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Psychological aspects associated with ACL rehabilitation and recurrence in football players: a systematic review

March 2024
Retos 55:397-410

DOI:10.47197/retos.v55.105115

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CC BY-NC-ND 4.0

Authors:

Luis Miguel Ramos-Pastrana

University of Murcia

Jose Maria Gimenez

University of Alicante

Aurelio Olmedilla Zafra

University of Murcia

Although most football players recover good physical function after anterior cruciate ligament (ACL) surgery, some do not return to their sport or to the same pre-injury level, and there is a risk of recurrence. Therefore, this study aimed to examine research on psychological aspects of ACL rehabilitation and Return to Play (RTP), as well as their influence on possible recurrence in football and futsal players. The search was conducted using the Scopus, PubMed, WoS, CENTRAL databases, and grey literature sources DART-Europe and OpenGrey. A total of nine studies met the inclusion criteria. The results indicated as the most evaluated psychological factor the psychological readiness to RTP through the Anterior Cruciate Ligament Return to Sport After Injury (ACL-RSI). Likewise, psychological interventions in ACL-injured football players have positive effects on mood states, reduces pain perception, and fear reinjury, among others. Risk profiles for recurrence included vulnerability to stress and high psychological readiness to RTP. Therefore, psychological interventions should be incorporated into the rehabilitation process and screening to identify players at risk for poor outcomes or recurrences. Additional research would help to understand the influence of other variables or optimal levels of psychological readiness to RTP. Keywords: anterior cruciate ligament; RTP; sports injury; psychology; rehabilitation.

PRISMA flow diagram

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Analysis of the studies included in the systematic review.

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2024, Retos, 55, 397-410

-397- Retos, número 55, 2024 (junio)

Psychological aspects associated with ACL rehabilitation and recurrence in football players: a

systematic review

Aspectos psicológicos asociados a la rehabilitación del LCA y las recidivas en futbolistas: una revisión

sistemática

Luis Miguel Ramos Pastrana, José María Giménez Egido, Aurelio Olmedilla Zafra

Universidad de Murcia (España)

Abstract. Although most football players recover good physical function after anterior cruciate ligament (ACL) surgery, some do not

return to their sport or to the same pre-injury level, and there is a risk of recurrence. Therefore, this study aimed to examine research

on psychological aspects of ACL rehabilitation and Return to Play (RTP), as well as their influence on possible recurrence in football

and futsal players. The search was conducted using the Scopus, PubMed, WoS, CENTRAL databases, and grey literature sources

DART-Europe and OpenGrey. A total of nine studies met the inclusion criteria. The results indicated as the most evaluated psycho-

logical factor the psychological readiness to RTP through the Anterior Cruciate Ligament Return to Sport After Injury (ACL-RSI).

Likewise, psychological interventions in ACL-injured football players have positive effects on mood states, reduces pain perception,

and fear reinjury, among others. Risk profiles for recurrence included vulnerability to stress and high psychological readiness to RTP.

Therefore, psychological interventions should be incorporated into the rehabilitation process and screening to identify players at risk

for poor outcomes or recurrences. Additional research would help to understand the influence of other variables or optimal levels of

psychological readiness to RTP.

Keywords: anterior cruciate ligament; RTP; sports injury; psychology; rehabilitation.

Resumen. Aunque la mayoría de los jugadores de fútbol recuperan una buena función física después de la cirugía del ligamento cruzado

anterior (LCA), algunos no regresan a su deporte o al mismo nivel previo a la lesión, y existe el riesgo de recidivas. Por tanto, este

estudio tuvo como objetivo examinar la investigación sobre los aspectos psicológicos de la rehabilitación del LCA y el retorno al juego

(RTP), así como su influencia en las posibles recidivas en jugadores de fútbol y fútbol sala. La búsqueda se realizó utilizando las bases

de datos Scopus, PubMed, WoS, CENTRAL y las fuentes de literatura gris DART-Europe y OpenGrey. Un total de nueve estudios

cumplieron los criterios de inclusión. Los resultados indicaron como factor psicológico más evaluado la disposición psicológica al RTP

a través del Anterior Cruciate Ligament Return to Sport After Injury (ACL-RSI). Asimismo, las intervenciones psicológicas en futbo-

listas lesionados de LCA tienen efectos positivos sobre los estados de ánimo, reducen la percepción del dolor y el miedo a volver a

lesionarse, entre otros. Los perfiles de riesgo para las recidivas incluyeron la vulnerabilidad al estrés y una alta disposición psicológica

para el RTP. Por lo tanto, las intervenciones psicológicas deben incorporarse al proceso de rehabilitación y al cribado para identificar a

los jugadores con riesgo de peores resultados o recidivas. Investigaciones adicionales ayudarían a comprender la influencia de otras

variables o los niveles óptimos de disposición psicológica para el RTP.

Palabras clave: ligamento cruzado anterior; RTP; lesión deportiva; psicología; rehabilitación.

Fecha recepción: 05-03-24. Fecha de aceptación: 13-03-24

Aurelio Olmedilla Zafra

olmedilla@um.es

Introduction

Injury is a significant concern in sports practice and re-

search in the field of physical activity and sports (Johnson &

Ivarsson, 2017; Schneider et al., 2006). Sports injuries have

a significant impact not only on athletic performance, but

also on the personal and social lives of injured athletes (Ru-

bio et al., 2020; Truong et al., 2020). Numerous theoreti-

cal models have been proposed in the scientific literature to

analyse the relationship between psychological variables and

sports injuries (Andersen & Williams, 1988; Brewer, 1994;

Heil, 1993). Wiese-Bjornstal et al. (1998) presented a com-

prehensive model that addressed the psychological response

to injury and the rehabilitation process, highlighting the

crucial role of stress in this context. For these authors, per-

sonal and situational factors are present throughout the pro-

cess, which is dynamic and circular. Cognitive appraisals

can influence emotions, which in turn can impact behav-

iour. Similarly, emotions affect behaviours and behaviours

affect cognitive appraisals, and so on. Finally, psychological

consequences are connected to the whole injury experi-

ence, around the three components of the model: cognitive

appraisal, emotional response, and behavioural response.

Based on this model, it is understood that stress is not only

an element of risk in sports injuries but also an obstacle to

recovery from these injuries.

One of the five fundamental lines of research on the re-

lationship between psychological factors and sports injuries

is the study of athletes’ emotional and psychological reac-

tions to injuries (Olmedilla & García-Mas, 2009). A consid-

erable diversity of cognitive reactions, such as intrusive

thoughts or reduced self-esteem, as well as emotional re-

sponses of sadness, anger or fear, have been observed. In

addition, behavioural changes such as eating disorders or al-

cohol consumption have been identified as a consequence of

sports injuries (Brewer, 2017). Following the model pro-

posed by Wiese-Bjornstal et al. (1998), the way in which

athletes perceive their injury, rather than the fact that it oc-

curred, plays a fundamental role in understanding the emo-

tional responses of injured athletes (Tracey, 2003). Like-

wise, this model can explain how athletes' willingness to

commit to rehabilitation, as well as the value they place on

this process, influences their cognitive, emotional, and be-

havioural reactions to the rehabilitation of their injury.

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According to Olmedilla & García-Mas (2023), some of the

psychological variables present in the recovery process are

pain, mood, catastrophic thinking, anxiety, depression,

perfectionism, and coping resources. Johnston & Carroll

(1998) provide an example of how psychological variables

affect rehabilitation processes. The authors observed that

athletes with fear of re-injury were hesitant, did not try as

hard as they could, and were suspicious of injury-provoking

situations (e.g., during rehabilitation and in sporting con-

texts). Likewise, the method of assessing rehabilitation also

affected the psychological and behavioural levels. Athletes

who perceived their rehabilitation positively reported feel-

ing happiness and relief, which promoted greater adher-

ence. Conversely, those who perceived it negatively re-

ported feeling frustrated, which led to hesitation and cau-

tion towards performing the exercises in their rehabilitation

program.

