A longitudinal examination of athletes' emotional and cognitive responses to anterior cruciate ligament injury

Adolescent Athletes with Stronger Athletic Identity Perceptions Have Weaker Fear Avoidance Perceptions During Musculoskeletal Injury Rehabilitation Return to Sports Preparation

BACKGROUND

Adolescent athletes who sustain a musculoskeletal sports injury are at high re-injury risk. This prospective study evaluated athletic identity perception and fear avoidance perception relationships during the return to sport preparation phase of musculoskeletal injury rehabilitation.

METHODS

From 140 consecutive physical therapy outpatients, 50 (26 females, 24 males) adolescent athletes (mean age 16.8, range 14 to 22 y) completed the 7-item Athletic Identity Measurement Scale (AIMS), the 10-item Athletic Fear Avoidance Questionnaire (AFAQ), and the AFAQ with 2 additional movement-related fear and pain questions (AFAQ+). Correlational analysis was performed of overall AIMS and AIMS subscale scores (social identity, exclusivity, negative affectivity), with AFAQ and AFAQ+ scores (P≤0.05).

RESULTS

Adolescent athletes were receiving treatment for musculoskeletal injuries sustained during soccer (n=10), lacrosse (n=7), baseball (n=6), basketball (n=5), volleyball (n=5), track or cross country (n=4), American football (n=4), field hockey or ice hockey (n=3), softball (n=2), tennis (n=2), and gymnastics (n=2). Lower extremity conditions included anterior cruciate ligament reconstruction (n=23) or other lower extremity conditions (n=17). Upper extremity conditions included shoulder dislocation or labral repair (n=6), elbow sprain or fracture (n=3), and clavicle fracture (n=1). The AIMS score displayed moderate inverse relationships with AFAQ (r=-0.40, P=0.008) and AFAQ+ (r=-0.41, P<0.004) scores. The "social identity" AIMS subscale score displayed a moderate inverse relationship with AFAQ (r=- 0.48, P<0.001) and AFAQ+ (r=-0.46, P=0.001) scores. The "exclusivity" AIMS subscale score displayed moderate inverse relationships with AFAQ (r=-0.40, P=0.005) and AFAQ+ (r=-0.46, P=0.001) scores. The "negative affectivity" subscale did not display significant relationships with AFAQ or AFAQ+ scores. Subject age displayed moderate inverse relationships with the AIMS "social identity" (r=-0.56, P<0.001) and "exclusivity" (r=-0.42, P=0.004) subscale scores and weak direct relationships with AFAQ (r=0.30, P=0.04) and AFAQ+ (r=0.32, P=0.02) scores.

CONCLUSION

Adolescent athletes with stronger athletic identity perceptions during the return to the sports preparation phase of musculoskeletal injury rehabilitation had weaker fear avoidance perceptions. As age increased from early to late adolescence, athletic identity perceptions became weaker, and fear avoidance perceptions became stronger. To decrease re-injury rates, early identification and surveillance of injured adolescent athletes with stronger, more exclusive athletic identity perceptions and weaker fear avoidance perceptions may influence rehabilitation progression and return to play decisions.

LEVEL OF EVIDENCE

Level-II, prospective cohort, correlational study.

Psychological Impact and Posttraumatic Stress Disorder Symptomatology After Ulnar Collateral Ligament Injuries in Baseball Players

Background

Significant psychological impact and prevalence of posttraumatic stress disorder (PTSD) have been well documented in patients sustaining anterior cruciate ligament injury.

Purpose

To examine PTSD symptomatology in baseball players after sustaining elbow ulnar collateral ligament (UCL) injury.

Study Design

Cross-sectional study; Level of evidence, 3.

Methods

Male baseball players of various competition levels (high school through Minor League Baseball [MiLB]) who underwent surgery for a UCL injury between April 2019 and June 2022 participated in the study. Before surgery, patients completed the Impact of Event Scale-Revised (IES-R) to assess PTSD symptomatology. Subgroup analysis was conducted according to level of play and player position.

Results

A total of 104 male baseball players with a mean age of 19.4 years (range, 15-29 years) were included in the study; 32 players (30.8%) were in high school, 65 (62.5%) were in college, and 7 (6.7%) were in MiLB. There were 64 (61.5%) pitchers, 18 (17.3%) position players, and 22 (21.2%) 2-way players (both pitching and playing on the field). A total of 30 (28.8%) patients scored high enough on the IES-R to support PTSD as a probable diagnosis, and another 22 patients (21.2%) scored high enough to support PTSD as a clinical concern. Nineteen patients (18.3%) had potentially severe PTSD. Only 4 players (3.8%) were completely asymptomatic. Subgroup analysis revealed college players as significantly more symptomatic than high school players (P = .02), and 2-way players were found to be significantly less susceptible to developing symptoms of PTSD compared with pitchers (P = .04).

Conclusion

Nearly 30% of baseball players who sustained a UCL injury qualified for a probable diagnosis of PTSD based on the IES-R. Pitchers and college athletes were at increased risk for PTSD after UCL injury compared with 2-way players and high school athletes, respectively.

Differences in Biomechanical Determinants of ACL Injury Risk in Change of Direction Tasks Between Males and Females: A Systematic Review and Meta-Analysis

BACKGROUND

Change of direction (COD) movements are associated with non-contact anterior cruciate ligament (ACL) injuries in multidirectional sports. Females appear at increased risk compared to males, which could be attributable to whole body kinematic strategies and greater multiplanar knee joint loads (KJLs) during COD which can increase ACL loading.

OBJECTIVE

The aim of this systematic review and meta-analysis was to examine and quantitatively synthesise the evidence for differences between males and females regarding KJLs and their biomechanical determinants (whole body kinematic strategies determining KJLs) during COD tasks.

METHODS

Databases including SPORTDiscus, Web of Science, and PubMed were systematically searched (July 2021-June 2023) for studies that compared differences in knee joint loads and biomechanical determinants of KJLs during COD between males and females. Inclusion criteria were: (1) females and males with no prior history of ACL injury (18-40 years); (2) examined biomechanical determinants of KJLs and/ or KJLs during COD tasks > 20°; (3) compared ≥ 1 outcome measure between males and females. Studies published between 2000 and 2023 examining a cutting task > 20° with a preceding approach run that compared KJLs or the whole body multiplanar kinematics associated with them, between sexes, using three-dimensional motion analysis.

RESULTS

This meta-analysis included 17 studies with a pooled sample size of 451 participants (227 males, 224 females). Meta-analysis revealed females displayed significantly less peak knee flexion during stance (SMD: 0.374, 95% CI 0.098-0.649, p = 0.008, I2: 0%); greater knee abduction at initial contact (IC) (SMD: 0.687, 95% CI 0.299-1.076, p = 0.001, I2: 55%); less hip internal rotation (SMD: 0.437, 95% CI 0.134-0.741, p = 0.005, I2: 34%) and hip abduction at IC (SMD: -0.454, 95% CI 0.151-0.758, p = 0.003, I2: 33%). No significant differences were observed between males and females for any internal or externally applied KJLs. All retrieved studies failed to control for strength, resistance training or skill history status.

CONCLUSION

No differences were observed in KJLs between males and females despite females displaying greater knee abduction at IC and less peak knee flexion during the stance phase of CODs, which are visual characteristics of non-contact ACL injury. Further research is required to examine if this translates to a similar injury risk, considering morphological differences in strain characteristics of the ACL between males and females. This observation may in part explain the disproportionate ACL injury incidence in female multidirectional athletes. Further higher quality controlled research is required whereby participants are matched by skill training history, resistance training history and strength status to ensure an appropriate comparison between males and females.

An examination of changes in psychological status across four phases of injury recovery and return to sport: A prospective weekly study of competitive athletes from acute care to return to sport

While ample research has shown that sport injuries are associated with poor psychological status, scant attention has been given to changes in injured athletes' psychological status over the full course of recovery and return to sport. The aim of the present study was to prospectively investigate potential changes in injured athletes' psychological status across four phases of recovery and return to sport. A total of 38 severely injured adult competitive athletes (58% female; mean age 24.1 ± 7.18 years) participated in this prospective weekly investigation (n = 319 observations). Athletes' were asked to indicate their current phase of recovery or return to sport (acute care, rehabilitation, adapted training, or full return to sport) after which they responded to visual analog scales assessing post-injury psychological status, including: perceived pain (frequency and intensity), emotions (positive and negative), anxiety (cognitive and physiological), motivation, self-efficacy, and satisfaction. During the acute care phase, participants showed higher scores of perceived pain, and physiological anxiety compared to the other phases. During the adapted training phase, amotivation was higher than in the acute care phase, and self-efficacy was lower than in other phases. At full return to sport, athletes showed less perceived pain, cognitive anxiety, and more satisfaction than during other phases. The present study provides a deeper prospective understanding of changes in athlete's psychological status over the course of injury recovery and return to sport and highlight the importance of monitoring psychological status.

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

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.

