Compare and Contrast each rhetorical situations

K N E E

Psychological predictors of anterior cruciate ligament reconstruction outcomes: a systematic review

Joshua S. Everhart • Thomas M. Best •

David C. Flanigan

Received: 5 April 2013 / Accepted: 27 September 2013 / Published online: 15 October 2013

� Springer-Verlag Berlin Heidelberg 2013

Abstract

Purpose Lack of return to sport following anterior cru-

ciate ligament (ACL) reconstruction often occurs despite

adequate restoration of knee function, and there is growing

evidence that psychological difference among patients may

play an important role in this discrepancy. The purpose of

this review is to identify baseline psychological factors that

are predictive of clinically relevant ACL reconstruction

outcomes, including return to sport, rehab compliance,

knee pain, and knee function.

Methods A systematic search was performed in PubMed,

Google Scholar, CINAHL, UptoDate, Cochrane Reviews,

and SportDiscus, which identified 1,633 studies for

potential inclusion. Inclusion criteria included (1) pro-

spective design, (2) participants underwent ACL recon-

struction, (3) psychological traits assessed at baseline, and

(4) outcome measures such as return to sport, rehabilitation

compliance, and knee symptoms assessed. Methodological

quality was evaluated with a modified Coleman score with

several item-specific revisions to improve relevance to

injury risk assessment studies in sports medicine.

Results Eight prospective studies were included (modi-

fied Coleman score 63 ± 4.9/90, range 55–72). Average

study size was 83 ± 42 patients with median 9-month

follow-up (range 3–60 months). Measures of self-efficacy,

self-motivation, and optimism were predictive of rehabili-

tation compliance, return to sport, and self-rated knee

symptoms. Pre-operative stress was negatively predictive,

and measures of social support were positively predictive

of knee symptoms and rehabilitation compliance. Kine-

siophobia and pain catastrophizing at the first rehabilitation

appointment did not predict knee symptoms throughout the

early rehabilitation phase (n.s.).

Conclusions Patient psychological factors are predictive

of ACL reconstruction outcomes. Self-confidence, opti-

mism, and self-motivation are predictive of outcomes,

which is consistent with the theory of self-efficacy. Stress,

social support, and athletic self-identity are predictive of

outcomes, which is consistent with the global relationship

between stress, health, and the buffering hypothesis of

social support.

Level of evidence Systematic review of prospective

prognostic studies, Level II.

Keywords Sports � Knee surgery � Psychology � Sports medicine outcomes � Risk assessment

Introduction

Sports-related knee surgery is a common procedure in the

USA, with approximately 130,000 anterior cruciate liga-

ment (ACL) reconstructions and 500,000 meniscus-related

procedures performed annually [30]. In the elective knee

surgery setting, an essential component of the initial

evaluation is an assessment of potential benefit and risk of

J. S. Everhart � D. C. Flanigan (&) Department of Orthopaedics, The Ohio State University Wexner

Medical Center, Suite 3100 Morehouse Medical Plaza 2050

Kenny Road, Columbus, OH 43221, USA

e-mail: [email protected]

T. M. Best

Department of Family Medicine, The Ohio State University

Wexner Medical Center, Columbus, OH, USA

T. M. Best � D. C. Flanigan OSU Sports Medicine, Sports Health and Performance Institute,

The Ohio State University Wexner Medical Center, Columbus,

OH, USA

123

Knee Surg Sports Traumatol Arthrosc (2015) 23:752–762

DOI 10.1007/s00167-013-2699-1

surgery versus the time and cost burden of operative

treatment and knee rehabilitation. Selection of an appro-

priate treatment strategy requires a thorough assessment of

patient lifestyle and treatment expectations, along with

consideration of factors such as pre-injury activity level,

desire to return to sport, occupational demands, willingness

to complete postoperative rehabilitation, and expectations

regarding postoperative knee function [16].

Despite this, variable sports-related outcomes continue

to be reported in selected patient populations [3, 4, 16].

Even after primary ACL reconstruction in an athletic

population with high rates of rehabilitation compliance, a

disappointing rate of return to previous level of sport par-

ticipation ranging between 47 and 70 % is reported at

greater than 4-year follow-up [3–5, 16, 39]. In many cases,

this lack of return to sport occurs without significant

functional deficits in knee stability and strength and with-

out persistent pain [3, 4, 16, 34, 39, 41]. Another factor to

consider is that return to sport after ACLR may not be in

the patient’s best interest if he or she is primarily interested

in avoiding additional injury, as primary ACLR patients are

at increased risk of injury to both the ipsilateral and con-

tralateral limb [9, 59].

Psychological differences between patients may be an

important contributing factor to this apparent mismatch

between postoperative knee function scores (successful

physiological outcomes) and rates of return to sport or pre-

injury activity levels (successful participation-related out-

comes) [4, 5]. Differences in psychological and behav-

ioural responses to pain are some of the most well-studied

factors that may contribute to a lack of return to sport [2, 4,

5]. Due to the trauma of acute injury, discomfort during

knee rehabilitation, and residual knee symptoms, some

patients may fall into a pattern of behaviours similar to

what is observed in patients with chronic pain syndromes

[2, 10, 31].

