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. 2024 Feb 19;18(1):102–109. doi: 10.1177/19417381241226896

The Psychology of ACL Injury, Treatment, and Recovery: Current Concepts and Future Directions

Andrew J Sheean 1, Mikalyn T DeFoor 2,*, Kurt P Spindler 3; IMPACT ACL Study Group, Justin W Arner 4, Aravind Athiviraham 5, Asheesh Bedi 6, Steven DeFroda 7, Justin J Ernat 8, Salvatore J Frangiamore 9, Clayton W Nuelle 10, Andrew J Sheean 11, Kurt P Spindler 12, Asheesh Bedi 13
PMCID: PMC12696311  PMID: 38374636

Abstract

Context:

Interest in the relationship between psychology and the outcomes of anterior cruciate ligament (ACL) reconstruction (ACLR) continues to grow as variable rates of return to preinjury level of activity continue to be observed.

Evidence Acquisition:

Articles were collected from peer-reviewed sources available on PubMed using a combination of search terms, including psychology, resilience, mental health, recovery, and anterior cruciate ligament reconstruction. Further evaluation of the included bibliographies were used to expand the evidence.

Study Design:

Clinical review.

Level of Evidence:

Level 4.

Results:

General mental health and wellbeing, in addition to a host of unique psychological traits (self-efficacy, resilience, psychological readiness and distress, pain catastrophizing, locus of control, and kinesiophobia) have been demonstrated convincingly to affect treatment outcomes. Moreover, compelling evidence suggests that a number of these traits may be modifiable. Although the effect of resilience on outcomes of orthopaedic surgical procedures has been studied extensively, there is very limited information linking this unique psychological trait to the outcomes of ACLR. Similarly, the available information related to other parameters, such as pain catastrophizing, is limited with respect to the existence of adequately sized cohorts capable of accommodating more rigorous and compelling analyses. A better understanding of the specific mechanisms through which psychological traits influence outcomes can inform future interventions intended to improve rates of return to preinjury level of activity after ACLR.

Conclusion:

The impact of psychology on patients’ responses to ACL injury and treatment represents a promising avenue for improving low rates of return to preinjury activity levels among certain cohorts. Future research into these areas should focus on specific effects of targeted interventions on known, modifiable risk factors that commonly contribute to suboptimal clinical outcomes.

Strength-of-Recommendation Taxonomy (SORT):

B.

Keywords: anterior cruciate ligament (ACL) injury, outcomes, resilience, return to sport, sports psychology

Rates of return to preinjury level of activity after anterior cruciate ligament (ACL) reconstruction (ACLR) remain unacceptably low,1,15,28,30 and this fact should compel clinicians and researchers to improve the multifaceted approach of return to sport (RTS) and preinjury level of activity. Many authors have elucidated the effects that patient psychological response to injury and treatment can have on clinical outcomes.2,5,12,16,23,31 It is clear that patients’ responses to illness and disease are predicated upon both physiological and psychological traits, and there is a substantial body of literature that has identified the strong effect that a patients’ psychology can have across the continuum of care. “Psychology” is a broad term and encompasses one’s underlying mental health in addition to a variety of patient-specific traits that govern how one perceives an injury and deals with the recovery process. Independent of the knee injury itself and the specific surgical procedure performed, whether patients feel “confident” enough to return to their preinjury activities is, in many respects, predicated upon their unique psychological phenotypes. Furthermore, predictable variations in these traits may be observed among certain groups according to patient age and biological sex. Definitive analyses of these nuances are lacking and represent a conspicuous knowledge gap and an opportunity for innovation in the management of ACL injuries. In addition, improved understandings of the effects of psychology on the clinical outcomes of ACLR would greatly strengthen subsequent analyses of patients known to have maladaptive responses to treatment. Most importantly, given that a number of these psychological processes and traits may be modifiable, this area of study represents a relatively unexplored avenue to improve upon the conspicuous limitations of ACLR.

Therefore, the purposes of this review are to (1) elaborate on how mental processes affect patients’ approach to ACLR, (2) review the most important psychological traits that have been implicated in patients’ ultimate readiness to return to activity, and (3) identify areas for ongoing study and innovation. The prognostic implications of these insights are clear, as the identification of certain psychological traits associated with better (or worse) outcomes would further refine expectations for the end state and trajectory of recovery.

