We conducted three focus groups with six or seven participants, with a total of 20 individuals 1–20 years (mean 6.5 years) post ACL reconstruction. Focus groups lasted between 65–72 minutes. Each group consisted of a mix of genders (9 males, 11 females), age ranges (21–51), sports, concomitant injuries, and participation levels. Twenty-five percent of participants had returned to their previous level of participation, and 85% reported having ongoing problems with their knee. Participants returned to a lower level of competition, changed, or did not return to sport due to factors relating to their knee, except participants 16 and 19, who returned to a lower level of competition due to other factors not related to their injury. When asked about their return to sport, participants reported that kinesiophobia and ongoing symptoms were the primary factors that affected their ability to return to their previous level of sport. Details of the selected participants are presented in Table 1.
Table 1
Participant
|
Age
|
Sex
|
Second injury
|
Time since injury (years)
|
Associated injuries
|
Main sport
|
Level of sport
|
Time to RTS (months)
|
Level of sport competition returned to
|
Ongoing problems
|
1
|
51
|
M
|
|
4
|
Unsure
|
Soccer
|
Local
|
18
|
Changed sports
|
None
|
2
|
50
|
F
|
|
4
|
Unsure
|
Netball
|
Social
|
24
|
Lower level
|
Minor
|
3
|
21
|
M
|
|
2
|
Meniscus, LCL
|
Touch Football
|
International
|
13
|
Changed sports
|
None
|
4
|
47
|
M
|
Y
|
12
|
Meniscus
|
Touch Football
|
National
|
9
|
Previous or higher level
|
Minor
|
5
|
29
|
F
|
|
13
|
None
|
Soccer
|
Local
|
12
|
Changed sports
|
None
|
6
|
29
|
M
|
|
1
|
PCL
|
Cricket
|
Local
|
13
|
Lower level
|
Moderate
|
7
|
45
|
F
|
Y
|
20
|
Meniscus, MCL, cartilage
|
Touch
|
National
|
17
|
Lower level
|
Minor
|
8
|
48
|
F
|
|
2
|
MCL
|
Tennis
|
Local
|
24
|
Changed sports
|
Moderate
|
9
|
38
|
M
|
|
18
|
Meniscus
|
Rugby
|
Regional
|
7
|
Lower level
|
Significant
|
10
|
24
|
F
|
|
2
|
MCL
|
Netball
|
Local
|
12
|
Previous or higher level
|
Minor
|
11
|
50
|
F
|
|
5
|
Meniscus
|
Gym/running
|
Social
|
-
|
Did not return to any sport
|
Minor
|
12
|
27
|
M
|
|
3
|
None
|
Netball
|
National
|
9
|
Previous or higher level
|
Minor
|
13
|
31
|
M
|
Y
|
11
|
Meniscus
|
Soccer
|
National
|
7
|
Previous or higher level
|
Significant
|
14
|
28
|
F
|
|
4
|
Meniscus, MCL, LCL
|
Weightlifting
|
Social
|
24
|
Did not return to any sports
|
Minor
|
15
|
19
|
M
|
|
2
|
Meniscus, fracture
|
Cricket
|
Regional
|
10
|
Previous or higher level
|
Minor
|
16
|
28
|
M
|
|
7
|
Meniscus, MCL
|
Rugby Union
|
Local
|
12
|
Lower level
|
Minor
|
17
|
40
|
F
|
|
2
|
Meniscus
|
Netball
|
Social
|
10
|
Changed sports
|
Minor
|
18
|
22
|
F
|
Y
|
6
|
Meniscus, MCL
|
Volleyball
|
Regional
|
24
|
Lower level
|
Minor
|
19
|
46
|
F
|
|
2
|
MCL, cartilage
|
Hockey
|
Social
|
12
|
Lower level
|
Minor
|
20
|
28
|
F
|
|
11
|
None
|
Netball
|
Regional
|
15
|
Lower level
|
Minor
|
M, male; F, female; Y, yes; MCL, medial collateral ligament; LCL, lateral collateral ligament; PCL, posterior cruciate ligament; RTS, return to sport |
Five organising themes were identified as key aspects of rehabilitation that present barriers and facilitators of rehabilitation adherence and participation on a patient’s journey back to sport. The research team developed a visual framework representing each theme as influencing factors of a patient's rehabilitation journey to return to sport (Fig. 1). The organising themes and associated sub-themes are not weighted, as each participant experiences barriers and facilitators differently according to their rehabilitation journey. The organising themes are psychological (organising theme 1), physiological (organising theme 2), rehabilitation service (organising theme 3), rehabilitation characteristics (organising theme 4) and interactions with others (organising theme 5). Nineteen sub-themes associated with each organising theme were formed based on the line-by-line coding of the transcript. Additional file two provides additional verbatim quotations for each subtheme.
Organising theme 1: Psychological factors
Participants detailed psychological factors which impacted their rehabilitation. Four subthemes were identified: the participant's expectations for rehabilitation (subtheme 1), the impact of kinesiophobia and fear of re-injury on rehabilitation (subtheme 2), the difficulties in staying motivated throughout rehabilitation (subtheme 3) and the need for support from clinicians, friends, family, their team, and external sources (subtheme 4).
