Smaller change in psychological readiness to return to sport is associated with second anterior cruciate ligament injury among younger patients.

McPherson AL, Feller JA, Hewett TE, and Webster KE. Am J Sports Med 2019. [Epub Ahead of Print].

Take Home Message: A patient who sustains a second anterior cruciate ligament (ACL) rupture was likely less psychologically ready to return to sport after an initial ACL injury than those who do not retear their ACL.

A patient with an ACL injury is at greater risk of reinjury after they return to play than an uninjured peer. Many researchers have focused on functional benchmarks after an ACL injury. Unfortunately, less focus has been given to the psychological changes after an ACL injury. Therefore, McPherson and colleagues completed a prospective, longitudinal study to assess if psychological readiness to return to sport is related to reinjury among people with a primary ACL injury. The authors analyzed data from 115 participants who were

(a) <20 years of age,
(b) injured during sport,
(c) undergoing a primary ACL reconstruction,
(d) without a history of knee injury, and
(e) returned to sport.

All participants completed Anterior Cruciate Ligament Return to Sport after Injury Scale (ACL-RSI) prior to surgery and again at 1 year after surgery. The ACL-RSI assesses a person’s readiness to return to sport. Based on an online survey completed by participants 2 to 4 years after surgery, the authors classified participants as either uninjured or having a second ACL injury. Overall, 21 participants sustained another ACL injury. Prior to surgery, both groups had similar readiness to return to sport. However, at the 1-year follow-up a participant who would develop a second ACL injury had lower psychological readiness to return to sport than participants who remained uninjured. On average, participants who would develop a second ACL injury had less than half the improvement in psychological readiness than their peers. At 1-year, the second injury group reported being

(a) more nervous about playing sport,
(b) less confident in playing sport without concern for the knee,
(c) more frustrated with having to consider the knee with respect to sport, and
(d) more fearful of reinjuring the knee by playing sport than their peers.

The results of the current study offer valuable insight into the psychological readiness of a person who may be at greater risk for a second ACL injury. We can infer from these findings that a person who is less psychologically ready to return to sport because of nervousness, frustration, or lack of confidence related to the knee as well as more fearful of reinjury may be more likely to sustain a second ACL injury after return to play. Interestingly, these differences were not apparent prior to surgery. Instead, participants who had a second ACL injury experienced less psychological improvement over the first year after surgery than those who did not sustain a second ACL injury. Clinicians should consider assessing a person’s readiness to return to sport throughout the first year after surgery and have a treatment plan to address these concerns during the rehabilitation process. Further, the authors noted that the psychological readiness score and relative change varied a lot among the participants. This is a clear reminder that clinicians should see their patients as individuals and work to tailor a treatment plan for the individual patient. It should be noted though that one potential limitation of this study is that there is a chance that an important secondary injury may have been missed or occurred prior to the 1-year assessment. The researchers attempted to identify all secondary ACL injuries but this was through self-reporting at 2 to 4 years after surgery. Future research could benefit from reviewing medical records to identify any significant injuries (e.g., meniscal tear, second ACL injury) and when they occurred. It would be interesting to expand on these findings to learn if they apply to other age groups and across various sports. In the meantime, clinicians should counsel and treat patients individually and address a patient’s psychological concerns about returning to sport while treating the physical injury.

Questions for Discussion: How do you help patients address psychological concerns about return to sport after an injury? What resources have you used or would you like to see available to better prepare you?

Written by: Kyle Harris

Reviewed by: Jeffrey Driban

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