March 2014

Fear fallout: Studies explore effects on ACL outcomes

In the moment: Sports medicine

3ITMsports-iStock9923335aBy Jordana Bieze Foster

The best time to address fear of reinjury in athletes after anterior cruciate ligament (ACL) reconstruction may be between three and six months after surgery, according to research from the University of Florida presented in February at the annual Combined Sections Meeting of the American Physical Therapy Association in Las Vegas.

The Florida research was just one of a number of studies on fear of reinjury after ACL reconstruction presented at the meeting—some of which raised as many questions as they answered about the extent to which concern about reinjury is associated with limb symmetry or predictive of return to sports.

Investigators from the University of Florida in Gainesville followed 43 athletes for one year after ACL reconstruction and identified seven who had not returned to sports at one year due to fear of reinjury or lack of confidence. They then analyzed those seven athletes’ scores over time for the Tampa Scale of Kinesiophobia (TSK-11) and the Pain Catastrophizing Scale (PCS).

The researchers found that the TSK-11 scores improved for six months after surgery, then deteriorated between six months and one year. The PCS scores followed a similar trend, but those tended to worsen after the three-month point, which corresponds to the initiation of advanced rehabilitation, according to Trevor Lentz, MPT, CSCS, a staff physical therapist at the university’s Shands Rehabilitation Center, who presented the findings.

“We think potentially the best time to intervene is between three and six months after surgery, but by monitoring PCS scores we may even be able to intervene earlier,” said Lentz, who noted that the presented findings are pilot data for a planned larger study.

In a second study of 42 athletes presented by Lentz at the meeting, the same group found that TSK-11 and PCS scores at six months after ACL reconstruction were not predictive of return-to-sports status at one year. However, they did find that the Knee Activity Self-Efficacy Scale, a measure of confidence, was one of three predictive factors (along with self-reported knee function and quadriceps torque symmetry index).

Interestingly, researchers from the University of Delaware in Newark did find that TSK-11 scores in 34 patients were significantly associated with the ability to meet return-to-sport criteria one year after ACL injury (in patients treated nonoperatively) or ACL reconstruction. However, some of the athletes had actually returned to sports despite not meeting the study’s return-to-sport criteria, noted Kathleen White, DPT, a graduate student in the university’s Biomechanics and Movement Science Program, who presented the findings.

There was also some disagreement among presented studies with regard to fear of reinjury and limb symmetry, a popular component of return-to-sport criteria.

Researchers from The Ohio State University in Columbus found that less fear of reinjury, as reflected by ACL-RSI (ACL-Return to Sports after Injury) scores, was associated with better single-limb hop symmetry in 19 athletes who had been cleared to return to sports after ACL reconstruction.

But a second study from the same university found that less fear of reinjury, based on ACL-RSI scores, was associated with poorer symmetry—specifically with regard to frontal plane kinematics during the initial contact phase of a drop vertical jump—in 10 athletes assessed after being cleared to return to sports following ACL reconstruction. Less surprisingly, a lower fear of reinjury was also associated with better self-reported knee function.

Selena Eskinazi-Budge, PT, a physical therapist in the university’s Sports Medicine Program, who presented the findings at the meeting, suggested the frontal plane asymmetry in the more confident athletes may be compensatory.

“Some of these athletes may be changing their knee kinematics to avoid feelings of instability,” Eskinazi-Budge said.


Lentz TA, Zeppieri G, Tillman S, et al. First-year recovery patterns differ among return-to-sport status groups following anterior cruciate ligament reconstruction. J Orthop Sports Phys Ther 2014;44(1):A51.

Lentz TA, Zeppieri G, Tillman S, et al. Derivation of a prognostic test-item cluster for return-to-sport participation status 1 year following anterior cruciate ligament reconstruction. J Orthop Sports Phys Ther 2014;44(1):A63.

White K, Snyder-Mackler L. Fear- and activity-avoidance scores predict passing return-to-activity criteria 1 year after anterior cruciate ligament Injury or reconstruction. J Orthop Sports Phys Ther 2014;44(1):A63-A64.

Kirby KW, Wadsworth TS, Di Stasi S, Hewett T. Understanding the relationship of fear with knee function at medical clearance following anterior cruciate ligament reconstruction. J Orthop Sports Phys Ther 2014;44(1):A66.

Eskinazi-Budge S, Di Stasi S, Roewer B, Hewett T. The relationship between frontal plane kinematics, self-reported function, and fear of reinjury in anterior cruciate ligament–reconstructed athletes. J Orthop Sports Phys Ther 2014;44(1):A64.

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