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J.A. FELLER, K.E. WEBSTER
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after undergoing ACL reconstruction surgery
[8]. At 12 months half of the athletes had
returned to competitive sports. Scores on the
ACL-RSI at 6 months were significantly lower
in the athletes who did not successfully return
to their competition sport at 12 months
compared to the athletes who did. Thus, an
athlete’s readiness to return to sport at 6 months
after ACL reconstruction surgery was related to
whether or not they actually returned to sport at
12 months. This result suggested that it may be
possible during rehabilitation to identify
athletes at risk of not returning to competitive
sport due to psychological.
The second and larger study of 187 patients
administered a battery of psychological
assessments, including the ACL-RSI scale,
before ACL reconstruction surgery, as well as
at 4 and 12 months after surgery [3]. At
12 months only 56 athletes (31%) had returned
to their previous level of sports participation,
despite scoring well on standard outcome
measures. Three variables; psychological
readiness to return to sport, the participant’s
estimate of the number of months it would take
to return to sport, and locus of control predicted
returning to sport by 12 months after surgery.
Psychological readiness, as measured by the
ACL-RSI, was the only variable to be
predictive of return to sport both preoperatively
and at four month postoperatively. Therefore
this study showed that even before the
participants
underwent
surgery,
their
psychological responses were associated with
their chances of returning to the pre-injury
level 12 months later. Furthermore, the results
of this study suggested that a score of less than
56 points on the ACL-RSI may indicate an
increased risk of not returning to the pre-injury
level and may therefore help clinicians to
identify at-risk athletes.
The patient cohort of the second study was
subsequently followed up at two years to
specifically see whether those who had not
returned by 12 month made a later return [4].
The group included 122 competitive and
recreational level athletes who had not
attempted sport at 12 months. Ninety-one per
cent of athletes reported having returned to
some form of sport. At 2 years after surgery
66% were still playing sport, with 41% playing
at their previous level and 25% playing at a
lower level. Thus, most of the athletes who
were not playing sport at 1 year had returned to
some form of sport within 2 years.
Nonetheless, only 41% of athletes were still
playing their pre-injury sport at 2 years post-
operatively. When sport participation data was
categorised by the type of sport, basketball had
the highest rate of return with 50% of athletes
playing at 2 years, followed by netball (41%),
Australian Rules (37%), and soccer (26%). It
appears that the sustained participation rates
for those athletes who do not return within the
first 12 months postoperatively are low. Once
again, a more positive psychological response
was associated with participation in the pre-
injury sport at 2 years.
Overall, the ACL-RSI scale appears to be a
useful tool for screening and identifying
athletes who may have difficulty resuming
sport after ACL reconstruction due to psy
chological reasons. The scale is currently
available in English, Swedish, French [6] and
German versions, with other translations
currently underway.
CONCLUSION
Knee injuries are associated with negative
psychological responses which may persist
following surgery such as ACL reconstruction,
and which may influence rehabilitation and an
athlete’s decision whether or not to return to
sport. Fear of re-injury is one such factor and
has been reported to be a relatively common
reason for patients choosing not to return to
sport following ACL reconstruction. The ACL-
RSI scale was developed as a tool to assess an
athlete’s psychological readiness to return to
sport following ACL reconstruction. It has
been shown to be a significant predictor of
whether an athlete will return to sport, not only
in the 4 to 6 month period following surgery,
but also pre-operatively. Whether negative
psychological factors can be addressed during
rehabilitation remains to be determined.