In a number of ways the quest to return to sport after suffering ACL injury has all the hallmarks of a classical hero’s journey. The hero of the story faces a long and arduous journey to get back onto their feet after the original injury and then the daunting challenge of attempting to return to participating in the sport - and from there the epic-length saga continues as they must first survive the initial period after their return and then strive to get back to their best thereafter. As with any hero journey, the outcome is uncertain and success is far from assured. Indeed the element of uncertainty extends to the journey as a whole: whilst we can forewarn the athlete of some of the challenges they are likely to face, it is nevertheless something of a journey into the unknown. From the outset choosing to embark on this quest calls for a great deal of courage on the part of the athlete. What is assured is that the journey will test them and their resolve will certainly be challenged along the way. Whilst all this may seem like hyperbole, portraying the quest in these terms I think helps us to understand what the athlete faces and how we might best serve them in the endeavour.
A QUICK PRIMER…
Most readers will be familiar with ACL injury, but briefly the anterior cruciate ligament (ACL) is one of two ligaments that binds the two joint surfaces of the knee together. As you might imagine the function served by the ACL is particularly important in sports that involve landing, pivoting and changing direction. Due to the demands these sports see more than their fair share of ACL injuries, especially for those at high risk - and sadly this disproportionately affects female athletes (in the absence of training intervention).
Naturally when the ACL ruptures this is a traumatic injury in more ways than one. Tackling the task of ACL rehabilitation in the attempt to return to sport is therefore a daunting proposition - almost as much for the practitioners as it is for the injured athlete!
THE ACL INJURY HYDRA…
ACL injury is something like the hydra: it is not a singular problem but one with many constituent parts. To successfully confront the hydra it helps a great deal to be aware of each of the sub-problems we will need to grapple with. We also need to be aware that it is not as straightforward as severing each head of the beast with a single swipe as it will grow back! Each individual problem that is part of the whole will therefore demand our continuing attention in order for the athlete to ultimately prevail.
As we come to understand the scope of what is required it also becomes clear that we must bring a range of tools to tackle these respective problems. In the upcoming e-learning course (shameless plug) we will describe a systematic approach that goes into each of these elements in detail. Beyond requiring an extensive toolbox, a collaborative team approach is likely called for.
OUR BIT-PART ROLE IN THE HERO’S TALE…
Given the stakes involved, the responsibility for guiding the athlete on this fraught and uncertain journey is not something that should be undertaken lightly.
Having assumed this responsibility we do have an obligation to paint a clear picture of the size and scope of the journey that faces the athlete. It is important that the athlete understands the risks involved and we need to ensure that they have realistic expectations as they make the decision to embark on the quest. Of course whilst we can (and should) help provide the athlete with some idea of the trials they are likely to face along the way, there will inevitably be unanticipated challenges that we cannot predict. To that extent, it is something of a journey into the unknown.
We must be also be mindful that it is their journey, not ours. Only the athlete themselves can do what needs to be done. We are simply there to be their guide and do our best to arm them with the tools that they will require in the endeavour. This role is important, but nonetheless we are non-combatants.
BRAVERY (AND HUMILITY) IS REQUIRED FROM ALL PARTIES…
When facing such a quest, we should acknowledge that part of our responsibility as practitioners is to help the athlete find the courage required. A great deal of tenacity will also be needed on the part of the athlete if they are to prevail and emerge victorious. We must do everything we can to help foster the resilience and problem-solving capabilities they will need to face the many trials they are likely to encounter along the way.
The urge to protect is understandable and natural - but paradoxically it can also be harmful. We need to remain mindful that the more we protect the athlete from exposure to stressors, the more de-conditioned and the less prepared they will be for the rigours they will face when they ultimately make their return. Whilst not necessarily intuitive, a growing evidence points to the value and potency of advanced training modes in restoring function and addressing the deficits that we otherwise see with more conventional and conservative rehabilitation and return to sport protocols.
Stress contagion is also a real and present danger - what the athlete is facing is scary enough without us adding to their anxiety. We need to create the conditions for the athlete to be courageous; they must voluntarily face these trials and confront the monsters that lurk. This likewise calls for bravery on our part.
Any urge to ride in our white horse and be their saviour is less forgivable. When we do something for the athlete that they could do themselves we rob them of the opportunity. In this way our actions can impede developing a sense that they are able to cope on their own. We should not be seeking to solve the injured athlete’s problems for them but rather help them to become a master problem-solver.
There is a strange phenomenon whereby ACL injury has such profile and sense of status associated with it that some practitioners seek to claim the mantle of ‘ACL injury specialist’ - and this leads to a tendency to place themselves firmly centre-stage. Once again such attitudes and actions can do real harm. We are aiming to develop autonomy, not a sense of dependency.
The more pivotal we are in the mind of the athlete, the less confident they will be in their own ability to face things alone - as they must do. Ratings of confidence and sense of self-efficacy are two of the biggest predictors of making a successful return to sport. For this reason alone, there is merit in lengthening the leash and handing over to another practitioner, particular during the latter stages of the rehab and return to sport process. This sends a strong message to the athlete that they are ready to fly solo.
POST SCRIPT
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