Abstract
Objectives
To examine sex differences in psychological readiness to return to sport following anterior cruciate ligament (ACL) reconstruction as well as to determine whether males and females separately fulfilled cut-off values (≥65) of psychological readiness necessary to return to sport.
Information sources
Web of Science, Scopus and PubMed were comprehensively searched from inception to January 2024 to identify relevant studies.
Eligibility criteria
Observational investigations that compared males and females with a history of ACL reconstruction concerning psychological readiness to return to sport.
Risk of bias
Studies were rated using the Methodological Index for Non-Randomised Studies.
Included studies
Only 11 reports fulfilled the eligibility criteria and were included in the quantitative analysis. A total of 2618 participants were subjected to the primary ACL reconstruction, out of 1631 males and 987 females. Psychological readiness to return to sport was evaluated approximately 9±2.9 months following surgery.
Synthesis of results
The main findings demonstrated that males had slightly higher psychological readiness to return to the sport than females (standardised mean difference 0.33; 95% CI 0.14 to 0.52; p=0.0007; I2=77%) after ACL surgery. In addition, the mean psychological readiness to return to the sport of males was 70.1±8.8 points and of females 65.1±8.8 points, indicating that both sexes exceeded recommendations necessary to return to sport.
Conclusion
Males had slightly higher psychological readiness to return to sport than females approximately 9±2.9 months after ACL reconstruction and both sexes exceeded the highlighted recommendations necessary to return to sport.
PROSPERO registration number
CRD42024497769: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42024497769.
Keywords: Gender, Knee injuries, Knee surgery, Sport and exercise psychology
WHAT IS ALREADY KNOWN ON THIS TOPIC?
Higher levels of psychological readiness to return to sport correlated with the increased rate of return to sport among individuals who were subjected to anterior cruciate ligament (ACL) reconstruction.
Available literature indicated that males return to sport at a significantly higher percentage compared with females following ACL surgery.
Sex differences with respect to the psychological readiness to return to sport in a population with a history of ACL reconstruction still need to be comprehensively synthesised.
WHAT THIS STUDY ADDS?
The present systematic review with meta-analysis provided evidence that males had slightly higher psychological readiness to return to the sport than females approximately 9±2.9 months after ACL reconstruction.
The average values of psychological readiness to return to the sport of males and females were 70.1 points and 65.1 points, respectively, indicating that both sexes exceeded the recommendations (≥65) required to return to sport following ACL surgery.
Since the psychological readiness to return to the sport of females was only slightly above the highlighted cut-off values regarding return to sport, implementation of various psychological interventions is recommended in the future.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
The findings of the present study have robust practical implications, highlighting the role and relevance of sports psychologists with respect to the improvement of psychological readiness to return to sports of females who were subjected to ACL reconstruction.
Introduction
The anterior cruciate ligament (ACL) is a fibrous structure that originates on the medial wall of the lateral femoral condyle and extends diagonally, attaching to the front part of the tibial joint surface. Its main function is related to the static stabilisation of the knee by preventing hyperextension of the joint, forward movement of the tibia and rotatory movements of the knee.1 It was established in the literature that ACL rupture is one of the most common knee injuries among athletes and physically active individuals.1 Moreover, approximately 70% of ACL injuries result from non-contact incidents, while the remaining 30% are contact-related.2 Since ACL has a crucial role in knee stabilisation and in cases of a complete ACL tear, physical therapy rehabilitation alone is not sufficient to neutralise the injury, most ACL tears are treated surgically using either autograft or allograft tendons.3 4 Over the past two decades, the number of ACL tears has increased by double, indicating that between 200 000 and 250 000 ACL injuries occur per year in the USA.5 6 At last, the annual expense for ACL reconstruction in the US healthcare system averages around $1 billion.1
Briefly, there are several relevant phases regarding the return to sport after ACL reconstruction.7 More specifically, these aspects refer to criterion-based postoperative rehabilitation, return to sport testing, a careful shared decision-making process and gradual periodised reintegration into sport-specific activities.7 An adequate and thorough implementation of all highlighted phases is highly desirable with respect to improving the possibilities of returning to sport and reducing the reinjury rates of athletes after ACL surgery. In addition, available literature revealed that numerous factors affected the return to sport among athletes who were subjected to ACL reconstruction, including sex,8 age,9 sports participation10 and psychological factors.11 It is shown that ACL rupture has a significant negative effect on the athlete’s psychological aspects, which affects the overall recovery process.12 In terms of return to sport after ACL reconstruction, the most relevant psychological factors are fear of reinjury and psychological readiness to return to sport.10 Most importantly, Podlog et al13 emphasised that ‘psychological readiness to return to sport after injury reflects an individual’s state of mental preparedness to resume sport-specific activities and is likely comprised of three dimensions, including cognitive appraisals (confidence, expectations, motivations, risk appraisals and internal or external pressures), affective (anxiety or fears about reinjury or movement and moods) and behavioural components (approach-avoidance behaviours to demonstrate physical function/neuromuscular control and engage in sport-specific tasks)’. Among several methods employed to evaluate psychological readiness to return to sport, the ACL-return to sport after injury (ACL-RSI) scale (Cronbach’s alpha=0.92) was most frequently implemented.14 The scale consists of 12 items covering three domains: emotions, confidence and risk appraisal.15 The total score is an indicator of the athletes’ readiness to return to sport.