Three basic psychological theories are tested in the

studies included in this review. We have presented these

theoretical frameworks in the context of ACL injury,

reconstruction, and rehabilitation in a series of conceptual

diagrams (Fig. 1). The fear-avoidance model of pain is a

cognitive-behavioural theory originally developed by Le-

them et al. [37]; this model has persisted for several dec-

ades and has been extensively validated [35]. In this model,

when patients experience a recurrent painful stimulus, an

exaggerated negative psychological response to pain or the

anticipation of pain (pain catastrophizing) [50] leads to an

active avoidance of movement out of fear of recurrent pain

or injury (kinesiophobia) [51]. The theory of self-efficacy

was originally proposed by Bandura [6]. In this theory,

individuals have intrinsic levels of self-efficacy, optimism,

and self-motivation, which are considered to be stable

personality traits (unchanging from year to year) and are

strongly associated with higher rates of task completion in

rehabilitation [1, 48] and exercise adherence [18]. Finally,

stress, health, and the buffering hypothesis of social sup-

port were developed by Cohen [12, 13]. In this model,

psychological stress is believed to globally affect physical

and mental health [63], and an individual’s degree of social

support is believed to modulate this effect [13, 57]. One’s

perceived level of social support can be derived from a

variety of relationships; of particular importance in sports

medicine are athletic self-identity and the team environ-

ment as a source of social support [24, 62], which can be

negatively impacted by injury [62].

Ardern et al. [4] recently demonstrate a consistent

association between psychological factors and returning to

sport after ACL injury. However, their review focuses on

cross-sectional analyses, and they comment that prognostic

studies are necessary to facilitate inferences regarding

causation. The purpose of this systematic review is to

address this gap in knowledge by identifying psychological

traits that have been demonstrated in a prospective manner

to increase risk of an unsatisfactory outcome after ACL

reconstruction. Specifically, this review is designed to

identify baseline psychological traits in patients

Fig. 1 Conceptual diagrams of the fear-avoidance model of pain (a), the theory of self-efficacy (b), and stress, health, and the buffering hypothesis of social support (c) in the context of ACL reconstruction

Knee Surg Sports Traumatol Arthrosc (2015) 23:752–762 753

123

undergoing ACL reconstruction that are predictive of

clinically relevant outcomes, including return to sport, knee

rehabilitation compliance, and postoperative knee pain and

function.

Materials and methods

Initial search and primary screening

The guidelines outlined in the PRISMA statement for

standardized reporting of systematic reviews were adhered

to in the preparation of this manuscript [38]. A search was

performed on the PubMed database (1975 to June, 2012)

with the Medical Subject Headings (MeSH) advanced

search tool (Fig. 2). Systematic searches were also per-

formed in CINAHL, UptoDate, Google Scholar, Cochrane

Reviews, and SportDiscus in addition to hand searching of

reference lists of key publications. The titles and abstracts

of the studies identified in the initial screen were then

individually reviewed for the following selection criteria:

1. Studies investigating ACL reconstruction outcomes.

2. Study population consists primarily of physically

active individuals of any experience level with a mean

age 13–65 years.

3. Prospective study design.

4. Predictive assessment of psychological factors as an

injury risk factor was either a primary or secondary

aim of the study.

5. Study is reported in manuscript form in a peer-

reviewed publication. Meeting abstracts, posters, and

thesis papers were excluded.

6. Study reports original research in English.

Nineteen studies met inclusion criteria. The design and

methodology of which were reviewed to determine whe-

ther their analysis and findings were directly applicable to

the objective of this review. Eight studies were excluded

because of their focus on cross-sectional comparisons

between psychological factors and outcome measures [10,

19, 32, 36, 44–46, 56]. Two prospective studies were

rejected because they included psychological testing as part

of their outcome measures but not their baseline measures

[28, 40]. Finally, one prospective study was excluded

because it consisted of a mixed surgical and non-surgical

population [26], resulting in a final total of nine studies

included in this review.

Assessment and risk of bias

In order to assess the quality of the nine selected studies,

the study authors used a modified Coleman score; the

original Coleman score was utilized as an orthopaedic

quality assessment tool for patellar tendinopathy outcomes

studies [14]. Modifications of several items in part A of the

original Coleman score were made in either content or

language to improve their relevance to injury risk assess-

ment studies in sports medicine. Item 3 was changed from

‘‘number of different surgical procedures’’ to ‘‘number of

different screening tests’’ included in each reported out-

come. Item 6 was changed from ‘‘description of surgical

procedure’’ to ‘‘description of clinical screening test’’. Item

7 of the original Coleman score was removed, the content

of which originally pertained to sufficient description of the

study rehabilitation protocol.

Theoretical frameworks and grouping of psychological

scales

As is the case in sports medicine, there are often multiple

clinical scales available to behavioural psychologists to

measure the same general factor; therefore, to facilitate

interpretation, we have grouped the individual scales used

by the included studies according to the psychological

theory being tested (Table 1).

Data collection and reporting

The surgical procedure, patient demographics, sample size,

length of follow-up, pre-operative measures, and outcome

measures for all included studies were systematically iden-

tified and recorded (Table 2). The description of study

Fig. 2 Study flowchart

754 Knee Surg Sports Traumatol Arthrosc (2015) 23:752–762

123

findings was limited to pre-operative psychological factors

and their predictive assessment of knee-related outcomes.

Effect sizes of the identified psychological risk factors were

reported as available from the study manuscript. We did not

perform any secondary calculations with the reported data

with the exception of Gobbi et al.’s [23] descriptive data for

the psychovitality scale; in this case, the authors used an

appropriate nonparametric test (Mann–Whitney U) but

reported inappropriate descriptive statistics (means instead

of medians with interquartile ranges) for these non-normally

distributed data. Finally, though the psychological scales

presented in this paper apply to one of three theories (Fig. 2),

there are insufficient validation studies in the current litera-

ture between scales in a given category to provide a mean-

ingful pooled estimate or perform a meta-analysis.

