Marlee Nicolos had thought it to be almost a forgone conclusion that she would someday tear an ACL. It seemed to happen to everyone, and someday it would happen to her too.
That didn’t soften the blow when the Santa Clara women’s soccer goalie suffered a knee injury at the end of her freshman season. Then, when she tore it again in September 2021, it just seemed cruel.
“It’s a club I didn’t want to be a part of,” she said. “But now that I’m here, I’m so proud of everyone who has been through it.”
Although studies have uncovered just how prevalent these injuries are in athletes, numbering in the hundreds of thousands annually, and specifically in women’s soccer players, who are four-to-six times as likely to tear an ACL than their male counterparts, researchers and medical professionals are just beginning to grasp their mental toll.
Getting injured while playing a sport is its own form of loneliness; a player not only loses her ability to participate in something she’s really good at, but also a sense of community. Sure, she can spend time with teammates and attend games, but it’s not the same as when she’s a contributor.
That is a reason 40% of athletes who tear their ACL deal with anxiety and depression in the aftermath, according to the Stone Clinic.
The sports world is facing a mental health reckoning. This story is part of a series examining the challenges faced at all levels of competition and how they are being addressed.
Stanford forward Emily Chiao’s history of knee trauma did not prepare her for the mental rigors of the nine-month rehabilitation after tearing her ACL moments into the first game of the 2021 season.
“It’s really traumatic, like I pushed (the play) out of my mind completely,” Chiao said. “Then sometimes laying in bed I would think, here’s what happened at that moment. I never wanted to see the video and still haven’t. I can play through it all in my head.
“An ACL is really daunting in general,” she said. “You have to get a handle on the fact that you wake up in bed and can’t lift your leg up. It feels like you’re hitting a milestone every day.”
Around 34% of soccer players who tear an ACL do it a second time. One study in the Journal of Athletic Training said any primary ACL injury causes a cascade of altered neuromuscular control that influences the risk of secondary injury.
Nicolos wasn’t as shaken the second time around by the changes out of her control — the fact her legs were different sizes as her muscles receded, for example — and tried to focus on the grueling process of rebuilding leg strength.
Between her past experience and the growing list of soccer players in her life who could give qualified advice, it felt like another rite of passage.
“I had a small comfort that I knew what to expect,” Nicolos said. “It’s sad, but it’s a part of women’s soccer. I have so many friends who have done it.”
Above: Santa Clara goalie Marlee Nicolos has torn an ACL twice. Left: USF freshman midfielder Cade Mendoza (17) suffered an ACL injury while she was still in high school.
Scott Strazzante, Staff Photographer / The ChronicleNicolos, a communications major who will have two more seasons with Santa Clara, made a film about ACL recovery after her second injury for one of her classes.
“Once it’s happened to you, it’s close to your heart,” she said.
For some, like Jordan Angeli, it happens three times or more.
“Everyone always called me mentally tough,” said the former Santa Clara player (2004-06) who now works as an analyst on Columbus MLS broadcasts. “And then I was struggling mentally, and I thought wow, if I am, it must be tough for everyone. No mental toughness is going to allow you to get through this. You have to learn how to set some of those thoughts aside.”
The Journal of the American Academy of Orthopedic Surgeons cited a study that stated “ACL-injured patients demonstrated seven times more depression compared with their baseline and were found to experience mood disturbances and lowered self-esteem.”
Angeli’s first two surgeries were within a year after her graph surgery was not done correctly the first time. She tore it again on a non-contact play when going up for a header, and a third time when she was tackled in her first professional season.
“I knew it shouldn’t feel like that,” she said.
In her isolation, Angeli found community in the physical and mental trauma of ACL recovery. She founded the ACL Club in 2015 and a podcast that highlights athletes who have been through the injury.
“I felt like people were craving a community,” she said. “It’s traumatic when you feel it. Your knee is essentially dislocated, and then the ACL is torn. That’s a feeling that you never want to feel ever again. It’s such an unnatural feeling.”
While ACL recovery times are quicker and surgeries less invasive than in decades past, the increase in prominence among elite women’s athletes can be attributed to year-round play in a single sport from young ages, said Nirav Pandya, Associate Professor of UCSF Orthopedic Surgery.
