‘Anger, depression and fear’: Inside the mental hurdles of lengthy ACL recovery

PART 1: The tear

When Kenna Skepnek stands atop the balance beam, her eyes shift downward with rapt concentration. During competition, a crowd watches as she balances on this unnatural island: 16.4 feet long by 4 inches wide, standing 4.1 feet off the floor. The average person requires six or seven strides to cross the beam, along with a certain level of attentiveness. Like walking atop a roadside curb or the bumper in front of a parking space, the focus becomes the feet and each ensuing step.

A gymnast like Skepnek is the rare type of person who sees the beam and thinks: I want to perform flips up there.

Skepnek, a Division I collegiate gymnast at Southeast Missouri State, felt good during a January practice when she climbed atop the beam after a two-week hiatus. Three competitions into the season, she had recently recorded a career-best score on her floor routine. She’d been taking time away from the beam because her left knee, reconstructed after an ACL tear two years earlier, was a little sore.

On this January day, however, her knee felt great.

“I’ve done these skills hundreds, if not thousands, of times,” said Skepnek, a 2016 Jacobs graduate from Algonquin. “Going into it, it was just another skill.”

As she landed her second skill, her right knee – not the reconstructed left knee – bent inward. In that moment, the force of her landing traveled up her foot and lower leg into her knee, where the anterior cruciate ligament took the brunt of the force from the awkward landing.

“That’s a hard feeling to explain,” Skepnek said. “For me, it wasn’t like a feeling. It just felt off.”

An estimated 200,000 Americans tear an anterior cruciate ligament each year. One 2014 study estimates that the rate of ACL injury among people ages 3 to 20 doubled between 1990 and 2009. A 2016 study asserts that nearly one in four athletes younger than the age of 25 who undergo ACL reconstruction and return to sport will suffer another ACL injury.

The recovery process is notoriously long and arduous, usually requiring a minimum of nine months. It is physically taxing, but less talked about is how mentally taxing it can be.

Skepnek, already an ACL tear veteran, tried to talk herself into good news. Maybe it was the medial collateral ligament or a sprain. An MRI later confirmed: Skepnek had suffered her second ACL tear.

“At least I knew what I had gone through before, so I knew how to prepare,” Skepnek said.

•••

Six months later, Skepnek readied the Shuttle 2000-1 all by herself. The 21-year-old knew what she was doing.

The Shuttle is like a leg press, if she were to use a leg press lying on her back. Skepnek lay down and pushed herself upward with her right leg.

“We saw a giant sea turtle,” she said to physical therapist Michael Humphrey. “And she was laying eggs. These girls came by and they said they’d lived here 10 years and never seen one.”

Skepnek had recently returned from a trip to Anna Maria Island in Florida. This was her first physical therapy session back at Northwestern Medicine Rehabilitation in Crystal Lake. Skepnek took two weeks away from therapy, and while she was kayaking in Florida, she felt no pain in her knee.

With three more months of recovery, she hoped to return to gymnastics in time for her senior season at Southeast Missouri State in January.

After ACL tears in both knees, there will be no more beam or vault. She hopes to return to floor – “My favorite,” she said – and finish out her career on healthy knees.

Shortly after her set on the Shuttle, Skepnek lunged across the room carrying a weighted ball, alternating lunges between right and left leg. Her right, which she had surgery on shortly after her January injury, shook noticeably.

“Any pain?” Humphrey said.

“Yeah, but like a two.”

“Still not worth it,” Humphrey advised.

The lunges came to a halt.

•••

The ACL is one of four major ligaments in the knee connecting the femur (thigh bone) and the tibia (shin bone). It keeps the tibia from sliding too far forward. These ligaments act like ropes, holding the bones together.

ACL tears come in varying shapes and sizes. The ligament could tear partially or fully. It could be accompanied by a ligament or meniscus tear.

“The injury itself can be extremely painful,” said Shaine Henert, kinesiology program director at Northern Illinois University and a sports psychology consultant. “The rehabilitation can be extremely painful and extremely challenging. The fear of re-injury is probably one of the most salient emotional responses that all athletes have.”

An ancient Egyptian medical text known as the Edwin Smith Papyrus dating to about 1600 B.C. included the first description of the ACL, but not until the early 1900s did doctors attempt to reconstruct the ligament.

Even until the 1970s, much was still debated about ACL injuries. Some athletes played through the injury. John Elway and Joe Namath played their entire pro careers each on an ACL that never properly healed.

Advancements in surgery techniques and rehabilitation have made the injury more manageable. The list of well-known athletes who returned from ACL reconstruction is long: Tom Brady, Alex Morgan and Tiger Woods, to name a few.

Former Chicago Bulls star Derrick Rose experienced a famously long and arduous recovery process. Minnesota Vikings running back Adrian Peterson tore his ACL on Dec. 24, 2011, and started Week 1 in 2012. Peterson finished the 2012 season nine yards shy of the NFL’s single-season rushing record, a recovery that remains unfathomable even among ACL experts.

The miracle recoveries like Peterson’s often skew an amateur athlete’s expectations.

