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

Background: persistent strength deficits and psychological impairments may compro-mise return to sport (RTS) after anterior cruciate ligament reconstruction (ACLR). Ob-jective: to 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 calcu-lated 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). 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. Overall, RTS rate was 91.7%, but a second ACL injury occurred in 18.2% of athletes. 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 ki-nesiophobia despite high RTS rates. Findings highlight the limitations of time-based and strength-only RTS criteria and support the need for an integrated physical, psychological, and neuro-cognitive approach to rehabilitation and RTS decision-making.