Psychological Readiness in Elite Versus Nonelite Athletes After Anterior Cruciate Ligament Reconstruction

Background: Psychological readiness encompasses fear of reinjury, confidence in performance, and risk appraisal. It is increasingly recognized as a critical factor influencing return to play (RTP) after anterior cruciate ligament (ACL) reconstruction (ACLR). Elite athletes typically exhibit high self-efficacy and a strong athletic identity while also facing intense external pressure to return. While these dynamics undoubtedly influence their response to injury and psychological recovery after ACLR, the precise differences in psychological readiness between elite and nonelite athletes have not been reported. Purpose: To compare psychological readiness between elite and nonelite athletes after primary ACLR. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 756 participants were included in this study. There were 252 elite athletes and 504 propensity score–matched, nonelite athletes (1:2 ratio). Elite athletes were those who played professional sport, represented their country at international competitions, or played intercounty-level Gaelic Games. Psychological readiness was compared between groups preoperatively and at 3, 6, and 9 months postoperatively using the ACL Return to Sport after Injury scale (ACL-RSI). Participants were contacted at 1 year and 2 years postoperatively to record if they had returned to play. Multivariable analysis was used to identify factors (eg, age, sex, elite level) associated with ACL-RSI scores at 9 months. Results: Preoperative ACL-RSI scores did not differ significantly between elite and nonelite groups (50.6 ± 27.4 vs 48.1 ± 26.6; P = .28). However, elite athletes had higher scores at 3 months (58.6 ± 23.4 vs 53.1 ± 21.9; P < .001), 6 months (67.4 ± 19.9 vs 63.1 ± 19.4; P = .01) and 9 months (72.7 ± 19.9 vs 68.6 ± 19.2; P = .009). Elite athletes had significantly higher RTP rates at 1 year (86% vs 69%; P < .001) and 2 years (94.3% vs 86.7%; P < .002). Multivariate analysis revealed that International Knee Documentation Committee score at 9 months (β = 1.10; 95% CI, 0.95-1.25; P < .001) and male sex (β = 3.7; 95% CI, 0.8-6.6; P < .01) were most associated with increased ACL-RSI scores at 9 months. After adjusting for other factors, elite status was not an independent predictor of psychological readiness. Conclusion: Our study demonstrated that preoperative ACL-RSI scores were comparable between elite and nonelite athletes. However, elite athletes had consistently higher ACL-RSI scores during rehabilitation and ultimately greater RTP rates. Knee function and male sex are the strongest predictors of ACL-RSI score. Being an elite athlete is not a primary predictor of psychological readiness, and psychological intervention should be considered in all athletes.