French Version of the Short Anterior Cruciate Ligament-Return to Sport After Injury Scale: Development and Validation

Background

The 12-item Anterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI) scale was developed to assess the psychological readiness of patients to return to sports after ACL reconstruction (ACLR). A short (6-item) English version was also developed, which has shown to have good reliability and validity.

Purpose/Hypothesis

We aimed to develop and validate a French version of the short ACL-RSI scale. We hypothesized that the same questions would remain in the selection as the English version and that the French version of the scale would have the same psychometric properties.

Study Design

Cohort study (diagnosis); Level of evidence, 3.

Methods

The full 12-item French ACL-RSI scale was administered to 1000 patients who had undergone ACLR surgery. Reliability (Cronbach alpha) and factor analysis of the full scale were determined. Item selection and elimination process was conducted to develop a short (6-item) version. The same methodology was used to develop the English short ACL-RSI scale. A minimal (3-item) version was also developed and assessed.

Results

Internal consistency of the full version of the French ACL-RSI was found to be high (Cronbach alpha = .95), suggesting item redundancy. The short (6-item) version was also found to have high internal consistency (Cronbach alpha = .92) and was strongly correlated with the full version (r = 0.98). The minimal (3-item) version was also found to have high internal consistency, as well as a strong correlation with the full version (r = 0.94).

Conclusion

The French version of the short (6-item) ACL-RSI scale was valid, discriminant, consistent, and reproducible. The minimal (3-item) version was also found to be useful and more efficient to collect the information provided by the full ACL-RSI in a French-speaking population.

Substantial influence of psychological factors on return to sports after anterior shoulder instability surgery: a systematic review and meta-analysis

PURPOSE

This systematic review and meta-analysis aimed to (1) determine the proportion of patients who underwent anterior shoulder instability surgery and did not return to sports for psychological reasons and (2) estimate differences in psychological readiness scores between patients who did and did not return to sports.

METHODS

The EBSCOhost/SPORTDiscus, PubMed/Medline, Scopus, EMBASE and Cochrane Library databases were searched for relevant studies. The data synthesis included the proportion of patients who did not return to sports for psychological reasons and the mean differences in the psychological readiness of athletes who returned and those who did not return to sports. Non-binomial data were analysed using the inverse-variance approach and expressed as the mean difference with 95% confidence intervals.

RESULTS

The search yielded 700 records, of which 13 (1093 patients) were included. Fourteen psychological factors were identified as potential causes for not returning to sports. The rates of return to sports at any level or to the preinjury level were 79.3% and 61.9%, respectively. A total of 55.9% of the patients cited psychological factors as the primary reason for not returning to sports. The pooled estimate showed that patients who returned to sports had a significantly higher Shoulder Instability-Return to Sport After Injury score (P < 0.00001) than those who did not, with a mean difference of 30.24 (95% CI 24.95-35.53; I2 = 0%; n.s.).

CONCLUSIONS

Psychological factors have a substantial impact on the rate of return to sports after anterior shoulder instability surgery. Patients who returned to sports had significantly higher psychological readiness than those who did not return to sports. Based on these results, healthcare professionals should include psychological and functional measurements when assessing athletes' readiness to return to sports.

LEVEL OF EVIDENCE

Level IV.

The Dutch language short Anterior Cruciate Ligament-Return to Sport after Injury scale has good to excellent construct validity, internal consistency, and test-retest reliability when assessing athletes undergoing rehabilitation after ACL injury or ACL reconstruction

OBJECTIVES

To examine the validity and reliability of the Dutch language short Anterior Cruciate Ligament-Return to Sport after Injury scale (short ACL-RSI-NL) in recreational athletes undergoing rehabilitation after ACL injury or ACL reconstruction (ACLR).

METHODS

The original 12-item version of the ACL-RSI had been translated into Dutch. Short ACL-RSI-NL items were derived from this 12-item Dutch version. Content validity was evaluated by a team consisting of eight ACL experts and eight athletes. A cohort of 115 athletes with ACL injury or after ACLR completed the short ACL-RSI-NL and related questionnaires at various time points during their rehabilitation. Construct validity (hypothesis testing using Spearman correlations), internal consistency (Cronbach's alpha), floor and ceiling effects (percentage of athletes having the lowest or highest score possible), and structural validity (exploratory factor analysis) were evaluated in the entire ACL athlete group. Test-retest reliability (using intra-class correlation, ICC; standard error of measurement, SEM; smallest detectable change, SDC, at both group and individual levels) was investigated in a subgroup of athletes with a stable outcome on psychological readiness within a two-week interval (n ​= ​27).

RESULTS

The short ACL-RSI-NL demonstrated good construct validity (83% of hypotheses confirmed). Internal consistency was excellent (Cronbach's alpha 0.84), and there were no floor and ceiling effects (≤13.9% lowest or highest score). Test-retest reliability was good (ICC 0.89 with 95% CI 0.77-0.95, SEM 6.93, SDC individual level 19.2, SDC group level 3.7). Exploratory factor analysis confirmed the presence of a single underlying factor (accounting for 56.4% of the total variance of the score).

CONCLUSION

The short ACL-RSI-NL exhibited good to excellent construct validity, internal consistency, and test-retest reliability. An averaged score ranging from 0 to 100 can be used to measure psychological readiness to return to sport. The short ACL-RSI-NL has potential for use in day-to-day practice to assess the psychological readiness of recreational athletes to return to sport after ACL injury or ACLR during their rehabilitation process.

LEVEL OF EVIDENCE

Level II.

Examination of the validity of the Injury-Psychological Readiness to Return to Sport (I-PRRS) scale in male professional football players: A worldwide study of 29 professional teams

Perceived confidence is an important dimension of an athlete's psychological readiness to return-to-play. However, there is no established and validated tool to evaluate confidence in professional football. This study aimed to provide preliminary evaluation of the internal structure of the Injury-Psychological Readiness to Return-to-Sport scale (I-PRRS) in a cohort of injured male professional footballers. Over an 18-month period, 29 teams from 17 leagues participated. Players sustaining injuries eliciting ≥ 3 weeks' time-loss were recruited. Cross culturally adapted to 4 further languages, the I-PRRS was administered on two occasions: 1) day before returning-to-training and 2) day before returning-to-match-play. In total, 113 injuries were recorded with 96 completed I-PRRS data sets collected. Confirmatory factor analysis indicated the I-PRRS was a unidimensional scale, with all items measuring the same construct. The scale demonstrated good internal consistency (ω = .88). When examining longitudinal invariance of the I-PRRS across administration time-points, indices of model fit supported scalar invariance. There was preliminary evidence of good internal structure for the I-PRRS in professional male footballers. However, before further research involving the I-PRRS can be endorsed, efforts to confirm or refute empirical developments pertaining to psychological readiness are necessary.

It is time to target psychological readiness (or lack of readiness) in return to sports after Anterior Cruciate Ligament tears

Functional recovery has for long been the focus of rehabilitation after an Anterior Cruciate Ligament (ACL) injury. It is now increasingly recognized that more attention should be given to patients` mental recovery, their psychological readiness for returning to sport, after such an injury. Within this relatively new field of science, clinicians need clarity on when and how psychological factors should be monitored and how inexpedient psychological responses may be addressed during rehabilitation. In this Expert Opinion suggestions on how targeting psychological readiness may improve rehabilitation and return-to-sport evaluations are made based on current evidence-and issues in need of further clarification are addressed.

Prevalence and Predictors of Postoperative Depression and Anxiety After Anterior Cruciate Ligament Reconstruction

PURPOSE

Preoperative mood disorders influence postoperative outcomes after anterior cruciate ligament (ACL) reconstruction (ACLR), but the prevalence and risk factors associated with postoperative depression/anxiety development remain unknown. The purposes of this study were to quantify the prevalence of postoperative diagnoses of depression or anxiety following ACLR in patients under the age of 25 and assess the interplay between patient sex and ACL reoperation on the prevalence of a depression or anxiety diagnosis following ACLR.

METHODS

ACLR patients under the age of 25 years old were identified in the Truven Healthcare Marketscan database. Patients with incomplete coverage +/- one year of the index surgical procedure were excluded. Patients were categorized by the presence of preoperative, postoperative, or no depression/anxiety using the International Classification of Diseases, Ninth Revision (ICD-9) codes. We compared patient demographics and reoperation rates following the index ACLR between the depression and anxiety categories. Additionally, logistic regression was fit to assess the interaction between sex and either ipsilateral or contralateral ACL surgery on postoperative depression/anxiety diagnosis.

RESULTS

Of the 42,174 patients, 10.7% had a new depression/anxiety diagnosis after ACLR. Postoperative depression/anxiety was nearly twice as prevalent for females (F: 14.4%, M: 7.6%) despite having similar rates of secondary ACLR (F: 15.5%, M: 13.0%). Those with postoperative depression/anxiety had a considerably greater prevalence of reoperation (18.8%) than those without depression/anxiety (13.7%) and those with pre-existing preoperative depression/anxiety (12.9%). Sex and reoperation were independently associated with postoperative depression/anxiety diagnosis.

