Age and Sex Differences in Anterior Cruciate Ligament-Return to Sport after Injury Subscale Scores of Emotion, Risk Appraisal, and Confidence After ACL Reconstruction

Dylan P Roman¹, Sophia Ulman², Lauren Butler³, Cody Walker⁴, Taylor Douthit⁵, Christopher M Kuenze⁶, Victor V Prati^{7

8}, Brant Sachleben⁴, Lucy Phan^{7

8}, Stephen LaPlante^{7

8}, Lee Pace^{7

8}, Dhalston Cage^{7

8}, John Roaten^{7

8}, John Abt^{7

8}, Dustin Loveland⁵, Elliot Greenberg^{7

8}, Meredith Link^{7

8}, Theodore Ganley⁹, Adam Weaver^{7

8}, Nicholas Giampetruzzi¹, Brooke Farmer^{7

8}, Terry L Grindstaff¹⁰, Edward Chang^{7

8}, Rachel Cherelstein¹¹, Corey D Grozier^{7

8}, Matthew Harkey^{7

8}, Arjun Parmar^{7

8}, Jessica Tolzman¹², Alexa Martinez¹³, Jacob Landers², Kylee Rucinski^{7

8}, Chelsea Harrison^{7

8}, Steven DeFroda^{7

8}, Richard Ma¹⁴, Natalie Kupperman^{7

8}, Xavier Thompson^{7

8}, Michelle Walaszek^{7

8}, Kevin Cross⁶, Elaine Reiche^{7

8}, Caitlin Brinkman^{7

8}, Tom Birchmeier^{7

8}, Joseph M Hart^{7

8}, Shelby Baez^{7

8}

Affiliations

¹ Connecticut Children's, Hartford, Connecticut, USA.
² Scottish Rite for Children, Dallas, Texas, USA.
³ Florida International University and Nicklaus Children's Hospital, Miami, Florida, USA.
⁴ Arkansas Children's Hospital, Little Rock, Arkansas, USA.
⁵ Children's Health Andrews Institute, Gulf Breeze, Florida, USA.
⁶ University of Virginia, Charlottesville, Virginia, USA.
⁷ University of North Carolina-Chapel Hill, Chapel Hill, North Carolina, USA.
⁸ Investigation performed at Connecticut Children's, Farmington, Connecticut, USA.
⁹ Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.
¹⁰ Creighton University, Omaha, Nebraska, USA.
¹¹ Inova Health System, Falls Church, Virginia, USA.
¹² Michigan State University, East Lansing, Michigan, USA.
¹³ Nicklaus Children's Hospital, Miami, Florida, USA.
¹⁴ University of Missouri, Columbia, Missouri, USA.

PMID: 40687702
PMCID: PMC12276498
DOI: 10.1177/23259671251356273

Age and Sex Differences in Anterior Cruciate Ligament-Return to Sport after Injury Subscale Scores of Emotion, Risk Appraisal, and Confidence After ACL Reconstruction

Dylan P Roman et al. Orthop J Sports Med. 2025.

. 2025 Jul 17;13(7):23259671251356273.

doi: 10.1177/23259671251356273. eCollection 2025 Jul.

Authors

Affiliations

¹ Connecticut Children's, Hartford, Connecticut, USA.
² Scottish Rite for Children, Dallas, Texas, USA.
³ Florida International University and Nicklaus Children's Hospital, Miami, Florida, USA.
⁴ Arkansas Children's Hospital, Little Rock, Arkansas, USA.
⁵ Children's Health Andrews Institute, Gulf Breeze, Florida, USA.
⁶ University of Virginia, Charlottesville, Virginia, USA.
⁷ University of North Carolina-Chapel Hill, Chapel Hill, North Carolina, USA.
⁸ Investigation performed at Connecticut Children's, Farmington, Connecticut, USA.
⁹ Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.
¹⁰ Creighton University, Omaha, Nebraska, USA.
¹¹ Inova Health System, Falls Church, Virginia, USA.
¹² Michigan State University, East Lansing, Michigan, USA.
¹³ Nicklaus Children's Hospital, Miami, Florida, USA.
¹⁴ University of Missouri, Columbia, Missouri, USA.

PMID: 40687702
PMCID: PMC12276498
DOI: 10.1177/23259671251356273

Abstract

Background: The Anterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI) scale is widely used after anterior cruciate ligament reconstruction (ACLR), but its 3 subscale domains of emotion, risk appraisal, and confidence are rarely considered when assessing readiness to return to sport (RTS). Current guidelines for ACL-RSI scores at time of RTS are derived from adult-only studies, and there is a need for age- and sex-specific data to guide RTS decision-making.

Purpose/hypothesis: The purpose of this study was to investigate differences in ACL-RSI subscale scores by age and sex. It was hypothesized that males and teens would report higher scores on emotion, confidence, and risk appraisal subscales compared with females and adults.