Scientific research also highlights the importance of cer-

tain psychosocial influences, such as fear of re-injury, life-

style changes, work demands, available social support, loss

of motivation, perceived self-efficacy, and psychological

readiness to return to play (RTP), appear to play in an ath-

lete's recovery and subsequent decision to return to sports

(Baez et al., 2020; Burland et al., 2019; Forsdyke et al.,

2022; Podlog & Eklund, 2010). Webster et al. (2018)

found that fewer pain symptoms and better self-reported

knee function were associated with psychological readiness

to RTP. Phelan et al. (2019) compared psychological read-

iness to RTP between uninjured athletes and those who had

undergone ACL surgery. The authors found that nine

months after surgery, psychological readiness did not re-

turn to the levels observed in the uninjured group. A meta-

analysis found that low psychological readiness to RTP was

associated with higher odds of graft rupture after ACLR

(Cronstrom et al., 2023). Similarly, younger individuals

with lower psychological readiness have a higher risk of sus-

taining a second ACL injury after returning to sports

(McPherson et al., 2019a). These findings are important

given that athletes who return to sports before feeling psy-

chologically prepared may experience anxiety, fear, and

stress, sustaining a second injury and decreasing perfor-

mance (Gómez-Espejo et al., 2022; Paterno et al., 2018).

ACL tears are among the most common sports-related

knee injuries (Majewski et al., 2006). In the case of football,

Requejo-Herrero et al. (2023) reported an average of 11

ACL tears per season and 17 recurrent injuries over 10 sea-

sons in La Liga Española. In other countries, such as Ger-

many, a total of 72 injuries have been reported, with an av-

erage of 9.6 ACL tears per season (Schiffner et al., 2018),

or in the Italian first division with 84 ACL injuries, 25% of

which were recurrent (Grassi et al., 2020). In addition,

some studies suggest that female players have a two to three

times higher risk of ACL injury than their male counterparts

(Waldén et al., 2011) and a higher incidence of a second

ACL injury (Hong et al., 2023). Serrat et al. (2023) re-

ported 94 ACL injuries over 10 seasons in female first and

second division players. In addition, 31.9% of the

footballers had already suffered an ACL injury in the previ-

ous seasons. On the other hand, although not many epide-

miologic studies on ACL injuries in futsal have been found,

some studies seem to indicate that it is one of the sports with

the highest incidence of injuries, with the main injured body

part being the lower limb, specifically the knees and ankles

(Gene-Morales et al., 2021; Ruiz-Pérez et al., 2021), and

ACL tears being one of the most frequent and severe (Ruiz-

Pérez et al., 2019). Regarding the RTP rate in football play-

ers, Zaffagnini et al. (2014) found that 95% of professional

football players returned to the same level of activity one

year after surgery, and 71% could still play competitive

football after four years. More recently, Farinelli et al.

(2023) reported an RTP rate of 92.6% in elite UEFA foot-

ball players. Despite this, many athletes with good knee

function do not return to their previous level of sports par-

ticipation after ACLR, suggesting the existence of other fac-

tors that influence RTP (Ardern et al., 2016).

Several reviews have found the influence of psychosocial

factors after ACLR. Athletes who suffered an ACL injury

may suffer from symptoms of depression, especially during

the first 6 weeks after ACL reconstruction, being more fre-

quent among professional athletes than among non-profes-

sionals (Piussi, Berghdal et al., 2022). Longo et al. (2023)

found that the main reasons for not RTP were concerns

about reinjury and pain, whereas self-efficacy, psychologi-

cal will, and age were associated with better functional out-

comes. Other factors that may help predict which athletes

are more likely to RTP include motivation to return, lower

levels of kinesiophobia, higher levels of self-efficacy, confi-

dence and subjective knee function, risk acceptance and so-

cial support (Momaya et al., 2024). In a recent meta-analy-

sis of 3744 patients, Xiao et al. (2023) found no significant

differences in the self-reported knee function of athletes

who had RTP compared to those who had not after ACL

surgery. However, the group that had RTP exhibited a

higher psychological readiness, higher self-efficacy, and

lower kinesiophobia than the other group. Similarly, Nwa-

chukwu et al. (2019) found that of the 795 patients who did

not achieve RTP, 64.7% cited psychological reasons for not

returning. Fear of reinjury was the most common reason

(76.7%); other psychological factors included lack of confi-

dence in the treated knee (14.8%), depression (5.6%), and

lack of interest/motivation (2.5%).

According to Olmedilla & García-Mas (2023), the psy-

chological elements that influence rehabilitation and RTP

can be subject to modification through appropriate inter-

ventions (Cognitive-Behavioural Therapy, EMDR or Mind-

fulness), improving the athlete's adherence and increasing

self-confidence at the time of RTP. However, these pro-

grams do not receive the systematic attention required for

traditional postoperative rehabilitation processes. Based on

the above, it is crucial to understand the relationship be-

tween psychological aspects in ACL injury rehabilitation

and subsequent RTP, especially considering that although

most patients recover good physical function after surgery,

some do not return to their sports or to the same pre-injury

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level, in addition to the current risk of recurrence.

Although there are reviews in the literature on this topic

(Longo et al., 2023; Momaya et al., 2024; Nwachukwu et

al., 2019), they generally include studies with different types

of sports, making it difficult to identify football-specific fac-

tors. Football is an intense sport where there are quick and

sudden changes of direction, jumps and landings with impact

and physical contact with other players. The ACL injury data

presented above also supports the idea of conducting a sys-

tematic review focusing on this sport. In fact, football has a

higher incidence of ACL injuries than other team sports like

volleyball and basketball (Joseph et al., 2013). Furthermore,

to our knowledge, there are no reviews that consider futsal,

so the inclusion of studies involving futsal players could po-

tentially lead to the development of new research avenues.

Therefore, this study aimed to examine research on psycho-

logical aspects of ACL rehabilitation and Return to Play

(RTP), as well as their influence on possible recurrence in

football and futsal players.

Method

Once the study context was defined and the objectives

were stated, a systematic review of the scientific literature

was conducted following the Preferred Reporting Items for

Systematic Reviews and Meta-Analyses Protocol (PRISMA;

Page et al., 2021) through the following stages:

• Selection of eligibility criteria.

• Description of the sources of information and search

strategies

• Process of selection, evaluation, extraction of infor-

mation and elaboration of a flow chart

• Collection and listing of data

Eligibility Criteria

To be included in the systematic review, an article must

meet the following inclusion criteria. These criteria are based

on the PICO (Participants/Intervention/Comparison/Out-

comes) strategy. The study population consisted of football

and/or futsal players (both male and female) who sustained

ACL injuries. Experimental and observational studies were

selected as intervention criteria. Comparison criteria in-

cluded single-group studies and those that included two

groups: injured and uninjured football players. For the out-

come criterion, only studies that used validated instruments

to measure psychological variables were included. On the

other hand, articles were excluded if: (1) access to the full

text was not available; (2) they were written in a language

other than Spanish or English; (3) they were qualitative re-

search, review articles, letters to the editor, editorial com-

mentaries, etc.; (4) their objective was to validate an instru-

ment; (5) they presented data from football players and other

athletes together; (6) they included injuries other than ACL

injuries.

Sources of information

The Scopus, PubMed, and Web of Science (WoS; Science

Citation Index Expanded and Social Sciences Citation Index)

databases were used for searching, critical reading, and eval-

uating the articles. The Cochrane Central Register of Con-

trolled Trials (CENTRAL) was also searched for potential

randomized and quasi-randomized controlled trials of inter-

est. In addition, DART-Europe and OpenGrey were con-

sulted as sources of grey literature.

Search strategy

A search was performed in the "title, abstract, and key-

words" fields of the four databases. The following strategy

was used: "return to competition" OR rtc OR "return to

sport" OR rts OR "return to play" OR rtp OR rehabilitation

OR recovery AND acl OR "anterior cruciate ligament" AND

psych* AND football OR soccer OR futsal. No filtering was

applied to the search, and publications through October 1,

2023, were included.

For the search in DART-Europe and OpenGrey, the fol-

lowing strategy was used "anterior cruciate ligament" AND

psych* and English or Spanish language as a filter.

Study selection process

Zotero v. 6.0.26 was used to pool the results of the

searches and eliminate duplicate studies. The extraction pro-

cess was based on the protocol of Ateef et al. (2022), which

was consulted in the International Prospective Register of

Ongoing Systematic Reviews (PROSPERO) database. Thus,

two reviewers performed the inclusion of trials in a two-stage

process. In the first phase, the records were screened by

reading the title, abstract, and keywords to identify poten-

tially relevant studies. In the second phase, the selected arti-

cles were read in full to ensure that they met the eligibility

criteria. Quality control was carried out by two trained re-

viewers as in similar studies (Caicedo-Parada et al., 2020).

