Athletes with “Never Quit” Mentality Face Increased Risk of ACL Re Injury

Researchers at Hospital for Special Surgery(HSS) found in a new study that athletes who report higher levels of psychological readiness to return to sport following anterior cruciate ligament (ACL) reconstructionmay actually face an increased risk of re-injury. The findings challenge long-held assumptions about the role of psychological confidence in return-to-sport decisions and highlight the need for more comprehensive evaluation methods. The study was presented on today at the American Physical Therapy Association (APTA) Combined Sections Meeting in Anaheim, CA.

Psychological impairment following ACL reconstruction has long been recognized as a factor influencing an athlete's ability to safely resume sport. Roughly one in three patients who undergo ACL reconstruction sustain a second ACL injury. While tools such as the ACL Return to Sports After Injury (ACL-RSI) questionnaire are commonly used to gauge psychological readiness-including emotion, confidence, and risk appraisal-their relationship to actual re-injury risk has not been well understood.

"We know that ACL injuries are not just physical-they have a profound psychological component," said Riley J. Williams, MD, sports medicine surgeon and Chief of the Sports Medicine Institute at HSS. "What this research shows is that confidence can sometimes outpace true physical readiness. Athletes may feel mentally prepared to return before their bodies are fully capable of withstanding the demands of sport. That disconnect can increase their risk for re-injury."

The study compared ACL-RSI scores between patients who sustained a second ACL injury and those who returned to sport without further injury.

A total of 58 athletes participated in the study (24 males, 34 females; mean age 23.5 ± 9.6). Of these, 21 athletes experienced a second ACL injury following their return to sport. All subjects completed return-to-sport testing at nine months post-operation (±1 month) and filled out the ACL-RSI questionnaire prior to physical testing.

Researchers tracked re-injuries on both the operative (n=4) and non-operative (n=17) sides. A matched control group was created based on age, sex, and graft type. Independent samples t-tests were conducted to evaluate differences in ACL-RSI scores between the groups.

"Our findings challenge the assumption that higher psychological readiness is always a positive indicator for return to sport," said Letty Krueger, PT, DPT, lead researcher and rehabilitation clinical manager at HSS Westchester. "In this study, athletes who reported the greatest confidence were actually the ones at higher risk for re-injury. This underscores the need to evaluate readiness through a combined lens of physical performance, psychological state, and clinical data-rather than relying on self-report scores alone."

Athletes who sustained a second ACL injury had significantly higher psychological readiness scores compared to those who did not:

• Re-injury group: 86.8 ± 11.2
• Uninjured group: 75.5 ± 17.3
• p = .02

At nine months post-operation, athletes who later experienced ACL re-injury reported significantly greater psychological readiness than those who returned to play without further injury. These findings suggest that elevated confidence-while often viewed as a positive marker-may not reflect true readiness for the physical demands of sport and may be associated with increased re-injury risk.

The study underscores the importance of a biopsychosocial approach, integrating psychological factors with objective physical and clinical measures when determining an athlete's readiness to return to sport. Researchers note that while higher ACL-RSI scores are associated with higher return-to-sport rates, this increased exposure may also contribute to elevated re-injury risk.

"Contrary to expectations, athletes who felt more confident and emotionally ready to return to sport were more likely to suffer re-injury," said Answorth Allen, MD, sports medicine surgeon and associate surgeon-in-chief at HSS. "This research reinforces the importance of evidence-based, multidimensional return-to-sport protocols. By integrating psychological screening with strength, functional, and biomechanical testing, we can make smarter, safer decisions that protect athletes and enhance long-term outcomes."

The findings indicate that psychological readiness scores-even when favorable-should not be used as a standalone metric for return-to-sport clearance. Elevated self-reported confidence may mask underlying physical or functional deficits, potentially placing athletes at greater risk. Clinicians and sports medicine professionals should interpret psychological measures within the broader context of recovery, emphasizing functional testing and physical preparedness.

Further research is needed to explore how psychological factors interact with physical recovery in influencing return-to-sport outcomes and susceptibility to future ACL injuries.

For more information about the study visit: Psychological Readiness after Aclr in Subjects with Subsequent Re-Injury Compared to Matched Controls

Letty Krueger, PT, DPT, Michelle Cilenti, PT, DPT, Debi Lynn Jones, PT, Robert G Marx, MD, MSc, Answorth A Allen and Riley J Willams