The ACL-RSI is a 12-item client-reported outcome measure designed to assess psychological readiness to return to sport after anterior cruciate ligament injury or reconstruction. It includes items related to emotions, confidence in performance and risk appraisal.
Scores are usually converted to a 0–100 scale, where higher scores indicate greater psychological readiness to return to sport. A lower score may suggest greater concern, lower confidence or greater perceived risk, but the ACL-RSI does not confirm readiness, diagnose a problem or determine clearance on its own.
The ACL-RSI is most useful when combined with symptoms, knee function, strength, hop or performance testing, sport demands, confidence, goals, workload exposure and professional judgement.
Returning to sport after ACL injury or reconstruction is not only a physical process. Strength, range of motion, hop performance and sport-specific skills matter, but psychological readiness is also important. Some clients may have good physical test results but still feel uncertain, fearful or hesitant about returning to sport. Others may feel confident before their physical capacity is fully prepared.
The ACL-RSI was developed to help measure the psychological impact of returning to sport after ACL injury and reconstruction. It gives professionals a structured way to record how the client feels about returning to sport, rather than relying only on informal conversation.
The scale is practical because it is short, easy to complete and directly relevant to sport participation. It can be used as a baseline measure, repeated during rehabilitation or training, and compared with physical test results. In Measurz, ACL-RSI scores can sit alongside strength tests, hop tests, balance tests, knee outcome measures, symptoms and return-to-sport notes.
Importantly, the ACL-RSI should not be used as a stand-alone clearance tool. A high score does not prove that the client is ready to return to sport, and a low score does not prove that the client cannot progress. The score should support assessment reasoning and shared discussion.
Outcome measure name: ACL-RSI
Full name: Anterior Cruciate Ligament Return to Sport after Injury scale
Measure type: Client-reported outcome measure
Primary construct: Psychological readiness to return to sport after ACL injury/reconstruction
Number of items: 12
Score range: Usually 0–100
Higher score means: Greater psychological readiness
Lower score means: Lower psychological readiness, greater concern, lower confidence or higher perceived risk
Best used for: ACL injury or ACL reconstruction populations with sport participation goals
Main caution: It does not determine return-to-sport clearance on its own.
The ACL-RSI is a questionnaire that measures psychological readiness to return to sport after ACL injury or ACL reconstruction.
The standard version includes 12 items. These items are commonly grouped conceptually into three areas:
Emotions
Confidence in performance
Risk appraisal
The client rates each item on an 11-point scale from 0 to 10. The total score is usually converted to a percentage-like score from 0 to 100.
The ACL-RSI is designed to capture thoughts and feelings that may influence return to sport, such as confidence, nervousness, fear of re-injury and belief in knee performance.
It is not a physical performance test. It should be combined with objective measures where relevant.
The ACL-RSI is used to support understanding of the psychological side of return to sport.
It may help professionals:
Record psychological readiness after ACL injury or reconstruction
Identify confidence or fear-related concerns
Track readiness over time
Support return-to-sport conversations
Compare psychological readiness with physical test results
Monitor change during training or rehabilitation
Guide further discussion about goals, concerns and sport demands
Improve communication between professionals and clients
The ACL-RSI is especially useful when physical test performance and confidence do not match. For example, a client may show improving strength and hop performance but still report low confidence or high fear of re-injury.
The ACL-RSI measures psychological readiness to return to sport.
It may provide insight into:
Confidence in returning to sport
Confidence in knee performance
Fear or concern about re-injury
Emotional response to return-to-sport situations
Risk perception
Readiness to perform sport-specific tasks
Psychological barriers to participation
Change in readiness over time
It does not directly measure:
ACL graft or ligament status
Knee stability with certainty
Strength
Power
Hop performance
Movement quality
Sport skill
Tissue healing
Injury risk with certainty
Whether the client is cleared for sport
The ACL-RSI is most useful for clients with an ACL injury history who have sport or high-level activity goals.
It may be useful for:
Field and court sport athletes
Recreational sport participants
Competitive athletes after ACL reconstruction
Clients returning to pivoting, cutting or jumping sports
Clients who report fear of re-injury
Clients with confidence concerns
Clients with performance goals after ACL injury
Professionals monitoring readiness over time
It is less useful for clients who do not have a return-to-sport goal, although some items may still help guide discussion around confidence and activity participation.
