Episode 124 | Dealing with Fear When Returning to Sport after ACL Injury

What is up team, getting straight into it today. Before we dive specifically into the topic, I did want to talk about one thing that we accomplished over the past few weeks. And I’m the one to quickly brush over any major milestones or this certain target because it’s just like, all right, we’ve accomplished it. It is awesome. And it’s one of those things that I never thought I would accomplish with this podcast. And my wife also tells me to pause and just celebrate. And I’m just going to do that for a second. And the milestone that we achieved is actually the podcast got 100,000 downloads, yeah, 100,000 downloads. It’s pretty cool, it’s pretty crazy, really. Because whenever I first started this, if you guys have gone back and listened to any of the episodes regarding the birth of this podcast and the idea, I was so close to just not even doing it. I was just like, who wants to listen to me? But then I was like, you know what, I’m going to go for it. 

I feel like a lot of ideas and things have developed in the world with things that were half-baked or not completely finished or perfect. And really perfect is arbitrary, when do we actually get to a point like that? There’s always going to be iterations of things. And this is just me mainly talking to myself and just saying, thank you for the support. Because if it wasn’t for you, there’s no way that this would have happened. This just means a lot to me, the ACL Athlete and our team to reach a milestone like this. Because when we see the 100,000 downloads, it’s not something where we’re touting and we’re just like, man, that’s cool for us, like the company. But it’s just more so of like what that number self-represents.

It’s more like 100,000 downloads means that people downloaded this many times. They spent the time and there was something appealing about a particular topic or the story that made them want to just take time out of their day and to be able to just listen to the episodes. Most importantly is to become educated about this process and to understand how to better make choices when you’re going along with your ACL rehab. And the thing that hits close to me is just those messages and the emails that I get every single week. There are people that are reaching out off of Instagram, I had someone off of Reddit the other day, who just literally messaged me and it was just wild. And so there’s just all kinds of places and domains that people reach out from. And I read every single one, I save every single one, and it still means a lot to me. Thank you for spending your time with me, and I do not take that for granted as our time as humans is so valuable and precious. So thank you. 

And to give you guys some additional stats here to help bring this home. This is a podcast that has been downloaded in 125 different countries or territories. This has been downloaded in 5,378 different cities. I mean, the number of cities and the countries here is just wild, places that I have never heard of in my entire life which is just cool to see. And it is just people who really care about being able to take control of their process which is what I care about so much. And lastly, before we dive into today’s topic, if you are someone who has gotten value out of this podcast in any way at all, I have one really small favor to ask. If you’re listening to this on Spotify or Apple Podcasts or any other platform, leave us a five-star review, please. This helps us in fulfilling our mission to share this info with as many ACLers, healthcare professionals, parents, coaches, etc. so we can really redefine ACL rehab. That’s our goal. Can we redefine what this process looks like from start to finish? Getting people back to the things that they love to do, feeling educated and empowered. And you’ll be a part of helping us achieve that by spreading the word. Please take a second to do that, if you can. We really appreciate it and it does help us out a lot.

Now, for why you’re actually here today, clicking on this specific episode: dealing with fear when returning to sport or activity after your ACL injury or surgery. We are diving into this topic today because I think it’s one that does cross our minds a lot, but it doesn’t get talked about a lot. Today, I just want to tackle this topic and see if we can get into the nitty-gritty of it and give you guys some tactical information to think about, not only from a clinical side or helping athletes get back to the sport, but also from the ACLer side, from my perspective and working with so many of these athletes. 

One thing before we start is that whenever I say ACL return to sports or performance or activity. These are all the same thing for the sake of today’s podcast, so I don’t have to keep saying sport and activity. Just lump together whatever it is that you want to get back to, whether it is just running or pickleball, hiking, or higher-demanding sports like soccer, martial arts, volleyball, football, etc. Return to sport and performance is the very end point every ACLer is hoping to get to, and activity and sport, all fall within that. Basically getting back to doing the thing, the thing that you love to do, the thing that this ACL injury and rehab is stopping you from doing, you’re getting back to the thing. We’re returning to the thing.

You’ve made it through most of the process. You’re feeling physically strong and athletic in the most perfect ACL world. You might be at the six to seven-month mark of the nine to 12-month process. But there’s also a strong chance you’re further along time-wise because ACL rehab is variable and everyone’s outcomes and process look so different, which you guys know and probably are experiencing, and that’s okay. If you’re not in that six out of nine-month timeframe and exposing yourself back to the sport, it’s pretty normal. And I’d say more people are not that ” norm” or what the protocol says. And they deal with the ups and downs of this process, and it’s delayed because it is just the human body and life. Let’s throw time or where we are out the window, and let’s think more about meeting the proper criteria to start doing some of the things that you want to do, that being your sports activity. I did it. I’m probably going to go back and forth, but I’m going to try and just say sport to keep it very simple.