CONCLUSION

Female sex and secondary ACL surgery are independently associated with an increased prevalence of postoperative depression/anxiety. Nearly one in seven young females are diagnosed with depression/anxiety after ACLR. Similarly, a greater proportion of patients who suffer a secondary ACL surgery are subsequently diagnosed with depression/anxiety. The orthopedic community must be cognizant of the increased risk of postoperative depression/anxiety for females and those who suffer a secondary ACL surgery, and screening for depression/anxiety in these at-risk populations with referrals to mental health professionals may be warranted.

Effect of Age and Sex on Psychological Readiness and Patient-Reported Outcomes 6 Months After Primary ACL Reconstruction

Background

Successful return to sport after anterior cruciate ligament (ACL) reconstruction (ACLR) can be affected by a patient's physical and psychological state throughout the rehabilitation process.

Purpose

To prospectively compare differences in patients at 6 months after primary ACLR with the ACL-Return to Sport after Injury (ACL-RSI), International Knee Documentation Committee (IKDC) or pediatric (Pedi)-IKDC, Hospital for Special Surgery Pediatric Functional Activity Brief Scale (Pedi-FABS), and Patient-Reported Outcomes Measurement Information System-Psychological Stress Experiences (PROMIS-PSE) scores.

Study Design

Prospective cohort study; Level of evidence, 2.

Methods

Patients enrolled were 8 to 35 years old who underwent primary ACLR and had their 6-month follow-up appointments between December 2018 and March 2020. Patients were divided into 3 age groups as follows: (1) preadolescents (10-14 years); (2) adolescents (15-18 years); and (3) adults (>18 years). Outcomes on the ACL-RSI, IKDC/Pedi-IKDC, Pedi-FABS, and PROMIS-PSE were compared according to age group, graft type (hamstring, patellar tendon, quadriceps, or iliotibial band autograft), and sex.

Results

A total of 176 patients (69 male, 107 female), with a mean age of 17.1 ± 3.1 years were included in the study. The mean ACL-RSI scores were significantly different among age groups (preadolescents, 75 ± 18.9; adolescents, 61.5 ± 20.4; and adults, 52.5 ± 19.8 [P < .001]) and graft types (P = .024). The IKDC and PROMIS-PSE scores were also significantly different among age groups (P < .001 and P = .044, respectively) and graft types (P = .034 and P < .001, respectively), with the iliotibial graft and the younger age group performing the best. There was no significant difference in the Pedi-FABS either by age group (P = .127) or graft type (P = .198). Female patients had lower ACL-RSI scores and higher (worse) scores on PROMIS-PSE than their male counterparts (P = .019 and P < .001, respectively), with no sex-based differences on IKDC or Pedi-FABS scores. The ACL-RSI and IKDC were positively correlated (Spearman r = 0.57; P < .001), while the ACL-RSI and PROMIS-PSE were negatively correlated (Pearson r = -0.34; P < .001).

Conclusion

This study suggests that psychological profiles and subjective perceptions of knee function 6 months after ACLR may vary in patients of different ages and between the sexes. Preadolescent patients had better scores on a majority of patient-reported outcomes compared with adolescent and adult patients.

The effects of different rehabilitation training modalities on isokinetic muscle function and male athletes' psychological status after anterior cruciate ligament reconstructions

BACKGROUND

Previously, researchers reported performance enhancements following long-term plyometric training in athletes with anterior cruciate ligament reconstruction (LCA). However, the effects of combined eccentric and plyometric training on measures of isokinetic strength and psychological statues in male athletes have not been examined yet. Knowledge on the effects of combined eccentric and plyometric training help to better plan and program rehabilitations sessions and thus return-to-sports.

OBJECTIVE

This study sought to compare the effects of three different rehabilitation training programs, eccentric training (ECC), plyometric training (PLYO), or combined eccentric and plyometric training (COMB), on psychological measures (kinesiophobia [TSK-CF], functional knee assessment, knee injury and osteoarthritis outcome score [KOOS], international knee documentation committee 2000 questionnaire [IKDC], and knee flexor and extensor isokinetic muscle performance (peak torque [PT], total work, ratio [R-HQ], and ratio of total work [R-TW]) at different angular velocities post ACL surgery in male elite athletes.

METHODS

Forty elite male athletes from different sports (e.g., athletics, team sports) with ACL reconstruction participated in this study. The study started after a 14-weeks post-surgery rehabilitation program, which was identical for all subjects. After this initial rehabilitation period, athletes were randomly assigned to three experimental groups, ECC (n = 10), PLYO (n = 10), and COMB (n = 10), and a control group (CON: n = 10). Testing was conducted pre- and post-the 6-weeks intervention period and included the TSK-CF, KOOS, and IKDC. Peak torque of the knee extensors/flexors was tested at 90, 180, 240 °/s, after the 6-weeks training program only.

RESULTS

Participants' adherence rate was 100% across all groups and none reported any training or test-related injury. No significant between-group baseline differences (pre-6-weeks intervention) were observed for any of the reported psychological and muscle strength parameters. Significant group-by-time interactions were found for TSK-CF (p = 0.001, d = 2.85), KOOS (p = 0.001, d = 1.31), and IKDC (p = 0.001, d = 1.07). The post-hoc analyses indicated that COMB showed larger pre-post improvements for all psychological variables (p < 0.001, d = 2.95 to 13.15), compared with PLYO, ECC, and CON. Contrast analyses demonstrated that COMB yielded significantly greater improvements compared with CON, PLYO, ECC for all isokinetic parameters at all three angular velocities (all p < 0.001, d = 0.99 to 4.61).

CONCLUSION

The results showed that COMB induced greater gains for measures of psychological status and isokinetic muscle strength compared with single-mode PLYO and ECC in elite male athletes during a post-surgery ACL rehabilitation period. Accordingly, it is recommended to implement COMB as an effective rehabilitation means to improve knee function in male elite athletes.

TRIAL REGISTRATION

This study does not report results related to health care interventions using human participants and therefore it was not prospectively registered.

Multicentre evaluation of anxiety and mood among collegiate student athletes with concussion

Objectives

Mental health problems are a premorbid and postinjury concern among college student athletes. Clinical phenotypes of anxiety and mood disruption are prevalent following mild traumatic brain injury, including concussion, a common sports injury. This work examined whether concussed student athletes with a history of mental health problems and higher symptoms of anxiety and mood disruption at baseline were more likely to have higher postinjury reports of mood and anxiety as well as prolonged resolution of postconcussive symptoms to near-baseline measures.

Methods

This was a retrospective cohort study of a multi-institutional database of standardised baseline and postinjury assessments among college student athletes. Anxiety/mood evaluation data among varsity college athletes from four institutions over 1 year were measured and compared at baseline and postconcussion recovery using descriptive statistics and multilevel/mixed-effects analysis.

Results

Data from 2248 student athletes were analysed, with 40.6% reporting at least one symptom of anxiety and/or mood disruption at baseline. Of the 150 distinct concussions, 94.7% reported symptoms of anxiety/mood disruption during recovery (recovery time=0-96 days). Higher anxiety/mood scores at baseline were significantly associated with higher scores following concussion (p<0.001). Recovery trajectories of anxiety/mood scores showed different patterns by sex and prolonged recovery.

Conclusion

Symptoms of anxiety and mood disruption are common at baseline among college student athletes. These students are at higher risk for symptomatology following injury, representing a screening cohort that may benefit from early counselling. Almost all student athletes will experience symptoms of anxiety and/or mood disruption following concussion.

Pain and Psychological Readiness to Return to Sport in Elite Volleyball Players: A Cross-Sectional Study

Pain is modulated by multiple factors. A relevant psychological process peculiar to athletes and which could be associated with pain is Psychological Readiness to Return to Sport (PRRS). The analysis of this association in competition context is particularly important.

OBJECTIVE

To determine the correlation between the PRRS and pain intensity in elite volleyball players during their participation in a continental sporting event.

METHODS

A cross-sectional study was conducted. Data from 107 male volleyball players (23.50 ± 4.08 years of age) participating in the South American Volleyball Championship were used. The athletes answered a self-report questionnaire on the day the championship began regarding their history of injuries in the previous six months. The athletes who declared injuries were asked about the current pain intensity using the Pain Numeric Rating Scale (NRS) and Psychological Readiness to Return to Sport using the Injury-Psychological Readiness to Return to Sport scale (I-PRRS).

RESULTS

43.93% (n = 47) of the athletes (23.70 ± 3.54 years) reported an injury in the six months prior to the championship. They presented a median on the NRS of three (interquartile range (IQR), 2-5), and 54 (IQR, 46-58) on the I-PRRS. The Spearman's Rho correlation test showed an inversely and moderate correlation (r_s = -0.36; p = 0.011; CI: -0.64--0.08) between pain intensity and PRRS.

