A common measurement of success for anterior cruciate ligament (ACL) reconstruction surgery is whether or not the individual is able to return to the sporting activities they enjoyed before injury (1). Over 90% of patients who undergo ACL reconstruction regain full knee function, however approximately 37% of patients do not return to their pre-injury athletic activities (2). Fear of reinjury is the most commonly cited reason for individuals who do not return to some of the activities that they participated in prior to injury (3). Identifying and addressing reinjury fears are crucial aspects of encouraging people to resume their pre-injury lifestyles and increasing the recovery success of ACL reconstruction surgeries.
The fear of injury or reinjury is common enough to have received an official definition: kinesiophobia. Kinesiophobia is defined as “an excessive, irrational and debilitating fear of physical movement and activity resulting from a feeling of vulnerability to painful injury or reinjury” (4). While anyone is susceptible to the fear of reinjury, it is often seen in elite athletes who must engage in aggressive athletic activity shortly after their recovery (5). Furthermore, as the age of a patient increases, fear of reinjury becomes more likely to change their lifestyle habits and/or prevent them from returning to pre-injury athletic activities (3). However fear of reinjury is not static and tends to decrease as time goes by after surgery (6). Post-ACL reconstruction fears have been hypothesized to fall under the fear avoidance model of skeletal pain (6). This model predicts that pain from an injury is perceived as a threat and that in response, an individual modifies their behavior to avoid pain (6). If left unbroken, this habit can potentially lead to long-term repercussions for knee health.
Fear of reinjury interferes with rehabilitation and has negative consequences for an individual’s recovery. Fear of reinjury may cause patients to avoid aspects of their rehabilitation that they find painful or uncomfortable (2). While these fear-inducing movements vary by individual, they are often basic, low-level movements that may not take tremendous effort but nonetheless induce fear of reinjury (2). This can lead to long-term deficits in knee function, as shown in a study examining ACL reconstruction patients that found fear of reinjury to be inversely related to knee functionality (6). The avoidance of painful movements and a failure to fully engage with the rehabilitation process can result in decreased strength and range of motion, prolonging the negative effects of an ACL injury (4, 3).
Ultimately, an individual’s fear of reinjury may play a large role in determining whether or not they will be able to return to pre-injury sports. Fear of reinjury has been found to be correlated with lower confidence levels in athletes’ ability to engage in athletic activities, as well as a lower likelihood that the individual will return to their sport (7). The negative lifestyle implications of fearing reinjury extend beyond returning to athletic activities, given that fear of reinjury may lead to sedentary behavior and weight gain (7).
Given the potentially devastating and avoidable consequences that accompany excessive fear of reinjury, physical therapists are actively searching for ways to help individuals overcome their post-surgery reinjury fears. A study recently found that patients who fear reinjury are more likely to have weaker quad strength post-surgery (3). It has been suggested that identifying and addressing this initial weakness soon after surgery may prevent individuals from succumbing to excessive reinjury fears (3). Progressive exposure to and conquering of scary, painful movements may also be an effective intervention for individuals who are reluctant to fully engage with their rehabilitation process (2). Additionally, addressing fears of reinjury cognitively through goal setting, relaxation, mental imagery and positive self-talk can augment the progress made in physical therapy (8).
Fear of reinjury is a serious long-term consequence of ACL injuries and its long-lasting effects highlight the importance of preventing ACL injuries in the first place. Esurgi is currently developing a real-time, wearable device that will allow athletes to pinpoint when and if they engage in movements that are considered high-risk for ACL injury. This device, called “JointSpy,” aims to reduce ACL injuries by providing athletes a better sense of which movements should be avoided during athletic activity. How would JointSpy help you rehabilitate athletes with ACL injuries?
1. Kvist, J., Ek, A., Sporrstedt, K., & Good, L. (2005). Fear of re-injury: A hindrance for returning to sports after anterior cruciate ligament reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy, 13(5), 393-397. doi:10.1007/s00167-004-0591-8
2. Papadopoulos, S. D., Tishukov, M., Stamou, K., Totlis, T., & Natsis, K. (2018). Fear of re-injury following ACL reconstruction: An overview. Journal of Research and Practice on the Musculoskeletal System, 02(04), 124-130. doi:10.22540/jrpms-02-124
3. Lentz, T. A., Zeppieri, G., George, S. Z., Tillman, S. M., Moser, M. W., Farmer, K. W., & Chmielewski, T. L. (2014). Comparison of Physical Impairment, Functional, and Psychosocial Measures Based on Fear of Reinjury/Lack of Confidence and Return-to-Sport Status After ACL Reconstruction. The American Journal of Sports Medicine, 43(2), 345-353. doi:10.1177/0363546514559707
4. Korri, S. H., Miller, R. P., & Todd, D. D. (1990). Kinesiophobia: a new view of chronic pain behaviour. Pain Manag, 3, 35-43.
5. Notarnicola, A., Maccagnano, G., Barletta, F., Ascatigno, L., Astuto, L., Panella, A., . . . Moretti, B. (2019). Returning to sport after anterior cruciate ligament reconstruction in amateur sports men: A retrospective study. Muscle Ligaments and Tendons Journal, 06(04), 486. doi:10.32098/mltj.04.2016.10
6. Chmielewski, T. L., Jones, D., Day, T., Tillman, S. M., Lentz, T. A., & George, S. Z. (2008). The association of pain and fear of movement/reinjury with function during anterior cruciate ligament reconstruction rehabilitation. journal of orthopaedic & sports physical therapy, 38(12), 746-753.
7. Tripp, D. A., Stanish, W., Ebel-Lam, A., Brewer, B. W., & Birchard, J. (2007). Fear of reinjury, negative affect, and catastrophizing predicting return to sport in recreational athletes with anterior cruciate ligament injuries at 1 year postsurgery. Rehabilitation Psychology, 52(1), 74.8. Nippert, A. H., & Smith, A. M. (2008). Psychologic stress related to injury and impact on sport performance. Physical medicine and rehabilitation clinics of North America, 19(2), 399-418.
8. Nippert, A. H., & Smith, A. M. (2008). Psychologic stress related to injury and impact on sport performance. Physical medicine and rehabilitation clinics of North America, 19(2), 399-418.