Specifically, the reliability of both was calculated using Co-

hen's kappa statistic with qualitative intervals of poor (< .20),

weak (.21–.40), moderate (.41–.60), good (.61–.80), and

very good (> .81) for the screening of records and selection

of studies, giving very good intraobserver and interobserver

agreement values according to Altman (1991). The lowest

value corresponded to the interobserver agreement in the

screening process, with a value of k = .885. Finally, it was

adopted a conservative strategy in the screening phase and in-

cluded all records to be evaluated in the eligibility phase. Fig-

ure 1 illustrates the screening process.

Figure 1. PRISMA flow diagram

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Quality appraisal

Methodological rigor was verified using a structured

rating system called the PEDro scale (Gómez-Conesa et al.,

2015). This system has been used in numerous studies

(Guede-Rojas et al., 2023; Kakavas et al., 2023; Liddle et

al., 2023; Pastora-Bernal et al., 2021). It is used to quantify

the external validity, quality of the methods used, and sta-

tistical description in randomized experimental studies. It

consists of 11 items with a score ranging from 0 to 10 (item

1 assesses external validity but is not included in the total

score). A higher score indicated better methodological

quality, although the following classification has been rec-

ommended (Cashin & McAuley, 2020): (9-10) excellent;

(6-8) good; (4-5) acceptable; and poor (< 4).

Data extraction and synthesis

Outcome data were extracted independently by one re-

viewer and subsequently verified by the other reviewers.

Study variables were coded and grouped into three catego-

ries: 1) general study descriptors (citation, objective and

study design); 2) study population (group, sample size, sex,

mean age and standard deviation); 3) outcomes (psycholog-

ical assessment instruments and psychologically relevant

findings). Data synthesis was performed using an emergent

synthesis approach, which according to Schick-Makaroff et

al. (2016), provides a systematic approach to synthesising

varied literature in a thematic area that includes various

types of data.

The results were summarised in narrative and summary

expression and in tables, according to the proposed

method. Results were structured with subheadings, includ-

ing demographic characteristics of study participants,

methodology of included studies, psychological assessment

instruments and psychologically relevant findings.

Results

Demographic characteristics of study participants

The results of the extraction process are summarized in

Table 1. Nine studies that indicated the influence of psycho-

logical variables in football players who sustained an ACL

injury were included. The years of publication of the arti-

cles ranged from 2016 to 2023, with Faltstrom et al. (2016,

2021, 2023) being the author with the most articles. The

total number of participants was 1404, of which 55% were

male and 45% were female. The mean age of the partici-

pants was between 20 and 33 years. All participants were

football players, and none were futsal players.

Methodology of included studies

The total PEDro scale scores assigned to the articles in-

cluded in this review are presented in Table 1. The most

common design was cross-sectional, with three articles

(Bortone et al., 2021; Correa et al., 2023; Faltstrom et al.,

2016) of good methodological quality. There were two ran-

domized clinical trials by Almuhaya et al. (2023) and

D'Isanto et al. (2022) with excellent and good methodolog-

ical quality, respectively. Two prospective cohort studies

(Faltstrom et al., 2021, 2023) have also achieved excellent

quality. Manara et al. (2022) conducted a case series study

of good methodological quality. Finally, the single case

study by Palmi et al. (2018) was not analysed using the

PEDro scale because of the risk of bias inherent in this type

of design.

Table 1.

Analysis of the studies included in the systematic review.

Article

Participants

Objective

Design

Psychological

Assessment

instruments

Psychologically relevant findings

Almuhaya

et al.

(2023)

PEDro

Scale: 10

EG = 18 male

players (26.5 ±

6.65 years)

CG = 17 male

players (26.1 ±

5.33 years)

To examine the feasibility and

acceptability of adding a struc-

tured educational session to the

rehabilitation program for football

players following ACL injury.

RCT

- TSK

- ACL-RSI

At follow-up, the intervention group showed improvement in

kinesiophobia and fear of another injury, as well as psycholog-

ical readiness for the RTP, compared to the control group

who did not receive the educational session.

Correa et

al. (2023)

PEDro

Scale: 8

15 male players

ready for RTP

(23 ± 5.89

years)

20 male players

not ready for

RTP (21 ± 3.78

years).

To investigate whether there are

differences in kinesiophobia and

performance on field tests and

exercises related to the injured

knee after medical discharge

between players who perceive

themselves to be psychologically

ready for RTP and those who do

not.

Cross-sec-

tional

- TSK-11

- ACL-RSI

Football players who did not consider themselves psychologi-

cally ready for RTP had worse field test performance and

greater dynamic knee valgus during the squat test compared

to those who did perceive themselves to be ready. Addition-

ally, they reported greater fear of movement-related pain and

lower knee function.

Fältström

et al.

(2023)

PEDro

Scale: 9

112 female play-

ers (20 ± 2

years).

To explore whether the associa-

tion between various risk factors

and ACL injury in female football

players would be affected by dif-

ferent follow-up times and statisti-

cal approaches.

Cohort

study

- ACL-QoL

- ACL-RSI

- SSP

- SMPS

At 12-month follow-up, female players with higher psycho-

logical readiness scores for RTP, lower impulsivity scores,

higher stress vulnerability scores, and better knee functional-

ity had an eightfold increased risk of sustaining a second ACL

injury.

Manara et

al. (2022)

PEDro

Scale: 8

666 male players

and 196 female

players with an

average of 30

years.

To determine the rate of

subsequent ACL injuries and RTP

rate in football players, as well as

to evaluate predictors of RTP and

ACL injury recurrence.

Case series

- ACL-RSI

Younger age and better psychological readiness were found to

be predictors of return to play (RTP). Those who had re-

turned to football and had not experienced an additional ACL

injury had higher overall ACL-RSI scores and were less fearful

of another injury.

D’Isanto

EG = 15 female

To examine the effect of Mirror

RCT

- VAS

The Mirror Therapy group reported a greater perception of

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et al.

(2022)

PEDro

Scale: 7

players (33 ±

1.8 years) y

CG = 15 female

players (32 ±

1.6 years)

Therapy added to conventional re-

habilitation on psychological read-

iness and pain perception in ACL

injured female football players.

- ACL-RSI

psychological readiness compared to the conventional physical

therapy group. On the other hand, both groups experienced a

reduction in pain perception after rehabilitation.

Bortone et

al. (2021)

PEDro

Scale: 8

30 male players

(26.9 ± 5.7

years).

To assess the clinical, psychologi-

cal and biomechanical condition of

football players who had the RTP

at 2 years after ACLR.

Cross-sec-

tional

- TSK

- ACL-RSI

Older football players exhibited a greater fear of re-injury and

lower motivation to RTP. Recreational football players re-

ported significantly higher levels of fear of re-injury compared

to those returning to the competitive level. Higher levels of

kinesiophobia were significantly associated with more com-

plaints of ACL injury and lower psychological readiness for

RTP. Football players with lower fear of re-injury demon-

strated better performance in terms of balance and strength

with fewer asymmetries. Although most participants reported

being psychologically ready to RTP at the time of assessment,

those with lower scores experienced greater limitations in

daily activities and took longer to perform the agility test,

particularly on the injured leg. Additionally, injury to the

dominant leg was associated with lower fear of re-injury and

lower psychological readiness for RTP.

Fältström

et al.

(2021)

PEDro

Scale: 9

117 female play-

ers (20 ± 2

years)

To investigate the combinations of

various clinical risk factors by

CART analysis that are associated

with secondary ACL injury in fe-

male football players after primary

unilateral ACLR.

Cohort

study

- ACL-QoL

- ACL-RSI

- SSP

- SMPS

Players who are at a higher risk of suffering a second ACL in-

jury are those who had low performance in the jumping test,

greater vulnerability to stress, were unadventurous, estimated

high psychological readiness for RTP, and performed well in

jumping with camber. This risk profile was three times more

likely to result in a second ACL injury.

Palmi et

al. (2018)

PEDro

Scale:

N/A

1 male player

aged 28 years

To evaluate the effectiveness of

Mindfulness in the rehabilitation

of an injured professional football

player.