Expectations Most participants expected a 12-month recovery but underestimated the effort required in completing rehabilitation to a sufficient standard and intensity to address post-operative deficits. They felt health practitioners failed to inform them of the possibility of ongoing pain and other injuries. However, they believed that physiotherapists are in the best position to set realistic expectations with their patients due to the ongoing relationship and early input (ideally before surgery). As explained by one participant, "If they were to see a physio beforehand, maybe they would have an understanding of what you've got to do here and that it's going to be a longer journey because if those expectations are, I guess, worked out beforehand, you're less likely to have that disappointment or that depression and things that go on after surgery” (participant 20).
Kinesiophobia and fear of re-injury Participants consistently reported that exposure to situations associated with their injury, such as jumping and change of direction, were the hardest to overcome. However, repetition and controlled exposure to these situations aided their ability to overcome their fears. As explained, “just making it more sport-specific, just recreating some of those scenarios that are scary. So, make sure you're comfortable with what you're doing and relate it into your sport” (participant 7).
Motivation Some participants lost motivation to complete rehabilitation due to not feeling supported in their return to sport ambitions. Slow progression and other priorities through the mid-stages of rehabilitation made it challenging to maintain motivation in completing rehabilitation; however, striving for and achieving key milestones and goals assisted in maintaining motivation over the long term. For example, "that one stage where it's like, yes, you can run for as long as you can. That was super ... It was motivating” (participant 15). Exposure to athletes who had returned to high-level sport also increased motivation.
Support Having a supportive team to guide you through surgery, recovery and rehabilitation aided in achieving a successful outcome. Support could be from external sources, such as online support groups, friends and family or the treating health practitioners. As explained by one participant, "one thing that's come out of just hearing everything today is that such a massive part of rehab is between the ears… that mental side and it all starts from the minute you walk into the door to your surgeon, and then you pick your physio and that person, and how they understand what you are going through” (participant 1).
Organising theme 2: Physiological factors
Participants mentioned physiological factors which impacted their rehabilitation; three subthemes were identified. These are: older individuals feeling discriminated against (subtheme 1), post-operative weight gain (subtheme 2), and the challenge of pain during rehabilitation (subtheme 3).
Age Unlike younger individuals, older individuals felt surgeons and physiotherapists failed to consider their return to sport goals. As detailed by one participant, “he must have said five, six times, well, at your age, women your age tend to. Do you want to just do Pilates? Do you want to just walk on the beach, because if that's the case, you don't need your ACL done? And I felt very patronised" (participant 2). Older individuals also felt it was slower and harder to recover from the surgery.
Weight gain Participants were seeking alternative means to exercise and dietary information to adjust to post-surgical inactivity. Many participants reported weight gain hindered rehabilitation and failed to lose it long term. As suggested by one participant, “I think a nutrition plan will help as well. Like you said, gaining weight is a potential issue.... And you're just like, I don't even know how to eat at all. I think that is really important” (participant 13).
Pain Participants reported persistent pain and complications such as patellofemoral pain, delayed rehabilitation progression and reduced adherence. "The fear, for me, was that I couldn't get rid of kneecap pain for so long and whether that was ever going to go away” (participant 19).
Organising theme 3: Rehabilitation service
Factors related to the delivery of the rehabilitation service were identified, resulting in five subthemes. These are challenges during their initial utilisation of health services (subtheme 1), difficulties in accessing health care (subtheme 2), the factors which influence the frequency and duration of supervised rehabilitation (subtheme 3), and the utility of group rehabilitation (subtheme 4) and telehealth (subtheme 5) as modes of service delivery.
Initial service delivery Initial interactions within the health care system were reported to present barriers to rehabilitation progression through delays in diagnosis and a failure of first contact practitioners to hear patient concerns. Many participants had similar stories, “I found it was kind of disconcerting when everyone's going around sharing their ACL stories that like half of us, when we were initially diagnosed was saying, oh, it's just bone bruising, like, oh, it's just a sprain." (participant 15). Participants also had a desire for a plan that encompassed a variety of options for their care to prepare for the entirety of rehabilitation adequately. Remarkably few participants completed any form of prehabilitation, but it was highly valued in those who did.
Access to health care Having the time to travel to and attend appointments was a common barrier for participants. Access issues were particularly evident in the early phases due to post-operative driving restrictions and others with high family and work commitments. “I think probably the difficulty for me was being a mum of two, working full time…. That was my difficulty” (participant 17).
Frequency and duration of service As rehabilitation progressed, the ever-increasing cost became a burden to participants and may result in early cessation of care; "So, I think the biggest barrier is access to physio being more affordable in Australia…. I'm at the start of my journey, that could be quite expensive over nine months for me to afford” (participant 6). Participants who ceased rehabilitation early (before six months) reported wishing they had continued longer to avoid long term problems. Some participants reported periodic review in the later stages of rehabilitation, at the recommendation of the physiotherapist, made it difficult to maintain motivation and overcome physical impairments, build confidence and physical capacities for return to sport.