Consider using ACL-RSI when:
A client has an ACL injury or ACL reconstruction history
Return to sport or high-level activity is a goal
Psychological readiness is relevant
The client reports fear, hesitation or uncertainty
You are tracking progress over time
You want to compare mental readiness with physical test results
You are preparing return-to-training or return-to-sport discussions
Common use points include:
Early baseline after return-to-training planning begins
Mid-stage rehabilitation or training
Before sport-specific reconditioning
Before return-to-training decisions
Before return-to-sport discussions
During follow-up after return to sport
Use caution when:
The client is not aiming to return to sport
The client has not yet considered sport participation
The client has difficulty understanding the response scale
The language version has not been validated for the client’s language or culture
The client is highly distressed and needs broader professional support
The score is being used without physical assessment findings
The score is being treated as a clearance threshold
The ACL-RSI should not be used to tell a client they are safe or unsafe to return to sport. It should be used to support discussion and monitoring.
You need:
ACL-RSI questionnaire
Scoring instructions
Measurz app
Time to complete, usually only a few minutes
Optional digital form or printed questionnaire
Related physical testing results where available
Helpful related Measurz records include:
Knee pain score
Knee confidence rating
Quadriceps and hamstring strength
Hop tests
Balance tests
Movement quality notes
Sport-specific goals
Training exposure
Return-to-sport discussion notes
Explain that the ACL-RSI asks about confidence, emotions and perceived risk related to returning to sport after ACL injury.
Use the same version each time for repeat testing.
The ACL-RSI is a self-report questionnaire.
The standard form includes 12 items rated from 0 to 10.
A safe instruction is:
“Please answer each item based on how you currently feel about returning to your sport or activity. There are no right or wrong answers. Your responses help us understand your confidence, concerns and readiness so we can track this alongside your physical assessment results.”
The client can complete it:
Digitally
On paper
With professional assistance if needed
As part of a Measurz assessment session
If assistance is provided, record that assistance was given.
The professional may explain how to use the scale, but should avoid leading the client’s answers.
If the client is unsure about a sport-specific item, relate it to their main target activity.
Use the scoring method provided by the validated version or official questionnaire source where available.
If an item is missing, avoid guessing. Record the missing item and consider the score incomplete unless the scoring guidance for the specific version allows calculation with missing responses.
Each item is scored from 0 to 10.
The usual total score is calculated by adding the item scores and converting to a 0–100 scale. With 12 items, the raw total ranges from 0 to 120. The converted score is usually:
Raw total divided by 120, multiplied by 100.
Higher scores indicate greater psychological readiness.
Retest using the same version and similar context.
Record:
Time since injury or surgery
Current training phase
Sport goal
Recent flare-ups
Exposure to sport-specific tasks
Any major changes in confidence or symptoms
ACL-RSI is not physically provocative. The main caution is emotional sensitivity. If the questionnaire raises significant fear, distress or anxiety, record this respectfully and consider whether further professional support is appropriate.
The ACL-RSI is usually scored from 0 to 100.
The 12-item scale includes items related to emotions, confidence in performance and risk appraisal. Many professionals use the total score clinically, although research may analyse domains or shorter versions.
A higher score may indicate:
Greater psychological readiness
More confidence in sport participation
Lower perceived risk
Less fear or nervousness
Greater belief in knee performance
A lower score may indicate:
Lower psychological readiness
More fear of re-injury
Less confidence
Greater uncertainty
More perceived risk
Need for further discussion or support
Add all 12 item scores, divide by the maximum possible score of 120, then multiply by 100.
Published studies have proposed different cut-offs for return-to-sport prediction or acceptable symptom state, but values vary by population, timing, sport and method. Do not treat a single cut-off as a universal pass/fail threshold.
A high ACL-RSI score may suggest the client feels psychologically ready or more confident about sport participation. It does not prove physical readiness, safe movement, adequate strength or low injury risk.
A low ACL-RSI score may suggest fear, low confidence or concern about returning to sport. It does not prove that the client cannot progress, but it may indicate that confidence and psychological readiness should be discussed.
The ACL-RSI does not prove:
Knee stability
Tissue healing
ACL graft status
Strength symmetry
Sport skill
Movement quality
Injury risk
Clearance for sport
A safe explanation is:
“Your ACL-RSI score gives us information about how confident and ready you feel about returning to sport. We will use this alongside your symptoms, strength, movement tests, sport goals and training progress rather than using it on its own.”
