Psychological and educational factors across the female anterior cruciate ligament continuum: a scoping review

Abstract

Anterior cruciate ligament (ACL) injuries represent a major burden in female athletes and are associated with prolonged rehabilitation, suboptimal return-to-sport outcomes, and elevated reinjury risk. Although research has traditionally focused on biological and biomechanical factors, psychological and educational dimensions may also influence prevention, rehabilitation, return to sport, return to performance, and reinjury. This scoping review aimed to map the current evidence regarding psychological and educational factors across the female ACL continuum. This scoping review followed the methodology described by Levac et al. and the Joanna Briggs Institute and was reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews. MEDLINE via PubMed, Embase, and the Cochrane Library were searched from January 2010 to March 2026. Eligible studies included female athletes aged ≥ 12 years exposed to ACL injury risk, ACL injury, or ACL reconstruction, and investigated psychological and/or educational factors related to prevention, rehabilitation, return to sport, return to performance, or reinjury. Study characteristics and frequencies were summarized descriptively, while recurring constructs and evidence gaps were synthesized narratively. Twenty-two studies were included. Psychological factors were investigated in 15 studies (68.2%; n  = 15), educational factors in six studies (27.3%; n  = 6), and combined psychological and educational factors in one study (4.5%; n  = 1). Directly reported female-athlete sample sizes ranged from 8 to 4556. Among studies reporting mean age, mean ages ranged from 15.0 to 33.0 years; competitive level was heterogeneous and incompletely reported, spanning youth/high-school, collegiate, recreational, national, and elite contexts. Football/soccer was the most frequent sport-specific population (31.8%; n  = 7). Educational factors were predominantly investigated during prevention and mainly concerned adherence, implementation barriers, coach education, and ACL injury knowledge. In contrast, psychological factors were mainly investigated after ACL injury or ACL reconstruction, particularly during rehabilitation, return-to-sport, and reinjury phases. Psychological readiness was the most frequently investigated construct (36.4%; n  = 8), followed by fear of reinjury or kinesiophobia (22.7%; n  = 5). Current evidence regarding psychological and educational factors across the female ACL continuum remains fragmented. Educational dimensions are mainly confined to prevention, whereas psychological dimensions are predominantly investigated after ACL injury or ACL reconstruction. Important evidence gaps remain regarding longitudinal assessment, educational factors beyond prevention, and interactions between psychological and educational dimensions across the continuum. This scoping review was not registered a priori.