Psychosocial experiences of competitive rugby players on the “long, long journey” to recovery following ACL ruptures and reconstruction

Abstract

Anterior Cruciate Ligament (ACL) injuries are serious and potentially career‐ending. Reconstruction surgery and extended rehabilitation typically follow, but some athletes never attain the same level of sport performance. The psychosocial experiences of athletes who sustain ACL injuries and their cognitive appraisal, emotional and behavioral responses to the injury, and reconstruction require further attention during the different recovery phases. The aim is to explore these psychosocial experiences, social support needs and sources thereof of competitive athletes who sustained unilateral ACL ruptures and underwent reconstruction surgery. Semi‐structured interviews with six competitive rugby players (M age: 22.3 ± 2.92 years), elicited information at seven time‐points. We analyzed the qualitative information through thematic analysis. Five common themes emerged: (1) cognitive appraisal, (2) emotional responses (negative and positive affective responses), (3) behavioral responses, (4) social support needs and sources thereof, and (5) adversity‐induced identity expansion (athletic and person‐centered identities). In‐vivo quotes gave a rich description of the athletes' experiences throughout the “long, long journey” to return‐to‐sport. These findings may sensitize and assist sports healthcare professionals, coaches, teammates, family, and friends to explore various psychosocial experiences throughout the injury and recovery period. Phase‐appropriate psychosocial support or referral to sport psychology services is recommended to enhance the recovery process, improve long‐term physical and mental health, and subsequent performance.

1. INTRODUCTION

Sport injuries are an accepted risk of high‐performance sport but may have detrimental effects on an athlete's performance, career, economic status, and physical state. ¹ The risk of injury and sustaining injuries itself may contribute to elevated levels of psychological burden that impact the athlete's overall sporting experience. Coaches and sports healthcare professionals should prioritize physical and mental health, performance excellence, and career longevity of athletes. ²

Anterior Cruciate Ligament (ACL) injuries are serious, season‐ending, and potentially career‐ending. ³ The gold standard treatment for athletes is ACL reconstruction surgery, especially for those who hope to return to the competitive sport level. ⁴ These injuries cause lengthy absence from sport, require extensive rehabilitation, are characterized by high rates of re‐injury, long‐term osteoarthritis, and decreased quality of life. ⁵

Whilst 80% of athletes who underwent ACL reconstruction surgery remain positive about making a successful return‐to‐sport (RTS), there is a risk that athletes may not RTS after successful reconstruction and rehabilitation. ⁶ Thirty‐nine per cent of the athletes who returned to sport did not reach their pre‐injury performance levels after 12 months. ⁷ Another study showed that 88% of athletes who underwent a first ACL reconstruction eventually returned to sport, but only 24% reached their preinjury performance levels after 12 months. At 24‐months post‐surgery, this rate had improved to 60%. ⁸ Whilst successful RTS and reaching pre‐injury performance levels may be the ultimate aims of reconstruction surgery and rehabilitation for most athletes (since not all athletes necessarily seek to RTS), the lengthy rehabilitation provides impetus to explore the athlete's psychosocial experience, and response to these injuries during the various phases of the recovery period.

Psychosocial factors have been shown to contribute to athletes failing to achieve their preinjury competitive performance levels, despite regaining functional abilities following reconstruction surgery and rehabilitation. ⁹ Barriers such as fear of reinjury, a loss of motivation, occupational demands, and lifestyle changes influence individual recovery and RTS decisions. ¹⁰ Psychological readiness to RTS is also associated with regaining preinjury performance levels. ⁷

Wiese‐Bjornstal et al.'s ¹¹ Integrated Model of the Response to the Sport Injury and Rehabilitation Process (hereafter referred to as the Integrated Model) provide a useful framework to explore personal and situational moderating factors, as well as cognitive, emotional, and behavioral responses (collectively referred to as psychosocial responses) of athletes to sport injuries. Researchers and applied practitioners can use the model to better understand the athlete's experiences from a physical, psychological, and social perspective. The authors recommended that future research use longitudinal designs, to study injured athletes from preinjury throughout the recovery process and into their RTS.