Results

Study characteristics

A total of eight prospective cohort studies were included

for review based on our screening methodology and

inclusion criteria (Table 2). All studies included both sexes

and did not differentiate between levels of sports compe-

tition in their analyses. Mean ages ranged from 22 to

32 years [11, 52]. Sample size ranged from 38 to 100

(mean 71 ± 22 patients) [23, 54] and duration of follow-up

ranged from 3 to 60 months [11, 52].

Quality assessment with modified Coleman score

None of the studies fulfilled all of the criteria in the modified

Coleman score (Table 3). The mean modified Coleman

score 63 ± 5 out of 90, with a range of 55–72. The studies

achieved a mean score of 41 ± 3 out of 50 points on part A,

which primarily evaluates baseline study characteristics. The

studies scored worse on part B (mean 22 ± 3 points out of

40), which primarily evaluates outcome criteria and

recruitment rates. Of the individual factors on the modified

Coleman score, item 2 had the lowest number of studies that

met the specified criteria (2/8 studies), which required a

mean follow-up of at least 2 years.

Fear-avoidance model of pain

There were negative findings regarding the psychological

response to pain or fear of re-injury and knee surgery

Table 1 Study scale definitions

Underlying theory Category Acronym Scale name Factor assessed

Fear-avoidance model of pain

[37]

Fear-avoidance response

to injury

PCS [50] Pain Catastrophizing

Scale

Emotional response to pain

TSK-11 [61] Tampa Scale for

Kinesiophobia

Fear of activity and re-injury

Theory of self-efficacy [6] Optimism and self-

efficacy

SIS[29] Sports Injury Survey Self-reported use of positive coping

skills during rehabilitation

SSP [25] Swedish universities

Scales of Personality

Survey of personality traits

including optimism & pessimism

(embitterment)

SER [58] Modified Self-Efficacy for

Rehabilitation Outcome

Scale

Perceived ability to perform tasks

during injury rehabilitation

K-SES[53] Knee Self-Efficacy Scale Perceived ability to perform knee-

related tasks

Self-motivation ACL-RSI [60] ACL-Return to Sport after

Injury scale

Perceived ability and motivation to

return to sport

SMI [21] Self-motivation inventory Self-motivation to complete a task

Psychovitality

[23]

Psychovitality Scale Motivation and perceived

likelihood to return to sport after

injury

Stress, health, and the

buffering hypothesis of

social support [13]

Stress and social support

in the context of athletic

injury

BSI [17] Brief Symptom Inventory Psychological distress

ERAIQ [49] Emotional Responses of

Athletes to Injury

Questionnaire

Emotional impact of injury and

perceived social support

SSI Social support inventory Overall perceived social support

AIMS Athletic Identity

Measurement scale

Athletic self-identity (a source of

social support among athletes)

Knee Surg Sports Traumatol Arthrosc (2015) 23:752–762 755

123

T a

b le

2 In

c lu

d e d

st u

d ie

s

A u

th o

r T

im in

g o

f

a ss

e ss

m e n

ts

S tu

d y

p a rt

ic ip

a n ts

B a se

li n e

m e a su

re s

O u

tc o m

e m

e a su

re s

S tu

d y

re su

lt s

M o

d ifi

e d

C o

le m

a n

sc o

re P

sy c h

o lo

g ic

a l

sc a le

s d

e fi

n e d

in T

a b

le 2

B re

w e r

e t

a l.

[8 ]

P re

-o p

e ra

ti v

e

b a se

li n

e a n

d

6 -m

o n

th

fo ll

o w

-u p

a ss

e ss

m e n

ts

N =

9 5

, 6

7 m

a le

, 2

8 fe

m a le

, m

e a n

a g

e 2

6 .9

± 8

.2 y

e a rs

5 3

%

c o

m p

e ti

ti v

e ,

4 3

% re

c re

a ti

o n

a l

a th

le te

s. 9

0 %

o f

A C

L in

ju ri

e s

o c c u

rr e d

d u

ri n g

sp o

rt

S e lf

-m o

ti v

a ti

o n

(S M

I) ,

a th

le ti

c

id e n

ti ty

(A IM

S ),

so c ia

l su

p p o

rt

(S S

I) ,

st re

ss (B

S I)

R e h

a b il

it a ti

o n

e ff

o rt

(s p

o rt

in ju

ry

re h a b il

it a ti

o n

a d h e re

n c e

sc a le

-

S IR

A S

), c o

m p

li a n

c e

(a tt

e n

d a n

c e ,

h o

m e

e x e rc

is e ,

& c ry

o th

e ra

p y

c o

m p

le ti

o n

), k

n e e

A P

la x

it y

(K T

a rt

h ro

m e te

r) ,

1 le

g h

o p

d is

ta n

c e

(h o p

in d e x

sc o re

), a c ti

v it

y le

v e ls

(T e g

n e r

a c ti

v it

y sc

o re

)

A ft

e r

a d

ju st

in g

fo r

a g

e ,

se lf

-

m o ti

v a ti

o n

(S M

I) w

a s

a ss

o c ia

te d

w it

h re

h a b

il it

a ti

o n

e ff

o rt

(r =

0 .2

6 ,

p \

0 .0

5 )

a n

d h

o m

e

e x e rc

is e

c o m

p le

ti o n

(r =

0 .4

8 ,

p \

0 .0

0 1

), so

c ia

l su

p p o

rt (S

S I)

w a s

a ss

o c ia

te d

w it

h h

o m

e

e x e rc

is e

c o m

p le

ti o n

(r =

0 .2

2 ,

p \

0 .0

5 ),

a th

le ti

c id

e n

ti ty

w a s

a ss

o c ia

te d

w it

h k

n e e

la x

it y

(r =

0 .3

8 ,

p \

0 .0

0 1

), h

o p

in d e x

sc o

re (r

= 0

.2 6 ,

p \

0 .0

5 ),

a n

d

k n

e e

sy m

p to

m s

(L y

sh o

lm sc

o re

)

(r =

0 .2

7 ,

p \

0 .0

5 ),

a n

d st

re ss

(B S

I) w

a s

a ss

o c ia

te d

w it

h k

n e e

la x

it y

(r =

- 0

.5 2 ,

p \

0 .0

0 1

)

6 3

B re

w e r

e t

a l.