Key Terms and Definitions

There is considerable variation in terms of how patients perceive the implications of an ACL injury, cope with the acute discomfort typical of the perioperative period, and endure the arduous months-long process of rehabilitating their reconstructed knee. Owing to the complexity of patient experiences across this continuum, a number of terms have been introduced, and familiarity with this vernacular is necessary to understand the state of the art terminology and appreciate the potential for innovation. Table 1 provides an overview of several of these terms as well as the instruments that have been validated to measure select psychological traits. While each of these entities are presented independently, it is important to acknowledge the complex interplay between the myriad factors that are both unique and interconnected in patients’ psychological phenotypes.

Table 1.

Overview of key measures relevant to patient psychology and ACL injury and treatment

Psychological Trait Measuring Instrument Year (Country of Description) Validation Questionnaire
Kinesiophopia TSK 44 1991 (USA) Yes 17 items
(4-point scale)
Locus of control MHLC 51 1978 (USA) Yes 18 items
(6-point scale)
Pain catastrophizing PCS 33 1995 (Canada) Yes 13 items
(5-point scale)
Psychological distress SF-12 MCS 18 1994 (USA) Yes 6 items
(combination of Y/N & 6-point scale)
Psychological readiness ACL-RSI 53 2008 (Australia) Yes 12 items
(11-point scale)
Resilience BRS 46
CD-RISC 7 		2008 (USA) Yes 6 items
(5-point scale)
2003 (USA) Yes 25 items
(5-point scale)
Self-efficacy K-SES 48 2005 (Sweden) Yes 22 items
(11-point scale)
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ACL, anterior cruciate ligament; ACL-RSI, anterior cruciate ligament-return to sport after injury scale; BRS, Brief Resilience Scale; CD-RISC, Connor-Davidson Resilience Scale; K-SES, Knee Self-Efficacy Scale; MHLC, Multidimensional Health Locus of Control; PCS, Pain Catastrophizing Scale; SF-12 MCS, Short-Form Health Survey Mental Component Summary; TSK, Tampa Scale of Kinesiophobia.

Quality of Life and Psychological Distress

The effect of mental health disorders and overt pathological traits on clinical outcomes is well described throughout the orthopaedic literature, and various forms of psychological distress can impact patients’ approaches to ACL injury and subsequent treatment. The term “psychological distress” encompasses a spectrum of conditions that includes acute stress, anxiety, and depression, among others, that can negatively affect patient mental wellbeing. Several reports have observed clear linkages between the presence of mental health conditions and the outcomes of ACLR, as reflected in Short-Form Health Survey (SF-12) Mental Component Summary (MCS) scores, which have been validated as a measure of quality of life (QoL) and are a useful screening tool for both depression and anxiety disorders. 18 Among a series of 231 patients, Nwachukwu et al 32 noted that higher scores on the MCS were predictive of return to play among athletes as well as the likelihood of achieving minimal clinically important differences on the International Knee Documentation Committee (IKDC) subjective knee evaluation form and Lysholm scale scores. More recently, and across a more robust dataset, the MOON Knee Group 30 identified lower MCS as an independent negative predictor of an inability to return to preinjury activity level among a subset of the 1188 patients in the Multicenter Orthopaedic Outcomes Network (MOON) knee cohort with preinjury Marx activity scores between 12 and 16. These results provide compelling evidence that psychological distress can be a key driver of ACLR outcomes through both direct and indirect effects.

