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

Last week we talked about psychological factors that are a significant part of rehabilitating the ACL injured athlete.  In this discussion, we talked in detail about sport locus of control, how vital that is and how we can impact this clinically in the very first visit with our athlete.  We also began the discussion about fear and confidence and how these two are categorized together.  For fear is a natural part of this injury, in particular if the injury is a non-contact injury.  For our purposes here, a non-contact ACL injury is being defined as an ACL injury that occurred without contact with another player or object.  Fear is more likely to occur in these athletes in particular because they simply ruptured their ACL because they “moved wrong”.  They are not quite sure what that movement was but they know they moved wrong and if they move wrong again, they might re-injure their ACL.

Any injured athlete will innately have a conscious or subconscious fear of re-injure.  For the ACL injured athlete, this is a legitimate fear as reinjure occurs in 20% of athletes in the first 2 years following an ACL reconstruction.  For many athletes, if this fear is not addressed, this will lead to compensatory strategies that can linger on throughout the remainder of their athletic career.  Some studies indicate that this may be a contributing factor to lateral displacement of the pelvis during the squatting motions which alters force attenuation throughout the lower kinetic chain and can lead to asymmetrical limb development in strength and power.  This not only has implications on potential risk for future injuries but also implications on future athletic performance. 

Some basic level of fear is to be expected and is healthy.  Some athletes need this to prevent them from going overboard and doing something stupid in the initial stages of the rehabilitation process.  However, fear which results in compensation and lack of progress along standardized protocol progression or anticipated timelines is not normal.  Fear which drives changing of lifestyle habits or social interactions is not normal.  Fear which limits progress is not normal.  Fear also increases risk for future injury.

There are a lot of factors that lead to reinjure but an athlete who returns to sport following an ACL injury.  However, those who have measurable fear or lack of confidence in the involved lower extremity are 4-6xs more likely to suffer an ACL reinjure.  So, fear must be overcome and there are things we can do clinically to address this ASAP.  So, how do we identify fear and how do we over come?  Some signs that an athlete is over fearful.

·        They express fear verbally or in an outcome measure (IKDC – International Knee Documentation Committee)

·        They have a lot of hesitation to move knee into terminal knee extension or becomes nauseous with moving knee into terminal knee extension

·        Athlete continues to walk with lack of terminal knee extension

·        Athlete has vagal responses in single leg full weight bearing activities (profuse sweating, nausea, drop in blood pressure, tunnel vision, dizziness, etc)

·        Athlete is visibly fearful of putting full body weight on the involved lower extremity or refuses to put full body weight on the involved lower extremity

These are just a few signs and there are many others.  That said, if we detect fear in our athlete or they voice it, we must address it.  As the provider, we cannot be afraid to talk about it with the athlete.  Let them know this is normal and why.  Let them know this is something we must overcome and how we are going to approach it.  By providing the athlete with education on fear and starting them in weight bearing activities early on will aid in building confidence and alleviate fear. 

Studies show that sooner an athlete starts full weight bearing activities and specifically single leg activities, the more confidence they get and the less fear they have.  Hence this is why we have also included confidence in this section.  Why does an athlete lack confidence in the limb?  One reason is fear and another is they have not sufficiently stressed the limb in single leg activities enough to build that confidence.  If an athlete lacks confidence, then they are also at a greater risk of reinjure.  Therefore building confidence early is vital.  Besides the encouraging them, successfully performing single leg activities is an important part of building confidence in an athlete. 

Does fear and lack of confidence really occur in the “manly” athlete?  Absolutely.  We can all think of professional athletes that we have seen that have had an ACL reconstruction that may be lacking some confidence.  We visually see this as their hesitation to move to the involved side.  Whether it is a cutting pattern to that side or throwing kicks with that particular leg, confidence is built very early in the process.  Starting an athlete on single limb activities early in the process (and as the protocol allows) improves their confidence so when it comes time to do more cutting and explosive work on that side, they can do this with a very high degree of confidence that their knee will be able to support them under that load.  Doing this and educating them about the movement patterns that are associated with non-contact ACL injuries will not only aid in building confidence, reduce fear but will also aid in the neuromuscular retraining needed to prevent these pathokinematics we see associated with these injuries.

The final aspect is communication among providers.  This is just as important to building confidence your referral sources have in you as much as with the athlete.   Next week we will dive into this 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.