Does Sex Impact Psychological Readiness to Return-to-Sport After ACL Reconstruction?

A Comparison of Psychological Readiness and Patient-Reported Function Between Sexes After Anterior Cruciate Ligament Reconstruction

Kuenze C, Bell DR, Grindstaff TL, Lisee CM, Birchmeier T, Triplett A, Pietrosimone B. J Athl Train. 56(2), 2020, doi:10.4085/1062-6050-0034.20

Full Text Freely Available

Take-Home Message

Males report better perceived knee function than females. However, both sexes have similar self-reported activity levels, fear of movement/re-injury, and psychological readiness after anterior cruciate ligament reconstruction (ACLR) and before return-to-sport.

Background

On average, males and females experience different functional outcomes, re-injury rates, return-to-sport rates, and long-term joint health outcomes after ACLR. One might suspect that these differences are also present for the psychological response after ACLR; however, we know little about the effect of sex on fear-based outcome measures.

Study Goal

To determine if there are sex differences in patient-reported outcome measures in knee function, fear of movement/re-injury, and psychological readiness to return-to-sport.

Methods

The authors recruited 45 pairs of males and females who had not fully returned-to-sport. They were matched for age and time since surgery. On average, the males and females had similar body mass index, preinjury activity level, and graft type. The participants completed the patient-reported outcome measures during one session at approximately 5-9 months from surgery. The authors assessed several outcomes:

activity level (Tegner Activity Scale),
readiness to return to sport (ACL Return-to-Sport after Injury scale),
fear of movement (Tampa Scale of Kinesiophobia), and
knee-related function and symptoms (International Knee Documentation Committee [IKDC] Subjective Knee Evaluation Score, and Knee Injury and Osteoarthritis Outcome Score).

The authors compared average scores between males and females and scores to clinical cut-offs or normative values.

Results

Males reported higher knee function based on the IKDC and less knee pain than females on the KOOS-pain subscale. The authors observed no other differences between sexes. Males had a 2.7 times greater chance of reporting IKDC scores greater than or equal to pre-established cut-off values compared to females (60% vs. 36%). Males and females were equally likely to reach meaningful cut-off scores for all other outcomes.

Viewpoints

Overall, the authors found moderate differences in self-reported knee function between males and females. Furthermore, men and women had similar psychological outcomes. The absence of sex differences in patient-reported activity level and psychological outcomes adds to the variability of outcomes in prior studies (see below). There are potential methodological details to this study that should be considered. For example, participants completed their surveys before returning to sport, approximately 5-9 months after surgery. Patients can present at varying levels of ability at this phase, and unfortunately, we have no clinical measures to describe this. Clinicians should consider that some measures may not be just sex dependent but influenced by an array of factors (e.g., sex, functional ability, social support, time since surgery). Hence, individual patients should be monitored throughout rehab and treated using a personalized approach to maximize their success.

Clinical Implications

Clinicians should take a holistic approach to assess a patient overtime after an ACLR and consider demographic information, objective measures, and patient-reported measures to define progress towards a patient’s goals.

Questions for Discussion

Do you think more significant sex-differences would be seen if data were collected at different time points in the recovery process? Do you think that providing additional clinical variables at this time point would provide new insight into subgroups of participants?