The scale of the problem is striking. ACL injury rates have doubled over the past two decades in both sexes, despite widespread adoption of injury prevention programmes, and Australia now records the highest and fastest-growing rate of ACL reconstruction surgery in the world. Female athletes carry a disproportionate share of this burden. In team sports, women face two to eight times greater risk of ACL injury than men, and the incidence in female soccer players is roughly 2.5 times higher than in their male counterparts. In Australian football, the relative risk for women, adjusted for season length and exposure hours, is 6.6 times that of men. As female participation in sport has grown more than tenfold over four decades, so too has the population of athletes navigating this injury.

Recovery outcomes are equally uneven. Irrespective of whether the injury is managed surgically or non-surgically, many athletes never return to their previous level of competition, if they return at all. One cited study found that only 37.3 percent of female athletes returned to their preinjury level of sport, and only 56 percent reported satisfaction with their physical activity levels. A recent meta-analysis also revealed that women report inferior activity and knee-related outcomes after ACL injury compared with men. Standard rehabilitation, meanwhile, remains anchored to objective physical milestones such as strength and hop tests, often leaving psychological and social dimensions unexamined. The new review set out to close that gap for female footballers specifically, drawing on the biopsychosocial model of athletic injury rehabilitation, which frames recovery as a dynamic interplay of biological, psychological, and social factors.

Methodologically, the review was rigorous. The researchers searched six electronic databases, including SCOPUS, CINAHL, MEDLINE, SPORTDiscus, PsycInfo, and Embase, on 1 May 2025, following the PRISMA extension for scoping reviews with a prospectively registered protocol on the Open Science Framework. Two reviewers independently screened 582 titles and abstracts, then assessed 74 full-text articles against eligibility criteria requiring female athletes with a mean age of 18 or older, participation in any football code, ACL injury managed surgically or non-surgically, and investigation of psychosocial influences on return to sport or physical activity. Just seven studies made the cut, encompassing 403 female players aged 16 to 56, with time since injury ranging from 1.5 to 24 years. Five of the seven used qualitative methods such as interviews and focus groups; two used questionnaires, including the ACL-Return to Sport after Injury scale and the Tegner Activity Score.

The numbers within those seven studies tell their own story. Of the 403 players, 222, or 55.1 percent, returned to sport, while 181, or 44.9 percent, did not. Among those who did return, competition levels ranged from elite international athletes to recreational players, and several dropped to lower levels than before their injury. Of the women who never returned to football, only ten, about 5.5 percent of non-returners, resumed other physical activities such as running, walking, or cycling, and even they fell short of their desired activity levels. Notably, six of the seven studies included both sexes, with female participants representing roughly 10 percent of samples, and 17 otherwise eligible studies were excluded because results were not reported separately for women, a stark illustration of the gendered gaps in sports science research.

From the synthesis, six psychosocial themes emerged: uncertainty, confidence, fear, motivation, social support, and athletic identity. Four operated predominantly as barriers. Uncertainty, the lack of knowledge about how to progress through rehabilitation or resume activity, pushed some players to lower competition levels or out of soccer entirely. One participant’s faltering recollection of being told simply to quit soccer captured the disorientation. Lack of confidence, present in six of the seven studies, manifested as distrust in the reconstructed knee; one player said she did not think she would ever quite have the confidence to perform sideways movements again. Fear of reinjury or pain emerged across five studies as the predominant barrier, with some athletes altering, limiting, or avoiding activity even decades later, and even those who knew their knees were structurally stable could not overcome it.

Social support, or the lack of it, cut both ways. Women who felt abandoned by healthcare professionals, or like outsiders unable to maintain peer relationships while injured, described social isolation that contributed to quitting sport or dropping down a level. Some said they had given up on physiotherapists because nobody seemed able to help them. Conversely, players embedded in supportive networks of teammates, coaches, family, and clinicians were more likely to return at their preinjury level. One athlete described teammates deliberately working at a lower technical intensity to expose her to contact situations in training, and being just as excited for her on game day as she was. That sense of being valued, the review suggests, reinforces identity and mitigates fear, creating a virtuous cycle that supports return.

The facilitators formed a coherent psychological toolkit. Confidence, when it developed through trust in clinicians and achievement of physical milestones, helped players return at or near their previous level; one described training fully with contact and cutting for three months before feeling ready, free of knee awareness. Motivation, the love of the game and the conviction of having matches left to play, drove others past their fear, with one cross-sectional study finding that players who returned scored significantly higher on motivation measures than those who did not. Athletic identity, the degree to which football was central to a player’s sense of self, pushed strong-identifying athletes back onto the field, though the review cautions it can be a double-edged sword, offering short-term motivational benefits while posing longer-term psychological risks if not balanced with a broader sense of self.

