Physical Therapy in Sport 9
Received 29 August 2006; received in revised form 19 September 2007; accepted 20 September 2007
of the 47% that had not returned to their pre-injury
ARTICLE IN PRESS
Corresponding author. Tel.: +613 9479 5796;
activity 3–4 years after surgery, 24% reported fear of re-
injury as the reason.
1466-853X/$ - see front matter r 2007 Elsevier Ltd. All rights reserved.
fax: +613 9479 5768.
E-mail address: firstname.lastname@example.org (K.E. Webster).
Anterior cruciate ligament (ACL) rupture is an
incapacitating knee injury that occurs frequently in
athletes. It is typically treated with surgical reconstruc-
tion and it is estimated that in the United States more
than 100,000 ACL reconstructions are performed
annually (Owings & Kozak, 1998). Although an
abundance of research has examined how knee function
is affected by this surgery, less attention has been paid to
psychological factors that may influence an athlete’s
return to sport (Podlog & Eklund, 2004). This is
significant as it has been demonstrated that up to 50%
of athletes do not return to their pre-injury level of sport
participation following ACL reconstruction despite
being physically rehabilitated (Feller & Webster, 2003;
Kvist, Ek, Sporrstedt, & Good, 2005). Unfortunately,
most authors do not report the reasons why athletes in
their study do not return to sport. One exception is a
recent study by Kvist et al. (2005) who surveyed 62
athletes following ACL reconstruction and found that
Keywords: Psychological responses; Athletic injury; Knee surgery; Rehabilitation
r 2007 Elsevier Ltd. All rights reserved.
Objectives: The purpose of this study was to develop a scale to measure the psychological impact of returning to sport after anterior
cruciate ligament (ACL) reconstruction surgery.
Main outcome measure: Three types of psychological responses believed to be associated with resumption of sport following athletic
injury—emotions, confidence in performance, and risk appraisal—were incorporated into a 12-item ACL-Return to Sport after
Injury (ACL-RSI) scale.
Participants: Two hundred and twenty participants who had undergone ACL reconstruction completed the scale between 8 and
22 months following surgery.
Results: The scale was shown to have acceptable reliability (Cronbach’s alpha ¼ 0.92). Participants who had given up sport scored
significantly lower on the scale (reflecting a more negative psychological response) than those who had returned or were planning to
return to sport (po0.001).
Conclusion: It was concluded that the decision to return to sport after ACL reconstruction is associated with a significant
psychological response. Preliminary reliability and validity was found for the ACL-RSI scale. This scale may help to identify athletes
who will find sport resumption difficult.
Development and preliminary va
psychological impact of returning
Kate E. Webster
Musculoskeletal Research Centre, La Trobe
ation of a scale to measure the
sport following anterior cruciate
eller, Christina Lambros
ersity, Melbourne, Victoria 3086, Australia
ARTICLE IN PRESS
Two further studies have also provided insight into
the psychological consequences of ACL reconstruction
surgery. Both LaMott (1994) and Morrey, Stuart,
Smith, and Wiese-Bjornstal (1999) examined athletes’
emotional response throughout rehabilitation using the
Emotional Response of Athletes to Injury Questionnaire
(ERAIQ). Both studies showed that athletes not only
experience negative emotions following injury, but also
have a second increase in negative emotions in the latter
part of rehabilitation. They referred to this as an
emotional ‘‘U’’ pattern. In the Morrey et al. study, this
second increase in negative emotions occurred 6 months
following surgery and was associated with clearance by
the orthopaedic surgeon to return to sport. Based on
these findings the authors suggested that returning to
sport had a significant psychological impact on the
athletes. No attempt was however made to document
whether or not the athletes actually returned to sport
In other sporting contexts, other factors such as
athletic confidence have also been raised (Johnston &
Carroll, 1998; Quinn & Fallon, 1999). In a qualitative
study, Johnston and Carroll (1998) asked 16 athletes
with a variety of injuries to recall their experiences from
the acute injury stage until return to sport. Using
grounded theory to describe the athletes’ responses, they
found that fear of re-injury was the predominant
emotional factor that was associated with returning to
sport. However, confidence in the ability to perform well
and appraisal of the risk of returning to sport were
also identified as key psychological responses in the
model. As the model proposed by Johnston and Carroll
describes both the situational and temporal context
of athletic injury it may be particularly useful for
understanding psychological aspects of recovery from
In regard to athletic confidence, the literature suggests
that confidence is vital among athletes returning to
competitive sport (Evans, Hardy, & Fleming, 2000;
Grove & Gordon, 1995; Quinn & Fallon, 1999) and that
physical and psychological readiness to return to sport
do not necessarily coincide (Podlog & Eklund, 2007).