[7 ]

P re

-o p

e ra

ti v

e

b a se

li n

e a n

d

6 -m

o n

th

fo ll

o w

-u p

a ss

e ss

m e n

ts

N =

6 1

, 2

1 fe

m a le

, 4

0 m

a le

, m

e a n

a g

e 2

6 ±

8 y

e a rs

(r a n

g e

1 4

– 4 7

).

5 7

% c o

m p

e ti

ti v

e 4

1 %

re c re

a ti

o n a l

a th

le te

s, 9

0 %

o f

in ju

ri e s

o c c u

rr e d

d u

ri n

g sp

o rt

S e lf

-m o

ti v

a ti

o n

(S M

I) ,

a th

le ti

c

id e n

ti ty

(A IM

S ),

so c ia

l su

p p o

rt

(S S

I) ,

st re

ss (B

S I)

R e h

a b il

it a ti

o n

e ff

o rt

(S IR

A S

) a n

d

c o

m p

li a n

c e

(a tt

e n d

a n

c e ,

h o

m e

e x e rc

is e ,

& c ry

o th

e ra

p y

c o

m p

le ti

o n

)

A g

e m

o d

u la

te d

th e

re la

ti o

n sh

ip

b e tw

e e n

p sy

c h o

lo g

ic a l

fa c to

rs

a n

d k

n e e

o u

tc o

m e s.

T h

e sa

m p

le

w a s

st ra

ti fi

e d

in to

th re

e a g

e

g ro

u p s

(m e a n

a g

e 1

8 ,

m e a n

a g e

2 4

, a n

d m

e a n

a g

e 3

0 ),

a n

d th

e

sl o p e

o f

th e

li n e a r

re g re

ss io

n

c h

a n

g e d

b y

st ra

ta .

A s

m e a n

a g e

in c re

a se

d , th

e re

la ti

o n sh

ip (s

lo p e )

b e tw

e e n

e x

e rc

is e

c o

m p

le ti

o n

(d e p

e n

d e n t

v a ri

a b

le )

a n

d 1

)

a th

le ti

c id

e n

ti ty

b e c a m

e m

o re

n e g

a ti

v e

(s ta

n d

a rd

iz e d

c o

e ffi

c ie

n t

b e ta

= -

0 .4

8 ,

p \

0 .0

0 1

), 2

) se

lf -m

o ti

v a ti

o n

b e c a m

e m

o re

p o si

ti v e

(b e ta

= 0

.3 1

, p

= \

0 .0

5 ),

a n

d 3

)

so c ia

l su

p p o

rt b

e c a m

e m

o re

p o

si ti

v e

(b e ta

= 0

.2 5 ,

p \

0 .0

5 )

6 0

756 Knee Surg Sports Traumatol Arthrosc (2015) 23:752–762

123

T a

b le

2 c o

n ti

n u

e d

A u

th o

r T

im in

g o

f

a ss

e ss

m e n

ts

S tu

d y

p a rt

ic ip

a n ts

B a se

li n e

m e a su

re s

O u

tc o m

e m

e a su

re s

S tu

d y

re su

lt s

M o

d ifi

e d

C o

le m

a n

sc o

re P

sy c h

o lo

g ic

a l

sc a le

s d

e fi

n e d

in T

a b

le 2

C h m

ie le

w sk

i

e t

a l.

[1 1

]

P o st

o p e ra

ti v e

b a se

li n

e (1

st

re h a b il

it a ti

o n

a p

p o

in tm

e n

t)

a n

d 3

-m o

n th

fo ll

o w

-u p

a ss

e ss

m e n

ts

N =

7 7

, 4

1 m

a le

, 3

6 fe

m a le

, m

e a n

a g

e 2

2 .4

± 7

.1 y

e a rs

, 7

0 /7

7

in ju

re d

d u

ri n

g sp

o rt

K n

e e

sy m

p to

m s

(i n

te rn

a ti

o n

a l

k n

e e

d o

c u

m e n

ta ti

o n

c o

m m

it te

e

su b

je c ti

o n

k n

e e

e v

a lu

a ti

o n

fo rm

-

IK D

C ,

a n

d n

u m

e ri

c ra

ti n g

sc a le

fo r

p a in

-N R

S ),

k in

e si

o p

h o

b ia

(T S

K -1

1 ),

p a in

c a ta

st ro

p h iz

in g

(P C

S ),

se lf

-e ffi

c a c y

(S E

R )

K n e e

sy m

p to

m s

(N R

S ,

IK D

C )