“It’s going to be about a year before you’re back to sports safely,” Humphrey said. “It’s going to probably be a year and a half, maybe longer before you’re 90, 100%.”

For an athlete who is used to performing at the top of his or her field, that means nine months of the Shuttle 2000-1, nine months of lunges, nine months of re-teaching the leg how to function.

“I looked at my leg and it didn’t move,” Skepnek said, recalling her first PT session after her initial ACL tear. “The signal is telling your leg to move and I can’t physically move it. It was kind of scary.”

For many athletes, it can be a lot to wrap their heads around.

“They all think they’re going to be like Adrian Peterson, they’re going to be back in four months setting records,” Humphrey said. “That doesn’t happen. He was a freak of nature.”

***

In the late 1980s while studying at Boise State in Idaho, Humphrey focused his master’s thesis on the psychological factors influencing ACL rehab. In 37 years as a physical therapist, Humphrey estimates he has provided therapy for more than 1,500 ACL patients.

When Humphrey was studying, there were no MRIs, no video. The first time he watched an ACL surgery, he leaned his eyes into a scope sticking out of the patient’s knee “like a meat thermometer” to see what was going on.

In those days, ACL surgery meant a hospital stay of four days. Today, outpatient surgery takes three hours. Most patients have surgery two or three weeks after the injury to allow swelling to subside.

Humphrey earned his master’s from Boise State in 1992. He has been at Northwestern Medicine Rehabilitation (formerly McHenry County Orthopedics) on Route 31 in Crystal Lake since 2005.

In his study, he tried to identify athletes who were too confident about their ACL recovery, and those who had little confidence, and then compare how well they recovered. Ideally, Humphrey wants to see “a happy medium.”

He remembers an athlete he worked with in Idaho who kept asking, “How much is this going to hurt?”

“To me, that was a red flag,” Humphrey said. “This was a Division I athlete, and his biggest concern was he was worried about the pain.”

Humphrey believes it’s best to be blunt with athletes about the challenges ahead. After an ACL tear, Humphrey said, a knee is never going to be quite the same. That doesn’t mean an athlete can’t still compete at a high level. He has seen high school athletes go on to compete in college, and college athletes move on to the professional ranks after ACL recovery.

“Guys and girls are always in tears with their diagnosis,” Humphrey said. “We’re just really supportive. We’ve seen so many of these. This sucks, but you’re going to get through it.”

PART 2: THE REHAB

Two athletes might not react to the same injury in a similar way.

“In terms of the experiences of recovering, especially the psychological recovery from an ACL injury, there’s really no universal pattern of psychological response,” said Henert, the NIU sports psychologist. “Even though there’s trends and common experiences, it does vary depending on the individual and the situation.”

Henert, who grew up in Ashton, Illinois, earned his Ph.D in psychosocial aspects of sport and physical activity from the University of Minnesota. He said much of an athlete’s emotional response to a setback is predicated on that person’s life experience.

A senior in college, like Skepnek, is going to have a much different outlook than a freshman in high school.

“If you’ve been put into situations where you’ve had to deal with difficult things and you’ve worked through them, then the idea is that now I have those tools,” Henert said.

Skepnek has those tools now, especially after her tearing her ACL the first time.

“It was more of a learning experience of what I can do besides my gymnastics to contribute to a team,” Skepnek said.

The focus turned from competing at a high level to recovering. It didn’t help that there were complications with her surgery. Skepnek’s scar tissue formed faster than usual and it hindered her recovery. In the end, she had not one but three surgeries on her left knee after her first ACL tear in 2016.

She was a freshman living in a dorm, walking on crutches for six weeks because of the complications. To be clear, she said, her teammates and friends were great about including her. Still, there were times when it was just easier to stay home.

“I’ve seen them all week,” Skepnek said. “Yeah, you can go do stuff. That kind of sucks and it made [recovery] feel longer. I felt like I was missing out on things even though they were including me as best they could.”

After her second ACL tear in January, her team had a meet at Illinois-Chicago shortly after her surgery and she couldn’t travel.

“Granted, I’ve seen Chicago before,” Skepnek said. “Just the fact I would get to be there with my teammates and show them around, that really sucked.”

Humphrey urges athletes to attend practice and be around their team. He will end physical therapy sessions early or sometimes reschedule them if an athlete’s team has a big game.

“It just makes sense,” Humphrey said. “As an athlete, you don’t want to be isolated.”

Henert, however, doesn’t necessarily agree. Many athletes thrive on the team environment. Others have a hard time watching from the sidelines.

“You have other athletes who don’t have the same personality and aren’t seeing it the same way,” Henert said. “They might be jealous or envious of the fact that they can’t practice.

“This experience is very individualized. Personality factors will influence how I think, feel and act. Knowing a person can help inform you of whether you want them to go to practice or not.”

***

Back at Northwestern Medicine this summer, Skepnek stood atop a raised platform and lowered one foot to the floor. It was a drop of a few inches. She tapped her foot on the ground, lifted it back atop the platform, then switched feet.

When she put her weight on her left leg, her healthy leg, she lowered her right foot without a problem. When she did so with her right leg, her recovering leg, it shook slightly as it lowered.

