Volume 8, Issue 7, July – 2023 International Journal of Innovative Science and Research Technology

ISSN No:-2456-2165

Evaluation of Self-Efficacy, Physical Activity

Participation and Return to Sports for an ACL
Injury in Indian Male Athletes
1 2
Dr. Ashishdev Gera (PT) Dr. Monika Awasthi (PT)
1 2
Assistant Professor Department of Physiotherapy Pysiotherapist,
Dolphin (PG) Institute of Biomedical & Natural Sciences Male District Hospital, Balrampur

3
Dr. Shivangi Gupta (PT)
3
MPT student of Department of physiotherapy
Dolphin (PG) Institute of Biomedical & Natural Sciences

Abstract:- Keywords:- Self-Efficacy, Physical Activity and ACL-Injury.

 Background: - I. INTRODUCTION
Self-efficacy is an individual’s confidence on their
ability to perform a specific task and key internal Self-efficacy refers to an individual's confidence in his
motivational process that can be affected by personal or her ability to perform a specific task or behavior to
and environmental variables and it influences achieve the successful completion of a desired outcome1.
motivational outcomes of choices efforts and goals.
According to Bandura theory, efficacy expectations
 Purpose: - determine how much effort people will expend and how
To find out the subject’s self- efficacy at grade 2(2 long they will persist in the face of obstacles and aversive
and 3 months) and grade 3(2 and 3 months) of ACL experiences. The stronger the perceived self-efficacy, the
injury and find out correlation the K-SES with the more active efforts.
subjective scales (physical activity, age and return to
sports). Self-efficacy expectations vary on several dimensions
they differ in magnitude, generality and strength2.
 Materials and Methods: -
25 subjects (16-35) of each grade 2 and grade 3 of Self-efficacy in subjects with ACL injury measured by
ACL injury (2 and 3 months) confirmed by MRI will instrument K-SES is found reliable and valid so, it makes
filled questionnaires form at 2 and 3 months from ACL easier to study the responsiveness of the K-SES and various
injury. Subjects completed six scales i.e., Marx scale, aspects of self-efficacy in the ACL population 3.
KOOS scale, K-SES scale, Lysholm scale, Tegner scale
and ACL-RSI scale. Analyzed using IBM SPSS 19. T-test The original K-SES is used to identify patients with
was used. P-value <0.05 was considered significant. high self-efficacy as well as subjects with low self-efficacy
from early after ACL injury and ACL reconstruction up to
 Results: - 12 months thereafter 4.The anterior cruciate ligament (ACL)
Grade 2 and 3 of 2 and 3 months shows not is officially injured during sports activities, mostly after
significant, shows only differences because of jumping, changing direction, running, sudden stoppage and
psychosocial and psychological factors, correlation seen overextended of lower leg5.Adolescent age group affects
self-efficacy on physical activity, return to sports and age more and increases the incidence rate of ACL Injury7.
of grade 2 and 3 it not shows significant because of
coping strategies and quality of life, less time duration. According to Bandura (1986) and researchers have
shown that self-efficacy is a key internal motivational
 Conclusions: - process that can be affected by personal and environmental
Self- efficacy, physical activity participation and variables it inflences motivational outcomes of choices
return to sport for an ACL injury in Indian male efforts and goals10.
athletes does not show significance because of internal
and external risk factors as observed in this study for The psychosocial factors include cognitive, affective
Indian male athletes. The differences show self-efficacy and behavioral factors which play important roles in the
in grade 2(2 and 3 months) and grade 3(2 and 3 months) recovery from an ACL injury so, all three factors are
of ACL injury because of psychosocial, psychological particularly important for roles in the outcome of the injury.
factors and environmental factors. these three factors have several components like