Single case

design (n=1)

- POMS

- PANAS

- SE

- Sport injury

questionnaire

The analysis of the psychological moment on the day of the in-

jury indicates a high degree of motivation and self-demand, as

well as perceived demand from the coach. Differences were

observed between negative and positive emotions, with the

former scoring higher. Regarding mood states, the dimen-

sions of tension, depression, anger, fatigue, and confusion de-

creased progressively throughout the weeks of psychological

work, while the vigour dimension increased. The average

evaluation of the sessions was positive, with particular empha-

sis on learning relaxation and thought management tech-

niques.

Fältström

et al.

(2016)

PEDro

Scale: 8

94 current fe-

male players

(20.1 ± 2.3

years)

88 female play-

ers had not re-

turned (20.8 ±

3 years)

To determine whether demo-

graphic factors, psychological fac-

tors, and ACL injury characteris-

tics were associated with RTP.

Second, to make comparisons of

current knee function, readiness

for RTP, and knee-related quality

of life between players who re-

turned to football and those who

did not.

Cross-sec-

tional

- Questionnaire

on factors re-

lated to the re-

turn to football

- ACL-QoL

- ACL-RSI

- SSP

- SMPS

The most common reasons for non-RTP were lack of confi-

dence in the knee and fear of re-injury. Current players had

higher motivation for RTP, higher scores on the personality

trait "adventure seeking" and "personal standards" of perfec-

tionism compared to players who did not return to football. A

one-point increase in motivation was associated with 1.5

times greater likelihood of returning to football. Likewise,

current players had higher scores on psychological readiness

for RTP and better quality of life related to ACL injury.

Note. N/A: Not applicable; EG: Experimental group; CG: Control group; ACL: Anterior cruciate ligament; RCT: Randomized Contro lled Trial; TSK/TSK-11:

Tampa Scale of Kinesiophobia; ACL-RSI: Anterior Cruciate Ligament Return to Sport After Injury; RTP: Return To Play; ACL-QoL: Anterior Cruciate Ligament -

Quality of Life; SSP: Swedish Universities Scales of Personality; SMPS: Sport Multidimensional Perfectionism Scale; VAS: Visual Analogue Scale; ACLR: Anterior

Cruciate Ligament Reconstruction; POMS: Profile of Mood States; PANAS: Positive and Negative Affect Schedule; SE: Session Evaluation.

Psychological assessment instruments

The most used psychological assessment instrument (n

= 8; 88.9%) was the Anterior Cruciate Ligament Return to

Sport After Injury (ACL-RSI), which was present in all in-

cluded studies, except Palmi et al. (2018). This was fol-

lowed by the Anterior Cruciate Ligament Quality of Life

(ACL-Qol) (n = 3; 33.3%), the Swedish Universities Scales

of Personality (SSP) (n = 3; 33.3%), and the Sport Multi-

dimensional Perfectionism Scale (SMPS) (n = 3; 33.3%).

The Tampa Scale of Kinesiophobia (TSK) was present in

two studies (22.2%) and its short version (TSK-11) in one

study (11.1%). The remaining instruments were used in

only one study. Table 2 lists the instruments used and the

variables assessed for each instrument.

Table 2.

Psychological evaluation instruments and assessed variables.

Questionnaire

Author

Variable assessed

Anterior Cruciate Ligament Return to Sport

After Injury (ACL-RSI)

Webster et al. (2008)

Psychological readiness for the athlete's return to sport after an ACL injury. It has

3 domains: emotions, risk appraisal and confidence in knee function and

performance.

Anterior Cruciate Ligament- Quality of Life

(ACL-QoL)

Mohtadi (1998)

Impact of ACL injury on patients' lives. It has 5 domains: symptoms, physical

complaints, work-related concerns, physical activity and sport participation and

lifestyle and social concerns.

Tampa Scale of Kinesiophobia (TSK)/TSK-11*

Miller et al. (1991)/

Woby et al. (2005)

Fear of movement and re-injury.

Swedish Universities Scales of Personality (SSP)

Gustavsson et al. (2000)

13 stable personality traits: somatic anxiety, psychic anxiety, stress susceptibility,

lack of assertiveness, impulsiveness, adventure seeking, detachment, social

desirability, embitterment, trait irritability, mistrust, verbal trait aggression,

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physical traits and aggression.

Sport Multidimensional Perfectionism Scale

(SMPS)

Dunn et al. (2002)

Perfectionism in sport. It has 4 dimensions: personal standards, concern about

mistakes, perceived parental pressure and perceived coach pressure.

Profile of Mood States (POMS)

Balaguer et al. (1993)

Mood states. It has 6 dimensions: tension, depression, anger, vigour, fatigue and

confusion.

Positive and Negative Affect Schedule (PANAS)

Sandín et al. (1999)

Affections considered positive and negative.

Visual Analogue Scale (VAS)

Hayes & Patterson (1921)

Subjective perception of pain.

Note. * This is a shortened version of the original TSK with 11 items.

In addition to these standardized instruments, some ar-

ticles use interviews and ad hoc questionnaires, such as the

Sports Injury Questionnaire by Palmi et al. (2018), which

assesses personal data, sport, and injury history. Similarly,

information on daily stressors, anxiety levels, coach de-

mands, motivation, attention, and psychological resources

on the day of injury was collected. Another instrument pre-

sented in this study is the Session Evaluation (SE), in which

the football player evaluated the criteria of learning, inter-

est, and intra-session comfort and answered two open-

ended questions about what he liked the most and what was

the most difficult.

Another example of an ad hoc instrument is the study

by Faltstrom et al. (2016), in which players answered a

questionnaire about factors related to returning to football

and the reasons they did not return to competition. Possible

reasons included "poor knee function," "don't trust my

knee," "fear of reinjury," "had a new injury," "team or

training changed," "family situation," "work situation,"

"don't enjoy playing anymore," or "other reasons." The au-

thors also assessed behavioural factors, including motivation

to RTP, reasons for playing football before the injury, and

risk-taking behaviours while playing football before the in-

jury.

Psychologically relevant findings

Three studies investigated the effect of different inter-

ventions on psychological variables during ACL rehabilita-

tion (Almuhaya et al., 2023; D'Isanto et al., 2022; Palmi et

al., 2018). Results showed improvements in kinesiophobia,

fear of re-injury, psychological readiness for RTP (Almu-

haya et al., 2023) and reduced pain perception (D'Isanto et

al., 2022). In addition, improvements in mood states were

observed throughout the psychological treatment (Palmi et

al., 2018).

Four studies investigated the influence of psychological

aspects associated with RTP (Bortone et al., 2021; Correa

et al., 2023; Fältström et al., 2016; Manara et al., 2022).

Fältström et al. (2016) reported that the most common rea-

sons for not RTP were lack of confidence in the knee and

fear of re-injury. Active players had higher motivation for

RTP, higher scores on the personality trait 'adventure seek-

ing' and 'personal standards' of perfectionism, compared to

players who did not return to football. Similarly, active

players had higher scores on psychological readiness for

RTP and better quality of life related to ACL injury. Poorer

performance on physical tests and greater kinesiophobia

have also been observed in football players who did not feel

psychologically prepared for the RTP (Bortone et al., 2021;

Correa et al., 2023), experienced more complaints of ACL

injury and greater limitations in daily activities (Bortone et

al., 2021), with psychological readiness being a predictor

for the RTP (Manara et al., 2022).

Two studies identified risk profiles for a second ACL in-

jury (Fältström et al., 2021, 2023). According to Fältström

et al. (2021), players at highest risk were those with low

performance in the jumping test, higher vulnerability to

stress, were unadventurous, estimated high psychological

readiness for the RTP and good performance in the jump

rope test. This risk profile was three times more likely to

suffer a second ACL injury. Recently, Fältström et al.

(2023) reported an eightfold increased risk for those players

with higher RTP psychological readiness scores, lower im-

pulsivity scores, higher stress vulnerability scores and better

knee functionality. In contrast, Manara et al. (2022) re-

ported higher overall ACL-RSI scores and lower fear of re-

injury in those players who had returned to football and had

not suffered an additional ACL injury.

Discussion

Considering football as an intense contact sport, its par-

ticular characteristics and the previously presented data on

ACL injuries, it is necessary to conduct a review that spe-

cifically focuses on this sport. This study aimed to identify

the psychological aspects of ACL rehabilitation, as well as

RTP, and its influence on possible recurrences in football

and futsal players. After the review, nine studies were

found that met the inclusion criteria. The first aspect to

highlight is that no research was found in the field of futsal.