One of the first studies that implemented this recommendation used the Integrated Model to examine the emotional response of student‐athletes who sustained moderate to severe injuries, at three timepoints (i.e., onset of injury, 1‐week, and 3‐weeks post‐injury). Feelings of loss, decreased self‐esteem, frustration and anger fluctuated, highlighting the complexity of the experience. ¹² Rehabilitation experts normally outline three distinct physiologic phases of rehabilitation programs, that is, the acute injury, repair, and remodeling phases. ¹³ Using a retrospective qualitative design, previously injured athletes were interviewed, noting changes in the psychosocial responses during three phases of the rehabilitation and recovery process (i.e., initially, during rehabilitation, and during RTS). The study also support the use of the Integrated Model as a framework for understanding how physical and psychosocial factors interact during the injury process. ¹³ These studies ¹² , ¹³ allude to certain methodological challenges of longitudinal qualitative research on the topic of athletic injury response, such as recall bias when using retrospective designs, ¹³ and inconsistencies about when information is elicited. ¹² , ¹³

Due to the lengthy rehabilitation and recovery period associated with ACL reconstruction, we took a longitudinal approach with in‐time interviews (where possible) at multiple timepoints to explore the athlete's psychosocial experiences and responses throughout the recovery process. This may provide unique insight into the experiences of athletes who rupture and undergo ACL reconstruction, and allow phase‐specific support by sports health professionals. The subsequent aim of this study is to explore the psychosocial experiences to the injury, as well as the social support needs and sources of social support of competitive athletes who sustained a unilateral ACL rupture and underwent reconstruction surgery, at seven time points from the day of the injury to the completion of their first competition post‐injury.

2. METHODS

2.1. Study design

This longitudinal study used a qualitative approach, to provide an in‐depth and rich description of the injured athlete's experiences and responses at multiple time points throughout the lengthy rehabilitation and recovery process.

2.2. Participants

We used a purposive sample of six competitive athletes, all men (M age: 22.3 ± 2.9, range: 20–28 years). These participants sustained a first unilateral ACL rupture and underwent reconstruction surgery less than 12 weeks before study participation. The sample included six rugby union players, three of whom competed in the Super 18 tournament, contested by professional teams from South Africa, New Zealand, Australia, Argentina, and Japan and three who competed in the Varsity Cup, the top South African collegiate tournament. All participants successfully returned to sport, between eight and 11 months after the injury. Participants were recruited through contacting various professional and University clubs, and through follow‐ups with individual athletes based on media reports on players who sustained ACL injuries.

2.3. Procedure

The Stellenbosch University Research Ethics Committee for Social, Behavioral and Humanities (SU‐HSD‐000794) approved the study. All participants provided informed consent, including permission to use a voice‐recorder. Efforts were made to ensure confidentially and anonymity. We offered consultation sessions with a clinical psychologist if recall and reflection on traumatic events caused distress, however, none of the participants used this service. We collected demographic, personal, and situational information regarding the time of the injury. Semi‐structured interviews were conducted at seven time‐points: (1) day of the injury, (2) presurgery (first day post‐injury up to surgery), (3) acute recovery phase (first week post‐surgery), (4) repair phase (weeks 2–6), (5) remodeling phase (week 7–4 months), (6) before RTS (dependent on meeting RTS criteria), and (7) after their first post‐injury competition.

The lead author conducted 24 semi‐structured interviews over 14 months, resulting in 42 time‐point specific interview scripts. In‐time interviewing took place where possible, to reduce recall bias. Early participant recruitment was difficult; therefore, interviews for some of the earlier phases were conducted retrospectively (see Table 1). When information from two time‐points were elicited during one interview, the interviewer first asked questions about the present experiences, after which information about the earlier phase was gathered.

TABLE 1.

Participants and semi‐structured interview schedule.

Participants Sport (Level)	Information session	Semi‐structured interviews
		Day of injury	Pre‐surgery	Acute recovery	Repair	Remodel‐ling	Before RTS	After first competition
Rugby (S18)	Informed consent, demographic, personal, situational factors at the time of the injury.	Retro1b	Retro2a	Retro2b	In‐time1a	In‐time3	Retro4b	In‐time4a
Rugby (VC)		Retro2a	Retro2b	Retro3a	Retro3b	In‐time1	Retro4b	In‐time4a
Rugby (S18)		Retro2a	Retro2b	Retro3a	Retro3b	In‐time1	Retro4b	In‐time4a
Rugby (VC)		Retro1b	Retro2a	Retro2b	In‐time1a	In‐time3	Retro4b	In‐time4a
Rugby (VC)		Retro1b	Retro2a	Retro2b	In‐time1a	In‐time3	Retro4b	In‐time4a
Rugby (S18)		Retro2a	Retro2b	Retro3a	Retro3b	In‐time1	Retro4b	In‐time4a

Note: ^1–4 chronological order of interviews, ^a information elicited at the start of session, ^b information elicited at end of session (when information about multiple phases were collected during the same interview).

Abbreviations: Retro, retrospective; S18, super rugby; VC, varsity cup.