Self-Efficacy

Previously defined as “the way people judge their capabilities to organize and execute courses of action required to attain designated types of performance,” self-efficacy is relevant across the continuum of care and can play a substantial role in how patients participate in their recovery.49,50 Stated differently, someone that is more confident in his or her ability to directly affect change in a given circumstance might be expected to expend more effort and demonstrate more endurance in times of difficulty. It then follows that this general approach is likely to result in higher rates of meaningful participation in postoperative rehabilitation, which is likely to be a key determinant of postoperative physical function. Thus, a person with high self-efficacy would be theoretically more likely to determine the trajectory and end state of his or her recovery. Originally described and validated by Thomeé and associates, the Knee Self-Efficacy Scale (K-SES), a 22-item scale comprised of 4 domains (daily activities, physical activities, sports/leisure activities, and knee function in the future) pertaining to patients’ confidence in executing physical tasks of increasing intensity, has been employed across multiple cohorts of patients recovering from ACLR.48,50 Among a relatively small group of 38 patients (25 male, 13 female; athletes; mean age, 29.7 years) with at least 12 months of follow-up after ACLR, the K-SES was a significant predictor of increased physical activity (Tegner activity scale), improved symptoms (Knee Osteoarthritis Outcomes Score [KOOS] sports/recreation subscale), and objective muscle function (hop test distance). 49 In a more robust cohort of 328 patients (120 male, 208 female; mean age, 27.8 ± 10 years), Piussi et al 37 assessed the relationship between the proportions of patients who did and did not achieve symmetric muscle function and K-SES results at 10 weeks, and at 4, 8, and 12 months postoperatively. Of note, patients who reported higher self-efficacy demonstrated significantly greater concentric isokinetic knee flexion/extension strength measurements in addition to higher KOOS QoL scores. 37 If muscle strength and function is considered to be a surrogate for successful postoperative rehabilitation, these results may substantiate the concept that patients with higher degrees of self-efficacy are more apt to meet objectively defined milestones indicating restoration of physical function.

Locus of Control

Locus of control is a related topic and refers to a person’s belief in the relationships between actions and outcomes and has been described as a determinant of one’s underlying self-efficacy. This concept has been further differentiated into 3 types: internal, external, and chance loci of control.6,43 “High” internal locus of control refers to the belief that one’s own actions reliably affect outcomes, whereas “high” external locus of control (ie, “low” internal locus of control) would suggest that an outcome is determined more so by external factors outside the control of one’s own actions. Chance locus of control refers to the belief that an outcome is affected neither by one’s own actions nor external factors and is simply a function of chance or random events. As commonly measured by the Multidimensional Health Locus of Control (MHLC) survey, 51 internal locus of control has been shown to be correlated most strongly with higher self-efficacy in patients undergoing ACLR. 47

Kinesiophobia: Fear of Reinjury

Kinesiophobia, which refers to patients’ “fear of movement” in anticipation of reinjury, has been consistently acknowledged as the single most important driver of whether patients ultimately return to their preinjury level of activity after ACLR.3,22,31,35 It is most commonly measured by the Tampa Scale of Kinesiophobia (TSK) and a shortened, 11-item version of that instrument; however, multiple assessments of this entity have been described. 56 A number of reports have observed associations between higher magnitudes of kinesiophobia and lower rates of return to preinjury activity level. A systematic review of 2918 athletes undergoing ACLR reported a mean time for RTS of 17.2 months with a 63.4% rate of RTS and 36.6% rate of inability to return to preinjury level of activity. In this review, fear of reinjury was the single most common reason cited for not returning to play (n = 394; 76.7%). 31 Flanigan et al 17 queried 73 patients with a history of either primary or revision ACLR characterized as “nonreturners” as to the reason for their lack of return to preinjury activity level. In all, 52% of “nonreturners” reported kinesiophobia as the primary reason for their lack of return. Of note, these authors did not use a validated measure of kinesiophobia and instead employed a simple question of whether the patient was afraid of reinjury or not. Similarly, Lentz et al 24 observed that, out of patients who did not return to their preinjury activity level (27 of 73), 52% (14 of 27) cited their self-reported reason due to fear of reinjury and/or a lack of confidence, versus those patients who self-reported not returning to their preinjury activity level secondary to knee pain, swelling, instability, muscle weakness, or “other.” Significantly higher mean TSK scores were noted among the subgroup of patients that did not return to their preinjury activity level versus those that were able to return at 6 and 12 months postoperatively (P < .001). These observations led the authors to speculate that the temporal crescendo of associations between kinesiophobia and the ultimate end state suggest that psychological traits may be of differential consequence as patients recover from surgery. Furthermore, these traits may exert their effects on a longer-term basis, as opposed to physical impairments that are more relevant to patients’ discomfort in the immediate postoperative period.