Study design: Cohort study; Level of evidence, 3.

Methods: ACL-RSI data were obtained from a multisite clinical outcome registry. Participants were included if they were between 6 and 12 months after primary, unilateral ACLR. Sex subgroups (female, male) and age subgroups (teen: 14-18 years; adult: 19-30 years) were established and compared to identify potential sex- and age-related differences in the ACL-RSI scale (total, subscales, and item scores). Descriptive statistics were computed and multiple 2-way analyses of variance were used to determine main effects and interactions between sex and age group. The significance level (α) was set to .05.

Results: A total of 154 participants (mean age, 20.2 ± 3.8 years; 53.9% female; mean time after ACLR, 8.7 ± 2.1 months) were included. The mean ACL-RSI total score across the cohort was 67.92 ± 24.65. A significant main effect of age group on ACL-RSI total score was found as teens exhibited significantly greater psychological readiness compared with adults (mean difference, 10.91 points). A significant main effect of age group on the confidence subscale score was found, with teens reporting significantly higher confidence in returning to sport compared with adults (mean difference, 14.05 points). The main effect of sex on ACL-RSI total score was not significant (P = .337).

Conclusion: Teens demonstrated significantly higher total scores and confidence on the ACL-RSI scale compared with adults. Therefore, when assessing a teen athlete's psychological preparedness to RTS, target scores determined from adult data may not be appropriate. Sex was not found to influence ACL-RSI scores. Future work should strive to create age- and sex-specific ACL-RSI cutoff scores for successful RTS after ACLR in teen athletes.

Keywords: anterior cruciate ligament; psychological readiness; rehabilitation.

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Conflict of interest statement

One or more of the authors has declared the following potential conflict of interest or source of funding: E.C. is a consultant for Avanos Medical and has received research support from Arthrex. L.P. is a consultant for Arthrex and JRF Ortho and a paid speaker for Arthrex; has received research support from Arthrex; is a committee member of the American Orthopaedic Society for Sports Medicine and PRiSM; and owns stock in OutcomeMD. R.M. is a consultant for Johnson & Johnson; has received research support from Novocart, Moximed, and Cartiheal; is a committee member of the American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and American College of Sports Medicine; and serves on the Associate Editor Panel for Journal of Bone and Joint Surgery American and as a board member of the Rugby Research & Injury Prevention Group. T.G. has received research support from AlloSource and Vericel, educational support from Arthrex and Paladin Technology Solutions, and hospitality payments from Arthrex; is an associate editor of The American Journal of Sports Medicine; serves as a committee member of POSNA and PRiSM; serves as a board or committee member of IPOS and AAOS; and serves as a board member of the AAP Section on Orthopedics. S.D. has been a speaker for AO North America; is a consultant for Stryker; and has received research support from Stryker, Arthrex, OREF, and AANA. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto. Ethical approval for this study was obtained the University of Virginia (HSR 230335).

Figures

The image depicts two bar graphs comparing ACL-RSI scores between adolescents (teens) and adults across various categories and specific items, indicating adolescents often score lower than adults as identified by significant differences marked with asterisks. — **Figure 1.**
Anterior Cruciate Ligament–Return to Sport after Injury (ACL-RSI) subscale, total, and item scores by age group. Significant age group differences are noted with an asterisk.

See this image and copyright information in PMC

References

1. Ardern CL, Ekas GR, Grindem H, et al. 2018 International Olympic Committee consensus statement on prevention, diagnosis and management of paediatric anterior cruciate ligament (ACL) injuries. Br J Sports Med. 2018;52(7):422-438. - PMC - PubMed
1. Ardern CL, Glasgow P, Schneiders A, et al. 2016 Consensus statement on return to sport from the First World Congress in Sports Physical Therapy, Bern. Br J Sports Med. 2016;50(14):853-864. - PubMed
1. Ardern CL, Osterberg A, Tagesson S, et al. The impact of psychological readiness to return to sport and recreational activities after anterior cruciate ligament reconstruction. Br J Sports Med. 2014;48(22):1613-1619. - PubMed
1. Ardern CL, Taylor NF, Feller JA, Webster KE. Fifty-five per cent return to competitive sport following anterior cruciate ligament reconstruction surgery: an updated systematic review and meta-analysis including aspects of physical functioning and contextual factors. Br J Sports Med. 2014;48(21):1543-1552. - PubMed
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Age and Sex Differences in Anterior Cruciate Ligament-Return to Sport after Injury Subscale Scores of Emotion, Risk Appraisal, and Confidence After ACL Reconstruction

Affiliations

Age and Sex Differences in Anterior Cruciate Ligament-Return to Sport after Injury Subscale Scores of Emotion, Risk Appraisal, and Confidence After ACL Reconstruction

Authors

Affiliations

Abstract

Conflict of interest statement

Figures

References

LinkOut - more resources

Full Text Sources