# Isokinetic Strength Recovery and Fear of Re-Injury After ACL Reconstruction in Male Soccer Players: A Retrospective Cohort Study

## TL;DR

This study found that male soccer players who had ACL surgery showed improved strength but still had long-term fear of re-injury, suggesting the need for a more comprehensive rehabilitation approach.

## Contribution

The study uniquely examines the relationship between isokinetic strength recovery and psychological outcomes after ACLR in competitive male soccer players.

## Key findings

- Quadriceps strength deficits persisted in the operated limb despite overall strength gains after ACLR.
- High kinesiophobia was present in 56.7% of athletes at long-term follow-up.
- No significant differences in psychological or strength outcomes were found between athletes with and without ACL re-injury.

## Abstract

Background/Objectives: Persistent strength deficits and psychological impairments may compromise return to sport (RTS) after anterior cruciate ligament reconstruction (ACLR). We investigate the relationship between thigh muscle isokinetic strength recovery at six months after ACLR and long-term psychological outcomes related to RTS in competitive male soccer players. Methods: Sixty male soccer players who underwent primary ACLR with bone–patellar tendon–bone autograft were retrospectively analyzed. Isokinetic testing of quadriceps and hamstrings was performed one week before surgery and six months post-surgery at 90°/s and 180°/s. Limb symmetry index (LSI) was calculated both pre- and post-operatively. At long-term follow-up (mean ≈ 4 years after RTS), athletes completed questionnaires assessing RTS status, ACL re-injuries, sport-related perceptions, and kinesiophobia using the Tampa Scale for Kinesiophobia (TSK). Statistical analyses were conducted to explore associations between post-operative LSI and TSK scores and to compare psychological and neuromuscular outcomes between athletes with and without ACL re-injury. Results: Absolute quadriceps and hamstring peak torque values significantly increased from pre- to post-surgery, with quadriceps strength deficits persisting only in the operated limb. However, quadriceps LSI significantly decreased post-operatively, while hamstring LSI remained stable. Pearson correlation analysis revealed a weak positive association between post-operative quadriceps LSI at 90°/s and TSK scores (r = 0.34). Overall, RTS rate was 91.7%, but a second ACL injury occurred in 18.2% of athletes. No significant differences were observed between re-injured and non-re-injured athletes in TSK scores or post-operative LSI values at either angular velocity (all p > 0.29). High kinesiophobia (TSK ≥ 37) was present in 56.7% of the cohort at long-term follow-up. Conclusions: Despite significant strength gains, quadriceps limb symmetry worsened six months after ACLR, with deficits confined to the operated limb, suggesting persistent neuromuscular inhibition. These physical deficits coexist with long-term kinesiophobia despite high RTS rates. The weak associations between strength symmetry and psychological outcomes highlight the multifactorial nature of RTS and support the need for an integrated physical, psychological, and neuro-cognitive approach to rehabilitation and RTS decision-making.