When Surgery Goes Well But Recovery Doesn’t
Maria S. had a straightforward ankle fracture. The surgery went well. The recovery did not. This is the story of what happened — and why it matters for every claim team managing a physical injury case.
The Claim
A successful surgery. A stalled recovery.
On paper, Maria’s case looked manageable. An ankle fracture sustained at work. Surgical repair. A clear treatment plan. A patient who, by all physical measures, should have been progressing.
But weeks into recovery, something was wrong. Physical therapy appointments were being missed. The return-to-work timeline was slipping. And when her case manager spoke with Maria, it became clear that the barrier wasn’t physical, or at least, not only physical.
This is a case about what happens when the injury heals but the fear doesn’t. And it is more common than most claims teams realize.
Meet Maria
Ten years of showing up for animals and the people who loved them.
Maria had been a veterinary technician at a busy clinic for a decade. She was the kind of person who remembered names, both human and animal. She had a foster dog at home most of the time, and some of her closest friendships started in weekend dog-walking groups.
She had always been a little nervous around large farm animals. It never stopped her from doing her job well. It was just a quirk she had learned to manage.
One afternoon, during routine rounding at a stable, a horse spooked and kicked her ankle. The fracture required surgery. By all clinical accounts, the procedure was successful.
What followed was not.
| “The procedure went well, but what followed did not. Maria experienced significant pain — more than she was expecting.” |
What Happened After Surgery
Pain turned into fear. Fear turned into avoidance.
Maria’s pain after surgery was more intense than she had anticipated. That gap between expectation and experience, common, and not her fault, triggered something that would become the real obstacle in her recovery.
She became afraid to move her injured ankle. Every twinge of discomfort felt like evidence that something was wrong, that she might cause further damage, that the surgical repair wasn’t holding. She began to limit her movement well beyond what her surgeon had recommended.
Physical therapy, the treatment most likely to restore her function, became something she dreaded. She started canceling appointments, then missing them without calling. Her physical therapist noted the pattern; the case manager did too.
Meanwhile, the prospect of returning to work, to a job that required her to be on her feet, to occasionally work around large animals, was moving from uncertain to frightening. Maria had always been a little nervous around horses. Now she had reason to believe they could genuinely hurt her. The same stable she had worked at for years had become, in her mind, a place of danger.
Her recovery wasn’t stalling because the surgery failed. It was stalling because fear was driving her behavior — and her behavior was preventing the very activities that would have helped her heal.
| What the case manager observed Repeated physical therapy cancellations and no-shows. A return-to-work timeline slipping significantly beyond the expected benchmark. Statements from Maria suggesting she didn’t think she could return to her previous role. Growing hesitation and withdrawal during check-in calls. |
The Referral
Something felt off. A case manager made the call.
Maria’s case manager had been in workers’ compensation long enough to recognize that what he was seeing wasn’t typical. The physical injury was healing. The clinical picture didn’t explain the plateau. Maria wasn’t being difficult, she was frightened.
He referred her to Ascellus Behavioral Health.
That referral, made before the claim became formally complex, before the timeline extended so far that course-correction would become difficult, is exactly the kind of early recognition that changes outcomes in this work.
| A note on referral timing Ascellus data and the published research are consistent: behavioral health intervention is most effective when it happens early — ideally within the first 90 days of a claim. The referral does not require a psychiatric diagnosis or a formal determination that the claim has a mental health component. It requires a clinical question: is something behavioral getting in the way of this worker’s recovery? |
The Assessment
What a behavioral health evaluation found in a physical injury case.
At intake, the clinical picture was clearer than the claims file had suggested. Maria presented with elevated anxiety, significant fear of movement, and trauma-related symptoms — all of which were directly interfering with her recovery. None of this required a psychiatric diagnosis. It required recognition and a structured response.
