RSI) scale, which had previously been validated in ankle ligament reconstruction patients, was adapted to evaluate the psychological preparedness for RTS in athletic patients who underwent peroneal tendinopathy surgery. The Foot and Ankle Outcome Score (FAOS) and Foot Ankle Ability Measurement (FAAM) scores were employed as patient-related outcome measurement (PROM) instruments. RESULTS: This study included 57 patients. There was a strong correlation between ALR-RSI and both FAOS and FAAM (r = -0.68 and 0.74, respectively). ALR-RSI was considerably higher in patients who returned to sports than in those who did not. The mean score was 72.9 ± 19.0 in patients who returned to the same preinjury level, 48.5 ± 24.0 in those who returned to a lower level and 53.6 ± 31.1 in patients who changed their athletic activity (p < 0.0001). Furthermore, ALR-RSI showed at least a similar discrimination ability when compared to FAOS and FAAM. The test-retest intraclass correlation coefficient was 0.95. The Cronbach's α statistic used to measure the internal consistency was high (0.95). A Youden index of 0.65 was observed for a cut-off score of 68 points. CONCLUSION: ALR-RSI is a valid instrument for assessing psychological readiness to RTS in an athletic population following peroneal tendon surgery. When compared to the most commonly used PROMs, it was strongly correlated and demonstrated at least similar discrimination capacity. This could assist surgeons in identifying athletes who will have poor postoperative results and advising them on their capability to RTS. LEVEL OF EVIDENCE: Level III.

Validation of the Ankle Ligament Reconstruction-Return to Sports after Injury (ALR-RSI) Score as a Tool to Assess Psychological Readiness to Return to Sport in an Active Population After Ankle Fracture Surgery: A Cross-sectional Study.

Ankle injuries account for 15% to 25% of all sports injuries resulting in significant pain and loss of function. The purpose of this cross-sectional study was to validate a scale to help surgeons quantify the psychological readiness to Return To Sport (RTS) in patients undergoing ankle fracture surgery. ALR-RSI was used to assess the psychological readiness for RTS in athletic patients who underwent ankle fracture fixation between January 2020 and January 2021. Participants filled out ALR-RSI and 2 Patient-Related Outcome Measurement (PROM) tools: Olerud-Molander Ankle Score (OMAS) and Self-Reported Foot and Ankle Score (SEFAS). A total of 93 patients were included. There was a strong correlation between ALR-RSI and both OMAS and SEFAS, with Pearson coefficients of r = 0.58 and 0.53, respectively. ALR-RSI was significantly higher in the RTS group than in those who no longer practiced their main preinjury sport. Moreover, the discriminant validity of ALR-RSI (AUC = 0.81) was better than that of the SEFAS and OMAS (AUC = 0.64 and 0.65, respectively, p = .001). The intra-class correlation coefficient ρ of 0.94 showed excellent reproducibility. At an optimal cutoff value of 76.7, ALR-RSI had a sensitivity of 81% and a specificity of 75% with a Youden index of 0.56. In conclusion, ALR-RSI was a valid and reproducible tool to evaluate the psychological readiness for RTS in an active population after an ankle fracture. This score could help surgeons identify athletes who may have unfavorable postoperative outcomes and provide support on the ability to RTS.

Preoperative Rehabilitation Enhances Mental and Physical Well-Being in Anterior Cruciate Ligament-Injured Individuals: A Mixed Methods Study.

CONTEXT: Rehabilitation after an anterior cruciate ligament injury is recommended to be started soon after the injury. When surgery is required, research supports the delivery of physiotherapy before anterior cruciate ligament reconstruction (prehabilitation) to optimize recovery and positive outcomes. Individuals attending prehabilitation have never been questioned regarding their adherence to prehabilitation, perception of utility in meeting needs, upcoming events, or anticipated recovery goals. DESIGN: Mixed methods cross-sectional study: Methods: 25 individuals before anterior cruciate ligament reconstruction (43% of eligible individuals from 12 clinics during the delivery period) were surveyed on their mindset and recovery expectancies. Semistructured interviews conducted in 9 of 25 participants assessed their lived experience of prehabilitation. RESULTS: Participants reported that preventing a reinjury (96% of responses) and feeling confident during daily activities about their knee (92%) were the higher rating expectations at this stage of their treatment course. Three themes were developed from the interviews and analyses. (1) Participants reported that prehabilitation was a period full of challenges with memories of the injury and uncertainties. (2) They viewed prehabilitation as a step to move forward by finding support and self-motivating. (3) They believed that prehabilitation would have positive impacts on the treatment outcomes. Participants were confident that prehabilitation would accelerate the recovery of muscle volume (88%) and strength (84%). CONCLUSION: Participants had positive experiences of prehabilitation, aligning with the findings on functional outcomes in the existing literature on prehabilitation.