Readiness to RTS/Return to Activity: the End State Defined

The complex interplay of these traits, characteristics, and factors ultimately manifests as a patients’ psychological readiness to return to his/her preinjury level of activity, and this state of being has been noted to have significant effect on the clinical outcomes of ACLR. 54 The measurement of psychological readiness to RTS and preinjury level of activity after ACLR has been studied extensively, and a number of relatively large cohort-based studies have substantiated the use of the ACL-return to sport after injury (ACL-RSI) scale as a useful instrument to measure psychological readiness. 52 Originally described in 2008 by Webster et al, 53 the ACL-RSI is a 12-item survey that assesses the emotions, confidence in performance, and risk appraisal of patients recovering from ACLR. Since then, several studies have demonstrated the significant association between greater magnitudes of psychological readiness and the likelihood of returning to preinjury activity level. Among 178 athletes (115 male, 63 female; mean age, 27 years) undergoing ACLR, Ardern et al 2 observed that higher ACL-RSI (odds ratio [OR], 1.10; 95% CI, 1.06-1.20) and TSK scores (OR, 1.21; 95% CI, 1.01-1.44) predicted return to preinjury activity level most strongly. In a relatively large cohort, Webster et al 54 explored variations in ACL-RSI scores across a relatively large cohort (635 athletes [389 male, 246 female]; mean age, 26 years) and identified that male sex, younger age, a shorter time between injury and surgery, greater limb symmetry, and higher subjective knee scores (IKDC) all had a positive effect on psychological readiness. The association between female sex and lower ACL-RSI are particularly noteworthy, as female and younger athletes present a greater risk of anxiety, depression, and stress than their male counterparts.31,38,42 This observation reflects previously noted discrepancies in rates of return to preinjury activity level, which most certainly represents an area for future study. In addition, the relationship between measured physical function and psychological readiness to RTS and preinjury level of activity is noteworthy. Similar to the aforementioned observations of Webster et al, 54 Cronström et al 11 noted that patients with higher ACL-RSI performed significantly better in several measures of physical function (peak isokinetic knee extension torque, single-leg hop for distance, side hop test). It is possible that these measures of improved physical performance are manifestations of more successful postsurgical rehabilitation, which could be due, in part, to more favorable psychological phenotypes. However, the relative contributions and causal direction of individual psychological traits to these processes remain unclear from the current available literature and are worthy of future research.

Avenues for Innovation and Future Direction

These terms and concepts are essential to a broader understanding of the role that psychology plays in ACLR recovery, which encompasses RTS/preinjury level of activity as well as reinjury. While the current evidence is limited, there is support that psychological traits, such as self-confidence and self-efficacy, may impact the risk of ACL reinjury in addition to the rate of RTS. 36 However, the relatively small number of patients in most of the referenced studies limits the strengths of conclusions that might be drawn from those results. In addition, there are several other relatively understudied, patient-specific psychological traits that warrant attention and represent opportunities for future innovation.

“Resilience” has been defined by the American Psychological Association as the ability to “adapt well in the face of adversity, trauma, tragedy, threats or significant sources of stress,” and has been recognized as a unique factor that may impact one’s overall state of health. Four instruments for objectively measuring resilience in musculoskeletal disease have been described, with the 6-item Brief Resilience Scale and 25-item Connor-Davidson Resilience Scale instruments demonstrating the highest psychometric ratings. 55 Higher levels of resilience have been associated with increased self-esteem, life satisfaction, and diminished symptoms of depression.19,40 Among several adult cohorts, higher levels of resilience have been correlated with improved physical function. 39 There are a limited number of recent reports that have investigated the relationship between resilience and outcomes after orthopaedic surgical interventions, the majority of which have focused on patients recovering from spinal cord injury and spine surgery, orthopaedic trauma, and total joint arthroplasty. Among these cohorts, increased levels of resilience have been associated with improved physical function postoperatively.4,8,14,26

Comparatively less has been reported on the relationship between resilience and functional outcomes in patients recovering from ACLR (Table 2). Among these studies, patients were stratified inconsistently based upon preoperative resilience, with no discernible relationships observed between preoperative values and postoperative outcomes. An appraisal of these studies highlights 2 important points: (1) there is a critical knowledge gap in the contemporary understanding of how resilience drives clinical outcomes associated with ACLR, and (2) studies are often small and lack sufficient sample size to perform robust statistical analyses.

