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

  • Knee
  • Published:
Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

Lack of return to sport following anterior cruciate 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) prospective design, (2) participants underwent ACL reconstruction, (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 (modified 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 rehabilitation 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. Kinesiophobia 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, optimism, 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.

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References

  1. Altmaier EM, Russell DW, Kao CF, Lehmann TR, Weinstein JN (1993) Role of self-efficacy in rehabilitation outcome among chronic low back pain patients. J Couns Psychol 40(3):335

    Article  Google Scholar 

  2. Ardern CL, Taylor NF, Feller JA, Webster KE (2012) Fear of re-injury in people who have returned to sport following anterior cruciate ligament reconstruction surgery. J Sci Med Sport 15(6):488–495

    Article  PubMed  Google Scholar 

  3. Ardern CL, Taylor NF, Feller JA, Webster KE (2012) Return-to-sport outcomes at 2 to 7 years after anterior cruciate ligament reconstruction surgery. Am J Sports Med 40(1):41–48

    Article  PubMed  Google Scholar 

  4. Ardern CL, Webster KE, Taylor NF, Feller JA (2011) Return to sport following anterior cruciate ligament reconstruction surgery: a systematic review and meta-analysis of the state of play. Br J Sports Med 45(7):596–606

    Article  PubMed  Google Scholar 

  5. Ardern CL, Webster KE, Taylor NF, Feller JA (2011) Return to the preinjury level of competitive sport after anterior cruciate ligament reconstruction surgery: two-thirds of patients have not returned by 12 months after surgery. Am J Sports Med 39(3):538–543

    Article  PubMed  Google Scholar 

  6. Bandura A (1977) Self-efficacy: toward a unifying theory of behavioral change. Psychol Rev 84(2):191

    Article  CAS  PubMed  Google Scholar 

  7. Brewer BW, Cornelius AE, Van Raalte JL, Petitpas AJ, Sklar JH, Pohlman MH, Krushell RJ, Ditmar TD (2003) Age-related differences in predictors of adherence to rehabilitation after anterior cruciate ligament reconstruction. J Athl Train 38(2):158–162

    PubMed Central  PubMed  Google Scholar 

  8. Brewer BW, Van Raalte JL, Cornelius AE, Petitpas AJ, Sklar JH, Pohlman MH, Krushell RJ, Ditmar TD (2000) Psychological factors, rehabilitation adherence, and rehabilitation outcome after anterior cruciate ligament reconstruction. Rehabil Psychol 45(1):20

    Article  Google Scholar 

  9. Brophy RH, Schmitz L, Wright RW, Dunn WR, Parker RD, Andrish JT, McCarty EC, Spindler KP (2012) Return to play and future ACL injury risk after ACL reconstruction in soccer athletes from the Multicenter Orthopaedic Outcomes Network (MOON) group. Am J Sports Med 40(11):2517–2522

    Article  PubMed Central  PubMed  Google Scholar 

  10. Chmielewski TL, Jones D, Day T, Tillman SM, Lentz TA, George SZ (2008) The association of pain and fear of movement/reinjury with function during anterior cruciate ligament reconstruction rehabilitation. J Orthop Sports Phys Ther 38(12):746–753

    Article  PubMed  Google Scholar 

  11. Chmielewski TL, Zeppieri G Jr, Lentz TA, Tillman SM, Moser MW, Indelicato PA, George SZ (2011) Longitudinal changes in psychosocial factors and their association with knee pain and function after anterior cruciate ligament reconstruction. Phys Ther 91(9):1355–1366

    Article  PubMed Central  PubMed  Google Scholar 

  12. Cohen S, Kamarck T, Mermelstein R (1983) A global measure of perceived stress. J Health Soc Behav 24:385–396

    Article  CAS  PubMed  Google Scholar 

  13. Cohen S, Wills TA (1985) Stress, social support, and the buffering hypothesis. Psychol Bull 98(2):310–357

    Article  CAS  PubMed  Google Scholar 

  14. Coleman BD, Khan KM, Maffulli N, Cook JL, Wark JD (2000) Studies of surgical outcome after patellar tendinopathy: clinical significance of methodological deficiencies and guidelines for future studies. Scand J Med Sci Sports 10(1):2–11

    Article  CAS  PubMed  Google Scholar 

  15. Cowan J, Lozano-Calderon S, Ring D (2007) Quality of prospective controlled randomized trials. Analysis of trials of treatment for lateral epicondylitis as an example. J Bone Joint Surg Am 89(8):1693–1699