Athletes with injuries have lower levels of sport
confidence than athletes without injury (LaMott, 1994)
and an athlete’s confidence in their ability to perform
well is lower when they are returning to sport after
injury (Johnston & Carroll, 1998). Athletic confidence
has not been considered in the context of ACL
reconstruction but based on the above research findings
it is reasonable to hypothesise that it may play a role in
the poor rate of return to sport after this surgery.
In regard to the way in which an athlete appraises the
risk of returning to sport, a key theme identified in
Johnston and Carroll’s model is whether to risk
returning prematurely to sport. Their work has shown
K.E. Webster et al. / Physica10
that clear differences exist between athletes who return
early and those who choose to wait. Specifically, athletes
who risk premature return tend to underestimate injury
severity and focus on short-term goals whilst ignoring
any possible long-term consequences of early participa-
tion. Whereas athletes who do not risk a premature
return are more likely to have undergone surgery, long
rehabilitation and have previous injuries. There have
been no empirical studies to evaluate how athletes
recovering from ACL surgery appraise the risk of
returning to their pre-injury sport.
In reviewing the literature we were unable to find a
scale that specifically looked at returning to sport
after athletic injury. Scales such as the ERAIQ are
excellent at documenting athletes’ emotions after injury
but do not include emotions, which are important in the
context of sport resumption, such as fear of re-injury.
The recently published Knee Self Efficacy scale (Tho-
mee, Wahrborg, Borjesson, Thomee, Eriksson, &
Karlsson, 2006), which was not available at the time
this study commenced, asks athletes who have suffered a
knee injury about their degree of certainty at being able
to return to the same activity level as before their injury
and about future knee function. Sport confidence
typically refers to the amount of confidence the athlete
has in their ability to perform well at their sport.
However, in the case of ACL reconstruction, it may also
relate to the amount of confidence the athlete has in
their knee function. It would be useful to identify
athletes as who might find returning to sport difficult
and measuring such responses might help to understand
the low rate of return to pre-injury levels of sport
participation following this type of surgery. Therefore,
the purpose of this study was to develop a scale which
measured athletes’ emotions, confidence and risk
appraisal when returning to sport after ACL reconstruc-
Two hundred and twenty athletes who had undergone
ACL reconstruction participated. There were 124 males
and 96 females aged between 16 and 54 years
(mean ¼ 29.2 years, SD ¼ 9.7). Athletes were eligible if
they had been participating in sport on a weekly basis
prior to injury. In addition, only athletes who planned
to return to sport after their surgery were included. The
average amount of time spent in sport participation
prior to injury was 6.5 h per week (range 2–26). Athletes
were excluded if they had not sustained their ACL injury
whilst participating in sport or had not been given
medical clearance to return to sport training by the
treating orthopaedic surgeon. Athletes were also ex-
cluded if they had given up sport for reasons other than
rapy in Sport 9 (2008) 9–15
their knee, such as pregnancy.
specific knee symptom of giving way, which is the
primary symptom experienced after ACL rupture.
Two items (9,10) were developed to measure athletes’
confidence in their overall ability to perform well at their
sport. Item 9 was specifically designed to com-
pare confidence in current and previous level of sport
performance. This was particularly relevant since one
of the aims of having ACL reconstructive surgery is
to return to previous levels of function and sport
Initially only one item (item 11) was included to
investigate the cognitive risk appraisal of the athlete to
re-injury. These initial 11 items were administered to a
pilot sample of 28 consecutive athletes who had under-
gone ACL reconstruction for comment regarding read-
ability, clarity and relevance of questions, or any other
suggestions they thought would improve the scale. From
this, it was suggested that the thought of having to go
through surgery and rehabilitation again was an
important consideration. Item 12 was thus added to
the scale to further explore risk appraisal.
