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Self-Reported Fear Predicts Functional Performance and Second ACL Injury After ACL Reconstruction and Return to Sport: A Pilot Study
Open accessAbstract
Background: Outcomes after anterior cruciate ligament reconstruction (ACLR) are highly variable. Previous studies have failed to report the relationship between fear, objective measures of function, and reinjury rates. The purpose of this study was to determine whether fear was related to functional performance measures and risk of second ACL injury after ACLR and return to sport (RTS). Hypothesis: Fear will be associated with performance on functional testing and second ACL injury rate. Study Design: Prospective cohort study. Level of Evidence: Level 2. Methods: A total of 40 patients cleared to RTS after ACLR completed the Tampa Scale of Kinesiophobia (TSK-11), hop testing, and quadriceps strength testing, bilaterally. Patients were tracked for 12 months after RTS to identify the incidence of second ACL injury. Chi-square analyses determined whether patients with high fear (TSK-11, ≥17) were more likely to have lower levels of activity, greater asymmetry on functional testing, and higher reinjury rates. Results: Patients with greater fear on the TSK-11 (≥17) at RTS were 4 times (odds ratio [OR], 3.73; 95% CI, 0.98-14.23) more likely to report lower levels of activity, 7 times (OR, 7.1; 95% CI, 1.5-33.0) more likely to have a hop limb symmetry lower than 95%, and 6 times (OR, 6.0; 95% CI, 1.3-27.8) more likely to have quadriceps strength symmetry lower than 90%. Patients who went on to suffer an ipsilateral second ACL injury had a greater TSK-11 score at the time of RTS (mean, 19.8 ± 4.0) than those who did not suffer a second ACL injury (mean, 16.4 ± 3.6) ( P = 0.03). Patients with a TSK-11 score of 19 or greater at the time of RTS were 13 times (relative risk, 13.0; 95% CI, 2.1-81.0) more likely to suffer a second ACL tear within 24 months after RTS. Conclusion: Patients with greater self-reported fear were less active, presented with lower single-leg hop performance and isometric quadriceps strength, and had an increased risk of suffering a second ACL injury in the 24 months after RTS. Clinical Relevance: Self-reported fear of movement/reinjury after ACLR at the time of RTS may be an important measure to incorporate into discharge criteria prior to release to return to pivoting and cutting sports after ACLR.
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Patients with high kinesiophobia (TSK-11 ≥19) at the time of return to sport were 13 times more likely to suffer a graft rupture within 20 years of return to sport compared to those with lower kinesiophobia.
“The same authors reported that patients with high kinesiophobia (TSK-11 score of 19 or greater) at the time of RTS were 13 times more likely to suffer a graft rupture within 20 years of RTS compared to those with lower kinesiophobia (Paterno et al., 2018).”
From The relationship between psychological readiness to return to sport and kinesiophobia in teens and young adults after anterior cruciate ligament reconstruction (2025) · cites this paper as Paterno et al., 2018
The Results report that patients with TSK-11 scores ≥19 at return to sport were 13 times more likely to suffer an ipsilateral second ACL tear. The reported follow-up period was 24 months, not 20 years. (LLM, conf=0.90)
Experimental — accuracy not yet measuredPatients with higher kinesiophobia (TSK-11 ≥17) are four times more likely to report lower physical activity levels (odds ratio 3.73; 95% CI, 0.98-14.23).
“Specifically, Paterno et al. (2018) reported that patients with higher kinesiophobia greater than or equal to 17 on the Tampa Scale of Kinesiophobia (TSK-11) are four times more likely to report lower physical activity levels (odds ratio 3.73; 95% CI, 0.98–14.23)”
From The relationship between psychological readiness to return to sport and kinesiophobia in teens and young adults after anterior cruciate ligament reconstruction (2025) · cites this paper as Paterno et al., 2018
Patients with higher kinesiophobia (TSK-11 ≥17) are six times more likely to have quadriceps strength asymmetry (odds ratio 6.0; 95% CI, 1.3-27.8).
“six times more likely to have quadriceps strength asymmetry (odds ratio 6.0; 95% CI, 1.3–27.8)”
From The relationship between psychological readiness to return to sport and kinesiophobia in teens and young adults after anterior cruciate ligament reconstruction (2025) · cites this paper as Paterno et al., 2018
Patients with higher kinesiophobia (TSK-11 ≥17) are seven times more likely to demonstrate hop test asymmetry (odds ratio 7.1; 95% CI, 1.5-33.0).
