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A Qualitative Investigation of the Decision to Return to Sport After Anterior Cruciate Ligament
Reconstruction: To Play or Not to Play
Vehniah K. Tjong, M. Lucas Murnaghan, Joyce M. Nyhof-Young and Darrell J. Ogilvie-Harris
Am J Sports Med 2014 42: 336 originally published online November 6, 2013
DOI: 10.1177/0363546513508762

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A Qualitative Investigation of the Decision to
Return to Sport After Anterior Cruciate
Ligament Reconstruction
To Play or Not to Play
Vehniah K. Tjong,*yz MD, M. Lucas Murnaghan,yz||{ MD,
Joyce M. Nyhof-Young,# PhD, and Darrell J. Ogilvie-Harris,yz||** MD
Investigation performed at the Orthopaedic Sports Medicine Program,
University of Toronto, Toronto, Ontario, Canada

Background: Primary anterior cruciate ligament (ACL) reconstruction is known to have excellent outcomes, but many patients do
not return to their preinjury level of sport participation. Previous studies have used subjective outcome scores to evaluate this
discrepancy, but none to date has used qualitative, in-depth patient interviews.
Purpose: To understand the factors influencing a patients decision to return to his or her preinjury level of sport after ACL
reconstruction.
Hypothesis: Extrinsic and intrinsic factors may affect ones decision to return to sport after primary ACL reconstruction despite
good functional knee scores.
Study Design: Case series; Level of evidence, 4.
Methods: An experienced interviewer conducted qualitative, semistructured interviews of 31 patients, aged 18 to 40 years, who
had undergone primary ACL reconstruction surgery. All participated in sport before injury and had a minimum 2-year follow-up
with no further surgeries or knee injuries. Qualitative analysis was then performed to derive codes, categories, and themes. An
assessment of preinjury and current sport participation by type, level of competition, and Marx activity score, along with
patient-reported knee function, was also conducted.
Results: Patient interviews revealed 3 overarching themes: fear, lifestyle changes, and innate personality traits. Elements of these
factors were shown to largely influence the decision to return to the preinjury sport both in those patients who had returned and
those who had not returned to sport. Less common factors included the surgeons advice not to return, depressed mood, and
persistent knee pain.
Conclusion: Patients who did not return to their preinjury level of sport after primary ACL reconstruction despite having good
knee function were largely influenced by fear, shifts in priority, and individual personalities. This study highlights the importance
for treating physicians to recognize and address psychological factors and lifestyle changes that largely contribute to a patients
postoperative decision to return to sport. Results from this study will allow surgeons and health care professionals to educate
patients contemplating surgery and to better understand the recovery process not only from sport-related surgeries but other
surgical interventions with the goal of returning to activity.
Keywords: qualitative interviews; anterior cruciate ligament reconstruction; return to sport; fear of reinjury

An anterior cruciate ligament (ACL) injury is one of the
most common traumatic injuries among physically active
patients.13 Although it is well known in the literature that
ACL reconstruction has favorable outcomes, many studies
have shown that a percentage of athletes do not return to
their preinjury level of activity.4 A recent meta-analysis
The American Journal of Sports Medicine, Vol. 42, No. 2
DOI: 10.1177/0363546513508762
2013 The Author(s)
demonstrated that an average of only 63% of patients return
to their preinjury level of sport after ACL reconstruction,
despite good to excellent International Knee Documentation
Committee (IKDC) subjective knee scores.6 Studies have
described fear of reinjury, mood, and social support to be
among the many factors that may influence this group of
injured athletes, although none has used methods to explore
these themes in detail.15,17,25,29 Subjective scores such as
the Tampa Scale for Kinesiophobia (TSK), Emotional
Responses of Athletes to Injury Questionnaire (ERAIQ),
and Profile of Mood States (POMS) have also been used to

336
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Vol. 42, No. 2, 2014 Deciding to Return to Sport After ACLR 337

study this population.2,18,29 However, the specific factors
influencing the postoperative return to sport have not
been investigated in a qualitative fashion. The primary
goal of this study was to understand the factors affecting
the cessation of sport participation after ACL
reconstruction.
