Hierarchical Regression of Psychological Readiness to Return to Sport Following Anterior Cruciate Ligament Reconstruction

Background and/or Objectives: Anterior Cruciate Ligament (ACL) injuries are some of the most common sports-related injuries in the United States. Athletes undergoing ACL reconstruction (ACLR) face a high risk of not returning to sport (RTS). While research has focused on objective factors, recent evidence suggests that psychosocial factors play a significant role in addressing the unexplained portion of athletes who fail to RTS despite meeting objective measures. This study examines psychological and biomechanical factors contributing to RTS readiness.

Design: A hierarchical regression analysis was used to assess predictors of psychological readiness for RTS. The ACL-Return to Sport after Injury (ACL-RSI) scale assessed athletes' psychological readiness for RTS.

Setting : A single-site investigation was performed from 2021-2023, utilizing a standardized assessment protocol approximately 6 months post-ACLR.

Participants : The initial cohort included 101 patients who underwent ACLR. Exclusion criteria included incomplete data and age < 36 years. The final analysis included 58 participants.

Interventions: N/A

Main Outcome Measures: The primary outcome was psychological readiness for RTS, assessed using the ACL-RSI scale. Predictor variables included age, sex, time since surgery, psychological factors: anxiety (PROMIS), kinesiophobia (TSK-11), pain (KOOS-Pain), symptoms (KOOS-Symptoms), perceived/subjective function (KOOS-Sport), and biomechanical factors: peak isokinetic extension strength symmetry (LSI) and single leg hop distance symmetry (LSI).

Results: After controlling for demographics and time from surgery, statistically significant changes in R² were found after adding anxiety: +18.1% R², kinesiophobia: +22.3% R², symptoms: +2.8% R², subjective function: +10.3% R², and hop distance: +2.7% R². The final model showed that significant predictors included subjective function, kinesiophobia, and hop distance. The adjusted R² was 0.62, leaving 38% variance unexplained.

Conclusions: Psychological factors, particularly anxiety, kinesiophobia, and subjective function, were the strongest additive predictors of psychological readiness for RTS, while objective function was not. Rehabilitation should prioritize psychological recovery and self-perceived function to improve RTS outcomes. Future research should explore additional psychosocial factors to address unexplained variance.