Returning to Sports After ACL Injury - Not Just Physical

ACL injury and subsequent surgical reconstruction is one of the most studied sports injuries in the modern literature. Strength, stability, and return to sports participation at the pre-injury level are all measures of the success of ACL reconstruction.

There has been lots of research on objective measures of function after ACL reconstruction, however in the past decade there has also been an increasing interest in defining and understanding the psychological or emotional aspects of return to sport or recreational activity after ACL injury.

The problem is not everyone returns to sport after major injury or surgery like ACL reconstruction. In fact estimates are that somewhere between one third and two thirds do not return to their pre-injury level of activity despite being physically okay to return. Studies have suggested that only a little over 1 in 2 athletes are able to return to competitive sports and 1 in 3 does not return to their pre-injury level of sport. These findings illustrate a disconnect between the physical and psychological readiness for return.

Psychological Readiness Psychological readiness is associated with returning to pre-injury activity. Those who return have been found to have more positive psychological responses, report better knee function, perceive a higher knee related quality of life, and are more satisfied with their current function.

Multiple factors have been identified in those who do not return, including fear of re-injury, pain related fear of movement, poor satisfaction or confidence in the person’s knee function, lifestyle changes resulting in shifts in personal priorities, and other innate personality traits.

How do we correct the problem? For many athletes there is a continuum of care—from the physician through the physical therapist (PT) and athletic trainer (ATC) and ultimately to the strength and conditioning coach and position coach. This optimally blends a combination of physical training and progressive sport preparedness, as well as promoting psychological preparation. One major challenge is to duplicate this for patients who are not in the same structured environment.

Certified athletic trainers specifically have educational competencies as part of their curriculum, which involve specific education and focus on psychological aspects of injury and return to sport. However, both the PT and ATC can through better identification of the problem, frame their efforts to foster positive physical and psychological progression through better identification of the problem.

Developing psychological coping skills such as positive self-talk, using mental imagery, relaxation, and appropriate goal setting are all instrumental in influencing positive behavioral and emotional outcomes. These tools can improve adherence to rehab, reduce stress and anxiety, improve self-efficacy (which equates to an individual’s confidence in performance of tasks), and promote an overall positive outlook. With this in mind, it’s important to continue identifying factors, which can facilitate sports participation and/or maintain a patient’s lifelong recreational activities.

References Ardern CL, et al. Br J Sports Med. 2014. 48:1543-1552. Ardern CL, et al. Br J Sports Med. 2014. 48:1613-619. Podlog L, et al. Physical Therapy in Sport. 12 (2011). 36-42. Hamson-Utley JJ, et al. J of Athletic Training. 2008. 43(3) 258-264. Kraemer W, et al. Sports Health. Sep-Oct 2009. 392-395