Rehabbing the ACL, both physically AND mentally
Dr. Lisa C. Clark, PT, DPT
The last time I wore the number 17, I was carried off the field. I had experienced the dreaded “pop”, the horrifying buckle, my worst fear. I had torn my ACL in double overtime, halfway through my senior lacrosse season. My college career was over and I was devastated. In the last 4 weeks of that season, I watched my teammates play the game I loved while I worked my hardest to prepare for a surgery I never wanted. The emptiness that I felt was overwhelming and lonely. I felt like my identity had been stripped from me. Being an athlete was all that I knew and, suddenly, it was just over.
Now, as a physical therapist, I treat athletes like me all the time. Luckily, many of them are young enough to return to their sports and find plenty of success, like receiving athletic awards and commit to colleges. The amount of joy that we both feel is tremendous. Many of these kids didn’t think they’d ever get back to sports, but they did and it took a lot of work to get there.
Tearing the anterior cruciate ligament (ACL) is, perhaps, the most feared diagnosis in all of sports. Physical symptoms include significant joint pain and swelling, loss of range of motion, quad weakness, difficulty walking, feelings of instability. In most cases, a reconstruction is the best option for anyone who would like to return to sports involving a change of direction. The rehabilitation process can take anywhere from 6-12 months. Many people staring this prognosis in the face are understandably overwhelmed. For athletes, though, this is an entire year of sports. Maybe 3 or 4 competitive seasons or a recruiting year that they’re missing out on. While they see their friends trying to make college decisions, they are just trying to walk, run, and squat properly.
Along with these physical symptoms comes the mental and emotional response, which is not often discussed, but is very prevalent. Perhaps even more important than rehabilitating the knee is rehabilitating the mind. Research shows that psychological responses, such as depression, anxiety, fear, and anger, are significant in cases where an athlete has suffered a severe injury. These emotions are shown to have a large effect on the rehab process. Athletes with depression, for example, are less likely to adhere to their treatment and home exercise programs. They struggle with returning to their sport, may experience a social withdrawal, and are at an increased risk for suicide. Literature suggests that athletes with depression are more likely to demonstrate poor functional and orthopedic outcomes and report a lower quality of life.
Even more significantly vulnerable for negative responses to injury are those who already have a history of depression. Athletes between the ages of 15-25 are the most at-risk group for ACL tears. This age group is also most vulnerable to suicide. Thus, depression following an injury is even more problematic in our adolescent and collegiate athletes. In general, injured athletes who gain self-worth and self-esteem from performance have been shown to be at risk for negative responses in comparison to their peers who are uninjured.
While this information is intimidating, it is worth mentioning that research indicates that most athletes return to their sports with minimal complications following proper rehabilitation. Therefore, as a clinician, I do all that I can to help ensure my patients that I thoroughly believe they will return to their pre-injury status. The hardest part is convincing them of the same thing, which can be an uphill battle. I always discuss the mental portion of ACL tears, like fear, discomfort, frustration, and grief. I let them know that these feelings are normal and encourage them to talk with teammates, coaches, family, friends, or even me. Sometimes just acknowledging these emotions and talking about them can take away their power. We also set goals and try to accomplish them one-by-one. I also try to schedule my ACL patients together so that they form a comradery with each other. That is sometimes more helpful than anything – strength in numbers and emotional support. If that isn’t enough, though, I encourage my patients to utilize the many resources we have to ensure our athletes are making a complete physical and mental recovery: primary care or mental health practitioner, sports psychologist, cognitive behavioral therapy, counselors or wellness professionals (to name a few).
If you are a PT/ATC/MD or any clinician reading this: please take the time to educate your ACL patients about how much mental health affects their outcomes and their return to athletics. Understand that depression can make it difficult for patients to be consistent with visits and remain compliant with home exercises, especially with time spans of 6-9 months. Instead of being frustrated, be encouraging. Show that you care and use what you know to help to motivate them. Increase their number of visits as they get closer to their return-to-sport to make sure they are sticking to their programs. Rehab compliance can help to improve their physical and mental ability. Prove to them why that is the case.
If you are an athlete who has suffered an ACL tear and are in any stage of recovery: your mental health is a HUGE factor in your return to what you love. Your PTs and the people working around you want what is best for you. These are some symptoms of depression: sadness, isolation, irritation, lack of motivation, anger, frustration, changes in appetite or sleep, and poor concentration.
If you experience any of them, please talk to someone about it. These feelings are perfectly normal and can be dealt with in whichever way is most appropriate. If any of these symptoms are interfering with your rehab process, it must be taken care of. As I mentioned above, remember that depression will make it difficult for you to stick with your exercises, but the more effort you put in, the better you will be both on and off the field. Stay involved in team activities. Go to practices and games and team functions. Do whatever fundamental drills you can participate in (stickwork, ball handling, hand-eye reaction drills, etc). You are still part of a team, even if you’re not putting on the uniform every day.
Treating patients with ACL injuries is my passion, not just because I’ve been down that road, but because I love getting to know and understanding the whole person. Not just their knee, but their emotions, their goals, their passions, and their motivations. It would be a mistake for me and all of my colleagues to not address the most important part of ACL rehabilitation: the mental recovery.