The clinical implications are significant. The authors argue that psychosocial screening should be incorporated routinely into rehabilitation and return-to-sport decision-making for female footballers, alongside physical testing. Fear of reinjury, in particular, may require strategies beyond physical rehabilitation, such as graded exposure to feared movements, with cutting and direction change, the very mechanisms of ACL injury, identified as common fear-evoking tasks. Referral to a sport psychologist may be warranted when risk factors surface. The stakes extend well beyond sport: female athletes with prior ACL injury face four to six times greater risk of knee osteoarthritis and more than double the risk of total joint replacement within 15 years, making sustained physical activity a long-term health imperative, not merely an athletic one.

What the review ultimately exposes is a research culture still calibrated to male athletes. Only about 6 percent of sport and exercise science studies focus exclusively on females, and women face sociocultural headwinds their male counterparts do not, including lower pay, reduced access to allied health support, short-term contracts, financial insecurity, and punishing schedules, with injured female players competing in nearly twice as many back-to-back fixtures. Females have a 25 percent lower rate of return to sport within five years of reconstruction, alongside greater psychological distress. The authors call for high-quality, female-focused research with longitudinal and quantitative designs to establish causality, and for future mixed-sex studies to report data separately by sex. Until then, the message for clinicians, coaches, and teammates is clear: a knee may heal on a timetable, but the mind returns to sport on its own, and it needs to be trained just as deliberately.

Subject of Research: Psychosocial factors influencing return to sport and physical activity in female football players after anterior cruciate ligament injury

Article Title: The Role of Psychosocial Factors in Returning to Physical Activity and Sport Among Female Football Players After Anterior Cruciate Ligament Injury: A Scoping Review

Article References: Meredith, S., Farley, J. B., Hunt, J., & Dent, E. (2026). The Role of Psychosocial Factors in Returning to Physical Activity and Sport Among Female Football Players After Anterior Cruciate Ligament Injury: A Scoping Review. Sports Medicine – Open, 12(1), Article 148. https://doi.org/10.1186/s40798-026-01118-6

Image Credits: AI Generated

DOI: 10.1186/s40798-026-01118-6

Keywords: ACL injury, female footballers, return to sport, fear of reinjury, psychosocial factors, sports rehabilitation, athletic identity, social support, women's soccer, scoping review, sports psychology, knee injury

The story begins in 1993, when Brewer and colleagues first defined athletic identity as the degree to which an individual identifies with the athlete role and introduced the original ten-item AIMS. That scale has since been translated into more than 20 languages and has fueled over 100 peer-reviewed studies worldwide. But decades of research exposed cracks in its design. Subsequent analyses suggested the scale might be multidimensional, and a 2001 revision trimmed it to seven items. Then, in 2022, Brewer and colleagues acknowledged a deeper problem: only one item on the revised scale—”I consider myself an athlete”—clearly measured self-identification as an athlete, while the other six seemed to capture precursors, correlates, or outcomes of that identification. The AIMS-3G was their answer, built from a pool of more than 100 candidate items refined down to 41 through expert review and factor analysis.

What makes the AIMS-3G distinctive is that it separates athletic identity itself from its properties and its processes. The core Athletic Identity scale contains just four items. Two additional scales capture properties: Prominence, reflecting how important being an athlete is relative to other parts of a person’s self-identity, and Self-Worth Contingency, measuring how much a person’s sense of self-worth depends on sporting performance and involvement. Two further scales capture processes—the dynamic elements that act upon and change athletic identity—namely Social Reinforcement, receiving validation from others for one’s sporting activities, and Self-Presentation, presenting oneself as an athlete. All 21 items are rated on seven-point agreement scales, and the entire instrument can be completed in minutes.

The Bern team translated the scale following the classical forward-backward procedure established by Vallerand, with two bilingual test developers and experienced sport psychologists independently producing translations. Crucially, they also consulted the developer of the AIMS-3G to confirm the intended meaning of each item, an unusually rigorous safeguard for content validity. Their participants, drawn from sport science courses at the University of Bern, were almost universally active in sport—98% reported extracurricular sporting activity across 58 different sports, ranging from football and volleyball to fitness training and floorball. On average they had practiced their main sport for ten years and trained just over four hours a week, and half competed, many at national or international level.

