Toward a biopsychosocial understanding of the mechanisms underpinning successful return-to-performance post ACLR

Introduction
Anterior cruciate ligament reconstruction (ACLR) is a pivotal intervention for elite athletes who experience ACL injury. The ultimate aim of return to sport (RTS) protocols is to help these athletes regain their pre-injury performance levels. Despite advancements in surgical techniques and rehabilitation, return-to-performance rates remain suboptimal. Recent research has made the call for RTS protocols to adopt a biopsychosocial approach that addresses the physical, psychological, and social aspects of recovery in an integrated manner. However, a significant knowledge gap exists regarding the critical determinants of a successful return-to- performance from this holistic perspective. This study aims to develop a nuanced understanding of the mechanisms underpinning successful return-to-performance from an integrated biopsychosocial framework.

Method
This study included a diverse group of participants from various sports and backgrounds, including orthopaedic surgeons, athletic trainers, strength and conditioning coaches, sport psychologists, physical therapists, and athletes who have undergone ACL reconstruction. This diverse participation ensured a comprehensive exploration of multi-stakeholder, cross-cultural perspectives. The study employed Concept Mapping (CM), a participatory research approach that integrates quantitative and qualitative methods to identify, organize, and visualize complex factors. CM was conducted in three phases: idea generation, sorting, and rating.

Preliminary results
Preliminary findings from the first phase of concept mapping revealed a diverse array of factors deemed crucial for a successful return to performance from a biopsychosocial perspective. Participants highlighted several key ideas including: (i) standardized and validated RTS test, (ii) improved mental and emotional rehabilitation, (iii) multidisciplinary decision-making for clearance to RTS, (iv) abandoning time-based RTS decisions, (v) strong social support systems, (vi) team involvement, and (vii) peer support for shared experiences.

Applied implications
While this research is ongoing, the preliminary findings provide promising insights from multiple stakeholders into the key determinants that critically influence a successful return to performance from an integrated biopsychosocial perspective. This nuanced, multifaceted understanding of the mechanisms driving successful return-to-performance is expected to highlight the most effective rehabilitation strategies for elite athletes. By addressing these insights, future policies can be shaped to refine ACL-RTS protocols, ultimately aiming to improve the success rates of elite athletes returning to their pre-injury levels of performance.