Pain. It’s the most common issue we hear in the clinic, and everyone’s experienced it at some point – whether it’s a stubbed toe, a banging headache, or a twisted knee. But what is pain, really? Is it simply a physical reaction to injury, or is there something more going on? The International Association for the Study of Pain defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage” (Wiech, 2016). The words “sensory” and “emotional” tell us that pain is more than just damage to our body; it’s heavily influenced by what we focus on, expect, remember, and feel. In fact, research confirms that these psychological and social factors play a huge role in how intense pain feels (Atlas & Wager, 2018). Consider this example: imagine a man walking his dog in the Australian Outback. He feels a small prick on his leg, then looks down to see he’s been bitten by a snake. His body reacts with a rush of burning pain, just as he’d expected. He receives treatment, recovers, and gets back to his routine. Two years later, while hiking in a similar setting, he feels a prick in his leg again. He immediately recalls that painful memory and responds with the same intensity of pain – only to find out it’s nothing but a thorn.

So, what’s really happening here? Here’s how our mind shapes pain:

• Attention: Focusing too much on a painful area tends to make it feel worse. When we concentrate on pain, our brain gives it more significance, which increases perceived intensity (Sharpe et al., 2020; Wiech, 2016).


• Expectations: What we expect to feel can also make pain better or worse. Research has shown that expecting pain to be severe makes us experience it that way. On the flip side, positive expectations can actually lessen the pain we feel (Atlas & Wager, 2018).


• Past Experiences: Pain memories are powerful. When we experience pain, our brain stores it, priming us to react strongly in similar situations. This response may have evolutionary roots, helping us avoid harm, but it also means our past pain experiences can amplify new, less serious ones (Tracey & Mantyh, 2017).


• Emotional State: Emotions like anxiety and fear can trigger a more intense pain experience. Negative feelings amplify our pain responses, while more neutral or positive mindsets tend to reduce them (Thompson et al., 2018; Wiech, 2016).

Pain, then, is more than a physical sensation. Our expectations, focus, memories, and emotions each shape how we experience it, giving us some insight into how to manage it effectively.

Reference List

 

• Atlas, L.Y., & Wager, T.D. (2018). How expectations shape pain. Neuroscience Letters, 693, 24–31.
• Sharpe, L., Jones, E., Ashton-James, C., et al. (2020). Attention and pain: mechanisms and clinical implications. Journal of Pain, 21(3–4), 233–244.
• Thompson, K.A., Tran, B., & Geaghan-Breiner, C. (2018). Biopsychosocial factors influencing pain perception. Pain Medicine, 19(6), 1107–1115.
• Tracey, I., & Mantyh, P.W. (2017). The cerebral signature for pain perception and its modulation. Neuron, 55(3), 377–391.
• Wiech, K. (2016). Deconstructing the sensation of pain: The influence of cognitive and emotional factors. Nature Reviews Neuroscience, 17(2), 83–92.

Recovering from an ACL injury can be daunting, but with the right plan, our patients can rebuild strength, regain confidence, and return to the activities they love. A structured, criteria-based approach is essential not just for recovery but for reducing re-injury risk and achieving long-term success.

Here’s the criteria based approach we use to guide our patients:

Acute Phase The focus is on reducing pain (≤3/10 on VAS), managing swelling, and restoring full knee extension. Early progress in these areas is crucial for setting the foundation for later phases. Key methods: neuromuscular stimulation, passive/active extension exercises, and gait re-education drills.

Early Rehabilitation This phase targets movement and endurance. Goals include achieving 120° of knee flexion and improving muscular control with exercises like leg presses and single-leg squats. Building strength here supports long-term stability.

Strength & Control We move into heavier strength training, focusing on 2–4 sets of 8–10 reps at 60–80% of one-rep max. Controlled jumping and landing drills (e.g., sub-maximal bilateral landings) are introduced to prepare for higher-intensity demands.

Advanced Plyometrics Single-leg plyometric training and advanced strength work dominate this phase. We aim for functional goals like an 80% limb symmetry index or 1.5× body weight on leg presses. This phase is about translating strength into power and functional movement.

Return to Sport Here, sports-specific training and multidirectional movements take priority. A safe return to play requires not only physical readiness but psychological confidence, assessed through validated tools and a multidisciplinary team (MDT) approach.

Why This Approach Works:

Recent research highlights the effectiveness of criteria-based protocols:

• Tailored Programs: Improve outcomes and reduce re-injury rates, ensuring progress at each phase of recovery (Griffin et al., 2020; Hewett et al., 2019).
• Strength and Neuromuscular Control: Critical for knee stability, reducing risks of compensatory injuries and re-injury (Krebs et al., 2021).
• Psychological Readiness: Athletes report higher confidence and readiness to return to sport when mental readiness is prioritised (Fitzgerald et al., 2020).

Conclusion:

Recovering from an ACL injury isn’t just about regaining movement it’s about returning stronger and more prepared for the challenges ahead. A criteria-based approach ensures that every phase of rehabilitation has clear goals tailored to each athlete’s unique needs.

References:

• Fitzgerald, G.K., Paterno, M.V., and Myer, G.D. (2020). Psychological readiness to return to sport after ACL reconstruction: A systematic review. Journal of Orthopaedic & Sports Physical Therapy, 50(10), pp. 558–566.
• Griffin, L.Y., Albohm, M.J., and Arendt, E.A. (2020). Understanding and preventing noncontact anterior cruciate ligament injuries: A review of the literature. Sports Health, 12(3), pp. 240–246.
• Hewett, T.E., Myer, G.D., and Ford, K.R. (2019). Preventing knee injuries in athletes: An evidence-based approach to training. Clinical Sports Medicine, 38(1), pp. 1–24.
• Järvinen, T.A.H., Järvinen, T.L.N., and Kalimo, H. (2021). Rehabilitation of the anterior cruciate ligament: A review. Sports Medicine, 51(3), pp. 447–461.
• Krebs, A., Naal, F.D., and Maffulli, N. (2021). The role of structured rehabilitation in the management of anterior cruciate ligament injury: A systematic review. British Journal of Sports Medicine, 55(12), pp. 684–690