    Article  PubMed  Google Scholar 

  16. Daniel DM, Fithian DC (1994) Indications for ACL surgery. Arthroscopy 10(4):434–441

    Article  CAS  PubMed  Google Scholar 

  17. Derogatis LR, Melisaratos N (1983) The Brief Symptom Inventory: an introductory report. Psychol Med 13(3):595–605

    Article  CAS  PubMed  Google Scholar 

  18. Desharnais R, Bouillon J, Godin G (1986) Self-efficacy and outcome expectations as determinants of exercise adherence. Psychol Rep 59(3):1155–1159

    Article  Google Scholar 

  19. Devgan A, Magu NK, Siwach RC, Rohilla R, Sangwan SS (2011) Functional outcome in athletes at five years of arthroscopic anterior cruciate ligament reconstruction. ISRN Orthop 2011:1–6

    Article  Google Scholar 

  20. DiMatteo MR, Lepper HS, Croghan TW (2000) Depression is a risk factor for noncompliance with medical treatment: meta-analysis of the effects of anxiety and depression on patient adherence. Arch Intern Med 160(14):2101

    Article  CAS  PubMed  Google Scholar 

  21. Dishman RK, Ickes W (1981) Self-motivation and adherence to therapeutic exercise. J Behav Med 4(4):421–438

    Article  CAS  PubMed  Google Scholar 

  22. Gaynes BN, Burns BJ, Tweed DL, Erickson P (2002) Depression and health-related quality of life. J Nerv Ment Dis 190(12):799

    Article  PubMed  Google Scholar 

  23. Gobbi A, Francisco R (2006) Factors affecting return to sports after anterior cruciate ligament reconstruction with patellar tendon and hamstring graft: a prospective clinical investigation. Knee Surg Sports Traumatol Arthrosc 14(10):1021–1028

    Article  PubMed  Google Scholar 

  24. Green SL, Weinberg RS (2001) Relationships among athletic identity, coping skills, social support, and the psychological impact of injury in recreational participants. J Appl Sport Psychol 13(1):40–59

    Article  Google Scholar 

  25. Gustavsson JP, Bergman H, Edman G, Ekselius L, von Knorring L, Linder J (2000) Swedish universities Scales of Personality (SSP): construction, internal consistency and normative data. Acta Psychiatr Scand 102(3):217–225

    Article  CAS  PubMed  Google Scholar 

  26. Hagger MS, Chatzisarantis NLD, Griffin M, Thatcher J (2005) Injury representations, coping, emotions, and functional outcomes in athletes with sports-related injuries: a test of self-regulation theory. J Appl Soc Psychol 35(11):2345–2374

    Article  Google Scholar 

  27. Harris JD, Siston RA, Pan X, Flanigan DC (2010) Autologous chondrocyte implantation: a systematic review. J Bone Joint Surg Am 92(12):2220–2233

    Article  PubMed  Google Scholar 

  28. Heijne A, Ang BO, Werner S (2009) Predictive factors for 12-month outcome after anterior cruciate ligament reconstruction. Scand J Med Sci Sports 19(6):842–849

    Article  CAS  PubMed  Google Scholar 

  29. Ievleva L, Orlick T (1991) Mental links to enhanced healing: an exploratory study. Sport Psychol 5(1):25–40

    Google Scholar 

  30. Kim S, Bosque J, Meehan JP, Jamali A, Marder R (2011) Increase in outpatient knee arthroscopy in the United States: a comparison of National Surveys of Ambulatory Surgery, 1996 and 2006. J Bone Joint Surg Am 93(11):994–1000

    Article  PubMed  Google Scholar 

  31. Kori SH, Miller RP, Todd DD (1990) Kinesiophobia: a new view of chronic pain behavior. Pain Manag 3(1):35–43

    Google Scholar 

  32. Kvist J, Ek A, Sporrstedt K, Good L (2005) Fear of re-injury: a hindrance for returning to sports after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 13(5):393–397

    Article  PubMed  Google Scholar 

  33. Langford JL, Webster KE, Feller JA (2009) A prospective longitudinal study to assess psychological changes following anterior cruciate ligament reconstruction surgery. Br J Sports Med 43(5):377–378

    Article  CAS  PubMed  Google Scholar 

  34. Lee DY, Karim SA, Chang HC (2008) Return to sports after anterior cruciate ligament reconstruction—a review of patients with minimum 5-year follow-up. Ann Acad Med Singap 37(4):273–278