Although it is true that it is a sport with less impact than

football, the need to study futsal as a separate specialty

seems justified, since differences have been found in psy-

chological characteristics related to performance between

football and futsal (Mirzaei et al., 2016), and the data on

lower extremity injuries, such as ACL rupture, suggest an

interesting field in which to develop research (Gene-Mo-

rales et al., 2021; Ruiz-Pérez et al., 2019, 2021).

Based on the objectives and results of the studies in-

cluded in this review, they can be divided into two groups.

The first group included articles that aimed to investigate

the effects of some treatments on the rehabilitation of foot-

ball players with ACL injuries (Almuhaya et al., 2023;

D'Isanto et al., 2022; Palmi et al., 2018). The treatments

included Mindfulness, Mirror Therapy, and incorporation

of a structured educational session into the conventional re-

habilitation program. The results showed benefits in mood

states, a positive evaluation of the sessions in learning psy-

chological techniques, improvement in the perception of

psychological readiness for RTP, reduced pain perception,

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and reduced kinesiophobia and fear of reinjury.

As can be seen, many psychological factors are present

in ACL rehabilitation. Some authors also highlight social

support, motivation and goal setting, self-efficacy, athlete

expectations regarding the time and effort required for this

process, kinesiophobia, and fear of re-injury (Johnson et al.,

2016; Walker et al., 2022). Piussi, Berghdal et al. (2022)

conducted a systematic review and found that athletes who

suffer an ACL injury may experience symptoms of depres-

sion, particularly during the first 6 weeks after ACLR. As

Burland et al. (2019) point out, all psychological responses

play a role in the outcome or success of recovery after in-

jury. For example, football players who exhibit lower levels

of self-confidence and less optimism (cognition) show

greater fear of re-injury (emotion), which may lead to

lower adherence to rehabilitation (behaviour) and influence

whether the football player achieves successful RTP (out-

come). In this sense, research such as that of Candel et al.

(2023) shows the role of catastrophic thinking on mood

states in football players with severe and very severe inju-

ries, where the greater the catastrophism (rumination,

helplessness, and magnification), the greater the negative

mood state (tension, depression, anger, and fatigue), and

the lower the positive mood state (vigour). Similarly, fear

of new exercises during rehabilitation can manifest as anger

or frustration (Kvist et al., 2023).

There is consensus on the importance of good psycho-

logical readiness for RTP times and outcomes, as it is a good

predictor of return to pre-injury level and recurrences in

football players (Figueroa et al., 2022). Kunnen et al.

(2020) found that football players manifested psychological

readiness for RTP based on confidence in four areas: in the

rehabilitation process, in their physical abilities, in medical

professionals, and in not fear of reinjury. These results are

of particular importance since work such as that of Gómez-

Espejo, Olmedilla, et al. (2022) shows that correct psycho-

logical readiness is related to good mental health during

RTP. Moreover, as readiness increased over time, levels of

stress, anxiety, and depression tended to improve.

Other studies have demonstrated the benefits of psycho-

logical interventions for knee rehabilitation (Cupal &

Brewer, 2001; Maddison et al., 2006, 2012). Brewer et al.

(2022) implemented an interactive multimedia program us-

ing a cognitive behavioural approach in athletes and non-

athletes with ACL injuries. Those who completed the pro-

gram demonstrated greater preoperative confidence in

their ability to cope than those who received standard care.

They also experienced lower levels of postoperative pain

and kinesiophobia as well as greater use and perceived use-

fulness of patient education materials. Therefore, even the

addition of a few psychoeducational sessions to conven-

tional rehabilitation programs may be an economical and ef-

fective means of addressing the psychological problems or

needs of football players at the time of injury and during

their ACL recovery process (Gómez-Espejo, García-Mas,

et al., 2022).

The second group of studies aimed to investigate factors

related to RTP and new ACL injuries (Bortone et al., 2021;

Correa et al., 2023; Faltstrom et al., 2016, 2021, 2023;

Manara et al., 2022). Thus, the factors associated with RTP

are higher motivation for RTP, better injury-related quality

of life, "adventure seeking" and "personal standards" as

personality traits and perfectionism. Conversely, the most

common reasons for not returning were lack of confidence

in the knee and fear of reinjury. These factors are compara-

ble to those identified in other reviews (Longo et al., 2023;

Momaya et al., 2024; Nwachukwu et al., 2019). For exam-

ple, Nwachukwu et al. (2019) reported the most common

reasons were fear of reinjury, lack of confidence in the

knee, depression, and lack of interest or motivation.

Momaya et al. (2024) identified motivation to return,

lower levels of kinesiophobia, higher levels of self-efficacy,

confidence and subjective knee function, risk acceptance

and social support as factors that might predict athletes

more likely to RTP. In contrast to previous reviews, per-

sonality factors as "adventure seeking" and "personal stand-

ards" related to RTP were found in this study. Accordingly,

it would be interesting to investigate other variables that

may play protective or facilitating roles in RTP.

These findings are also consistent with other studies.

Webster et al. (2018) found that fewer pain symptoms and

better self-reported knee function were associated with

psychological readiness to RTP. Even in athletes with ACL

injuries without surgical treatment, a relationship between

good knee function and good psychological readiness for

RTP prior to injury has been observed (Slater et al., 2023).

In this respect, social support also plays an important role

at RTP. For example, Forsdyke et al. (2022) found that

reinjury anxiety mediates the relationship between social

support and psychological readiness for RTP in football

players. This suggests that increasing positive perceptions of

social support will decrease reinjury anxiety during rehabil-

itation, which may help football players to be more psycho-

logically prepared for RTP.

Other studies discussed in this review demonstrated the

effect of psychological readiness for RTP and kinesiophobia

or fear of injury on physical test performance (Bortone et

al., 2021; Correa et al., 2023). Bortone et al. (2021) as-

sessed players two years after ACLR and found that higher

levels of kinesiophobia were significantly associated with

higher ACL injury complaints and poorer psychological

readiness for RTP. In addition, those with less fear of rein-

jury showed better performance in terms of balance and

strength with less asymmetry, while those with lower psy-

chological readiness scores reported greater limitations in

daily activities and longer times to perform the agility test,

especially in the injured leg. Correa et al. (2023) investi-

gated whether there were differences in kinesiophobia and

performance on field tests and exercises related to the in-

jured knee after medical discharge between players who

perceived themselves as psychologically prepared for RTP

and those who did not. The authors found that players who

did not perceive themselves to be psychologically prepared

for RTP had worse field test performance and greater

2024, Retos, 55, 397-410

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dynamic knee valgus during the squat test compared to

those who perceived themselves to be prepared. Addition-

ally, these players had greater kinesiophobia and lower self-

reported knee function. In this regard, there is no doubt

that fear of re-injury and motivation play critical roles dur-

ing rehabilitation and subsequent RTP. Kvist et al. (2023)

explored the influence of fear after ACLR on rehabilitation

and RTP. However, research by Kunnen et al. (2020) with

football players showed that the motives for returning to

competition were the happiness that football gave them, the

sense of belonging, and the love of their sport, which were

stronger than the fear of re-injury. Sonesson et al. (2017),

on the other hand, reported that greater motivation during

rehabilitation was associated with a return to pre-injury

sports activity and greater satisfaction with the level of knee

activity and function. Johnston & Carroll (1998) observed

that athletes with fear of re-injury were hesitant, did not

work as hard as they could, and were wary of injury-pro-

voking situations. Athletes who perceived their rehabilita-

tion as positive reported feelings of happiness and relief,

which promoted greater adherence. In contrast, those who

perceived it negatively reported feeling frustrated, which

led to hesitation and caution in performing exercises in their

rehabilitation program.

Finally, two articles included in the review presented

risk profiles for a second ACL injury. Faltstrom et al.

(2021) found that one of the highest risk profiles was those

players who had low performance in the jump test, greater

susceptibility to stress, were unadventurous, estimated high

psychological readiness for RTP, and obtained good results

in the jumping jack. These players were three times more

likely to suffer a second ACL injury. The second study was

published by Faltstrom et al. (2023). They found a risk pro-

file in which players with higher psychological readiness

scores for RTP, lower impulsivity scores, higher stress vul-

nerability scores, and higher knee functionality had an

eight-fold increased risk of sustaining a second ACL injury

at the 12-month follow-up. In contrast, Manara et al.

