Rehabilitation after first-time anterior cruciate ligament injury and reconstruction in female football players: a study of resilience factors

Anterior cruciate ligament (ACL) injury is a major problem in sport, especially in women’s team sports such as football [1]. The rehabilitation period is long and demanding and the average time to return to play in women’s football is about 8.5 months or longer [2]. Negative mood disturbance, reduced self-confidence, and fear of re-injury may be experienced by ACL-injured athletes resulting in a lower return to sporting activity [3, 4]. The majority of previously published research in the area of psychosocial factors during rehabilitation after ACL injury has focused on risk factors that might inhibit a successful return to play, such as fear of re-injury [5] and external locus of control [6]. In contrast, only a few studies have primarily focused on psychosocial factors facilitating athletes’ rehabilitation [5]. Nevertheless, factors previously associated with more successful rehabilitation after injury, in sports such as football and rugby, includes setting goals and objectives during rehabilitation [7], belief in the efficacy of treatment [8], rehabilitation practitioner expectations of patient adherence [9], social support [10], and constructive communication [11].

Resilience is a dynamic capability that helps people strive to realize their goals [12, 13]. The dimensions of resilience, which include self-efficacy, self-control, hardiness, ability to engage support and help, learning from difficulties, social problem-solving, and persistence despite obstacles to progress, are all recognized as qualities that are important for positive experiences and that, together with adaptive behaviors during rehabilitation, will increase the chance for positive outcomes in relation to severe injuries [14, 15]. In a study of 32 recovered knee- and ankle-injured athletes (mean overall recovery time of 10 weeks), the largest differences between the fastest and slowest “healers” were found related to three variables [16]. Fast healers used more goal setting, positive self-talk, and healing imagery than slow healers. These results support the idea that certain attitudes and psychosocial factors may enhance the effectiveness of particular treatments, as well as an injured athlete’s ability to cope. The results from a more recent correlational study showed that problem-focused coping strategies aimed at improving autonomy and confidence were psychologically beneficial for ACL-injured professional rugby union players in terms of enhanced well-being [17]. In a systematic review of the psychological factors associated with returning to sport following injury [18], positive psychological responses, including high levels of motivation and confidence, were associated with a greater likelihood of returning to the athletes’ pre-injury levels of participation. In addition, a high internal health locus of control and high self-efficacy were useful cognitive factors to master ACL injury rehabilitation, together with a low level of fear of re-injury. Moreover, athletes who successfully returned to sports were more experienced and more established players compared to those who did not return to sports after their injuries [18]. Taken together, the existing literature points out several psychosocial factors that may help players cope successfully with rehabilitation. However, to the best of our knowledge, no study has examined these issues in a homogeneous sample of first-time ACL-injured elite female football players.

Based on a social constructivist narrative theory, the objectives of this study were to understand the psychosocial variables that characterize players who express a resilient behaviour during rehabilitation after a first-time ACL injury and subsequent reconstruction.