CONCLUSIONS

In male elite volleyball players who participate in a Continental Championship in South America, higher levels of PRRS was correlated to lower pain intensity.

Anterior Cruciate Ligament-Return to Sport After Injury Scale: Reliability and Validity of the Persian Version

BACKGROUND

The Anterior Cruciate Ligament-Return to Sport after Injury scale (ACL-RSI) is used to measure athletes' psychological readiness in terms of their emotions, confidence in performance, and risk appraisal with respect to return to sport after ACL reconstruction.

OBJECTIVE

To translate and cross-culturally adapt the ACL-RSI to the Persian version and evaluate the reliability and validity of this scale in patients with ACL reconstruction.

STUDY DESIGN

Clinical measurement study (psychometric analysis).

METHODS

To assess test-retest reliability, 100 participants were asked to complete the Persian version of the ACL-RSI 2 times with a 7- to 10-day interval. In the first assessment, the patients also filled the Injury-Psychological Readiness to Return to Sport Questionnaire, Tampa Scale of Kinesiophobia, International Knee Documentation Committee Subjective Knee Form, and Knee Injury and Osteoarthritis Outcome Score. Internal consistency (Cronbach alpha, α), test-retest reliability (intraclass correlation coefficients), measurement error (standard error of measurement and minimum detectable change), and construct validity (Pearson r) were determined.

RESULTS

Our results showed good internal consistency (Cronbach alpha = .94) and excellent test-retest reliability (intraclass correlation coefficients = .90 (.85-.93)]. Standard error of measurement and minimum detectable change were 4.64 and 12.85, respectively. No significant bias was observed between test and retest. In addition, based on the results of correlation analysis, all hypotheses of this study were confirmed. The Persian version of the ACL-RSI had a strong correlation with Injury-Psychological Readiness to Return to Sport (I-PPR) (P < .001, r = .76) and Tampa scale of Kinesiophobia (TKS) (P < .001, r = -.68). Furthermore, a moderate correlation was observed between the Persian version of the ACL-RSI and the International Knee Documentation Committee Subjective Knee Form (P < .001, r = .44) and between this version of the ACL-RSI and the subscales of Knee Injury and Osteoarthritis Outcome Score (P < .001, r = .30-.55).

CONCLUSION

Given its acceptable reliability and validity, the Persian version of the ACL-RSI seems to be a suitable tool for evaluating psychological readiness to return to sport after ACL reconstruction.

Current study on the influence of psychological factors on returning to sports after ACLR

It is considered that psychological factors are important in determining exercise regression outcomes of patients with anterior cruciate ligament reconstruction (ACLR). This review summarizes the definition and research progress of current undefined psychological factors related to returning to sports (RTS) after ACLR, as well as the application of corresponding measuring scales, and common psychological interventions in the field. The aim is to understand and clarify the impact of psychological factors in the ACL injury and rehabilitation, and to provide a theoretical basis for the application of psychological evaluation and intervention in the later stage. It is believed that there are still many prospects for the research in this field.

Psychological readiness to return to sports practice and risk of recurrence: Case studies

Returning to sport after the sports injury is a difficult decision because it's multicausal and the fact that a rash decision can result in numerous negative consequences. Given the importance of psychological variables for the correct rehabilitation of the injured athlete and his or her optimal return to sports practice, there seems to be little information on this subject. In this sense, the objective is to determine the relationship between the subjective psychological disposition of the athlete in the process of Return to Play (RTP) with the type of mood profile and his mental health. This is based on the fact that each athlete evaluates his or her recovery differently and has different levels of anxiety, depression, and stress. For this purpose, four athletes participated in the study. Two males and two females from the sports of indoor soccer and soccer, who had just returned to sports after a moderate or severe injury. The average age was 24.25 years. Various measurements were taken after practices and after matches, to assess mood, psychological readiness, anxiety, stress, and depression. The results confirm Morgan's iceberg profile and the influence that subjective psychological perceptions and assessed emotional states have on athletes' incorporation into their sports practice with a guarantee of success.

Understanding Youth Sport Coaches' Perceptions of Evidence-Based Injury-Prevention Training Programs: A Systematic Literature Review

OBJECTIVE

To systematically review and summarize the knowledge, attitudes, beliefs, and contextual perceptions of youth sport coaches toward injury-prevention training programs by using the Theoretical Domains Framework to guide the organization of results.

DATA SOURCES

Systematic searches of PubMed and Google Scholar were undertaken in November 2021.

STUDY SELECTION

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol was followed. Results were limited to full-text articles that were published in peer-reviewed journals and printed in English. Additional studies were added after a citation search of included studies. Studies were eligible for inclusion if researchers evaluated youth sport coaches' knowledge, beliefs, contextual perceptions, or all 3 of anterior cruciate ligament injury-prevention training programs.

DATA EXTRACTION

Data charting was performed by 1 author and confirmed by a separate author.

DATA SYNTHESIS

Of the 1194 articles identified, 19 were included in the final sample. Among articles in which researchers assessed knowledge (n = 19), coaches' awareness of the existence and components of injury-prevention training programs was inconsistent. Among articles in which researchers assessed beliefs (n = 19), many coaches had positive attitudes toward injury-prevention training programs, but few believed youth athletes are at a high risk of injury. Among articles in which researchers assessed contextual perceptions (n = 13), many coaches did not feel they had access to information about injury-prevention training programs and cited a lack of time, space, support, and other resources as barriers to implementation.

CONCLUSIONS

Our findings support the need for programs, protocols, and policies to enhance knowledge of and support for youth sport coaches who wish to implement injury-prevention training programs. A gap exists in the research about addressing the needs of youth sport coaches in the United States high school sports setting. The use of multilevel implementation science frameworks (such as the Theoretical Domains Framework) will be beneficial for identifying constructs that affect implementation and developing train-the-trainer programming to meet the needs of individual youth sport coaches.

Rehabilitation After Anterior Cruciate Ligament Injury: Review of Current Literature and Recommendations

PURPOSE OF REVIEW

Anterior cruciate ligament reconstruction (ACLR) is a common surgical procedure with an estimated 120,000 cases performed in the USA each year. Physical therapy plays a critical role in the successful recovery of both surgically and non-surgically managed patients. Interestingly, ACL rehabilitation protocols vary greatly with little consensus among practitioners. Nonetheless, there has been agreement over the last decade to shift from conservative, standardized length protocols to more accelerated, individualized protocols that vary in length and modalities based on patient-specific findings and preferences. This review summarizes the most recent trends, opinions, and modalities in ACL rehabilitation research, with a specific focus on novel methods to treat the specific psychosocial needs of ACL deficient patients.

RECENT FINDINGS

We found that new protocols emphasize early weight bearing, open kinetic chain (OKC) exercises, and other alternative modalities such as neuromuscular electrical stimulation and blood flow restriction. We also found a recent trend toward the use of clinical milestones to determine when a patient is ready for the next phase of a "step-up" rehabilitation program. One particularly nascent topic of research is the inclusion of methods to treat the psychosocial impacts of ACL injury, recovery, and the anxiety around return to sport. Rehabilitation strategy has become increasingly patient-dependent, and the new modalities being utilized are accelerating patient recovery. Return to sport is a particularly important factor for many ACLR patients, and recovery has an important psychological component that has only recently been addressed in the literature, with positive preliminary findings.

Injury-related psychological distress and the association with perceived running ability in injured runners

OBJECTIVE

Examine injury-related psychological distress and association with perceived running ability in injured runners.

DESIGN

Prospective longitudinal study.

PARTICIPANTS

Forty-three patients with a running-related injury.

MAIN OUTCOME MEASURES

Data collection at initial physical therapy visit and 12-16 weeks later included Optimal Screening for Prediction of Referral and Outcome - Yellow Flag (OSPRO-YF) and Athlete Fear Avoidance Questionnaire (AFAQ) for injury-related psychological distress, and University of Wisconsin Running and Recovery Index (UWRI) for perceived running ability. OSPRO-YF composite score, total yellow flags, and yellow flags in each domain (negative mood, fear-avoidance, positive affect/coping) were calculated.

RESULTS

UWRI score and OSPRO-YF composite score and yellow flags significantly improved over time, while AFAQ score and yellow flags in OSPRO-YF negative mood domain did not. AFAQ scores were significantly correlated with UWRI score at baseline, follow-up and change over time, while OSPRO-YF composite score and yellow flags were not. Baseline OSPRO-YF composite score and AFAQ score were not correlated with follow-up UWRI score.

CONCLUSIONS

Injury-related psychological distress is elevated when injured runners start rehabilitation, and generally improves; however, negative mood and athletic fear-avoidance may persist. Higher athletic fear-avoidance is associated with lower perceived running ability at the same time point or interval.