(2022) found that players who had returned to competition

and had not suffered a second ACL injury had a better psy-

chological disposition and a greater lack of fear of re-injury.

First, these results support the proposed models of Ander-

sen & Williams (1988) or Wiese-Bjornstal et al. (1998), and

the role of stress. Based on the revised model of Williams

& Andersen (1998), it is possible that football players at

higher risk of injury are more concerned with protecting

themselves from re-injury, which could increase their stress

levels, reduce their attentional focus, and lead to errors in

decision-making and sport performance. If increased mus-

cle tension is included as a response to stress, it would in-

crease the likelihood of injury, which would not occur in

those with less susceptibility to stress and less fear of rein-

jury.

Nevertheless, these results reflect the complexity of risk

factor analysis, as a certain contradiction was found regard-

ing high psychological readiness for RTP and the possibility

of recurrence. On the one hand, studies such as McPherson

et al. (2019a) show that young athletes with lower psycho-

logical readiness for RTP have a higher risk of a second ACL

injury. McPherson et al. (2019b) found that those who sus-

tained a second ACL injury did not significantly improve in

psychological readiness for RTP from the pre-intervention

assessment to one year after ACLR, and improved less com-

pared to those who were not injured. Additionally, the in-

jured group reported being more nervous about participat-

ing in sports, more frustrated and less confident about par-

ticipating in sports without worrying about the knee, and

more fearful of reinjuring while participating in sports. In a

meta-analysis by Cronstrom et al. (2023), low psychologi-

cal readiness for RTP was associated with a higher likeli-

hood of graft rupture after ACLR. In contrast, Piussi,

Beischer et al. (2022) compared the psychological charac-

teristics of athletes who had suffered a second ACL injury

with those who did not. The authors found that those who

suffered a new ACL tear had better psychological readiness,

that is, greater confidence in performance, fewer negative

emotions, and a lower risk assessment of returning to

sports, as well as greater knee-related self-efficacy.

According to Piussi, Beischer et al. (2022), athletes who

progress rapidly in rehabilitation and reach the RTP criteria

develop a stronger psychological profile, that is, higher RTP

disposition and higher knee-related self-efficacy. This

would mean that both athletes and health professionals

could suggest that RTP is possible, but at the cost of ignor-

ing biological healing and important phases of rehabilita-

tion. Thus, higher self-reported psychological readiness for

RTP and higher knee-related self-efficacy may lead to ear-

lier and riskier exposure to sports participation, and thus, a

greater risk of ACL reinjury. In fact, Loose et al. (2018)

found that most football players wanted to make their own

decisions about returning to sport and often decided to re-

turn to sport after injury against the recommendation of

their physician. Coaches often return injured players to play

sooner against the physician's decision, although in most

cases, they believe that the physician plays the main role in

the decision to RTP. In addition, approximately 30% of

players and 70% of coaches reported a new injury after not

following the doctor's advice not to RTP after a serious in-

jury. This discrepancy also reflects the current reality of

RTP processes in elite football.

A complementary explanation would be that proposed

by Webster (2022) based on the Yerkes-Dodson law

(Yerkes & Dodson, 1908). According to this law, perfor-

mance increases with physiological or mental arousal but

only up to a certain point, after which performance de-

creases when arousal levels become too high. For Webster

(2022), the same inverted "U" pattern may also explain the

relationship between psychological responses and the risk

of further ACL injury, i.e., too much or too little would

not be optimal. Finally, the results may vary depending on

the relationships between variables. It is likely that suscep-

tibility to stress plays a moderating role between psycho-

logical readiness and a second ACL injury. Other psycho-

logical variables, such as certain personality traits, may also

2024, Retos, 55, 397-410

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influence possible relationships. For example, Olmedilla et

al. (2022) found that adaptive perfectionism, including "per-

sonal standards," played a protective role against symptoms

of anxiety, stress, and depression. In addition, because these

mental health indicators are related to injury, the likelihood

of injury was lower. Conversely, maladaptive perfectionism

was associated with worse mental health symptoms and a

higher risk of injury.

Limitations, future lines of research and practi-

cal implications

Although the present review was conducted according to

PRISMA recommendations (Page et al., 2021), it has some

limitations. The quality of the review is limited to the data

available in the included studies. In this sense, according to

the scores obtained on the PEDro scale, the studies would

have good or excellent methodological quality, except for the

study by Palmi et al. (2018), owing to its single-case design.

Based on the expected paucity of studies, we did not include

limitations regarding year of publication and design, there-

fore the included articles are heterogeneous. As a result, the

conclusions and findings should be interpreted with caution.

Another limitation is that the level of the football players was

not considered, so the total sample of the review included

from amateur to elite level. It would be interesting to con-

duct research that makes comparisons at the competitive

level, as well as to analyse the possible age and gender differ-

ences that some studies have found regarding ACL injury and

subsequent RTP. Similarly, based on the suggestion of

Olmedilla & García-Mas (2023), further research could be

carried out with the aim of studying the characteristics that

differentiate football players who have not suffered ACL in-

juries or recurrences from those who have. The results ob-

tained could be used to implement prevention protocols as a

"vaccine" in football and futsal teams.

In view of the results obtained, it is necessary to consider

the psychological aspects of rehabilitation and their influence

on RTP. A simple screening regarding motivation and fear of

re-injury can help to identify those players who may have a

lower adherence to rehabilitation and thus, a higher risk of

worse evolution and subsequent RTP. Additionally, the im-

plementation of psychological interventions such as Cogni-

tive Behavioural Therapy, EMDR or Mindfulness, as well as

specific strategies such as motor imagery, relaxation or goal

setting (Lope & Solís, 2020; Olmedilla & García-Mas, 2023;

Pastora-Bernal et al, 2021), would complement conventional

rehabilitation protocols, which generally focus on physical

and functional recovery of the knee. Such interventions could

help football players to reduce pain perception and kinesio-

phobia, while improving their mood, perception of social

support and optimal psychological readiness for RTP.

Conclusion

Although some football players meet the clinical criteria

for RTP, some do not return to their pre-injury levels or

do not return to RTP. This systematic review provides ev-

idence on the psychological factors present in the rehabili-

tation of ACL injuries and their influence on RTP and pos-

sible recurrences. On the other hand, the main factors as-

sociated with RTP are higher motivation for RTP, better

injury-related quality of life, and adventure seeking and per-

sonal standards as personality traits and perfectionism. Con-

versely, the most common reasons for not returning were

lack of confidence in the knee and fear of re-injury. Fear of

reinjury and poorer psychological readiness were also asso-

ciated with poorer performance on physical tests. In terms

of risk profiles, the results suggest that susceptibility to

stress and high psychological readiness, in combination with

other variables, may increase the risk of sustaining a second

ACL injury. Therefore, further studies are needed to ex-

plore the optimal level of psychological readiness and pos-

sible intervention of other factors such as age or gender, in-

cluding psychological variables such as perfectionism. Fi-

nally, the included studies also suggest positive effects of

psychological interventions on mood states, improved per-

ceptions of psychological readiness for RTP, reduced pain

perception, and reduced kinesiophobia and fear of reinjury.

Based on these findings, screening is recommended to iden-

tify players at risk of both poor rehabilitation and recur-

rence. Likewise, future research could focus on the charac-

teristics of football players without ACL injuries and de-

velop prevention protocols as a "vaccine" to be imple-

mented in football and futsal teams.

Acknowledgements

This study has been carried out, in part, thanks to the

collaboration agreement between the Football Federation

of the Region of Murcia (FFRM) and the University of

Murcia (UM), Project FFRM+UMU-36731–GIN-

VEST12574.

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Datos de los autores y traductor:

Luis Miguel Ramos Pastrana

luismiguel.ramos@um.es

Autor/a – Traductor/a

José María Giménez Egido

josemaria.gimenez@um.es

Autor/a

Aurelio Olmedilla Zafra

olmedilla@um.es

Autor/a

ResearchGate has not been able to resolve any citations for this publication.

