One of the most significant injuries an athlete may face is a torn anterior cruciate ligament (ACL). Like concussions, the ACL is becoming a common discussion point in media, or parent discussions due to the significant impact the injury places on the athlete. Commonly overlooked is the reason WHY athletes do not fully return to their prior level of function with their sport when returning from an ACL reconstruction. Recent research demonstrates 60% of athletes return to their prior level of function in their sport after an ACL injury. Huh, 60 percent? I was greatly surprised and disappointed by this number and openly questioned the data. After consulting with the author, (I love twitter), I was able to understand the reason. Athletes have a very difficult time returning fully to sport due to the psychological factors related to the injury and not the injury itself. I have treated a large number of ACL reconstruction patients in my career and many of these athletes are hesitant to return to sport. The main reason for hesitation with return to play is fear. Some of the reasons for fear are:
- Athletes who tear their ACL are competing at a high level and usually are competing when the injury occurs. They fear re-tearing the ACL. They understand their ACL was completely normal prior to the injury, but now they will be competing with a reconstructed ACL. This gives even the toughest minded athlete hesitation.
- After tearing the ACL an athlete is naïve to the progression of their rehab. They are walking in blind to the total experience. Progressing slowly for months at a time and the sweat equity needed to progress properly is arduous. Athletes fear starting their rehab over if they tear their ACL again.
- A natural obstacle with ACL reconstruction is the fear of not performing at the same level as their prior level of function. Athletes who are passionate about their sport are very concerned about their “starting position”, ability to compete at a high level, and fear of not living up to expectations from themselves, coaches or parents. They are afraid of disappointment.
Athletes are tough people. They are used to preparing physically and mentally for competitions, however facing a return to play after an ACL reconstruction is very difficult. Even professional athletes struggle with return to play decisions after ACL reconstruction recovery. For example, Derrick Rose is a professional NBA basketball player for the Chicago Bulls who is a previous league MVP recipient. He tore his ACL in the playoffs of 2012 and had a long return to the court. He elected to sit the entire 2012-2013 season even though he was released by his surgeon for competition. Derrick has been criticized by his fans for this decision, however even he had reservations about return to play before mentally ready. So, what are some ways I like to “mentally” prepare and athlete to return to play from an ACL injury?
- Proper mourning. Athletes are almost mechanical and want to progress into the rehab aggressively from the start. I like to progress slowly. The ACL reconstruction is a marathon-not a sprint, it is so important to pace oneself. Athletes need to recognize the loss they have sustained from this injury: team leaving them behind with the season, change in status as a “non-athlete”, change in identity, or coming to terms with how/why the injury occurred. Too many athletes want to speed through the mourning process, creating the potential for depression later.
- Continuing a social climate. Athletes are accustomed to being part of a team or unit. They should be a piece of the overall puzzle of team success. I urge athletes and coaches to continue to involve the player in team function/practices/games. These players can take an associate coaching role with head coach requiring their advice and planning.
- Proper rehab. Achieving full knee range of motion, full strength, ideal balance and conditioning will give the athlete courage and confidence to return to competition. Returning to play in better condition than prior to injury gives the athlete confidence to return to play with less chance of injury.
- Creating sport specific goals. Athletes do tend to look forward and typically set goals. Specific goals related to their sport allow them to continue to prepare mentally for return to play. Focusing on specific outcomes will allow the athlete to test their level of function during the sport specific activities in the clinic.
- Proper return to play progression. Too many times athletes, parents and/or coaches feel pressured to return athletes back to the field/court/diamond as soon as they are “cleared”. A physician may “clear” an athlete to return to competition, although the athlete may not have been progressed through a full return to play criteria. Athletes should take a stepwise approach with structured benchmarks to allow return to play. Benchmarks should be gradual and allow the athlete to feel successful physically and mentally.
ACL surgery is a challenging procedure for athletes, coaches and parents. With athletes returning to prior level of competitive function at 60% of preinjury levels, it is important to discuss the psychological implications about return to play. Athletes should address the psychological implications of their injury during the entire course of care as well. Have you sustained an ACL injury requiring a reconstruction? What are the tools you used to help overcome the psychological barrier of return to play?
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