MATERIALS AND METHODS
Participants
All patients between 18 and 40 years of age who had
undergone primary, unilateral ACL reconstruction with
a minimum 2-year follow-up and preinjury participation
in sport were included in the study. Surgery was per-
formed at a single university-affiliated hospital by a single
orthopaedic surgeon between 2002 and 2010. Patients with
any need for further surgery or those who had been treated
over 10 years ago were excluded from the study to decrease
confounding surgical factors as well as recall bias.
Approval from the research hospital ethics board was
granted before study commencement.
Recruitment and Data Collection
Recruitment was performed in 2 phases. Eligible patients
were initially contacted by mail, followed by a telephone
inquiry. Upon consent, interviews were scheduled and
informed consent obtained. Thirty- to 45-minute audio-
recorded telephone interviews by a single trained inter-
viewer (V.K.T.) were conducted using a study-specific
question guide. These open-ended questions were distilled
from a review of sports medicine, psychology, and qualita-
tive studies pertaining to sport injury. The interviewer
used the method of active passivity21 by not interrupting
patients unless the discussion deviated significantly from
the aim of the interview.
Semistructured interviews were used to elucidate
patient-derived concepts and themes regarding the decision
to return to sport after ACL reconstruction. Open-ended
questions with an iterative approach to the question guide
allowed for more patient expression and an opportunity to
address unquantifiable concerns while giving the inter-
viewer freedom to probe deeper into a patients response
(see the Appendix, available in the online version of this
article at http://ajsm.sagepub.com/supplemental). Detailed
information gathered during each separate interview was
a unique feature of this qualitative research that could not
otherwise be obtained using quantitative methods.
As a supplement to the interviews, preinjury and cur-
rent Marx activity scores as well as current patient-
perceived knee scores were obtained as secondary outcome
measures. Sport participation was defined by 3 categories:
type of sport, level of competition (recreational, varsity
high school, varsity college/university, professional), and
Marx activity score. The Marx activity score is a validated
score (of a possible 16) that measures the weekly frequency
of participation in cutting and pivoting activities. Only
those patients who had identical preinjury and current
postoperative values in all 3 categories were classified as
having successfully returned to their preinjury level of
play. Patients who did not return to sport were defined
as never having returned to sport at any time after their
surgery. The sample size was determined once data satura-
tion was obtained.22 In other words, data collection was
stopped once new concepts, themes, and explanations no
longer emerged from the interviews.
Data Analysis
Anonymity was preserved during transcription using an
alphanumeric identifier for each patient. Throughout
data collection, iterative adaptations of the interview ques-
tion guide took place to capture aspects of patients
responses that were not previously evident. This process
occurred between each interview and allowed for more
thorough data capture and analysis. Three members of
the research team (V.K.T., M.L.M., J.M.N.-Y.) applied
the method used by Strauss and Corbin27 of open coding,
axial coding, and selective coding to each of the transcribed
interviews.20 Line-by-line coding of the data was then
grouped into commonalities that reflected categories. Con-
nections between these categories were then classified as
themes. These themes became the overarching, patient-
derived explanations for the factors influencing a patients
decision to return to sport after ACL reconstruction. Sec-
ondary outcome measures were statistically analyzed
using the 2-tailed Student paired t test.
RESULTS
Within a 3-month period, 31 patients were interviewed.
Thirty-eight patients who were otherwise qualified for
this study declined participation. Twenty (64%) patients
had not returned to their preinjury level of sport as defined
by the 3 previously mentioned criteria (type of sport, level
of play, Marx activity score), and 11 (36%) patients had

*Address correspondence to Vehniah K. Tjong, MD, Division of Orthopaedic Surgery, University of Toronto, 149 College Street, Room 508A, Toronto,
ON M5T 1P5, Canada (e-mail: vtjong@gmail.com).
y
Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
z
Orthopaedic Sports Medicine Program, University of Toronto, Toronto, Ontario, Canada.

The Hospital for Sick Children, Toronto, Ontario, Canada.
||
Womens College Hospital, Toronto, Ontario, Canada.
{
Wilson Centre, University of Toronto, Toronto, Ontario, Canada.
#
Helliwell Medical Education Centre, University Health Network, Toronto, Ontario, Canada.
