Perceptions of rehabilitation and return to sport among high school athletes with ACL reconstruction: a qualitative research study

Key points

1. 01Psychosocial barriers, including fear of re-injury and uncertainty about full recovery, were reported more consistently than physical barriers
2. 02Social comparison was a double-edged factor: negative when athletes fell behind peers, positive when paired with recovered athletes as role models
3. 03Access to an on-site school athletic trainer was a unique and valued source of emotional and practical support
4. 04Participants valued individualized, sport-specific rehabilitation over generic exercise progressions
5. 05Overly protective messages from parents and coaches were perceived as hindering confidence and motivation

How it was conducted

Design

Qualitative phenomenographic, cross-sectional study using semi-structured interviews

Participants

10 high school athletes (6 female, 4 male; mean age 16.8 years) who had undergone ACL reconstruction and had not yet returned to sport

Time since surgery

Mean 5.5 months (SD 1.4 months)

Sports represented

Basketball, soccer, football, volleyball, skiing, ice hockey, and lacrosse

Analysis

Thematic analysis with inductive line-by-line coding; conceptual saturation guided recruitment

Outcome measures

KOOS, Tegner Activity Scale, Tampa Scale of Kinesiophobia (TSK-11), and Athlete Fear Avoidance Questionnaire (AFAQ) completed prior to interview

What they found

• Three primary higher-order themes emerged: Types of Barriers for Returning to Physical Activity, Positive Recovery Factors, and Negative Recovery Factors
• Psychosocial barriers (fear of re-injury, uncertainty, loss of identity, role adjustment) were reported with greater consistency than physical barriers (pain, fatigue, stiffness)
• Interview duration ranged from 20 to 53 minutes with a median of 28 minutes
• Patient-reported knee function, post-injury physical activity, and psychosocial outcomes varied greatly among participants
• No quantitative effect sizes or p-values were reported, consistent with the qualitative design

Limitations

• Very small sample of 10 participants limits generalizability
• All participants had not yet returned to sport; perceptions may change as rehabilitation progresses
• Single-site recruitment (Michigan State University sports medicine clinics) may not reflect diverse settings or access levels
• The study captures perceptions at one point in time and cannot assess how attitudes evolve over the full recovery arc

Why it matters

For patients

Young athletes recovering from ACL surgery should know that fear, uncertainty, and social pressures are common and worth discussing openly with their care team, not just their physical symptoms.

For clinicians

Clinicians should screen for psychosocial barriers early, incorporate sport-specific and individualized goals, leverage peer mentoring with recovered athletes, and coordinate with school athletic trainers as a front-line support resource.

For readers

This study fills a gap by capturing the lived experience of adolescent ACL patients specifically, a population whose contextual pressures differ meaningfully from adults studied in prior research.