Association Between Meeting Return-to-Sport Criteria and Psychological Readiness to Return to Sport After Anterior Cruciate Ligament Reconstruct

Ueda Y, Matsushita T, Shibata Y, Takiguchi K, Ono K, Kida A, Ono R, Nagai K, Hoshino Y, Matsumoto T, Sakai Y, Kuroda R. Orthop J Sports Med. 2022 May 10;10(5):23259671221093985. doi: 10.1177/23259671221093985.

 Full Text Freely Available

Take-Home Message

Patients returning to activity following an anterior cruciate ligament reconstruction (ACLR) that meet return-to-sport criteria typically reported higher psychological readiness scores.


Many clinicians and patients consider returning to pre-injury activity a primary goal of an ACLR. Unfortunately, many patients never meet their expectations about returning to pre-injury activity levels. Both psychological and clinical/functional factors are necessary to determine readiness for returning to sport. However, the extent to which this relationship exists between the clinical/ functional and psychological readiness factors remains unclear.

Study Goal

Ueda and colleagues performed a cross-sectional study to identify whether patients who met functional criteria for return to sport after an ACLR had higher psychological readiness than those who did not meet any of the criteria.


The authors recruited 144 patients (~26 years old; 57% male) between 2017 and 2019 at a single center. All patients regularly participated in a sport before their ACL rupture. The authors excluded patients if they had a multi-ligament injury, other surgery (except for meniscus) during or after ACLR, or a history of lower limb surgery. All patients underwent a single-bundle or double-bundle ACLR using a bone–patellar tendon–bone graft or hamstring tendon (semitendinosus or gracilis). Patients could return to practice starting 9 months after surgery. They then received clearance for full return if they met functional return-to-sport criteria. However, some patients opted to return despite failing to meet these criteria. Researchers evaluated knee function ~12 months post ACLR. Specifically, they assessed strength and limb symmetry using an isokinetic dynamometer at 60 degrees/second. Performance was determined using the sing-leg hop test. The International Knee Documentation Committee (IKDC) form assessed patient-reported knee function. Knee laxity was measured using a KT-2000 arthrometer. Patients completed the ACL Readiness to return to sport (ACL-RSI) to determine psychological readiness. Lastly, they used a yes/no question (“have you been able to return to sport that you had played before the injury”) to determine which patients returned to pre-injury levels. Then, they evaluated the readiness to return to sport scores among people who met or failed 4 return-to-sport criteria:

  1. Isokinetic quadriceps strength limb symmetry index > 90%
  2. Isokinetic hamstring strength limb symmetry index > 90%
  3. Single-leg hop distance limb symmetry index > 90%
  4. IKDC subjective score > 90


Overall, 95 patients (66%) returned to a pre-injury level of sport, and 49 patients (34%) did not. Twenty-three patients (16%) met none of the criteria for return to sport, 27 (19%) met 1 of the criteria, 34 (24%) met 2 criteria, 35 (24%) met 3 criteria, and 25 (17%) met all 4 criteria. Patients who met the return-to-sport criteria for hamstring strength, single-leg hop distance, and IKDC subjective score had higher psychological readiness scores than those who missed the criteria. Meeting the criterion for quadriceps strength was unrelated to psychological readiness scores. Patients that met none of the criteria had lower psychological readiness scores than those that met 2 or more of the return-to-sport criteria. Furthermore, those that met one criterion had lower psychological readiness than those who met all four.


The authors found that passing return-to-sport criteria based on objective or self-reported measures of knee function relate to better psychological readiness scores. Furthermore, the more criteria a person passes, the better the psychological readiness score. Intuitively, we may believe that if we can get people functionally ready to pass these criteria, they may also become psychologically prepared to return to sport. However, a person with lower psychological readiness could be more anxious or hesitant to perform certain exercises, which would make it harder for them to pass the criteria. This study clarified that the patients’ functional ability is related to psychological readiness, not which one caused the other. Indeed, this could vary from person to person.

Clinical Implications

Medical professionals should monitor functional and psychological factors that play a role in a patient’s ability/willingness to return to sport following ACLR.

Questions for Discussion

What do you do to determine functional and psychological readiness for return to play? Do you have specific criteria your patients need to meet before return to sport? If so, how is it similar or different from what the authors implemented here?

Related Posts

  1. BEAR in Mind: There’s a New ACL Repair Technique on the Block
  2. Does Sex Impact Psychological Readiness to Return to Sport After ACL
  3. Factors Associated With Psychological Readiness to Return to Sport After Anterior Cruciate Ligament Reconstruction Surgery

Written by: Jane McDevitt
Reviewed by: Jeffrey Driban