**Toronto Western Hospital, Toronto, Ontario, Canada.
The authors declared that they have no conflicts of interest in the authorship and publication of this contribution.

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338 Tjong et al The American Journal of Sports Medicine

TABLE 1
Patient Demographicsa 95 patients met
inclusion criteria
Patients Who Patients Who
Returned to Did Not Return
Characteristic Preinjury Sport to Preinjury Sport
31 patients
38 declined consented and 26 were unable to
Age group, y
participation participated in the be contacted*
18-29 6 (40) 9 (60)
study
30-40 5 (31) 11 (69)
Sex
Male 9 (41) 13 (59) 20 patients had not 11 patients had
Female 2 (22) 7 (78) returned to returned to
Occupation preinjury sport preinjury sport
Student 3 (38) 5 (62)
Full-time employment 8 (35) 15 (65)
Type of sport Figure 1. Study participation. *Wrong number, change of
Soccer 4 (36) 7 (64) address, and no answer after repeated calls. yPatients with
Football 1 (25) 3 (75) identical types of sport, levels of competition, and Marx
Ultimate Frisbee 1 (25) 3 (75) activity scores.
Basketball 2 (33) 4 (67)
Other (hockey, martial 3 (50) 3 (50)
arts, squash) Im the sole breadwinner here. Even though I know I could
Level of play go back, I wouldnt risk it (A11). The driving force behind
Recreational 7 (35) 13 (65)
these fears was carefully questioned, and in every instance,
Varsity high school 2 (50) 2 (50)
Varsity college/university 2 (33) 4 (67)
they were found to be self-driven and without an external
Paid professional 0 (0) 1 (100) party affecting the decision not to return to sport.
Total 11 (36) 20 (64) This was a stark contrast to the patients who returned to
their preinjury sport. Nearly half of the patients in this group
a
Values are expressed as n (%). admitted to being fearful or scared, particularly during their
initial return to sport. However, all of these patients
described their struggle to overcome this hurdle and eventu-
returned. Patient demographics and study participation ally relieved themselves of any fears that prevented them
are outlined in Table 1 and Figure 1. from playing sport: I did have some fear during the first
year of play, but as I became more confident and had better
Patient-Derived Themes strength, my mental toughness won (A20). Another patient
shared a similar experience: After I kept pushing and work-
From the 31 patients interviewed, 97 codes, 12 categories, ing to regain strength with my knee, the worry and fear just
and 3 overarching themes emerged. These themes are went away (A22). Interestingly, 1 patient who returned to
highlighted and illustrated with quotations from the playing basketball explained how he would approach getting
patient interviews below. injured again with a different perspective devoid of worry or
Fear. The most frequently encountered reason why fear: The second time around, I would not have any fear
patients decided not to return to their preinjury level and since I know it goes away and only delays and gets in the
type of sport revolved around fear. Almost all of the way of recovery (A15).
patients from this group expressed some type of fear, Overall, fear was a predominant theme expressed by
whether it was a fear of reinjury, fear of pain, fear of being patients in both groups. While one group focused on their
debilitated, fear of added financial burden, and even fear of fears and attributed much of their decision to stop playing
playing the sport itself. their preinjury level of sport to fear, the other group chose
One patient gave a powerful analogy to his experience: to use their fears as motivators or barriers to overcome in
If you got into a bad car accident on a highway, then you returning to play.
may not drive on that road again. Thats how I feel about Priorities. Changes in family commitments, job
my ACL (A07). Some patients even experienced disturbing demands, and life stages composed the second most pre-
flashbacks or physical reminders that perpetuated their dominant theme influencing nearly half of the patients
fear of returning to sport: I have this fixation on the scar. who chose not to return to their preinjury level of sport.
Every time I thought I could get back out there, the scar Several examples illustrate the family taking priority
would remind me and almost haunt me (A01); I get flash- over sport. One patient said, Im pregnant. The time com-
backs of the collision that put me out. The fear of a retear mitment I would have to put in to sustain my level of play
definitely stays on my mind (A10). A subset of these would be unsustainable for my household (B07). Simi-
patients described their fear of placing a financial burden larly, another patient reported, I have a family now, so
on their families as a result of loss of work from injury: I theres definitely less time. I couldnt do that anymore,
couldnt afford to get hurt in the same wayIm self- especially 6 times a week. My priorities have definitely
employed. For me, no work means no bills get paid (A06); changed (B05).