The return-to-sport phenomenon has been extensively examined among athletes undergoing ACL reconstruction.616,18 More precisely, there is compelling evidence that indeed a high percentage of athletes return to sport and return to sport at the preinjury levels of competition following ACL surgery. For instance, it was demonstrated that 83% of elite athletes with a history of ACL reconstruction successfully return to sport.17 Analogously, Ardern et al8 reported that 65% of athletes return to the preinjury levels of sports participation after surgery of ACL. Furthermore, as underlined, there is abundant evidence regarding the importance of sex in the return to sport in the ACL population.19,22 All studies are quite unambiguous, indicating that males return to sport at a markedly higher percentage compared with females who experienced ACL injury and underwent the reconstruction procedure. Specifically, a recently conducted investigation by Klemm et al21 emphasised that 74.9% of males and 65.4% of female athletes return to sport after ACL reconstruction. Additionally, it was also revealed that female sex was an independent negative predictor of return to sport in soccer players who underwent ACL surgery.19
Numerous studies explored the relationship between psychological readiness and return to sport among athletes who were subjected to ACL reconstruction.23,27 All available evidence suggested that psychological readiness was a strong positive predictor of return to sport after ACL surgery. It is also essential to highlight that several meta-analyses demonstrated that athletes who return to sport28 and return to sport at the preinjury level of competition29 following ACL reconstruction had noticeably higher values of psychological readiness compared with athletes who did not return to sport and did not return to sport at the preinjury level of participation, respectively. Most importantly, Webster and Feller30 explored the cut-off values of psychological readiness required to return to sport in athletes who underwent ACL surgery. The authors revealed that the ACL-RSI values of ≥65 were considered indicators of successful recovery. In fact, individuals who passed the thresholds of psychological readiness had three times greater odds of returning to sport between 6 and 12 months following ACL reconstruction.30
To date, to the best of the author’s knowledge, several systematic reviews and meta-analyses thoroughly examined sex differences concerning outcomes closely related to the psychological readiness to return to sport, such as the overall return to sport rate,31 return to preinjury level of sport32 and physical activity level assessed with Tegner Activity Scale.33 Therefore, the currently existing body of evidence referring to the disparities in psychological readiness to return to sport between males and females subjected to ACL reconstruction still needs to be comprehensively summarised. Additionally, considering that relevant literature indicates that psychological readiness is strongly related to the return to sport, comparing this phenomenon among males and females should have significant sex-specific implications concerning the return to sport in athletes with a history of ACL reconstruction. Thus, the primary objective of this study was to investigate sex differences in psychological readiness to return to sport among individuals who underwent ACL surgery. The secondary goal was to examine whether males and females individually met the cut-off values (≥65), as suggested by Webster and Feller,30 regarding the psychological readiness required to return to sport following ACL reconstruction. The authors hypothesised that (1) males would have significantly higher psychological readiness to return to sports relative to the females and that (2) only males would exceed the cut-off recommendations of psychological readiness necessary to return to sports (≥65).
Methods
Study design and protocol registration
This systematic review with meta-analysis was performed according to all guidelines available in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.34 The PRISMA checklist is given as an online supplemental file 2. The study protocol has been registered in the International Database of Prospectively Registered Systematic Reviews in Health and Social Care (PROSPERO, CRD42024497769). There were no amendments with respect to the registration of the study protocol. The registration of protocol occurred after a preliminary search was conducted, but before screening was completed and data extraction started.
Search strategy
Three electronic databases, including PubMed, Web of Science and Scopus, were thoroughly searched from inception to December 2023. Keywords were gathered via experts’ opinions and relevant systematic reviews from the area of sports and medical sciences. A Boolean search syntax with operators ‘AND’ and ‘OR’ was employed during a search of each database and the following keywords were applied (‘males’ OR ‘females’ OR ‘men’ OR ‘woman’ OR ‘sex’ OR ‘gender’) AND (‘psychological readiness to return to sport’ OR ‘ACL-RSI scale’ OR ‘return to play’ OR ‘return to sport’ OR ‘exercise psychology’ OR ‘sport psychology’) AND (‘anterior cruciate ligament’ OR ‘anterior cruciate ligament reconstruction’ OR ‘anterior cruciate ligament surgery’ OR ‘ACL injury’ OR ‘knee’). The full search strategy is provided in the online supplemental file 3. A search of Google Scholar and the reference lists of articles that fulfilled eligibility criteria was conducted in an attempt to provide additional evidence referring to the sex differences in psychological readiness for return to sport among individuals with a history of ACL reconstruction. Lastly, to ensure that all available studies are included, the search of databases was updated at the end of January 2024.
Selection process
Retrieved titles were saved, while duplicates were removed using the Zotero software V.6.0 (available at: https://www.zotero.org/).35 The process of selecting literature was divided into three subsequent phases: (1) review of abstracts and titles; (2) estimation of the articles sought for retrieval and (3) analysis of full-text records assessed for eligibility. The entire search process as well as a selection of studies were carried out independently by two reviewers (AR and SJ). Disagreements at any stage were resolved through discussion among the authors until a consensus was reached. Still, if it was not possible to reach an agreement between reviewers, the second investigator (MM) clarified all inconsistencies. It should also be noted that the reviewers were not blinded to the journals and authors of the articles during this process.
Eligibility criteria
Studies were estimated for eligibility based on the PICOS (P—participants, I—interventions, C—comparators, O—outcomes, S—study design) criteria36: (P) examined population referred to the individuals who underwent ACL reconstruction. There were no limitations regarding demographic parameters and surgical variables of respondents, such as ACL reconstruction type or time since surgery; (I) considering that all trials were observational, no criteria related to the interventions were applied; (C) although no control group was observed, a comparison in psychological readiness to return to sport was conducted between males and females; (O) psychological readiness to return to sport was assessed as a main outcome using the original and short versions of the ACL-RSI scale and (S) observational studies, such as cohort, case-control, cross-sectional and case series, were eligible for inclusion. Additionally, studies that were not written in English language were not included. Likewise, systematic reviews and meta-analyses, not-peer-reviewed papers (preprints), case reports, editorials, books, PhDs or master’s theses, not full-text available articles and qualitative studies were not considered adequate for inclusion in the present study. Finally, investigations were excluded if the ACL injury was treated non-surgically or if, in addition to the ACL rupture, other knee injuries were reported.
Data extraction
One independent reviewer (AO) retrieved all necessary data from the full-text articles included in the quantitative analysis using a Microsoft Excel template. All extracted data was reviewed by the second investigator (MM) (online supplemental file 4). The retrieved data was divided into the following categories: (1) authors and years of the records publications; (2) study design with the level of evidence; (3) demographic characteristics of the examined population, such as number of involved males and females, mean age and the competitive level of athletes; (4) surgical parameters included the ACL reconstruction type, follow-up period, and graft types and (5) estimated outcomes were referred to as the psychological readiness to return to sport that was evaluated with the ACL-RSI scale. It is indispensable to highlight that the follow-up period pertained to the time between the surgery of the ACL and the evaluation of psychological readiness to return to sport among athletes. In cases of missing data, corresponding authors of relevant investigations were not contacted by email. Data was not extracted from the figures of the included studies.
