What Are Our Patients Really Telling Us? Psychological Constructs Associated With Patient-Reported Outcomes After Anterior Cruciate Ligament Reconstruction

Burland JP, Howard JS, Lepley AS, DiStefano LJ, Lepley LK, Frechette L. Journal of Athletic Training. 2020. 55 (7): 707–716.

Full Text Freely Available

Take-Home Message

People with a high level of perceived disability typically had unclear expectations; less internal motivation, confidence, and social support; and more avoidance tendencies and fear after anterior cruciate ligament reconstruction than those with low levels of perceived disability.


Some people with a history of an anterior cruciate ligament (ACL) injury may experience poor long-term outcomes; such as reduced physical activity, increased disability, and disrupted psychological well-being. Patient-reported outcome instruments are commonly used to monitor outcomes after an ACL injury. However, it is unclear why some people report poor patient-reported outcomes. Therefore, the authors used a mixed-methods study design to 1) assess and characterize the factors driving responses on patient-reported outcomes, and 2) evaluate the relationship between responses on patient-reported outcomes and qualitative findings. The authors recruited 21 college students who underwent primary ACL reconstruction (average: 3 years before the study), were cleared to return to sport, and had no other lower extremity injury/surgery. Participants completed 4 patient-reported outcome scales: International Knee Documentation Committee (IKDC) form, Knee Injury and Osteoarthritis Outcomes Score (KOOS), ACL-Return to Sport after Injury scale, and Tampa Scale of Kinesiophobia. The authors then conducted a 15- to 20-minute interview with each participant regarding barriers and factors influencing recovery after ACLR.

Using the patient-reported outcomes, the authors identified 10 participants with a high level of perceived disability and 11 participants with a low level of perceived disability. The group with low perceived disability reported fewer barriers (e.g., fear of reinjury, avoidance behaviors, inattention of providers, limitations in coverage) and more facilitators (e.g, social support, clear expectations, desire to return to prior level of sport, confidence in limb) during recovery. Symptoms and restricted therapeutic rehabilitation were frequent external factors that harmed recovery. Interestingly, all participants experienced negative emotions at some point after the ACL injury.


The authors found several psychological factors related to worse patient-report outcomes. They also suggested that the KOOS Quality of Life subscale, ACL-Return to Sport after Injury scale, and Tampa Scale of Kinesiophobia may help assess some of these factors. Quotations from the interviews such as “I haven’t even gotten on a mountain bike since before my surgery because, is that one ride really worth being on crutches?” illustrate patients’ fear of re-tearing their ligament. If a clinician identifies psychological barriers in a patient, they may suggest additional support or psychological counseling. Interventions such as guided imagery, goal setting, and relaxation may be beneficial. However, athletic trainers and physical therapists also need to recognize their role in a patient’s psychology. An individual stated that “it’s really important to understand that those health care providers are there for them and have their best interest in mind.” Clinicians can directly impact some common external factors like providing clear expectations of the rehabilitation process and minimizing the perception that they are inattentive to a patient’s status. By being clear about the duration, intensity, and potential shortcomings of the rehabilitation process, as well as providing continued support, clinicians can make it more likely that their patients return to play and experience better well-being.

Questions for Discussion

What can clinicians do to best support their athletes? When and how often should these patient-reported outcomes be administered?

Written by: Ryan Paul
Reviewed by: Jeffrey Driban

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