The lead author was a registered Biokineticist with the South African Health Professions Council. She completed a 5‐day workshop in qualitative research methodologies. Her interest in the research topic stemmed from her husband's own ACL reconstruction, and her clinical work with injured athletes. She had to bracket her own biases based on her and her husband's lived experience of ACL reconstruction, and her previous experiences when treating injured athletes. She met regularly with the third author (a sport psychology consultant well versed in supervising qualitative studies) to discuss the interviews and reduce the risk of influencing the process of eliciting and analyzing the data. The second author, a leading international sports physician became a soundboard for the analysis and interpretation of the findings.

2.4. Interview script

Wiese‐Bjornstal et al.'s ¹¹ Integrated Model considers personal and situational factors, as well as the cyclical effect thereof, on cognitive appraisal (thoughts), emotional responses (affect) and behaviors throughout the recovery process. The Integrated Model was the lens through which we explored the longitudinal psychosocial experiences of injured athletes. Semi‐structured interviews enabled an in‐depth understanding of the complexity and dynamic nature of individual injury responses, and to observe and analyze common experiences by each participant over time. The interview script consisted of the following central questions that aligned with the Integrated Model, with minor word changes for each specific recovery phase:

• Provide background information about yourself and your sport participation at the time of the injury.

• Describe your experience and responses to sustaining the injury and the events thereafter, up to surgery.

• Describe your thoughts/what you were thinking during the (name of recovery phase).

• Describe your feelings and emotions during the (name of recovery phase).

• Describe your current behavior/behavior during the (name of recovery phase), with specific probes exploring coping behavior, methods, and techniques.

• Describe the types of support you are receiving/received during the (name of recovery phase), and your need for social support during the (name of recovery phase).

The study aims, procedures, confidentiality and anonymity was explained during the initial interview and briefly recapped during each subsequent interview. The semi‐structured and conversational nature of the interviews allowed deviation from the interview script. The participant's responses led to follow‐up questions and probes. Interviews with three participants were conducted in‐person at a quiet and convenient location, whereas interviews with the three remaining participants were conducted online. Two other participants dropped out of the study due to the repetitive nature and time investment. All interviews were recorded and transcribed verbatim. Interviews conducted in Afrikaans were first transcribed and analyzed. Selected in‐vivo quotes were translated into English thereafter.

2.5. Qualitative analysis

Thematic analysis (TA) was used to analyze and report repeated patterns of meaning within the large data set. ¹⁴ The TA described the participants' experiences, meanings, and realities. Transcribing and rereading the interviews allowed emersion in the data. The first and third authors coded the data through open, manual coding that enabled the formulation of higher‐order themes. The Integrated Model ¹¹ guided the deductive coding process, but additional (inductive) codes and themes emerged. The unit of analysis was any single coherent idea, that is, words, phrases, or sentences. We gave attention to credibility (by detailing the systematic research process that we followed from start to finish), transferability (by using the Integrated Model as point of departure for the deductive coding), and confirmability (through providing a thick description and reaching data saturation) and reached agreement though constantly reflecting, discussing, and critically comparing codes and themes at regular intervals.

2.6. Findings

Table 2 contains an example of the raw data codes, categories of codes, sub‐themes, and themes during the acute recovery phase (first week post‐surgery). Word count restrictions does not allow elaboration on the remaining six time‐points. Table 3 contains time‐point specific cognitive appraisal, affective responses (both negative and positive emotions), behavioral responses, social support needs of the participants and the sources thereof. These findings do not reflect each participant's unique experience or individual journey towards recovery and RTS. Rather, it provides an overview of common experiences and responses during each phase. In‐vivo quotes provide a rich narrative and thick description of the main findings.

TABLE 2.

List of emergent themes during the acute recovery phase (first week post‐surgery).

Themes	Sub‐themes	Categories of codes	Codes
Cognitive appraisal	Loss of sport	Becoming a spectator	Agonizing to watch on tv (& avoiding altogether)/missing match‐day involvement
		Changing daily routine	Free time/boredom
	Loss of independence	Loss of socialization	Missing out on parties & fun
		Inability to perform normal activities & roles
	Acceptance	Reality starting to kick in	Needing to take it easy
		Adopting a positive mindset	Mentally challenging to be injured/resetting goals
Affective response	Negative	Fear of surgery outcome/ Concern about long‐term prognosis	Worry/concern/distress
		Feeling sad/frustrated/useless/hopeless/depressed/impatient
	Positive	Confident in surgery outcome & surgeon	Being relieved/motivated/brave/hopeful/happy
Behavioral response	Managing pain & swelling	Pain medication Improve knee function
	Movement restricted	Mobility exercises	Wearing a massive brace/adjusting body position
		Rehabilitation program	Realizing importance of proper rehabilitation/shifting focus to strengthening the knee
Social support needs and sources thereof	Informational support	Feedback on surgery	Surgeon/nurses
		Rehabilitation plan	Physiotherapists
	Tangible support	Physical assistance	Admitting to needing help, e.g., toilet, shower, transport
	Emotional support	Parents/family/friends/coach/teammates
Establishing and expanding identity	Athletic identity	Meaning of sport	Source of passion & purpose
		Being a professional athlete	A big part of life/(Still) being part of team (again)
	Person centered identity	Sense of self	Identity separate from sport/independent identity

