Patients Who Return to Sport After Primary Anterior Cruciate Ligament Reconstruction Have Significantly Higher Psychological Readiness: A Systematic Review and Meta-analysis of 3744 Patients

Background: Although objective outcomes assessing knee function are essential measurements for return to sport, psychological factors have become increasingly recognized as equally important parameters for determining an athlete’s ability to return to sport after surgery. Purpose: To systematically review the literature to determine whether patients who returned to sport after anterior cruciate ligament (ACL) reconstruction had improved psychological scores (as measured with validated questionnaires) compared with patients who did not return to sport. Study Design: Systematic review and meta-analysis; Level of evidence, 3. Methods: A systematic review was performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and was preregistered on PROSPERO. Four databases were searched for level 1 to 3 studies that compared at least 1 psychological outcome measured by a validated questionnaire for patients who did and did not return to sport after primary ACL reconstruction. The following data were recorded: study and patient characteristics; psychological metrics (ACL–Return to Sport Injury [ACL-RSI] scale, Knee Self-Efficacy Scale [K-SES], and Tampa Scale of Kinesiophobia [TSK/TSK-11]); International Knee Documentation Committee (IKDC) score; and clinical metrics. Study methodological quality was analyzed using the methodological index for non-randomized studies (MINORS), and the mean difference (MD) and 95% CI were calculated for each psychological outcome score using the inverse variance method. Results: We included and analyzed 16 articles (3744 patients; 38.9% female; mean age range, 17-28.7 years; mean MINORS score, 19.9 ± 1.4). Overall, 61.8% of athletes returned to sport (66.8% of male patients; 55.4% of female patients). Patients who returned scored significantly higher on the ACL-RSI scale (MD, 20.8; 95% CI, 15.9 to 25.7; P < .001), significantly higher on the K-SES (MD, 1.3; 95% CI, 0.2 to 2.3; P = .036), and significantly lower on the TSK/TSK-11 (MD, 10.1%; 95% CI, −12.1% to −8.2%; P = .004). Those returning to sport did not exceed the minimal clinically important difference for IKDC score versus those not returning to sport. Conclusion: Patients who returned to sport after primary ACL reconstruction had significantly higher psychological readiness, higher self-efficacy, and lower kinesiophobia compared with those who did not return to sport, despite having clinically similar knee function scores. Evaluation of psychological readiness, in combination with other objective measurements, is a critical component of return-to-sport evaluation in athletes after primary ACL reconstruction. Registration: CRD42021284735 (PROSPERO).