Return to sport after anterior cruciate ligament reconstruction: a qualitative analysis

Abstract Introduction Return to sport is a desired outcome in individuals submitted to anterior cruciate ligament reconstruction (ACLR). Objective Understand the factors that affect return to pre-injury level sport after ACLR from the patient’s perspective. Methods The sample consisted of 29 individuals submitted to ACLR who participated in sport before the ligament injury. This is a narrative analysis with a qualitative approach, using a semi-structured interview as a methodological resource. Standardized instruments were also applied to evaluate psychological readiness to return to sport, via the Anterior Cruciate Ligament – Return to Sport after Injury Scale (ACL-RSI); self-perceived knee function using the International Knee Documentation Committee (IKDC) subjective questionnaire; and the frequency of participation in sports with the Marx scale. Results Analysis of the interviews produced three main themes related to post-ACLR return to sport: self-discipline, fear of reinjury and social support. In qualitative analysis, the average scores obtained were 59.17 (± 23.22) on the ACL-RSI scale, 78.16 (± 19.03) for the IKDC questionnaire and 9.62 (± 4.73) and 7.86 (± 5.44) for the Marx scale before and after surgery, respectively. Conclusion: Psychological factors influence the decision to return to sport post-ACLR. Physiotherapists should therefore be aware of the psychological aspects and expectations of patients, and that other health professionals may be needed to help prepare these individuals to return to their preinjury sports level and achieve more satisfactory outcomes after ACLR.


Introduction
Sport is no longer viewed as simply a leisure or competitive activity, but in recent years has also become an important strategy in social inclusion and mitigating problems related to health and education.1 Thus, sport plays a key role in contributing to preventing chronic degenerative diseases and antisocial behavior.2 However, it can also lead to injury resulting from mechanical trauma or joint and muscle overuse.3 Anterior cruciate ligament (ACL) rupture is the most prevalent injury in sports that require abrupt changes in direction at high speeds or sudden decelerations with high axial loads on the knee.4 After injury, decision making about whether to undergo ligament reconstruction or conservative treatment is influenced by different factors, such as the extent of the injury, degree of instability, physical activity level and patient's functional needs.5 Many individuals with this injury opt for ACL reconstruction as opposed to conservative rehabilitation with the goal of returning to sport.6 Return to preinjury level sport is the desired outcome of patients who undergo physiotherapy to treat these injuries.5 However, a systematic review with meta-analysis demonstrated that only 65% of those submitted to this surgical procedure are able to return to their preinjury level of sport.7 It should be noted that the authors of the meta-analysis did not establish mandatory postoperative physiotherapy as an inclusion criterion.Thus, it is possible that some participants in the studies analyzed had not undergone physiotherapy, representing a limitation for the return to sport outcome.Nevertheless, the fact that a considerable portion of patients do not obtain the desired outcome after surgery is important, given the functional aspects of social participation.Patients' perception of their functional status is one of the psychological factors that seem to influence engagement in sport and can be evaluated using standardized questionnaires developed for this purpose.11 However, studies that investigate the psychological aspects surrounding the return to sport, such as self-reported knee function after surgery, primarily use methods that do not provide an in-depth assessment of these issues.9-11 Likewise, aspects such as lifestyle, employment status and social support were not explored in detail in the Brazilian population submitted to knee ligament reconstruction.
As such, the aim of this study was to identify the barriers, facilitators and meaning of the return to sport from the perspective of patients who undergo ACLR.

Discussion
The aim of this study was to identify the barriers, facilitators and meaning of the return to sport from the perspective of patients who undergo ACLR.The interviews demonstrated that psychological factors influenced the outcome of post-ACLR return to sport, with enjoyment, self-discipline and fear of reinjury cited most often.Fear was identified as a relevant factor in the decisions of both groups (those who returned to sport and those who did not).Social support also played an important role in patient decisions about returning to sport after surgery.
The first theme identified in interview analysis was self-discipline, considered a significant factor in the decision to return to sport by many of the interviewees.
Self-discipline and persistence in pursuing this outcome are evident in the interviews of several patients who returned to sport, as shown in the following statement:  Despite the fear of reinjury, especially in the early stages of returning to sport, all patients who did so described their struggle to overcome this obstacle.
This strategy to deal with obstacles is known as coping or active coping.24 An example of this is evident in the following statement : There is a fear of going through it all over again, of needing more surgery or getting the same injury, but my desire to be active again was greater than the fear. (P8) In a study similar to our investigation, but conducted in Canada, fear was also prominent in the interview statements of both groups, but predominated among those who did not return to sport, 25 with 64% of interviewees not returning to their preinjury level.This differs from our findings, where returning to sport was more prevalent.
Athletes experience considerable stress when undergoing ACLR and dealing with this adversity seems to be the most important coping strategy used, as observed by Dias and Fonseca.