TABLE 3.

Psychosocial experiences and responses during seven timepoints across the ACL recovery and return‐to‐sport process.

Themes	Day of the injury	Pre‐surgery	Acute recovery (First week post‐surgery)	Repair (week 2–6 post‐surgery)	Remodeling (week 7–4 months post‐surgery)	Before RTS	After first competitive match
Cognitive appraisal	Confusion/“how serious is it?”/	“Out for 6–9 months”/serious injury	Loss of sport, independence, socialization	“Long, long journey” ahead	Monotony of rehabilitation	Regaining competency and confidence	“Survived” first test/direct impact
Negative affective response	Disbelief/disappointment/sadness/depression	Sense of loss/hopelessness	Fear of surgery outcome & long‐term prognosis	Frustration/depression	Irritation/impatience	Fear of re‐injury & not achieving pre‐injury levels of performance	Fear of re‐injury & not achieving pre‐injury levels of performance
Positive affective response	Excitement about new challenge	Hopeful/optimistic	Confident in surgery outcome	Satisfied with progress/at ease	Motivated	Eagerness/being ready	Gratitude
Behavioral response	Physical and lifestyle adjustments	Seeking confirmation (e.g., second opinion)	Managing pain/mobility exercises	Avoiding potentially dangerous situations	Adhering to individualized rehabilitation/self‐ empowerment	Sport‐specific fitness and conditioning	Hesitancy/tentativeness
Social support needs and sources thereof	Physical assistance/comfort	Injury information/confirmation of diagnosis	Feedback on surgery/rehabilitation plan/ Physical assistance	Physical rehabilitation (e.g., Physio)/previously injured players	Multiple emotional support sources; sport healthcare professionals, coaches, family.	Require “green‐light”/cleared for RTS	Player becomes a resource to other injured players
Identity	Dominant athletic identity			Adversity (i.e., injury) induced identity expansion		Person‐centered identity

2.7. Day of the injury

At this time point there seems to be much confusion and uncertainty about the nature and severity of the injury. One participant experienced denial or disbelief, possibly stemming from previously observing other players sustaining ACL ruptures and having preconceived ideas about what it feels like to rupture an ACL, “From what I have seen before, guys who get an ACL injury do not just casually walk of the field like I did… I was thrown off. I mean, I was able to do things that are not usually possible…” Another player noted “I was in denial and I thought, no, it's not so bad, and it's three months and then I'm back… I didn't think it was an ACL.” Their emotional responses were mostly negative with one player stating, “I don't think I have ever been so negative….” Another player experienced fear, “I was pretty scared, because I didn't really know if I would play rugby again and how big the operation would be.” Some remained positive and excited about the challenge ahead, “It's a good challenge as well, to see where I'm at, you know? Not just as [name], the rugby player, but [name] off the field as well.” One participant required physical assistance, “I called my parents, they came and looked after me for the rest of the evening… I needed to shower and eat. They helped me with that.” Another player mentioned, “I drove with one of my teammates and he carried me into the room.”

2.8. Presurgery

At this timepoint the upcoming surgery occupied the minds of the participants. They contemplated when they would be able to RTS, “about six months,” “seven to eight months,” “six to nine months,” and “out for nine months.” Reality settled in, “…out in the news and everyone sending me messages… I think that's when it really hit me that this was something serious. I wasn't doing so well in that week leading up to the operation.” There was also a sense of optimism, “I was actually quite excited. I have never had surgery, so I was excited to see what was going to happen. I was excited about afterwards, when I could start the whole healing process, because you can't start doing anything before the surgery.” Most participants accepted the diagnosis and prognosis, whilst another needed to consult a different specialist, “…they were going to have me in theatre the next day, but I said ‘no, I first want to get a second opinion…’ He (second doctor) looked at my knee and obviously said the same thing [name of first doctor] said which wasn't nice to hear the second time around.”