Return to Sport After Anterior Cruciate Ligament Reconstruction Requires Evaluation of >2 Functional Tests, Psychological Readiness, Quadriceps/Hamstring Strength, and Time After Surgery of 8 Months.

PURPOSE: The purpose of this study was to examine the factors commonly used to determine readiness for return to sport (RTS) in the ACL reconstruction (ACL-R) patient population and assess which were most influential to successfully returning to sport and avoiding re-tear. METHODS: The PUBMED, EMBASE and Cochrane Library databases were queried for studies related to RTS in ACL-R. Inclusion and exclusion criteria were applied to identify studies with greater than 1-year outcomes detailing the rate of return and re-tear given a described RTS protocol. Data of interest were extracted, and studies were stratified based on level of evidence and selected study features. Meta-analysis or subjective synthesis of appropriate studies was used to assess more than 25 potentially significant variables effecting RTS and re-tear. RESULTS: After initial search of 1503 studies, 47 articles were selected for inclusion in the final data analysis, including a total of 1432 patients (31.4% female, 68.6% male). A meta-analysis of re-tear rate for included Level of Evidence 1 studies was calculated to be 2.8%. Subgroups including protocols containing a strict time until RTS, strength testing, and ≥2 dynamic tests demonstrated decreased RTS and re-tear heterogeneity from the larger group. Time to RTS, strength testing, dynamic functional testing, and knee stability were also found to be among the most prevalent reported criteria in RTS protocol studies. CONCLUSIONS: This study suggests a multifactorial clinical algorithm for successful evaluation of RTS. The "critical criteria" recommended by the authors to be part of the postoperative RTS criteria include time since surgery of 8 months, use of >2 functional tests, psychological readiness testing, and quadriceps/hamstring strength testing in addition to the modifying patient factors of age and female gender. LEVEL OF EVIDENCE: Level IV, systematic review of Level I-IV studies.

Kinesiophobia Is Negatively Associated With Psychological Readiness to Return to Sport in Patients Awaiting Anterior Cruciate Ligament Reconstruction.

PURPOSE: To identify the factors associated with anterior cruciate ligament return to sport after injury (ACL-RSI) scores in patients awaiting ACL reconstruction (ACLR). METHODS: This was a retrospective cross-sectional observational study conducted at a single clinical center. We recruited patients scheduled for primary ACLR, aged 16-45 years, and with modified Tegner activity scale scores ≥5 before ACL injury. The main outcome was psychological readiness to return to sport (RTS), as measured using the ACL-RSI scale. Participants' personal and injury-related information were obtained, and their psychological status (Tampa Scale for Kinesiophobia [TSK] and athletic identity measurement scale) and knee functions (effusion, range of motion, joint stability, and knee flexion angle during a single-leg squat) were examined. All variables were assessed the day before the surgery. RESULTS: A total of 105 patients (median [interquartile range]: age, 20.0 [9.0] years; body mass index, 22.8 [4.3] kg/m2; days from injury to surgery, 63.0 [65.0] days; 44% female) were enrolled. Univariate analysis indicated that only the TSK score was associated with the ACL-RSI scores (r = -0.305; P = .02). Multiple regression analysis of factors, including sex, preinjury Tegner activity scale score, and days from injury to surgery, further showed that only the TSK score was associated with the ACL-RSI scores (P = .002; 95% confidence interval -1.738 to -0.394). CONCLUSIONS: In patients awaiting ACLR, kinesiophobia was moderately negatively associated with psychological readiness to RTS, while other factors were not. LEVEL OF EVIDENCE: Level III, retrospective cross-sectional observational study.

Editorial Commentary: Supporting Patients Psychologically and Reducing Kinesiophobia May Improve Anterior Cruciate Ligament Reconstruction Outcomes.