“seven times more likely to demonstrate hop test asymmetry (odds ratio 7.1; 95% CI, 1.5–33.0)”
From The relationship between psychological readiness to return to sport and kinesiophobia in teens and young adults after anterior cruciate ligament reconstruction (2025) · cites this paper as Paterno et al., 2018
Higher kinesiophobia is associated with decreased hop performance, reduced quadriceps strength, and increased risk of second injury in youth athletes after ACL reconstruction.
“Higher kinesiophobia has also been associated with decreased hop performance, reduced quadriceps strength, and increased risk of second injury in youth athletes after ACLR (Paterno et al., 2018).”
From The relationship between psychological readiness to return to sport and kinesiophobia in teens and young adults after anterior cruciate ligament reconstruction (2025) · cites this paper as Paterno et al., 2018
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Citations
Cites
Psychometric properties of the TSK-11: A shortened version of the Tampa Scale for Kinesiophobia
Woby, S. R., Roach, N. K., Urmston, M., & Watson, P. J. (2005) · Pain · doi:10.1016/j.pain.2005.05.029 · Cited by 923 · cited 1×
“The TSK-11 is a shortened form of the original version and has been shown to have comparable psychometric properties in patients with low back pain.(34) Scores on the TSK-11 were used to divide patients into 2 groups: those reporting high fear and those reporting low fear.”
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Cited by
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Truong, L. K., Mosewich, A. D., Holt, C. J., Le, C. Y., Miciak, M., & Whittaker, J. L. (2020) · British Journal of Sports Medicine · doi:10.1136/bjsports-2019-101206 · Cited by 205
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Butler, L., Baez, S., Walker, C., Roman, D., Douthit, T., Kuenze, C., Ulman, S., & ARROW (2025) · Frontiers in Psychology · doi:10.3389/fpsyg.2025.1623398 · Cited by 9
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Metadata
- Authors
- Paterno, M. V., Flynn, K., Thomas, S., & Schmitt, L. C.
- Affiliations
- Cincinnati Children's Hospital Medical Center (US)
- Children's Hospital Colorado (US)
- The Ohio State University (US)
- Corresponding author
- Paterno, Mark V.
- Venue
- Sports Health: A Multidisciplinary Approach
- Publisher
- SAGE Publications
- Published
- 2017-12-22
- Volume
- 10
- Issue
- 3
- Pages
- 228-233
- ISSN
- 1941-0921 (ISSN-L)
- 1941-7381
- PMC
- PMC5958451
- OpenAlex
- W2776549039
- Cited by
- 338
- References
- 1
- Citations by year
- 2026: 44 · 2025: 53 · 2024: 52 · 2023: 54 · 2022: 35 · 2021: 42 · 2020: 33 · 2019: 22 · 2018: 3
- FWCI
- 16.18
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Sports Health A Multidisciplinary Approach (publishedVersion)
- Europe PMC (PubMed Central) (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Funders
- Cincinnati Children's Hospital Medical Center
- National Institutes of Health
- National Institute of Arthritis and Musculoskeletal and Skin Diseases (F32AR055844)
- Topics
- Health Sciences › Medicine › Surgery › Knee injuries and reconstruction techniques
- Health Sciences › Health Professions › Physical Therapy, Sports Therapy and Rehabilitation › Musculoskeletal pain and rehabilitation
- Health Sciences › Medicine › Orthopedics and Sports Medicine › Foot and Ankle Surgery
- Keywords
- anterior cruciate ligament reconstruction, second ACL injury, kinesiophobia, fear-avoidance beliefs, return to sport, functional performance, single-leg hop test, Tampa Scale for Kinesiophobia, reinjury risk, knee function, activity level, limb symmetry, isometric strength
- MeSH terms
- Return to Sport, Anterior Cruciate Ligament Injuries, Adolescent, Athletic Injuries, Fear, Humans, Pilot Projects, Prospective Studies, Recurrence, Risk Factors, Quadriceps Muscle, Muscle Strength, Self Report, Anterior Cruciate Ligament Reconstruction
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