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I'm trying to figure something out about my daughter. She's an extreme sports athlete but ruptured her ACL and had to have surgery. She says she wants to get back into sports, but I don't really see her making any effort to do so. Is there something we can do as parents to help her?

Anterior cruciate ligament (ACL) tears are among the most common sports injuries -- especially for females. With over 200,000 ACL injuries every year just in the United States alone, data on recovery is providing us with some clues as to why some athletes return to full play and others don't. In fact, we now know that up to half of all athletes who have ACL reconstruction don't return to the same sports they participated in before surgery. And if they do, they function at a reduced level compared with their preinjury performance. Why does this happen? Could your daughter be one of those athletes who never quite get back into the game? Studies show there may be several factors here. The first is the possibility that athletes are discharged from physical therapy too soon. Impairments such as loss of motion, strength, and proprioception (joint position sense) may not be restored enough to achieve full function again. And sports that contribute to this type of knee injury often require motions such as cutting, pivoting, or jumping. Sometimes the athlete is afraid of reinjuring him or herself. They stop moving in ways that they think might cause pain or reinjury. This response to their first injury is called kinesiophobia. Pain intensity and fear avoidance behaviors can lead to a difference between what patients think they can do and what they can really do. This shows up when test results are compared with what the patient reported being able to do. For example, by self-report, they will say they can't hop on that leg or perform leg presses because they don't have enough strength in that leg. But when a physical therapist tests their motion and strength, they perform better than expected. In these cases, patient’s perception of their pain intensity and fear of movement limit function. Fear-avoidance behaviors of this type are commonly reported in studies on back pain. Fear-avoidance is considered a psychologic variable. The concept has been less well studied in knee injuries such as after ACL surgery. Identifying the problem (whatever it turns out to be) and focusing some attention in overcoming any barriers to recovery may require some outside help. If these two areas (pain intensity and fear-avoidance behaviors) are holding her back, she may be a good candidate for some sessions with a physical therapist. The therapist can assess what's going on and help her get back on target. If she's just lost her drive and motivation, then that may be a different story requiring a different approach.

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