Fear of Re-inury in People who have Returned to Sport Following Anterior Cruciate Ligament Reconstruction Surgery
Ardern CL, Taylor NF, Feller JA, Webster KE. J Sci Med Sport. 2012 June [Epub ahead of print] https://www.ncbi.nlm.nih.gov/pubmed/22695136
The goal of anterior cruciate ligament reconstruction (ACLR) is to restore knee function to allow patients to return to sports participation, yet 2 years after surgery only 45% of these individuals have returned to their previous level of activity [Ardern, 2011]. Fear of re-injury has been reported in athletic populations [Kvist, 2005] and time from injury to surgery as well as gender has been suggested as potential factors that influence return to sports participation in ACLR patients [Karlsson, 1999; Ardern, 2011]. The purpose of this study was to evaluate fear of re-injury among athletes with a history of ACLR and have returned to any level of sports participation.
Out of a potential 533 participants, 209 participants met the inclusion criteria for this cross-sectional study: (1) regular participation in sports prior to injury, (2) at least 2 years after surgery, (3) clearance to return to full sports participation, and (4) participation in any level of sports activity at the time of the study. The primary outcome measure, fear of re-injury, was evaluated by a series of 8 novel questions that were developed by the authors. The questions were scored on a 10-point scale, with a higher score indicating less fear of re-injury. The authors determined that there was no sampling bias as there were no differences between individuals that completed the survey and those that did not. Furthermore, there were no differences between those that participated in the study less than 4 years after surgery and those that were greater than 4 years after surgery. As a whole, the entire cohort responded that they had minimal fear, with an average score of 60 out of 80 (75%). However when evaluated by activity level, those that had NOT returned to their previous level of activity reported a higher fear of re-injury on all questions, except one question regarding the environmental conditions of participation (e.g., concern about a wet playing field). Conversely, this same environmental question was the only question that females reported a higher fear of re-injury compared to males. There were no other differences between males and females. Participants that had undergone ACLR > 3 months after injury reported higher fear of re-injury scores than those with less time between injury and surgery; particularly regarding risk of injury while playing their sport, effort to participate at 100%, wary of injury-provoking situations, hesitant to participate in sports, and satisfaction with performance. There was no difference between any groups for the question about whether they wear a brace or strap. Finally, females who waited more than 3 months after injury to have surgery and had not returned to their previous level of activity had a higher fear of re-injury compared to other participants.
Overall, this study found that individuals who have not returned to their previous level of activity or delayed their time from injury to surgery had a greater fear of re-injury. It is possible that fear of re-injury is a barrier to returning to previous level of sports participation; however these factors only contribute to a greater fear of re-injury after ACLR. Because of the study design we cannot determine a cause and effect relationship. Prospectively following patients from injury to 2 years after surgery using psychological measures may help provide us a better understanding of the relationship between these factors and an increased fear of re-injury. This study enabled us to identify athletes that may have a higher fear of re-injury after ACLR. Additional rehabilitation or counseling for these individuals throughout the post-operative rehabilitation phase may be warranted to allow these athletes to successfully and safely return to full sports participation. Do you provide counseling services for athletes that have undergone ACLR or traumatic athletic injuries? Do you feel that this would be beneficial to our athletes?
Written by: Kathleen White
Reviewed by: Jeffrey Driban
Related Posts:Predictors of Failure After ACL Reconstructions
Predictors of Self-Reported Knee Function in Nonoperatively Treated Individuals with ACL Injury
Factors Used to Determine Return to Unrestricted Sports Activities After Anterior Cruciate Ligament Reconstruction
Providing "counseling" is quite a question – athletic trainers and physical therapists are probably not adequately trained to provide psychological counseling for our patients. However, providing opportunities for them to test the abilities of their limb in a safe and structured environment may be crucial to decreasing their fear. Unfortunately due to insurance limitations, patients are not in formal PT long enough to progress to those activities.
Thanks for your comment Andrew. I agree that allowing patients to test their abilities in a safe environment is key to their ability to return to sports. If insurance is limiting PT intervention then maybe referring these patients to sports psychologists would be a beneficial alternative.
With patients returning to sport I would hope that good communication between the athlete's PT and AT would help the athlete's anxiety as they transition back their team. I make sure the patient is introduced to drills and other sport-specific activity at a pace they are both physically and mentally ready to handle. If a sport psychologist was involved, I would want to make sure they were trained or specialized in the injury process.
Its important to realize that after any significant injury an athlete can go through the grieving process. As ATs we are not qualified to provide counseling but there are other things we can do to help our athletes mentally that are within our scope of care. We can encourage them and help them gain back their confidence through goals during rehab sessions. If its an athlete we can help them keep their team identity by allowing them to do rehab with the team during practice and allowing them to participate in practice as it becomes safe to do so. Its important to know your athletes so you can detect changes in their outlook that may indicate they need help beyond what you can provide. Although not every athlete/patient will need a sports psychologist it would be helpful to have one as a contact that way you can point your patient in the right direction and refer them to someone you know. This I think will make the patient less apprehensive.
Thank you for your comment Kristen. I agree that working with a sports psychologist may be a beneficial addition for these athletes.