Study risk of bias assessment
The evaluation of the methodological quality of the studies was performed by two reviewers (AO and VR) using the Methodological Index for Non-Randomised Studies (MINORS).37 All inconsistencies among reviewers were resolved via discussion, while the third party (MM) was consulted for clarification if it was not possible to reach a consensus between them. The MINORS contains eight items for non-comparative studies and four additional items for comparative research. For each aspect, the following scores are given: 0 (not reported), 1 (reported but inadequate) and 2 (reported and adequate). The maximum overall score for non-comparative and comparative studies is 16 and 24, respectively. A higher score indicated higher study quality and a lower risk of bias. For non-comparative investigations, the overall quality score is interpreted in line with the established criteria: 0–4=very low quality; 5–8=low quality; 9–12=moderate quality and 13–16=high quality.38 Regarding comparative articles, the overall quality score was categorised as follows: 0–6=very low quality; 7–12=low quality; 13–18=moderate quality and 19–24=high quality.39
Data analysis
Data processing was carried out using Review Manager V.5.4 (The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen, Denmark). Standardised mean differences (SMD) and 95% CI were calculated regarding sex disparities in psychological readiness for return to sport among athletes with a history of ACL reconstruction. The interpretation of individual and pooled SMD was conducted based on Cohen’s recommendations as trivial (SMD<0.2), small (0.2≤SMD<0.5), moderate (0.5≤SMD<0.8) and large (SMD≥0.8).40 A random-effects model with the Hartung-Knapp-Sidik-Jonkman adjustment has also been applied. Heterogeneity among studies was estimated using I2, with thresholds of 25%, 50% and 75% indicating low, moderate and high levels, respectively.41 The funnel plot graph determined publication bias in studies included in quantitative analysis. Differences between males and females relating to the analysed outcome were considered statistically significant if the p-value was <0.05.
Results
Study selection
A comprehensive electronic search of PubMed, Web of Science and Scopus yielded a total of 770 records, while 388 duplicates were removed using Zotero software V.6.0. Further, concerning screening, 298 records were excluded after reviewing the titles and abstracts, and 84 full-text reports were assessed for eligibility. Two reviewers (AR and SJ) most commonly excluded reports if psychological readiness to return to sport was not evaluated outcome and if no sex comparison in the main outcome was reported (online supplemental file 5). No additional records were identified via a search of relevant citations or Google Scholar. In summary, 11 reports satisfied each eligibility criteria and were involved in the quantitative analysis. The overall search strategy is available in the PRISMA flow diagram (figure 1).
Figure 1. Preferred reporting items for systematic reviews and meta-analyses flow diagram depicts the overall search strategy.
Study characteristics
Investigations are available in the databases between 2019 and 2023. Studies were most commonly conducted in the USA42,45 and Australia46,49 as well as in European countries, such as Spain,50 Sweden51 and France.52 In regard to study design, prospective cohort,43 45 48 retrospective cohort,42 case-control,46 47 52 cross-sectional44 51 and case series49 50 were recorded. Concerning level of evidence, level III42 44 46 47 51 52 was most commonly observed, while two studies reported level IV49 50 and three articles indicated level II43 45 48 of evidence. There were 2617 individuals with a history of primary ACL reconstruction, 1631 males and 986 females, with a mean age of 21.4±5.0 years. No differences in age between males and females were observed in studies that reported this variable separately.42,44 The range of respondents' age across all included studies was between 15.2±1.5 years and 30.0±4.2 years. Available literature addressed elite and recreational athletes,44 49 52 exclusively recreational athletes,46 51 and athletes who competed at the amateur level.50 In addition, psychological readiness to return to sport was evaluated between 6 and 12 months following ACL surgery. Most importantly, according to the nine studies42,4547 that clearly reported a follow-up period, psychological readiness to return to sport was assessed at a mean of 9±2.9 months following reconstruction. Hamstring autograft (n=2201) was most frequently applied out of graft sources. All details regarding study design, demographic and surgical variables are summarised in table 1.
Table 1. Main characteristics of involved studies.
| Author (year) | Country | Study design (level of evidence) | Sample size (n) | Sex | Mean age (years) | Level of play | ACL reconstruction type | Follow-up period | Graft source |
| Beneito Pastor et al (2022)50 | Spain | Case series (IV) | 43 | M=38 F = 5 | 24.7±8.0 | Amateur athletes | NR | NR | NR |
| Cronström et al (2023)51 | Sweden | Cross-sectional (III) | 143 | M=71 F = 72 | 25.0±5.7 | Recreational athletes | NR | 12 months | Hamstring=113, patellar tendon=17 grafts and NR=13 |
| Dombrowski et al (2023)42 | USA | Retrospective cohort (III) | 127 | M=63 F = 64 | M=20.1 ± 6.9 F=19.1±8.5 | NR | Primary | 8 months | BTB autograft=57, hamstring autograft=57, peroneal autograft=1 and allografts=12 |
| Franck et al (2021)52 | France | Case-control (III) | 670 | M=471 F=199 | 27.6±10.4 | Elite and recreational athletes | Primary | 6 months | BTB=52 and hamstring tendon=618 grafts |
| Kostyun et al (2021)43 | USA | Longitudinal, prospective cohort (II) | 93 | M=42 F=51 | M=15.1±1.5 F=15.3±1.4 | NR | Primary | 6 months | Hamstring autograft=93 |
| Kuenze et al (2021)44 | USA | Cross-sectional (III) | 90 | M=45 F=45 | M=18.7±2.7 F=18.8±2.8 | Elite and recreational athletes | Primary unilateral | 6.9 months | Hamstring autograft=48 and patellar tendon=42 |
| Manara et al (2022)46 | Australia | Case-control (III) | 626 | M=474 F=152 | 30.0±4.2 | Recreational athletes | Primary | NR | Hamstring tendon autograft=626 |
| McPherson et al (2019)47 | Australia | Case-control (III) | 94 | M=51F=43 | 17.8±2.0 | NR | Primary | 12 months | Hamstring graft=86, patellar tendon graft=6 and other graft types (ie, synthetic graft, quadriceps tendon)=2 |
| Milewski et al (2023)45 | USA | Prospective cohort (II) | 176 | M=69F=107 | 17.1±3.1 | NR | Primary | 6 months | BTB=31, hamstring=128, quadriceps=4 and iliotibial band=13 autografts |
| Webster and Feller (2021)48 | Australia | Diagnostic cohort (II) | 441 | M=257 F=184 | 24.6±7.4 | Non-elite athletes | Primary | 12 months | Hamstring=338, patellar tendon=11, quadriceps=42 autografts and NR=50 |
| Webster and Feller (2022)49 | Australia | Case series (IV) | 115 | M=50F=65 | 16.2±0.9 | Elite and recreational athletes | Primary unilateral | 12 months | Hamstring tendon graft=94 and NR=21 |
| Summary of parameters | Mean age=21.4±5.0 | 9±2.9 months |
The age of the examined population is expressed as mean and standard deviationSD. ACL, ; BTB, bone-patellar tendon-bone; F, females; M, males; NR, not reported..