Once the 12 items were generated, they were
ARTICLE IN PRESS
10. Are you confident about your ability to
perform well at your sport?
11 72.93 (25)
11. Do you think you are likely to re-injure
your knee by participating in your sport?
2 59.94 (25)
12. Do thoughts of having to go through
surgery and rehabilitation again prevent you
from playing your sport?
10 70.35 (30)
Item 2 was from the Quality of Life Outcome Measure for Chronic
ACL Deficiency (ACL-QOL) scale (Mohtadi, 1998).
Athletes were recruited from the private practice of a
specialist knee orthopaedic surgeon when they attended
for routine review. They participated in the study
between 8 and 22 months (mean ¼ 12 months) following
their reconstructive surgery. This range allowed for the
inclusion of participants who were at various stages of
rehabilitation. All athletes were allowed to commence
sport specific drills 3 months after surgery, commence
training at 6 months and competition once they had
been training without problems or restrictions for
1 month. Nine percent (20/220) of participants had
undergone a previous ACL reconstruction. For 17
participants the previous reconstruction was on the
contralateral knee and for three it was on the same knee.
2.2. Scale development
Items developed for the scale were centred on the
three psychological responses identified by the literature
as associated with the return to sport phase: emotions,
confidence in performance and risk appraisal. The
original items are presented in Table 1.
To develop items in the emotions category, an extensive
search of the literature identified fear of re-injury
(Johnston & Carroll, 1998; Mohtadi, 1998; Morrey
et al., 1999; Smith, Stuart, Wiese-Bjornstal, Milliner,
O’Fallon, Crowson, 1993), frustration (Mohtadi, 1998;
Morrey et al., 1999; Smith, Scott, O’Fallon, & Young,
1990; Smith et al., 1993), and nervousness and tension
(Chan & Grossman, 1988; Smith et al., 1993)as
commonly reported emotions experienced by athletes
during rehabilitation and the commencement of sport.
Thus five items (1–5) were developed to measure these
emotions. Item 1 was generated to measure feelings of
nervousness associated with returning to sport. Item 2
elicited information regarding feelings of frustration, and
was taken directly from item 16 of the Anterior Cruciate
Ligament-Quality of Life (ACL-QOL) questionnaire
(Mohtadi, 1998). Item 3 ‘‘do you feel relaxed about
playing your sport’’ was generated to measure feelings of
tension. Initially this item was phrased as ‘‘do you feel
tense about playing your sport’’; however, the word tense
was replaced with the positive antonym relaxed to achieve
a balance between negatively and positively worded items.
Two items were generated to represent fear of re-injury.
The first (item 4) was adapted from item 31 of the ACL-
QOL ‘‘How fearful are you of re-injuring your knee?’’ and
was made sport specific with the addition of ‘‘by playing
your sport’’. The second (item 5) explored the concept of
Five items (6–10) were generated to cover two aspects
of sport confidence: confidence in knee function
and confidence in the ability to perform well. Three
items (6–8) were developed to target the athlete’s
confidence in their knee function. Item 6 was adapted
K.E. Webster et al. / Physica
from the ACL-QOL (Mohtadi, 1998) and related to the
Original items in the ACL-Return to Sport after Injury Scale
Scale item Order
1. Are you nervous about playing your sport? 3 57.56 (30)
2. Do you find it frustrating to have to consider
your knee with respect to your sport?
6 50.93 (34)
3. Do you feel relaxed about playing your
12 69.64 (26)
4. Are you fearful of re-injuring your knee by
playing your sport?
7 52.63 (29)
5. Are you afraid of accidentally injuring your
knee by playing your sport?
9 55.10 (28)
Confidence in performance
6. Are you confident that your knee will not
give way by playing your sport?
4 65.97 (27)
7. Are you confident that you could play your
sport without concern for your knee?
5 62.14 (29)
8. Are your confident about your knee holding
up under pressure?
8 67.40 (26)
9. Are you confident that you can perform at
your previous level of sport participation?