Table 2.

Summary of studies relevant to resilience and ACLR

Author (Year) LoE Subjects, n Age, years a Sex (M/F) Resilience Measure/ Stratification Groups PROs Collected RTS Major Conclusions
Zwolski (2023) 58 3 41 (athletes) 16.6 (13-26) 12/29 BRS ACL-RSI, KOOS, SMS, self-perception profile Not reported Younger age, male sex, and meeting perceived physical competence were associated with higher psychological readiness to RTS, but not with motivation or resilience
Meade (2023) 29 4 103 (athletes and nonathletes) 31.1 (10.1) 63/40 BRS
HR: 26-28NR: 18-25
LR: 11-17		 SF-
12, VAS pain score		 Not reported Higher resilience led to greater postoperative SF-12 scores and lower postoperative VAS pain scores when compared with patients with lower resilience
Zhang (2021) 57 4 71 (athletes) 19
(14-43)		 30/26 BRS
HR: 28-30
NR: 19-27
LR: ≤18		 SANE RTS 9 months postoperatively at same level of play or higher:
75% 9 of 12 (HR)
55%, 5 of 9 (LR)		 There was no difference in age, sex, or graft choice for ACLR among resilience cohorts. Resilience was not associated significantly with RTS rates
Drayer (2020) 13 3 50 (active-duty military) b 35.2 42/8 BRS
HR: ≥24
LR: <24		 IKDC, KOOS, PROMIS-43, VR-12 2.3% (HR)
22.2% (LR)		 Higher resiliency preoperatively was associated with improved postoperative PROs at 6 months. There was a lower rate of changing MOS after injury in patients with high resilience
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ACL, anterior cruciate ligament; ACLR, anterior cruciate ligament reconstruction; ACL-RSI, anterior cruciate ligament return to sport after injury; BRS, Brief Resilience Scale; F, female; HR, high resilience; IKDC, International Knee Documentation Committee; KOOS, Knee injury and Osteoarthritis Outcome Score; LoE, level of evidence; LR, low resilience; M, male; MOS, military occupation specialty; NR, normal resilience; PROs, patient-reported outcomes; PROMIS, patient-reported outcomes measurement information system; SANE, Single Assessment Numeric Evaluation; SF-12, Short-Form Health Survey-12; SMS, sport motivation scale; RTS, return to sport; VAS, visual analogue score.

a

Age presented as average with range or standard deviation as applicable.

b

ACLR, 21 of 50; general knee arthroscopy, 29 of 50.

“Pain catastrophizing” is another psychological factor that appears to drive surgical outcomes. Pain catastrophizing has been described as a maladaptive cognitive approach that is associated with a magnification of the threat from painful sensations and the anticipation of pain. 34 Of note, this phenomenon has been noted to affect how pain is experienced by persons with chronic pain and healthy persons alike. A number of reports have identified higher pain catastrophizing as a risk factor for increased opioid usage, increased healthcare utilization, and decreased patient expectation of full recovery after orthopaedic surgical interventions.14,41 Furthermore, pain catastrophizing and pain-related cognitive bias measures can mediate the relationship between pain intensity and activity intolerance. 10 While pain catastrophizing has been studied extensively among cohorts of patients recovering from spine surgery, comparatively less interest has been devoted to this psychological trait’s effect on outcomes of ACLR. In fact, we are aware of only 1 report that has assessed the relationship between pain catastrophizing and outcomes of ACLR. Although Jochimsen et al 20 concluded that pain catastrophizing did not predict worse clinical outcomes after ACLR, the strength of this conclusion was diminished substantially by the size of the cohort (46 patients) and the short duration of clinical follow-up (6 months). In our estimation, there have been no sufficiently sized cohorts of patients recovering from ACLR to accommodate any meaningful analysis as to the effect, if any, of pain catastrophizing on recovery trajectory and ultimately whether patients return to their preinjury level of activity.