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Vol. 42, No. 2, 2014
Patients also attributed an increase in work hours as
a hindrance to returning to play: I travel for work and
spend much more time doing other things compared with
when I was younger and still a student. Life gets in the
way (A02); I have a very strict work schedule . . . . its def-
initely not the lack of want. If I had more time, I know that
my knee could handle it, and I could go back (B02).
The idea of aging and moving on to different stages in
life was also well described by the patients: I was 17
when I hurt my knee. Now, Im a grown-up, and playing
hockey 4 times a week is just not in the books for me
(A09). One patient also mentioned that her family had
moved, and she was not able to find another recreational
soccer league to join around her new place of residence.
On the other hand, patients who did return to their pre-
injury level of activity regarded sports as a high priority in
their lives and one that was influential in their decision to
return to sport. Their need to preserve their level of fitness
and athletic identity was a major influence: I needed to go
back to feel whole again (A16); Life just wouldnt be the
same without squash for me . . . . thats just who I am
(A19); My life revolves around sports, so of course I would
try my best not to give it up (A17).
Some younger athletes emphasized that they currently
lack any other commitments: There was absolutely noth-
ing holding me back from playing basketball again. Im
not married, school doesnt take up much time, and Im
an athlete at heart (B09); I have the time to play soccer
most of the week, whereas people with other commitments
likely do not (B08).
Personality. Throughout the interviews, patients
described their individual personalities to highlight why
they made their respective decisions. Those who did not
return to their preinjury level of sport described themselves
as being cautious, having a relaxed outlook, being procrasti-
nators, and having a lack of self-confidence. For instance, 1
patient mentioned, I am the cautious type and have become
even more so since the injury. Im one of those people who
double-check and triple-check before crossing the street
(A13). Another patient who did not return to sport shared
a similar perspective: I was always questioning my physio-
therapist when she said I was ready to move on, and I didnt
think I could. I took things very slowly and very gingerly
with my knee (A01). One patient recognized that her deci-
sion to stop playing soccer was solely based on her personal-
ity: I know my knee is fine and can handle the stresses of
the sport . . . but I am not the type of person who really likes
to be challenged. I definitely tend to choose the easy route
for most things in life (B04). Another patient also identified
her personality as a major influence: Im a relaxed type of
personnot exactly highly motivated. In fact, if it wasnt for
my parents, Id have delayed the whole thing, and my knee
would likely have been worse (B02).
In contrast, patients who did return to their preinjury
level of activity perceived themselves as being self-
motivated, competitive, team oriented, and self-aware
and having Type A personalities. Three examples of these
patients strong characteristics are as follows: Initially, I
was told not to return to basketball for 10 months, but I
returned in 3-and-a-half months. I am more motivated,
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Deciding to Return to Sport After ACLR 339
TABLE 2
Summary of Secondary Outcomesa
Patients Who Patients Who
Returned to Did Not Return
Preinjury Sport to Preinjury Sport P Value
Preinjury Marx 13.0 6 1.6 12.9 6 1.3 .89
activity score
Current Marx 13.0 6 1.6 5.5 6 1.6 \.001
activity score
Patient-perceived 8.5 6 0.7 7.7 6 0.6 .08
knee score
a
Values are expressed as mean 6 standard deviation.
more competitive, and more goal focused than most. I
rise to the challenge since I am a born athlete (B09); I
made rehab goals for myself and followed them. I can be
a pretty regimented person, and in this case, it helped
me get back (A16); Im a Type A, competitive personality,
and I dont like to be told No; so needless to say, if I
wanted to go back, I was going to go back (A19).
There were less common reasons why patients did not
return to their preinjury sport. Three patients mentioned
that if not for their surgeons advice to stop, they would
feel comfortable attempting to play sport again. Only 1
patient attributed her knee pain and decreased range of
motion as the primary reason why she did not return to
soccer. Several patients described a depressed mood as
one component, but not the leading reason, affecting their
decision not to return. As well, 2 patients commented that
encouragement from their varsity coaches and teammates
was essential to their return to play.
