Altered Cognitive Control and Cortical Oscillatory Dynamics in Athletes With ACL Reconstruction During Decision-Making Under Uncertainty

BACKGROUND: Anterior cruciate ligament (ACL) injury induces neuroplastic changes within the central nervous system (CNS) that may persist beyond reconstruction and rehabilitation. PURPOSE/HYPOTHESIS: The purpose was to compare neurocognitive performance and cortical oscillatory activity between open-skill athletes (eg, soccer, basketball, or handball players) without ACL injury history and athletes with ACL reconstruction (ACLR) during a probabilistic go/no-go task. It was hypothesized that athletes with ACLR would exhibit poorer behavioral performance and less efficient oscillatory dynamics, particularly higher theta and lower suppression of beta and alpha power oscillations after goal stimulus onset. STUDY DESIGN: Controlled laboratory study. METHODS: A total of 90 open-skill athletes (45 non-ACLR, 45 ACLR) performed a probabilistic go/no-go task while electroencephalographic recording was performed. Time-frequency analysis targeted midfrontal theta (4-7 Hz), left-lateralized central beta (15-25 Hz), and posterior alpha (8-12 Hz) oscillations during prestimulus and target stimulus windows. Linear mixed-effects models examined group differences in cognitive performance and oscillatory power. RESULTS: = 0.55) were reduced, reflecting impaired motor cortical disinhibition and less efficient visual-attentional resource deployment, especially under high uncertainty conditions. CONCLUSION: Athletes with ACLR showed persistent alterations in the cortical oscillatory mechanisms associated with conflict monitoring, motor preparation, and attentional allocation under uncertainty. These neurocognitive alterations may compromise adaptive motor responses in sport contexts characterized by high uncertainty and cognitive mental demand, potentially increasing reinjury risk. These findings support the integration of neurocognitive assessment into return-to-sport protocols. CLINICAL RELEVANCE: Alterations in cortical oscillatory dynamics during decision-making under uncertainty may reflect reduced efficiency in cognitive control, motor preparation, and attentional allocation, which are not detected by standard assessments. Exercise professionals should consider integrating these assessments into return-to-sport protocols to address the persistent CNS alterations that may underlie reinjury risk in athletes with ACLR.