Psychological Responses Matter in Return to Sport After ACLR

 In the July issue of the American Journal of Sports Medicine, there was a great research study published called Psychological Responses Matter in Returning to Preinjury Level of Sport After  Anterior Cruciate Ligament Reconstruction Surgery.  This study begins to address a very real issue that is encountered when dealing with athletes after ACL reconstruction (ACLR) who are attempting to return to sport.  Although we think this might be just with our younger athletes or female athletes, is that truly the case?  According to recent studies, only 63% of high school and 69% of college football players return to sport following ACLR.  Of those, only 43% return at the same level and 27% at a lower level.  Although this is high school and college, we see similar percentages when looking at pro-athletes.  Current studies looking at college and professional soccer players who had ACLR shows that only 72% returned to play.  This study does not indicate percentage of those players that returned to the same level or lower level, but you can imagine it is similar to the previously mentioned studies.   So why is this the case? 

Questions like this have plagued those of us that work in the sports medicine realm for years.  What makes the difference between athlete A and B and how can you, as a clinician help to improve the odds of a safe return to sport?  All too often, the one component that is missed is the psychological component.  For many, it is an uncomfortable aspect of care to address.  It is too touchy feely.  Yet, how can you address the “whole” athlete if you don’t address? 

The purpose of this study was to determine whether psychological factors predicted return to pre-injury level of sport by 12 months after ACLR.  In this study, the authors worked with 187 recreational and competitive level athletes who had undergone an ACLR.  The primary outcome measured was to return to “pre-injury” level of sports participation.  The psychological factors evaluated were psychological readiness to return to sport, fear of re-injury, mood, emotions, sport locus of control (whether they were in control of their destiny/outcome or that was determined by external factors) and recovery expectations.  The psychological factors were measured pre-operatively, at 4 months post op and 12 months post op.

What the authors found was at 12 months, only 56 athletes or 31% had returned to their pre-injury level of sports participation.  The most significant psychological factors contributing to inability to return to pre-injury levels were: psychological readiness, fear of re-injury, sport locus control and the athlete’s pre-operative estimate of the number of months it would take to return to sport.  As ground breaking as this study is, it is nothing new to those of us who treat these patients every day.  Yet it also highlights some very key take aways. 

One key take away for me is the role of the rehab provider.  If they are not personally vested in assisting the athlete achieving success, if they approach it with apathy, then they are doing the athlete a serious disservice.  As a provider, our role is as an educator and coach, with emphasis in this case on coach.  Coaching is not passive.  It is methodical in approach, motivational and inspiring and purposefully driven to the end goal all while also being empathetic to the patient.   

It also highlights the importance of building the patient’s confidence during the course of rehabilitation.  There are a lot of ways to do this, one of which is getting them to do single leg activities early (within protocol) and often.  Building the confidence in the limb as soon as possible so that they can see putting weight on the leg will not result in re-injury.  Sounds basic right?  Unfortunately it is not.  The following picture demonstrates just that.  Athlete who was being returned to sport, who was not doing a lot of single limb exercise or activities and who lacked such confidence in his limb, that he would shift his weight like this “every time” he squatted.  Fortunately, he had a movement assessment prior to return to sport but this case highlights what happens when things go wrong.  Not just above the shoulders of the patient but the clinician as well.

About the author:  Trent Nessler, PT, DPT, MPT.  Trent is a practicing physical therapist with 14 years in sports medicine and orthopedics.  He has a bachelors in exercise physiology, masters in physical therapy and doctorate in physical therapy with focus in biomechanics and motor learning.  He author of a textbook “Dynamic Movement Assessment™: Prevent Injury and Enhance Performance”, is associate editor of the International Journal of Athletic Therapy and Training, Member of the USA Cheer Safety Council and founder/developer of the Dynamic Movement Assessment™.

Reference:

1.     Ardern C, Taylor N, Feller J, Whitehead T, Webster E.  Psychological Responses Matter in Returning to Preinjury Level of Sport After Anterior Cruciate Ligament Reconstruction Surgery.  Am J Sports Med.  41:1549-1558. 2013.

2.     Brophy R, Schmitz L, Wright R, Dunn W, Parker R, Andrish J, McCarty E, Spindler K.  Return to Play and Future ACL Injury Risk After ACL Reconstruction in Soccer Athletes From a Multicenter Orthopaedic Outcomes Network (MOON) Group.  Am j sports med.  40:2517-2522, 2012.

3.     Holm I, Oiestad B, Risberg M, Gunderson R, Aune A.  No Difference in Prevalence of Osteoarthritis or Function After Open Versus Endoscopic Technique for Anterior Cruciate Ligament Reconstruction: 12 Year Follow-up Report of Randomized Controlled Trial.  Am j sports med.  40:2492-2498, 2012

4.     McCullough K, Phelps K, Spindler K, Matava M, Dunn W, Parker R, Reinke E.  Return to High School – and College-Level Football After Anterior Cruciate Ligament Reconstruction: A Multicenter Orthopaedic Outcomes Network (MOON) Cohort Study.  Am j sports med.  40:2523-2529, 2012