Secondary Outcomes. Table 2 summarizes the second-
ary outcome measures. In comparing both groups that
were interviewed, no significant differences existed
between preinjury mean Marx activity scores (12.9 did
not return vs 13.0 returned; P = .89), while quite a signifi-
cant difference existed between current mean scores (5.5 vs
13.0, respectively; P \ .001). Although current patient-
perceived knee scores (nonvalidated score of 10) did not
show a statistically significant similarity between the 2
groups (7.7 6 0.6 did not return vs 8.5 6 0.7 returned),
some overlap is evident. In other words, there are patients
who reported good knee scores (.8) and still chose not to
return to sport as well as patients who reported poorer
knee scores (\7) and currently have returned to their pre-
injury level of play.
DISCUSSION
Fear
Physical readiness and psychological readiness to return to
sport do not always coincide. Over the past quarter cen-
tury, studies have attempted to understand this phenome-
non more clearly by developing subjective scores and scales
to assess the psychology behind an athletes decision to
return to sport. Specifically, for ACL reconstruction in
340 Tjong et al
athletes, an adaptation of the TSK has been used as a pop-
ular tool to associate the fear of reinjury with an athletes
decision not to return to sport after surgery.11,17,29
Although it is arguably the best validated scale, the TSK
was originally developed to assess the relationship
between the fear of movement in patients with chronic
low back pain and has not been validated for athletes after
ACL reconstruction.30,31 Furthermore, multiple studies
using self-reported questionnaires have found the fear of
reinjury to be a major factor influencing patients in their
decision to return to sport after ACL surgery.3,9,19,23 Yet,
only a small number of studies have identified the fear of
reinjury after ACL reconstruction using interviews. Two
such examples come from the sports physical therapy liter-
ature that found the fear of reinjury to be inversely related
to a patients adherence to postoperative rehabilitation and
was also a common source of frustration throughout ACL
rehabilitation.14,24 Recently, a survey of sports medicine
physicians supported this notion and relayed that the
fear of reinjury is one of the most discussed topics between
physicians and patient-athletes.7 It also mentioned that
orthopaedic surgeons reported the lowest frequency of non-
injury-related psychological discussions compared with
other physicians.7
Not surprisingly, fear was a predominant theme among
study patients who chose not to return to their preinjury
level of play. Not only did these patients identify their
fear of reinjury, many also described nonphysical fears
such as the fear of loss of income, fear of repeating rehabil-
itation, and even fear of sporting incompetence. Podlog and
Eklund25 described the phenomenon of injured athletes
being fearful of not meeting the expectations of their
coaches or teammates and concerns over upholding ones
reputation. In their review, coaches indicated that unreal-
istic player expectations can result in a vicious circle of
frustration, poor performance, and reduced confidence.
Furthermore, it is arguable that patients fear of placing
a burden on their families reflects on their selfless priority
to support their family even when they are confident in
their ability to return to sport.
Interestingly, fear was also a theme that emerged from
the group of patients who had returned to sport. A willing-
ness to reinitiate playing sport despite fear was a key com-
ponent that differentiated this group from those who
allowed their fears to prevent them from even trying to
play again. One study from the pain management litera-
ture reported that patients who are motivated to confront
their fear of movement or reinjury are more likely to
return to their previous level of activity compared with
those who avoid the problem.16 After interviewing 10 com-
petitive gymnasts who had undergone a serious injury,
Chase et al10 concluded that mental preparation in the
form of imagery or relaxation and sources of self-efficacy
such as previous performance success and social support
helped to overcome the fear of reinjury in these athletes.
Models for return to sport and strategies to help ath-
letes overcome obstacles in their recovery have been
described in the sports psychology literature.1,28 Taylor
and Taylor28 discussed a model of progressive stages: ini-
tial return, confirmation of recovery, return to physical
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The American Journal of Sports Medicine
and technical ability, high intensity training, and return
to competition. This road map gives athletes a sense of pre-
dictability and control over their recovery but does not give
a time frame, identify obstacles, or suggest reasons why
some athletes do not achieve a full return. Although
a catered road map may prove to be a useful tool in helping
to understand and achieve rehabilitation success, there are
still other uncontrollable factors involved in the return to
sport. This study helps elucidate some of these factors.
