A Mini Review of Kinesiophobia in Sport and Fitness Populations Following Anterior Cruciate Ligament Injuries

Musculoskeletal injuries, such as a rupture or tear of the anterior cruciate ligament (ACL), are particularly common in sport and exercise settings. Previous literature indicates that severe injuries, especially those that limit or terminate physical activity or athletic involvement, can lead to emotional and psychological difficulties [1]. Post-ACL recovery entails a comprehensive healing process after an ACL tear or rupture, that often involves a reconstruction surgery and structured physical therapy. Similar to the progression of physical therapy that is used to reduce swelling, restore knee range of motion, rebuild muscular strength, and safely return the patient to normal unrestricted activities, Quinn and Fallon (1999) suggest that the psychological recovery from injury must also progress in a stage-like fashion [2-4]. Thus, a concentration of research literature regarding injury recovery has highlighted the emotional responses and mental aspects of rehabilitation. Since ACL injuries are considered a major injury that requires longterm rehabilitation and reconditioning, psychological therapy and mental skills are commonly incorporated in the recovery process. Previously studied ACL rehabilitation interventions and treatments included the use of imagery [5], cognitive-behavioral based therapy [6], goal setting [7], visual modeling [8] or Video-Insight [9], and educational app-based support [10]. These approaches have been used with ACL-injured populations to aid in psychological readiness or the psychological preparedness to return to physical activity and sport following injury. Key components of psychological readiness are those such as confidence, motivation, coping skills, and lack of hesitation, but the most concerning for individuals recovering from ACL injury is kinesiophobia [2,11-14].

For the review of literature pertaining to kinesiophobia, database searches of MedLine (PubMed) and SPORTDiscus with Full Text (EBSCOhost) included publications from inception through March 1, 2024. The search criteria included a combination of keywords and subject headings representing “anterior cruciate ligament injury”, “ACL injury”, “kinesiophobia”, “injury fear”, and “reinjury anxiety”. Database filters were utilized to remove publication types such as systematic reviews, conference abstracts, editorials, or magazine articles. From the database search on March 1, 2024, a resulting 16,769 articles were imported into a web-based application called Rayyan where articles were first screened. To be included in this review, articles were delimited to those written in English, published in a peer-reviewed journal, accessible for full-text review, and reported original data collected from human participants. Only publications that utilized the Tampa Scale of Kinesiophobia, the most commonly used measure of kinesiophobia, and particularly those that involved participants of an anterior cruciate ligament injury were considered. Screening of articles was conducted first by reviewing the article titles and abstracts. After the initial abstract review, 258 articles were deemed relevant with ACL psychological recovery, kinesiophobia, and injury-related fears. Full-text reviews, including a manual search for eligible relevant references, were conducted to exclude 187 articles for various reasons. Of the total screened 258 articles, a resulting 71 studies were selected to be included for this review.

Upon analysis of the research design, psychometric measures, participants, sports, and results, the 71 included studies were sourced from peer-reviewed journals. All included studies were published from 1983 to 2024 and involved populations of ACL patients, with 90% of studies including athletic populations. Of the 71 total studies, the majority of research utilized quantitative approaches such as cross-sectional, prospective, retrospective, random controlled, and case study/series designs. Two studies were of qualitative research designs [15,16], and only one used a mixed methods approach [11]. Only studies that incorporate the Tampa Scale of Kinesiophobia (TSK), as opposed to other kinesiophobia or pain catastrophizing scales, were considered in this review. However, studies utilized various versions of the TSK that included 17 items (TSK-17), 13 items (TSK-13), or 11 items (TSK-11). The most frequently used kinesiophobia measures were the TSK-17 and TSK-11 with 35 studies utilizing each respectively; only one study used the TSK-13 [6]. Several of the included studies in this review tested the translation of the TSK into different languages such as Japanese [17], Dutch [18], Swedish [19], Italian [20], Brazilian-Portuguese [21], and Spanish [22]. The TSK has also been used as a validation measure for the development of other kinesiophobia scales such as the ACL Return-to-Sport After Injury Scale (ACL-RSI) [23] or the ACL Reasons Survey [24], also utilized in various languages such as Turkish [25], Brazilian-Portuguese [26] and Swedish [27].

