Anterior cruciate ligament (ACL) reconstruction surgery and subsequent return to sport rates continue to be a big concern for sports medicine surgeons and their athletes. While a lot of research has focused on the physical recovery after an ACL injury, a recent study, “Factors Associated With Psychological Readiness to Return to Sport After Anterior Cruciate Ligament Reconstruction Surgery,”) published on May 2, 2018 in the American Journal of Sports Medicine, has found that there are gender differences in an athlete’s psychological readiness to return to sport after ACL reconstruction surgery.
Gender Differences in ACL Return to Sport Rates
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According to this study, female gender was one of the factors associated with a negative psychological state in relation to returning to their sport. Psychological readiness includes confidence in their ability to perform at the same preinjury level and their perception that the injury was healed.
In this study, the researchers identified factors that contribute to an athlete’s psychological readiness to return to sport after ACL reconstruction surgery. The study population included a cohort of 389 males and 246 females (635 total) who underwent ACL reconstruction and had been cleared to return to sport. At about a year post surgery, they all completed the Anterior Cruciate Ligament—Return to Sport After Injury (ACL-RSI) scale which is designed to measure psychological readiness to return to sport after ACL injury or reconstruction surgery. Demographics were taken and sporting outcomes, surgical timing (how much time had lapsed between injury and surgery), clinical factors, functional measures and symptoms of pain and function were measured. Patients were then grouped by whether they returned to competitive sport or not.
The mean ACL-RSI score for the cohort was 65 points. Only 25% of the patients had returned to competitive sport. When broken down by gender, 17% of female patients versus 30% of male patients returned to competitive sport.
According to a univariate analysis, male sex (β = 5.8; 95% CI, 2-10), younger age (β = –0.2; 95% CI, –0.4 to 0.01), a shorter interval between injury and surgery (β = –0.1; –0.1 to –0.02), a higher frequency of preinjury sport participation, greater limb symmetry and higher subjective knee scores all had a positive effect on psychological readiness to return to sport.
In the multivariate analysis, subjective knee scores and age accounted for 37% of the variance in psychological readiness (p < .0001). The only difference between the groups (those who had and had not returned to sport) was that female sex was a significant contributor for the group of athletes who did not return to sport.
The researchers wrote, “Male patients who participated frequently in sport before ACL injury had higher psychological readiness. Conversely, female patients had a more negative outlook and may therefore benefit more from interventions designed to facilitate a smooth transition back to sport.”
They also called for future research to examine the relationship between psychological readiness to return to sport and further ACL injury.
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This is a fascinating development. In my practice we've seen similar outcomes with the revised protocol. The key differentiator seems to be patient selection criteria. Has anyone else noticed the correlation with BMI thresholds?
Great point. I'd push back slightly on the conclusion, the sample size in the cited study is too small to draw population-level inferences. That said, the directional signal is compelling and worth a larger RCT.
We implemented a similar approach last year. Early results are promising but we're still gathering 12-month follow-up data. Happy to share our protocol if anyone is interested.
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