Conclusion
In this study, the positive outcome of returning to sport surpassed the small number of individuals who did not return, establishing self-discipline and enjoyment of sport as decisive factors in this outcome.Thus, the results indicate that physiotherapists must be aware of psychological factors and patients' goals, and that other health professionals may be needed to help prepare these individuals to return to their preinjury sports level and achieve more satisfactory outcomes after ACLR.
Another noteworthy aspect regarding the interviews that does fall within the themes identified here was weight gain as a decisive factor in the decision not to return to sport, reported by two patients: Several factors have been proposed to explain successful return to sport after ACLR.8 In recent years, psychological factors have been investigated as possible variables that may help or hinder individuals submitted to ACLR in returning to their preinjury sport level.9 The negative emotions experienced by athletes after injury hamper their rehabilitation, making psychological, social and contextual factors critical to successful rehabilitation.10 Thus, personal psychological factors can also influence this clinical outcome in terms of the individual's return to their preinjury activity level.
sites) to prevent third party interference.Patients filled out a form before the interview to provide demographic and clinical data for sample characterization.Data on physiotherapy quality and treatment plan were not collected because this was not the focus of the proposed qualitative approach.As such, the quality of the physiotherapy treatment received might be one of the factors mentioned by participants, depending on their ability to critically assess and identify barriers and facilitators in the return or not to sport after surgery.Interviewing was halted once new information rarely emerged, confirming saturation.The interviews were recorded and then transcribed in full, with prior authorization from participants, who signed a consent form.Participants were assigned a number (P1, P2, etc.) to protect their identity.The study was approved by the Research Ethics Committee of Minas Gerais State University (protocol number: 2.239.953).The script used for the interview contained ten questions that addressed: 1-what influenced the return or not to sport; 2 -how the interviewee felt about the possibility of knee reinjury; 3 -coping with the injury/ surgery; 4 -history of previous severe injuries; 5 -the influence of family support; 6 -outside pressure to return to sport; 7 -the influence of financial status on rehabilitation; 8 -advice and guidance from professionals on returning to sport; 9 -the role of health professionals monitoring rehabilitation; 10 -the rehabilitation process from surgery to return or not to sport.Three standardized data collection instruments were also used, in order to achieve better sample characterization regarding relevant aspects involved in the return to sport.The instruments were applied before the interview, after participants had filled out the form providing demographic and clinical data.The Anterior Cruciate Ligament -Return to Sport after Injury Scale -(ACL-RSI) was used to assess psychological readiness to return to sport after ligament reconstruction.13 It contains 12 items divided into three subscales (emotions, confidence and risk appraisal), with each item graded from 0 to 10.The scores for each item are added and the total converted into a percentage, with the result ranging from 0 to 100.The instrument demonstrates adequate validity, reliability and internal consistency.13,14 The International Knee Documentation Committee (IKDC) subjective questionnaire was applied to evaluate patients' perception of their knee function and consists of 18 items related to symptoms, daily activities and sports and knee function, with the result converted to a scale from 0 to 100, whereby the higher the score, the better the knee function.The validity, reliability and internal consistency of the IKDC have been tested and confirmed as adequate.15-17 The Marx scale analyzed the frequency of sports activities before injury and after ligament reconstruction, at the time of the interview.It was developed to measure how often individuals perform physical activities that are difficult for those with knee pathologies.Items are scored from 0 to 16 and activities are divided into four categories: running, changing direction, deceleration and pivoting.The higher the score, the more frequent the individual's participation in sports.18 Data analysis The quantitative data obtained from the standardized instruments were analyzed by descriptive statistics via mean and standard deviation.The qualitative data were assessed by content analysis, whereby a set of criteria are used as a guide to identify topics or themes that can be considered a unit of meaning in the text analyzed.19 To establish discussion, interview data, information from the scientific literature and interpretations of the statements within the themes were triangulated.20 FISIOTERAPIA EM MOVIMENTO Physical Therapy in Movement Rabelo LM et al.Fisioter Mov.2023;36:e36124 4 the support received is linked to different mental and physical health outcomes that affect how they perceive stressful situations and their emotional and psychological well-being.According to Gokeler et al., 10 a person's level of social support modulates the psychological stress that accompanies ACL injury, reconstruction surgery and rehabilitation.This is consistent with patient accounts that highlight the positive influence of social support from family members or friends on their decision to return to sport: It was a challenge in my life, but with support from my family and friends, thank God I was able to return.(P9) In times like those you really need support, someone to help and encourage you, I think it makes a big difference.(P10) My whole life, I made so many friends through soccer and that definitely influenced my decision to go back.(P11) This motivational factor may be linked to different definitions of social support that emphasize different aspects of interpersonal relationships.In general, social support is defined as any information, spoken or not, and/or material assistance and protection offered by other people and/or groups to those with whom they have regular contact that result in emotional effects and/ or positive behavior.28 FISIOTERAPIA EM MOVIMENTO Physical Therapy in Movement Rabelo LM et al.Fisioter Mov.2023;36:e36124 6 related to post-ACLR return to sport from the perspective of patients, who do not have the scientific knowledge to critically analyze some factors that may be linked to the outcome analyzed, such as the surgical techniques used or the quality of the physiotherapy received after surgery.This could explain why psychosocial factors were more frequently cited by participants than physical and functional aspects.

Table 1 -
Participants' (n = 29) scores on the instruments used think it's about willpower, about really wanting it, because when you want it, you go after it.It's mind over body; if you want it, if you really enjoy something, then you have to go after it; it's about overcoming ourselves.developmentand improved performance in activities of daily living.Physical exercise and sport promote continuous learning in practitioners when they find meaning in the activity.Some accounts obtained in the present study illustrate this point: Note: Marx scale preinjury and post-surgery; IKDC = International Knee Documentation Committee; ACL-RSI = Anterior Cruciate Ligament -Return to Sport after Injury Scale; SD = standard deviation.