Abstract
Background:
The incidence of anterior cruciate ligament (ACL) injury and surgical reconstruction in youth athletes is increasing. In the United States, most athletes elect to undergo ACL reconstruction (ACLR), with the goal of returning to their previous level of athletic performance. Although surgery and rehabilitation address the underlying impairments in knee stability and function, recent literature indicates psychological or emotional factors, such as fear or confidence, may be contributing factors limiting successful return to play. The Anterior Cruciate Ligament Return to Sport after Injury (ACL-RSI) is a 12-item scale designed to assess an athlete’s psychological readiness to return to sports across three separate domains (emotions, confidence in performance and risk appraisal). In adults, the ACL-RSI is reliable and valid, and several studies have documented that athletes with higher scores are more likely to successfully return to their pre-injury level of sports participation. The predictive abilities of this scale, have led many experts to advocate for the ACL-RSI to be used as part of rehabilitation guidelines, in order to identify those athletes that may benefit from a modified course of post-operative rehabilitation or additional emotional or psychological support. Although the information from the ACL-RSI is valuable in adults, the utility of this scale has never been explored within the pediatric population. Thus, the purpose of this study is to evaluate the utility of the ACL-RSI within the pediatric population and establish normative values among healthy children.
Hypothesis:
As all of these subjects were currently healthy, we hypothesized that mean scores should demonstrate a positive skew towards higher levels of confidence (ceiling effect) with values of 80-100 on each question.
Methods:
A group of 84 healthy, youth athletes between the ages of 8-14, completed the ACL-RSI. All subjects were currently involved in competitive sports at the time of participation. The athletes were instructed to complete the 12-item ACL-RSI questionnaire and were able to seek assistance from parents as necessary. Each item is scored on a scale ranging from 0-100 and a total score is calculated from summing all responses and expressing them a percentage of 100%. Higher scores indicate a greater degree of athletic confidence or more positive psychological response to injury. Mean and variability measures for each question and total score were calculated and compared to existing literature.
Results:
A total of 83 subjects (mean age 11.1 ± 1.2) completed the questionnaire in full. There were slightly more females (n=46, 54.8%) than males. The majority of participants were White (70%), African American (13%) or more than one race (10%). The most frequent primary sport was soccer (38%), followed by baseball (27%) and basketball (26%). The mean ACL-RSI score for the entire sample was 79.9 (SD 14.1). Individual question analysis revealed lower than expected mean scores (<80%) with large standard deviations for 7 out of 12 questions. (Table 1) With the exception of only question #1 and #12, responses demonstrated such large variability that both the maximum and minimum (0-100) scores were selected, indicating both ceiling and floor effects. (Table 1)
Conclusions/Significance:
The mean ACL-RSI score (79.9) within this group of uninjured pediatric athletes was similar to previous values for post-ACLR adults that successfully return to sports. However, it was surprising that the mean score wasn’t higher, as this was a healthy population of un-injured youth athletes, and we hypothesized that our data would demonstrate a positive skew towards the upper range of this scale. Response ranges including 0 (indicating either high fear or severe lack of confidence) within nearly all questions was unexpected. Additionally, there were particularly low mean scores and high variability within 7 of the 12 questions. All of these factors raise the suspicion that children may not fully comprehend the material or have difficulty interpreting the response system of the ACL-RSI and thus calls into question the validity of this scale in youth athletes. Similar to other research efforts that have modified adult outcome scales to be utilized within the pediatric population, our results support further exploration of the utility of the ACL-RSI within pediatric athletes and may possibly suggest that a pediatric specific version should be created.
ACL-RSI questions and scoring distribution
| Question | Mean Score (range, min-max) | Standard Deviation |
|---|---|---|
| 1. Are you nervous about playing your sport? | 88.7 (50-100) | 13.8 |
| 2. Do you find it frustrating to have to consider your knee with respect to your sport? | 85.1 (0-100) | 22.6 |
| 3. Do you feel relaxed about playing your sport? * | 77.8 (0-100) | 25.2 |
| 4. Are you fearful of re-injuring your knee by playing your sport? * | 72.3 (0-100) | 32.6 |
| 5. Are you afraid of accidentally injuring your knee by playing your sport? * | 75.1 (0-100) | 30.4 |
| 6. Are you confident that your knee will not give way by playing your sport? * | 71.8 (0-100) | 32.3 |
| 7. Are you confident that you could play your sport without concern for your knee? * | 75.8 (0-100) | 30.5 |
| 8. Are you confident about your knee holding up under pressure? * | 76.1 (0-100) | 30.8 |
| 9. Are you confident that you can perform at your previous level of sports participation? | 83.5 (0-100) | 23.7 |
| 10. Are you confident about your ability to perform well at your sport? | 86.7 (0-100) | 22.4 |
| 11. Do you think you are likely to re-injure your knee by participating in your sport? * | 79.5 (0-100) | 24.5 |
| 12. Do thoughts of to go through surgery and rehabilitation again prevent you from playing your sport? | 84.2 (10-100) | 23.3 |
| Total ACL-RSI Score | 79.9 (47.5-100) | 14.1 |
* denotes those questions with mean scores below 80%