2.9. Acute recovery (first week post‐surgery)

Various forms of loss were evident, “I could not drive or could not go anywhere, and they (his teammates) were telling me about all the places or the parties they were going to go to and sent me pictures…Obviously, I was like, I wanna be there, be with my friends…” There was uncertainty about the outcome of the surgery, “I was afraid that it wasn't successful.” There were also thoughts about the future, “There was a time when I thought, well, if I can't play again, then, what will I do?” The check‐up visit to the surgeon was an important milestone, “…he said everything is fine and that I can start with rehab after a week or two. It was just small movements, but even that was something big for me, because I could do something again.” The surgeon's feedback had a positive effect, “…he was very positive about the operation and obviously made me feel very positive and confident as well.” Some focussed on managing the pain and discomfort, whilst others, “…wanted to strengthen my knee as quickly as possible, start rehab quickly… Do strengthening exercises and walk better and start to run.”

2.10. Repair (week 2–6 post‐surgery)

During this phase there was a realization that, “I've got a long, long journey ahead of me, to get my knee better and my leg right… to be back on the field in a couple of months.” Physiotherapists played a key role during this phase, but monotony crept in, “…you are very limited to what you can do, so it was sort of just… just very boring the whole time.” A perceived lack of progress caused growing frustration, “I knew where I was going, but it was still frustrating.” Other participants were satisfied with their progress and adapted their behavior to reduce the inherent risk, “If I knew I was going to a place where there was going to be a lot of people, I used my crutches instead of just walking around in my brace. People see the crutches and give you more space, instead of just being in a brace and someone easily bumping into you.” Those who suffered the same injury before became a source of support, “(Name of the national team captain) gave me a call and said he ‘did his ACL’ as well, and he continued to play… that was a big deal, especially a guy like him, calling me and wishing me well… it was a very big deal.”

2.11. Remodeling (week 7–4 months post‐surgery)

In this period, the slow progress and the monotony of rehabilitation dawned on many, “You come in and do the same stuff, the same routines, same process every day.” Some participants became impatient and irritated, “I'm in that phase where I'm getting a bit irritated.” There were evidence of hard work and motivation, “I'm still positive, because I want to recover. The rehab sessions are tough, but I enjoy them, because I know that is what I must do to fix my knee.” Adherence to the rehabilitation prescriptions of the Biokineticists were common. Biokineticists are registered South African healthcare professionals concerned with preventative, rehabilitative and exercise modalities, to treat orthopedic conditions and noncommunicable diseases, to optimize function, movement, and sport performance. Some participants had self‐researched phase‐appropriate performance standards, “I educated myself. Every time I checked YouTube or when I Googled ACL at five, six weeks, not once was there something that I didn't do or wasn't on par with… that I didn't do or did too late.” Some players perceived their coaches as distant. “I wouldn't say there's much interaction between myself and the coach. We just walk past each other in the passage, you know. How are you, how's the injury? You know? That sort of thing. But I don't think there's much of an interaction… it doesn't go further than that.” Teammates, who recovered from ACL ruptures, provided valuable support, “…speaking to guys who'd been in the same situation…they say this is a tough period where your knee is feeling good, but it actually isn't 100% yet.”

2.12. Before RTS (timeframe subject to meeting RTS criteria)

During this phase, the participants focused on regaining self‐confidence and increasing competency, “I was starting to get a bit of confidence back.” They also had to overcome fear of possible re‐injury, “I don't know how many bumps the knee will be able to take, and I think I'm a bit afraid to play rugby again.” In the lead‐up to the first match, one participant felt, “…stressed, because it was my first game in a very long time. I didn't know what to expect and I was nervous. I remember the night before; it was as if I was playing my first game of rugby ever. I was just thinking, just overthinking everything really. A lot of bad thoughts went through my mind.” Some were anxious, “…the biggest one is probably if I'll be able to play at my previous level.” A lengthy absence from the game caused doubt, “I'm a bit nervous about how I'm gonna cope with being out of the game for almost a year.” A sense of expectation was growing, “I'm very excited for what's to come.” There was a gradual reintegration into on‐field training and a strong focus on sport‐specific fitness and conditioning, “Those first two months of starting to run again were probably the toughest part.” Being part of the team again offered more social support, including various forms of assistance from coaches, but the players still required the “green light” to RTS, “I go maybe every second week to see our team doctor, just so he can tell me how I'm doing. I'm constantly keeping them up to date and they are letting me know how the progress is going.”