“The hard thing has been at lower levels,” Pandya said. “I’ve seen girls who need surgery and I’m like, God, you’re 10 years old and you just tore your ACL.”
Santa Clara’s Sally Menti (right), recovering from an ACL injury, stands on the sidelines with teammate Lucy Mitchell, who is recovering from an ankle injury.
Scott Strazzante, Staff Photographer / The ChronicleYear-round female athletes who play soccer or basketball have a 5% chance of tearing their ACL each year they participate in their sport. That represents a 20% chance of tearing an ACL while playing high school soccer.
The collegiate careers of USF freshmen Hannah Burns and Cade Mendoza will be all post-ACL recovery. They had both already committed to play for the Dons when they suffered their injuries.
Some committed athletes worry about losing their scholarship if they get injured as a high school upperclassman. Mendoza said USF assured her that she was not at risk, but anxiety still took hold in her mind.
“There was nothing you could do, you can’t reverse it,” she said. “I definitely cried here and there.”
Mendoza and Burns bonded over their injuries at different points in recovery. They both also got advice from senior Marie Marlow, who tore her ACL last season.
“We consoled each other because soccer is our life, and now you’re so abruptly outside of it,” Mendoza said. “It’s a glass box, you can see it, but you can’t go into it.”
Burns’ process has been particularly challenging; she didn’t get surgery until three months after the initial injury. She’s started practicing on her own, but watching the Dons from the sideline has been both a blessing and a curse for her mental recovery.
“At first it was hard,” she said. “We have home games you go to and it makes you want to play. The first few months were the hardest, trying to wrap your head around how this happened.”
Athletes who tore an ACL when pandemic restrictions were in place faced even deeper isolation, making recovery more emotionally daunting, Nicolos and Mendoza both said. Most classes were remote, or with social distancing. Being on a team lacked its usual closeness. In college soccer for the first fall back, players could only pass with one teammate at practice.
The mental health side effects of injury recovery are only just beginning to be analyzed in the medical industry.
At Santa Clara, athletes are screened for anxiety and depression during recovery, said the school’s sports psychologist, Tyler Webster.
“Systemically we’re building this idea that in order to deal with this big loss (of a season or career) you need to focus on the emotional and mental impact,” Webster said. “Before, in sports, it was always you hide your injuries and recover as fast as you can and only sit out if it’s really bad. Now I think we all know that’s not the best practice anymore.”
Young players recovering from ACL injuries, from college to as early as middle school, face unique challenges in that their minds and bodies are experiencing trauma at a formative age.
“You’re taking a young teenager with knee surgery, and they start to get degenerative changes in their knees at 19 or 20 years old,” Pandya added. “A lot of times athletes concentrate on the short term, but seven or eight years from now, the knee is going to hurt even more. We don’t yet know the other effects that can have on your mind as well.”
After Nicolos tore her ACL the first time, she experienced a mental block when running backwards and coming to a full stop that left her unsure if she could return. She felt lost.
Ultimately, she broke through thanks to visualization-technique sessions of the game, where everything down to what she could smell at the time of the injury was replicated.
“So she had to really visualize herself making that motion over and over again where she didn’t get injured,” Webster said.
The second time she tore it, there wasn’t a clear play Nicolos could point to for the trauma, so the return hasn’t been as difficult mentally from that perspective. She just knew when throwing the ball that something was wrong and felt a tweak after getting hit in the previous game.
“Not knowing if her knee would hold up or is strong enough to do the things she’s used to, that was a real fear,” Webster said. “A lot of the coping is around that anticipated anxiety.”
That lingering anxiety is common in this club.
Sometimes Chiao still pauses when she feels a tweak in her knee. Mendoza cited frustration that she couldn’t burst towards the ball as quickly as she used to. Burns is still unsure what that first time back on the field is going to feel like.
Twice through it, Nicolos knows how they feel. The fear hasn’t been absolved from her mind entirely, but the joy of returning to soccer has surpassed that as she’s gone on to start every game this season for Santa Clara.
She hopes to someday see a landscape where ACL tears aren’t a rite of passage for elite women’s soccer players.
“Getting the first game under my belt was a sigh of relief,” she said. “Like I can do it, this didn’t ruin my life.”
Marisa Ingemi is a San Francisco Chronicle staff writer. Email: [email protected]