    PubMed  Google Scholar 

  35. Leeuw M, Goossens MEJB, Linton SJ, Crombez G, Boersma K, Vlaeyen JWS (2007) The fear-avoidance model of musculoskeletal pain: current state of scientific evidence. J Behav Med 30(1):77–94

    Article  PubMed  Google Scholar 

  36. Lentz TA, Tillman SM, Indelicato PA, Moser MW, George SZ, Chmielewski TL (2009) Factors associated with function after anterior cruciate ligament reconstruction. Sports Health 1(1):47–53

    Article  PubMed Central  PubMed  Google Scholar 

  37. Lethem J, Slade PD, Troup JDG, Bentley G (1983) Outline of a Fear-Avoidance Model of exaggerated pain perception–I. Behav Res Ther 21(4):401–408

    Article  CAS  PubMed  Google Scholar 

  38. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gotzsche PC, Ioannidis JP, Clarke M, Devereaux PJ, Kleijnen J, Moher D (2009) The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. J Clin Epidemiol 62(10):e1–e34

    Article  PubMed  Google Scholar 

  39. Linschoten NJ, Johnson CA (1997) Arthroscopic debridement of knee joint arthritis: effect of advancing articular degeneration. J South Orthop Assoc 6(1):25–36

    CAS  PubMed  Google Scholar 

  40. Månsson O, Kartus J, Sernert N (2012) Pre-operative factors predicting good outcome in terms of health-related quality of life after ACL reconstruction. Scand J Med Sci Sports 23(1):15–22

    Article  PubMed  Google Scholar 

  41. McCullough KA, Phelps KD, Spindler KP, Matava MJ, Dunn WR, Parker RD, Reinke EK (2012) Return to high school- and college-level football after anterior cruciate ligament reconstruction: a Multicenter Orthopaedic Outcomes Network (MOON) cohort study. Am J Sports Med 40(11):2523–2529

    Article  PubMed Central  PubMed  Google Scholar 

  42. Mithoefer K, McAdams T, Williams RJ, Kreuz PC, Mandelbaum BR (2009) Clinical efficacy of the microfracture technique for articular cartilage repair in the knee: an evidence-based systematic analysis. Am J Sports Med 37(10):2053–2063

    Article  PubMed  Google Scholar 

  43. Moussavi S, Chatterji S, Verdes E, Tandon A, Patel V, Ustun B (2007) Depression, chronic diseases, and decrements in health: results from the World Health Surveys. Lancet 370(9590):851–858

    Article  PubMed  Google Scholar 

  44. Ochiai S, Hagino T, Tonotsuka H, Haro H (2011) Prospective analysis of health-related quality of life and clinical evaluations in patients with anterior cruciate ligament injury undergoing reconstruction. Arch Orthop Trauma Surg 131(8):1091–1094

    Article  PubMed  Google Scholar 

  45. Pizzari T, Taylor NF, McBurney H, Feller JA (2005) Adherence to rehabilitation after anterior cruciate ligament reconstructive surgery: implications for outcome. J Sport Rehabil 14(3):201

    Google Scholar 

  46. Rosenberger PH, Kerns R, Jokl P, Ickovics JR (2009) Mood and attitude predict pain outcomes following arthroscopic knee surgery. Ann Behav Med 37(1):70–76

    Article  PubMed  Google Scholar 

  47. Scherzer CB, Brewer BW, Cornelius AE, Van Raalte JL, Petitpas AJ, Sklar JH, Pohlman MH, Krushell RJ, Ditmar TD (2001) Psychological skills and adherence to rehabilitation after reconstruction of the anterior cruciate ligament. J Sport Rehabil 10(3):165–173

    Google Scholar 

  48. Scholz U, Sniehotta FF, Schwarzer R (2005) Predicting physical exercise in cardiac rehabilitation: the role of phase-specific self-efficacy beliefs. J Sport Exerc Psychol 27(2):135–151. http://journals.humankinetics.com/jsepbackissues/JSEPVolume27Issue2June/PredictingPhysicalExerciseinCardiacRehabilitationTheRoleofPhaseSpecificSelfEfficacyBeliefs. Accessed 5 Oct 2013

    Google Scholar 

  49. Smith AM, Scott SG, O’Fallon WM, Young ML (1990) Emotional responses of athletes to injury. Mayo Clin Proc 65(1):38–50

    Article  CAS  PubMed  Google Scholar 

  50. Sullivan MJL, Bishop SR, Pivik J (1995) The pain catastrophizing scale: development and validation. Psychol Assess 7(4):524

