Gender Differences in Psychological Responses to Recovery After Anterior Cruciate Ligament Reconstruction Before Return to Sport

Key Points

• After anterior cruciate ligament reconstruction, male and female high school athletes reported similar psychological experiences reflecting fear of movement, loss of athletic identity, and self-improvement but differences based on locus of control and psychological distress.

• Clinicians should consider addressing psychological barriers after anterior cruciate ligament reconstruction using nuanced, gender-specific psychological interventions.

Gender differences are apparent in adolescents recovering from anterior cruciate ligament (ACL) reconstruction (ACLR). Females were 1.4 times less likely to return to their preinjury level of sport after ACLR than their male counterparts,¹ and 24% to 30% of young female athletes who did return to sport (RTS) went on to experience a second ACL injury within 2 years of ACLR.^2,3 These findings suggest a potential disconnect among the goals of the patient, the approach to rehabilitation, and the criteria used to evaluate readiness for RTS among young female athletes. Current recommendations^4,5 suggest that the evaluation of patient-reported psychological readiness for physical activity and sport (ie, no emotional disturbances, high self-efficacy, and little fear of reinjury) is a critical component of the clinical criteria used to clear individuals for safe reengagement in unrestricted physical activity after ACLR. This has most commonly been accomplished through patient-reported outcome measures (eg, Knee-Self Efficacy Scale and Athlete Fear Avoidance Questionnaire) that evaluate anxiety, confidence, fear of reinjury, and self-efficacy. The Anterior Cruciate Ligament Return to Sport After Injury (ACL-RSI)⁶ and the Tampa Scale of Kinesiophobia-11 (TSK-11)⁷ may be used to assess psychological readiness for RTS and fear of movement, respectively. Adequate psychological readiness and less fear of movement after ACLR have been linked to successful RTS within 1 year and a reduced risk of second ACL injury within 2 years after ACLR among young and active individuals.^5,7,8

Although this knowledge is clinically important, Sims and Mulcahey⁹ proposed a thematic structure to help health care professionals define and understand the meaningfully different psychological and social responses in psychological distress, self-efficacy, locus of control, fear of reinjury, and athletic identity of adult male and female patients recovering from ACLR. This thematic structure incorporates many of the concepts proposed by Wiese-Bjornstal et al,¹⁰ who described a dynamic biopsychosocial model rooted in explaining how cognitive, emotional, and sociologic aspects interact to...