by Dan Fisher | August 17, 2017

Returning to sport or activity after a knee injury is a difficult and demanding process that requires combining the recovery of physical health with confidence in the knee and motivation to be active again.  Arden et al. found that improving motivation and confidence while reducing fear is correlated to an improved likelihood of returning to a preinjury level of participation along with reducing the time to returning to sport (1).  If we are not confident in the recovery of the knee, how can we expect to ever be motivated to return to our activities that demand performance of the knee?  On the other hand, if we are not motivated to become active again, then why are we even having our knee fixed in the first place?  The physical and mental benefits of physical activity are undeniable, and, as such, returning to activity should be a goal and outcome measure for the recovery.

In a study of factors related to returning to pre-injury sport and recreational activity for patients who had anterior cruciate ligament reconstruction, Arden et al. found that less than 50% of the patients returned to their preinjury activity, citing psychological readiness as the main limiting factor (2).  Suffering a knee injury often involves an excruciating amount of pain that is hard to forget.  In addition, the injury can imprint a memory of how the injury happened and result in avoiding the movement or action that caused the injury.   Physical therapist Trevor Lentz, in an article titled the psychology of returning to sports after ACL surgery, cites fear-avoidance beliefs (avoidance of activities based on fear) and pain catastrophizing (exaggerated response to actual or anticipated pain) as the primary psychological barriers to returning to sport (3).  As such, being cleared for activity with a healthy knee does not necessarily guarantee a calm mind when faced with returning to sport or recreational activity.  Even if a proper treatment is performed and knee health is restored, fear and avoidance may still persist, reducing or delaying sport participation. Furthermore, Leeuw et al. found that pain-related fear is associated with a decrease in physical task performance (4).

The question is then if these are not physical limitations, but rather mental barriers, how can they be addressed and removed over the course of the treatment?  Arden et al. cited self-determination theory as a defining influence of a patient’s successful return to sport.  This theory states that autonomy, competence and relatedness drive self-motivation and engagement in activities.  This suggests that generating a sense, in the patient, of control and knowledge of progress during the recovery along with a stronger relationship with the care team will increase the likelihood of a successful return to sport or activity (1).    We believe patients with knowledge of the treatment and their progress back to health are better equipped to build confidence in their recovery and their ability to return to activity.  Furthermore, when patients are actively involved and have the data to be knowledgeable of their progress, they are empowered with the ability to better collaborate with their healthcare providers and develop a feeling of self-efficacy about their recovery.

I have personally been dealing with an injury that I was cleared to return to activity from over a month ago.  However, I was slow to return due to a remaining nagging pain.  Once I began using the RecovAware app to track my data, I was able to build a personal recovery profile and see my pain levels, function scores, and mental readiness scores drastically improve as I pushed through the lingering pain and removed my fear of re-injury.  Furthermore, I was given a sound mind that if my pain didn’t decrease, I could consult my doctor and physical therapist with the data history to determine if there was a real lingering problem.


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1. Arden, C. L.; Taylor, N. F.; Feller, J. A.; Webster, K. E. A systematic review of the psychological factors associated with returning to sport following injury. British Journal of Sports Medicine 2013, 47 (17), 1120-1126.

2. Ardern, C. L.; Osterber, A.; Tagesson, S.; Gauffin, H.; Webster, K. E.; Kvist, J. The impact of psychological readiness to return to sport and recreational activities after anterior cruciate ligament reconstruction. British Journal of Sports Medicine 2014, 48 (22), 1613-1619.

3. Lentz, T. The psychology of returning to sports after ACL surgery. (accessed June 1, 2017).

4. Leeuw, M.; Goossens, M. E. J. B.; Linton, S. J.; Crombez, G.; Boersma, K.; Vlaeyen, J. W. S. The Fear-Avoidance Model of Musculoskeletal Pain: Current State of Scientific Evidence. Journal of Behavioral Medicine 2007, 30 (1), 77-94.


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