2.13. After the first competition (i.e., race or match)

Getting through the first physical impact during a competition, confirmed they were back, “It's a scary moment. I remember the first time I was tackled. The guy was coming from my right (injured side). When he tackled me, I stayed down on the ground. I reached for my leg, and I felt my knee, straightened my knee, and realised I'm good. I got up and felt really good about it. I had my first contact… I remember being so happy that I got through it.” Being able to compete again after what could have been a career‐ending injury resulted in gratitude, “I started appreciating what I have and what I could've lost.” Hesitancy and tentativeness were noted, “…the first 20 min I was a ghost on the field, because I was a bit worried about my knee.” One player mentioned, “It has become a mental thing… to be more cautious, because I suppose any small thing can sort of trigger that knee again and something could go wrong.” Returning to their sport meant they could support others who experienced similar injuries, “…good to be on the other side, where I can sort of help him and be in a position to give advice.”

2.14. Adversity‐(i.e., injury) induced identity expansion

Multiple identities were apparent. Sustaining the injury, the reconstruction and lengthy rehabilitation and recovery allowed expansion of their identities. At first, strong athletic identities were present, “I'm very passionate about my rugby… very fortunate I can do it as a job.” The ambition to represent the national team remained “…everyone who plays rugby in South Africa wants to play for the Springboks… so that's still a big dream of mine.” Others distinguished between their athletic and personal identities from the start, “It's a good challenge as well, to see where I'm at… Not just as [name], the rugby player, but [name] off the field as well.” Likewise, “…we get so caught up in being rugby players, we forget what it's like to just be a normal 23‐year‐old guy, …of being a rugby player and playing for the (name of Super Rugby team), that you don't see what is happening on the other side.” There were attempts to integrate sport and life, “I try to be as balanced as possible, so that one thing doesn't influence the other. If I have a problem at home, it won't influence my rugby, and rugby won't affect my home. I try to balance my life so that everything is just a part of my life.”

The injury lay‐off induced a shift towards a more person‐centred identity, “I can't be on the field, so I don't break my mind about not being able to play. At the end of the day, rugby is only a part of who I am. The rest of my life can't stop when one part stops.” Another player noted: “I try to switch off when I walk off the field. I used to think that rugby was everything, but I've realised there is a life after rugby and outside of rugby.” Going through the experience provided new insight, “I started seeing life from a whole new perspective… appreciating what I have and seeing what I could've lost…” Their RTS shifted their athletic identity back into focus, “I'm back playing rugby, which is all I want to be doing.”

3. DISCUSSION

Some injury rehabilitation specialists deem psychological impairments following ACL injuries as more challenging than regaining full physical functioning and many of them felt they were inadequately trained to deal with the athletes' psychological burden. ¹⁵ The ensuing discussion focus on the cognitive appraisal, negative and positive affective responses, behavioral responses, social support needs and sources of social support experienced by our participants throughout the various phases of the recovery process. This is by no means a comprehensive overview of their experiences, but these findings may guide the development of phase‐appropriate patient‐centred care guidelines. Sport healthcare professionals, organizations, and other stakeholders must be cognisant of the experiences of the athletes during each phase of recovery, as well as the needs of the athlete during each phase, to ensure that the recovering athlete receives adequate support throughout the recovery period and thereafter.

3.1. Day of the injury

A few participants experienced confusion and thought extensively about the seriousness of their injuries. Past research noted that those who perceived their injuries as serious appraised it more negatively. ¹⁶ Disbelief, disappointment, sadness, and depression were common negative responses. Others noted positive emotions, such as excitement about the new challenge they faced. Due to the physical impairment, there was an immediate lifestyle adjustment, as well as a need for physical assistance and comfort from immediate family or close friends. The source, type of support and the individual needs of the athlete has been shown to change across the phases of the injury rehabilitation. ¹⁶

3.2. Presurgery

Seeking confirmation or additional medical opinions are understandable for athletes who struggle to accept an initial diagnosis that requires reconstruction surgery and lengthy rehabilitation. Initial positive appraisals (e.g., hope, optimism) may change to negative (e.g., a sense of loss, hopelessness) if the final diagnosis is different to what the individual expected or hoped for. Accepting the diagnosis and prognosis is key to successful rehabilitation. ¹⁷ The attention shifted to processing injury information and treatment decisions. Misdiagnosis and poor communication (that was experienced by one participant) is a leading cause of confusion. ¹⁸ Most of our participants preferred and valued support from sports healthcare professionals during this phase, which is in line with earlier research. ¹⁹