Group rehabilitation Group rehabilitation was widely supported across participants to facilitate rehabilitation progression by developing physical capacities while also providing support and motivation through interaction with others. One patient noted, "Just to be part of a group of people that we had gone through the same thing, just for accountability and motivation because you lose your self-confidence until you can really get going again” (participant 8).
Telehealth Telehealth was accepted as a mode of service to reduce financial and travel burdens but only in combination with in-person appointments to monitor pain, exercise technique, overcome kinesiophobia and deliver hands-on therapies. As one patient expressed, “I think there're some things that you could've done fine with telehealth that probably would've helped with the cost of some of it and the access…. but like some of the stuff that I had to do with my physio, I don't think I would ever have been able to do it if I didn't feel they were right there to catch me if I fell off a block. I just wouldn't have done it. I don't think” (participant 10).
Organising theme 4: Rehabilitation characteristics
Participants spoke about barriers and facilitators they encountered during rehabilitation sessions and interactions with their physiotherapist. The four subthemes identified were: difficulties in completing exercises independently (subtheme 1), the desire for informational support (subtheme 2), the need for clear and progressive goal setting and reassessment (subtheme 3) and the relationship with their physiotherapist built on trust and collaboration (subtheme 4).
Exercise delivery Participants consistently reported difficulty completing their rehabilitation as prescribed due to therapists providing unclear instructions and excessive use of technical language. As one participant described, “I probably didn't feel like I was getting very good instruction as to what to do... It wasn't that I wasn't willing to commit to the time, it was I just wasn't sure what I was supposed to be doing” (participant 19). However, participants highly valued being informed of the reason for exercise selection and a clear path for progression. To enhance exercise adherence, they recommended using exercise prescription applications and the therapist considering individual circumstances such as work, family, and exercise competency. Further, participants often expressed that the late stage of rehabilitation was poorly executed and failed to expose them to training to prepare them for a return to sport; “I think the other barrier for physio is once you get to nine months, and you're doing most of your strengths pretty equal, is that specific skills that you want to be outside running, changing direction, and you can't do that in a small clinic, and that's kind of where I left once, I wanted to be outside” (participant 7).
Informational support Due to the long rehabilitation process, participants consistently reported seeking external sources of information to assess their progress, answer questions and provide motivation. They did express concern over verifying external sources of information. They recommended therapists “not give all of the information the first time you see someone, because it's just too much. It's like a drip-feed, and then building on it each time” (participant 5).
Goal setting and reassessment Participants highly valued the process of collaboratively setting and achieving relevant goals and milestones but reported that it was poorly executed (e.g., solely time-based) or never provided to them; "’Here's where you are. This is where you're going. These are our checkpoints along the way.’ And then let's talk about it, and see if you're happy with it, and if we're there and if not, why not? What are we going to do about it to get you to where you should be? I mean, that didn't happen to me, and I thought it should've done” (participant 1). Setting non-clinical goals (such as completing fun runs or fitness challenges) should also be considered.
Therapeutic relationship Many participants described how a strong therapeutic relationship built on trust, knowledge and support enhanced rehabilitation and guided them through a lengthy rehabilitation process. For example, one participant stated, “it's the relationship that you build which is based on trust. You trust that that physio will get you there, and the physio has also got to trust that you're going to do your job, and you're not going to let the physio down. So, it's building that” (participant 2). They also expressed that the selection of the wrong therapist can significantly hinder rehabilitation.
Organising theme 5: Interactions with others
Participants spoke on how their interactions with others or the wider community impacted their rehabilitation. Three subthemes were identified: the ability of the surgeon to influence the plan for care and rehabilitation (subtheme 1), the importance of supportive family and friends (subtheme 2), and the desire to stay involved with their team (subtheme 3).
The surgeon Some participants reported a positive, motivating, and supportive interaction enabled rehabilitation; however, some initial surgeon interactions were perceived as impersonal, negative, and demotivating, which inhibited recovery. The surgeon is in a highly influential position, “whatever they say, you believe because…. you put your trust in them…. they need to build some comfort and warmth inside, warm and fuzzy to make you feel that it's going to be okay” (participant 1). Participants also reported never being recommended to undertake a period of prehabilitation from their surgeon.
Friends and family Participants valued friends and family who facilitated rehabilitation through offering transport, encouragement, and supervision during rehabilitation. However, they often felt that others failed to understand the significance of the injury; “I think people around you didn't understand either, isn't it? Because it's like when you hurt your back because it's not a big gaping wound and people can't see it, they don't... Not as much empathy” (participant 11).
Team and coaches The opportunity to stay involved with their team through coaching and support roles was highly valued by participants. They often felt isolated from their team when unable to participate in training and games. As one participant detailed, “I was a little bit isolated. Because the team, they're doing a real intense workout and you're like, I'm just going to use some TheraBand’s and hope for the best” (participant 10).