The Impact of Psychological Factors on Return to Sports after Anterior Cruciate Ligament Reconstruction: A Systematic Review

Article

Full-text available

Jul 2023

The rehabilitation of those who have undergone anterior cruciate ligament reconstruction (ACL-R) is a complex process that involves many factors. Physical ability recovery is not the only factor in the return to sport; psychosocial factors such as anxiety, pain response, self-esteem, locus of control, and fear of re-injury also play an important role. A systematic search was conducted on the PubMed, Medline, Cochrane, CINAHL and Embase databases using the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). No randomized controlled trials (RCTs) were identified. The Methodological Index for Non-Randomized Studies (MINOR) was used to assess the quality of the identified non-RCT studies. A total of 308 studies were identified, of which 32 met the eligibility criteria. The results of these studies were obtained using the KOOS (ADL, Sport, QoL), ACL, TSK-11, K-SES, questionnaires/interviews, and other scales as instrumental approaches. This systematic review and meta-analysis revealed that psychological factors have a significant influence on the post-anterior cruciate ligament reconstruction outcomes of athletes. Fear of re-injury and pain were the primary factors that limited return to sport, whereas self-efficacy, psychological will, and age were associated with better functional outcomes and were essential for male and young patients. Clinicians should focus on both physical and psychological components to optimize rehabilitation.

Effect of strength training on knee proprioception in patients with knee osteoarthritis. A systematic review and meta-analysis

Article

Full-text available

Nov 2023

Proprioception is significantly impaired in knee osteoarthritis (KOA), contributing to reduced functionality. Strength training (ST) is essential in KOA by improving muscle strength, although it may also be effective in improving proprioception. The purpose was to determine the effect of ST on knee proprioception in KOA patients. Pubmed, CINAHL, Scopus, WOS, and PEDro were searched for randomized controlled trials (RCTs) (inception to March 2023). Comparisons for ST were physical exercise different from ST, non-exercise-based interventions, and no intervention. Methodological quality was assessed using the PEDro scale, and risk of bias (RoB) using the Cochrane tool. Meta-analyses were performed by comparison groups using the standardized mean difference (SMD) (Hedge's g) with random effects models, also considering subgroups by proprioception tests. Finally, six RCTs were included. The mean PEDro score was 6.3, and the highest proportion of biases corresponds to performance, selection, and detection. The meta-analysis indicated that only when compared with non-intervention, ST significantly improved knee proprioception for the joint position sense (JPS) (active + passive), JPS (passive), and threshold to detect passive motion (TTDPM) subgroups (g = −1.33 [-2.33, −0.32], g = −2.29 [-2.82, −1.75] and g = −2.40 [-4.23, −0.58], respectively). However, in the knee JPS (active) subgroup, ST was not significant (g = −0.72 [-1.84, 0.40]). In conclusion, ST improves knee proprioception compared to non-intervention. However, due to the paucity of studies and diversity of interventions, more evidence is needed to support the effectiveness of ST. Future RCTs may address the limitations of this review to advance knowledge about proprioceptive responses to ST and contribute to clinical practice.

The Effects of Exercise-Based Injury Prevention Programmes on Injury Risk in Adult Recreational Athletes: A Systematic Review and Meta-Analysis

Article

Full-text available

Oct 2023
SPORTS MED

Background Injuries are common in adult recreational athletes. Exercise-based injury prevention programmes offer the potential to reduce the risk of injury and have been a popular research topic. Yet, syntheses and meta-analyses on the effects of exercise-based injury prevention programmes for adult recreational athletes are lacking. Objectives We aimed to synthesise and quantify the pooled intervention effects of exercise-based injury prevention programmes delivered to adults who participate in recreation sports. Methods Studies were eligible for inclusion if they included adult recreational athletes (aged > 16 years), an exercise-based intervention and used a randomised controlled trial design. Exclusion criteria were studies without a control group, studies using a non-randomised design and studies including participants who were undertaking activity mandatory for their occupation. Eleven literature databases were searched from earliest record, up to 9 June, 2022. The Physiotherapy Evidence Database (PEDro) scale was used to assess the risk of bias in all included studies. Reported risk statistics were synthesised in a random-effects meta-analysis to quantify pooled treatment effects and associated 95% confidence intervals and prediction intervals. Results Sixteen studies met the criteria. Risk statistics were reported as risk ratios [RRs] (n = 12) or hazard ratios [HRs] (n = 4). Pooled estimates of RRs and HRs were 0.94 (95% confidence interval 0.80–1.09) and 0.65 (95% confidence interval 0.39–1.08), respectively. Prediction intervals were 0.80–1.09 and 0.16–2.70 for RR and HR, respectively. Heterogeneity was very low for RR studies, but high for HR studies (tau = 0.29, I2 = 81%). There was evidence of small study effects for RR studies, evidenced by funnel plot asymmetry and Egger’s test for small study bias: − 0.99 (CI − 2.08 to 0.10, p = 0.07). Conclusions Pooled point estimates were suggestive of a reduced risk of injury in intervention groups. Nevertheless, these risk estimates were insufficiently precise, too heterogeneous and potentially compromised by small study effects to arrive at any robust conclusion. More large-scale studies are required to clarify whether exercise-based injury prevention programmes are effective in adult recreational athletes.

The Effect of Ball Heading and Subclinical Concussion On the Neuromuscular Control Of The Lower Limb: A Systematic Review International Journal of Sports Physical Therapy

Article

Full-text available

Oct 2023
Int J Sports Phys Ther

Background Soccer is unique among sports because it is the only sport that involves purposeful use of the head to control, pass, or shoot the ball. Over the previous five years, a relationship between lower extremity (LE) injury and sports related concussion (SRC) has been established in various sporting populations. Athletes at the high school, collegiate, and professional levels have demonstrated a greater risk for sustaining a LE injury post SRC. The purpose of this systematic review was to examine the relationship of the SRC with the incidence of LE injuries. Methods Ten databases were searched with the following keywords: Lower limb, ball heading, neuromuscular control, concussion, MEDLINE, Ovid MEDLINE(R) Daily, and Ovid MEDLINE(R), EMBASE, and Scopus. The search was limited to English-language and peer-reviewed publications, until 15/12/2022. The PEDro scale was used for the assessment of the risk of bias among the included studies. All included papers were qualitatively analyzed. Results A total of 834 studies were identified and 10 articles (four concussion-MSK biomechanics, six concussion-MSK injury) were included in the qualitative analyses. Included papers ranged from low to high quality. Due to the heterogeneous nature of the included study designs, quantitative meta-analysis was unable to be performed. All four of the included concussion-MSK biomechanics studies demonstrated, to some degree, that worse cognitive performance was associated with lower extremity MSK biomechanical patterns suggestive of greater risk for MSK injury. Among the six injury related studies, two investigations failed to determine group differences in cognitive performance between subsequently injured and non-injured athletes. Conclusion More research is needed to better understand the relationship of SRC and lower extremity injuries and the extent to which they are related to concussions and/or repetitive neurotrauma after ball heading sustained in soccer. Level of Evidence 2

Risk Factors for Sustaining a Second ACL Injury after Primary ACL Reconstruction in Female Football Players: A Study Investigating the Effects of Follow-Up Time and the Statistical Approach

Article

Full-text available

May 2023

Background Studies evaluating risk factors for sustaining an anterior cruciate ligament (ACL) injury have different, sometimes contrasting, results. Different follow-up times and statistical approaches may be a reason for these differences. The aim of this study was to explore if different follow-up times and statistical approaches, classification and regression tree (CART) analysis and Cox regression, would impact on the association between various candidate risk factors and ACL injury in female football players. In total, 112 active female football players, 18 ± 8 months after ACL reconstruction (mean age ± SD, 20 ± 2 years), were included and followed for at least 36 months. At baseline, all players underwent assessment of range of motion of knee and ankle joints, functional tests, and answered questionnaires regarding knee function, psychological and personality traits. Nineteen independent variables were included for the CART analysis and for univariable Cox regression and compared using four different follow-up times: 0–12, 0–24, 0–36, and 0–>36 months. Results Forty-three (38%) players sustained a second ACL injury. The identified risk factors varied depending on follow-up time both with CART analysis and with Cox regression. CART identified 12 of the 19 independent variables and selected between 5 and 6 of the variables in the four different follow-up times associated with second ACL injury. The accuracy of the different follow-up times for the CART varied between 86 and 93% with 77–96% sensitivity and 70–81% specificity. Cox regression identified two risk factors: knee extension at 0–36 months and 0–>36 months, and time between primary injury and surgery at 0–>36 months. The accuracy varied between 54 and 64% with 44–88% sensitivity and 32–71% specificity. Conclusions The identified risk factors associated with a second ACL injury varied depending on the follow-up time and statistical approach used. Thus, in future research on risk factors, the time athletes are followed up and the type of statistical methods used are important to discuss.

