Beyond Physical Recovery: Psychological Factors and Assessment Tools in Return to Sport Decision-making after Anterior Cruciate Ligament Reconstruction - A Scoping Review.

BACKGROUND

Anterior cruciate ligament reconstruction (ACLR) is among the most common surgical interventions following sport-related knee injury, yet fewer than two-thirds of athletes return to their pre-injury level of sport. Psychological factors are increasingly recognized as critical determinants of successful return to sport (RTS), yet psychological instruments remain inconsistently integrated into RTS decision-making and no consensus exists on which tools best capture the multidimensional nature of psychological readiness. The purpose of this review was to examine the psychological instruments used in RTS decision-making among athletes recovering from ACLR and identify gaps in current assessment practices.

STUDY

DESIGN

Scoping Review.

METHODS

A comprehensive search was conducted across MEDLINE (via PubMed), SPORTDiscus, Web of Science, Scopus, and CINAHL for peer-reviewed English-language studies published between 1999 and 2024 involving athletes who underwent ACLR and reported psychological factors or assessment tools relevant to RTS. Title, abstract, and full-text screening were independently conducted by two reviewers, with discrepancies resolved through discussion and, when necessary, referral to a third reviewer. The review was conducted in accordance with the Joanna Briggs Institute (JBI) methodology for scoping reviews. Forty-four studies met eligibility criteria and were included.

RESULTS

Twelve psychological assessment tools were identified across 44 studies. The Anterior Cruciate Ligament Return to Sport after Injury (ACL-RSI) scale was the most frequently used instrument, appearing in 35 of 44 studies. The Tampa Scale of Kinesiophobia (TSK) appeared in 11 studies and the Knee Self-Efficacy Scale (K-SES) in 8 studies. No single instrument captured the full psychological complexity of RTS readiness.

CONCLUSION

Psychological readiness is a multidimensional construct requiring assessment beyond a single instrument. The ACL-RSI, TSK, and K-SES18 each capture distinct dimensions of psychological readiness, and considering them together may help clinicians identify psychological barriers that may not be captured by a single instrument. However, whether a combined assessment approach improves RTS decision-making or outcomes has not been directly tested and warrants prospective investigation.

LEVEL OF EVIDENCE: 2a.