Athletic Training and Sports Health Care

Guest Editorial Free

Rehabbing the Mind Within Anterior Cruciate Ligament Rehabilitation: Are We Addressing Patients' Expectations?

Jo Ann Kaye, MSc; Jenny Alexanders, PhD

Patients who undergo anterior cruciate ligament (ACL) surgery experience not only physical problems, but also psychological distress such as anger, depression, anxiety, and fear.1 These psychological issues are said to be responsible for up to 50% of athletes failing to return to their preinjury level of sport following ACL surgery, despite being fully physically rehabilitated.2 Therefore, it is important that addressing the psychological well-being of patients during ACL rehabilitation is a priority.

Empirical evidence suggests that patients' expectations are often to return to full sport/function within 9 to 12 months after ACL surgery.3 Although these expectations are not unrealistic when viewed from a purely biomedical perspective (eg, tissue healing and neuromuscular function), from a biopsychological standpoint, the psychological symptoms that occur concurrently may be one explanation as to why these expectations may be unattainable.1

Potter et al.4 conducted a focus group–based study investigating both patients' and sports health care professionals' perceptions of patient expectations in musculoskeletal outpatients. The results revealed that sports health care professionals' expectations of patients were being punctual and gaining respect and trust, whereas patients' expectations were more physical in nature, including symptomatic relief, a “hands on treatment” approach, and to return to a preinjury level of function within the shortest time frame. Although these patients did not specifically undergo ACL surgery, they did experience musculoskeletal injuries including lower limb trauma.

This suggests that discussing both patients' and sports health care professionals' expectations may help identify whether there are any conflicting views that may need addressing. For example, the patient may expect to attend physiotherapy every day compared to the United Kingdom's National Health Service expectations of once a week, or an athlete may expect to run by week 2 after ACL surgery compared to the sports health care professional expecting a 9-month recovery. Discussing patient and clinician expectations from the outset may allow the clinician to appropriately explain prospective treatment, educate as to the clinical consequences of unrealistic expectations, and allow a more collaborative approach to rehabilitation. This may reduce any psychological issues (eg, anxiety or fear of movement) that patients may experience when expectations are not effectively addressed.

Fear of movement and fear of reinjury are complex responses to injury that can continue long after an injury occurs, but are modifiable behaviors.1 Fear of reinjury has been identified as the main cause of athletes not returning to preinjury levels.2 This reinforces the significance of meeting expectations from a patient and a clinician point of view, to provide realistic and collaborative decision making toward rehabilitation.

Beach and Inui5 suggested that addressing patients' expectations not only promotes patient centeredness, but also builds a strong rapport. The effects of this therapeutic alliance have been linked with certain positive outcomes (eg, greater patient satisfaction and increased patient engagement). A suggested approach to assist sports health care professionals to effectively manage patient expectations is called the patient–practitioner collaborative model.6 This model consists of four phases: establishing a therapeutic rapport, diagnostic process as a mutual enquiry, finding common ground through negotiation, and intervening and following up.6 Implementing this model to help manage patients' expectations requires comprehensive communication skills.

Effective communication involves many strands of micro-counseling skills, such as active listening, empathy, and reflection; all have been empirically shown to enhance patients' psychological well-being during their physiotherapy sessions.1 Effective communication is an extremely complicated skill that requires a considerable amount of underpinning psychologically based theory; thus it is not just about being approachable, nice, and a good listener.7,8 Addressing patient expectations using effective communication and psychological models can create a positive mind-set, reduce anxiety and fear of reinjury, and promote self-confidence and control over their individual rehabilitation.8

Although research demonstrates the critical importance for sports health care professionals and other practitioners in using psychological methods to support patients following ACL surgery,9 sports health care professionals are rarely aware of the underpinning theoretical models of psychology. Therefore, understanding these models may help sports health care professionals to adapt and implement psychological models and communication more effectively in rehabilitation environments.

Despite the trend over the past decade to embed psychology within traditional ACL rehabilitation, it has not been widely accepted by sports health care professionals to produce any significant change.10 We argue that one approach to assist sports health care professionals in effectively managing patient expectations would be to consider using the patient–practitioner model combined with active listening, empathy, and allowing patients to have a voice in the rehabilitation process. This may not only have an impact on the psychological well-being of the patient, but also improve the outcome of rehabilitation.


  1. Schwab Reese LM, Pittsinger R, Yang J. Effectiveness of psychological intervention following sport injury. J Sport Health Sci. 2012;1:71–79. doi:10.1016/j.jshs.2012.06.003 [CrossRef]
  2. Webster KE, Feller JA, Lambros C. Development and preliminary validation of a scale to measure the psychological impact of returning to sport following anterior cruciate ligament reconstruction surgery. Phys Ther Sport. 2008;9:9–15. doi:10.1016/j.ptsp.2007.09.003 [CrossRef]
  3. Feucht MJ, Cotic M, Saier T, et al. Patient expectations of primary and revision anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2016;24:201–207. doi:10.1007/s00167-014-3364-z [CrossRef]
  4. Potter M, Gordon S, Hamer P. Identifying sports health care professional and patient expectations in private practice physiotherapy. Physiotherapy Canada. 2003;55:195. doi:10.2310/6640.2003.9435 [CrossRef]
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  7. Kurtz S, Silverman J, Draper J. Teaching and Learning Communication Skills in Medicine. Boca Raton, FL: CRC Press; 2016.
  8. Tracey J. Inside the clinic: health professionals' role in their clients' psychological rehabilitation. J Sport Rehab. 2008;17:413–431. doi:10.1123/jsr.17.4.413 [CrossRef]
  9. Jevon SM, Johnston LH. The perceived knowledge and attitudes of governing body chartered sports health care professionals towards the psychological aspects of rehabilitation. Phys Ther Sport. 2003;4:74–81. doi:10.1016/S1466-853X(03)00034-8 [CrossRef]
  10. Harland N, Lavallee D. Biopsychosocial management of chronic low back pain patients with psychological assessment and management tools: overview. Physiotherapy. 2003;89:305–312. doi:10.1016/S0031-9406(05)60043-0 [CrossRef]

From the School of Health and Social Care, Teesside University, Middlesbrough, United Kingdom.

The authors have no financial or proprietary interest in the materials presented herein.

Correspondence: Jo Ann Kaye, MSc, School of Health and Social Care, Centuria Building, Teesside University, Middlesbrough TS1 3BX, United Kingdom. E-mail:


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