1 73.10 (25)
rapy in Sport 9 (2008) 9–15 11
randomly ordered (order is indicated in Table 1). For
ARTICLE IN PRESS
and sporting information was combined into a self-
administered document titled ‘‘The Survey of Sport
Participation Following ACL Reconstruction Surgery’’.
The title of the document enabled the participants to
have a basic idea about the purpose of the study,
without giving information regarding the precise aims
and hypotheses, thus minimising potential response
bias. The study procedures were approved by the
University Ethics Committee. As well as completing
the scale, participants were required to provide informa-
tion regarding sport participation prior to injury and
current sport status. For current sport status, partici-
pants were specifically asked to indicate whether or not
they had attempted to resume sport participation. This
information was later used to divide subjects into
groups: those that had returned to sport and those that
had not. If subjects had resumed sport participation, the
level of participation (e.g. training, modified competi-
tion, full competition) was documented.
2.4. Data analysis
All items were scored by superimposing a 20-point
grid over the line. Values were assigned in increments
of 5 ranging from 0 to 100. A value of 0 indicated
extremely negative psychological responses whilst a
value of 100 represented no negative psychological
responses. All data were entered into SPSS (version 10)
for statistical analysis.
2.5. Statistical analysis
The following four steps were undertaken to examine
the psychometric properties of the scale:
1. Item scores: The mean and standard deviation was
obtained for all 12 items. A mean closer to the centre
of the possible range (i.e. 50) is desirable for an item
since it allows for a larger variance in responses to the
question (DeVellis, 1991).
2. Internal consistency: Internal consistency was assessed
by calculating Cronbach’s alpha. The higher the alpha
coefficient, the more likely it is that the items on the
scale measure one underlying construct. Inter-item
correlations and item to total correlations were also
ce a mark on the line, which they thought best
scribed them in relation to the two descriptors.
he newly developed scale along with demographic
items, a 10 cm Visual Analogue Scale was used.
scriptors ‘‘extremely’’ and ‘‘not at all’’, representing
posite ends of the question continuum, were placed at
er end of the scale. Participants were instructed to
K.E. Webster et al. / Physica
calculated to identify items, if any, which did not score rel
t accounted for 67.8% of the total variance.
ores for the 12 items were therefore summed and
eraged to provide a single score for the scale. It is
portant to note that although the scale was designed
und three constructs, these constructs were all highly
scale were both developed to examine confidence in
The scale was found to have high internal consistency,
th a Cronbach’s alpha of 0.96. Inter-item correlations
re also high, with a mean of 0.69 (min 0.49, max
3). The deletion of any item did not significantly
er or increase coefficient alpha.
Principal components analysis confirmed the presence
one underlying factor with an eigenvalue of 8.14
consistently against the other items of the scale, or did
not score well against the scale as a whole. Correlations
were also examined to determine whether omission of
any items altered Cronbach’s alpha.
3. Factor analysis: Principal components analysis was
performed in order to determine whether the scale
was measuring more than one construct. Tinsley and
Tinsley (1987) suggested that a sample size of 5–10
persons per scale item is sufficient to establish a
representative factor analysis. Our ratio of 220
subjects to 12 items was sufficient. If one underlying
construct was primarily accountable for the variance
of the scale, then a total score could be computed.
4. Validity: If psychological factors are affecting return
to sport after ACL reconstruction, subjects who had
not returned to sport should score lower on the scale
compared to subjects who had returned to sport.
Divergent validity of the scale was therefore assessed
by comparing the scores on the scale between
participants who had returned to sport and partici-
pants that had not returned to sport using one-way
3.1. Psychometric properties
The mean and standard deviation of scores for each
item of the scale are listed in Table 1. The means ranged
between 50.93 and 73.1 (Table 1). All items scored
relatively close to the centre of the response range
(i.e. 50), and had large standard deviations, both
features considered preferable properties of scale items
(DeVellis, 1991). The range for each item was 0–100.
The four items scoring lowest on the scale were those
measuring frustration, fear, and nervousness. These
items were all designed to encompass the emotions
experienced by the athlete when returning to sport.