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interpretations, appraisals and beliefs that come under  Criteria:-
cognition, it concerns the conscious assessments athletes
make after an injury. affective factors include emotions,  Inclusion Criteria: -
feelings and mood disturbances. furthermore, the behavior Suspected ACL injury and ACL deficient,16-35 years
of the athletes refers to someone's effort, actions, and of age athlete, Injured before one or two months before,
activities about an injury9. Able to read and understand the English language,
Unilateral ACL injury, Grade 2 and Grade 3 of ACL injury
After the injury, athletes usually report anger, confirmed by consulted doctor through MRI.
depression, anxiety, a lack of confidence and fear of
sustaining a reinjury so, there is evidence that these  Exclusion Criteria: -
psychological disturbances may affect recovery and Bilateral ACL injury, Previous ACL surgery, Cartilage
returning to sport and also increase the risk of sustaining a Injury requiring surgery, Multiple ligament reconstruction,
reinjury6. For example, after injury recreational athletes Questionnaire data were in complete, ACL reconstruction.
were found to experience lower mood disturbances than
competitive athletes and were slower to recover  Outcome Measures
psychosocially8. Knee pain, Physical activity, Knee function, Knee
symptoms, Self-efficacy, Daily activities, Quality of life,
Recovery after sports injury is influenced not only by Psychological readiness to return to sport.
physical factors but also by psychological factors.
Therefore, successfully transition back to the sport after  Operational Definition
injury Athletes need to be physically as well as
psychologically ready6. It means for return to sports both  Self-Efficacy: -
factors are important physical as well as psychological Self-efficacy refers to confidence in one’s abilities to
factors. successfully perform a particular behavior. Self-efficacy was
introduced in 1977 by Albert Bandura11.
The most common psychological issues athletes face is
fear of reinjury, concerns about the inability to perform at  Physical Activity: -
the previous level, feelings of isolation, lack of athletic WHO defines physical activity as any bodily
identity, insufficient social support, and pressure to return to movement produced by skeletal muscles that requires
sport and this puts negative influences on the rehabilitation energy expenditure. Physical activity refers to all movement
of an ACL injury. ACL rehabilitation requires a minimum including during leisure time, for transport to get to and
of 6 months of physical therapy before returning to sport8. from places, or as part of a person’s work12.

Patients' positive psychological responses are more  ACL Injury: -

likely to have better rehabilitation outcomes, as having less An ACL injury was defined as a partial or complete
fear and anxiety is positively correlated to returning to rupture of the ligament that occur for the first time or as a
sport7.Apply self-efficacy education and its role on recurrence. The ligament injury could occur in isolation or
rehabilitation in improving physical activity participation in combination with another knee joint injuries13.
and return to sports if some differences seen in grade 2 and
grade 3 of 2 and 3 months respectively.To find out the II. REVIEW OF LITERATURE
subject’s self-efficacy at grade 2 (2 and 3 months) and grade
3 (2 and 3 months) of ACL injury and find out correlation (2019) Takuya kitaguchi et al in their study
the K-SES with the subjective scales including physical “Importance of functional performance and
activity, age and return to sport. psychological readiness for return to preinjury level of
sports 1 years after ACL reconstruction in competitive
 Hypothesis athletes” concluded that in competitive athletes, SLH<81%
and ACL-RSI<55points at 6 months after surgery were
 Alternate Hypothesis: - Self-efficacy, physical activity associated with a greater risk of unsuccessful RTS at 1 year
participation and return to sport for an ACL injury in after surgery. SLH and ACL-RSI at 6 months could serve as
Indian male athletes show significance. screening tools to identify athletes who have difficulties
 Null Hypothesis: - Self-efficacy, physical activity with returning to sports after ACL reconstruction.
participation and return to sport for an ACL injury in
Indian male athletes does not show significance. (2021) Christopher kuenze et al in their study
“Assessing physical activity after ACL injury: Moving
 Sample Size: - beyond return to sport” concluded that in clinicians and
researchers have relied on return to sport status or self-
 Number of Subjects: - 50 reported PA participation via surveys. These approaches are
 Sources of Subjects: -Pavilion ground Dehradun and not consistent with current recommendations for PA
Maharana Pratap sports college Dehradun. assessment and do not allow for comparison with
 Study Design: -Cohort study. contemporary PA recommendation and guidelines. Return to
 Sampling Method: - Judgmental or purposive sampling sport, patient reported outcome measures, and device-based

