This is a two-part blog post about the psychological effects of an ACL reconstruction.
Have you every had someone sit in front of you and breakdown crying as you attempt to help? Do they turn their head away and bite their lower lip to hide their pain, or clench their fist so tight the hand turns white? Do people look through you in a blank stare as you are explaining to them the plan or process? I do… often.
Psychology is one prerequisite for physical therapy school to apply for admission. I am very happy to have taken these required classes, as this is necessary to treat patients effectively. The person presenting in my office requiring help from his physical limitation is also affected by his mental limitations. These challenges weigh on me tremendously due to the empathy I have for each one of these situations. I put my heart into these patients through consistent planning of their physical therapy plan of care, change of an exercise, or communication about pain, weakness or limitations. I walk with these patients in the same direction, focusing on their long-term success, and feeling the emotion they bring to their treatments.
I would like to share with you three examples of patients rehabbing an ACL reconstruction.
Patient 1 is a hardworking, determined, 17-year-old athlete who torn her ACL and meniscus at the midpoint of her season. She was a high level athlete who competed on her high school volleyball team. She was determined to return to play better than before and overall her psychological stability was strong related to her stages of grief. She presented to me after 6 weeks of bracing and non-weight bearing due to a repaired meniscus with her ACL reconstruction. Patient 1 was willing to progress with all aspects of her PT plan of care, however she was very limited with her range of motion to her knee. Her orthopedic surgeon threatened her with a manipulation under anesthesia. Patient 1 and I discussed the need to progress her range of motion fully with knee flexion and she consented to a more intense knee flexion stretching program. I was not ready after one of our sessions to see a tear soaked area on the pillow once she left. She was a very stoic person, so I did not realize with her head turned away from me she had tears running down her face and saturating the clinic pillow. I was flabbergasted she was able to progress through her level of pain! Patient 1 regained her full range of motion and advanced well with her rehabilitation. She was one of the hardest working and motivated patients I have ever treated. When she returned to sport, I’d rode the journey with her, it was difficult to watch her return to volleyball. I knew her leg was strong, her preparation was excellent, however I’d walked ever step with her and wanted her only to excel. Of course she did…beyond anyone’s expectations and is now competing at the collegiate level.
Patient 2 sustained an ACL tear while playing basketball. She was a self-motivated athlete who naturally took to sports performed at a high level with all sports of her choice. A tear to the ACL was very traumatic for her, but equally traumatic to the parents… mainly dad. He asked me in anger after the news of her ACL tear, looking to place blame or error on her injury, “How could this happen or what should we have done to prevent this?” My response to him was, “Don’t have your daughter play athletics.” I was not flippant but expressing the point to her father the inherent risk in sport. There are certain ways to lower the risk of ACL tears for women: jump training, prevention programs focused on hip external rotator/hip abduction strengthening, and biomechanical adaptation. However, these are not 100% preventable. Overall, Patient 2 had a very successful rehab in regard to her stages of grief and her physiological progression of her rehabilitation. She regained equal quad strength and girth to the muscle, but also progressed into jump training, running or agility training. She was able to return to her sports at a high level but was never able to fully regain her level of competitive spirit as once experienced. This was challenging and frustrating for her dad, who enjoyed watching his daughter fly around with reckless abandon. As Patient 2 matured, she discussed difficulty psychologically returning to sport knowing the pain, energy and work it took after her ACL. She struggled knowing her knee was 100% strong prior to her ACL tear and now she had a reconstruction ligament in her knee. These feelings are not uncommon for high-level high school athletes.
Patient 3 was the hardest. He was a high level senior wrestler looking to challenge for a state championship. His junior year ended with a tear to the ACL in practice and he was not able to complete for district, regionals or state. His attitude was excellent, beaming with positivity and determination. Pain to the knee did not limit him as he demonstrated full gait ambulation without deviation the day after his tear. Patient 3 was determined to return to play. We spent 8 long months rehabbing his knee with progressions in balance, lower leg strength training, 3-dimensional movements or sport specific progressions regarding power, quickeness or speed. We advanced with the proper progressions in return to sport for the period of a month regarding running, light practice, wrestling contact controlled and return to competition with varying level of wrestling preparation. Patient 3 completed his rehab and returned to his first senior event at home with a large crowd in attendance. As I sat in attendance at his first home event, I watched as he challenged the opposing wrestler on the mat. He commanded the first minute and attacked aggressively. Patient 3 and his opponent traveled out-of-bounds when the referee blew his whistle. Patient 3 became twisted as both wrestlers fell to the mat, and his reconstructed leg became pinned underneath his body. Agony, despair and anxiety ensued as I watched from the sideline. He had obviously sustained injury but he attempted to continue through the pain. It was too difficult to continue to watch an athlete I rehabbed for eight months struggle to perform. He demonstrated heart as he fought through the 1st round and attempted the second round. Deep in my heart I was crushed. I had never had an athlete sustain a re-injury after the rehabilitation and especially on their first night of return to play. Patient 3 eventually could not continue to participate and was removed from competition.
Overall, the psychological process of returning to play after an ACL injury is proportionate to the energy required over 8-9 months to return to sport without modifications. The time frame necessary required a lack of participation in sport through multiple sport seasons. Athletes may lose their identity of self and question who they are as a person in retrospect. I challenge each athlete to recognize the stages of grief (Denial, Bargaining, Anger, Depression, Acceptance) and to mourn the loss of their ACL. It may seem odd to express grief over a body part, but mostly I have the athlete recognize the loss of their function, identity or participation in activities they have performed since they were seven. I enjoy the rehab process due to the intimate relationship I develop with each athlete through the journey of return to sport, but this also leaves me vulnerable. It is always challenging for me to observe my patient return to sport after cleared to play. I have a hard time not feeling like a family member due to the work we spent together and understanding the climb required to achieve the success of return to sport. But overall, I think this is why I enjoy my job so much…
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