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. 2024 Apr 30;10(1):49.
doi: 10.1186/s40798-024-00712-w.

Anterior Cruciate Ligament Return to Sport after Injury Scale (ACL-RSI) Scores over Time After Anterior Cruciate Ligament Reconstruction: A Systematic Review with Meta-analysis

Timothy C Sell  1 , Ryan Zerega  1 , Victoria King  1 , Charles R Reiter  1 , Hailey Wrona  1 , Garrett S Bullock  2   3 , Nilani Mills  4 , Anu Räisänen  5   6 , Leila Ledbetter  7 , Gary S Collins  8   9 , Joanna Kvist  10   11 , Stephanie R Filbay  12 , Justin M Losciale  13   14
Affiliations

Anterior Cruciate Ligament Return to Sport after Injury Scale (ACL-RSI) Scores over Time After Anterior Cruciate Ligament Reconstruction: A Systematic Review with Meta-analysis

Timothy C Sell et al. Sports Med Open. .

Abstract

Background: Psychological readiness is an important consideration for athletes and clinicians when making return to sport decisions following anterior cruciate ligament reconstruction (ACLR). To improve our understanding of the extent of deficits in psychological readiness, a systematic review is necessary.

Objective: To investigate psychological readiness (measured via the Anterior Cruciate Ligament-Return to Sport after Injury scale (ACL-RSI)) over time after ACL tear and understand if time between injury and surgery, age, and sex are associated with ACL-RSI scores.

Methods: Seven databases were searched from the earliest date available to March 22, 2022. Articles reporting ACL-RSI scores after ACL tear were included. Risk of bias was assessed using the ROBINS-I, RoB-2, and RoBANS tools based on the study design. Evidence certainty was assessed for each analysis. Random-effects meta-analyses pooled ACL-RSI scores, stratified by time post-injury and based on treatment approach (i.e., early ACLR, delayed ACLR, and unclear approach).

Results: A total of 83 studies were included in this review (78% high risk of bias). Evidence certainty was 'weak' or 'limited' for all analyses. Overall, ACL-RSI scores were higher at 3 to 6 months post-ACLR (mean = 61.5 [95% confidence interval (CI) 58.6, 64.4], I2 = 94%) compared to pre-ACLR (mean = 44.4 [95% CI 38.2, 50.7], I2 = 98%), remained relatively stable, until they reached the highest point 2 to 5 years after ACLR (mean = 70.7 [95% CI 63.0, 78.5], I2 = 98%). Meta-regression suggests shorter time from injury to surgery, male sex, and older age were associated with higher ACL-RSI scores only 3 to 6 months post-ACLR (heterogeneity explained R2 = 47.6%), and this reduced 1-2 years after ACLR (heterogeneity explained R2 = 27.0%).

Conclusion: Psychological readiness to return to sport appears to improve early after ACL injury, with little subsequent improvement until ≥ 2-years after ACLR. Longer time from injury to surgery, female sex and older age might be negatively related to ACL-RSI scores 12-24 months after ACLR. Due to the weak evidence quality rating and the considerable importance of psychological readiness for long-term outcomes after ACL injury, there is an urgent need for well-designed studies that maximize internal validity and identify additional prognostic factors for psychological readiness at times critical for return to sport decisions.

Registration: Open Science Framework (OSF), https://osf.io/2tezs/ .

Keywords: Athletes; Knee; Psychological readiness; Return to sport.

PubMed Disclaimer

Conflict of interest statement

The authors declare no conflicts of interest.

