Monday, April 13, 2020

Psychological Measures for Return to Play Following ACLR - Part VI

Over the last couple of weeks we have been discussing kinesiophobia (fear of movement) and how if high levels of this are present on return to sport that athletes are at greater risk for reinjury.  We also discussed some movement patterns that we see in our athletes that is also highly associated with kinesiophobia.  Specifically those with a lateral shift and increased frontal plane motion and speed of motion during single limb testing tend to have higher levels of kinesiophobia.  During the last 2 weeks, we discussed some training techniques we can employ that will help to reduce these abnormal movement patterns and aid in reducing kinesiophobia.

Although the majority of our discussion has been around the Tampa Scale for Kinesiophobia as a way of measuring fear with return to sport, there is another measure out there called the ACL-RSI.  Webster et al Am J Sport Med 18 did a study to look at generating and validating a short version of the original ACL-RSI scale.  The original ACL-RSI (pictured below) was developed in 2008 and is a 12 item scale that measures 3 types of response believed to be associated with risk of injury: emotions, confidence in performance and risk appraisal.

The short version is a 6 item version that also measures these same three types of responses (it is available as an app).  In this study the authors administered both versions of the ACL-RSI to 535 athletes who had undergone ACLR at 6 months post op.  The predictive validity for return to sport at 12 months following ACLR was determined and compared.  The results showed that the short version had a fair to good predictive ability for 12 month return to sport outcomes.  This is great for those of us in a busy athletic or clinical setting as this will help cut down on some time. 

So when it comes to emotions, confidence in performance and risk appraisal what really matters?  That is what Webster et al Am J Sport Med 2018, sought to identify.  In this study, the authors looked at factors that contribute to an athlete's psychological readiness to return to sport following ACLR.

635 athletes (389 male, 246 female) who underwent an ACLR and were cleared to return to play filled out the Anterior Cruciate Ligament Return to Sport After Injury (ACL-RSI) questionnaire. In this study the authors captured demographic information (age, sex), sporting outcomes (preinjury frequency of participation), surgical timing (injury to surgery interval), clinical factors (ligament laxity), functional measures (single limb hop symmetry) and symptoms of pain and function (measured via IKDC).  Statistical models were applied to determine association with the above measures and the athletes psychological readiness for return to play.

After univariate analysis for the entire group, the following factors were found to have a positive impact on psychological readiness.
  • Male sex
  • Younger age
  • Shorter injury to surgery interval
  • Higher frequency of sport participation 
  • Greater limb symmetry 
  • Higher subjective knee scores
Further analysis of the data revealed that subjective knee scores and age accounted for 37% of the variance in psychological readiness.  


Self reported symptoms and function was one of the largest influences on psychological readiness.  Knowing this, this should guide us a lot on how we approach the ACLR athlete.  If you look in depth at the IKDC, what you see is where we need to apply some focus.

  • Pain and swelling - the first 6 questions of the IKDC is focused on pain and swelling.  Although inflammation and pain control are a normal part of what we do, we need to be very aggressive in this and managing this early in the rehab process.  The longer this goes on the more of a psychological impact it will have and the more likely we are to see this reflected on the IKDC.
  • Confidence in limb - the next 4 questions are related to functional ability in functional activities.  Controlling pain early in the rehab process and combining with early initiation of functional activity (gait without a limp, ascending/descending stairs, squatting motion through functional range of motion with symmetry) progressed to functional single limb activities (single leg hop, lateral hops, diagonal hops) will help improve confidence.
In addition to the above, all to often in PT, we are afraid to push the athlete.  Current standard of care is there is a big gap between PT and performance.  Clinically, we need to close the gap.  As long as we keep within the parameters of physiological healing process, within the physician's protocol and mindful of the athlete's technique and biomechanics, we could AND SHOULD push the athlete to the next level.  Doing so will help them build confidence, will help them see their capability with functional activities and improve chances for a safe and full return to performance.  

Although the previous 2 studies were in support of the ACL-RSI, is this the tool we should use for helping us determine return to sport?  Next week, we will begin to investigate this a little more.  I hope you find this helpful and please share with others you think might be interested.    Make sure to keep up with me on Instagram @bjjpt_acl_guy, twitter @ACL_prevention and on the web at where I post the most up to date information.  #ViPerformAMI #ACLPlayItSafe

Dr. Nessler is a practicing physical therapist with over 20 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment and ACL injury prevention.  He is the founder | developer of the ViPerform AMI, ViPerform AMI RTSport, ACL Play It Safe Program, Run Safe Program and author of a college textbook on this subject.  Trent has performed >5000 athletic movement assessments in the US and abroad and speaks nationally and internationally on the subject.  He serves as the National Director of Sports Innovation for Select Medical and serves as movement and injury prevention consultant for numerous colleges and professional teams.  Trent is also a competitive athlete and purple belt in Brazilian Jiu Jitsu. 

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