ACLanterior cruciate ligamentBTBbone-patellar tendon-boneFfemaleMmaleNRnot reported
Results of syntheses
Meta-analysis revealed that males had slightly higher psychological readiness to return to the sport than females following ACL reconstruction (SMD=0.33, 95% CI 0.14 to 0.52; p=0.0007; I2=77%). In addition, the range of psychological readiness to return to sport for males was between 47.3 points and 79.7 points, and for females it was between 44.2 points and 75.9 points. Taking into account data provided in the 11 studies,35,4250 the average ACL-RSI score for males and females was 70.1±8.8 points and 65.1±8.8 points, respectively. The mean score of psychological readiness to return to sport of both sexes was above the cut-off recommendations required to return to sport (≥65). All the details regarding statistical analysis are depicted in figure 2. The funnel plot indicates that no publication bias among studies was observed (online supplemental file 6).
Figure 2. Sex differences in psychological readiness to return to sport among individuals who were subjected to the anterior cruciate ligament reconstruction.
Risk of bias in studies
Since all investigations evaluated sex disparities in ACL-RSI scores, they were considered comparative. The range of overall quality scores was between 13 and 19, while the mean overall score of the included studies was 16.6±1.8. Therefore, the quality of each study, as well as the pooled quality score, is deemed as moderate. The major issues were noted in items such as ‘unbiased assessment of the study endpoint’ and ‘loss to follow-up less than 5%’. In contrast, the clearly stated aim, the inclusion of consecutive patients, prospective collection of data and endpoints appropriate to the aim of the study were the highest rated. The quality assessment of the involved studies is demonstrated in table 2.
Table 2. Quality evaluation of the included investigations.
| Author (year) | Clearly stated aim | Inclusion of consecutive patients | Prospective collection of data | Endpoints appropriate to the aim of the study | Unbiased assessment of the study endpoint | Follow-up period appropriate to the aim of the study | Loss to follow-up less than 5% | Prospective calculation of the study size | An adequate control group | Contemporary groups | Baseline equivalence of groups | Adequate statistical analyses | Overall quality score |
| Beneito Pastor et al (2022)50 | 2 | 1 | 1 | 2 | 0 | 1 | 0 | 1 | 1 | 1 | 1 | 2 | 13 |
| Cronström et al (2023)51 | 2 | 2 | 2 | 1 | 0 | 2 | 0 | 2 | 1 | 1 | 1 | 2 | 16 |
| Dombrowski et al (2023)42 | 2 | 2 | 2 | 2 | 0 | 1 | 0 | 1 | 2 | 2 | 2 | 1 | 17 |
| Franck et al (2021)52 | 2 | 2 | 2 | 2 | 0 | 2 | 0 | 2 | 2 | 2 | 1 | 1 | 18 |
| Kostyun et al (2021)43 | 2 | 2 | 2 | 2 | 0 | 2 | 1 | 1 | 2 | 2 | 2 | 1 | 19 |
| Kuenze et al (2021)44 | 2 | 2 | 1 | 1 | 0 | 2 | 0 | 2 | 1 | 2 | 2 | 2 | 17 |
| Manara et al (2022)46 | 2 | 2 | 1 | 1 | 0 | 0 | 1 | 2 | 1 | 1 | 2 | 2 | 15 |
| McPherson et al (2019)47 | 2 | 1 | 2 | 2 | 0 | 2 | 1 | 1 | 2 | 2 | 1 | 1 | 17 |
| Milewski et al (2023)45 | 2 | 1 | 2 | 2 | 0 | 2 | 0 | 1 | 1 | 2 | 1 | 1 | 15 |
| Webster and Feller (2021)48 | 2 | 2 | 2 | 2 | 0 | 2 | 1 | 2 | 1 | 2 | 1 | 2 | 19 |
| Webster and Feller (2022)49 | 2 | 2 | 2 | 2 | 0 | 2 | 0 | 1 | 1 | 2 | 1 | 2 | 17 |
| Summary of quality | * | * | * | * | * | * | * | * | * | * | * | * | 16.6±1.8 |
Each item is scored 0 (not reported), 1 (reported but inadequate), and 2 (reported and adequate). The maximum overall score for comparative studies is 24.
Discussion
Summary of main findings
The current meta-analysis aimed to (1) examine sex disparities in psychological readiness to return to sport among individuals who were subjected to the reconstruction of ACL and (2) determine whether separately males and females satisfied recommendations of psychological readiness required to return to sport following ACL surgery. Consistent with the first hypothesis, the obtained results demonstrated that males had slightly higher psychological readiness to return to sport relative to females after ACL reconstruction. Partially in agreement with the second hypothesis, both sexes exceeded the cut-off ACL-RSI score necessary to return to sport. Specifically, the mean values of psychological readiness to return to the sport of males were 70.1 points and of females 65.1 points, approximately at the 9-month follow-up period.
Comparisons with the evidence relating to the other psychological factors and self-reported outcomes
The main findings of this investigation are partially in accordance with the available scientific literature. Namely, evidence referring to the sex differences in fear of reinjury is quite inconclusive. More precisely, several studies did not reveal sex disparities,53 54 while in others,55 females had a greater fear of reinjury compared with males. For instance, Lisee et al54 suggest that males and females had similar values of fear of reinjury evaluated with the short form of the Tampa Scale of Kinesiophobia. Still, males have been less concerned in terms of environmental conditions in which sports activities were performed than females between 2 and 7 years after ACL surgery.55 On the other hand, the obtained results of the present investigation are supported by the meta-analyses that addressed sex differences in self-reported outcomes, such as physical activity levels and function of the knee joint. In fact, males had substantially higher scores on the Tegner Activity Scale, Marx Activity Scale,32 and they also showed greater knee function assessed with the International Knee Documentation Committee31 and Lysholm33 questionnaires relative to the females. The most relevant finding of this research is that males had slightly higher ACL-RSI scores compared with females after ACL surgery. Namely, 10 out of 11 included investigations indicated that males had higher psychological readiness to return to sport than females. More specifically, the range of mentioned differences across all studies was between 0.5 and 14.2 points. Only one investigation45 reported that females had 0.8 points higher psychological readiness to return to sport relative to males. Overall, the obtained results of the present systematic review with meta-analysis suggested that males had on average 5 points greater ACL-RSI scores than females following ACL reconstruction. There are several possible explanations for the highlighted sexual disparities. Most importantly, convincing evidence indicated that particularly knee function56,58 and physical activity engagement59 positively correlated (r=0.60 and r=0.55, respectively)56 57 with the psychological readiness to return to sport in the ACL population. Therefore, emphasised sex differences regarding physical activity and knee function may also explain why males had higher psychological readiness to return to the sport than females undergoing ACL surgery.
