Surgery, rehab often not enough after ACL injury

As sports fans, we are all too familiar with ACL injuries. So many players from our favorite college and professional sports have suffered these injuries that we can often predict the diagnosis when television cameras show a gruesome knee injury. And we know what to expect for the player and the team. We read about our heroes having surgery and missing the rest of the season but ultimately returning the following year.

So when our sons and daughters suffer these same injuries, we can expect that they will return to sports uneventfully, right? As College GameDay’s Lee Corso likes to say, “Not so fast.”

Wide receiver in football practiceA study presented earlier this month at the American Orthopaedic Society for Sports Medicine’s Specialty Day in San Francisco, California raises concerns about successful return to sports after ACL tears. The authors examined data from the Multicenter Orthopaedic Outcomes Network, where they collected data from high school and college football players over a two-year period. While sports medicine surgeons have largely believed that success in terms of return to sports is very high after ACL reconstruction, in this study only 62% of the high-school football players and 70% of the collegiate athletes returned to play. Tweet this statistic.

According to the authors, psychological factors played a significant role in players’ failure to return to sports. They questioned the players’ perception of their own skill and performance after returning from ACL surgery. At the high-school level, 45% said they returned to play at the same skill and performance level, while 26% returned at a lower level. College players fared worse, with 36% saying they returned at the same level and 32% at a lower level. Of the performance-related causes noted for not returning to play at all, fear was a major or contributing factor in over half of high school players and just under half of college players.

Senior author Kurt P. Spindler, MD pointed out one of the key messages from this data. “While return to play may be perceived as the central concern for a competitive athlete recovering from an injury, it is easy to ignore psychological factors keeping a player off the field. Fear of re-injury and concern over decreased performance may hinder even the most physically capable athlete.”

While parents reading this column might be inclined to dismiss these findings if their sons or daughters play a sport other than football, I would caution against doing so. I hear athletes of all sports, genders, and ages express anxiety about playing on their surgically reconstructed knees. They are scared about the first time they will be hit, land on it, or turn suddenly. Maybe they retain vivid memories of their knees buckling initially, or maybe they just lack confidence, but these fears are real.

Patellar tendon ACL graftUnfortunately, there might not be an easy solution to these psychological issues. Surgeons can create new ligaments that are more than strong enough to protect the knee. Physical therapists and athletic trainers can aggressively rehabilitate the athlete and restore full strength, motion, and functional ability. But it might be reasonable to include sports psychologists and counselors in the sports medicine teams working with athletes after major injuries and surgeries. Parents and coaches could also maintain an open dialogue with the athletes to recognize signs that they are afraid to play.

For decades, sports medicine research has focused on improving surgical techniques, rehab protocols, and even injury prevention programs, and rightly so. But we need to start addressing psychological aspects of sports injuries. The latest arthroscopic technology or most glamorous sports performance program will be irrelevant if the fear of re-injury compromises an athlete’s return to play.

Note: The following post appears in my sports medicine column in the March 1, 2012 issue of The Post and Courier.

8 Responses to Surgery, rehab often not enough after ACL injury

  1. This is a good article bringing up a very valid point. I believe that teaching kids from the outset that rehab and PT are going to be their lifelong friends after an ACL tear would be helpful. Thanks!

  2. Great article which address a major overlook in the management of this injury in my opinion. It is encouraging that sport psych researchers are currently looking into ways of measuring psychological readiness for return to play following major knee injuries.

    • Thanks! I think most of us in sports medicine – myself included occasionally – focus so much on musculoskeletal components of ACL surgery and rehab and miss the psychological effect the injury has on the athlete and ability to play. I think we have a long way to go to better understand some of these obstacles, but at least we seem to be headed in that direction.

  3. Great information. I’m very much into helping athletes, parents and coaches learn ways to prevent and/or recovery quicker and faster from injury. Thanks!

  4. I had a knee reconstruction with a 1.2 cm medial menisus posterior horn tear left in situ but the surgeon mentioned that he might propagate. Why not trim it then ? How can a medial meniscus tear propagate ? Would I need to twist my knee again for that to happen ?

  5. It’s also common in my work industry. As a Firefighter and a Paramedic we not only deal with dangers at work doing 911 jobs. The unknown part for us is the injuries we indore doing physical fitness training at work like Crossfit. I actually tore my ACL the first time playing tag FBall at work on some down time in the late 1990’s. I tore it again stepping from rear bumper of fire truck with a large bundle of hose on my shoulder Fed 2015. Sense February I have had two surgeries on same ACL. There is nothing in place for the fear of us not being able to go back to work. I’m 42yo and if I can’t pass my physical agility test I’ll have 30 days then I try again. If I fail it then I will be released from my possition with the Department. This really suck physically, and Mentally. FYI I’m from NC so we have no union help for employee rites and it’s horrible.

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david-headshot I am an orthopaedic surgeon and sports medicine specialist in Charleston, South Carolina.

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