Item 11, which assessed risk appraisal, also had a low
an score of 59.94. The two items scoring highest on
rapy in Sport 9 (2008) 9–15
ARTICLE IN PRESS
Divergent validity was assessed by comparing scores
between subjects who had returned to sport (either
training or full competition) and subjects who had not
yet attempted sport. Results showed that the 151 (69%)
subjects who had returned to sport scored significantly
higher on the scale (mean score of 70, range 11–99) than
the 69 (31%) subjects who had not returned to sport
(mean score of 46, range 0–92, po0.0001). Although
there were no differences between the ages or the time
spent participating in sport prior to injury between the
two groups, the average time that had elapsed since
ACL surgery was significantly greater for the group that
had returned to sport (mean 14 months versus 11
months). Subjects were therefore further divided into
four groups: subjects that had given up sport, subjects
that had not attempted sport but were still planning to
return, subjects who had returned to training only and
subjects that had returned to full competition.
A one way between group analysis of covariance was
conducted to compare ACL-RSI scores between these
four groups. The time that had elapsed since surgery was
Given up sport
Plan to retu
Mean time since
12 months 10 month
Fig. 1. Scores on
K.E. Webster et al. / Physica
used as the covariate in this analysis. Preliminary checks
were conducted to ensure there was no violation of the
assumptions of normality, linearity, homogeneity of
variances and homogeneity of regression slopes. After
adjusting for the time that had elapsed since surgery,
there was a significant difference between the four groups
for ACL-RSI scores [F(3,215) ¼ 34.39, po0.0001]. There
was no relationship between time since surgery and RSI-
scores [F(1,215) ¼ 0.27, p ¼ 0.61].
Pairwise comparisons (with Bonferroni correction) of
the adjusted group means showed that subjects who had
given up sport scored significantly lower on the scale
than the other three groups (po0.001, Fig. 1). Con-
versely, subjects who had returned to full competition
scored significantly higher (po0.001). There was no
difference between subjects who were planning a return
to sport and subjects who had recommenced training.
The adjusted group means were as follows: subjects that
had given up sport mean score of 39.1 (standard error
¼ 3.2), subjects that had not attempted sport but were
still planning to return mean score of 54.9 (3.3), subjects
who had returned to training mean score of 63.0 (2.4)
and subjects that had returned to full competition mean
score of 76.3 (2.1).
The four groups did not differ with respect to age, sex,
the amount of time spent participating in sport prior to
injury or the time between injury and ACL reconstruc-
In this study, a theoretical approach to scale
construction was used to develop a 12-item scale to
measure psychological factors associated with returning
to sport following ACL reconstruction surgery. Scale
items were created around three specific psychological
responses hypothesised to be related to sport resump-
tion; emotions, confidence and risk appraisal. This is the
first attempt that we are aware of to specifically develop
a scale that incorporates these three responses, which
12 months 14 months
rapy in Sport 9 (2008) 9–15 13
were found to be highly related to each other and
formed a uni-dimensional scale.
The scale was shown to have a number of features
which are desirable when developing a new scale. These
included acceptable internal consistency, the range of
scores obtained for each item were diverse, and the
length of the scale makes it suitable for clinical
application. Feedback from the target population was
also sought in the development stage to maximise
relevance. The format would also appear to be
satisfactory as participants did not leave any items
blank when completing the scale.
Scores for the scale items indicated that overall,
subjects scored lowest for the items that related to
emotions. This is consistent with the previous literature,
which indicates that there is a significant emotional
response to athletic injury. However, it also builds on
ARTICLE IN PRESS
the literature to suggest that athletes have a significant
emotional response specifically when returning to sport.
Subjects also felt that they were at risk of re-injuring
their knee by returning to sport. The way athletes
appraise the risk of returning to sport has been
recognised as an important component of injury
rehabilitation (Johnston & Carroll, 1998) but one in
which little empirical data has been obtained to support
its inclusion in injury recovery models. The present
study provides empirical data, which indicates that it is a
factor worthy of consideration. However, there are a
few unique aspects of this study that should be noted.
