What question did this study set out to answer?

To explore sex-based differences in physical and psychological recovery post ACL reconstruction and their impact on return to sport.

February 2, 2026Open Access

Sex-based differences in physical and psychological recovery, and return to sport, following anterior cruciate ligament reconstruction

Key Points

To explore sex-based differences in physical and psychological recovery post ACL reconstruction and their impact on return to sport.
Prospective recruitment of 104 patients (49 females, 55 males) undergoing ACL reconstruction.
Assessment pre-operatively and at 6-, 12-, and 24-months using patient-reported outcome measures and performance tests.
Statistical analysis using repeated measures ANOVA and Pearson's correlations to evaluate scores and associations.
Significant improvements in all patient-reported outcome measures (p<0.05), with females reporting lower ACL-RSI and IKDC scores.
Males showed higher peak strength measures (PKET and PKFT) at specific time points (p<0.05).
At 24-months, a higher percentage of males (60%) returned to pivoting sports compared to females (41%).

Abstract

Objectives: Despite the increasing rate of anterior cruciate ligament (ACL) tears and surgical reconstruction (ACLR), little is known about the post-operative recovery in males versus females. Sex-based recovery differences after ACLR are yet to be examined, and identifying any differences is the first step to then understanding why they exist, subsequently permitting more tailored patient education on pre- and post-operative expectations, as well as permitting more targeted management. This study sought to investigate sex-based differences in the physical and psychological recovery, as well as return to sport (RTS), after ACLR. Methods: This study prospectively recruited 104 patients (49 females, 55 males) that underwent ACLR with a hamstrings tendon autograft. Patients were assessed pre-operatively and at 6-, 12- and 24-months post-surgery, via patient-reported outcome measures (PROMs) including the International Knee Documentation Committee (IKDC) form, the Tegner Activity Scale (TAS) and the Anterior Cruciate Ligament Return to Sport after Injury (ACL-RSI) score. All patients completed a 4-hop test battery consisting of the 6-meter timed hop (6MTH) and the single (SHD), triple (THD) and triple crossover (TCHD) hop tests for distance, as well as assessment of peak isokinetic knee extensor (PKET) and flexor (PKFT) strength. Repeated measures analysis of variance was employed to statistically analyze absolute measures and limb symmetry indices (LSIs) over time and between sexes, while Pearson’s correlations assessed any association between ACL-RSI scores and performance LSIs. The percentage of males (versus females) that had returned to pivoting sports within the first 24 months was assessed. Results: All PROMs significantly improved (p0.05) were observed in hop test LSIs, males demonstrated significantly higher mean LSIs for PKET at 6 (p=0.037) and 24 (0.047) months, and PKFT at 6 (p=0.007) and 12 (p=0.002) months. Several physical performance measure LSIs, and operated limb absolute scores, were significantly correlated with ACL-RSI scores. At 24-months, a significantly greater (p=0.030) percentage of males (60%) versus females (41%) had returned to pivoting sports. Conclusion: This study demonstrates the disparity between sexes in physical and psychological recovery, as well as RTS status, in community-level patients undergoing ACLR. The development and implementation of enhanced post-operative patient-centered care may be warranted tailored to sex, encompassing rehabilitation, education, and counseling after ACLR to promote increased engagement in rehabilitation, expedited physical recovery, and improved RTS outcomes.

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