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Psychological factors are associated with return to pre-injury levels of sport and physical activity after ACL reconstruction



The impetus of anterior cruciate ligament reconstruction (ACLR) is to allow patients to return to sport and to remain engaged in physical activity. Many patients exhibit deficits in psychological domains of health-related quality of life which may impede return to sport and physical activity participation. Therefore, the purpose of this study was to examine the association of patient-based, specifically psychological, and functional outcomes with return to sport and physical activity.


Forty participants, a minimum of 1-year post-ACLR, reported to the laboratory for one-testing session. Participants completed a series of patient-based and functional outcome assessments. Participants were also instructed to wear a pedometer for 1 week to monitor their daily steps.


Twenty-five participants (62%) did not return to sport and 29 participants (72%) did not average 10,000 steps per day. Individuals with elevated levels of self-reported kinesiophobia were 17% less likely to return to sport. Self-reported knee self-efficacy and knee-related quality of life accounted for 27.1% of the variance of average daily step counts.


Psychological factors, specifically injury-related fear and self-efficacy, were associated more significantly than functional outcomes with return to sport and physical activity levels. Clinicians should examine psychological factors throughout rehabilitation in patients after ACLR. Future research should explore the effectiveness of psychoeducation techniques to decrease injury-related fear and enhance self-efficacy in this population.

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This publication was supported by the Mid-Atlantic Athletic Trainers’ Association Research and Grants Awards. Its contents are the authors’ sole responsibility and do not necessarily represent official Mid-Atlantic Athletic Trainers’ Association Research and Grant Awards views.

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Correspondence to Shelby E. Baez.

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The authors have no conflicts of interest to disclose.


The authors received funding for this study through the Mid-Atlantic Athletic Trainers' Research and Grants Awards.

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This study was approved by Old Dominion University (16-213) and the University of Kentucky's (43341) Institutional Review Boards. All procedures performed in this study were in accordance with the ethical standards of the institutions.

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Baez, S.E., Hoch, M.C. & Hoch, J.M. Psychological factors are associated with return to pre-injury levels of sport and physical activity after ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 28, 495–501 (2020).

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  • Physical activity
  • Anterior cruciate ligament reconstruction
  • Return to sport
  • Pedometer
  • Step counts