Practical significance of results
Available literature demonstrates that males return to sport after ACL reconstruction at a higher percentage compared with females. Likewise, there is evidence that psychological readiness positively correlated with a return to sport, indicating that athletes with a higher ACL-RSI score had an increased possibility of returning to sport following ACL surgery. Collectively, the reported sex disparities of the current meta-analysis provided one possible explanation for why males return to sport at a higher percentage than females after ACL reconstruction. Furthermore, the findings of this study are particularly meaningful for sports psychologists. Namely, besides that, sex disparities in psychological readiness to return to sport were observed in favour of males, the mean values of ACL-RSI scores of females were only slightly above the cut-off recommendations required to return to sport in the ACL population. For all these reasons, the implementation of psychological interventions that will increase the psychological readiness to return to the sport of females is warranted in the future. In other words, cooperation between sport psychologists, physiotherapists and strength and conditioning coaches appears necessary to improve ACL-RSI scores of females and consequently potentially increase the percentage of females that return to sport following ACL reconstruction. Nonetheless, taking into account the mean values of psychological readiness to return to the sport of males, it is also necessary to emphasise that they also could have certain benefits with respect to the administration of psychological interventions. Of note, the revealed mean differences of 5 points in favour of males regarding the assessed outcome are substantially lower than the existing minimally important changes of 13.4 points and 15.1 points for the original and short versions of the ACL-RSI scale, respectively48; therefore, the findings of the present study are not considered clinically meaningful. Interestingly, the obtained results could be associated with the return to sports time in individuals with a history of ACL reconstruction. It was demonstrated that the psychological readiness to return to sport was evaluated approximately 9±2.9 months after surgery. Hence, recorded sex differences are probably relevant for sports in which return to sport time following ACL reconstruction is around 9 months, such as soccer60,62 and basketball.63 Overall, more studies are necessary to verify this assumption.
Strengths and limitations
There are certain strengths of the presented research that should be emphasised. This is the first meta-analysis that summarised available scientific evidence that addressed the sex differences in psychological readiness to return to sport following ACL surgery, significantly extending and deepening the current body of knowledge pertaining to this phenomenon. In addition, the obtained results have robust practical implications and are useful, particularly for sports psychologists, as well as for physiotherapists and strength and conditioning coaches. Almost every study was published within the last 2 or 3 years. Therefore, the findings and evidence of the present systematic review with meta-analysis can be considered indeed innovative and actual.
In addition to the mentioned strengths of the study, several limitations need to be taken into account during the interpretation of the revealed sex disparities regarding psychological readiness to return to sport. Although 2618 individuals who underwent ACL reconstruction participated in this meta-analysis, an apparent inequality of numbers of males and females was observed (1631 vs 987, respectively). Moreover, I2 was 77%, indicating a high level of heterogeneity among studies included in the quantitative analysis. Likewise, it is necessary to acknowledge that the overall average methodological quality of all studies was moderate. It should also be noted that data extraction was conducted independently by one reviewer. Additionally, sensitivity analysis and certainty of evidence assessment were not performed. A literature search was conducted only via three electronic databases, potentially limiting the number of identified studies. At last, since the current investigation involved only observational studies, level III evidence was most frequently recorded.
Perspectives
This investigation provided several indeed interesting future directions. First, based on the ACL reconstruction types, it is recommended to evaluate differences in psychological readiness to return to sport between males and females who were subjected to the revision of the ACL surgery. Second, in the future, sex disparities should be explored among athletes with a history of ACL reconstruction who are older than 30 years. Third, since this investigation only included a reconstructed population, it would be interesting to examine the differences in psychological readiness to return to the sport between surgically and non-surgically treated respondents with a history of ACL injuries, including the role of sex. Finally, examining psychological readiness to return to sport exclusively in a sample of elite athletes with a history of ACL injury and reconstruction represents a valuable future direction.
Conclusion
The present systematic review with meta-analysis found that males had an average of 5 points higher psychological readiness to return to sport than females following ACL reconstruction. Moreover, the mean ACL-RSI score of males was 70.1 points and of females 65.1 points, indicating that both sexes exceeded recommendations necessary to return to sport. In general, the results obtained are useful, especially for sports psychologists, as well as for physiotherapists and strength and conditioning coaches, emphasising that various psychological interventions aimed to increase psychological readiness to return to sport of females who were subjected to ACL reconstruction are warranted. Additionally, revealed differences between males and females in psychological readiness to return to sport are potentially relevant for sports in which return to sport time after ACL surgery is approximately 9 months. Investigating sex disparities in the analysed outcome among exclusively elite athletes with a history of ACL reconstruction represents a valuable recommendation for future studies.
supplementary material
Footnotes
Funding: The current study was funded by the Provincial Secretariat for Higher Education and Scientific Research, grant number 142-451-3098.
Provenance and peer review: Not commissioned; externally peer reviewed.
Patient consent for publication: Not applicable.
Ethics approval: Not applicable.
Data availability free text: Raw and converted data are provided on a data repository at www.osf.io (https://osf.io/p2fhg/). The project was created under the name 'Males have higher psychological readiness to return to sports than females after anterior cruciate ligament reconstruction'.
Contributor Information
Anja Obradovic, Email: aoanjaobradovic@gmail.com.
Marko Manojlovic, Email: markomanojlovic1995@gmail.com.
Aleksandra Rajcic, Email: saska.gym@gmail.com.
Stefan Jankovic, Email: stefanj92bl@gmail.com.
Nikola Andric, Email: nikola.trenaznaekspertiza18@gmail.com.
Vuk Ralic, Email: vukralic999@gmail.com.