K in

e si

o p h o b ia

(T S

K -1

1 )

a n d

se lf

-

e ffi

c a c y

(S E

R )

a t

th e

fi rs

t

re h a b il

it a ti

o n

a p p o in

tm e n t

(b a se

li n

e )

d id

n o

t p

re d

ic t

1 2

w e e k

p o

st o

p e ra

ti v

e p

a in

(N R

S )

o r

k n

e e

fu n

c ti

o n

sc o

re s

(I K

D S

) a ft

e r

a d

ju st

m e n

t fo

r a g

e ,

se x

, a n

d b

a se

li n

e k

n e e

p a in

(N R

S )

w it

h h

ie ra

rc h

ic a l

re g

re ss

io n

m o d

e ll

in g

(p [

0 .0

5 )

5 5

G o

b b

i a n

d

F ra

n c is

c o

[2 3 ]

P re

-o p

e ra

ti v

e

b a se

li n

e a n

d

1 2

-m o

n th

fo ll

o w

-u p

a ss

e ss

m e n

ts

N =

1 0

0 ,

6 7

m a le

, 3

3 fe

m a le

m e a n

a g

e 2

8 y

e a rs

(r a n

g e

1 7

– 5

0 ),

b o

th

c o m

p e ti

ti v e

a n d

re c re

a ti

o n a l

a th

le te

s

K n

e e

sy m

p to

m s

(I K

D C

a n

d

S A

N E

), a c ti

v it

y le

v e ls

(T e g n e r

a n d

M a rx

a c ti

v it

y sc

a le

s) ,

a n d

m o

ti v

a ti

o n

to re

tu rn

to sp

o rt

(p sy

c h

o v

it a li

ty )

K n

e e

is o

k in

e ti

c st

re n

g th

, k

n e e

m o

ti o

n a n

a ly

si s,

re tu

rn to

sp o

rt

P sy

c h

o v

it a li

ty sc

o re

s si

g n

ifi c a n

tl y

d if

fe re

d b

e tw

e e n

p a ti

e n

ts w

h o

re tu

rn e d

to sp

o rt

(n =

2 4

p a ti

e n

ts )

a t

1 2

m o n

th s

(m e d

ia n

1 6

p o

in ts

IQ R

1 4

– 1 8

) a n

d n

o n

-

re tu

rn e rs

(n =

2 4

p a ti

e n

ts )

(m e d

ia n

9 p

o in

ts IQ

R 8

– 1

5 )

(p \

0 .0

0 1

, M

a n

n –

W h

it n

e y

U )

7 2

L a n

g fo

rd e t

a l.

[3 3 ]

P o st

o p e ra

ti v e

b a se

li n

e (a

t

3 -m

o n

th )

a n

d

1 2

-m o

n th

fo ll

o w

-u p

a ss

e ss

m e n

ts

N =

8 7

, 5

5 m

a le

, 3

2 fe

m a le

, m

e a n

a g

e 2

7 .5

± 5

.7 y

e a rs

, a ll

p a rt

ic ip

a n ts

p la

y e d

sp o

rt s

o n

w e e k

ly b

a si

s p

ri o

r to

in ju

ry

D is

tr e ss

d u

e to

a th

le ti

c in

ju ry

(E R

A IQ

), m

o ti

v a ti

o n

to re

tu rn

to

sp o

rt (A

C L

-R S

I)

K n

e e

is o

k in

e ti

c st

re n

g th

, la

x it

y ,

L a c h

m a n

/p iv

o t

sh if

t te

st ,

ra n

g e

o f

m o

ti o

n ,

p re

se n

c e

o f

e ff

u si

o n

,

si n

g le

h o

p /c

ro ss

-o v

e r

h o

p

p e rf

o rm

a n

c e

A C

L -R

S I

a t

6 m

o n

th s

w a s

si g

n ifi

c a n

tl y

h ig

h e r

in a th

le te

s

w h

o re

tu rn

e d

to sp

o rt

a t

1 2

m o n

th s

(m e a n

6 3

.2 ±

1 7

.2 )

th a n

n o

n -r

e tu

rn e rs

(m e a n

5 1

.8 ±

1 6

.8 )

(p =

0 .0

0 5

). A

tr e n d

to w

a rd

s si

g n ifi

c a n c e

w a s

o b

se rv

e d

fo r

d if

fe re

n c e s

in

E R

A IQ

sc o re

s b e tw

e e n

re tu

rn e rs

a n

d n

o n

-r e tu

rn e rs

a ft

e r

a d

ju st

m e n

t fo

r a ss

e ss

m e n

t ti

m e

p o

in t

(p =

0 .0

8 ,

tw o

-f a c to

r

re p e a te

d -m

e a su

re s

A N

O V

A ).

E R

A IQ

sc o re

s d id

n o t

si g

n ifi

c a n

tl y

d if

fe r

b e tw

e e n

re tu

rn e rs

a n

d n

o n

-r e tu

rn e rs

(p =

0 .0

8 );

n o

a d

ju st

m e n

t w

a s

n e c e ss

a ry

fo r

a g e ,

g ra

ft -t

im e ,

ti m

e b

e tw

e e n

in ju

ry a n

d su

rg e ry

,

o r

a c ti

v it

y le

v e ls

a s

a ll

w e re

n o

n -

si g

n ifi

c a n

t c o v

a ri

a te

s (p

[ 0

.0 5

)

6 3

Knee Surg Sports Traumatol Arthrosc (2015) 23:752–762 757

123

T a

b le

2 c o

n ti

n u

e d

A u

th o

r T

im in

g o

f

a ss

e ss

m e n

ts

S tu

d y

p a rt

ic ip

a n ts

B a se

li n e

m e a su

re s

O u

tc o m

e m

e a su

re s

S tu

d y

re su

lt s

M o

d ifi

e d

C o

le m

a n

sc o

re P

sy c h

o lo

g ic

a l

sc a le

s d

e fi

n e d

in T

a b

le 2

S c h

e rz

e r

e t

a l.

