Anterior Cruciate Ligament Return to Sport after Injury Scale (ACL-RSI) Scores over Time After Anterior Cruciate Ligament Reconstruction: A Systematic Review with Meta-analysis.

After tearing an anterior cruciate ligament, athletes often worry not just about physical healing but about feeling mentally ready to return to sport. This review pulled together 83 studies that used a specific questionnaire, the ACL-RSI, to track that psychological readiness from before surgery through several years afterward. The pattern that emerged was fairly consistent: readiness scores were low before surgery, rose noticeably by three to six months after reconstruction, then stayed fairly flat for a long stretch, before reaching their highest point somewhere between two and five years post-surgery.

Shorter time between injury and surgery, being male, and being older were linked to higher readiness scores early on, though these links faded by one to two years out. What makes this interesting is that psychological readiness doesn't just track with physical recovery timelines. The major caveat is that most included studies carried a high risk of bias, and the certainty of every finding was rated weak to limited, so these patterns should be read as suggestive rather than settled.

If you've had anterior cruciate ligament surgery, you may have noticed that feeling physically able to play again and feeling mentally ready are not the same thing. This review looked at 83 studies that measured psychological readiness using a specific questionnaire, tracking how people felt from before their injury through several years after surgery.

Readiness scores were low before surgery, climbed by three to six months afterward, then plateaued for a while before reaching their highest levels between two and five years later. People who had surgery sooner after their injury, men, and older individuals tended to report higher readiness scores in the early months, though these differences became less clear by one to two years out. This doesn't mean these factors determine how someone will feel, only that they were associated with scores in the studies reviewed.

Importantly, most of the studies had a high risk of bias, and the overall confidence in these findings was rated weak to limited. So while the pattern of slow, uneven psychological recovery seems real across many studies, the details about who recovers readiness faster remain uncertain.

This is a summary of research, not medical advice. Talk to your own healthcare provider about anything affecting your care.

This systematic review and meta-analysis pooled ACL-RSI scores across 83 studies to characterize psychological readiness trajectories following ACL tear and reconstruction. Pooled mean scores rose from 44.4 (95% CI 38.2-50.7) pre-surgery to 61.5 (95% CI 58.6-64.4) at three to six months post-reconstruction, then remained relatively stable until peaking at 70.7 (95% CI 63.0-78.5) between two and five years.

Heterogeneity was substantial across all pooled estimates (I2 values of 94-98%), reflecting considerable variability in study populations, timing, and methods. Meta-regression suggested shorter injury-to-surgery interval, male sex, and older age were associated with higher scores specifically at the three to six month mark, explaining 47.6% of heterogeneity, with this association weakening to 27.0% explained heterogeneity by one to two years. However, 78% of included studies were judged high risk of bias, and evidence certainty was rated weak or limited across every analysis, meaning these associative patterns should not be interpreted as robust prognostic factors. Clinically, the trajectory itself, an early rise followed by a long plateau and a late peak beyond two years, is a notable pattern worth appraising critically given the evidence quality, rather than treating pooled estimates as settled benchmarks for return-to-sport decision-making.