Tamara Zlicic, Email: tamarazlicicuns@gmail.com.
Branko Aleksic, Email: brankoaleksic33@gmail.com.
Srdjan Ninkovic, Email: srdjan.ninkovic@mf.uns.ac.rs.
Aleksander Veraksa, Email: aleksander.veraksa@gmail.com.
Patrik Drid, Email: patrikdrid@gmail.com.
Data availability statement
Data are available in a public, open access repository.
References
- 1.Kaeding CC, Léger-St-Jean B, Magnussen RA, et al. Epidemiology and Diagnosis of Anterior Cruciate Ligament Injuries. Clin Sports Med. 2017;36:1–8. doi: 10.1016/j.csm.2016.08.001. [DOI] [PubMed] [Google Scholar]
- 2.Hewett TE, Myer GD, Ford KR. Anterior cruciate ligament injuries in female athletes: Part 1, mechanisms and risk factors. Am J Sports Med. 2006;34:299–311. doi: 10.1177/0363546505284183. [DOI] [PubMed] [Google Scholar]
- 3.Murray MM, Martin SD, Martin TL, et al. Histological Changes in the Human Anterior Cruciate Ligament After Rupture*. J Bone Joint Surg Am Vol. 2000;82:1387–97. doi: 10.2106/00004623-200010000-00004. [DOI] [PubMed] [Google Scholar]
- 4.Kuršumović K, Charalambous CP. Relationship of Graft Type and Vancomycin Presoaking to Rate of Infection in Anterior Cruciate Ligament Reconstruction: A Meta-Analysis of 198 Studies with 68,453 Grafts. JBJS Rev. 2020;8:e1900156. doi: 10.2106/JBJS.RVW.19.00156. [DOI] [PubMed] [Google Scholar]
- 5.Arundale AJH, Silvers-Granelli HJ, Myklebust G. ACL injury prevention: Where have we come from and where are we going? J Orthop Res. 2022;40:43–54. doi: 10.1002/jor.25058. [DOI] [PubMed] [Google Scholar]
- 6.Yu B, Garrett WE. Mechanisms of non-contact ACL injuries. Br J Sports Med. 2007;41 Suppl 1:i47–51. doi: 10.1136/bjsm.2007.037192. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Dingenen B, Gokeler A. Optimization of the Return-to-Sport Paradigm After Anterior Cruciate Ligament Reconstruction: A Critical Step Back to Move Forward. Sports Med. 2017;47:1487–500. doi: 10.1007/s40279-017-0674-6. [DOI] [PubMed] [Google Scholar]
- 8.Ardern CL, Taylor NF, Feller JA, et al. Fifty-five per cent return to competitive sport following anterior cruciate ligament reconstruction surgery: an updated systematic review and meta-analysis including aspects of physical functioning and contextual factors. Br J Sports Med. 2014;48:1543–52. doi: 10.1136/bjsports-2013-093398. [DOI] [PubMed] [Google Scholar]
- 9.Feller J, Webster KE. Return to sport following anterior cruciate ligament reconstruction. International Orthopaedics (SICOT) . 2013;37:285–90. doi: 10.1007/s00264-012-1690-7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Webster KE, Nagelli CV, Hewett TE, et al. Factors Associated With Psychological Readiness to Return to Sport After Anterior Cruciate Ligament Reconstruction Surgery. Am J Sports Med. 2018;46:1545–50. doi: 10.1177/0363546518773757. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Czuppon S, Racette BA, Klein SE, et al. Variables associated with return to sport following anterior cruciate ligament reconstruction: a systematic review. Br J Sports Med. 2014;48:356–64. doi: 10.1136/bjsports-2012-091786. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Ardern CL, Kvist J, Webster KE. Psychological Aspects of Anterior Cruciate Ligament Injuries. Oper Tech Sports Med. 2016;24:77–83. doi: 10.1053/j.otsm.2015.09.006. [DOI] [Google Scholar]
- 13.Podlog L, Wadey R, Caron J, et al. Psychological readiness to return to sport following injury: a state-of-the-art review. Int Rev Sport Exerc Psychol. 2022:1–20. doi: 10.1080/1750984X.2022.2081929. [DOI] [Google Scholar]
- 14.Webster KE, Feller JA. Exploring the High Reinjury Rate in Younger Patients Undergoing Anterior Cruciate Ligament Reconstruction. Am J Sports Med. 2016;44:2827–32. doi: 10.1177/0363546516651845. [DOI] [PubMed] [Google Scholar]
- 15.Webster KE, Feller JA, Lambros C. Development and preliminary validation of a scale to measure the psychological impact of returning to sport following anterior cruciate ligament reconstruction surgery. Phys Ther Sport. 2008;9:9–15. doi: 10.1016/j.ptsp.2007.09.003. [DOI] [PubMed] [Google Scholar]
- 16.Ross BJ, Savage-Elliott I, Brown SM, et al. Return to Play and Performance After Primary ACL Reconstruction in American Football Players: A Systematic Review. Orthop J Sports Med. 2020;8:2325967120959654. doi: 10.1177/2325967120959654. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Lai CCH, Ardern CL, Feller JA, et al. Eighty-three per cent of elite athletes return to preinjury sport after anterior cruciate ligament reconstruction: a systematic review with meta-analysis of return to sport rates, graft rupture rates and performance outcomes. Br J Sports Med. 2018;52:128–38. doi: 10.1136/bjsports-2016-096836. [DOI] [PubMed] [Google Scholar]
- 18.Ardern CL, Webster KE, Taylor NF, et al. Return to sport following anterior cruciate ligament reconstruction surgery: a systematic review and meta-analysis of the state of play. Br J Sports Med. 2011;45:596–606. doi: 10.1136/bjsm.2010.076364. [DOI] [PubMed] [Google Scholar]
- 19.Sandon A, Werner S, Forssblad M. Factors associated with returning to football after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2015;23:2514–21. doi: 10.1007/s00167-014-3023-4. [DOI] [PubMed] [Google Scholar]