A systematic video analysis of 21 anterior cruciate ligament injuries in elite netball players during games

This systematic video analysis of 21 anterior cruciate ligament (ACL) injuries sustained by elite-level netball players during televised games, describes the situation, movement pattern and player behaviour, providing insight regarding the injury mechanism. Seventeen of the ACL injuries occurred from jump-landing actions and only two from cutting manoeuvres. A common scenario was identified for 11 players. In this scenario, players were decelerating rapidly after jumping to receive a high pass, utilising a double-footed landing with a wide base of support (WBOS). Deceleration appeared to be applied predominantly via the injured leg with the knee extended and foot planted. Often the players appeared unbalanced on landing leaning too far back. ACL injury risk was possibly exacerbated by the players head turning away from the injured side. A further compressive knee moment may have been placed on the lateral aspect of the knee by bringing the ball from a high position to a low position at the estimated time of injury. Players may benefit from landing technique training programmes that encourage shoulder-width foot landings, with ≥30° knee flexion, a small amount of plantar-flexion and good balance. Incorporating challenges to players balance and ability to cope with perturbations may also be beneficial. Training programmes should include instruction on securing the ball in a stable above pelvis-level position after receiving a pass and bringing their whole body around during landing into the direction of their next pass, rather than simply turning their head to look.

Fear of Movement and Reinjury in Sports Medicine: Relevance for Rehabilitation and Return to Sport

Athletes are defined by their ability to move and are often accustomed to pain as it relates to their sports and exercise regime. The forced movement restriction and pain associated with an acute or overuse injury has a profound effect not only on their physical abilities but also on their psychological well-being and social context. With the goal of returning to sport, the rehabilitation focus historically has been on recovery of physical attributes, but more recent research is addressing the psychological factors. This Perspective proposes that-according to the current evidence in sports medicine-the fear that affects choice of treatment, rehabilitation, and return to sports is intertwined with physical capacity and recovery of function. Past injury is also 1 of the main risk factors for a sports injury; therefore, fear of reinjury is not irrational. For an athlete, the fear related to a sports injury encompasses the fear of reinjury along with fear of not being able to return to the sport at their highest performance level-and the fear of having lifelong debilitating pain and symptoms. This Perspective reviews the evidence for the influence of fear of movement and reinjury on choice of treatment, rehabilitation, and return to sport and provides suggestions on how to address this fear during the continuum of treatment and return to sports.

Self-Reported Symptoms of Depression and Anxiety After ACL Injury: A Systematic Review

Background:

Depression and anxiety symptoms can occur in patients following an anterior cruciate ligament (ACL) injury, and the presence of these symptoms has been associated with poorer self-reported knee function in this type of injury.

Purpose:

To investigate the prevalence and severity of self-reported symptoms of depression and anxiety following an ACL injury.

Study Design

Systematic review; Level of evidence, 4.

Methods:

PubMed, Cochrane Library, Embase, PsycINFO, AMED, and PEDro databases were searched using a combination of keywords relating to ACL, depression, anxiety, and their synonyms. Inclusion criteria were clinical studies written in English that reported on patients with an injured and/or reconstructed ACL and assessed symptoms of depression and/or anxiety. Data extraction was performed independently by 2 authors. Data synthesis was performed using an emergent synthesis approach. The quality of the included studies was assessed using the methodological index for non-randomized studies or the Mixed-Methods Appraisal Tool. Certainty of evidence was determined using the Grading of Recommendations Assessment, Development and Evaluation.

Results:

After abstract screening, 37 studies were assessed in full text, of which 16 were included. The studies comprised 682 patients (417 male [61%]). The depression symptoms appeared to be more severe in elite athletes compared with recreational athletes. Symptoms decreased over time from moment of ACL reconstruction to up to 2 years postoperatively. The prevalence of self-reported symptoms of anxiety after an ACL injury was reported in 1 study (2%). There were no differences in anxiety symptoms between professional and amateur athletes or between adolescents and adults. The overall quality of the studies was low or very low.

Conclusion:

Patients who sustain an ACL injury can suffer from symptoms of depression, especially during the first 6 weeks after ACL reconstruction. Depressive symptoms are more common among professional versus nonprofessional athletes. Levels of anxiety symptoms were not above the cutoffs for a diagnosis of anxiety after an ACL injury.

Arabic Version of the Short Anterior Cruciate Ligament-Return to Sport After Injury Scale: Translation, Cross-cultural Adaptation, and Validation

Background:

The short version of the Anterior Cruciate Ligament–Return to Sport After Injury (ACL-RSI) scale is a self-reported questionnaire developed to assess the psychological readiness of patients to return to sports after ACL reconstruction (ACLR).

Purpose:

To translate, cross-culturally adapt, and validate the short version of the ACL-RSI scale into the Arabic language (ACL-RSI-Ar).

Study Design:

Cohort study (diagnosis); Level of evidence, 2.

Methods:

The original short version of the ACL-RSI scale was forward and backward translated, cross-culturally adapted, and validated following international standardized guidelines. Sixty patients who participated in sports activities and underwent ACLR completed the ACL-RSI-Ar, the International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form, and Knee injury and Osteoarthritis Outcome Score (KOOS) scales. To assess test-retest reliability, 34 participants completed the ACL-RSI-Ar scale twice. Statistical tests were conducted to test the internal consistency, reliability, and construct and discriminant validity of the ACL-RSI-Ar scale.

Results:

The ACL-RSI-Ar showed adequate internal consistency (Cronbach alpha = 0.734) and excellent test-retest reliability (intraclass correlation coefficient, 0.871). The ACL-RSI-Ar was strongly correlated with the IKDC (Spearman ρ = 0.515, P < .001) and weakly to strongly correlated with all KOOS subscales (Spearman ρ = 0.247-0.590, P < .05). Patients who returned to sports had significantly higher scores on the ACL-RSI-Ar scale when compared with those who did not return to sports (P = .001).

Conclusion:

The short ACL-RSI-Ar scale, as translated, was internally consistent, reliable, and valid for evaluating psychological readiness to return to sports after ACLR in Arabic-speaking patients.

Psychosocial factors 3-months after anterior cruciate ligament reconstruction predict 6-month subjective and objective knee outcomes

The objective of the study was to determine if psychological readiness for sport and knee self-efficacy assessed early (3 months) after anterior cruciate ligament reconstruction (ACLR) are predictive of self-reported functional outcomes, quadriceps strength, and knee mechanics while running at the time of return to sport training (6 months). Thirty athletes with unilateral ACLR completed the ACL Return to Sport after Injury (ACL-RSI) and Knee Self-Efficacy Scale (K-SES) 3 months after ACLR and completed self-reported functional outcomes, isometric quadriceps strength testing, and three-dimensional running gait analysis 6 months after ACLR. The 3-month ACL-RSI significantly correlated with the 6-month International Knee Documentation Committee (IKDC; r = 0.565, p = 0.001), Knee Injury and Osteoarthritis Outcome Score (KOOS) sport/recreational activities (KOOS_Sport ; r = 0.548, p = 0.002) and quality of life (KOOS_QoL ; r = 0.431, p = 0.017), and quadriceps strength (r = 0.528, p = 0.003). The 3-month K-SES significantly correlated with the 6-month IKDC (r = 0.528, p = 0.003), KOOS_Sport (r = 0.430, p = 0.018), KOOS_QoL (r = 0.411, p = 0.024), quadriceps strength (r = 0.465, p = 0.010), and knee flexion excursion (r = 0.472, p = 0.008). With multivariate modeling, both the ACL-RSI and K-SES were predictive of the IKDC (R²  = 0.411; p = 0.001). Only the ACL-RSI was predictive of the KOOS_Sport (R²  = 0.300; p = 0.002), KOOS_QoL (R²  = 0.186; p = 0.017), and quadriceps strength (R²  = 0.279; p = 0.003), whereas only the K-SES was predictive of knee flexion excursion (R²  = 0.173; p = 0.022). Athletes with greater psychological readiness for sport and knee self-efficacy at 3 months demonstrated higher scores on self-reported functional outcomes, greater quadriceps strength, and greater knee flexion excursion at 6 months after ACLR. This study indicates that psychosocial measures may be important to include into early post-surgical evaluations to help guide and facilitate interventions to restore subjective and objective knee function.

Effect of personality traits on rehabilitation effect after anterior cruciate ligament reconstruction: An observational study

BACKGROUND

Anterior cruciate ligament (ACL) reconstruction requires an extended period of postoperative rehabilitation. Psychological factors can affect recovery after surgery. Study of psychological factors is still limited to self-motivation, fear and pain. Study of personality traits associated with early rehabilitation outcome after ACL reconstruction is scarce.

OBJECTIVE

We aimed to explore the effect of personality traits on early rehabilitation after ACL reconstruction and provide a reference for clinicians in designing a personalized rehabilitation plan.

METHODS

This prospective analysis investigated 155 patients at 3 and 6 months after ACL reconstruction. Follow-up involved administration of a general data questionnaire, the Chinese Big Five Personality Inventory Brief Version, the Tegner activity score, the International Knee Documentation Committee Subjective Knee Score, the Knee injury and Osteoarthritis Outcome Score, the Lysholm Score and a balance test.

