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

Setting and research design

The participants of this study were identified through a prospective injury surveillance audit carried out in the Swedish Women’s Elite Football League in the 2012 season. The prospective study followed the same design as that previously reported in a similar setting [19]. The Women’s Elite Football League consists of 12 teams with approximately 250 players. During the season 2012, 13 of these players sustained a first-time total ACL tear (all underwent reconstructive surgery) and were approached for inclusion in this study.

We then adopted a two-step design, the first step using an expert evaluation process [20, 21] to identify resilient players (among the 13) based on players’ descriptions of being injured. This was conducted based on interview transcripts and no specific criteria were developed for separating resilient injured players from other players before the start of analyses. The primary goal of this procedure was to obtain a sub-sample of cases from which further data could be extracted [21]. This selection was done through the expert evaluation and the psychosocial profiles being obtained. The players who reported a mixture of several adaptive and maladaptive behaviors and emotions during rehabilitation, such as engaging in primarily emotion-focused strategies, an inability to accept the situation of being severely injured, and expressing worries and concern about the rehabilitation process, were excluded from further analyses.

In the second step, we performed a thematic content analysis (for more information, see Content analysis) focusing only on those players who were identified as showing resilient behaviors during rehabilitation (n = 8). In line with the above description of the dimensions of resilience, injured players who demonstrated high self-efficacy as well as high social problem-solving abilities and adaptive behaviors, such as actively working to set reasonable goals during rehabilitation, were identified as resilient players. Their interview data was included into the thematic content analysis.

Participants

Interview guide

The interview guide, consisting of four broad questions (see below), was designed to gather information about the players’ rehabilitation period. We used an open-ended, low-structured interview guide with questions covering a broad area of what happened in their sport and in their lives during the rehabilitation period, including their physiological and emotional states.

The players were asked to: (1) provide background information (i.e., age, years in professional football); (2) describe the event when the injury occurred; (3) tell their stories of how they experienced their situations during rehabilitation from the ACL injury and reconstructive surgery; and (4) describe, as fully as possible, the ways in which they felt their life situation influenced their behaviors during rehabilitation. Additional questions and probes were asked in order to provide richness to the stories.

Procedure

The time and place of the interviews were scheduled for the post-season (December 2012 to January 2013), and took place 6 months (range 4–9) post reconstruction. All players were located in Sweden at the time of the interviews. The first interview was intended to be a pilot interview to test the interview guide. Because no subsequent changes were made to the interview guide, this interview was included in the study. The second author is well acquainted in qualitative methodology and especially in social constructivist narrative theory [22], which allowed us to recapture the way in which selves and identities were grounded in cultural forms of language and sense-making. The second author conducted all the interviews, lasting 25–65 min and transcribed verbatim all the interviews prior to analysis. The study was reviewed by the Regional Ethical Review Board, Linköping University, Sweden (# M240-09). Informed consent was obtained from all participating players.

Content analysis

To deal with credibility, one aspect of trustworthiness in qualitative studies [25], the authors repeatedly read through the interview transcripts while comparing and validating them against the sub-themes, themes, and core themes, ensuring that no relevant data had been inadvertently or systematically excluded and that no irrelevant data had been included. The authors read and re-read the transcripts throughout the data analysis process. Moreover, another expert in sport and exercise psychology and highly trained in qualitative research was invited to triangulate the steps outlined in the data analysis (1–6). The authors first introduced the verbatim transcriptions of each interview, after which the additional colleague was asked to comment on the condensed statements, codes, sub-themes, themes, and core themes. After several discussions comparing and sorting sub-themes, themes, and core themes in logical order, suggestions were recommended and changes were made accordingly once consensus had been reached.

Thematic content analysis of identified resilience group

This theme contains the narratives of how helpful social interaction and dialogue were with coaches and teammates within sport as well as partners, family, and friends outside sport. The helpfulness of teammates is illustrated in the following: “At the same time, several other injured players have been here [rehab center]. We have exercised together with our physiotherapist…We have trained a lot together. I think it has helped us very much.” Still another player said “I have received a lot of support from the girls on the team. They have encouraged me a lot, it feels good … Supportive teammates are always important; they help me to think about other things.”

Some examples of the support from coaches were: “Our coach has been really good; he has listened to me and often asked how I felt and so on” and “The coach pushed me to train harder on my own. It was great to feel that engagement from him.”