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assessment approaches should be used in complementary return to acceptable levels of physical activity, symptoms
manners to comprehensively assess PA participation after and muscle function 1 year after ACL reconstruction.
ACLR. However, appropriate techniques should be used
when assessing PA in adult and adolescent populations. (2016) Clare Ardern et al in their study “Satisfaction
with knee function after primary anterior cruciate
(2005) P. Thomeé et al in their study “A new ligament reconstruction is associated with self-efficacy,
instrument for measuring self- efficacy in patients with quality of life, and returning to the preinjury physical
an anterior cruciate ligament injury” concluded that good activity” concluded that people who had returned to their
reliability and good face, content, construct and convergent pre-injury physical activity, and reported higher knee-related
validity were demonstrated for this new instrument (K-SES) self-efficacy and quality of life were more likely to be
for measuring perceived self-efficacy in patients with an satisfied with the outcome of ACL reconstruction.
ACL injury. The K-SES is recommended for studied
designed to evaluate prognostic and outcome expectations of (2019) Kate E. Webster et al in their study
perceived self-efficacy in patients with an ACL-insufficient “Expectations for return to preinjury sport before and
knee. after anterior cruciate ligament reconstruction”
concluded that patients had high expectations for returning
(2013) Roland Thomeé et al in their study “Return to to their preinjury level of sport at the time of undergoing
sports after anterior cruciate ligament reconstruction in initial ACLR. Expectations were lower for those who had
women” concluded that women who successfully returned undergone previous ACLR. Female patients and patients
to their pre-injury sports activity, had, in the early who had undergone previous ACLR were more likely to
postoperative tests a higher physical activity, a higher change their expectations and cease sport participation.
physical activity, a higher goal for their future physical These data can be used to provide patients with realistic
activity, lower pain and symptoms, better knee function, a return-to-sport expectations in the first postoperative year
higher knee related quality of life and a higher LSI and highlight the challenge for patients who aim to return
compared with those women that did not return. from multiple ACL injuries.

(2007) P. Thomeé et al in their study “Self-efficacy, III. PROCEDURE

symptoms and physical activity in patients with an
anterior cruciate ligament injury: a prospective study” Subjects of Grade 2 & Grade 3 confirmed by the MRI
concluded that K-SES has good responsiveness with with ACL injury will filled Questionnaires form at 2 months
significantly increased self-efficacy during the rehabilitation and 3 months from ACL injury will be recruited from sports
process for patients with an ACL-deficient knee as well as academy as per inclusion and exclusion criteria. Explanation
for patients who had undergone ACL reconstruction. The will be done regarding the study. Subjects completed the six
improvement in perceived self-efficacy could, however, scales i.e, Marx scale, KOOS scale, K-SES scale, Lysholm
only be partly explained by the improvement in subjective scale, Tegner scale and ACL-RSI scale.
symptoms. Furthermore, self-efficacy differed significantly
with gender, age and physical activity level early in the Marx scale includes 4 items: frequency of running,
rehabilitation process. cutting, deceleration and pivoting subjects based on the
“healthiest and most active state in the past year”. It
(2022) Ojoawo Adesola Ojo et al in their study emphasizes high level knee function of functional activities.
“Relationship among self- efficacy, physical activity and Total score is obtained by adding the individual items score
beliefs in patients with knee osteoarthritis” concluded range 0-16, where 0=less time in a month and 4=4 or more
that majority of the respondents had a high general self- time in a week14.
efficacy. There was a significant but inverse relationship
between self-efficacy and each of pain self-efficacy and KOOS scale assess short and long relevant outcome
belief among patients with knee osteoarthritis. following knee injury. It has five outcomes: pain (5 items),
symptoms (7 items), activity of daily living (17 items), sport
(2010) Pia Thomeé et al in their study “A and recreation function (5 items), and knee related quality of
Randomized, controlled study of a rehabilitation model life (4 items), where 0=no problem and 4= extreme problem
to improve knee-function self-efficacy with ACL injury” and each of the 5 scores is calculated as the sum of the items
concluded that there was no evidence that the clinical included15.
rehabilitation model with strategies to enhance self-efficacy
resulted in a better outcome than the rehabilitation protocol K-SES scale consists of 22 items it assesses self-
used for the control group. efficacy in daily activity (7 items), sports and leisure
activities (5 items), physical activity (6 items) and knee
(2007) Pia Thomeé et al in their study “Self-efficacy function in future (4 items). K-SES scale have 2 factors: 1st
of knee function as a pre-operative predictor of outcome factor refers self-efficacy related to present functioning and
1 year after anterior cruciate ligament reconstruction” 2nd factor refers to knee function in the future. Items are
concluded that patients’ perceived self-efficacy of knee scored on an 11 points scale 0=not certain and 10= very
function pre-operatively is of predictive value for their certain16.

