The main result of the present study, describing resilient athletes’ experiences of rehabilitation after ACL injuries, is that we identified three core themes representing psychosocial factors that appeared to help players cope with rehabilitation: constructive communication and rich interaction with significant others, a strong belief in the importance and efficacy of one’s own actions, and an ability to set reasonable goals.
Analyzing the results of the narratives of the resilient players, it is striking how most of the players emphasized the adaptive and combined effects of supportive communications and interaction with significant persons both inside and outside their sport. Furthermore, it is also evident from the literature that a substantial part of previous research has focused on intra-individual resilience factors such as self-efficacy [8] and, to a lesser extent, on inter-individual factors such as beneficial communication with the head coach and other supportive persons during rehabilitation [11]. Although much of the attention of coaches, sports medicine team members, and sport psychologists is focused on preparing athletes for competition, this attention often vanishes when an athlete is injured. Some players in the present study also reported feelings of being excluded, neglected, or of little importance due to their physical incapacity. Despite these often observed phenomena, the resilient players appeared to benefit from interacting and constructively communicating with important persons such as parents, head coaches, teammates, and friends inside and outside the context of their sport. Some players also talked about the positive challenges the rehabilitation period brought in terms of having the opportunity to connect socially with networks of teammates and friends. These positive social features of rehabilitation processes have adaptive qualities and parallel previous research findings [10, 11].
The resilient players were also characterized by having high beliefs in their own actions, including being success-oriented and having positive attitudes as they faced their rehabilitation periods. In many ways, they matched past profiles in previous studies on athletes who have experienced successful rehabilitation after severe sports injuries [15, 16]. Personality features, such as resilience and stamina, are important psychosocial factors in the long-term management of a severe injury, usually driven by strong self-efficacy beliefs. In line with this finding, these resilient players appear not only to accept their injuries in positive ways but also to exhibit a sense of balance and satisfaction, managing challenging situations effectively. The players appeared to regard their situations as being controllable and exhibited rehabilitation behaviors that were clearly adaptive and oriented on the future. These strong self-efficacy beliefs warrant further investigation in the light of the knowledge provided to sports medicine teams when it comes to learning more about important psychosocial factors during the rehabilitation of elite female athletes.
The third core theme relates to the ability to organize oneself and plan for future activities using goals during the rehabilitation period. In part, this ability relates to the particularly relevant concept of dispositional optimism (as compared to optimistic behavior). Scheier et al., [26] the originators of this concept, defined it as representing a general expectation that good, rather than bad, outcomes will occur. These general expectations are believed to positively influence health because they tend to determine the extent to which an individual is willing to initiate health-oriented behaviors and persist with those behaviors when facing setbacks and other difficulties. Scheier et al.’s dispositional optimists tended to have more positive expectations before, during, and after surgery than those who did not obtain high scores for dispositional optimism. More specifically, dispositional optimists were found to make plans and set goals for recovery to a greater extent than pessimists [27], in much the same ways as the players in the current study. Another way to discuss the core theme of ability to set reasonable goals is related to the biopsychosocial model of Wiese-Bjornstal [28]. Research involving this model found that athletes who successfully returned to sport were characterized as having low re-injury anxiety and were more experienced and established athletes [29]. This line of research also revealed a positive relationship between goal-setting and adherence, which in turn yielded a positive relationship with the outcomes of the rehabilitation for ACL-injured athletes in the present study.
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”.