Priorities
One of the most overlooked reasons why patients do not
return to their preinjury levels of activity after ACL recon-
struction is a personal lifestyle change. Many patients in
this study were transitioning between several life stages:
high school to university education, single to married life,
full-time student to full-time or part-time work. This inev-
itable aging process along with unpredictable relocations
or priority shifts due to family or work can often be the sin-
gle reason why patients are not able to return to their pre-
vious frequency of participation and level of sport.
On the other hand, the present study also demonstrates
that patients placing a high priority on sports are more
likely to return to their preinjury levels of play after sur-
gery. These patients tended to be younger with fewer con-
flicting commitments. Interestingly, a few patients in the
older age bracket described sports as being their major
form of stress relief and fitness maintenance, thereby neces-
sitating its presence in their lives and preserving their iden-
tity as an athlete. In support of these findings, one review
mentioned the love of sports as being a salient motive to
return from a serious injury.25 In the context of return to
sport, however, the literature on this topic is sparse.
Personality
Another major contrast represented in this study was the
difference in personalities between the 2 patient groups.
All patients who had returned to their previous sporting
level fell under the category of self-motivators or those
with highly competitive personalities. Psychologists
describe intrinsic motivation as an inherent tendency to
seek out challenges with a natural intent for growth and
enhancement.26 Podlog and Eklund25 extended this self-
determination framework in their review of athletes who
returned to sport after a serious injury. Their findings sug-
gest that internal motivation can be a large component of an
athletes decision to return to sport. Similarly, after inter-
viewing patients undergoing rehabilitation after ACL recon-
struction, Pizzari et al24 found self-motivation to be the
single most important psychological factor influencing exer-
cise adherence postoperatively. Eastlack et al12 argued that
return to sport might be more related to personality charac-
teristics than to instrumented anterior joint laxity and
defined those who returned to sport as being copers whose
joint laxity did not differ from noncopers who did not
return to sport after ACL reconstruction.
Among patients who did not return to preinjury levels
after ACL reconstruction, nearly half attributed their
Vol. 42, No. 2, 2014
decision to previously having or consequently developing
a cautious personality. While some may argue that people
naturally become less impulsive with age and experience,
a traumatic sports injury may reasonably beget a similar
increase in cautiousness. Without in-depth personality
assessments, this correlation cannot be confirmed. Several
qualitative studies have shown a strong relationship
between a patients personality, willingness, and likelihood
of returning to his or her preinjury level of sport after
a serious injury.12,14,29 A recent systematic review reported
that personality factors including impulsiveness as mea-
sured by the Karolinska Scales of Personality were not
related to returning to sport after injury.5 This discordance
highlights the gaps that may accompany subjective out-
come scores and the necessity for ongoing research.
The less common findings in this study have also been
mentioned in the literature. High school and college foot-
ball athletes mentioned that advice from sources such as
their treating surgeon has negatively affected their return
to play.23 Postinjury anxiety and depression have been rec-
ognized as factors contributing to a perceived and actual
delay through rehabilitation after ACL surgery.2,29 Social
support during recovery after a serious ski-related injury
has also been found to contribute to athletic well-being
and return to sport.8
Secondary Outcomes
The significant difference in current mean Marx activity
scores (5.5 vs 13.0, respectively; P \ .001) between those
who did not return to sport and those who did was
expected. This scoring system was chosen to assist in defin-
ing what constituted a return to a preinjury level of sport
according to the frequency of cutting and pivoting activity
and not as a tool to predict a patients suitability to return
to play. The similarity between mean patient-perceived
knee scores in both groups (7.7 6 0.6 did not return vs
8.5 6 0.7 returned) supports the idea that there are factors
contributing to a patients decision to return to his or her
preinjury sport outside of knee pain, strength, range of
motion, and stability. Some patients who reported good
knee scores still chose not to return to sport, while some
with poorer knee scores did return. Correlations with a val-
idated knee outcome score such as the IKDC score would
serve as a better marker for knee function in future work.