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Tegner activity level scale describes their current ACL-RSI measures psychological readiness to return
activity level and that before injury. Scores varies 0-10 to sport after an ACL injury score of each category were
where, 0=sick leave or disability pension because of knee added and average the total score between 0 to 100 points
problem and 10= participation in nation and international where higher points indicates greater psychological
elite competitive sports17. readiness to return to sport18

Lysholm scale assess a subject knee specific symptom. Before collecting data, individual consent was taken
Maximum score is 100 points where, 91-100 is excellent, along with demographic data.
84-90 is good, 65-83 is fair, 64 or less is unsatisfactory17.

IV. ESTIMATED TIME NEEDED FOR DATA COLLECTION (THREE MONTHS)

 Result:-

Table 1 For Grade-2, Compare in between 2 Months & 3 Months

Grade-2 Grade-2
Mean Value 2 months 3 months x-y D D2 V SD
Age 19.4 19.4 0 2 0 0 0
ACL RSI 620.8 792.8 172 2 29584 1232.667 35.10935
Marx Scale 12.96 6.44 6.52 2 42.51 1.77125 1.330883
K-SES Intrument
Daily activities 42.16 12.12 30.04 2 902.41 37.60042 6.131918
Sports & Leisure activities 6.32 4.32 2 2 4 0.166667 0.408248
Physical activities 43.76 19.32 24.44 2 597.31 24.88792 4.988779
Knee function in the future 16.6 13.6 3 2 9 0.375 0.612372
Lysholm knee Score 69.56 85.16 15.6 2 243.36 10.14 3.184337
Tegner Activity Score
Activity level before injury 9.56 8.72 0.84 2 0.71 0.029583 0.171998
Current activity level 7 6.88 0.12 2 O.014 0.006 0.0007
KOOS
Pain 10.52 2.72 7.8 2 60.84 2.535 1.592168
Symptom 13.08 7.84 5.24 2 27.45 1.14375 1.069462
Functional Daily Living 8.92 2.72 6.2 2 38.44 1.601667 1.26557
Function, Sports & Recreational activities 8.64 3.2 5.44 2 29.59 1.232917 1.110368
Quality of Life 7.48 3.64 3.84 2 14.74 0.614167 0.783688

Table 2 For Grade-3, Compare in between 2 Months & 3 Months

Grade-3 Grade-3
Mean Value 2 months 3 months x-y D D2 V SD
Age 20.92 20.92 0 2 0 0 0
ACL RSI 610 707.6 97.6 2 9525.76 396.9067 19.92252
Marx Scale 6.04 8.2 2.16 2 4.67 0.194583 0.441116
K-SES Intrument
Daily activities 51.16 45.12 6.04 2 36.48 1.52 0.073
Sports & Leisure activities 2.68 3.24 0.56 2 0.31 0.012917 0.0067
Physical activities 50.92 46.08 4.84 2 23.43 0.97625 0.988054
Knee function in the future 20.68 24.28 3.6 2 12.96 0.54 0.734847
Lysholm knee Score 54.36 35.16 19.2 2 368.64 15.36 3.919184
Tegner Activity Score
Activity level before injury 9 8.6 0.4 2 0.16 0.006667 0.08165
Current activity level 4.2 6.48 2.28 2 5.19 0.21625 0.465027
KOOS
Pain 13.64 12.32 1.32 2 1.74 0.0725 0.269258
Symptom 0.44 0.56 0.12 2 0.014 0.000583 0.024152
Functional Daily Living 32.32 21.96 10.36 2 107.33 4.472083 2.11473
Function, Sports & Recreational activities 15.16 13.96 1.2 2 1.44 0.06 0.244949
Quality of Life 32.32 21.96 10.36 2 107.33 4.472083 2.11473