For general fitness clients, the ACL-RSI may be less sport-specific unless the client is returning to activities that feel similar to sport, such as running, group training, hiking, jumping or gym-based performance.
A lower score may reflect uncertainty about knee confidence rather than competitive sport fear.
For athletes, the ACL-RSI may be highly relevant because sport often involves speed, contact, cutting, pivoting, jumping and unpredictable environments.
A score may be influenced by previous injury experience, competition pressure, team selection, confidence in the knee and exposure to sport-specific training.
For older adults, ACL-RSI may be less relevant unless the person has a clear return-to-sport or high-level activity goal. Interpretation should consider goals, activity expectations and confidence in daily or recreational tasks.
Youth athletes may need age-appropriate explanation and support. A score may be influenced by parent expectations, coach pressure, team identity and understanding of the questionnaire. Use validated youth or language versions where available.
For clients returning after ACL injury or reconstruction, repeated ACL-RSI scores can help track confidence and readiness over time. A single score is less useful than change across stages.
Persistent pain, swelling, giving-way sensations or low confidence may lower ACL-RSI scores. Interpretation should include both physical and psychological contributors.
ACL-RSI is not primarily a work outcome measure. If the client’s main goal is work rather than sport, consider a more relevant functional outcome measure and use ACL-RSI only if sport or high-demand activity is also relevant.
ACL-RSI responsiveness and meaningful-change evidence continues to develop.
Recent studies have examined ACL-RSI responsiveness and thresholds such as MCID, MIC and PASS after ACL reconstruction. These values can vary depending on timing, population, baseline score, sport level, anchor method and follow-up period.
Some recent research has reported MCID or MIC thresholds for ACL-RSI after ACL reconstruction, but values should be matched carefully to the population and timeframe studied. Do not apply one value universally.
MDC and SEM values are less consistently reported than reliability and validity measures. Where a study provides MDC or SEM for the exact version and population, use that value for that context.
Evidence supports ACL-RSI as responsive to change in psychological readiness over time after ACL injury or reconstruction, but responsiveness depends on stage, sport exposure and recovery context.
Reported meaningful-change values vary across populations and methods. Use values that best match the client group, measure version and testing context.
If no directly relevant MCID/MDC/SEM is available for the client’s context, interpretation should rely more heavily on:
Baseline comparison
Repeated measurement
Client goals
Symptom change
Confidence change
Training exposure
Physical test results
Professional judgement
ACL-RSI does not have one universal normative value that applies to all clients.
Reference or comparative values are most useful when matched to:
Time since ACL injury or reconstruction
Sport level
Sex
Age group
Return-to-sport status
Graft or surgical context where relevant
Language version
Short versus full version
Systematic review evidence shows ACL-RSI scores are commonly lower earlier after ACL injury/reconstruction and may improve over time, but scores vary widely between individuals.
Practical comparison guidance:
Compare the client with their own baseline.
Compare repeated scores at similar recovery stages.
Interpret alongside sport exposure.
Review confidence and risk appraisal items, not only the total score.
Use population-specific research values only when they closely match the client.
ACL-RSI should not be used as a strict pass/fail benchmark.
The ACL-RSI has been studied across ACL reconstruction and sport populations and is generally considered a reliable and valid measure of psychological readiness to return to sport.
Evidence supports:
Internal consistency of the total scale
Construct validity with related psychological and functional constructs
Association with return-to-sport outcomes
Responsiveness to change over time
Cross-cultural validation in several language versions
Short-form development and validation in some populations
Known limitations include:
Different versions and translations may perform differently.
Cut-offs vary across studies.
High psychological readiness does not prove physical readiness.
Low readiness may reflect multiple factors, not one single barrier.
Evidence is strongest in ACL-related sport populations, not all knee conditions.
