November 2016

Psychological aspects of ACL rehabilitation

11ACL_iStock_33322316The ability to identify and treat patients at risk for mental health issues after anterior cruciate ligament (ACL) injury may help improve psychological readiness for reconstructive surgery, attitudes toward postoperative rehabilitation, and successful surgical and rehabilitation outcomes.

By John Reaume, MD, MHSA; Dana Reaume, PsyD; and Melissa A. Christino, MD

Anterior cruciate ligament (ACL) injuries are among the most common orthopedic sports injuries, occurring almost 300,000 times annually.1 The athlete’s response to an ACL injury extends from the time of the initial injury, through rehabilitation, and ultimately to return to activity. As the rate of youth and adolescent athletes participating in sports continues to grow, the number of injuries is also expected to rise. Rehabilitation following an ACL reconstruction (ACLR) is challenging, with return to sport contingent on both physical and psychological factors.

Michael Jordan, who many consider the best basketball player of all time, once said, “My body could stand the crutches, but my mind couldn’t stand the sidelines.”2 Although Jordan wasn’t sidelined by an ACL injury, his personal perspective on the psychological impact of a significant injury speaks volumes about the emotional paralysis, sense of loss, and uncertainty that is often associated with a physical injury.

Emotional reactions to injury are normal. Mind, body, and sports clinicians agree the emotional responses to injury can include sadness, irritation, feelings of isolation, disengagement, lack of motivation, anger, frustration, changes in appetite, and even sleep disturbance.3 Problematic reactions are defined as those that do not resolve, and may worsen, over time. Such excessive reactions will impact recovery and may ultimately lead to performance failure. While in most cases ACL injury rehabilitation leads to a successful return to preinjury status, in some patients the injury may unmask or trigger more serious mental health or emotional issues. In particular, athletic injuries associated with excessive time loss from sport may result in ongoing physical and emotional suffering and may benefit from psychological intervention.3

Psychological aspects of ACLR

Injury is both a physical and psychological process. The ability to return to preinjury status following ACLR is a critical component of successful postsurgical outcomes. An understanding of the inherent distress associated with injury can positively impact the recovery process. Psychological factors that have been associated with recovering from ACL surgery include self-efficacy, fear of reinjury, psychological distress, and locus of control.

Behavioral strategies directed at improving an athlete’s sense of self-efficacy may increase compliance with treatment and help create a smoother path to recovery.

Self-efficacy refers to an individual’s belief that he or she possesses the skill set necessary for success. Thomeé et al used the knee self-efficacy scale (K-SES) to evaluate 38 patients who had undergone ACLR to predict patient outcomes in physical activity, knee symptoms, and muscle function one year postoperatively.4 The study concluded perceived preoperative self-efficacy of knee function has predictive value for return to acceptable levels of physical activity, symptoms, and muscle function one year after ACL reconstruction.

Fear of reinjury, which may be referred to as kinesiophobia, has been linked to suboptimal outcomes after ACL reconstruction in multiple studies. Psychological distress refers to a range of symptoms and experiences of a person’s internal life that are commonly held to be troubling, confusing, or out of the ordinary, and can manifest in suboptimal performance. A study of competitive versus recreational athletes who have undergone ACLR found competitive athletes experienced greater mood disturbance and had a prolonged rate of psychological recovery compared with their recreational counterparts.5

11acl_istock_89142727Locus of control refers to the degree to which an individual believes they have control of the outcomes of their lives as opposed to control being dictated by external forces. The Multidimensional Health Locus of Control (HLOC) scale was used along with validated knee, sport, and health outcome surveys to identify the relationship between perceived locus of control and outcomes in 198 patients who had undergone ACLR at a mean 5.1 +/- 2.9 years postoperatively.6 The authors concluded patients with high internal HLOC scores were more satisfied with their knee function.

When an injury occurs, the athlete must be able to process the medical information provided by the interdisciplinary team, both cognitively and emotionally. The response to injury is not necessarily predictable. Injuries can be devastating to individuals who have established a strong personal identification with being an athlete.

Psychology and ACLR outcomes

In their study on self-protective changes in athletic identity following ALCR that included 24 months of follow-up, Brewer et al prospectively followed 72 men and 36 women undergoing ACLR using preoperative and postoperative athletic identity measures (based on the Athletic Identity Measurement Scale [AIMS]).7 Ninety-six percent of study participants identified as athletes (49% as competitive athletes, 47% as recreational athletes). The study found a significant decrease in mean AIMS score, indicating a decrease in athletic identity, across the 24-month period following surgery; the greatest reductions in athletic identity were seen in the participants who had the slowest physical rehabilitation progress between six and 12 months after surgery. The study suggested the reduced athletic identification in these participants was a self-protective effort against a perceived threat to their positive self-image. It is not uncommon for injured athletes to feel social isolation from their team and teammates, which can negatively affect self-image.

Despite the high success rates of ACL reconstructions for restoring knee stability,8 many athletes do not regain their preinjury ability, which may lead to decreased performance and sports-related satisfaction. A recent study found only 31% of athletes returned to their preinjury level of sport at 12 months postoperatively and that psychological factors may play an important role in determining outcomes.9

Christino et al also found psychological factors were significantly associated with patient perceptions and functional outcomes after ACLR.10 The authors performed a cross-sectional study of 27 young (mean age 25.7 years) mostly athletic (89%) individuals who underwent ACLR performed by a single surgeon. The authors used physical and psychological outcome measures. Sixty-five percent of the self-described athletes reported returning to sports at a competitive level. Those who returned to sports had significantly higher self-esteem and Knee Injury and Osteoarthritis Outcome Score – Quality of Life Subscale (KOOS-QOL) scores than those who did not. Functional hop-test performance and validated outcome measures were associated with higher levels of self-esteem and locus of control. Interestingly, objective knee stability was not significantly different between those who returned to competitive sports and those who did not.

