So many times, athletes and parents alike are singularly focused on the physical rehab necessary after an injury.  Often, what the athlete is not talking about is the psychological impact of the injury.  Suddenly, their identity and self worth may come into question.  They feel disconnected from teammates and coaches.  Their daily routine consists of rehab and not practice/play.  Deep inside their head they are quietly wondering, “Will I ever be the same again?”


Aside from some of the obvious questions that race through an injured athlete’s mind, one of the biggest and most often unspoken concerns is the fear of re-injury.  Having worked with athletes of all sports, ages and abilities, I have seen firsthand how important it is for an athlete to go through a functional and sequential progression that assures that they are able to run, jump, cut, pivot and decelerate again without pain or instability.

I have worked with hundreds of athletes over the course of my career that have suffered ACL injuries.  The longer I practice, the more I become convinced that we probably have been pushing or allowing these athletes to go back to their sports before they are really ready (physically and/or mentally).  Six months has long been the benchmark for most orthopaedic surgeons.  The graft is well healed, but often the mind and body are not really ready.

While I have seen athletes who have great strength, stability, hop testing scores above 90% and look good on movement drills, sometimes these same athletes still have asymmetrical squat patterns, FMS scores lower than 14 or apprehension about returning to their sport.  In addition, fear of re-injury is a big factor that impacts confidence and readiness to return to activity.

Consider some of these facts about modifiable factors with return to sports after ACLR from the May/June 2015 Sports Health Journal:

  • Motivation, confidence, self-efficacy, optimism and low fear are associated with a greater likelihood of returning to preinjury level  after athletic injury and ACLR
  • Lower fear of reinjury and greater pyschological readiness to return to sport favored returning to preinjury level after surgery
  • Combinable data from 10 studies suggests that fear of reinjury, psychological readiness to return to sport and one’ subjective assessment of knee function were predictive of level of return to sport
  • As many as 1 in 2 athletes who do not return to their preinjury level of sport report the main reason is fear of reinjury

Interestingly enough, nonmodifiable factors that may increase the risk of not returning to preinjury level of sport after ACL surgery include: female sex, older age and participating at a nonelite level prior to injury.  Research also indicates that 1 in 3 do not return to their preinjury level of sport, while 1 in 2 athletes do not return to competitive-level sport after surgery.

Athletes may fear pain, possible consequences of a subsequent injury or having to go through rehab again.  As clinicians, strength coaches and trainers, we need to be cognizant of this piece of the puzzle.  Understanding the athletic mind and recognizing the warning signals of a non coper or someone struggling with modifiable risk factors will impact the rehab process and athlete’s success rate.  Using scales such as the IKDC, Tampa Scale for Kinesiophobia (TSK) and ACL-Return to Sport after Injury scale all provide insight and clues about how an athlete views their recovery and ability to return.

Below are some links to abstracts pertaining to ACL surgery and the Tampa Scale

Kinesiophobia after ACL injury and reconstruction

Analysis of shortened versions of the Tampa Scale

To assist athletes in the mental recovery after ACL surgery, I suggest the following:

  1. Have an honest conversation at the outset about general timeframes but not specifically promising return to sport at 6 months post-op.  Instead, discuss milestones, functional testing goals/norms and educate them that athletes go back at different points in time.
  2. Assess their mental state of mind early and often through conversation and outcome measures
  3. Refer to a sports psychologist when appropriate and provided the athlete is willing
  4. Maintain close communication with parents, coaches and others involved in the athlete’s care who may have additional insight and input
  5. Encourage positive self talk, visualization and use words of affirmation during the rehab process

In the end, we must partner with the athlete in their recovery.  We need to assess their mental profile, readiness to return to sport and fear of reinjury.  As therapists and conditioning coaches, we must let them know it is normal to have apprehension and fear, while consistently assisting them to overcome those obstacles in order to return to their physical and mental best again.

Reference: Arden CL. Anterior cruciate ligament reconstruction-not exactly a one-way ticket back to the preinjury level: a review of contextual factors affecting return to sport after surgery. Sports Health. 2015;7(3):224-30.