First, ACL rupture is a serious injury that requires a
relatively long rehabilitation period. As such, the
decision whether to risk returning to sport may be more
augmented for this type of injury compared to other less
severe injuries. Second, it is an injury that receives
considerable media attention, particularly when athletes
successfully or unsuccessfully try to make an early
return to sport. Although this has not been specifically
investigated, it is reasonable to hypothesise that this
media attention may provide a somewhat biased picture
to the amateur athlete and cause them to overestimate
or underestimate the risks associated with sport
resumption following ACL reconstruction.
In addition to evaluating the psychometric properties
of the scale, the results also provide preliminary
evidence to suggest that psychological factors may play
a role in whether or not an athlete decides to return to
sport after an ACL reconstruction. Although all subjects
had achieved a successful outcome and had been cleared
to return to sport, only 40% had in fact returned to full
competition. This is despite the fact that all subjects
were planning to return to sport before surgery. More-
over, those that had not returned to sport appeared to
have had ample time to do so given that their mean time
from surgery was the same as the group that had
successfully returned. This further emphasises the need
to focus attention on the return to sport transition. It is
also worth noting that we focussed on what the athlete
had attempted rather than the success of the attempt. As
such, some athletes may have attempted to return to
sport but not yet been successfully able to do so. Future
studies may wish to more closely examine the athletes’
success at returning to sport.
Interestingly, subjects did feel reasonably confident
that they could perform well at their sport and at their
previous level of sport participation with mean scores of
73 out of 100 for both items. In comparison they were
less confident that their knee would function well during
sport (average scores of 62–68 for knee function items).
These results suggest that it may be useful for clinicians
to make a distinction between general sport confidence
(i.e. confidence people have in their overall sporting
ability after surgery) versus confidence in the injured
K.E. Webster et al. / Physica14
body part when incorporating confidence-boosting
strategies into rehabilitation programs. The results
of this study specifically suggest that attention should
be focussed on improving confidence in the injured
Whilst it cannot be determined from the present data
whether athletes’ concerns were alleviated by sport
resumption, there was little difference between the group
of subjects that were planning a return to sport and the
group of subjects that had recommenced training. This
is of importance if interventions are to be considered.
Future research should thus be directed towards the
temporal process of these psychological factors, now
that a tool has been developed which would appear to
enable their evaluation. The ultimate goal is to be able
to predict athletes that require psychological counselling
or intervention so that psychological recovery from
injury can occur in parallel with physical recovery. We
are therefore using this scale at a number of critical time
points during the rehabilitation process (when athletes
are able to commence sport specific drills 3 months after
surgery, and when athletes commence training at 6
months) in hope of being able to identify athletes that
might find sport resumption difficult. To demonstrate
the predictive power of the scale, prospective long-
itudinal studies such as this are required.
Whilst the large sample size was a strength of this
study, the subjects formed a relatively homogenous
population and for the majority this was their first ACL
reconstruction. As such, we did not address the issue of
previous experience. Past research has however shown
that first time injured athletes tend to experience the
rehabilitation period as more stressful and are less
confident than athletes who have sustained multiple past
injuries (Johnson, 1996). As such, the issue of past
experience is worthy of future attention and studies are
needed to clarify whether there are differences in the
way first time injured athletes and multiply injured
athletes approach returning to sport.
Overall, this study has shown the potential impor-
tance of examining psychological responses associated
with returning to sport in athletes who undergo ACL
reconstruction surgery. Although the scale was specifi-
cally designed for use in this population it could be
easily adapted for other types of knee injuries or
sporting injuries in general. The Knee Self Efficacy
scale (Thomee et al., 2006) has been designed for
athletes who have and have not undergone surgery to
reconstruct the ACL and whilst it appears to measure
different psychological responses no empirical compar-
ison has been made between this scale and the present
one. In a review on the psychology of sport injury
rehabilitation Brewer (2001) comments that the devel-
opment of psychological measures specific to the sport
injury rehabilitation context will help to provide
researchers with standardised instruments and enable
rapy in Sport 9 (2008) 9–15
more fine grained research questions to be answered. It
is hoped that the present scale will help in the
achievement of both these aims.
Conflict of Interest Statement
No conflict of interest.
All procedures were approved by the Faculty of
Health Sciences Ethics Committee at La Trobe Uni-
versity prior to data collection.
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