Athletes face an uphill battle after an anterior cruciate ligament tear if they want to return to their sport. Almost one-third of patients never return to their preinjury level of sport involvement, and many athletes dread this outcome. Although this distress is an understandable reaction, it can be demotivating, and psychological engagement in the recovery process is crucial to achieving desired outcomes. In particular, psychological readiness to return to sport is associated with greater likelihood of returning to sport. However, other psychological factors, including kinesiophobia, can negatively impact readiness to return to sport preoperatively and postoperatively. Supporting patients psychologically and reducing kinesiophobia throughout the recovery process may be essential to improving outcomes after an anterior cruciate ligament tear.

Patients that maintain their pre-injury level of physical activity 3-5 years after ACL reconstruction are, 18 months after surgery, characterised by higher levels of readiness to return to sport.

PURPOSE: To characterise patients who had returned to their pre-injury physical activity (PA) or higher at 18 months and maintained that level of PA 3-5 years after the primary ACL reconstruction and to describe the level, frequency, and type of PA participation during the first 5 years after ACL reconstruction  METHOD: Data, from follow-ups at 18 months and 3-5 years after an ACL reconstruction, were extracted from a rehabilitation-specific register. Patients, 15-65 years of age, were included. The data comprised patient-reported outcomes and the results from two questions with respect to the level, frequency, and type of PA. Comparisons were made between patients who had and had not maintained their pre-injury level of PA at the follow-up 3-5 years after an ACL reconstruction. RESULTS: A total of 272 patients met the inclusion criteria. The mean follow-up time was 3.8 years (min-max: 2.9-5.1) after the ACL reconstruction. Of patients who had returned to their pre-injury or a higher level of PA at the 18 month follow-up (n = 114), 68% (n = 78) maintained that level at the 3- to 5-year follow-up after ACL reconstruction. These patients reported a higher level of psychological readiness to return to sport (98 versus 79; p = 0.013). Moreover, these patients were 6.0 years older (p = 0.016) and were characterised by male sex (56% versus 44%; p = 0.028) and a lower level of pre-injury PA (p = 0.013). At the follow-up 3-5 years after the ACL reconstruction, more than 90% met the recommendations for PA. However, the prevalence of physical inactivity had increased and the involvement in organised PA had decreased compared with the 18-month follow-up. CONCLUSIONS: Two out of three patients who have returned to their previous level of PA at 18 months can be expected to maintain that level, 3-5 years following ACL reconstruction. These patients were mainly characterised by a higher level of psychological readiness, especially in patients who participated in knee-strenuous sport and were younger than 20 years of age. The results of this study suggest that patients become more physically inactive over time, implicating the importance of clinicians helping patients find a suitable PA that may help patients maintain an active lifestyle.

Anterior Cruciate Ligament-Return to Sport After Injury Scale: Reliability and Validity of the Persian Version.

BACKGROUND: The Anterior Cruciate Ligament-Return to Sport after Injury scale (ACL-RSI) is used to measure athletes' psychological readiness in terms of their emotions, confidence in performance, and risk appraisal with respect to return to sport after ACL reconstruction. OBJECTIVE: To translate and cross-culturally adapt the ACL-RSI to the Persian version and evaluate the reliability and validity of this scale in patients with ACL reconstruction. STUDY DESIGN: Clinical measurement study (psychometric analysis). METHODS: To assess test-retest reliability, 100 participants were asked to complete the Persian version of the ACL-RSI 2 times with a 7- to 10-day interval. In the first assessment, the patients also filled the Injury-Psychological Readiness to Return to Sport Questionnaire, Tampa Scale of Kinesiophobia, International Knee Documentation Committee Subjective Knee Form, and Knee Injury and Osteoarthritis Outcome Score. Internal consistency (Cronbach alpha, α), test-retest reliability (intraclass correlation coefficients), measurement error (standard error of measurement and minimum detectable change), and construct validity (Pearson r) were determined. RESULTS: Our results showed good internal consistency (Cronbach alpha = .94) and excellent test-retest reliability (intraclass correlation coefficients = .90 (.85-.93)]. Standard error of measurement and minimum detectable change were 4.64 and 12.85, respectively. No significant bias was observed between test and retest. In addition, based on the results of correlation analysis, all hypotheses of this study were confirmed. The Persian version of the ACL-RSI had a strong correlation with Injury-Psychological Readiness to Return to Sport (I-PPR) (P < .001, r = .76) and Tampa scale of Kinesiophobia (TKS) (P < .001, r = -.68). Furthermore, a moderate correlation was observed between the Persian version of the ACL-RSI and the International Knee Documentation Committee Subjective Knee Form (P < .001, r = .44) and between this version of the ACL-RSI and the subscales of Knee Injury and Osteoarthritis Outcome Score (P < .001, r = .30-.55). CONCLUSION: Given its acceptable reliability and validity, the Persian version of the ACL-RSI seems to be a suitable tool for evaluating psychological readiness to return to sport after ACL reconstruction.

