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Chapter 478IntroductionA rupture of the anterior cruciate ligament (ACL) is the most common ligament injury in athletes and can be season or even career ending for many.46 ACL reconstruction (ACLR) is indicated in athletes with persistent instability despite non-operative treatment, especially if they wish to return to jumping, cutting, and pivoting sports.10 After ACLR, more than 90% of the athletes expect to return to their pre-injury level.11 However, only 55% actually return to competitive sports.4Historically the focus of ACLR was restoring anterior tibial translation (ATT), however it is known that the ACLR also plays an important role in limiting the range of tibial rotation (rTR).15 Despite reconstruction, numerous patients with ACLR report feeling instability in the knee or the knee giving way, especially in dynamic movements such as cutting and pivoting.29 Instability and stiffness of the knee are known factors in unsuccessful return to sport.2,13How this instability manifests itself in the biomechanics of the lower limbs and how it relates to successful return to sport is unclear 32, although, altered biomechanics have been related to increased risk for secondary ACL injury. 7,27,35,36Kinesiophobia and fear of giving way are also associated with a decline in the rate of returning to preinjury level of sports.2,13,33,38 This suggests that psychological factors play a significant role in (un)successful return to sport.2 Fear of (re)injury is even one of the most cited reasons for patients to not return to sport.24,43 Studies assessing psychological factors, for example with the ACL-Return to Sports after Injury (ACL-RSI) scale, showed that ACL patients with higher scores on psychological readiness were more likely to successfully return to sport.14,25,26,40 Moreover, research has shown that patient reported outcome measures (PROMs) can differentiate between individuals with low versus high knee function, as well as those with more versus fewer knee symptoms.28 Certain PROMs assessing selfreported knee function, like the IKDC questionnaire, have been related to objective outcome measures, such as extensor strength 48, hop distance 1,39,41, postural control 34, and neurophysiological impairments.8Mark Zee.indd 78 03-01-2024 08:56