As sports fans, we are all too familiar with ACL injuries.

So many players from our favorite college and pro sports teams have suffered anterior cruciate ligament injuries that we can often predict the diagnosis when television cameras show a gruesome knee injury. And we know what to expect for the player and the team. We read about our heroes having surgery and missing the rest of the season but ultimately

returning the following year.

So when our sons and daughters suffer these same injuries, we can expect that they will return to sports uneventfully, right? As ESPN's Lee Corso likes to say, "Not so fast."

A study presented earlier this month at the American Orthopaedic Society for Sports Medicine's Specialty Day in San Francisco raises concerns about successful return to sports after ACL tears. The authors examined data from the Multicenter Orthopaedic Outcomes Network, where they collected data from high school and college football players over a two-year period.

While sports medicine surgeons have largely believed that success in terms of return to sports is very high after ACL reconstruction, in this study only 62 percent of the high school football players and 70 percent of the collegiate athletes returned to play.

According to the authors, psychological factors played a significant role in players' failure to return to sports. They questioned the players' perception of their own skill and performance after returning from ACL surgery.

At the high school level, 45 percent said they returned to play at the same skill and performance level, while 26 percent returned at a lower level. College players fared worse, with 36 percent saying they returned at the same level and 32 percent at a lower level. Of the performance- related causes noted for not returning to play at all, fear was a major or contributing factor in over half of high school players and just under half of college players.

Author Dr. Kurt P. Spindler pointed out one of the key messages from this data: "While return to play may be perceived as the central concern for a competitive athlete recovering from an injury, it is easy to ignore psychological factors keeping a player off the field. Fear of re-injury and concern over decreased performance may hinder even the most physically capable athlete."

While parents reading this might be inclined to dismiss these findings if their sons or daughters play a sport other than football, I would caution against doing so. I hear athletes of all sports, genders and ages express anxiety about playing on their surgically reconstructed knees. They are scared about the first time they will be hit, land on it or turn suddenly. Maybe they retain vivid memories of their knees buckling initially or maybe they just lack confidence, but these fears are real.

Unfortunately, there might not be an easy solution to these psychological issues. Surgeons can create new ligaments that are more than strong enough to protect the knee. Physical therapists and athletic trainers can aggressively rehabilitate the athlete and restore full strength, motion and functional ability. But it might be reasonable to include sports psychologists and counselors in the sports medicine teams working with athletes after major injuries and surgeries. Parents and coaches could also maintain an open dialogue with the athletes to recognize signs that they are afraid to play.

For decades, sports medicine research has focused on improving surgical techniques, rehab protocols and even injury prevention programs, and rightly so. But we need to start addressing psychological aspects of sports injuries. The latest arthroscopic technology or most glamorous sports performance program will be irrelevant if the fear of re-injury compromises an athlete's return to play.

Dr. Geier is an orthopaedic surgeon and Director of MUSC Sports Medicine. For more information about ACL injuries and other sports medicine topics, go to Dr. Geier's blog at drdavidgeier.com.