3.3. Acute recovery (first week post‐surgery)

This phase was characterized by a loss of independence and socialization opportunities. Missed opportunities to compete and concerns over stifled career development often accompany traumatic injuries. ¹⁸ Frustration, sadness, uselessness, hopelessness, depression, and impatience surfaced among our participants. Whilst short‐term negative emotions are understandable and normal, prolonged negative affective responses have been shown to have a debilitative effect on RTS, ²⁰ whereas acceptance and a positive outlook may buffer future‐orientated fears. ¹⁸ Our participants were generally confident in the outcome of the injury and subsequently positive about the process of repair ahead of them. During this phase, injured athletes must adjust to their physical impairment and loss of functioning, manage their pain levels, and regain mobility. Healthcare practitioners should inform athletes about the outcome of the surgery, the rehabilitation plan, and the envisaged timeline for RTS.

3.4. Repair (week 2–6 post‐surgery)

During this phase our participants become aware of the “long, long journey” ahead of them. This phase elicited a range of emotional responses among them, for example. frustration and depression, whereas others were at ease and satisfied with their progress. Cautious behavior and avoiding risky situations is a hallmark of ACL reconstruction recovery, ¹³ with some of the participants mentioning this type of behavior. Physiotherapists were key in providing physical rehabilitation and treatment, whereas previously injured players became a source of social support and encouragement.

3.5. Remodeling (week 7–4 months post‐surgery)

This phase was characterized by the monotony of rehabilitation. The participants experienced a broad range of emotions during this phase. Past research stated that emotions tend to shift from negative to positive as athletes neared RTS. ²¹ Irritation and impatience were commonly experienced by the participants due to slow progress, concurring with past research. ¹³ High motivation levels were noted among the participants, with earlier research identifying both intrinsic and extrinsic motivators as drivers of rehabilitation. ²² Resilience and goal‐directed behavior has been shown to enhance satisfaction with the progress, ²³ , ²⁴ whilst goal setting has also been shown to contribute to rehabilitation adherence. ²⁵ There was evidence of the participants adhering positively to their rehabilitation programs. Previous research showed that such adherence positively affected successful RTS, however, withdrawal and isolation hampered adherence. ²⁰ Self‐empowerment and self‐monitoring on rehabilitation milestones helped some of the participants gain a sense of control. Emotional support was provided by multiple sources, including healthcare professionals, family, teammates, and coaches. The role of teammates became more prevalent as the players neared RTS. Ironically, some of the participants perceived their coaches as being distant, precisely when past research suggest coaches should be providing social support, informational support, and assistance, to prevent isolation and exclusion. ²⁶

3.6. Before RTS (timeframe subject to meeting RTS criteria)

Deteriorating skill levels and low confidence may hinder a return to pre‐injury performance levels, whereas realistic performance expectations facilitate successful RTS. ²⁷ RTS protocols should focus on regaining competency, restoring self‐confidence, and enhancing psychological readiness to return. Longer recovery periods and greater training exposure increases knee function confidence and decreases fear of reinjury. ²⁸ Excitement and eagerness were common during this phase as the participants awaited clearance to RTS, as noted in an earlier study. ¹³ Fear of reinjury is a leading psychological barrier athletes must overcome and is a key reason why certain athletes do not reach their pre‐injury competitive performance levels. ²⁹ , ³⁰ Those who successfully return, play with less fear or anxiety. ²⁹ Fear of reinjury was noted among a few of the current participants. If this fear persists, referrals to clinically trained sport psychologists may be necessary. During this phase, injured athletes, who remain involved in their sport during their rehabilitation, experience a greater sense of belonging, feel more valued, and stay up to date with the team's tactical development. ³¹

3.7. After the first competitive match

Getting through the first competitive match was an important milestone for most participants. The first test or direct impact to the injured knee marked their return to full readiness. Fear of reinjury and not reaching pre‐injury performance levels were common. Past research showed that it is reasonable to expect substandard performances at first, whilst skill improvements may be gradual. ²⁷ Lower fear of reinjury and higher psychological readiness to RTS are associated with successful returns to preinjury playing levels. ³² Restricted functionality, lengthy recovery, and increased awareness of injury‐associated movement patterns contributed to fear of reinjury and not achieving pre‐injury performance levels. ³³ These challenges may prevail for some time, even after regaining physical functionality. Gratitude was commonly experienced by the participants, whereas hesitancy and tentativeness persisted. At first, these injured players required social support, whereas they now grew into a resource for other injured players. Sport healthcare professionals should consider support groups for injured athletes by introducing them to other players who sustained similar injuries, however, patient‐client confidentiality should be maintained.