Editorial Commentary: Why the Mind Matters in Anterior Cruciate Ligament Injury Recovery: Psychological Readiness and Return to Sport.

Following anterior cruciate ligament injury and surgery, it is important that we prepare athletes to return to sport not only from a physical perspective but also a psychological one. Typically, we are concerned for an athlete who has low confidence or high anxiety. However, can being too psychologically ready to return to sport also be a bad thing? While the optimal psychological profile will vary from person to person, evidence is emerging that more extreme responses may have detrimental consequences and increase the risk of further injury.

The ALR-RSI score is a valid and reproducible scale to assess psychological readiness before returning to sport after modified Broström-Gould procedure.

PURPOSE: Psychological readiness scores have been developed to optimize the return to play in many sports-related injuries. The purpose of this study was to statistically validate the ankle ligament reconstruction-return to sport injury (ALR-RSI) scale after modified Broström-Gould (MBG) procedure. METHODS: A similar version of the ACL-RSI scale with 12 items was adapted to quantify the psychological readiness to RTS after MBG and to describe construct validity, discriminant validity, feasibility, reliability and internal consistency of the scale, according to the COSMIN methodology. The term "knee" was replaced by "ankle". The AOFAS and Karlsson scores were used as references patient-related outcome measurements (PROMs). RESULTS: A total of 71 patients were included. The ALR-RSI score after MBG procedure was highly (r > 0.5) correlated to the AOFAS and Karlsson scores, with a Pearson coefficient r = 0.69 [0.54-0.80] and 0.72 [0.53-0.82], respectively. The mean ALR-RSI score was significantly greater in the subgroup of 55 patients who resumed sports activity compared to those that no longer practiced sport: 61.9 (43.8-79.6) vs 43.4 (25.0-55.6), (p = 0.01). The test-retest showed an "excellent" reproducibility with a ρ intraclass correlation coefficient of 0.93 [0.86-0.96]. The Cronbach's alpha statistic was 0.95, attesting an "excellent" internal consistency between the 12 ALR-RSI items. CONCLUSION: The ALR-RSI score is a valid and reproducible tool for the assessment of psychological readiness to RTS after an MBG procedure for the management of CLAI, in a young and active population. The ALR-RSI score may help to identify and counsel athletes on their ability to return to sport. LEVEL OF EVIDENCE: III.

[How and why to monitor apprehension after anterior cruciate ligament surgery]. / Évaluation de l'appréhension avant la reprise de sport suite à la chirurgie du ligament croisé antérieur - Comment la monitorer et pourquoi ?

Numerous studies highlight the psychological aspect being the most frequent factors limiting the resumption of sport, following an anterior cruciate ligament reconstruction surgery, even before strength, the capacity of performing high impact pivoting movements, endurance, or joint stability. Scores that quantify apprehension, have been developed as clinical tool to monitor psychological readiness and in some cases to delay the moment for return to sport. Unfortunately, there are no established cut-off values for these scores to predict when and if return to sport at the same level as pre-traumatically can be resumed. The psychological aspect of return to sport remains individual, and influenced by age, type, and level of physical activity.

De nombreuses études mettent en avant l'aspect psychologique comme étant l'un des principaux facteurs limitant la reprise de sport après reconstruction du ligament croisé antérieur, même avant le manque de force, les sauts et mouvements en pivot à haute intensité, l'endurance ou la stabilité mécanique du genou. Des scores, permettant de quantifier le degré d'appréhension, ont été élaborés afin de suivre la confiance ressentie du patient lors de mouvements liés au sport et de retarder la reprise sportive si nécessaire. Malheureusement, pour l'instant, aucun consensus n'est établi dans la littérature autour d'une valeur seuil de ces différents scores pour la reprise de sport. L'interprétation de ces scores reste pour l'instant une évaluation individualisée, influencée par l'âge, le type et le niveau du sport pratiqué par le patient.