    Article  Google Scholar 

  51. Swinkels-Meewisse EJ, Swinkels RA, Verbeek AL, Vlaeyen JW, Oostendorp RA (2003) Psychometric properties of the Tampa Scale for kinesiophobia and the fear-avoidance beliefs questionnaire in acute low back pain. Man Ther 8(1):29–36

    Article  CAS  PubMed  Google Scholar 

  52. Swirtun LR, Renström P (2008) Factors affecting outcome after anterior cruciate ligament injury: a prospective study with a six-year follow-up. Scand J Med Sci Sports 18(3):318–324

    Article  CAS  PubMed  Google Scholar 

  53. Thomeé P, Wahrborg P, Borjesson M, Thomeé R, Eriksson BI, Karlsson J (2006) A new instrument for measuring self-efficacy in patients with an anterior cruciate ligament injury. Scand J Med Sci Sports 16(3):181–187

    Article  PubMed  Google Scholar 

  54. Thomeé P, Währborg P, Börjesson M, Thomeé R, Eriksson BI, Karlsson J (2008) Self-efficacy of knee function as a pre-operative predictor of outcome 1 year after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 16(2):118–127

    Article  PubMed  Google Scholar 

  55. Thomeé R, Renstrom P, Karlsson J, Grimby G (1995) Patellofemoral pain syndrome in young women. I. A clinical analysis of alignment, pain parameters, common symptoms and functional activity level. Scand J Med Sci Sports 5(4):237–244

    Article  PubMed  Google Scholar 

  56. Tripp DA, Stanish W, Ebel-Lam A, Brewer BW, Birchard J (2011) Fear of reinjury, negative affect, and catastrophizing predicting return to sport in recreational athletes with anterior cruciate ligament injuries at 1 year postsurgery. Sport Exerc Perform Psychol 1 (S):38–48

    Article  Google Scholar 

  57. Uchino BN, Cacioppo JT, Kiecolt-Glaser JK (1996) The relationship between social support and physiological processes: a review with emphasis on underlying mechanisms and implications for health. Psychol Bull 119(3):488–531

    Article  CAS  PubMed  Google Scholar 

  58. Waldrop D, Lightsey OR Jr, Ethington CA, Woemmel CA, Coke AL (2001) Self-efficacy, optimism, health competence, and recovery from orthopedic surgery. J Couns Psychol 48(2):233

    Article  Google Scholar 

  59. Wasserstein D, Khoshbin A, Dwyer T, Chahal J, Gandhi R, Mahomed N, Ogilvie-Harris D (2013) Risk factors for recurrent anterior cruciate ligament reconstruction: a population study in Ontario, Canada, with 5-year follow-up. Am J Sports Med. doi:10.1177/0363546513493580

    Google Scholar 

  60. Webster KE, Feller JA, Lambros C (2008) Development and preliminary validation of a scale to measure the psychological impact of returning to sport following anterior cruciate ligament reconstruction surgery. Phys Ther Sport 9(1):9–15

    Article  PubMed  Google Scholar 

  61. Woby SR, Roach NK, Urmston M, Watson PJ (2005) Psychometric properties of the TSK-11: a shortened version of the Tampa Scale for Kinesiophobia. Pain 117(1):137–144

    Article  PubMed  Google Scholar 

  62. Yang J, Peek-Asa C, Lowe JB, Heiden E, Foster DT (2010) Social support patterns of collegiate athletes before and after injury. J Athl Train 45(4):372–379

    Article  PubMed Central  PubMed  Google Scholar 

  63. Zautra AJ, Burleson MH, Matt KS, Roth S, Burrows L (1994) Interpersonal stress, depression, and disease activity in rheumatoid arthritis and osteoarthritis patients. Health Psychol 13(2):139–148

    Article  CAS  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Orthopaedics, The Ohio State University Wexner Medical Center, Suite 3100 Morehouse Medical Plaza 2050 Kenny Road, Columbus, OH, 43221, USA

    Joshua S. Everhart & David C. Flanigan

  2. Department of Family Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA

    Thomas M. Best

  3. OSU Sports Medicine, Sports Health and Performance Institute, The Ohio State University Wexner Medical Center, Columbus, OH, USA

    Thomas M. Best & David C. Flanigan

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  1. Joshua S. Everhart
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Correspondence to David C. Flanigan.

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Everhart, J.S., Best, T.M. & Flanigan, D.C. Psychological predictors of anterior cruciate ligament reconstruction outcomes: a systematic review. Knee Surg Sports Traumatol Arthrosc 23, 752–762 (2015). https://doi.org/10.1007/s00167-013-2699-1

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