The main strengths of this study were its qualitative
design and use of in-depth, semistructured interviews to
reveal some new answers to an old question. Another
strength was that the interviewer was not involved in
any aspect of care for the patients interviewed. Because
of the nature of the interview setting, some patients may
have been reluctant to share their views on sensitive topics
such as self-reported personality or knee function despite
confidentiality, although this was never expressed.
Patients who agreed to participate may have had divergent
views from those who declined. Reasons for declining to
participate in the study were not recorded as part of this
study. Social desirability bias or those who wished to
appear stronger or more confident than actuality could
also have affected the results. This study is also limited
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Deciding to Return to Sport After ACLR 341
to a patient population of 1 urban academic surgeon,
with a study bias of the majority of patients being recrea-
tional athletes compared with varsity- or professional-level
athletes. Future investigations using a mixed-methods
approach combining quantitative subjective outcome
scores with qualitative methods may better support this
work and lead to the development of strategies to help ath-
letes and physicians better understand the phenomenon of
returning to sport after a serious injury.
CONCLUSION
This study identifies 3 main themes of fear, priority, and
personality as having the most influence on patients
when deciding whether to return to their preinjury level
of sport after successful ACL reconstruction. The results
imply that sports medicine and health care professionals
should invest more attention to psychological factors, indi-
vidual lifestyle choices, and patient goals to (1) fully under-
stand the community of athletes who have suffered a major
injury requiring surgery and (2) more effectively address
their needs. While the orthopaedic community searches
for innovative advances in ACL reconstruction to improve
outcomes, a re-evaluation of whether a postoperative
return to sport is an appropriate outcome measure for sur-
gical success is warranted. Insight from this study has
broad implications for patients returning to sport after sur-
gery and can also provide education for those contemplat-
ing surgery. Future work using both the foundation from
this study with quantitative knee scores can further
develop our understanding of the postoperative return to
work, service, or sport.
ACKNOWLEDGMENT
A world of thanks to Sebastien Buret for leading the
recruitment effort for this study. His time and patience
are greatly appreciated.
REFERENCES
1. Andersen M, Williams J. Returning to Action and the Prevention of
Future Injury. Melbourne: Oxford University Press; 2001.
2. Appaneal R, Levine B, Perna F, Roh J. Measuring post-injury depres-
sion among male and female competitive athletes. J Sport Exerc Psy-
chol. 2009;31:60-76.
3. Ardern CL, Taylor NF, Feller JA, Webster KE. Fear of re-injury in peo-
ple who have return to sport following anterior cruciate ligament
reconstruction surgery. J Sci Med Sport. 2012;15(6):488-495.
4. Ardern CL, Taylor NF, Feller JA, Webster KE. Return-to-sport out-
comes at 2 to 7 years after anterior cruciate ligament reconstruction
surgery. Am J Sports Med. 2012;40(1):41-48.
5. Ardern CL, Taylor NF, Feller JA, Webster KE. A systematic review of
psychological factors associated with returning to sport following
injury [published online October 13, 2012]. Br J Sports Med.
doi:10.1136/bjsports-2012-091203.
6. Ardern CL, Webster KE, Taylor NF, Feller JA. Return to sport follow-
ing anterior cruciate ligament reconstruction surgery: a systematic
review and meta-analysis of the state of play. Br J Sports Med.
2011;45:596-606.
342 Tjong et al
7. Barton J, Grana W, Indelicato P, ONeill D, George S. A survey of
sports medicine physicians regarding psychological issues in
patient-athletes. Am J Sports Med. 2007;35(12):2140-2147.
8. Bianco T. Social support and recovery from sport injury: elite skiers
share their experiences. Res Q Exerc Sport. 2001;72(4):376-388.
9. Brophy R, Schmitz L, Wright R, et al. Return to play and future ACL
injury risk after ACL reconstruction in soccer athletes from the Multi-
center Orthopaedic Outcomes Network (MOON) Group. Am J Sports
Med. 2012;40(11):2517-2522.
10. Chase M, Magyar M, Drake B. Fear of injury in gymnastics: self-
efficacy and psychological strategies to keep on tumbling. J Sports
Sci. 2005;23(5):465-475.