Of the 71 included studies, there were a total of 5,520 participants ranging from 14 to 60 years of age (M = 24.7). Most studies (n = 44) included more male participants (61.9%) than female participants (38.1%), with some studies exclusively sampling males [3,7,28,29] while only two studies sampled females only [30,31]. Eighteen studies involved samples of non-athletic populations [32-34], while other studies sampled from various levels such as “physically active adults” [35,36], recreational athletes [37,38], and semi-professional athletes [3,39]. Some of the athletic-based studies included samples from specific sports such as soccer [22,26,39], handball [7], football [40], running [41], karate [42], gymnastics [47], and various others.

The terms “kinesiophobia”, “fear of reinjury”, and “reinjury anxiety” have been used synonymously in previous literature; however, a careful examination reveals important differences between the three [43]. The American Psychiatric Association (2013) defines anxiety as a state of worry in anticipation of a potential threat [44]. General anxiety, then, given the complexity of ACL injuries (i.e., surgical versus non-surgical recovery strategies, surgical graft types, concomitant injuries, etc.), may be considered a normal response as many patients await the uncertainties of the rehabilitation process [45]. Continually, given the prevalence of secondary ACL injuries, reinjury anxiety related to the anticipation or uncertainty of a potential reinjury to either the same ACL or contralateral knee ligaments, may also be deemed as a rational response [45,46]. Fear, although similar to anxiety, is an emotional reaction in response to a threat [44,47]. Little et al. (2023) explained that fears throughout the ACL recovery process are multifaceted and are driven by underpinning psychological (i.e., self-identity, loneliness, rumination, anxiety, trauma) and socio-economical (i.e., impact of financial situations, time away from work/sport) factors [16]. However, as the anxieties and fears that accompany an ACL injury do not typically resolve with time, reinjury anxieties and fears may be determined as an irrational emotional response [12,29,48,49]. A pilot research study by Van Wyngaarden et al. (2021) even found that some post-ACL patients reported to still experience fears of reinjury up to ten years after their injury [49].

It is this persistent and lingering fear of reinjury that distinguishes the term kinesiophobia, described as the excessive and debilitating fear of movement or physical activity or injury [45,50,51]. Kinesiophobia was originally introduced in the context of those who suffer from chronic pain [52]; however, in the case of post-ACL patients, actual pain levels may not be the key concern [45,51,53]. The term “pain catastrophizing” has been commonly associated with kinesiophobia, which refers to the exaggerated negative reactions that one has to a painful experience [53,54]. Although the perceptions of pain differ from person to person, pain catastrophizing may intensify one’s feelings of helplessness and negative thoughts during the injury recovery process [54,55]. Gulrandhe et al. (2021) references the fear-avoidance model to explain that those recovering from ACL injury may experience the negative emotions associated with pain due to their exaggerated fears [56].

Post-injury pain levels and pain catastrophizing, however, are inconsistent and greatly fluctuate throughout the months of ACL recovery [53]. Since 70-80% of ACL injuries occur from accidental or non-contact movements, kinesiophobia for ACL recovery patients typically encompasses the fear of movement [51,57]. Particularly within athletics and fitness, many post-ACL athletes develop hesitation or fear of sports-related activities that mimic the cause of their original knee injury [58]. Meierbachtol et al. (2020) reported that post-ACL recovery patients showed increased kinesiophobia levels during rehabilitation with fear-evoking situations or movements such as jumping, cutting, pivoting, or changing directions; kinesiophobia also increased as the intensity and complexity of movements advanced, typical in the progressive nature of the rehabilitation process [3,4,33,59]. Thus, according to the fear-avoidance model, athletes’ kinesiophobia or injury-related fears, if not addressed, may develop into movement or activity avoidance [32,45,51,60]. Padaki et al. (2018) reported that more than 87% of athletes who endure an ACL injury often experience symptoms of avoidance and post-traumatic stress disorder, along with kinesiophobia [61]. Thus, post-ACL kinesiophobia may affect athletes’ mental health and wellbeing, which in turn, can significantly hinder their injury recovery and physical rehabilitation.