Different kinds of personality-related factors for helping injured players cope effectively during rehabilitation emerged in the analysis. Numerous players had positive, determined attitudes, yet at the same time maintained a mindful stance under the core theme Strong belief in the importance and efficacy of one’s own actions. Tolerance, persistence, acceptance, and life satisfaction were all features of this core theme.

In much the same way, another player stated, “The ACL injury and the rehabilitation afterwards felt like a piece of cake. I remember I thought like that the last time I was severely injured”.

One issue that repeatedly arose during the interviews was that players made plans and set clear goals for the future during rehabilitation. For instance, one player stated that, “My outlook and goal is to be back in 6 months after the operation … we play Champions League then. I will be physically and mentally ready at that time”.

Methodological considerations

One methodological issue to consider is that some players’ memory recall may have been inaccurate due to the fact that, on average, 6 months passed between the interviews and the injury dates, but the relatively high level of agreement between the findings and previous research speaks to the credibility of the results. One important sampling issue is that the resilient players played for/represented several different teams. It is therefore not possible to state definitively that the resilient players were predominantly located in supportive, constructive, and positively oriented teams, or had coaching staff sensitized to rehabilitation difficulties, or came from successful clubs. Another methodological consideration is whether adequate and quality data were collected to support the study (data saturation). It appears that the players’ narratives indicated behaviors that closely matched the dimensions of resilience, which include for instance self-efficacy, an ability to engage support and help, and learning from difficulties, characteristics often mentioned in the literature [14, 15]. Another related and important consideration is about the amount of data necessary to answer our research question in a credible way [30]. It is our belief that the data were sufficient to deal with the focus of our research, i.e., resilient players who exhibit self-reliance and engage in resilience-related behaviors. We feel confident in how well data and processes of analysis address the intended focus, despite the complexity of the phenomena under study.

Also, another methodological issue important to reflect on is related to the selection of narrative constructivism as the theoretical foundation for the study. The reason for selecting this approach was that it emphasizes the importance of considering a person’s story as a reflection of his or her identity, emotions, and understanding of the past, present, and future [31]. Because the aim of the study was to capture the players’ experiences in relation to the situation of being injured, we find this approach especially suitable.

Finally, the focus of the study is not the rehabilitation speed or readiness for play but rather individual experiences of rehabilitation following the reconstruction of a first-time ACL injury and the factors that contribute to a resilient, successful rehabilitation. Because the approach is idiographic, no causal relationships could be claimed between the variables and the group of interest. Future studies, tentatively based on a biospsychosocial perspective, are therefore recommended to collect combinations of different type of data to provide further evidence to support the need to capture psychosocial data on injured athletes. Such evidence can guide the development of effective techniques that will facilitate rehabilitation.

Clinical implications

Building on the results of the present study, some practical suggestions based on adaptive behaviors of ACL-injured elite female football players during rehabilitation from ACL reconstructive surgery can be made. In the communication between the medical team and the injured player, it seems essential that both partners jointly draw up a plan for physical and mental recovery, in preparation for successful rehabilitation. Social support, in terms of communication and rich interaction, was a central theme in the present study, but curiously enough interaction with medical team was rarely mentioned. We can, however, on the strength of this theme put forward suggestions for medical team. This means that the medical team have an important mission to maintain constructive communication and rich interaction throughout the entire rehabilitation period. This implies not leaving the injured players isolated and outside the team (an inclusive tactic that is also the task of teammates and coaches). Also, the medical team should aim to help the players increase their self-efficacy by acknowledging and reinforcing progress in the rehabilitation process, for example. A player’s self-efficacy is not solely held within the player and it can be increased or decreased depending on the social context and the contingencies of reinforcement and punishment in the sport and rehabilitation environments. It seems equally important for the medical team to encourage injured players to set daily goals for healing and improvement, as well as long-term goals for recovery. For the injured players, having experienced prior successful rehabilitations and thus having confidence and trust in their recovery, it is recommended that they take advantage of the time out as an opportunity to rest and reflect. Finally, for the injured players, it is suggested that they continuously take advantage of the social support systems that exist both inside and outside sport (e.g., family, teammates, and medical team). This support appears to positively influence the sometimes long and arduous period that usually occurs during injury rehabilitation, or, as one player said of her physiotherapist and fellow injured athletes, “We have trained a lot together. I think it has helped us very much”.