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Table 3 Correlation in Present K-SES for grade-2 & Grade-3 (Sum of Daily activity,
sport-leisure activities , Physical activities) & Future Knee function, Separately
K-SES for Grade-2 2 months 3 months M SD Present SD V
Daily activities 42.16 12.12 30.04 6.1319 2.3841 0.8859 0.7848
Sports & Leisure activities 6.32 4.32 2 0.4082
Physical activities 43.76 19.32 24.44 4.9887
Knee function in the future 16.6 13.6 3 0.6123

K-SES for Grade-3 2 months 3 months M SD Present SD V

Daily activities 51.16 45.12 6.04 0.073 0.3559 0.18947 0.03589
Sports & Leisure activities 2.68 3.24 0.56 0.0067
Physical activities 50.92 46.08 4.84 0.988054
Knee function in the future 20.68 24.28 3.6 0.73484
Where V=Variance, SD=Standard Deviation

For Grade-2 For Grade-3

A=(SD^2)/No.of n for RL 7.589926667 0.619380829
B=(SD^2)/No.of n for LL 7.113926667 0.211428686
C= A+B 14.70385333 0.830809515
D =SQRT © 3.834560383 0.911487529
DF 28 28
t-value 0.02312319 0.084255174
p-value 0.481716012 0.433453082

Graph- 1 Age of all subjects of both Grade (25 each) with mean age

Graph- 2 ACL RSI for Grade-2

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Graph- 3 ACL RSI for Grade-3

Graph- 4 Marx Scale for Grade-2

Graph- 5 Marx Scale for Grade-3

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Graph- 6 According to K-SES Instrument for Grade-2

Graph- 7 According to K-SES Instrument for Grade-3

Graph- 8 According to Tegner Activity Score for Grade-2

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Graph- 9 According to Tegner Activity Score for Grade-3

Graph- 10 According to KOOS for Grade 2

Graph- 11 According to KOOS for Grade 3

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Graph- 12 Correlation in Present K-SES for Grade-2

(Sum of Daily activity, sport-leisure activities & Physical activities) & Future Knee function, show no significant difference

Graph- 13 Correlation in Present K-SES for Grade-3

(Sum of Daily activity, sport-leisure activities & Physical activities) & Future Knee function, shows no significant difference.

Graph- 14 Correlation in K-SES for grade-2 & Grade-3

(Sum of Daily activity, sport-leisure activities & Physical activities) & Future Knee function, shows no significant difference in its
relation with Age of subjects.

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Graph- 15 Correlation in K-SES for grade-2

(Sum of Daily activity, sport-leisure activities & Physical activities) & Future Knee function, shows no significant difference in its
relation with TAS (Tegner Activity Score) of subjects.

Graph- 16 Correlation in K-SES for grade-3

(Sum of Daily activity, sport-leisure activities & Physical activities) & Future Knee function, shows no significant difference in its
relation with TAS (Tegner Activity Score) of subjects.

Graph- 17 Correlation in K-SES for grade-2

(Sum of Daily activity, sport-leisure activities & Physical activities) & Future Knee function, shows no significant difference in its
relation with ACL RSI of subjects.

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Graph- 18 Correlation in K-SES for grade-3

(Sum of Daily activity, sport-leisure activities & Physical activities) & Future Knee function, shows no significant difference in its
relation with ACL RSI of subjects.