As has been shown in a number of studies, patients’ psychological response to ACLR can be modulated successfully through psychosocial interventions such that rates of return to preinjury level of activity can be improved. 9 Similarly, a number of reports have convincingly demonstrated that both resilience and pain catastrophizing are modifiable traits. 27 Joyce et al 21 performed a systematic review and meta-analysis of 11 randomized controlled trials, observing compelling results that illustrated that resilience can be improved through cognitive behavioral therapy and mindfulness-based interventions. Similarly, Patel et al 34 performed a systematic review of 5 randomized controlled trials involving patients recovering from total knee replacement, observing that pain catastrophizing can be improved by cognitive behavioral therapy. However, to date, we are unaware of published results of trials to determine whether these types of interventions are efficacious in patients recovering from ACLR.

We propose that general mental health, resilience, and pain catastrophizing, along with other condition-specific patient-reported outcome measures, be measured before ACLR and then on a recurring basis throughout the recovery process. Doing so before a surgical intervention would aid in identifying those patients that may be “at risk” for slower recovery and/or worse outcomes and provide a basis for undertaking interventions intended to improve maladaptive responses. Studies have shown the effectiveness of teaching positive self-talk, goal setting, guided imagery, mindfulness, and relaxation techniques, whether that be on an individual basis at a preoperative appointment or in a weekly group education session. 25 Formal intervention initiated by referral to a sports psychologist and/or primary care sports medicine physician can reduce postinjury psychological consequences and improve psychological coping. In addition to a routine postoperative course of physical therapy, physical therapists can also be trained on techniques to reduce postinjury psychological distress, improve psychological coping, and reduce reinjury anxiety. 45

Conclusion

The impact of psychology on patient response to ACL injury and treatment represents a promising avenue for improving low rates of return to preinjury activity levels among certain cohorts. A number of psychological traits, including self-efficacy, resilience, pain catastrophizing, locus of control, and kinesiophobia, may have a substantial effect on recovery after ACLR. Future research into these areas should focus on specific effects of targeted interventions on known, modifiable risk factors that commonly contribute to suboptimal clinical outcomes.

Footnotes

The following authors declared potential conflicts of interest: A.J.S. has received stock or stock options from Springbok Analytics and consulting fees from Stryker. K.P.S. has received research support from DJ Orthopaedics and National Institutes of Health (NIAMS & NICHD), consulting fees from the NFL and Novopods, and royalties from Oberd. A.B. has received royalties and consulting fees from Arthrex and royalties from SLACK Incorporated and Springer. A.A. has received speaking fees from Arthrex. S.D. has received speaking fees from AO North America, research support from Arthrex, and royalties from Springer. J.J.E. has received consulting fees from Johnson & Johnson. S.J.F. has received speaking payments from Anika Therapeutics and consulting fees from Zimmer. C.W.N has received financial support from AO Foundation, speaking fees from Arthrex and Vericel, and consulting fees from Guidepoint Consulting.

Contributor Information

Andrew J. Sheean, San Antonio Military Medical Center, San Antonio, Texas.

Mikalyn T. DeFoor, San Antonio Military Medical Center, San Antonio, Texas.

Kurt P. Spindler, Cleveland Clinic Foundation, Westin, Florida.

Justin W. Arner, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.

Aravind Athiviraham, University of Chicago, Chicago, Illinois.

Asheesh Bedi, NorthShore University Health System, Skokie, Illinois.

Steven DeFroda, University of Missouri, Columbia, Missouri.

Justin J. Ernat, University of Utah, Salt Lake City, Utah.

Salvatore J. Frangiamore, Cleveland Clinic Sports Medicine, Cleveland, Ohio.

Clayton W. Nuelle, University of Michigan, MedSport, Ann Arbor, Michigan.

Andrew J. Sheean, San Antonio Military Medical Center, San Antonio, Texas.

Kurt P. Spindler, Cleveland Clinic Foundation, Westin, Florida.

Asheesh Bedi, NorthShore University Health System, Skokie, Illinois.

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