An expectation of return to preinjury levels of function can be one of the most important aspects of the physical and psychological adaptations to ACLR and rehabilitation. A cohort study of 122 competitive and recreational athletes who had not returned to their preinjury level of sport one year after ACLR helps illustrate this point.11 Patients were given a questionnaire regarding return to sport, sports participation, and psychological responses at one and two years postoperatively. Additionally, a physical therapist evaluated physical function at the one-year mark.

The study found that two years after ACLR, 66% returned to playing sports, but only 41% returned to their preinjury level of sport. Psychological factors, such as decreased readiness to return to sport and mood disturbance, negatively impacted the athletes’ return to preinjury levels of function. Physical factors, such as previous ACLR and poor hop-test symmetry, were also found to be predictive of not returning to preinjury levels of function. The authors concluded that return to sport after ACLR is multifactorial and that psychological factors may play an important role.

Another major factor in the post-ACLR recovery process is fear of reinjury. A recent meta-analysis, which included 48 studies involving 5770 athletes who had undergone ACLR with an average 41.5-month follow-up, looked at the factors influencing return to sport.10 The authors found 90% of participants achieved normal to near-normal physical knee functioning in terms of knee range of motion, strength, and ligamentous stability. While 82% returned to some degree of sports participation, only 44% returned to a competitive level at final follow-up. Of the multiple factors that can influence an athlete’s ability to return to competitive sport, fear of reinjury was the most common reason cited for inability to function at preinjury levels.

It is essential to assess how the athlete feels about his or her potential for recovery and how he or she is dealing with the ACL injury and the recovery from an emotional standpoint. Equally important is determining the athlete’s level of social connectedness and his or her sense of control over the rehabilitation process. Ongoing appraisals of the athlete’s mental and physical coping skills needed to recover are imperative components of a thorough clinical evaluation.

Focusing on the athlete rather than the injury may prove helpful in encouraging an open discussion of feelings and emotions.


Interventions to optimize self-efficacy, the belief in one’s ability to overcome obstacles and to succeed, hold great potential for symptom management. An athlete’s preoperative assessment of expectations may be indicative of self-efficacy, self-esteem, and HLOC. Behavioral strategies directed at improving his or her sense of self-efficacy may increase compliance with treatment tasks, and may help to create a more favorable path of recovery.12

While not specific to ACL injuries, an integrated model of psychological response to injury and rehabilitation targets three responses to injury that, in turn, will determine the patient’s approach and adherence to the rehabilitation process.13 All three responses are mediated by both personal (personality, motivation, self-belief, perception of control, resilience, history of injury) and situational factors (social support, resources available, life stressors, requirements of the sport). The three responses are:

Cognitive appraisal: what we think about the injury and its relationship to our lives and goals;

Emotional response: how we feel about the injury, our future, and how mood and energy are affected; and

Behavioral response: what we do in response to injury and functional loss, ie, planning and execution.

Of the three, cognitive appraisal plays a central role. As mind-body clinicians have surmised, it’s primarily mind over matter.

The consequences of being sidelined may negatively impact an athlete’s ability to cope with the stress of injury and rehabilitation and may result in catastrophic thinking.  Catastrophizing can be defined as predicting the worst-case scenarios, and often generates increased feelings of helplessness, rumination, and magnification of symptoms, leading to increased emotional disturbance, avoidance of painful or threatening activities, and increased perceived disability. Stress inoculation and resiliency training are cognitive behavioral interventions that involve empowering the individual to reduce the stress associated with the injury and to develop enhanced coping strategies for overcoming the obstacles associated with rehabilitation.

The intensity of symptoms experienced by individuals undergoing ACLR rehabilitation may be reduced by enhancing coping strategies. Guided imagery and relaxation training have been associated with improved psychological coping and reduced reinjury anxiety.14 These strategies involve using the senses to create mental images focused on having the desired outcome. Other psychological techniques have also been described that effectively help athletes recover from injury. Acceptance and commitment therapy and written disclosure have demonstrated effectiveness in reducing negative psychological consequences, improving psychological coping, and reducing reinjury anxiety.15,16 These psychological techniques involve realistic goal setting and adherence to and compliance with the multifaceted rehabilitation protocol.


The literature suggests a significant need to develop and imple­ment interventions that target improvement of postinjury psychological outcomes to help injured athletes recover successfully from ACL injury and surgery. Educating athletes about the mental health risks associated with injury may prove instrumental in optimizing per­formance and return to play. Establishing interdisciplinary teams that integrate mental healthcare providers, such as sports and health psychologists, working alongside lower extremity clinicians—including orthopedic surgeons, sports medicine physicians, physical thera­pists, and athletic trainers—could go a long way toward demys­ti­fying the psychological factors and mental health issues associated with ACL injury.

The ability to identify and treat patients at risk for mental health issues after ACL reconstruction may help improve psychological readiness for surgery, attitudes toward postoperative rehabilitation, and successful surgical and rehabilitation outcomes. Future research should focus on intervention studies designed to increase compliance with treatment, enhance surgical outcomes, and improve return to sport.

John Reaume, MD, MHSA, is a chief orthopedic surgery resident at Dwight David Eisenhower Army Medical Center in Fort Gordon, GA. Dana Reaume, PsyD, is a licensed clinical psychologist who holds special certification in pain management and is a private consultant in Augusta, GA. Melissa A. Christino, MD, is an orthopedic surgeon specializing in sports medicine at Children’s Orthopaedics of Atlanta.

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