This simple movement – she did it over and over – was a long way from the skills she performed on the beam or the floor.

In August, star Indianapolis Colts quarterback Andrew Luck shocked the NFL when he announced his retirement at age 29, citing, in part, his constant rehab for various ailments. Luck never tore his ACL, but he went through a litany of injuries in his six-year NFL career: torn cartilage in two ribs, a partially torn abdomen, a lacerated kidney, a torn labrum in his shoulder, at least one concussion and, most recently, an unspecified ankle injury.

“So many athletes, I’ve heard them say that their rehab exercises are way harder than any other strength and conditioning training they’ve ever done in their life,” Henert said.

As Skepnek watched herself in the mirror, full attention on her bending knee, it’s easy to see how years of on-again, off-again physical therapy could wear an athlete down.

Next, Skepnek did a similar exercise where she dropped from one foot atop the platform onto both feet on the ground and immediately jumped straight in the air.

The idea was to re-teach herself how to land – softly, knees over feet, not knock-kneed.

“Stick the landing,” Humphrey joked with the gymnast.

PART III: THE RETURN

Skepnek hadn’t had butterflies in her stomach in such a long time. The first time she performed her floor routine as a collegiate athlete was at a meet at Texas Woman’s University in Denton, Texas.

It was Feb. 25, 2018, a year later than she hoped to make her Southeast Missouri State debut.

“It was really nerve-wracking because you haven’t competed in a long time and you’re finally back,” Skepnek said. “You’re going out in front of a crowd of thousands of people. You’re nervous. What if I mess up? I wasn’t really thinking about my knee at that point.”

Skepnek scored an 8.950 on floor that day. She competed four more times during the 2018 season, improving her floor score to a season-best 9.675 by mid-March.

So much of her identity as an athlete over the past year had been focused on her knee. Those worries faded away in the heat of competition, but they never fully disappeared.

“I’d say it’s always in the back of my mind,” Skepnek said. “At this point, when you’re a collegiate gymnast, you’ve done these skills so many times, I’ve done the skill that I tore it on probably hundreds to thousands of times, so it’s really just knowing that it’s a fluke accident and that your leg is strong enough to handle that.”

Now, after her second ACL surgery and rehabilitation, Skepnek wants to feel those butterflies once more.

***

Following months of physical therapy after an ACL injury, returning to sports can be a daunting psychological hurdle. Even after Skepnek returned to practice her first time, it was a long time before she felt comfortable taking off her knee brace.

“It was kind of like a crutch,” she said of the brace. “It was more mental than physical. I knew my knee was OK, but as long as the brace was on it, I’m not going to tear it again.”

Eventually the trainers said it was time to lose the brace. Skepnek was nervous.

“Psychologically, I would guess that she convinced herself that the brace was making everything OK,” Henert said. “Not the rehabilitation and the fact that her body had recovered, but in her mind she thought, ‘This brace is going to protect me.’ It’s kind of like a shield. ... Without knowing this athlete personally, that would be my guess.”

Humphrey spends a lot of time during PT sessions teaching athletes how to jump and land properly. Women, especially, tend to be more likely to land with their knees pointed inward, which puts the knee at risk.

Eliminating the bad habits that led to an ACL tear, hopefully, will prevent future injuries. These techniques can be applied before an injury, as well, though Humphrey said it’s a hard sell.

“We’ve tried to do free ACL prevention things for teams, for individuals,” Humphrey said. “Nobody thinks they’re going to get hurt, so nobody wants to do prevention until it’s too late.”

And while ACL patients returning to sports are concerned with their injured knee, there should be as much concern for the other knee.

“You’ve got to keep training, ideally forever,” Humphrey said. “You want to keep this [knee] strong, but if this one’s torn, we know that [the other knee] is at risk. Genetically and biomechanically there was a reason [the first one tore].”

***

Only a few times has Humphrey been so worried about an athlete’s response to an ACL injury that he felt it necessary to seek outside help.

“It’s pretty rare, but that happens,” Humphrey said. “We try and have a conversation with the parents right away. If they need to get some counseling, we do try and watch for that. It’s been pretty minimum.”

Athletes are highly motivated to recover. Still, an amateur athlete is not a professional. There’s classes, homework and work competing for an athlete’s time.

“[The] most common emotional responses would be anger, depression and a fear of re-injury,” Henert said. “Those seem to be the three most common things that we see at any age. Particularly if it’s a competitive sport.”

Skepnek, who is ever bubbly and positive, believes it has been easier going through her second recovery. After a recent physical therapy session, she sat atop a trainer’s table icing her right knee, telling her story. This was her final PT session with Humphrey late in the summer before heading back to Missouri.

She unwrapped the ice pack from around her knee, revealing the scar that begins at the lower portion of her kneecap and spans a few inches below her knee. Skepnek had at least three more months of recovery remaining, but she had her sights set on one thing: returning for her senior season.

“Am I crazy for going back again?” she said.

She laughed away her question.

“That’s what I love to do,” Skepnek said. “Compete. At least one last time.”