The statistical heart of the study was a head-to-head comparison of competing factor models using exploratory structural equation modeling, or ESEM. Initial exploratory factor analyses of one to six factors showed that models with fewer than five factors fit poorly, while five- and six-factor models fit well; parallel analysis and the weak definition of a sixth factor settled the question in favor of the five-factor solution. When the researchers then tested confirmatory factor analysis (CFA) against ESEM, ESEM emerged as clearly superior. This matters because CFA forces every item to load on a single construct, whereas ESEM allows small cross-loadings—a more realistic representation of how psychological items actually behave. Factor loadings in the ESEM solution were moderate to high, cross-loadings were small, and the five latent factors correlated only moderately with each other, suggesting related but genuinely distinct dimensions.

The team did not stop there. They also tested bifactor models, in which every item loads both on a general factor and on its specific factor, to see whether the construct might be better conceived as hierarchical. Although a bifactor-ESEM solution showed excellent fit, it offered virtually no improvement over the plain ESEM model, and some of its specific factors were weakly defined or nearly empty. Combined with the original authors’ theoretical stance that the five dimensions do not simply reflect facets of one global construct, the researchers retained the five-factor ESEM solution. Reliability was strong for four of the five scales, with McDonald’s omega coefficients between .81 and .91, and adequate at .72 for Social Reinforcement, the weakest scale.

Perhaps the most technically demanding part of the study was the measurement invariance testing, which asks whether the questionnaire measures the same thing in different groups. Using multi-group structural equation modeling, the team demonstrated strict—or at least partial strict—invariance across gender, across participation in organized versus independent sport, and across competition participation. This is the psychometric green light that allows researchers to compare latent scores between groups without fearing that any differences reflect measurement bias rather than real differences. For continuous variables such as age, years of involvement, and training volume, the team used differential item functioning tests within MIMIC models, which confirmed that the predictors influenced responses only through the latent factors themselves—no item-level bias was detected.

Substantively, the results painted a familiar but nuanced picture of who identifies most strongly as an athlete. Men scored significantly higher than women on the core Athletic Identity factor, a small-to-medium effect, while women scored higher on Social Reinforcement. Participants who trained independently scored lower on Athletic Identity, Prominence, and Social Reinforcement than club members, and competitors scored higher than non-competitors on nearly every factor, with medium-to-large effects. Younger participants reported higher Self-Worth Contingency and Social Reinforcement, and both greater training volume and longer involvement predicted higher scores on several factors. Construct validity analyses linked the AIMS-3G factors to sport satisfaction, physical self-concept, and both harmonious and obsessive passion, largely in line with expectations.

One surprise stands out: Self-Worth Contingency was significantly and negatively correlated with Physical Appearance self-concept. The authors offer a thought-provoking post hoc explanation rooted in objectification theory—the more a person’s self-worth hinges on sporting success, the more the body may be perceived as an instrument for performance rather than an object of aesthetic appreciation, inviting more critical appearance evaluations. Equally striking were the substantial correlations between Prominence and Self-Worth Contingency and obsessive passion (around .51 to .52), consistent with the dualistic model of passion, in which people with obsessive passion feel an obligation to engage in their activity to validate themselves and gain social recognition.

Three items underperformed slightly, echoing weaknesses noted in the original English validation, and one item—”Most of my friends are athletes”—struggled in both language versions, hinting at a conceptual issue. The researchers refined the German translations of these items and tested the alternatives in a follow-up sample of 104 students; the revised versions outperformed the originals on discrimination, item difficulty, and related metrics, and the revised scales correlated at .92 to .95 with the originals. The authors recommend adopting the revised items and call for translations into further languages, noting that the original AIMS had already crossed more than 20 linguistic borders. For elite sport—where injuries, deselection, and retirement can shatter an identity built around being an athlete—a validated, cross-culturally comparable measure of that identity may ultimately help researchers and practitioners spot the double-edged sword of strong athletic identity before it cuts.

Subject of Research: Psychometric validation of the German-language AIMS-3G athletic identity questionnaire

Article Title: Further psychometric examination of the third-generation athletic identity measurement scales (AIMS-3G): evidence from a German-language version

Article References: Schmid, M. J., Brewer, B. W., & Schmid, J. (2026). Further psychometric examination of the third-generation athletic identity measurement scales (AIMS-3G): evidence from a German-language version. Current Psychology, 45(18), Article 1542. https://doi.org/10.1007/s12144-026-10068-x

Image Credits: AI Generated

DOI: 10.1007/s12144-026-10068-x

Keywords: athletic identity, AIMS-3G, psychometrics, sport psychology, measurement invariance, exploratory structural equation modeling, scale validation, passion, physical self-concept, athletes, self-worth contingency, German translation