3.8. Adversity‐induced identity expansion

Identities are multiple, dynamic, and intersecting. Athletic identity develops as athletes progress through the various levels of competitive sport. Those who commit themselves exclusively to their athletic role often neglect other dimensions of who they were and fail to explore educational and alternative lifestyle options during their playing careers. ³⁴ This may hinder the development of coping strategies that enable successful career transitions later. Athletic identity tend to decrease 6–12 months after ACL surgery, and those with a narrow sense of self may experience their injuries as more threatening. ³⁵ Some athletes separate themselves from their athletic identity to protect their self‐esteem during challenging times in their sporting careers and to remain positive despite adversity. ³⁶ Some participants voiced a shift from a dominant athletic identity towards a more balanced and person‐centered identity.

Recovering from injury may lead to discovery, growth, and greater self‐understanding. ³⁷ Getting the athlete ready to RTS becomes the immediate focus, whereas their athletic identity should also be reinforced. This may be an ideal opportunity for coaches and healthcare practitioners to probe on person‐centered identity development, in preparation for future and inevitable sport career termination. Transitions out of sport, whether normative (planned) or nonnormative (unplanned, often acutely) often prove challenging for top athletes, as some of them develop an overly strong unilateral athletic identity.

4. CONCLUSION

Our longitudinal qualitative findings provided an in‐depth understanding of how athletes experience ACL ruptures and reconstruction and their experiences through the various rehabilitation phases on the “long, long journey” to RTS. These findings:

1. Identified typical cognitive (thoughts), emotional (feelings), and behavioral responses of athletes on their respective recovery journeys, thereby sensitizing the multi‐disciplinary team of sports healthcare professionals to what injured athlete's may encounter during various phases of the lengthy rehabilitation process.

2. May enable the sports healthcare professionals to probe their athletes with respect to their thoughts, feelings, and behaviors to ventilate possible negative responses.

3. Emphasize the need for phase‐appropriate psychosocial support (by coaches, teammates, family, and friends) or referrals to sport psychology service providers for psychological interventions, to reduce psychological burdens and enhance the athlete's overall RTS experience.

4. Show that athletes who successfully returned to sport after injury could become a valuable resource to share their experiences and to support athletes who suffered similar injuries.

5. Suggest that injured athletes should be encouraged to expand their athletic and person‐centered identities and to grow on multiple levels amidst the adversity.

4.1. Limitations and recommendations

Despite efforts to recruit participants for the study soon after they sustained their injuries, this proved to be difficult. From Table 1 it is evident that most of the interviews during the first three phases and before the RTS were conducted retrospectively. Subsequently, the study suffers from recall bias. However, in‐time data collection is a strength of the study compared to the tendency to explore these experiences retrospectively.

The injured athlete, coaching staff, sports healthcare professionals and other stakeholders should work together to improve the reintegration of the injured athlete to the team and training environment and should collectively aim to foster their psychological readiness to RTS. Several types of social support may facilitate this process, especially during the acute recovery and repair phases, when isolation is common.

Future studies may consider mixed methodologies to explore the psychosocial experiences of injured athletes before and after their RTS. The manner and extent to which sports healthcare professionals integrate psychological factors, in particular psychological readiness to RTS, during the RTS decision‐making process requires further investigation. Future research should explore the nature of psychological readiness, as it is an important construct that is still not fully understood. Rehabilitation setbacks, re‐ruptures and revision surgery experiences and responses are other avenues to explore. Empirical studies should aim to close the existing research‐practice gaps.

4.2. Perspective

This study provided a long‐term perspective on the psycho‐social experiences of competitive athletes on their journey to full recovery following ACL reconstruction surgery. It draws attention to their phase‐specific needs and who is likely to provide the necessary support during the lengthy recovery period. It calls for greater collaboration between and training of a multidisciplinary team comprising sports physicians, orthopedic surgeons, nurses, physiotherapists, sport psychologists, and other rehabilitation experts, as well as nonclinicians such as strength and conditioning coaches, coaches, team managers, teammates, family, and friends. Wiese‐Bjornstal et al.'s (1998) Integrated Model of Psychological Response to Sport Injury and Rehabilitation Process ¹¹ offers an ideal framework to explore the athletes thoughts, feelings, and behaviors, within each phase of the injury‐rehabilitation process to ventilate possible negative responses, make the necessary referrals, and adequately support these athletes to enhance their recovery and RTS.

Borman A, Derman W, Grobbelaar H. Psychosocial experiences of competitive rugby players on the “long, long journey” to recovery following ACL ruptures and reconstruction. Scand J Med Sci Sports. 2024;34:e14604. doi: 10.1111/sms.14604

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.