Three standardized measures were administered at intake to establish a clinical baseline. The results confirmed what her case manager had observed: Maria was not simply being non-compliant. She was experiencing a level of psychological distress that was making recovery genuinely difficult.
| Measure | What it assesses | At referral | At discharge |
| PCL-5 | Trauma symptoms (0–80; higher = more severe) | 37 | — Part 2 |
| GAD-7 | Anxiety (0–21; 15+ = severe) | 15 | — Part 2 |
| PHQ-9 | Depression (0–27; 10–14 = moderate) | 10 | — Part 2 |
Discharge scores will be published in Part 2 — May 2026.
Importantly, no psychiatric diagnosis was added to Maria’s claim. Despite measurable psychological distress, the intervention was framed within a medical management pathway focused entirely on functional recovery. This is one of the core commitments of Ascellus Behavioral Health: right-sized care that addresses what is actually impeding recovery, without unnecessarily expanding the claim.
Ascellus maintains a rate of under 2% for adding psychiatric diagnoses to physical injury claims.
The Treatment Approach
Eight sessions. Work-focused. Evidence-based. Not what most people picture when they hear ‘behavioral health.’
Maria completed eight sessions using the Work-Focused Unified Protocol — a structured, evidence-based behavioral health treatment designed specifically for situations like hers: a physical injury complicated by fear, avoidance, and a stalled recovery arc.
This is not general outpatient therapy. There are no open-ended conversations about childhood or life history. The treatment has a clear structure, clear goals, and a clear endpoint. Every session is oriented toward one question: what does Maria need to be able to do to return to work, and what is currently standing in the way?
| “Instead of challenging her skepticism directly, her treating psychologist worked with her to map out what returning to work would actually require — and what continuing on her current path might cost her.” |
The first session focused on motivation. Maria was skeptical that a behavioral approach could help with something that felt so physical. That skepticism was respected, not dismissed. It became the starting point for a conversation about what recovery would require and what was at stake if the current pattern continued.
From there, treatment progressed through a structured set of modules: understanding how pain is processed in the brain, developing more accurate mental frameworks around physical sensation, identifying the specific avoidance behaviors that were reinforcing her fear, and beginning to replace them with deliberate alternatives.
The clinical concepts at work — fear-avoidance, pain catastrophizing, graded exposure — are well-established in the research literature and highly applicable to workers’ compensation. What matters in practice is how they are applied: in a context that is non-stigmatizing, work-focused, and oriented toward the functional goals that actually matter for a return-to-work outcome.
| What ‘work-focused’ means in practice Every session tracked Maria’s progress on functional goals directly tied to her job: weight-bearing tolerance, movement confidence, ability to be in environments with large animals. Clinical improvement was measured not just on standardized scales, but on the specific capacities her work required. |
What Happened Next
The results are not what most claims teams expect.
Maria completed her course of treatment. Her case manager received clear, WC-aligned documentation at every stage. Her primary treating physician made the return-to-work determination based on functional readiness, not just physical clearance.
What happened to the claim — the return-to-work timeline, the clinical measures, and what it meant in terms of cost and indemnity exposure — is the subject of Part 2.
We will share those numbers next month. They are worth waiting for.
| Coming in Part 2 What happened when Ascellus intervened — and what it meant for the claim Maria’s outcomes tell a story that challenges how most claims teams think about physical injury cases. The numbers are not what you’d expect — and the implications for your claims are real. Part 2 publishes in May. |
| Seeing signs of stalled recovery in a physical injury claim? Ascellus Behavioral Health delivers work-focused, evidence-based behavioral health intervention built specifically for workers’ compensation. If something feels off about a recovery trajectory, we can help you find out why — and what to do about it. ascellus.com | partners@ascellus.com | 866.678.2924 |
Case details have been modified to protect patient privacy. Clinical measures are presented as reported at intake. ODG benchmarks referenced are for injury type and complexity profile and are used to contextualize outcomes, not as direct comparisons. Discharge data and outcomes will be published in Part 2.
