Psychological Readiness and Return to Sport After ACL Reconstruction

Anterior cruciate ligament (ACL) injury is one of the most common knee injuries in athletes participating in pivoting and cutting sports. Primary ACL reconstruction is widely performed to restore knee stability, improve functional performance, and facilitate return to sport. Despite advances in surgical techniques and rehabilitation protocols, many athletes do not return to their preinjury level of sports participation. Increasing evidence suggests that successful recovery after ACL reconstruction depends not only on physical function but also on psychological factors.

Psychological readiness to return to sport has emerged as an important determinant of rehabilitation outcomes following ACL reconstruction. Fear of reinjury, lack of confidence in the reconstructed knee, and reduced self-efficacy may delay or prevent return to sport even in individuals who demonstrate satisfactory physical recovery. Patient-reported outcome measures, including the Anterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI) scale, the Tampa Scale for Kinesiophobia (TSK), the International Knee Documentation Committee (IKDC) Subjective Knee Form, and the Tegner Activity Scale, are commonly used to evaluate these psychological and functional aspects of recovery.

Previous studies have reported significant relationships between psychological readiness, kinesiophobia, subjective knee function, and return-to-sport outcomes following ACL reconstruction. However, most investigations have focused on single postoperative time points or relatively homogeneous patient populations. Consequently, limited evidence is available regarding how these outcomes change throughout different stages of postoperative recovery and whether the relationships among these variables differ according to time since surgery.

The aim of this observational cross-sectional study is to evaluate psychological readiness, kinesiophobia, subjective knee function, sport activity level, and return-to-sport status in athletes who have undergone primary ACL reconstruction between 3 and 24 months after surgery. Participants will be classified according to postoperative recovery period, allowing comparisons between different stages of rehabilitation.

Psychological readiness will be evaluated using the ACL-RSI, kinesiophobia using the TSK, subjective knee function using the IKDC Subjective Knee Form, and sport activity level using the Tegner Activity Scale. Information regarding return-to-sport status and relevant demographic and clinical characteristics will also be collected. The study will investigate differences in these outcomes across postoperative recovery periods and examine the relationships between psychological and functional recovery and return-to-sport status.

The findings of this study are expected to improve understanding of the recovery process following ACL reconstruction and provide clinicians with evidence regarding the timing of psychological and functional recovery. The results may contribute to optimizing rehabilitation strategies, identifying athletes who require additional psychological support, and improving clinical decision-making related to return to sport.

Inclusion criteria

• Age ≥18 years.
• History of unilateral primary anterior cruciate ligament (ACL) reconstruction.
• Between 3 and 24 months after ACL reconstruction at the time of assessment.
• Regular participation in sports before ACL injury with a preinjury Tegner Activity Scale score of ≥4.
• Ability to read and understand Turkish and independently complete the study questionnaires.
• Willingness to participate in the study.
• Provision of written informed consent.

Exclusion criteria

• Revision ACL reconstruction.
• Reinjury or graft rupture of the reconstructed ACL.
• Bilateral ACL injury.
• History of ACL reconstruction in the contralateral knee.
• Concomitant major ligament, cartilage, bone, or extensor mechanism surgery that is expected to substantially affect rehabilitation, weight-bearing status, return-to-sport timing, or knee function following primary ACL reconstruction.
• Other lower-extremity injuries or surgical conditions unrelated to ACL reconstruction that limit sports participation at the time of assessment.
• Neurological, rheumatologic, cardiopulmonary, or other severe systemic diseases that substantially limit sports participation.
• Cognitive, psychiatric, or communication disorders that preclude reliable completion of the study questionnaires.