[4 7

]

P o st

o p e ra

ti v e

b a se

li n

e (1

st

re h a b il

it a ti

o n

a p

p o

in tm

e n

t)

a n

d 6

m o n

th

fo ll

o w

-u p

a ss

e ss

m e n

ts

N =

5 4

, 1

7 fe

m a le

, 3

7 m

a le

, m

e a n

a g

e 2

8 ±

8 y

e a rs

5 2

%

c o m

p e ti

ti v e

a n d

4 6

% re

c re

a ti

o n a l

a th

le te

s

P o

si ti

v e

c o

p in

g sk

il ls

d u

ri n

g

re h a b il

it a ti

o n

(S IS

)

R e h

a b il

it a ti

o n

e ff

o rt

(S IR

A S

) a n

d

c o

m p

li a n

c e

(a tt

e n d

a n

c e ,

h o

m e

e x e rc

is e

a n d

c ry

o th

e ra

p y

c o

m p

le ti

o n

)

A ft

e r

a d

ju st

m e n

t fo

r c o

v a ri

a te

s

w it

h m

u lt

ip le

re g

re ss

io n

a n

a ly

si s,

u se

o f

g o

a l

se tt

in g

a s

a p

o si

ti v

e

c o

p in

g st

ra te

g y

w a s

p re

d ic

ti v

e o

f

h o

m e

e x e rc

is e

c o

m p

le ti

o n

(b e ta

= 0

.3 5

, p \

0 .0

5 )

in

a d

d it

io n

to re

h a b

il it

a ti

o n

e ff

o rt

(S IR

A S

) (b

e ta

= 0

.5 1

,

p \

0 .0

0 5

). U

se o

f p

o si

ti v

e se

lf -

ta lk

a s

a c o

p in

g st

ra te

g y

w a s

c o rr

e la

te d

w it

h h o m

e e x e rc

is e

c o

m p

le ti

o n

(r =

0 .5

2 ,

p \

0 .0

5 )

in u

n a d

ju st

e d

c o

rr e la

ti o

n a n

a ly

si s

6 4

S w

ir tu

n a n

d

R e n

st rö

m

[5 2 ]

P re

-o p

e ra

ti v

e

b a se

li n

e a n

d

6 0

-m o

n th

fo ll

o w

-u p

a ss

e ss

m e n

ts

N =

5 7

a t

b a se

li n

e ,

4 6

a t

fo ll

o w

-u p

,

m e a n

a g

e 3

2 ±

7 .9

y e a rs

. 2

2 /4

6

p a ti

e n

ts u

n d

e rw

e n

t A

L C

R (a

v e ra

g e

9 m

o n

th s

a ft

e r

d a te

o f

in ju

ry ),

2 4

/4 6

p a ti

e n

ts h

a d

A C

L R

, 2

4 /4

6

n o

n -o

p e ra

ti v

e m

a n a g

e m

e n

t

P e rs

o n a li

ty tr

a it

s (S

S P

) a n d

a c ti

v it

y

le v

e ls

(T e g

n e r)

K n

e e

sy m

p to

m s

(k n

e e

in ju

ry a n

d

o st

e o

a rt

h ri

ti s

o u

tc o

m e

sc o

re -

K O

O S

) a n

d a c ti

v it

y le

v e ls

(T e g

n e r)

L o

w p

e ss

im is

m sc

o re

s w

e re

a ss

o c ia

te d

w it

h h

ig h

e r

K O

O S

sc o

re s

(S p

e a rm

a n

’s rh

o =

-

0 .3

6 ,

p \

0 .0

5 ).

N o

a d

ju st

m e n

t

fo r

a g e

o r

p re

-i n ju

ry a c ti

v it

y

le v

e ls

w a s

p e rf

o rm

e d

a s

b o

th

m e a su

re s

h a d

n o

n -s

ig n

ifi c a n

t

c o rr

e la

ti o n s

w it

h o u tc

o m

e s

(p [

0 .0

5 )

6 7

T h

o m

e é

[5 5 ]

P re

-o p

b a se

li n

e ,

1 2

-m o

n th

fo ll

o w

-u p

N =

3 8

, 1

3 fe

m a le

, 2

5 m

a le

, m

e a n

a g

e 2

9 .7

y e a rs

(r a n

g e

1 6

– 5

5 )

A c ti

v it

y le

v e ls

(T e g

n e r)

, a n d

se lf

-

e ffi

c a c y

(K -S

E S

)

A c ti

v it

y le

v e ls

(T e g

n e r

a n

d

p h y si

c a l

a c ti

v it

y sc

a le

-P A

S )

k n e e

sy m

p to

m s

(K O

O S

a n

d L

y sh

o lm

k n

e e

sy m

p to

m sc

o re

), a n d

o n

e

le g

h o

p (h

o p

in d

e x

sc o

re )

P e rc

e iv

e d

se lf

-e ffi

c a c y

a t

c o

m p

le ti

n g

k n

e e -r

e la

te d

ta sk

s in

th e

fu tu

re (K

-S E

S -f

u tu

re )

w a s

p re

d ic

ti v e

o f

a n

a c c e p ta

b le

o u

tc o

m e

a c c o rd

in g

to K

O O

S

sc o re

(s p o rt

s- re

c re

a ti

o n

O R

1 .6

,

p =

0 .0

0 2

; q

u a li

ty o

f li

fe O

R 1

.5 ,

p =

0 .0

3 7

), T

e g

n e r

sc o

re (O

R

1 .7

, p

= 0

.0 0 3

), o

r h

o p

in d e x

sc o

re (O

R 2

.2 ,

p =

0 .0

4 ).