RESULTS

Among the 155 patients included (124 males), Neuroticism was negatively correlated with subjective knee scores at 3 and 6 months after surgery (p<0.001). The odds of a poor balance test result was increased for each 1-point increase in Neuroticism score (odds ratio [OR] 1.74, 95% confidence interval [CI] 1.28-2.36, p<0.001). We found a positive correlation between Conscientiousness score and subjective knee scores at 3 and 6 months after surgery (p<0.001). For every 1-point increase in Conscientiousness score, the odds of a poor balance test result were decreased (OR 0.29, 95% CI 0.16-0.54, p<0.001). Agreeableness and Openness to experience scores were positively correlated with subjective knee scores at 3 and 6 months after surgery (p<0.001). We found no correlation between Extraversion and subjective knee scores at 3 and 6 months after surgery (p>0.05) but a positive correlation with the Tegner activity score at 3 and 6 months after surgery (p<0.05).

CONCLUSION

We found a significant correlation between the Big Five personality dimensions and the early rehabilitation effect after ACL reconstruction, which can provide a reference for clinicians in designing a personalized rehabilitation plan.

Game Utilization and Performance Following RTP From ACL Reconstruction Does not Influence a Subsequent Second ACL Injury in National Football League Players

Purpose

The purpose of this study is to evaluate differences in game utilization or performance following primary anterior cruciate ligament (ACL) reconstruction between National Football League (NFL) players with and without a second ACL injury.

Methods

NFL players who underwent ACL reconstruction between 2013 and 2017 were identified. Players were classified as having one injury (“tear”) or having later sustained a subsequent second (reinjury or contralateral) ACL injury (“retear”). Players were excluded if they tore their ACL prior to the NFL, did not return to play (RTP), did not play the season before injury, or had concomitant injuries. Demographic characteristics, game utilization statistics, and season approximate value (SAV) performance metrics were recorded. Statistical analysis compared data after RTP from primary ACL reconstruction (seasons +1, +2, and +3) relative to the season before injury (season −1) between cohorts using mean differences and relative percentages.

Results

Analysis included a total of 45 players, 32 in the “tear” group and 13 in the “retear” group. Demographics, level of play, and time to RTP after primary ACL reconstruction did not differ between the groups (P > .05). Tear and retear groups demonstrated similar utilization and performance metrics the season prior to injury (−1) and the 3 seasons following RTP (season of injury is “0”). Both groups had a similar decrease (relative percentage) in games played and started, snap counts, and SAV during the 3 seasons following RTP compared to baseline (P > .05). The draft pick position was correlated with the relative percentage of games started the first season after RTP (r = .6, P = .02).

Conclusions

Game utilization and performance metrics following ACL reconstruction were not associated with a subsequent second ACL injury. Players with a higher draft pick position were more likely to return to the starting lineup following primary ACL reconstruction. Ultimately, player game utilization and performance following primary ACL reconstruction is not predictive of a subsequent second ACL injury.

Level of Evidence

Level III, retrospective case-control study

Psychological Factors Change During the Rehabilitation of an Achilles Tendon Rupture: A Multicenter Prospective Cohort Study

OBJECTIVE

The authors sought to gain insight into the changes in psychological factors during rehabilitation after Achilles tendon rupture (ATR) and to explore the association between psychological factors during rehabilitation and functional outcome 12 months after ATR.

METHODS

Fifty patients clinically diagnosed with ATR were invited to visit the hospital 3, 6, and 12 months after injury for data collection. They completed questionnaires assessing psychological factors: psychological readiness to return to sport (Injury Psychological Readiness to Return to Sport Questionnaire); kinesiophobia (Tampa Scale for Kinesiophobia); expectations, motivation, and outcome measures related to symptoms and physical activity (Achilles Tendon Total Rupture Score); and sports participation and performance (Oslo Sports Trauma Research Centre Overuse Injury Questionnaire). To determine whether psychological factors changed over time, generalized estimating equation analyses were performed. Multivariate regression analyses were used to study the association between psychological factors at 3, 6, and 12 months and outcome measures at 12 months after ATR.

RESULTS

Psychological readiness to return to sport improved, and kinesiophobia decreased significantly during rehabilitation. Psychological readiness at 6 and 12 months showed significant associations with sports participation and performance. Kinesiophobia at 6 months was significantly associated with symptoms and physical activity. Motivation remained high during rehabilitation and was highly associated with symptoms and physical activity, sports participation, and performance.

CONCLUSION

Psychological factors change during rehabilitation after ATR. Patients with lower motivation levels during rehabilitation, low psychological readiness to return to sports, and/or high levels of kinesiophobia at 6 months after ATR need to be identified.

IMPACT

According to these results, psychological factors can affect the rehabilitation of patients with ATR. Physical therapists can play an important role in recognizing patients with low motivation levels and low psychological readiness for return to sport and patients with high levels of kinesiophobia at 6 months post-ATR. Physical therapist interventions to enhance motivation and psychological readiness to return to sport and to reduce kinesiophobia need to be developed and studied in the post-ATR population.

LAY SUMMARY

With Achilles tendon rupture, level of motivation, psychological readiness for return to sport, and fear of movement can affect rehabilitation outcome. A physical therapist can help recognize these factors.

Implementing ACL Injury Prevention in Daily Sports Practice-It's Not Just the Program: Let's Build Together, Involve the Context, and Improve the Content

Although the benefits of current anterior cruciate ligament (ACL) injury prevention programmes have been demonstrated in efficacy studies, they, unfortunately, have had limited public health impact to date. For example, the incidence of ACL injuries continues to rise in adolescent athletes. Raising awareness and educating coaches and athletes is not enough to facilitate the widespread, sustained use of these programmes in the real-world setting. Considering the profound burden of ACL injuries, it is necessary to continue to improve the current ACL injury prevention programmes through co-creation. First, the uptake of the programmes should be optimized by a better appreciation and understanding of the individual, socio-cultural and environmental context (i.e., community). Second, the content of the programmes should be optimized to better reflect the demands of the sport by creating more ownership and increasing motivation (incorporating challenging, sport-specific and fun elements) with the end-users. In addition, implicit motor learning, random practice and differential learning are concepts that should be integrated when practising to obtain the most optimal results when learning or finetuning skills.

Sleep and psychological factors are associated with meeting discharge criteria to return to sport following ACL reconstruction in athletes

This study aimed to determine if sleep quality and psychological factors were associated with time to meet the discharge criteria to return to sport (RTS) following anterior cruciate ligament reconstruction (ACL-R) among athletes. A cohort-study design included 89 athletes following ACL-R. Each participant completed a battery of questionnaires at 6 different time points: within 3 days of injury occurrence and at post-surgery (1.5 m, 3 m, 4.5 m, 6 m and when discharge criteria were met). Assessment included sleep quality and quantity, symptoms of depression, anxiety, stress, psychological readiness to RTS and fear of re-injury. The primary outcome was the time needed to meet all discharge criteria to RTS. Sleep parameters and psychological factors were not associated with time to meet the discharge criteria to RTS. However, athletes that had lower scores of anxiety (OR 1.2 (95% CI 1.0, 1.3) and insomnia (OR 1.2 (95% CI 1.0, 1.3) at baseline were more likely to meet the RTS discharge criteria. Athletes with better sleep quality at 3m, 4.5m and 6m were more likely to meet the RTS discharge criteria OR 1.3 (95% CI 1.1, 1.7), 2.0 (95% CI 1.1-3.4) and 1.4 (95% CI 1.0, 1.9) respectively. Sleep quality and psychological factors were not associated with time to meet the discharge criteria to RTS but impacted whether athletes adhered and completed their rehabilitation program or not. Monitoring sleep quality and psychological factors of athletes before and following ACL-R surgery is important to identify athletes who could have difficulties in adhering to and completing their rehabilitation program to RTS.

Evaluation of the Responsiveness of the Anterior Cruciate Ligament Return to Sport After Injury (ACL-RSI) Scale

Background

The Anterior Cruciate Ligament Return to Sport After Injury (ACL-RSI) scale is a reliable and valid tool for evaluation of psychological readiness to return to sport after ACL injury, but its responsiveness to change has not been extensively evaluated.

Purpose

To determine the responsiveness of the ACL-RSI scale.

Study Design

Cohort study (diagnosis); Level of evidence, 2.

Methods

The ACL-RSI scale and the knee confidence question from the Knee injury and Osteoarthritis Outcome Score-Quality of Life subscale was completed at 6 and 12 months after ACL reconstruction surgery. Responsiveness was assessed using distribution and anchor-based methods for the full- and short-form versions of the scale and subgroup analyzed for sex. From distribution statistics, the standardized response mean (SRM) and the smallest detectable change (SDC) were calculated. Using the anchor-based method, the minimally important change (MIC) that was associated with an improvement in knee confidence was determined using receiver operating characteristic analysis.