The relationship between personality traits and sport performance

Article

Full-text available

Apr 2023

This article was aimed to investigate the relationship between personality traits with sport performance. The method of the study is descriptive correlational. The data was collected using questionnaires and through field study procedure. The population of the study consisted of 229 non elite football and futsal players in the 2010-2011 season in Ardebil city. The sample size was equated with the population. Personality was assessed using the NEO-Five Factor Inventory (NEO-FFI; Costa & McCrae, 1992) and athlete's performance was assessed by coach's rating (Piedmont et al., 1999). The stepwise regression analysis indicated that from among personality components only Conscientiousness have positive significant correlation with sport performance. The result, also, indicated that conscientiousness was the sole predictor of sport performance.

The experience and influence of fear after anterior cruciate ligament reconstruction: an interview study with young athletes

Article

Full-text available

Apr 2023

Background Despite good physical function, many athletes do not return to sports after an anterior cruciate ligament reconstruction (ACLR). One important reason for this is fear of new injury. The aim of this study was to investigate young athletes’ experiences of knee-related fear after an ACLR and how they perceive this fear to affect them in their sporting and everyday life. Methods A qualitative interview study was conducted, using semi-structured interviews. Athletes who were active in contact or pivoting sport before an ACL injury, with the goal of returning to the same sport and who scored highly on fear of new injury at six months post-ACLR, were asked to participate. Ten athletes (six women and four men, aged 17–25 years), were interviewed by an independent researcher, 7–9 months after ACLR. Content analysis employing an abductive approach was used. Results The analysis resulted in three categories with associated subcategories: 1. The expressions of fear; (i) reason for fear, (ii) changes in fear over time, and (iii) injury situation. 2. Reactions, consequences, and adaptations; (i) reactions, (ii) behavioural adaptation and influence on rehabilitation and daily life, (iii) present consequences, and (iv) consequences for the future. 3. Fear and adaptations related to returning to sports; (i) fear related to returning to sports and, (ii) adaptations in sports and life due to fear. Fear was described in broad and complex ways, with fear of a new injury being expressed as one of several aspects. Various reasons (e.g., seeing others getting injured in the past, previous experience of injury, failed rehabilitation, perceived knee instability) were given to explain the fear, and athletes reacted both physically and mentally to fear. Both positive and negative adaptations to fear were described, in both daily life and sports. Conclusion The results contribute to an increased understanding of fear as an essential psychological factor to consider during rehabilitation and leaves the way open for research to investigate how physiotherapists can work to manage fear better among ACLR patients.

Return to Play and Pattern of Injury After ACL Rupture in a Consecutive Series of Elite UEFA Soccer Players

Article

Full-text available

Mar 2023

Background Anterior cruciate ligament rupture represents a career-threatening injury for professional soccer players. Purpose To analyze the pattern of injury, return to play (RTP), and performance of a consecutive series of elite professional soccer players after anterior cruciate ligament reconstruction (ACLR). Study Design Case series; Level of evidence, 4. Methods We evaluated the medical records of 40 consecutive elite soccer players who underwent ACLR by a single surgeon between September 2018 and May 2022. Patient age, height, weight, body mass index, position, injury history, affected side, RTP time, minutes played per season (MPS), and MPS as a percentage of playable minutes before and after ACLR were retrieved from medical records and from publicly available media-based platforms. Results Included were 27 male patients (mean ± SD age at surgery, 23.2 ± 4.3 years; range, 18-34 years). The injury occurred during matches in 24 players (88.9%), with a noncontact mechanism in 22 (91.7%). Meniscal pathology was found in 21 patients (77.8%). Lateral meniscectomy and meniscal repair were performed in 2 (7.4%) and 14 (51.9%) patients, respectively, and medial meniscectomy and meniscal repair were performed in 3 (11.1%) and 13 (48.1%) patients, respectively. A total of 17 players (63.0%) underwent ACLR with bone–patellar tendon–bone autograft and 10 (37.0%) with soft tissue quadriceps tendon. Lateral extra-articular tenodesis was added in 5 patients (18.5%). The overall RTP rate was 92.6% (25 of 27). Two athletes moved to a lower league after surgery. The mean MPS% during the last preinjury season was 56.69% ± 21.71%; this decreased significantly to 29.18% ± 20.6% ( P < .001) in the first postoperative season and then increased to 57.76% ± 22.89% and 55.89% ± 25.8% in the second and third postoperative seasons. Two (7.4%) reruptures and 2 (7.4%) failed meniscal repairs were reported. Conclusion ACLR in elite UEFA soccer players was associated with a 92.6% rate of RTP and 7.4% rate of reinjury within 6 months after primary surgery. Moreover, 7.4% of soccer players moved to a lower league during the first season after surgery. Age, graft selection, concomitant treatments, and lateral extra-articular tenodesis were not significantly associated with prolonged RTP.

The Influence of Psychosocial Factors on Patients Undergoing Anterior Cruciate Ligament Reconstruction

Article

Jan 2024

Context Anterior cruciate ligament (ACL) injuries greatly impact patients in terms of future performance, reduced physical activity and athletic participation, and overall economic burden. Decades of research have investigated how to improve ACL reconstruction (ACLR) outcomes. Recently, there has been growing interest to understand the effects of psychosocial factors on patient outcomes. Study Design Clinical review. Evidence Acquisition A search of the PubMed database was performed in March 2023. Articles were reviewed by at least 2 authors to determine relevance. We highlighted publications of the past 5 years while incorporating previous pertinent studies. Level of Evidence Level 5. Results There is no standardization of psychosocial factors regarding ACLR. As such, there is a lack of consensus regarding which psychosocial measures to use and when. There is a need for clarification of the complex relationship between psychosocial factors and physical function. Despite this, psychosocial factors have the potential to help predict patients who are more likely to return to sport: (1) desire/motivation to return; (2) lower levels of kinesiophobia; (3) higher levels of self-efficacy, confidence, and subjective knee function; (4) risk acceptance; and (5) social support. However, there are no standardized interventions to improve psychosocial factors after ACLR. Conclusion Psychosocial factors affect outcomes after ACLR. However, the interplay between psychosocial factors and physical function is complex. There is emerging evidence that testing and interventions may improve ACLR outcomes. There is a lack of standardized interventions to determine or improve psychosocial factors after ACLR. Further research is needed to identify psychosocial factors and to develop standardized interventions for clinicians to implement to improve clinical outcomes.

Performance in field-tests and dynamic knee valgus in soccer players psychologically ready and not ready to return to sports after ACL reconstruction

Article

Apr 2023

Background: The objective was to compare the performance in field tests, dynamic knee valgus, knee function, and kinesiophobia of soccer players who were psychologically ready and not ready to return to unrestricted training or competitions after ACL reconstruction. Methods: Thirty-five male soccer players who had undergone primary ACL reconstruction at least 6 months were divided based on the Anterior Cruciate Ligament Return to Sport after Injury (ACL-RSI) questionnaire score into ready (≥60) and not-ready (<60) groups. The modified Illinois change of direction test (MICODT) and reactive agility test (RAT) were used to impose the demand for directional change and reactive decision-making. We assessed the frontal plane knee projection angle (FPKPA) during a single-leg squat and distance in crossover hop test (CHD). In addition, we assessed kinesiophobia through the shortened version of the Tampa Scale of Kinesiophobia (TSK-11) and knee function using the International Knee Documentation Committee Subjective Knee Form (IKDC). Independent t-tests were used to compare the groups. Results: The not-ready group had lower performance on the MICODT (effect size (ES) = -1.2; p < 0.001) and RAT (ES = -1.1; p = 0.004) tests and higher FPKPA (ES = 1.5; p < 0.001). In addition, they presented lower IKDC (ES = 3.1; p < 0.001) and higher TSK-11 (ES = -3.3; p < 0.001) scores. Conclusions: Physical and psychological deficits may persist in some individuals after rehabilitation. On-field tests and dynamic knee alignment evaluation should be included in the athlete evaluation before the decision-making about clearance to sports participation, especially in athletes who perceive themselves as psychologically not ready.

Psychological aspects associated with ACL rehabilitation and recurrence in football players: a systematic review

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