What the authors found was sobering.
Firstly, prior to ACLR 613 of 675 ACLR patients (91%) reported that they expected to return to sport, with 84% expecting to return to their same pre-injury level of sport. These expectations were higher in those undergoing their first ACLR compared to their 2nd or 3rd ACLR procedure. When age was considered, those aged under 20 years of age had significantly higher expectations to return to pre-injury levels of sport compared to those who were aged over 20.
When the authors looked at actual return to sport rates at 12 months post-op, they found a very different reality.
At 12 months post-op, only 24% of patients who expected to return to their previous level of sport had returned – compared to 84% who expected to return to pre-injury level of sport pre-operatively. Sadly, 15% of the 675 patients had decided to give up sport by 12 months, with 9% of these patients previously expecting to go back to sport.
For the patients who had changed their expectations or decided to give up sport, 71% were fearful of re-injury, 18% did not feel that their knee was ready, and 10% noted other reasons as being too busy, no longer interested in sport and not being able to afford a potential further reconstruction or procedure. Overall, females had 2x greater odds of giving up on returning back to sport; and having undergone a previous ACLR reconstruction had 3x greater odds of giving up on returning back to sport.
So clearly, there is a big difference between expectations and reality, and this is something we should be addressing early in rehab. Of course, we want to be encouraging our patients to return to sport in a safe, realistic and timely fashion; but reassuring our patients that it’s absolutely ok, and not a “failure” of rehab, if they don’t return to sport before 12 months.
Regarding assessing and monitoring psychological readiness to return to sport, as mentioned before it’s important that we look beyond strength and hop tests in our clinical assessments. There are 2 patient reported outcome measures that are very good at identifying fear and confidence issues in ACL patients; the ACL-RSI and the TSK-11. What is even better about these 2 measures is that the scores your patient records can identify certain populations at greater risk of ACL re-injury so that you can apply an intervention, and then reassess at a later date to see if their score has changed to be at a lower risk of reinjury.
For the ACL-RSI, McPherson et al (2019) found that in ACLR patients aged under 20, those with ACL-RSI scores of LESS THAN 76.7 have an increased risk of second ACL injury at least 4 years after returning to sport than those who scored GREATER THAN 76.7.
For the TSK-11, Paterno et al (2018) found that in a group of 40 young athletes (mean age 16yrs) that a TSK-11 score of >19 at the time of return to sport had a 13x greater risk of ipsilateral graft rupture within the first 2 years upon return to sport.
The results of these 2 studies are clear indication that we need to be also looking at these 2 patient reported questionnaires in our return to sport testing along with the strength tests, hop tests, movement quality assessment in a fresh and fatigued state, and function/QOL patient reported outcome measures.
So I guess the million dollar question is – “how do we increase someone’s confidence and lower their fear of re-injury?”.