Functional and Psychological Predictors of Return to Sport and Reinjury Risk in Professional Athletes After ACL Reconstruction.

BACKGROUND: Return to sport (RTS) after anterior cruciate ligament (ACL) reconstruction (ACLR) depends on both physical performance and psychological readiness. Although functional tests and patient-reported outcome measures (PROMs) are used widely, the most sensitive and clinically relevant criteria for predicting safe RTS and reducing reinjury risk in elite athletes remain unclear. HYPOTHESIS: Absolute hop performance metrics, combined with psychological readiness scores, will more accurately discriminate reinjury risk than traditional limb symmetry index (LSI) thresholds in professional athletes after ACLR. STUDY DESIGN: Prospective cohort with nested retrospective matched case-control design. LEVEL OF EVIDENCE: Level 2. METHODS: A total of 127 professional athletes completed standardized testing (2021 to 2024) comprising 10 functional hop tests and 3 PROMs, including the ACL-RTS after Injury (ACL-RSI) scale. Reinjury outcomes were tracked for 3 years. In the nested case-control analysis, 32 athletes with noncontact graft reinjury were matched with 32 injury-free ACLR controls. Between-group differences in hop performance, LSI, and PROM scores were analyzed. RESULTS: Of the 10 hop tests, 7 showed significant side-to-side differences in absolute performance (P = 0.01-0.04). LSI had limited discriminatory value, with only 1 significant result among female athletes (P = 0.03). Strong and significant correlations were found between hop performance and ACL-RSI scores (r = 0.43-0.73; P < 0.05), indicating a substantial link between physical performance and psychological readiness. CONCLUSION: Absolute hop performance measures combined with PROMs are more sensitive than LSI in detecting elevated reinjury risk. The ACL-RSI scale may help determine readiness for high-demand functional testing and safe RTS. CLINICAL RELEVANCE: Incorporating absolute hop performance metrics with psychological readiness assessment may improve RTS decision-making and reduce reinjury risk in elite athletes.