Results

A total of 441 patients (257 men, 184 women; mean age of 25 years) were included in this study. An SRM of 0.7 was found for both versions, indicating a moderate level of responsiveness. The MIC was 13.4 points for the full-form version and 15.1 points for the short-form version. These values were larger than SDC values at the group level but not at the individual patient level. Responsiveness was similar between male and female patients.

Conclusion

The ACL-RSI scale had sufficient responsiveness to investigate the efficacy of an intervention at a group level, but it may be more limited at an individual patient level.

Mental Health in Patients Undergoing Orthopaedic Surgery: Diagnosis, Management, and Outcomes

»

Mental health and psychosocial factors play a critical role in clinical outcomes in orthopaedic surgery.

»

The biopsychosocial model of disease defines health as a product of physiology, psychology, and social factors and, traditionally, has not been as emphasized in the care of musculoskeletal disease.

»

Improvement in postoperative outcomes and patient satisfaction is incumbent upon the screening, recognition, assessment, and possible referral of patients with high-risk psychosocial factors both before and after the surgical procedure.

An Interactive Cognitive-Behavioural Multimedia Program Favourably Affects Pain and Kinesiophobia During Rehabilitation After Anterior Cruciate Ligament Surgery: An Effectiveness Trial

Psychological interventions have been found effective in helping athletes cope with the challenges associated with knee surgery. In this investigation, an interactive cognitive-behavioural multimedia program was evaluated as a means of delivering psychological interventions to individuals experiencing anterior cruciate ligament (ACL) surgery in a field trial with 69 ACL surgery patients (30 women and 39 men; 24 competitive athletes, 41 recreational athletes, and 4 nonathletes; M _age = 35.01, SD = 11.98 years). Results indicated that compared to participants who received standard care, participants who received the multimedia program reported greater preoperative confidence in ability to cope, lower postoperative pain and kinesiophobia, and greater use and perceived utility of patient education materials. The findings suggest that the multimedia program has promise as an economical and effective means of educating and delivering psychological interventions to people experiencing ACL surgery and rehabilitation.

Psychosocial barriers and facilitators for a successful return to work following injury within firefighters

Objective

The aim was to explore firefighter’s experiences during their recovery from injury. Focused specifically on exploring perceived psychosocial barriers and facilitators firefighters faced during recovery and return to work.

Methods

Semi-structured interviews were used to provide an in-depth understanding of the firefighter’s experiences. The semi-structured interviews were informed by a topic guide. The topic guide focused on five main themes, (1) overall experience of returning to operational duties following an injury, (2) perceived barriers experienced during their return to work, (3) perceived facilitators experienced during their return to work, (4) confidence in participating in physical activity following injury and (5) where they felt areas of improvement could be made with the return to work process. Thematic analysis of the data collected was undertaken using The Framework Method.

Results

Two main themes were sought after transcription: barriers and facilitators. From these, nine subthemes were identified (1) communication, (2) confidence in physical activity participation, (3) modified duties, (4) physiotherapy, (5) return to operational duties, (6) support, (7) inconsistency, (8) use of station gyms, (9) detachment from the watch.

Conclusions

Consideration should be made for the consistency of procedures followed during an individual’s return to work following an injury. Further research is needed to understand if the themes identified in this study are the same for other fire services. Further research is also needed to understand how the findings may be best implemented within the fire service.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00420-021-01712-z.

Patient expectations and perceived social support related to return to sport after anterior cruciate ligament reconstruction in adolescent athletes

OBJECTIVE

Examine the relationship between pre-operative competitive status and return to sport expectations post-operatively among adolescents undergoing ACL reconstruction. Assess the association between perceived levels of social support and doubts in returning to sport after ACL reconstruction.

DESIGN

Cross-sectional.

SETTING

Outpatient sports medicine clinic at a single institution.

PARTICIPANTS

12-18 years old with an ACL tear who were planning to undergo ACL reconstruction.

MAIN OUTCOME MEASURES

Psychovitality questionnaire responses and Multidimensional Scale of Perceived Social Support (MSPSS) questionnaire scores.

RESULTS

86% of participants expected to return to sports in six months or less after surgery; there was no significant difference in expected time to return to sport between competitive vs. recreational athletes. Competitive athletes were less likely to be content returning to a lower activity level after surgery compared to recreational athletes. There were no significant differences in MSPSS scores between those who did and did not report doubts in their ability to return to their previous sports.

CONCLUSION

Most of our adolescent athlete population expected to return to sport after ACL reconstruction within six months of surgery. Those with and without doubts in their ability to return to sports did not significantly differ in levels of perceived social support.

Physical Performance Improves With Time and a Functional Knee Brace in Athletes After ACL Reconstruction

Background:

Athletes who return to sport (RTS) after anterior cruciate ligament reconstruction (ACLR) often have reduced physical performance and a high reinjury rate. Additionally, it is currently unclear how physical performance measures can change during the RTS transition and with the use of a functional knee brace.

Purpose/Hypothesis:

The purpose of this study was to examine the effects of time since surgery (at RTS and 3 months after RTS) and of wearing a brace on physical performance in patients who have undergone ACLR. We hypothesized that physical performance measures would improve with time and would not be affected by brace condition.

Study Design:

Controlled laboratory study.

Methods:

A total of 28 patients who underwent ACLR (9 males, 19 females) completed physical performance testing both after being released for RTS and 3 months later. Physical performance tests included the modified agility t test (MAT) and vertical jump height, which were completed with and without a knee brace. A repeated-measures analysis of variance determined the effect of time and bracing on performance measures.

Results:

The impact of the knee brace was different at the 2 time points for the MAT side shuffle (P = .047). Wearing a functional knee brace did not affect any other physical performance measure. MAT times improved for total time (P < .001) and backpedal (P < .001), and vertical jump height increased (P = .002) in the 3 months after RTS.

Conclusion:

The present study showed that physical performance measures of agility and vertical jump height improved in the first 3 months after RTS. This study also showed that wearing a knee brace did not hinder physical performance.

Clinical Relevance:

Wearing a functional knee brace does not affect physical performance, and therefore a brace could be worn during the RTS transition without concern. Additionally, physical performance measures may still improve 3 months past traditional RTS, therefore justifying delayed RTS.

Differences in Postinjury Psychological Symptoms Between Collegiate Athletes With Concussions and Orthopedic Injuries

OBJECTIVE

To describe the differences in postinjury psychological symptoms among Division I collegiate student athletes who sustained concussions versus orthopedic injures and to examine the effects of injury type on postinjury psychological symptoms during the course of recovery.

DESIGN

A prospective cohort study with repeated measures.

SETTING

Two Big 10 Conference universities.

PARTICIPANTS

Student athletes who were at least 18 years old and participated in one of 9 National Collegiate Athletic Association (NCAA) Division I-sponsored sports during the 2007 to 2011 seasons.

MAIN OUTCOME MEASURES

Baseline depressive symptoms and anxiety were measured at enrollment. On identification of an eligible injury, follow-up surveys were conducted among injured athletes at multiple intervals until the injured athlete returned to play. Depressive symptoms, anxiety, fear of return-to-play, and fear of reinjury were measured at the postinjury follow-ups.

RESULTS

The concussion group had significantly lower scores of fear of return-to-play (B = -0.94, P = 0.0278) and fear of reinjury (B = -1.11, P = 0.0152) compared with the orthopedic injury group. The concussion group scored higher on depressive symptoms than the orthopedic injury group at 1 month after injury (P = 0.0264), although both groups scored similarly at baseline (P = 0.9729) and at 1 week after injury (P = 0.1475).

CONCLUSIONS

Patterns of psychological disturbance differ after concussions and orthopedic injures. Further research is warranted to identify the factors contributing to these differences and to develop effective intervention programs to prevent these symptoms.

Modelling the effect of minor orthopaedic day surgery on patient mood at the early post-operative period: A prospective population-based cohort study

Objective

The effect of minor orthopaedic day surgery (MiODS) on patient’s mood.

Methods

A prospective population-based cohort study of 148 consecutive patients with age above 18 and less than 65, an American Society of Anaesthesiology (ASA) score of 1, and the requirement of general anaesthesia (GA) were included. The Medical Outcomes Study – Short Form 36 (SF-36), Beck Anxiety Inventory (BAI) and Beck Depression Inventory (BDI) were used pre- and post-operatively.

Results

The mean physical component score of SF-36 before surgery was 45.3 (SD = ±10.1) and 8 weeks following surgery was 44.9 (SD = ±11.04) [n= 148,p= 0.51, 95% CI = (−1.03 to 1.52)]. For the measurement of the changes in mood using BDI, BAI and SF-36, latent construct modelling was employed to increase validity. The covariance between mood pre- and post-operatively (cov = 69.44) corresponded to a correlation coefficient,r= 0.88 indicating that patients suffering a greater number of mood symptoms before surgery continue to have a greater number of symptoms following surgery. When the latent mood constructs were permitted to have different means the model fitted well withχ2(df = 1) = 0.86 for whichp= 0.77, thus the null hypothesis that MiODS has no effect on patient mood was rejected.