Psychological impairments after ACL injury - Do we know what we are addressing? Experiences from sports physical therapists.

Psychological impairments can follow an anterior cruciate ligament (ACL) injury and can impact the rehabilitation process. Our aim was to investigate experiences of sports physical therapists (PTs) in addressing psychological impairments in patients after ACL injury. We conducted four focus group interviews with fourteen sports PTs. The PTs' experiences of working with psychological impairments after ACL injury were summarized in four main categories: (1) "Calling for a guiding light", where PTs stated that the most common method of acquiring knowledge on addressing psychological impairments was through discussions with colleagues, and, at the same time, PTs expressed an insufficient knowledge of how to address psychological impairments; (2) "Meeting the burden of psychological impairments" where PTs stated that psychological impairments are greater than physical; (3) "Trying to balance physical and psychological aspects" where patient education and assessments were reported to be important in order to understand psychological impairments during rehabilitation; and (4) "Goal setting: a helpful challenge" where sports PTs expressed a need for specific knowledge of the rehabilitation of psychological impairments following ACL injury. To help provide the current best practice, we encourage researchers to develop psychologically centered interventions for rehabilitation after an ACL injury, and PTs to stay up-to-date with the literature published on the subject, including to implement eventual interventions.

Increased Prevalence and Associated Costs of Psychiatric Comorbidities in Patients Undergoing Sports Medicine Operative Procedures.

PURPOSE: To evaluate the prevalence of preoperatively diagnosed psychiatric comorbidities and the impact of these comorbidities on the healthcare costs of ten common orthopaedic sports medicine procedures. METHODS: Patients undergoing 10 common sports medicine procedures from 2007 to 2017q1 were identified using the Humana claims database. These procedures included anterior cruciate ligament reconstruction; posterior cruciate ligament reconstruction; medial collateral ligament repair/reconstruction; Achilles repair/reconstruction; Rotator cuff repair; meniscectomy/meniscus repair; hip arthroscopy; arthroscopic shoulder labral repair; patellofemoral instability procedures; and shoulder instability repair. Patients were stratified by preoperative diagnoses of depression, anxiety, bipolar disorder, or schizophrenia. Cohorts included patients with ≥1 psychiatric comorbidity (psychiatric) versus those without psychiatric comorbidities (no psychiatric). Differences in costs across groups were compared using Mann-Whitney U tests, with significance defined as P < .05. Linear regression analysis was used to assess rates of procedures per year from 2006 to 2016. RESULTS: In total, 226,402 patients (57.7% male) from 2007 to 2017q1 were assessed. The prevalence of ≥1 psychiatric comorbidity within the entire database was 10.31% (reference) versus 21.21% in those patients undergoing the 10 investigated procedures. Patients with psychiatric comorbidity most frequently underwent rotator cuff repair (28%), hip labral repair (26.3%) and meniscectomy/meniscus repair (25.0%%) had ≥1 psychiatric comorbidity. Compared with the no psychiatric cohort, diagnosis of ≥1 psychiatric comorbidity was associated with increased health care costs for all 10 sports medicine procedures ($9678.81 vs $6436.20, P < .0001). CONCLUSIONS: The prevalence of preoperatively diagnosed psychiatric comorbidities among patients undergoing orthopaedic sports medicine procedures is high. The presence of psychiatric comorbidities preoperatively was associated with increased postoperative costs following all investigated orthopaedic sports medicine procedures. LEVEL OF EVIDENCE: Level III; retrospective comparative study.

Are Patient and Surgeon Expectations after ACL Reconstruction Realistic?

