Sex differences in psychological readiness returning to sport after anterior cruciate ligament reconstruction: a systematic review and meta-analysis

Background Psychological readiness is an important component of return-to-sport (RTS) assessment following anterior cruciate ligament reconstruction (ACLR). Although sex differences in psychological readiness have been reported, the available evidence remains inconsistent. This systematic review and meta-analysis aimed to compare psychological readiness between male and female patients following ACLR and examine potential variation according to postoperative follow-up duration, population type, and surgical procedure. Methods PubMed, Web of Science, Embase, and the Cochrane Library were searched from inception to June 16, 2026. Observational studies of patients undergoing ACLR were eligible if psychological readiness was assessed using the ACL-RSI or its validated short version and sex-specific data were available for quantitative comparison. Random-effects meta-analysis using Hedges’ g was performed. Prespecified subgroup analyses, leave-one-out sensitivity analyses, methodological quality assessment, and publication bias assessment were conducted. Results Twenty studies involving 4,000 participants (2,381 males and 1,619 females) were included. Male patients demonstrated significantly greater psychological readiness than female patients, with a small effect (Hedges’ g = 0.24, 95% CI: 0.09–0.38; p = 0.003; I 2 = 64.0%). No significant subgroup differences were observed according to postoperative follow-up duration ( p = 0.443), population type ( p = 0.212), or surgical procedure ( p = 0.764). Conclusion Male patients demonstrated slightly greater psychological readiness to return to sport following ACLR than female patients. No evidence of subgroup differences was observed according to postoperative follow-up duration, population type, or surgical procedure. These findings provide updated quantitative evidence of sex-related differences in psychological readiness following ACLR and support individualized assessment during rehabilitation and RTS decision-making.