11. Chmielewski T, Jones D, Day T, Tillman S, Lentz T, George S. The
association of pain and fear of movement/reinjury with function dur-
ing anterior cruciate ligament reconstruction rehabilitation. J Orthop
Sports Phys Ther. 2008;38(12):746-753.
12. Eastlack M, Axe M, Snyder-Mackler L. Laxity, instability, and func-
tional outcome after ACL injury: copers versus noncopers. Med Sci
Sports Exerc. 1999;31(2):210-215.
13. Griffin L, Agel J, Albohm M, et al. Noncontact anterior cruciate liga-
ment injuries: risk factors and prevention strategies. J Am Acad
Orthop Surg. 2000;8:141-150.
14. Heijne A, Axelsson K, Werner S, Biguet G. Rehabilitation and recov-
ery after anterior cruciate ligament reconstruction: patients experi-
ences. Scand J Med Sci Sports. 2008;18:325-335.
15. Kocher M, Steadman J, Briggs K, Zurakowski D, Sterett W, Hawkins
R. Determinants of patient satisfaction with outcome after anterior
cruciate ligament reconstruction. J Bone Joint Surg Am. 2002;84:
1560-1572.
16. Kori S, Miller R, Todd D. Kinesiophobia: a new view of chronic pain
behavior. Pain Manag. 1990;3:35-43.
17. Kvist J, Ek A, Spornstedt K, Good L. Fear of re-injury: a hindrance for
returning to sports after anterior cruciate ligament reconstruction.
Knee Surg Sports Traumatol Arthrosc. 2005;13:393-397.
18. Langford J, Webster K, Feller J. A prospective longitudinal study to
assess psychological changes following anterior cruciate ligament
reconstruction surgery. Br J Sports Med. 2009;43:377-378.
For reprints and permission queries, please visit SAGEs Web site at http://www.sagepub.com/journalsPermissions.nav
Downloaded from ajs.sagepub.com at Universita' degli studi di Roma "Foro Italico" on February 19, 2014
The American Journal of Sports Medicine
19. Lee DY, Karim SA, Chang HC. Return to sports after anterior cruciate
ligament reconstruction: a review of patients with minimum 5-year
follow-up. Ann Acad Med Singapore. 2008;37(4):273-278.
20. Lingard L, Albert M, Levinson W. Grounded theory, mixed methods,
and action research. Br Med J. 2008;337:459-461.
21. Malterud K. Qualitative research: standards, challenges, and guide-
lines. Lancet. 2001;358:483-488.
22. Marshall MN. Sampling for qualitative research. Fam Pract. 1996;
13:522-525.
23. McCullough K, Phelps K, Spindler K, et al. 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. 2012;40(11):2523-2529.
24. Pizzari T, McBurney H, Taylor N, Feller J. Adherence to anterior cru-
ciate ligament rehabilitation: a qualitative study. J Sports Rehabil.
2002;11:90-102.
25. Podlog L, Eklund RC. A longitudinal investigation of competitive ath-
letes return to sport following serious injury. J Appl Sport Psychol.
2006;18:44-68.
26. Ryan R, Deci E. Self-determination theory and the facilitation of intrin-
sic motivation, social development, and well-being. Am Psychol.
2000;55:68-78.
27. Strauss A, Corbin J. Basis of Qualitative Research: Grounded Theory
Procedures and Techniques. Newbury Park, California: Sage Publi-
cations; 1990.
28. Taylor J, Taylor S. Psychological Approaches to Sports Injury Reha-
bilitation. Gaithersburg, Maryland: Aspen; 1999.
29. Tripp D, Stanish W, Ebel-Lam A, Brewer B, Birchard J. Fear of rein-
jury, negative affect, and catastrophizing predicting return to sport in
recreational athletes with anterior cruciate ligament injuries at 1 year
post surgery. Sport Exerc Perform Psychol. 2011;1:38-48.
30. Vlaeyen J, Kole-Snijders A, Boeren R, van Eek H. Fear of movement/
(re)injury in chronic low back pain and its relation to behavioural per-
formance. Pain. 1995;62(3):363-372.
31. Woby S, Roach N, Urmston M, Watson P. Psychometric properties of
the TSK-11: a shortened version of the Tampa Scale for Kinesiopho-
bia. Pain. 2005;117:137-144.