BACKGROUND: Patient expectations may affect their satisfaction and functional outcomes after treatment of musculoskeletal injuries. Although there is evidence that patient expectations of ACL reconstruction (ACLR) are inflated, there is limited knowledge about the relationship between physician and patient expectations and patient outcomes after they completely recover from ACLR. Furthermore, it is unclear if specific patient factors influence these expectations. QUESTIONS/PURPOSES: (1) Are patient and surgeon expectations of knee function 18 months after ACLR similar? (2) Are patients' and surgeons' expectations of outcomes similar to patients' actual 2-year outcomes? (3) Is there a relationship between preoperative or intraoperative parameters and expectations? (4) Is there a relationship between preoperative or intraoperative parameters and 2-year ACLR outcomes? METHODS: One-hundred twenty-nine patients undergoing primary ACLR were prospectively enrolled in this study, with 98 (76%) completing 2-year follow-up. Patients completed the IKDC Subjective Knee Evaluation preoperatively and at 3, 6, 12, and 24 months postoperatively. Patients also completed the same questionnaires preoperatively to evaluate expected knee function 18 months after surgery. Immediately postoperatively, surgeons completed the same questionnaires regarding the expected postoperative outcome at 18 months postoperative. Preoperative and intraoperative data were collected to determine an association between expectations and outcomes. Nonparametric analysis was performed using the Mann-Whitney U test, the paired Wilcoxon signed ranks tests and Spearman's correlations, as applicable. RESULTS: There was no difference between patient and surgeon expectations (patient, 94.8 [range 47.4-100] versus surgeon, 94.3 [range 46-100]; p = 0.283), and there was no correlation between higher patient expectations and higher surgeon expectations (r = 0.168, p = 0.078). Patient and surgeon expectations were greater than the actual postoperative outcomes (2-year postoperative: 89.7 [range 32.2 to 100]; p < 0.0001); however, the differences are unlikely to be perceived. There was no correlation between higher 2-year postoperative outcomes and higher patient expectations (r = 0.14, p = 0.186) or higher surgeon expectations (r = 0.019, p = 0.86). Arthroscopic evidence of cartilage damage was independently associated with the worst patient and surgeon expectations. The surgeons themselves were also independently associated with surgeon expectation (p < 0.001). No parameters were associated with postoperative outcomes. CONCLUSIONS: There are no clinically significant differences between surgeon expectations, patient expectations, and 2-year actual outcomes. However, there is also no correlation between the patient expectations, surgeon expectations, and actual outcomes. Although expectations are similar to actual outcomes for most patients, surgeons are unable to accurately predict outcomes for specific patients; thus, preventing adequate patient counseling. Surgeons should be cautious when evaluating and counseling patients preoperatively and avoid assuming high expectations. LEVEL OF EVIDENCE: Level II, therapeutic study.

Return to sport after anterior cruciate ligament injury: Panther Symposium ACL Injury Return to Sport Consensus Group.

PURPOSE: A precise and consistent definition of return to sport (RTS) after anterior cruciate ligament (ACL) injury is lacking, and there is controversy surrounding the process of returning patients to sports and their previous activity level. The aim of the Panther Symposium ACL Injury RTS Consensus Group was to provide a clear definition of RTS and description of the RTS continuum, as well as to provide clinical guidance on RTS testing and decision-making. METHODS: An international, multidisciplinary group of ACL experts convened as part of a consensus meeting. Consensus statements were developed using a modified Delphi method. Literature review was performed to report the supporting evidence. RESULTS: Key points include that RTS is characterized by achievement of the pre-injury level of sport and involves a criteria-based progression from return to participation to return to sport, and ultimately return to performance. Purely time-based RTS decision-making should be abandoned. Progression occurs along a RTS continuum with decision-making by a multidisciplinary group that incorporates objective physical examination data and validated and peer-reviewed RTS tests, which should involve functional assessment as well as psychological readiness. Consideration should be given to biological healing, contextual factors and concomitant injuries. CONCLUSION: The resultant consensus statements and scientific rationale aim to inform the reader of the complex process of RTS after ACL injury that occurs along a dynamic continuum. Research is needed to determine the ideal RTS test battery, the best implementation of psychological readiness testing and methods for the biologic assessment of healing and recovery. LEVEL OF EVIDENCE: IV.

The Japanese version of the anterior cruciate ligament-return to sport after injury (ACL-RSI) scale has acceptable validity and reliability.