Now, let’s say you’re ready to start getting back to your sport. And as a team of physical therapists, strength and conditioning coaches, and athletic trainers, in the performance space, we have developed these principles and the research-backed framework and continuum through which we help our ACLers do the thing, and get back to the sport. This progresses from our return to participation, sport, and then performance, and there are many ACL research articles that talk about this. But then we dive into the actual practical pieces of this with our progressions from going to simple to complex, control to chaos. 

Also, if you have not dove into Matt Taberner’s work with “Control to Chaos.” It is awesome and it helps to dive into some of these pieces. From close to open environment, low duration to high duration or volume, and then low intensity to high intensity. And you can think about this as basically easy drilling and exposure and controlling this and gradually exposing you more and more to that complexity. Maybe it’s possible contact, the volume, the intensity, and these are all levers or dials we’ll pull on and guide our athletes with no matter the sport or activity they’re trying to get back to, from hiking, skiing, volleyball, soccer, basketball, rugby, jiujitsu, Muay Thai, dancing, skateboarding, stunt work, etc. 

We’ve done it all and we have so many athletes who reach out to us because they injured their knee from so many different things. They have different goals that they want to get back to. We have to figure this out, and we can’t just be like, all right, here’s this specific protocol, and you guys are all going to do the exact same thing because the demands of each of these sports are so different. You think about the needs of someone playing volleyball versus someone who is a jiujitsu athlete versus someone who’s a skateboarder or dancer. The way the body moves, the integration of it all, the isolation of it all, and the stressors and the demands are going to be different. Sure, there’s foundational pieces that’ll be similar, but we have to make sure that we get these people back to the thing or help guide them back to the thing. So that’s what we’re trying to do.

Now, some of this stuff, depending on your sport, we might be able to integrate some of this stuff super early. But then there comes a time where we actually need to get back to doing the thing or the sport and start to expose you more and more to it because your foundation is set. You pass certain criteria, hopefully, to be able to move forward and to start stressing and testing the knee and the body to see, all right, can we start doing this in a progressive manner?

And this topic today has been something that I’ve been mulling over for a long time. Something I’ve been wanting to talk about. And we just had one of these ACLers that I’ve been working with for a long time. She came to us later in the ACL process. She has been so freaking dialed into her own process, communicating, showing up every day, feedback, all the things. She’s a remote athlete. And she ended up having to have a cyclops lesion taken out, which was just a little tricky. And the knee overall, when you look at the initial injury, man, she put a doozy on it. And there were so many things that were done to her knee from ACL meniscus, MCL, LCL, to bone bruising, to a fracture, to a chondral lesion. There are a lot of things going on. And then she ended up developing a cyclops lesion. And then we had to get that out. 

And then now it’s been just one day after another, and we are finally there to be able to progress her along in this return-to-performance continuum, as we say. Participation in the sport to returning to the sport, to returning to performance, which in a nutshell is basically, hey, let’s start getting you to do some of the things in the sport controlled. Let’s get you back to actually practicing and doing this with teammates or with more intensity and volume, and then it’s progressing into playing minutes to the level of intensity, which is the performance piece. You’re full-on gameplay without any concerns, and you’re ready to go. 

Today’s goal is to talk more about how this looks from the mental side of it. As we know ACL rehab is such a mental battle, it’s such an internal thing that we deal with. And in all honesty, I’ve shared this before, but if you have not gone through it, it’s hard to really resonate with that. Doing this twice myself, there was such a mental battle. Honestly with the second one more than the first one. Everyone thinks the second one’s going to be easier because you’ve gone through it, you’re aware of it, you know the ins and outs. But it’s almost two different things. And I would say the second time you’re almost just like, what should I do differently? Or should I have done something different the first time? It ends up being this mental game you play with yourself. And even when you’re trying to get back to the sport and to the thing, trying to address fear and all those feelings that come along with it is key.

And the thing that I think should be addressed here is basically should you feel 100% as soon as you start playing your sport or activity. And I’m going to give you my complete honesty here as more of an ACLer than anything. This is different than what you see from most of the ACL gurus out there who are like, yeah, you should be 100%. You shouldn’t think about your knee and you should be better than you were before. And yes, those things have merit and truth to them. And we’ll even teach some of those things. But the thing is, there’s a strong chance that you’re not going to feel 100% mentally confident before you start playing your sport or activity. And it’s okay. It’s okay to feel that. And it’s something that doesn’t get talked about much. But as the ACLer and especially the clinical side of working with these athletes, I see this all the time. 

