The “Hidden” Side of ACL Rehab: The Psychological Side of Recovery

The ACL, short for Anterior Cruciate Ligament, is a piece of strong connective tissue that connects the thigh bone (femur) to the shin bone (tibia).

Georgio Baylouny

What is an ACL?

Its primary function anatomically is to passively resist anterior translation of the tibia on the femur. In other words, it is designed to assist in stopping the shin bone from sliding forward on the thigh bone. Especially when your leg is planted firmly on the ground. Resisting such motion especially important in athletics, which commonly require cutting, jumping and landing maneuvers that may require stability of the leg.

How is the ACL Injured?

ACL injuries most commonly occur in a non-contact fashion, usually in a position of extension and/or valgus (knock-knee posture) while performing an athletic task. Depending on the severity of the injury and individuals’ ability to stabilize their knee after injury, surgical intervention may be required to reconstruct the ACL.

I’ve Had ACL Surgery…Now What?

Following surgery, you will begin your physical therapy and rehabilitation journey. This typically lasts 6 months – 1 year. That’s a long time to be away from the sport or activity that you love! A traditional approach to physical therapy with likely include quadriceps activation and range of motion exercises early on. Then progress to lower extremity strengthening, neuromuscular training, and more sport-specific movements. (This all depends on the individual’s goals!)

As a whole, Physical Therapists have been quite proficient in their treatment of the physical impairments associated with ACL injury (although the profession as a whole still has a way to go in terms of adequately loading athletes and varying movement interventions in a manner that mimics the environments that the athlete will be exposed to during their sport, but I digress).

Despite demonstrating proficiency in treating the physical impairments, most of the literature reports that less than 50% of athletes return to their pre-injury level of competition! As a former collegiate athlete who underwent ACL reconstruction surgery and was able to return to my prior level of competition, this statistic eats me alive. Why might this be the case?Well, some of the factors that I touched on earlier contribute – under-loading patients, not preparing athletes for their dynamic environment that they are returning to, and not using enough objective tests to determine readiness. Research suggests that there is another “hidden” component – the patient and/or athlete’s psychology.

The Hidden Side of ACL Injury Rehabilitation

The psychological side of injury and rehabilitation is an aspect that many doctors and therapists unintentionally ignore or miss. Research now shows that higher levels of motivation throughout the rehabilitation process are a key indicator of return to prior level of competitive activity and overall satisfaction by 1 year after surgery. Staying motivated through a 6 to 12 months period is no easy task (take it from someone who can personally attest to that)! Therefore it’s very important to develop a strong, therapeutic relationship with your physical therapist so they understand what you are motivated by and your true goals. This will you and your PT to develop a collaborative, realistic game plan to achieve your goals. This is something we make a priority at PhysioRX.

In addition to the contribution of motivation, confidence performing higher level movements and fear of re-injury are other psychological factors that must be addressed during the rehab process. Once again, building a strong relationship with your healthcare provider is massively important in allowing for clear lines of communication regarding confidence and fear. You are doing yourself a disservice if you do not seek out an individual who grasps the importance of treating more than just your knee (or any body part for that matter). This is especially important as you near the “return to sport” phase of rehab. Failure to do so is likely to lead to a mediocre outcome that you may not be completely satisfied with when it comes to getting back on the playing field.


In summary, rehabilitation from ACL reconstruction surgery is a complex process that is multifactorial in nature. Despite prior beliefs that solely addressing an individual’s physical impairments was the be-all and end-all, it is now understood that a rehab program should also tackle the psychological side pertaining to return to sport or return to prior level of activity. The most effective means of doing so is to find a healthcare provider that understands the importance of developing a strong, therapeutic alliance with their patients and creates an individualized game plan for each person that walks through their doors.

Dr. Zach Friedenreich, PT, DPT

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