Psychological Readiness: The Missing Piece in Returning to Sport After ACL Reconstruction

Recovering from an ACL (anterior cruciate ligament) injury is often viewed as a physical challenge. But for many athletes, the biggest hurdle isn’t strength or mobility — it’s mindset.

Even after surgery and rehabilitation, returning to sport can bring fear of re-injury, hesitation, and a lack of confidence. A recent study from the Sydney Orthopaedic Research Institute (SORI) highlights just how important psychological readiness is in this phase of recovery.

Led by Dr. David Parker and Dr. Brett Fritsch, the study was published in the Journal of Orthopaedic Case Reports and offers new insight into the relationship between mental and physical readiness after ACL reconstruction.

About the Study

The study involved 201 patients who had undergone ACL reconstruction. Each patient completed the ACL-RSI (Anterior Cruciate Ligament–Return to Sport after Injury) questionnaire before and after their return-to-sport functional testing. This testing typically includes strength assessments, hop tests, and other objective measures of knee function.

The researchers wanted to know: does completing a physical assessment change how ready someone feels to return to sport?

What the Results Showed

• Psychological readiness improved after testing. ACL-RSI scores significantly increased after patients completed their functional assessment. Being able to see their progress helped many feel more confident.

• Males reported higher readiness than females overall. This finding suggests there may be sex-based differences in how psychological recovery progresses.

• For females, better physical performance did not always mean greater confidence. In fact, improvements in hop test results were negatively associated with changes in ACL-RSI scores. Some women performed well but still didn’t feel ready to return.

  
  

Why This Matters

Historically, return-to-sport decisions have focused on physical recovery — strength, symmetry, stability. But this study reinforces that mindset and mental readiness are just as important. If an athlete isn’t mentally prepared, they may modify their movements, underperform, or be at higher risk of re-injury.

Clinical Takeaways

This research supports a more holistic approach to return-to-sport decision making:

• Include psychological assessment tools like the ACL-RSI alongside functional testing

• Be aware that recovery may look different between male and female patients

• Create space for conversations about fear, confidence, and expectations

At SORI, our work is driven by the belief that recovery should address both the physical and psychological aspects of healing. Supporting athletes in both areas leads to better outcomes, reduced risk of re-injury, and a safer return to the sport they love.

Learn More

You can read the full study and explore more of SORI’s 2025 publications at www.sori.org.au/our-research/publications