P a ti

e n ts

w e re

c la

ss ifi

e d

a s

h a v in

g

a n

‘‘ a c c e p

ta b

le o

u tc

o m

e ’’

if th

e y

h a d

a p o st

o p e ra

ti v e

d e c re

a se

in

T e g n e r

a c ti

v it

y sc

o re

(c o m

p a re

d

to p

re -i

n ju

ry le

v e ls

) o

f B

2 ,

a

p o

st o

p e ra

ti v

e K

O O

S -s

p o

rt s/

re c re

a ti

o n

o r

K O

O S

-q u a li

ty o f

li fe

su b

sc o

re o

f [

7 6

o r

a h

o p

in d

e x

sc o

re o

f [

9 0

%

5 9

758 Knee Surg Sports Traumatol Arthrosc (2015) 23:752–762

123

outcomes in the included studies (Table 2). In particular,

Chmielewski et al. [11] reported no association between

kinesiophobia (TSK-11) and pain catastrophizing (PCS) at

the first rehabilitation appointment and knee symptoms at

12 weeks postsurgery after adjustment for age, sex, and

baseline knee pain (NRS) with hierarchical regression

modelling (n.s.); however, interpretations of this negative

finding are limited by the study timeframe, which only

includes the early postoperative rehabilitation phase.

Theory of self-efficacy

A significant relationship was demonstrated between fac-

tors that contribute to a patient’s general belief or confi-

dence in a successful recovery and the actual outcome from

surgery (Table 2). Thomeé et al. [54] found that perceived

self-efficacy at completing knee-related tasks in the future

(K-SES-future) was predictive of an acceptable outcome

according to KOOS score, Tegner activity score, or hop

index score. Similar associations were reported by Gobbi

et al. [23] and Langford et al. [33] between measures of

perceived ability and benefit of returning to sport (psych-

ovitality and ACL-RSI scores, respectively) and actual

return to sport at 12-month follow-up. Finally, Swirtun and

Renström [52] found that patients with low pessimism

scores (high optimism) had higher KOOS scores at 5-year

follow-up (Spearman’s rho = -0.36, p \ 0.05). Self-efficacy in general was also found to affect reha-

bilitation-specific outcome measures (Table 2). Scherzer

et al. [47] found that patients who utilized goal setting or

positive self-talk had had greater rates of home exercise

completion and higher perceived effort during rehabilita-

tion. Brewer et al. [8] found that patients with higher self-

motivation (SMI) were more compliant with home exercise

programs (r = 0.48, p \ 0.001) and had greater effort during rehabilitation (SIRAS) (r = 0.26, p \ 0.05). A

follow-up cohort study by the same research group [7]

found that the strength of this relationship appears to be age

dependent, with self-motivation being a stronger predictor

of home exercise completion in older patients

(beta = 0.25, p \ 0.05).

Stress, health, and the buffering hypothesis of social

support

There was some evidence to support an association

between stress, social support, and knee surgery outcomes

(Table 2). Specifically, Langford et al. [33] found a trend

towards significance for differences in ERAIQ scores

among athletes who returned to sport at 12 months and

non-returners after adjustment for assessment time point

(p = 0.08, two-factor repeated-measures ANOVA).

Brewer et al. [8] found that higher levels of stress (BSI)

were associated with increased knee laxity, and athletic

identity (AIMS) was associated with decreased knee laxity;

social support (SSI) was positively associated with home

exercise completion (r = 0.22, p \ 0.05). Brewer et al. [7] demonstrated that as age increases, the relationship

between athletic identity and knee outcomes becomes less

significant, and social support becomes more significant.

Discussion

The most important finding of this systematic review is that

several psychological factors have been consistently dem-

onstrated to be predictive of postoperative outcomes fol-

lowing ACL reconstruction. Sports-related knee surgery

requires a substantial rehabilitative effort on the part of the

patient to achieve a satisfactory outcome. Additionally,

patients must be ready and willing to overcome the fear of

re-injury to return to their original level of activity and

Table 3 Modified Coleman scores

Study Part A Part B Total

score 1 2 3 4 5 6 Total 7 8 9 Total

Brewer et al. [8] 10 0 7 15 5 5 42 12 4 5 21 63

Brewer et al. [7] 10 0 7 15 5 5 42 12 6 0 18 60

Chmielewski et al. [11] 10 0 0 15 5 5 35 12 8 0 20 55

Gobbi and Francisco

[23]

10 5 7 15 5 3 45 4 11 12 27 72

Langford et al. [33] 10 0 7 15 5 3 40 0 8 15 23 63

Scherzer et al. [47] 10 0 0 15 5 5 39 7 8 10 25 64

Swirtun and

Renström [52]

7 0 7 15 5 5 44 12 8 5 23 67

Thomeé et al. [54] 7 5 7 15 5 5 39 7 11 5 20 59

Average score 40 ± 3.6 22 ± 2.9 63 ± 4.9

Knee Surg Sports Traumatol Arthrosc (2015) 23:752–762 759

123

sports participation. This relationship between patient

psychological traits and postoperative outcomes may par-

tially explain why a subset of patients fail to return to sport

despite adequate surgical restoration of knee function.