Conclusions

MiODS affects patient mood which deteriorates at 8 weeks post-operatively regardless of the pre-operative patient mood state. More importantly patients suffering a greater number of mood symptoms before MiODS continue to have a greater number of symptoms following surgery.

Psychometric Analysis and Effectiveness of the Psychological Readiness of Injured Athlete to Return to Sport (PRIA-RS) Questionnaire on Injured Soccer Players

The decision-making process about when an athlete may safely return to training and competition after an injury is a difficult decision. Safe return to training and competition is characterised by physical and psychological readiness to return to the sport. The objectives of this study are (1) to assess the measurement properties of the Psychological Readiness of Injured Athlete to Return to Sport questionnaire (PRIA-RS), and (2) to analyse the effectiveness which the PRIA-RS questionnaire possesses when applied during four consecutive seasons on professional soccer players. One hundred and nine male soccer players from the Albacete Soccer Club (Spain) were involved during four consecutive seasons for the current study: 2012–2013, 2013–2014, 2014–2015 and 2015–2016. Psychometric analysis (validity, reliability, internal consistency and effectiveness) and external psychometric analysis (evaluating measures of patient-reported outcomes (EMPRO)) were confirmed and supported. The main results of the study reveal that the psychometric properties of this questionnaire are optimum for their application in a professional sports context.

Psychological, social and contextual factors across recovery stages following a sport-related knee injury: a scoping review

Objective

To explore the role of psychological, social and contextual factors across the recovery stages (ie, acute, rehabilitation or return to sport (RTS)) following a traumatic time-loss sport-related knee injury.

Material and methods

This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews and Arksey and O’Malley framework. Six databases were searched using predetermined search terms. Included studies consisted of original data written in English that identified or described a psychological, social or contextual factor related to recovery after a traumatic time-loss sport-related knee injury. Two authors independently conducted title–abstract and full-text reviews. Study quality was assessed using the Mixed Methods Appraisal Tool. Thematic analysis was undertaken.

Results

Of 7289 records, 77 studies representing 5540 participants (37% women, 84% anterior cruciate ligament tears, aged 14–60 years) were included. Psychological factors were investigated across all studies, while social and contextual factors were assessed in 39% and 21% of included studies, respectively. A cross-cutting concept of individualisation was present across four psychological (barriers to progress, active coping, independence and recovery expectations), two social (social support and engagement in care) and two contextual (environmental influences and sport culture) themes. Athletes report multiple barriers to recovery and valued their autonomy, having an active role in their recovery and diverse social support.

Conclusion

Diverse psychological, social and contextual factors are present and influence all stages of recovery following a traumatic sport-related knee injury. A better understanding of these factors at the time of injury and throughout rehabilitation could assist with optimising injury management, promoting RTS, and long-term health-related quality-of-life.

Superior knee self-efficacy and quality of life throughout the first year in patients who recover symmetrical muscle function after ACL reconstruction

PURPOSE

The aim of this study was to (1) describe psychological outcomes during the first year after an anterior cruciate ligament (ACL) reconstruction and (2) compare psychological outcomes in patients who recover symmetrical muscle function with patients who do not.

METHODS

The included patients had undergone a unilateral ACL reconstruction. Patients with a re-rupture and contralateral ACL injury were excluded. Three groups, based on the results from 5 tests of muscle function 12 months after reconstruction, were created. Three validated questionnaires (the Knee Self-Efficacy Scale; the Knee injury and Osteoarthritis Outcome Score subscale "Quality of Life"; the ACL Return to Sport after Injury scale) and a single question "Have you achieved your goal with rehabilitation?" were analysed in 4 different follow-ups after ACL reconstruction (10 weeks, 4, 8 and 12 months). Means and standard deviations were analysed with standard t tests and reported with 95% confidence intervals.

RESULTS

A total of 328 patients (120 men, 37%), mean age 27.8 ± 10 years, were included. Patients who did not recover symmetrical muscle function (n = 56; 17%) at the 12-month follow-up reported inferior knee-related self-efficacy and quality of life than patients who recovered symmetrical muscle function (n = 96; 29%) at all follow-ups, except quality of life at 4 months. The proportion of patients who stated they achieved their rehabilitation goal at 12 months was 17% for the entire cohort, 24% for patients who recovered muscle function and 5% for patients who did not recover muscle function.

CONCLUSION

Patients who recovered strength and hop symmetry 12 months after ACL reconstruction had superior knee-related self-efficacy and greater quality of life during the whole first year after ACL reconstruction. These results can aid clinicians in the decision-making process by providing knowledge of patients who might need further attention during rehabilitation.

LEVEL OF EVIDENCE

III.

Conservative treatment of Achilles tendon partial tear in a futsal player: A case report

Background and purpose: Achilles tendon is the most commonly injured part in the lower limb, especially in athletes. Treatment options for Achilles tendinopathy and total rupture are well described; however, there is a lack of information regarding treatment protocols for partial tears. Thus, the purpose of this case report was to describe the examination, intervention and outcomes of patient who suffered an acute Achilles tendon partial tear. Case description: A case is described here, in which the diagnosis of Achilles tendon partial tear was based on both magnetic resonance imaging and physical evaluation. Both the patient and the physical therapy team opted for non-surgical treatment. A 12-week course of conservative treatment including exercise, tendon loading, electrical stimulation, and photobiomodulation is described. Outcomes: Ankle dorsiflexion range of motion and hop tests. Discussion: This case report demonstrated that non-surgical treatment for Achilles tendon partial tear was effective for this patient and enabled the athlete to return to pre-injury levels of activity 6 months following the injury.

Psychosocial Barriers After Anterior Cruciate Ligament Reconstruction: A Clinical Review of Factors Influencing Postoperative Success

CONTEXT

Psychosocial factors arising after anterior cruciate ligament (ACL) injury may have a direct influence on an individual's decision to return to sport after ACL reconstruction (ACLR). While there is ample evidence to suggest that deficits in quadriceps strength, neuromuscular control, and clinical functional tasks exist after ACLR, the root and contribution of psychological dysfunction to an individual's success or return to sport after ACLR is still largely uncertain and unexplored. Given the discrepancy between successful functional outcomes and the percentage of athletes who return to sport, it is important to thoroughly address underlying factors, aside from physical function, that may be contributing to these lower return rates.

EVIDENCE ACQUISITION

Articles that reported on return to sport, psychological factors, and psychosocial factors after ACLR were collected from peer-reviewed sources available on Medline (1998 through August 2018). Search terms included the following: anterior cruciate ligament OR ACL AND return-to-sport OR return-to-activity, anterior cruciate ligament OR ACL AND psychological OR psychosocial OR biopsychosocial OR fear OR kinesiophobia OR self-efficacy, return-to-activity AND psychological OR psychosocial.

STUDY DESIGN

Clinical review.

LEVEL OF EVIDENCE

Level 5.

RESULTS

Psychosocial factors relative to injury are important components of the rehabilitation process. To fully understand how psychosocial factors potentially influence return to sport, an athlete's emotions, experiences, and perceptions during the rehabilitation process must be acknowledged and taken into consideration.

CONCLUSION

Acknowledgment of these psychosocial factors allows clinicians to have a better understanding of readiness to return to sport from a psychological perspective. Merging of the current ACLR rehabilitation protocols with knowledge related to psychosocial factors creates a more dynamic, comprehensive approach in creating a positive and successful rehabilitation environment, which may help improve return-to-sport rates in individuals after ACLR.

The association of psychological readiness to return to sport after anterior cruciate ligament reconstruction and hip and knee landing kinematics

BACKGROUND

Anterior cruciate ligament tears have a negative psychological impact on athletes. Currently, it is not clear if psychological readiness to return to sport has an impact on an athlete's landing biomechanics. Thus the purpose of the study is to investigate whether there is an association of psychological readiness to return to sport and single-leg landing biomechanics.

METHODS

Athletes with an anterior cruciate ligament reconstruction (n = 18) completed the Anterior Cruciate Ligament-Return to Sport after Injury scale to measure psychological readiness to return to sport, knee strength testing, and a single-leg landing task. A multivariate linear regression model was built for the involved and uninvolved limb based on sagittal and frontal plane knee and hip range of motion. Significance was set at p < 0.05.

FINDINGS

Knee extensor/flexor strength testing showed significant differences (p < 0.05) between involved and uninvolved limbs. Nearly 40% of the variance in psychological readiness scores (p = 0.025) can be accounted for by the involved limb's frontal plane hip and knee range of motion. Knee frontal plane range of motion was the only significant factor, and the standardized coefficients indicate that greater knee frontal plane range of motion and lower hip frontal plane range of motion were associated with higher psychological readiness. No other associations were found between psychological readiness and sagittal or frontal plane sing-leg biomechanics of the involved or uninvolved limbs.

INTERPRETATION

Greater psychological readiness to return to sport is associated with the involved limb's frontal plane knee and hip range of motion during a single-leg landing biomechanics.