Recognizing the likelihood of ligament retears or contralateral injuries amongst ACL-recovering individuals, the coupled focus of physical rehabilitation and psychological preparedness is crucial for recovery success [13]. Previous research indicates that kinesiophobia may relate to several physiological outcomes [62], such as poor knee function [39,63-67], poor joint biomechanics (i.e., knee flexion, hip flexion, knee abduction angle) [30,39,68], gait and plyometric asymmetry [28,36,39,69-70], poor quadricep and hamstring muscle activation [35-37,69,71], and patellafemoral pain [72]. For example, Baez et al. (2023) found that post-ACL patients with high kinesiophobia levels reported to have experienced more persistent knee-related symptoms following their ACL reconstruction [68]. The physiological results of an ACL injury continue to affect not only the individual’s physical recovery but also is associated with a poor knee-related quality of life [40,73,74]. Consequently, post-ACL athletes with high kinesiophobia tend to have lower physical activity levels following their injury [48,75]. These consequences of kinesiophobia influence the rehabilitation progress and the individual’s physical preparedness to resume exercise or sport activities.

Nonetheless, the choice to return to sport and physical activity after an ACL injury is multifaceted and relates to the athlete’s perceived satisfaction of their rehabilitation. Ardern et al. (2016) illustrated an adapted biopsychosocial model that includes the various physical, psychological, and social/contextual factors that are incorporated into the decision to return to sport such as functional performance, perceived pain levels, motivation to return, and recovery expectations [83]. Those with high confidence in their knee and physical reconditioning, high sport satisfaction or “love of the game” [76] and high psychological readiness tend to return to their sport after injury [38,76-79]. Although many athletes and fitness enthusiasts report that kinesiophobia was the primary reason for not returning to sport or certain physical activities [43,80], approximately 45-49% of athletes still choose to resume their sport involvement [81,82]. Of those who returned to sport, their levels of kinesiophobia tend to be lower than those who chose to refrain from sport, indicating that kinesiophobia and psychological readiness may be negatively correlated [84-86]. However, this relationship is not consistent across the research literature and is not predictive of athletic success following activity return. McPherson et al. (2019) and Zarzycki et al. (2024) found that post-ACL athletes who reported to have high psychological readiness and low kinesiophobia levels were at a high risk for a second ACL injury, and although kinesiophobia generally diminishes as ACL rehabilitation progresses [12,31,34,87-92], this does not mitigate the fact that 37% of athletes suffer from a second ACL injury within two years of returning to sport [13]. Continually, Webster et al. (2008) reported that post-ACL recovery patients who had returned to sport within 12 months experienced more negative emotions, lower confidence levels, and more frequent thoughts of reinjury fears [23]. Thus, as many athletes would like to return to sports and fitness activities as quickly as possible, this may not be the best option in regard to their recovery and long-term physical and psychological health.

In conclusion, this review provides a comprehensive overview of the existing literature on kinesiophobia in the context of ACL injury recovery, particularly among athletes and fitness enthusiasts. As primarily quantitative methodologies have been used in the past to examine kinesiophobia, there is a gap in research regarding the use of qualitative and mixed methodologies to understand this complex psychological construct. Qualitative information from athletes’ accounts of severe injuries may provide details of the thoughts, feelings, and attitudes experienced throughout the recovery process. Particularly, as the majority of participants in the included studies were males, inquiry of female athletes’ perspective may provide further insight of their particular fear-related challenges of post-ACL recovery.

Anterior cruciate ligament injuries typically involve extensive periods of physical rehabilitation and psychological recovery; thus, a multifaceted approach is required. Particularly, as many post- ACL recovering individuals aim to return to physical activity and sport participation following injury, previous research highlights the importance of psychological therapy and mental skills training to address the challenges faced during rehabilitation. It has been widely reported that kinesiophobia, or the excessive fear of movement or reinjury, is the most common concern among post- ACL injury patients. Often associated with pain catastrophizing, avoidance behaviors, and lack of confidence, it can significantly hinder recovery, as well as facilitate long-term psychological consequences. For example, individuals experiencing kinesiophobia may lack confidence in their ability to perform physical tasks, or physical self-efficacy. Thus, understanding the intersection of kinesiophobia and its potential effects on injury recovery can lead to earlier identification and intervention to prevent or minimize its impact. Raising awareness among athletes, coaches, and healthcare professionals about the psychological factors of injury recovery may provide a more supportive environment, promote psychological well-being, and facilitate successful rehabilitation.

None.

No conflict of interest.

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