Figures

Fig. 1
Fig. 1
Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Flowchart
Fig. 2
Fig. 2
Forest Plots for the pooled ACL-RSI scores for all studies, stratified by time. Forest plot for the pooled mean (95%Confidence Interval [CI]) ACL-RSI score for all studies, stratified by time since ACL tear. A Forest plot for ACL-RSI scores pooled mean (95% confidence interval) pre-ACLR. B Forest plot for ACL-RSI scores pooled mean (95% confidence interval) from 3 to 6-months post ACL tear. C Forest plot for ACL-RSI scores pooled mean (95% confidence interval) from 7 to 12-months post ACL tear. D Forest plot for ACL-RSI scores pooled mean (95% confidence interval) from 1 to 2-years post ACL tear. E Forest plot for ACL-RSI scores pooled mean (95% confidence interval) from 2 to 5-years post ACL tear. ACL-RSI, Anterior Cruciate Ligament Return to Sport Index; MRAW, Raw mean was used for analysis
Fig. 3
Fig. 3
Pooled ACL-RSI scores for only early ACLR studies, stratified by time. Forest plot for the pooled mean (95%Confidence Interval [CI]) ACL-RSI score for all studies classified as early ACLR, stratified by time since ACL tear. A Forest plot for ACL-RSI scores pooled mean (95% confidence interval) pre-ACLR. B Forest plot for ACL-RSI scores pooled mean (95% confidence interval) from 3 to 6-months post early ACLR. C Forest plot for ACL-RSI scores pooled mean (95% confidence interval) from 7 to 12-months post early ACLR. D Forest plot for ACL-RSI scores pooled mean (95% confidence interval) from 2 to 5-years post early ACLR. ACL-RSI, Anterior Cruciate Ligament Return to Sport Index; MRAW, Raw mean was used for analysis
Fig. 4
Fig. 4
Pooled ACL-RSI scores for only late ACLR studies, stratified by time. Forest plot for the pooled mean (95% Confidence interval [CI]) ACL-RSI score for all studies classified as delayed ACLR, stratified by time since ACL tear. A Forest plot for ACL-RSI scores pooled mean (95% confidence interval) pre-ACLR. B Forest plot for ACL-RSI scores pooled mean (95% confidence interval) from 3 to 6-months post late ACLR. C Forest plot for ACL-RSI scores pooled mean (95% confidence interval) from 7 to 12-months post late ACLR. D Forest plot for ACL-RSI scores pooled mean (95% confidence interval) from 1 to 2-years post late ACLR. E Forest plot for ACL-RSI scores pooled mean (95% confidence interval) from 2 to 5-years post late ACLR. ACL-RSI, Anterior Cruciate Ligament Return to Sport Index; MRAW, Raw mean was used for analysis
Fig. 5
Fig. 5
Pooled ACL-RSI scores for all unclear studies, stratified by time. Forest plot for the pooled mean (95%Confidence Interval [CI]) ACL-RSI score for all studies with unclear treatment strategy, stratified by time since ACL tear. A Forest plot for ACL-RSI scores pooled mean (95% confidence interval) pre-ACLR. B Forest plot for ACL-RSI scores pooled mean (95% confidence interval) from 3 to 6-months post ACL tear. C Forest plot for ACL-RSI scores pooled mean (95% confidence interval) from 7 to 12-months post ACL tear. D Forest plot for ACL-RSI scores pooled mean (95% confidence interval) from 1 to 2-years post ACL tear. E Forest plot for ACL-RSI scores pooled mean (95% confidence interval) from 2 to 5-years post ACL tear. ACL-RSI, Anterior Cruciate Ligament Return to Sport Index; MRAW, Raw mean was used for analysis
Fig. 6
Fig. 6
Pooled ACL-RSI scores for studies where there was an intention to RTS, stratified by time. Forest plot for the pooled mean (95%Confidence Interval) ACL-RSI score for all studies that were judged to have an intent to return-to-sport, stratified by time since ACL tear. A Forest plot for ACL-RSI scores pooled mean (95% confidence interval) pre-ACLR. B Forest plot for ACL-RSI scores pooled mean (95% confidence interval) from 3 to 6-months post ACL tear. C Forest plot for ACL-RSI scores pooled mean (95% confidence interval) from 7 to 12-months post ACL tear. D Forest plot for ACL-RSI scores pooled mean (95% confidence interval) from 2 to 5-years post ACL tear. ACL-RSI, Anterior Cruciate Ligament Return to Sport Index; MRAW, Raw mean was used for analysis
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