Age and sex differences in ACL-Return to Sport after Injury subscale scores (emotion, risk appraisal, confidence) after ACL reconstruction

Key points

1. 01Teens scored about 11 points higher on ACL-RSI total score than adults (mean difference 10.91 points, P = .007).
2. 02The confidence subscale drove the age difference, with teens averaging 14.05 points higher than adults (P < .001).
3. 03No significant sex differences were found on any ACL-RSI subscale or total score.
4. 04High teen confidence may mask low emotional readiness if only the total score is reviewed.
5. 05Emotion subscale scores were the lowest across all groups, suggesting fear and stress are the dominant psychological barrier regardless of age or sex.

How it was conducted

Design

Cohort study (Level of evidence 3); multisite clinical outcome registry (ARROW)

Participants

154 patients aged 14-30 years, 6-12 months after primary unilateral ACL reconstruction; 53.9% female; mean age 20.2 years; mean time post-surgery 8.7 months

Age groups

Teen: 14-18 years (n = 70, mean age 16.91 years); Adult: 19-30 years (n = 84, mean age 22.85 years)

Outcome measure

ACL-RSI scale: 12-item, 0-100 score with three subscales - emotion (5 items), confidence (5 items), risk appraisal (2 items)

Analysis

Two-way ANOVA for main effects of sex and age group and their interaction; ordinal logistic regression for individual item scores; significance set at P < .05

What they found

• Mean ACL-RSI total score for the full cohort: 67.92 +/- 24.65.
• Significant main effect of age group on ACL-RSI total score: F(1, 150) = 7.406, P = .007, partial eta-squared = 0.047; teens scored 10.91 points higher than adults.
• Significant main effect of age group on confidence subscale: F(1, 152) = 11.552, P < .001, partial eta-squared = 0.071; teens scored 14.05 points higher than adults.
• Main effect of sex on ACL-RSI total score: not significant (P = .337).
• Interaction effect between sex and age group on ACL-RSI total score: not significant (P = .996).
• Teen males mean total ACL-RSI: 75.96 +/- 20.31; adult males: 65.04 +/- 22.54; teen females: 72.08 +/- 25.00; adult females: 62.81 +/- 25.98.
• Mean emotion subscale scores: teen males 67.54 +/- 26.20, adult males 61.29 +/- 27.32, teen females 67.14 +/- 28.48, adult females 55.68 +/- 30.37; no significant age or sex main effects.
• Mean risk appraisal subscale scores: teen males 69.07 +/- 30.67, adult males 64.57 +/- 28.52, teen females 73.75 +/- 25.99, adult females 61.18 +/- 28.63; no significant age or sex main effects.
• Teens reported significantly higher confidence that the knee would not give way (chi-square [1, 156] = 5.708, P = .017), that it would hold up under pressure (chi-square [1, 156] = 6.283, P = .012), and in their ability to perform well (chi-square [1, 156] = 3.990, P = .046).
• Teens felt more relaxed about playing their sport (emotion item 12): chi-square [1, 156] = 6.609, P = .010.

Limitations

• ACL-RSI was collected across a range of 6-12 months post-surgery (mean 8.7 months), not at a single standardised time point, introducing variability.
• Patients aged 12-14 years had insufficient data and were excluded, so findings may not generalise to early adolescents.
• Level of competition and sport type were not recorded, yet the ACL-RSI was designed for athletes planning to return to organised competitive sport.
• Whether participants had actually returned to sport at the assessment time point was not confirmed, limiting interpretation of readiness scores as a true pre-clearance snapshot.

Why it matters

For patients

Teenage athletes after ACL reconstruction may feel more confident and psychologically ready to return to sport than adults, but this does not mean they are free from emotional concerns such as fear of reinjury.

For clinicians

Adult-derived ACL-RSI cutoff scores (e.g., total score greater than 72 at 12 months) should not be directly applied to teens; clinicians should review confidence and emotion subscale scores separately, as high teen confidence can inflate total scores and hide unresolved emotional barriers.

For readers

This multisite registry study provides the first age- and sex-stratified ACL-RSI subscale data and makes a case for developing teen-specific psychological readiness benchmarks before return-to-sport clearance.