 Interpretations of Result: - We evaluated self-efficacy, physical activity

participation and return to sport for an ACL injury in Indian
 Grade 2 of 2 and 3 month shows not significant male athletes. we found a non-significant role of self-
p=0.4817 efficacy, physical activity participation and return to sport
 Grade 3 of 2 and 3 month shows not significant for an ACL injury in Indian male athletes but differences are
p=0.4334 found in grade 2 (2 and 3 months) and grade 3 (2 and 3
 Grade 2 (2 and 3 month) on grade 3 (2 and 3 month) months) of ACL injury, so we could intend to apply self-
shows differences because of psychosocial and efficacy education and its role on rehabilitation in improving
psychological issues in Indian male athletes. physical activity participation and return to sports for better
 Compare scale on KSES and tegner of grade 2 and result found and for Indian athletes there is some personal
grade 3 shows not significant because it can be factor, behavior and environmental factors have profound
associated with other factors of self-efficacy like coping effects on outcomes and there is less time for this study and
strategies or quality of life in Indian population but the injury leads to a long rehabilitation period (6-12 months)
partly show differences in self-efficacy and physical and may result in future impairment such as reduced range
activity of grade 2 and grade 3. of motion, reduced strength and difficulty with functional
 KSES on ACL-RSI of grade 2 and grade 3 shows not abilities such as jumping, twisting and cutting (Wojtys et al.,
significant because of less time limit, ACL injury 1996; Arangio et al., 1997; Carter and edinger, 1999; Pfeifer
recovery period is 6 to 12 months. and Banzer, 1999; Hiemstra et al., 2000; Brandsson et al.,
 KSES on age of 2nd and 3rd grade of ACL injury shows 2001; Solomonow and Kroogsgaard, 2001).
not significant because athletes are all in younger age
(16 to 26) but shows some differences comes on age of Physical activity of grade 2 of 3 months decreases as
2nd and 3rd grade means that chances are there for compare to 2 months and as same as in grade 3 of 3 months
significance. decreases as compare to 2 months because of the internal
risk factors and external risk factors seen different from
V. DISCUSSION other countries like internal factors includes body
composition (example- body weight, fat mass, BMI),
Total 50 subjects (25 subjects in each two groups) physical fitness (example- maximum 02 uptakes) and skill
were taken according to the inclusion & exclusion criteria, levels and external factor includes (weather, floor and turt
those who satisfied the criteria were allowed to perform the type, maintenance) etc. and all these factors put impact on
study, All total 50 subjects successfully completed the study. cognition (includes- interpretations, appraisals and beliefs).
All the subjects were taken from Pavilion ground Dehradun, (Pia Thomeé et al., 2007) used physical activity scale to
Maharana Pratap sports college Dehradun, sports club assess physical activity in terms of intensity and frequency,
Dehradun. on inclusion criteria such as gender male only, so this is also the one reason of decreases in physical
young aged (Age 16-45years) with different sports. We activity level even No intervention was performed in our
excluded the subjects with recent injury at beginning or study further studies are therefore needed to confirm
during study, ACL injury impose serious physical, whether early intervention aimed at reinforcing self-efficacy
psychological, psychosocially and economic burderns on belief would improve the outcome for subjects with an ACL
athletes. After injury self- efficacy is importance for injury & after month. (Pia Thomeé et al., 2008) also
rehabilitation outcome. concluded that 1 year after ACL reconstruction, about 60%

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had successfully returned to an acceptable outcome level of LIMITATION OF THE STUDY
pre-injury physical activity because of reduced capacity of
muscle function reason for reduced physical activity.  Time limit of the study was less.
 Baselining physical activity data is not there for
In previous studies (Laxdal et al., 2005) concluded that comparing the differences.
age and gender did not appear to have any impact on According to my studies English knee self-efficacy
outcome in their large cohort study of patients after an ACL scale is not suitable for Indian athletes because they showed
reconstruction. In the present study, age did not have any their interest only in their specified game.
significant effect on outcomes because all athletes are
younger, aged minimum 16 and maximum 26. FUTURE STUDIES

We concluded that Return to sport increases in grade 2  For better result we can assume that more time can be
and grade 3 while self-efficacy increases with time because considering factor.
pain decreases along with time progression and  Future studies should pretest the KSES in a
psychological responses of patients changed over time standardized way and minimize and maximum of
during the rehabilitation means that negative emotions of patients age varied across the different follow-ups.
patients decreased and their feelings about the return to
sports increases. According to (Chmielewski T.L. et al., REFERENCES
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ISSN No:-2456-2165
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