Common errors include:
Using the score as a clearance decision
Treating a cut-off as universal
Ignoring individual item responses
Comparing different language versions without caution
Not recording time since surgery or injury
Not linking the score to sport exposure
Not combining with physical tests
Assuming low score means poor motivation
Assuming high score means low risk
Limitations include:
Self-report bias
Sport-specific context may not suit all clients
Meaningful-change thresholds vary
Scores may be influenced by recent symptoms or training experiences
It does not assess physical capacity
It does not identify the cause of fear or low confidence on its own
The ACL-RSI can support:
Return-to-sport discussions
Psychological readiness monitoring
Baseline and retest tracking
Client education
Sport-specific goal planning
Team communication
Progress reporting
Comparison with strength and hop testing
Identifying when confidence and physical capacity do not align
It is especially useful when recorded repeatedly in Measurz alongside objective knee assessments.
Record:
Outcome measure name: ACL-RSI
Version used: 12-item standard version or short version if used
Total score
Score range: 0–100
Direction: higher score indicates greater psychological readiness
Date completed
Completion method: digital, paper or interview-assisted
Sport or activity goal
Time since injury or surgery
Current training phase
Pain score if relevant
Symptoms such as swelling, giving way or confidence loss
Item-level concerns where useful
Missing items
Assistance provided
Language/version used
Baseline comparison
Retest date
MCID/MDC comparison where supported by relevant evidence
Related physical findings such as strength, hop testing and movement quality
Notes on interpretation
Further assessment or support notes where appropriate
Recording these details improves repeatability, communication, client education, assessment reasoning, monitoring over time, team consistency and reporting quality.
IKDC Subjective Knee Form
KOOS
KOOS-ACL
Knee Self-Efficacy Scale
Tampa Scale of Kinesiophobia
Tegner Activity Scale
Lysholm Knee Score
Knee Outcome Survey
Single-leg hop tests
Quadriceps strength testing
Hamstring strength testing
It measures psychological readiness to return to sport after ACL injury or reconstruction.
A higher score generally indicates greater confidence, lower fear and greater psychological readiness to return to sport.
A lower score may indicate fear, lower confidence, higher perceived risk or uncertainty about returning to sport.
No. It should not be used as a stand-alone clearance tool.
It can be repeated at key stages of training or return-to-sport planning, especially when confidence, symptoms or sport exposure changes.
It is most relevant for people returning to sport or high-demand activity after ACL injury.
Yes. Item-level responses can help identify whether concerns relate more to emotion, confidence or risk appraisal.
Symptoms, goals, strength testing, hop tests, movement quality, sport-specific exposure and professional judgement.
The ACL-RSI measures psychological readiness to return to sport after ACL injury or reconstruction.
Scores usually range from 0 to 100, with higher scores indicating greater readiness.
It includes emotion, confidence and risk appraisal items.
The score does not prove physical readiness or clear someone for sport.
Meaningful-change values vary by population, timing and method.
Measurz recording should include version, score, sport goal, time since injury/surgery, symptoms, physical test findings and retest context.
Faleide, A. G. H., Inderhaug, E., Vervaat, W., Breivik, K., Bogen, B. E., Mo, I. F., & Magnussen, L. H. (2021). Anterior cruciate ligament-return to sport after injury scale: Responsiveness and minimal important change. Orthopaedic Journal of Sports Medicine, 9(6), 23259671211031240. https://doi.org/10.1177/23259671211031240
Piussi, R., Beischer, S., Thomeé, R., & others. (2025). Thresholds for minimum clinically important difference, minimal important change and patient acceptable symptom state for the ACL-RSI and Knee Self-Efficacy Scale after ACL reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy.
Sadeqi, M., Klouche, S., Bohu, Y., Herman, S., Lefevre, N., & Gerometta, A. (2018). Progression of the psychological ACL-RSI score and return to sport after anterior cruciate ligament reconstruction: A prospective 2-year follow-up study. Orthopaedic Journal of Sports Medicine, 6(12), 2325967118812819. https://doi.org/10.1177/2325967118812819
Webster, K. E., Feller, J. A., & Lambros, C. (2008). Development and preliminary validation of a scale to measure the psychological impact of returning to sport following anterior cruciate ligament reconstruction surgery. Physical Therapy in Sport, 9(1), 9–15. https://doi.org/10.1016/j.ptsp.2007.09.003
Webster, K. E., Feller, J. A., & others. (2018). Development and validation of a short version of the Anterior Cruciate Ligament Return to Sport after Injury scale. Orthopaedic Journal of Sports Medicine, 6(4), 2325967118763763. https://doi.org/10.1177/2325967118763763
