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The Psychology of an ACL Injury

I would like to start this post by first pointing out that I am not a psychologist, psychiatrist, or licensed clinical social worker. I am a Doctor of Physical Therapy by trade, but have also completed some formal education in the realm of sport psychology. At UConn, I wrote my Master’s thesis on voluntary and involuntary career termination, or retirement from sport, and the havoc this transition can wreak on an athlete’s life. While I have taken a myriad of psychology courses, I am by no means an expert. I will try to keep this post as evidence-based as possible and will also be sharing a little bit of my own story.

Last week, I was talking with another PT about different career development opportunities. She said, “I can’t believe that some people waste their time at continuing education courses on things like psychology, when they could be learning valuable manual techniques or other things they could immediately apply in the clinic.” I couldn’t help but just smile and laugh. What an ignorant statement that couldn’t be further off base.

I “wasted” my time at the Micheli Lecture at Boston Children’s Hospital on the Psychology of Sports Injury and Rehabilitation. It was absolutely refreshing to see a room full of MD’s, DPT’s, ATC’s, RN’s, NP’s, etc. sitting down and talking to each other about the mental and emotional side of injury. When a patient walks through the clinic doors, we can’t just see him/her as an injured body part. Sure – the therapeutic exercise and manual therapy is extremely important, but I might argue that the humanistic aspect of treatment is sometimes the most beneficial for patients. Great clinicians are those who are able to meet their patients where they are and then empower them to take control over their recovery process. I’ve been super blessed to have encountered a number of great clinicians throughout the course of my athletic career, and if it wasn’t for their encouragement and support, I’m not sure I would have bounced back as many times as I did. Now, I’m trying my best to pay it forward and be that clinician for someone else.

So – let’s talk about mental health. One in five Americans is affected by mental illness. There is a plethora of research supporting the causative relationship between athletic injury and depression/anxiety. With an estimated 40-50% of collegiate student-athletes sustaining an injury during participation in NCAA-sanctioned sports, it is no mystery that a large portion of them also suffer from subsequent depression or anxiety. The National College Health Assessment surveys showed that about 31% of male and 48% of female NCAA student-athletes reported either anxiety or depressive symptoms annually during the 2008 and 2012 academic years. That’s insane. Nearly half of all NCAA female student-athletes have experienced, or are currently experiencing, anxiety or depressive symptoms. Unfortunately, the stigma associated with mental health disorders often shames athletes into silence and prevents them from seeking formal help. This toxic environment of shame, fear, and silence won’t change unless we consciously act to change it, so let’s change it.

New research is alluding to the fact that there may be a possible dose-response relationship between sport-related concussion (SRC) and depression. There is a 2-3x greater risk of depression after an athlete sustains three concussions. There is also a 2.9x greater incidence in depression and anxiety in athletes who sustain musculoskeletal (MSK) injury while participating in their sport. So… If I’ve tallied 4 SRC and 4 MSK ACL tears, where does that put me? I’m not a mathematician, but you could probably guess that I’ve dealt with my fair share of depression and anxiety.

What are some of the common psychological issues athletes face when recovering from an ACL injury?

Athletes rehabbing an ACL injury often experience fear, isolation, loss of identity, loss of purpose, depression, or anxiety. Cognitive, emotional, and behavioral responses have been well documented throughout the course of ACL rehabilitation, and while there are general trends that emerge in the research, it is important to note that there is tremendous variability in how an athlete responds psychologically during rehabilitation. In general, self-efficacy and perceived “percent rehabilitated” tends to increase over the course of rehabilitation. Pain and emotional distress (including stress, depression, frustration, and anxiety) tends to decrease over the course of rehabilitation. However, some athletes are predisposed to experience this emotional distress more than others. Athletes who demonstrate high levels of self-identification with the athlete role, pain, pain catastrophizing, and/or neuroticism (i.e. baseline depression/anxiety) tend to experience more emotional distress with ACL injury. While strong self-identification with the athlete role can have its downs, it is also predictive of adherence to rehabilitation. Rehab professionals can predict which patients will be compliant with their therapy by identifying those with strong athletic identity, self-motivation, belief in efficacy of treatment, self-efficacy, and those who participate in goal-setting, positive self-talk, and imagery.

Did you know that, on average, only 81% of people return to sport following ACL reconstruction, 65% return to their pre-injury level of sport, and 55% return to competitive-level sport after surgery? Multiple narrative and systematic reviews of literature have been conducted suggesting that athletes are less likely to return to sport after ACL reconstruction if, during rehab, they display re-injury anxiety/fear of re-injury, low self-motivation, lack of confidence in their knee, or low “psychological readiness” to return to sport. Interestingly enough, research also shows that athletes who are supported by certified athletic trainers experience an 87% decrease in depression and 78% decrease in anxiety when returning to sport. Having a clinician who sees and encourages an injured athletes on a routine basis can make a world of difference in the recovery process.

Post-Traumatic Stress Disorder (PTSD) is also a common manifestation in athletes attempting to return to sport post ACL reconstruction. PTSD is a constellation of symptoms including reliving the traumatic experience, needing to “hash out” the injury, ruminating over injury, nightmares, and/or hallucinations. One in 3 kids develop Acute Stress Disorder (ASD) following musculoskeletal injury, which basically means that the aforementioned symptoms occur for less than 30 days. Once you cross the one-month mark, it can now be deemed PTSD. One in 6 kids with musculoskeletal injury develop PTSD and have increased difficulty recovering from a psychological standpoint. This can manifest in increased heart rate or nervous sweating just by lacing up your cleats. I’ve seen statistics as high as 33% of patients with minor orthopedic injuries developing some sort of PTSD, with even higher statistics for athletes experiencing repeat ACL tears.

Athletes are often forced into involuntary career termination/athletic retirement due to “career-ending” injuries. I’ve done some qualitative research in this domain, and can tell you from both a scientific and personal standpoint, that career-ending injuries are a different kind of beast. I tore my ACL for the fourth time in 2017. Physically, anyone can rehab an ACL tear. The body will inevitably heal in 9-12 months. The brain/spirit will take a little bit longer. After lots of self-reflection, I realized that I could not continue to play and jeopardize both my physical and mental health. I often joke about having PTSD when a soccer ball rolls by, but honestly, part of that is true. When interviewing the participants of my thesis research back at UConn, there were a couple of themes that emerged in athletes who experienced a positive transition from sport. They were: staying involved in sport, divesting from athletic identity, and finding a new focus. I’ve put some of these ideas into practice by coaching high school soccer (shoutout to ABSOCC) and by diving headfirst into my new career at the New England Return to Sport Center, where I am on a never-ending mission to help sidelined athletes get back in the game.

Stay tuned for The Psychology of an ACL Injury: Part II, where I will discuss signs and symptoms of mental illness, as well as different treatment strategies to get you out of that funk and back onto the field.

If you or anyone you know is struggling with thoughts of depression or suicide, call the NAMI helpline at 800-950-6264 or text ‘NAMI’ to 741741.


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