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What Psychological Factors Influence ACL Return to Sport?

Despite surgical advancements and growing ACL rehabilitation, many ACL rehabilitation outcomes remain subpar. Studies show only 44-55% of patients return to their pre-injury levels of athletic performance. The graft is not the issue, as studies show the failure load and tensile strength of the grafts are greater than native ACLs. One potential reason for mediocre return to sport rates is also a major cause of re-tears – inadequate rehabilitation. Players may return to sport before recovering strength and power to pre-injury levels. If the programming is poor and they return too quickly, they will lack sufficient fitness, increasing the risk of another injury. But this only covers one side of the equation. We need to address potential psychosocial factors as well. Social factors include pressure from teammates, coaches, colleges (scholarship opportunities), parents, and fans. This paper addresses some of the psychological factors.

There are several factors to consider when approaching the return to sport phase of ACL rehabilitation: self-efficacy, affect, fear of reinjury, self-confidence, locus of control, self-motivation, and self-esteem. All these factors are interrelated. Does the patient believe they have the capacity to return to sport? If not, why? You may believe they are ready based on your objective assessments of strength and power, but they may be concerned about situations you cannot replicate in the clinic, such as jumping for a rebound with 4 other players competing for the ball. Until you understand the patient’s concerns, you cannot devise a personalized rehabilitation and return to sport plan.

One of the biggest jumps in rehabilitation is moving from a closed environment to an open environment. In the clinic, patients do not have to react to opponents. They rarely reach the same level of fatigue they would in a full competition. If we are sending a patient back to the field with less than 100% strength and power relative to pre-injury levels, we are taking a huge risk. Tack on fear of injury and uncertainty with movement, and you have a recipe for re-injury. There are several questionnaires you can use to objectively measure these psychological factors (e.g., the Tampa scale for kinesiophobia). You can also use psychological interventions such as relaxation, guided imagination, and positive self-talk. A biopsychosocial approach to care does not only pertain to pain.

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