And you might feel confident in your knee and your ability to do stuff in the gym and even maybe some field or court-based stuff, basically the jumping and running and cutting. You’ve been working on that stuff and you feel confident in those things and they feel relatively good. But when you add the sport into the equation, that’s a different ballgame. Pun intended. I think what’s assumed is that if you pass your return-to-sport testing, or you’re looking good in your rehab and you’re training, you should also feel 100% to go and do the thing, which is your sport. And sure you may have the physical qualities from range of motion to strength, to power to jumping, cutting, and running abilities to do the thing, at least we hope. And that’s the main requisite we want to have. Hopefully, in your later stages, there’s also a progression to work your sport-specific things in to build this up alongside any remaining qualities we need to continue building. 

But let’s say you’ve done all this and you haven’t actually done the thing yet. For example, maybe you’re a skier and you tore your ACL skiing. You’ve done all the rehab and performance training, but you haven’t clicked into your skis and you haven’t taken that lift and you haven’t come down a run yet. It’s how you tore it. Do you think that won’t be crossing your mind to some degree while you’re riding up that lift or about to get onto the mountain and ride down it? Yeah. Everyone does it. And I’d say the majority of ACLers can attest to this feeling. When you start to play your sport or try to expose yourself back to those things, there’s a little bit of anxiety and fear and hesitation with it, and that’s okay. And that’s where that stuff that you do leading up to it, your preparation from the range, all the way to strength and power and cutting, and all the things that you need to have in order to do these things are going to be so key. And then there’s the sport-specific side of it all as well. And a lot of this is also going to depend on what you’re getting back to specifically. If it’s something just lifting weights where it’s super controlled, like Olympic weightlifting or running or hiking. No offense. But there’s a lot of predictability with these activities. And I’m not trying to say they’re lesser to any degree, but typically most people feel less fear given the nature of the sports.

And we contrast that with, if it’s something that is with higher intensity of running, jumping, cutting, slowing down at high speeds while changing direction, or maybe there’s contact along with moving parts of a complex game like soccer, rugby, football, basketball, etc. Or maybe where your feet might be fixed into something like skis or snowboarding. Those are all different players as well. And it makes sense because there’s more fear built up with this because you’re basically just demanding more of the body, there’s more unpredictability. And it’s likely how you tore it in the first place. Doing those high-demanding tasks on your knee. There’s more things that will be built up, especially the fear of getting back to the thing.

And it’s a big reason we say it could take 9 to 12 months plus in this process to really feel like yourself. And that’s if there’s very little hiccups in the process, but that’s very rare. And part of it is definitely getting physically prepared. Of course, alongside that are the mental components that should build with it as you physically do. But then there’s actually doing the thing, and that in and of itself is a mental challenge to progressively get comfortable with. And the sports specificity of it is also key here. At the end of the day, no matter how much training we do in the gym or on the field, you won’t incur the same stressors on your body as doing the thing. Everyone knows this feeling, too. They’ve been training for something and then they go to actually do the thing, their sport, activity, whatever it is. And they wake up the next day sore, especially whenever they’re first getting back to it, or there’s a higher intensity demand to it. 

I remember that with football. We got crushed with summer training. We had two a day, three a day. It was gross in South Georgia with the humidity. This was before all the rules were kicked in about the heat and temperature to stay inside. I remember athletes who had to go to the hospital because they were dehydrated. It was nuts. We had crazy training. And the thing is, is that there was a conditioning process that came along with it during the summer. And then as we got into pre-season and the camps and everything, we started to put on the pads and started doing the hitting drills and stuff. We felt like we trained super hard, but until you literally put those pads on and you start doing physical contact. I remember waking up those first few days and you’re just like, wow, my body feels beat up. And it’s because no matter what, you’re still not going to be used to the physical stressors like doing the thing. Same thing with wrestling, the same thing with baseball. Heck, I noticed that when I went and played pickleball for the first time. It’s normal to feel this. There’s a physical getting used to those stressors alongside that is building up the mental confidence as you gradually expose yourself to do that thing.

When I tore my ACL for the first time, it was non-contact in a football scrimmage. High school football was a big deal for me. I was about to start the next year and yeah, non-contact injury. And then I rehabbed basically all of my junior year, and then I came back to my senior year. Do you think that I was fearful, scared, nervous, and thought about my knee that first practice back? You’re freaking right, I was. I was definitely nervous and it was just something that I was like, this is how I did it. So even cutting in open space made me a little nervous, even though I had done it repeatedly multiple times before that. And then now I’m about to take on gameplay and the complexity of people hitting me potentially, blindsiding me. It took time to get this out of my head. And I thought that that was something that was abnormal. But as I’ve been in this process, I’ve realized it’s more normal than we think. 