PURPOSE: The anterior cruciate ligament-return to sports after injury (ACL-RSI) scale assesses the psychological impact of returning to sports (also referred to as psychological readiness) after ACL reconstruction. The aim of this study was to evaluate important measurement properties of the Japanese version of ACL-RSI scale. METHODS: Ninety-three participants who underwent ACL reconstruction filled out the Japanese version of ACL-RSI scale, the Tampa scale for kinesiophobia (TSK), the International Knee Documentation Committee-Subjective Knee Form (IKDC-SKF), and Knee injury and Osteoarthritis Outcome Score (KOOS). To assess test re-test reliability, 50 of the 93 participants re-answered the Japanese version of ACL-RSI scale within 10 days. Floor and ceiling effects, internal consistency, construct validity, and reliability of the Japanese version of ACL-RSI scale were analysed. RESULTS: There were no floor and ceiling effects. The Japanese version of ACL-RSI scale showed good internal consistency (Cronbach's alpha = 0.912). It was positively correlated with total points of IKDC-SKF and the Lysholm score, and with the all sub-categories of the KOOS, and it was negatively correlated with the TSK. Reliability of the Japanese version of ACL-RSI scale was satisfactory. CONCLUSION: The Japanese version of ACL-RSI scale has acceptable measurement properties. It can be a useful for evaluation of psychological readiness for return to sports in Japanese athletes who undergo primary ACL reconstruction. Information provided by the Japanese version of the ACL-RSI scale may also help to identify athletes who find return to sport a challenge, and guide conversations regarding treatment and rehabilitation plans. LEVEL OF EVIDENCE: II.

Timing of anterior cruciate ligament reconstruction and preoperative pain are important predictors for postoperative kinesiophobia.

PURPOSE: Fear of movement (kinesiophobia) is a major limiting factor in the return to pre-injury sport level after anterior cruciate ligament reconstruction (ACLR). The aim of this study was to gain insight into the prevalence of kinesiophobia pre-ACLR, 3 months post-ACLR and 12 months post-ACLR. Furthermore, the preoperative predictability of kinesiophobia at 3 months post-ACLR was addressed. METHODS: A retrospective study with data, which were prospectively collected as part of standard care, was conducted to evaluate patients who underwent ACLR between January 2017 and December 2018 in an orthopaedic outpatient clinic. Patient characteristics (age, sex, body mass index), injury-to-surgery time, preoperative pain level (KOOS pain subscale) and preoperative knee function (IKDC-2000) were used as potential predictor variables for kinesiophobia (TSK-17) at 3 months post-ACLR in linear regression analysis. RESULTS: The number of patients with a high level of kinesiophobia (TSK > 37) reduced from 92 patients (69.2%) preoperatively to 44 patients (43.1%) 3 months postoperatively and 36 patients (30.8%) 12 months postoperatively. The prediction model, based on a multivariable regression analysis, showed a positive correlation between four predictor variables (prolonged injury-to-surgery time, high preoperative pain level, male sex and low body mass index) and a high level of kinesiophobia at 3 months postoperatively (R2 = 0.384, p = 0.02). CONCLUSION: The prevalence of kinesiophobia decreases during postoperative rehabilitation, but high kinesiophobia is still present in a large portion of the patients after ACLR. Timing of reconstruction seems to be the strongest predictor for high kinesiophobia 3 months post-ACLR. This study is the first step in the development of a screening tool to detect patients with kinesiophobia after ACLR. Identifying patients preoperatively opens the possibility to treat patients and thereby potentially increase the return to pre-injury sport level rate after ACLR. LEVEL OF EVIDENCE: III.

Superior knee self-efficacy and quality of life throughout the first year in patients who recover symmetrical muscle function after ACL reconstruction.

PURPOSE: The aim of this study was to (1) describe psychological outcomes during the first year after an anterior cruciate ligament (ACL) reconstruction and (2) compare psychological outcomes in patients who recover symmetrical muscle function with patients who do not. METHODS: The included patients had undergone a unilateral ACL reconstruction. Patients with a re-rupture and contralateral ACL injury were excluded. Three groups, based on the results from 5 tests of muscle function 12 months after reconstruction, were created. Three validated questionnaires (the Knee Self-Efficacy Scale; the Knee injury and Osteoarthritis Outcome Score subscale "Quality of Life"; the ACL Return to Sport after Injury scale) and a single question "Have you achieved your goal with rehabilitation?" were analysed in 4 different follow-ups after ACL reconstruction (10 weeks, 4, 8 and 12 months). Means and standard deviations were analysed with standard t tests and reported with 95% confidence intervals. RESULTS: A total of 328 patients (120 men, 37%), mean age 27.8 ± 10 years, were included. Patients who did not recover symmetrical muscle function (n = 56; 17%) at the 12-month follow-up reported inferior knee-related self-efficacy and quality of life than patients who recovered symmetrical muscle function (n = 96; 29%) at all follow-ups, except quality of life at 4 months. The proportion of patients who stated they achieved their rehabilitation goal at 12 months was 17% for the entire cohort, 24% for patients who recovered muscle function and 5% for patients who did not recover muscle function. CONCLUSION: Patients who recovered strength and hop symmetry 12 months after ACL reconstruction had superior knee-related self-efficacy and greater quality of life during the whole first year after ACL reconstruction. These results can aid clinicians in the decision-making process by providing knowledge of patients who might need further attention during rehabilitation. LEVEL OF EVIDENCE: III.

