Female Athletes With Better Psychological Readiness Are at Higher Risk for Second ACL Injury After Primary ACL Reconstruction

Abstract

Background: Approximately 1 in 4 athletes returning to sports will sustain a second anterior cruciate ligament (ACL) injury. Psychological factors related to kinesiophobia, confidence, and psychological readiness are associated with second ACL injury; however, the evidence is conflicting. Hypothesis: Athletes who sustain a second ACL injury (ie, graft rupture or contralateral ACL rupture) within 2 years of ACL reconstruction (ACLR) would have greater kinesiophobia, less confidence, and lower psychological readiness prior to return to sport (RTS) compared with athletes who do not sustain a second ACL injury. Study Design: Secondary analysis of a prospective randomized trial. Level of Evidence: Level 3. Methods: A total of 39 female Level I/II athletes completed the following measures after postoperative rehabilitation and a 10-session RTS and second ACL injury prevention program: ACL Return to Sport after Injury (ACL-RSI) scale, the 11-item Tampa Scale of Kinesiophobia (TSK-11), and question 3 on the Knee injury and Osteoarthritis Outcome Score (KOOS) quality of life (QoL) subscale. Athletes were dichotomized based on whether they sustained a second ACL injury within 2 years of ACLR or not. Independent t tests determined group differences in TSK-11, KOOS-QoL, ACL-RSI, and the 3 individual components of the ACL-RSI (ie, emotions, confidence, risk appraisal). Results: Nine athletes sustained a second ACL injury (4 graft ruptures and 5 contralateral ACL ruptures). The group that sustained a second ACL injury had higher scores on the ACL-RSI ( P = 0.03), higher on the risk appraisal questions of the ACL-RSI ( P < 0.01), and met RTS criteria sooner than athletes who did not ( P = 0.04). All second ACL injuries occurred in athletes who underwent primary ACLR with hamstring tendon autografts. Conclusion: Athletes who sustained a second ACL within 2 years of ACLR had a more positive psychological outlook, higher scores on the specific questions related to the risk appraisal construct of the ACL-RSI, and met RTS criteria sooner than athletes who did not sustain a second ACL injury. Clinical Relevance: Counseling athletes about delaying RTS to reduce the risk of second ACL injury may be especially important in athletes who display high psychological readiness and meet RTS criteria sooner.