There is a consistent relationship between patients’ self-

confidence, optimism, and motivation to recover from

injury and the actual outcome of knee surgery [8, 23, 52,

54]. These factors likely contribute to a patient’s psycho-

logical ‘‘readiness’’ for knee surgery and the subsequent

rehabilitation process. This concept is supported by Ban-

dura’s theory of self-efficacy, which describes the rela-

tionship between intrinsic levels of perceived self-efficacy

(confidence in the ability to complete a task) and actual

behaviour (follow-through) [6]. The majority of studies in

this review lend support to our proposed theoretical

framework of self-efficacy in the context of ACL injury,

surgery, and rehabilitation (Fig. 2), as their measures self-

motivation, self-efficacy, and optimism were associated

with future knee pain, function, and return to sport [7, 8,

23, 33, 47, 54]. Because global measures related to self-

efficacy such as intrinsic optimism [52] and intrinsic self-

motivation [8] are considered to be stable (unchanging

within a year) personality traits, a pre-operative assessment

of these factors to gauge a patient’s psychological ‘‘readi-

ness’’ for sports-related knee surgery has the potential to

help guide individualized treatment recommendations.

The relationship between stress, social support (either

general or in relation to athletic identity), and knee surgery

outcomes is not surprising, as these factors also have an

effect on compliance with medical treatment, overall

quality of life, and general health status [20, 22, 43]. In

particular, levels of stress and perceived social support

appear to affect objective outcomes such as rates of return

to sport in addition to subjective outcomes such as self-

reported pain severity [33, 46]. An interesting age-specific

relationship in which pre-operative activity levels more

positively affect knee surgery outcomes in younger athletes

was identified by several studies in this review. The posi-

tive association between activity levels and outcomes may

be partially due to increased athletic self-identity, which

Brewer et al. [7] postulate is a source of positive social

support in younger individuals (\30 years age). Younger athletes may derive greater perceived social support from

sports participation than older adults; conversely, surgery

outcomes for older adults (30–40 years) were less strongly

associated with athletic self-identity and more strongly

associated with a general social support index SSI [7].

Investigators should be cognizant of the potential modify-

ing effect of age on these factors when interpreting sports-

related surgical outcomes in a population containing mul-

tiple age groups. Additionally, clinicians and physical

therapists should be aware that younger patients in partic-

ular may be negatively affected by loss of sports

participation and a team environment as a source of social

support. An appropriate way to counterbalance this loss of

social support would be to encourage use of positive cop-

ing strategies such as positive self-talk and goal setting as

described by Scherzer et al. [47] Finally, though stress is

responsive to treatment, routine screening of patients

without any prior indication of either condition may lead to

a high rate of false positives and an unnecessary number of

referrals to mental health professionals. Therefore, addi-

tional research is needed to determine the strength of

relationship between stress and surgical outcomes to more

appropriately assess the risk versus benefit of mental health

screening in a sports medicine setting.

The fear-avoidance model has an important role in

patient behaviour following knee surgery, as kinesiophobia

(negative response towards pain) and pain catastrophizing

(active avoidance of activities out of fear of recurrent pain

and injury) are two psychological factors that are strongly

correlated with lack of return to sport [2, 4, 32, 34, 56].

However, the current review is unable to characterize the

ability of pre-operative screening of patients for heightened

pain catastrophizing and kinesiophobia to predict levels of

these factors after knee rehabilitation. Likely, the negative

findings reported by Chmielewski et al. [11] are largely due

to an inadequate follow-up period, as the range of activities

allowed at 12 weeks postsurgery is far different from full

clearance of sports activities after rehabilitation comple-

tion. Further research with adequate follow-up is indicated

to determine the prognostic role, if any, that a baseline

assessment of pain perceptions or fear of recurrent injury

has on knee surgery outcomes.

The limitations of this review are primarily related to the

quality and design of the included studies. Our review

included prospective studies only, and the quality of studies

included in our review as assessed by the modified Cole-

man score (mean 62.9/90) is comparable to other recent

systematic reviews on sports medicine topics by Mithoefer

et al. [42] (mean 58/100), Cowan et al. [15] (mean 59/100)

and Harris et al. [27] (mean 54/100). However, the major

limitation of our review is that the relationship between

psychological factors and knee surgery outcomes is likely

understated. Two common shortcomings of the included

studies were a small sample size and short follow-up per-

iod, both of which lead to a decreased ability to detect

clinically significant relationships between baseline psy-

chological factors and knee surgery outcomes. Negative

findings were reported for a primary or secondary study

aim in at least 3 of 8 studies, but only one study reported a

power analysis or reasons why a sample size could not be

estimated a priori [11, 33, 52]. Additionally, inadequate

follow-up may minimize the observed effect of psycho-

logical factors on outcomes due to incomplete improve-

ment in knee symptoms and function in many patients at

760 Knee Surg Sports Traumatol Arthrosc (2015) 23:752–762

123

that time point. Finally, use of differing outcome measures

(return to sport, symptom scales, physiological measures,

and measures of compliance) and ceiling effects of symp-

tom scales can both increase false negative error rates.

Conclusion

In conclusion, patient psychological factors are predictive

of ACL reconstruction outcomes. Self-confidence, opti-

mism, and self-motivation are predictive of outcomes,

which is consistent with the theory of self-efficacy.

Stress, social support, and athletic self-identity are pre-

dictive of outcomes, which is consistent with the global

relationship between stress, health, and the buffering

hypothesis of social support. Additional research is nee-

ded to determine the potential role of psychological

screening as a pre-operative predictive tool for knee

surgery outcomes or alternatively as an opportunity for

risk factor intervention.

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