Importance of functional performance and psychological readiness for return to preinjury level of sports 1 year after ACL reconstruction in competitive athletes.

PURPOSE: This study aimed to identify independent predictive factors for return to sports (RTS) after anterior cruciate ligament (ACL) reconstruction in competitive-level athletes and to determine optimal cut-off values for these factors at 6 months after surgery. METHODS: A total of 124 competitive athletes (50 males and 74 females; mean age, 17.0 years; preinjury Tegner activity scale > 7) who underwent primary ACL reconstruction were enrolled. Assessments at 6 months after surgery consisted of knee functional tests [quadriceps index, hamstrings index, and single-leg hop for distance (SLH)] and 2 self-report questionnaires [IKDC subjective score and ACL-Return to Sport after Injury scale (ACL-RSI)]. At 1 year after surgery, athletes were classified into the RTS group (n = 101) or non-RTS group (n = 23) based on self-reported sports activities. After screening possible predictive factors of RTS, multivariate logistic regression and receiver operating characteristic curve analyses were performed to identify independent factors. RESULTS: Multivariate logistic regression analysis identified SLH (odds ratio, 2.861 per 10 unit increase; P < 0.001) and ACL-RSI (odds ratio, 1.810 per 10 unit increase; P = 0.001) at 6 months as independent predictors of RTS at 1 year after surgery. Optimal cut-off values of SLH and ACL-RSI were 81.3% (sensitivity = 0.891; specificity = 0.609) and 55 points (sensitivity = 0.693; specificity = 0.826), respectively. CONCLUSION: In competitive athletes, SLH < 81% and ACL-RSI < 55 points at 6 months after surgery were associated with a greater risk of unsuccessful RTS at 1 year after surgery. SLH and ACL-RSI at 6 months could serve as screening tools to identify athletes who have difficulties with returning to sports after ACL reconstruction. LEVEL OF EVIDENCE: III.

The Use of Psychological Patient Reported Outcome Measures to Identify Adolescent Athletes at Risk for Prolonged Recovery Following an ACL Reconstruction.

BACKGROUND: Psychological response to injury and the recovery process impact return to play and can put an athlete at risk for prolonged recovery. The purpose of this study was to investigate the psychological changes that occur surrounding an anterior cruciate ligament (ACL) reconstruction utilizing a set of patient reported outcomes measures (PROMs) that focus on psychological factors. METHODS: Consecutive patients undergoing a primary ACL reconstruction, ages 12 to 18, were recruited. Patients were included if they verbalized a desire to return to the same sport and a baseline Tegner of >6. Functional and psychological PROMs were administered preoperatively, 6 months, and 1 year postoperatively. A Y-Balance Test was utilized to assess for clearance. RESULTS: Of the 68 participants, 36 were female (52.9%) and 32 male, with a mean age of 14.5 years. On average, participants were cleared to return to sport 259.1 days postoperatively. Of the measures given preoperatively, only the Athletic Coping Skills Inventory-28 (ACSI)-28 correlated with delayed recovery time (rs=-0.291, P=0.04). Lower baseline ACSI-28 subscale scores in coachability (rs=-0.298, P=0.03) and Coping with Adversity (rs=-0.341, P=0.01) were correlated with delayed recovery. Participants that took longer than average to recover scored significantly lower on the ACSI-28 preoperatively than those with a shorter recovery time (62.04 vs. 54.8, P<0.01). Participants that scored <58 on their preoperative ACSI-28 took 2 months longer to recover than participants who scored ≥58 (9.6 vs. 7.65 mo, P<0.01). At 6 months postoperatively, higher ACSI-28 subscale Concentration (rs=-0.357, P<0.01) and Peaking Under Pressure (rs=-0.274, P=0.04) scores correlated with shorter recovery time. CONCLUSIONS: The ACSI-28 significantly correlated with recovery time following ACL reconstruction. A baseline score of 58 may be a valuable cutoff to identify youth athletes at risk for prolonged recovery. LEVEL OF EVIDENCE: Level II-prospective study.