- 20.Brophy RH, Schmitz L, Wright RW, et al. Return to play and future ACL injury risk after ACL reconstruction in soccer athletes from the Multicenter Orthopaedic Outcomes Network (MOON) group. Am J Sports Med. 2012;40:2517–22. doi: 10.1177/0363546512459476. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Klemm HJ, Feller JA, Webster KE. Comparison of Return-to-Sports Rates Between Male and Female Australian Athletes After ACL Reconstruction. Orthop J Sports Med. 2023;11:23259671231169199. doi: 10.1177/23259671231169199. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Webster KE, Feller JA. Return to Level I Sports After Anterior Cruciate Ligament Reconstruction: Evaluation of Age, Sex, and Readiness to Return Criteria. Orthop J Sports Med. 2018;6:2325967118788045. doi: 10.1177/2325967118788045. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Faleide AGH, Magnussen LH, Strand T, et al. The Role of Psychological Readiness in Return to Sport Assessment After Anterior Cruciate Ligament Reconstruction. Am J Sports Med. 2021;49:1236–43. doi: 10.1177/0363546521991924. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Sadeqi M, Klouche S, Bohu Y, et al. Progression of the Psychological ACL-RSI Score and Return to Sport After Anterior Cruciate Ligament Reconstruction: A Prospective 2-Year Follow-up Study From the French Prospective Anterior Cruciate Ligament Reconstruction Cohort Study (FAST) Orthop J Sports Med. 2018;6:2325967118812819. doi: 10.1177/2325967118812819. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Kitaguchi T, Tanaka Y, Takeshita S, et al. Importance of functional performance and psychological readiness for return to preinjury level of sports 1 year after ACL reconstruction in competitive athletes. Knee Surg Sports Traumatol Arthrosc. 2020;28:2203–12. doi: 10.1007/s00167-019-05774-y. [DOI] [PubMed] [Google Scholar]
- 26.Ardern CL, Taylor NF, Feller JA, et al. Psychological responses matter in returning to preinjury level of sport after anterior cruciate ligament reconstruction surgery. Am J Sports Med. 2013;41:1549–58. doi: 10.1177/0363546513489284. [DOI] [PubMed] [Google Scholar]
- 27.Ardern CL, Österberg A, Tagesson S, et al. The impact of psychological readiness to return to sport and recreational activities after anterior cruciate ligament reconstruction. Br J Sports Med. 2014;48:1613–9. doi: 10.1136/bjsports-2014-093842. [DOI] [PubMed] [Google Scholar]
- 28.Xiao M, van Niekerk M, Trivedi NN, et al. Patients Who Return to Sport After Primary Anterior Cruciate Ligament Reconstruction Have Significantly Higher Psychological Readiness: A Systematic Review and Meta-analysis of 3744 Patients. Am J Sports Med. 2023;51:2774–83. doi: 10.1177/03635465221102420. [DOI] [PubMed] [Google Scholar]
- 29.Ardern CL. Anterior Cruciate Ligament Reconstruction-Not Exactly a One-Way Ticket Back to the Preinjury Level: A Review of Contextual Factors Affecting Return to Sport After Surgery. Sports Health. 2015;7:224–30. doi: 10.1177/1941738115578131. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Webster KE, Feller JA. Who Passes Return-to-Sport Tests, and Which Tests Are Most Strongly Associated With Return to Play After Anterior Cruciate Ligament Reconstruction? Orthop J Sports Med. 2020;8:2325967120969425. doi: 10.1177/2325967120969425. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 31.Mok AC, Fancher AJ, Vopat ML, et al. Sex-Specific Outcomes After Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis. Orthop J Sports Med. 2022;10:23259671221076883. doi: 10.1177/23259671221076883. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32.Bruder AM, Culvenor AG, King MG, et al. Let’s talk about sex (and gender) after ACL injury: a systematic review and meta-analysis of self-reported activity and knee-related outcomes. Br J Sports Med. 2023;57:602–10. doi: 10.1136/bjsports-2022-106099. [DOI] [PubMed] [Google Scholar]
- 33.Tan SHS, Lau BPH, Khin LW, et al. The Importance of Patient Sex in the Outcomes of Anterior Cruciate Ligament Reconstructions: A Systematic Review and Meta-analysis. Am J Sports Med. 2016;44:242–54. doi: 10.1177/0363546515573008. [DOI] [PubMed] [Google Scholar]
- 34.Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71. doi: 10.1136/bmj.n71. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 35.Takats S, Stillman D, Cheslack-Postava F, et al. Zotero (6.0.26) [windows 10]. corporation for digital scholarship. 2023. https://www.zotero.org/ Available.
- 36.Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. Ann Intern Med. 2009;151:W65–94. doi: 10.7326/0003-4819-151-4-200908180-00136. [DOI] [PubMed] [Google Scholar]
- 37.Slim K, Nini E, Forestier D, et al. Methodological index for non-randomized studies (minors): development and validation of a new instrument. ANZ J Surg. 2003;73:712–6. doi: 10.1046/j.1445-2197.2003.02748.x. [DOI] [PubMed] [Google Scholar]
- 38.Khan W, Khan M, Alradwan H, et al. Utility of Intra-articular Hip Injections for Femoroacetabular Impingement: A Systematic Review. Orthop J Sports Med. 2015;3:2325967115601030. doi: 10.1177/2325967115601030. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 39.Pithon MM, Baião FCS, Sant Anna LID de A, et al. Assessment of the effectiveness of invisible aligners compared with conventional appliance in aesthetic and functional orthodontic treatment: A systematic review. J Investig Clin Dent. 2019;10:e12455. doi: 10.1111/jicd.12455. [DOI] [PubMed] [Google Scholar]
- 40.Cohen J. Statistical Power Analysis for the Behaviors Science. 2nd Edn. Hillsdale: Laurence Erlbaum Associates, Publishers; 1988. [Google Scholar]
- 41.Higgins JPT, Thompson SG, Deeks JJ, et al. Measuring inconsistency in meta-analyses. BMJ. 2003;327:557–60. doi: 10.1136/bmj.327.7414.557. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 42.Dombrowski N, Cleary CJ, Bernard CD, et al. Psychological Readiness Is Weakly Related to Physical Function Tests at Return to Sport for Men and Not at All for Women Following Anterior Cruciate Ligament Reconstruction and Rehabilitation. Arthroscopy. 2024;40:1870–8. doi: 10.1016/j.arthro.2023.11.029. [DOI] [PubMed] [Google Scholar]
- 43.Kostyun RO, Burland JP, Kostyun KJ, et al. Male and Female Adolescent Athletes’ Readiness to Return to Sport After Anterior Cruciate Ligament Injury and Reconstruction. Clin J Sport Med. 2021;31:383–7. doi: 10.1097/JSM.0000000000000751. [DOI] [PubMed] [Google Scholar]
