2025 ISAKOS Biennial Congress Paper
Psychological Readiness Is The Main Barrier To Return To Play Following Revision Anterior Cruciate Ligament Reconstruction
Timothy McAleese, MRCS MCh, Dublin 9, Dublin IRELAND
Neil Welch, BSc MSc PhD, Dublin IRELAND
Enda King, PhD, MSc, Doha QATAR
Niamh Keane, BSc MSc, Kerry IRELAND
Kieran Moran, PhD, Dublin IRELAND
Mark Jackson, FRCS, Dublin IRELAND
Daniel Withers, MB Chb FRCS (Orth), Dublin IRELAND
Raymond Moran, FRCSI, Dublin IRELAND
Brian M. Devitt, MD, PhD, FRCS, FRACS, Dublin, Leinster IRELAND
UPMC Sports Surgery Clinic, Dublin, IRELAND
FDA Status Not Applicable
Summary
Psychological readiness is the main barrier to Return to Play following Revision Anterior Cruciate Ligament Reconstruction
Abstract
Background
Despite advances in modern surgical techniques, return to play rates (RTP) after revision anterior cruciate ligament reconstruction (ACLR) often fall short of patients’ expectations. There is growing awareness that the psychological recovery of patients is as important as the functional recovery of the knee.
Purpose
To determine the rate of RTP and identify the barriers to return to play after revision ACL reconstruction. Secondarily, we compared the progression of psychological readiness throughout rehabilitation between those who achieved RTP and those who did not return. Finally, we assessed if RTP could be predicted based on an athlete's psychological readiness at different time points during rehabilitation.
Design: Cohort study; Level 3 evidence
Methods
This investigation included 301 patients who underwent revision ACLR at a single centre between 2014-2018. Pre-operatively, patients completed a questionnaire recording their target level of return to play along with the ACL-RSI scale. The ACL-RSI scale was administered again at 3 months, 6 months, 12 months and 2 years. At 2 years follow-up, patients reported in a questionnaire if they had or had not returned to play and the factors that prevented RTP were evaluated.
Results
The mean age was 25.4 +/- 6.3 years and 85.4% of patients were male. Pre-operatively, 95.1% of patients undergoing revision ACLR planned to return to sport. However, the RTP rate was 63.4% at 2-years. The main barriers to RTP were fear of re-injury (44%), lack of confidence in performance (13%) and knee pain (11%). The mean pre-operative ACL-RSI score was significantly higher in patients who returned to play (50.6 +/- 23.5 vs. 39.3 +/- 24.3, p < .002). The mean ACL-RSI was significantly higher in those who achieved RTP at 3 months, 6 months and 12 months. A pre-operative ACL-RSI score of 43.3 points predicted RTP in patients <23 years old with a sensitivity of 76% and specificity of 71% (AUC 0.74). The ACL-RSI can help predict RTP at all time points, demonstrating the most accuracy pre-operatively and 6 months postoperatively. At 6 months, a cut-off score of 49.6 points predicted RTP in patients <23 years (sensitivity 74%, specificity 67%) and a cut-off score of 37.1 points predicted RTP in patients >23 years (89% sensitivity, 53% specificity).
Conclusions
The main barrier to RTP after revision ACLR was fear of re-injury. Patients with lower psychological readiness are less likely to RTP and can be detected using the ACL-RSI scale. These patients may benefit from a psychological rehabilitation programme.