Anterior Cruciate Ligament Injury: Is It Just An Athletic Injury or A Major Life Lesson?

Over the course of the last several years, we have looked at multiple papers highlighting the long term effects an anterior cruciate ligament (ACL) injury has on our athletes.  We know there is an impact to the long term joint health and athletic performance, but we can’t ever ignore the impact on the future systemic health and psychological status of the athlete.  It always surprising how few people completely understand the totality of the “life impact” these injuries have on our athletes.  This is especially true in our younger athletes.  But, we should all realize if we address the psychological factors immediately, it will not only impact the immediate results and outcome but also the long outcome, future athletic performance and long term psychological status of the athlete.  Case in point.

Imagine for a moment that you are a star high school athlete.  Everything you do revolves around your sport and your identity as an athlete of that sport.  All your friends are athletes, your teachers see you as an athlete and you identify yourself as athlete.  Even your family and relatives see you as an athlete.  It is always a topic of school conversations, social interactions and family discussions.  So, imagine you have an ACL injury and all of the sudden, in one day, everything that you have known is suddenly and dramatically changed.  Your personal identity has changed!

It is seeing it and realizing it from this perspective that helps us understand why so many young athletes suffer depression as the result of an ACL injury.  According to 2014 statistics from the NCAA, Division I athletes who suffer an ACL injury have a reported higher rate of depression, average of 1.0 drop in GPA and have a higher rate of obesity.  Knowing this, addressing the psychological component has to be a huge and vital part of the rehabilitation process.  As a parent, it is imperative that the provider “you choose” for rehabilitation not only has experience in rehabilitation of the ACL injured athlete but also has an approach that is conducive to addressing the psychological component of this injury.  Remember it is your choice and you should choose someone that you feel will address the physical and psychological components of your child’s injury. 

Is this too touchy feely for athletics?  Some might say yes but what does the research tell us?  

According to a 2013 paper published by Ardern et al in the American Journal of Sports Medicine, several psychological factors that must be addressed in order to optimize outcomes, performance and successfully and safely return to sport are:

•  Sport Locus of Control
•  Fear
•  Confidence
•  Communication among providers

What is Sport Locus of Control?  Sport locus of control is simply, “Does the athlete feel like they have control over their own destiny”?  Think about it.  Would you want to be in control of your destiny or would you want to control your destiny.  What happens when you feel like you have no control?  It is depressing, right.  Now think about that from the athlete’s perspective.  After an ACL reconstruction, so many athletes feel like they have no control over their future destiny.  This is extremely hard for an athlete as it is their control over their destiny, their hard work, their focus and their dedication that has led to their success in their individual sport.  Now, there is a tendency to feel they have to now rely on someone else for them to be able to have a successful outcome and return to sport.  Their fate now resides in the ability of someone that they know very little about and/or may have only known for a short period of time.  So how do you address that as a clinician?

This is addressed Day 1 of the rehabilitation process.  Something as simple as the therapist’s body language and/or patient interaction can have a very positive or very negative impact.  As a therapist, make sure you are reading your athlete’s body language and status.  They are great, especially initially (when they are in beginning phases and more vulnerable) of expressing this non-verbally.  Look for it and respond appropriately to.  If done well, this will be a huge component of building a very solid report with your athlete.  So many times you can tell by how the athlete is responding to you, whether or not they are asking leading questions or whether they are withdrawn or disengaged or simply how they are posturing their body.  Those are some of the obvious signs.  Some of the not so obvious signs are how are they sleeping, are they still engaged in their social circles, are they losing or gaining weight, or have they become angry or despondent.  

One thing that should always happen on Day 1 is that the therapist must give the athlete sport locus of control.  A statement as simple as:

“I am here as your coach and your educator.  I will teach you what to do and why.  I will coach and encourage you throughout the process.  But, it is up to you to dig deep, stay focused and keep your head in the game.  This will be your toughest game yet, but you can and you will do it.  I will help you do it but you are in control.  This is not something that cannot be overcome and it is not an undouble task.  This is where champions are made and you are a champion.”

In this scenario you are explaining your role, their role, letting them know they are in control and that you believe in them.  Now this may be a little elaborate or over the top, but you get the idea.  The goal of the therapist is just as much clinical treatment as it is professional motivation.  If the athlete is given this control and truly believes they have sport locus of control, they will be much more successful.

The next two factors that impact the psychological status of the athlete are fear and confidence.  We categorize these two together as these really go hand in hand.  Next week we will dive into these two in more detail, so stay tuned.  If you like what you read, the biggest compliment you can give is to share the passion.  Follow us on twitter @ACL_prevention or follow us on Facebook at Athletic Therapy Services and #MoveRight.

Dr. Nessler is a practicing physical therapist with over 20 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment.  He is the developer of an athletic biomechanical analysis, is an author of a college textbook on this subject  and has performed >5000 athletic movement assessments.  He serves as the National Director of Sports Medicine Innovation for Select Medical, is Chairman of Medical Services for the International Obstacle Racing Federation and associate editor of the International Journal of Athletic Therapy and Training.   He is also a competitive athlete in Jiu Jitsu.