- 44.Kuenze C, Bell DR, Grindstaff TL, et al. A Comparison of Psychological Readiness and Patient-Reported Function Between Sexes After Anterior Cruciate Ligament Reconstruction. J Athl Train. 2021;56:164–9. doi: 10.4085/1062-6050-0034.20. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 45.Milewski MD, Traver JL, Coene RP, et al. Effect of Age and Sex on Psychological Readiness and Patient-Reported Outcomes 6 Months After Primary ACL Reconstruction. Orthop J Sports Med. 2023;11:23259671231166012. doi: 10.1177/23259671231166012. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 46.Manara JR, Salmon LJ, Kilani FM, et al. Repeat Anterior Cruciate Ligament Injury and Return to Sport in Australian Soccer Players After Anterior Cruciate Ligament Reconstruction With Hamstring Tendon Autograft. Am J Sports Med. 2022;50:3533–43. doi: 10.1177/03635465221125467. [DOI] [PubMed] [Google Scholar]
- 47.McPherson AL, Feller JA, Hewett TE, et al. Smaller Change in Psychological Readiness to Return to Sport Is Associated With Second Anterior Cruciate Ligament Injury Among Younger Patients. Am J Sports Med. 2019;47:1209–15. doi: 10.1177/0363546519825499. [DOI] [PubMed] [Google Scholar]
- 48.Webster KE, Feller JA. Evaluation of the Responsiveness of the Anterior Cruciate Ligament Return to Sport After Injury (ACL-RSI) Scale. Orthop J Sports Med. 2021;9:23259671211031240. doi: 10.1177/23259671211031240. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 49.Webster KE, Feller JA. Psychological Readiness to Return to Sport After Anterior Cruciate Ligament Reconstruction in the Adolescent Athlete. J Athl Train. 2022;57:955–60. doi: 10.4085/1062-6050-0543.21. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 50.Beneito Pastor D, Morales-Santias M, Bustamante Suarez de Puga D, et al. Psychological readiness to return to sports after anterior cruciate ligament reconstruction in amateur sport. Rev Esp Cir Ortop Traumatol. 2022;66:113–20. doi: 10.1016/j.recot.2021.07.006. [DOI] [PubMed] [Google Scholar]
- 51.Cronström A, Häger CK, Thorborg K, et al. Factors Associated With Sports Function and Psychological Readiness to Return to Sports at 12 Months After Anterior Cruciate Ligament Reconstruction: A Cross-sectional Study. Am J Sports Med. 2023;51:3112–20. doi: 10.1177/03635465231192983. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 52.Franck F, Saithna A, Vieira TD, et al. Return to Sport Composite Test After Anterior Cruciate Ligament Reconstruction (K-STARTS): Factors Affecting Return to Sport Test Score in a Retrospective Analysis of 676 Patients. Sports Health: A Multidisciplinary Approach. 2021;13:364–72. doi: 10.1177/1941738120978240. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 53.Kvist J, Ek A, Sporrstedt K, et al. Fear of re-injury: a hindrance for returning to sports after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2005;13:393–7. doi: 10.1007/s00167-004-0591-8. [DOI] [PubMed] [Google Scholar]
- 54.Lisee CM, DiSanti JS, Chan M, et al. Gender Differences in Psychological Responses to Recovery After Anterior Cruciate Ligament Reconstruction Before Return to Sport. J Athl Train. 2020;55:1098–105. doi: 10.4085/1062-6050-558.19. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 55.Ardern CL, Taylor NF, Feller JA, et al. Fear of re-injury in people who have returned to sport following anterior cruciate ligament reconstruction surgery. J Sci Med Sport. 2012;15:488–95. doi: 10.1016/j.jsams.2012.03.015. [DOI] [PubMed] [Google Scholar]
- 56.Fones L, Kostyun RO, Cohen AD, et al. Patient-Reported Outcomes, Return-to-Sport Status, and Reinjury Rates After Anterior Cruciate Ligament Reconstruction in Adolescent Athletes: Minimum 2-Year Follow-up. Orthop J Sports Med. 2020;8:2325967120964471. doi: 10.1177/2325967120964471. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 57.Ebert JR, Edwards P, Preez LD, et al. Knee extensor strength, hop performance, patient-reported outcome and inter-test correlation in patients 9–12 months after anterior cruciate ligament reconstruction. Knee. 2021;30:176–84. doi: 10.1016/j.knee.2021.04.012. [DOI] [PubMed] [Google Scholar]
- 58.Correa RV, Verhagen E, Resende RA, et al. Performance in field-tests and dynamic knee valgus in soccer players psychologically ready and not ready to return to sports after ACL reconstruction. Knee. 2023;42:297–303. doi: 10.1016/j.knee.2023.04.011. [DOI] [PubMed] [Google Scholar]
- 59.Legnani C, Del Re M, Viganò M, et al. Relationships between Jumping Performance and Psychological Readiness to Return to Sport 6 Months Following Anterior Cruciate Ligament Reconstruction: A Cross-Sectional Study. JCM. 2023;12:626. doi: 10.3390/jcm12020626. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 60.Hong IS, Pierpoint LA, Hellwinkel JE, et al. Clinical Outcomes After ACL Reconstruction in Soccer (Football, Futbol) Players: A Systematic Review and Meta-Analysis. Sports Health: A Multidisciplinary Approach. 2023;15:788–804. doi: 10.1177/19417381231160167. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 61.Farinelli L, Abermann E, Meena A, et al. Return to Play and Pattern of Injury After ACL Rupture in a Consecutive Series of Elite UEFA Soccer Players. Orthop J Sports Med. 2023;11:23259671231153629. doi: 10.1177/23259671231153629. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 62.Bonanzinga T, Grassi A, Altomare D, et al. High return to sport rate and few re-ruptures at long term in professional footballers after anterior cruciate ligament reconstruction with hamstrings. Knee Surg Sports Traumatol Arthrosc. 2022;30:3681–8. doi: 10.1007/s00167-022-06944-1. [DOI] [PubMed] [Google Scholar]
- 63.Nwachukwu BU, Anthony SG, Lin KM, et al. Return to play and performance after anterior cruciate ligament reconstruction in the National Basketball Association: surgeon case series and literature review. Phys Sportsmed. 2017;45:303–8. doi: 10.1080/00913847.2017.1325313. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
Data are available in a public, open access repository.