And then the first game actually happened. And then another level of fear and nervousness sat in. Now the intensity has driven up really high because at the end of the day when we practice, it’s not near the intensity of typically when we go to gameplay. And so that fear set back in and I was just nervous. Then I had to really channel back in, and I’m like, all right, I’ve practiced. I know my knee is functional. It’s strong, it’s healthy, and I’m able to do things. And I also worked my butt off, incredibly hard. And I was confident in my abilities and knew I was ready. I let that supersede the fear that was setting in. Because a lot of the time, the fear that comes in is normal, but it’s not realistic. And it went away after I got more and more reps in with practices and games and felt more confident. And sure, there were still moments where sometimes I had crept back in or I slipped or something, but I didn’t let that play tricks on me. I knew it was normal human fear that wasn’t real. 

The take-home here is it normal to feel fear, scared, or nervous before doing the thing, your sport or activity? Yes. Do you need to be 100% confident in your sport before doing it? No, it takes time to progressively get there. Do you need to be confident in your knee and body to physically do what you want to do? Yes. Do you need a specific plan and guidance to gradually expose you back to the thing? Yes, 100%. And this is probably where I see the biggest gap outside of a lack of testing in ACL rehab. 

First, you need to pass the right criteria to be cleared. We need to know that you can do things, even at a basic level. If we controlled it, isolated it down, can you do the thing? This also includes an ACL RSI which is basically a questionnaire that’s been backed by research to show relationships between re-injury rates and psychological readiness, which is something we need to objectively assess in this process. It’s something that we give every single athlete we work with to check in and see how they’re doing. And also, look at the subjective pieces of what they might have scored 100% on. And maybe some of the ones that scored a 50 or an 80 and have conversations about it.

Second, you need to have a clear path to know how you’re going to get back to the thing, the sport, the activity. If you’re aiming to get back to soccer, skiing, jiujitsu, to basketball, to dancing, to skateboarding, to any of those things, you need to know how to do that. It’s not just, hey, I feel good enough, and let’s try it and go zero to a hundred. Because honestly, that’s a pretty bad recipe, especially if you don’t have testing to anchor that down to. Instead, we want to have a solid progression and framework to do this. Graded exposure back to the thing, and the thing that I always use is the dimmer switch analogy because I think that it just gives such a great example and understanding of how to best explain this.

If you’re one of my athletes, you exactly know what a dimmer switch is. And I probably said this so many times, whether we’re doing specific exercises or the way that we’re building up this process progressively. Instead of it being an on-and-off switch where I just go and flip the switch, go and do it, whatever. This entire process instead, including getting back to the thing is a dimmer switch. Slowly ramping up, slowly pushing and brightening up that light from being off, getting used to the stressors placed on your body, increasing the duration, increasing the intensity, increasing the unpredictability, increasing the complexity so you can get used to it. Just know that dealing with fear and those negative emotions that can set in is normal. And you’re normal, you’re not crazy. And if your PT or whoever you’re working with is saying like, hey, you need to just let that stuff go or you shouldn’t be feeling that. I disagree. And it’s just one of those things where I’m just going to pull from my anecdote and work with hundreds of ACLers.

This is just one of the things that can creep in, and it’s okay. It’s just can we get in front of this and we need to make sure that we have a good foundation built. You need to make sure that you have passed really solid testing to make sure you are clear of your criteria, and then you need to make sure you have a solid game plan and guide to get you the rest of the way there, back to the thing, back to the sport, back to the activity. That is the thing that you want to do. 

I hope that this helps guys. Fear is a major thing that we deal with in this process. And it’s one of those things that you will on and off deal with just because it is the thing that you’ve experienced. And sometimes fear can be healthy. It allows you to assess risk-reward, make calculated decisions, and not doing something stupid, and it should be there. But the thing is, if it’s stopping you from doing everything or for you to do the thing that you want to do, that’s a problem. Give this some thought. And if you have any questions or if you’re someone who’s dealing with this and wants some direction or just wants some help, then reach out to us. You can find us on social media at ravipatel.dpt or at theaclathlete. 

And then you can go straight to our website which is in the show notes. You can send us a contact form if you’re interested in coaching. You could always go there. There are plenty of options that exist. If you just need a nudge in the right direction, just send us a message and we’re here and we’re happy to help. Now, we are at the end of the episode, and the good news is you can scroll and give us a review because you’re finished and you remembered at the beginning that we are asking for a favor to please do that. If you have the time, we would be honored and we appreciate it so much. 

Until next time, team. This is your host, Ravi Patel, signing off.