To examine the association of fear avoidance and self-efficacy psychological factors within 4 weeks after anterior cruciate ligament (ACL) reconstruction with knee impairment resolution and readiness for advanced rehabilitation at 12 weeks post-surgery.
Seventy-five patients participated. Data collection included demographics; questionnaires on fear avoidance (Pain Catastrophizing Scale, PCS; shortened Tampa Scale for Kinesiophobia, TSK-11) and self-efficacy (modified Self-Efficacy for Rehabilitation Outcome Scale, SER; Knee Activity Self-Efficacy, KASE) at 1, 4, and 12 weeks post-surgery; and knee impairment measures (pain intensity, range of motion, and quadriceps symmetry index) at 12 weeks post-surgery. Readiness for advanced rehabilitation (READY or NOT READY) was determined by knee impairment resolution criteria; demographics and questionnaire scores were compared between groups. Questionnaire scores at 1 and 4 weeks post-surgery and the change between time points were examined for association with knee impairment measures and group assignment.
READY included 32 patients; NOT READY included 43 patients. Questionnaire scores improved in both groups over time. Significant correlations across groups were: PCS scores at 1 and 4 weeks post-surgery with pain intensity at 12 weeks post-surgery (r = 0.24 and 0.29, respectively) and KASE score 4 weeks post-surgery with range of motion deficit at 12 weeks post-surgery (r = − 0.26). Contact injury was more prevalent in READY. After accounting for mechanism of injury, higher TSK-11 and fear of re-injury subscale scores at 4 weeks post-surgery increased the odds of NOT READY assignment at 12 weeks post-surgery (odds ratios 1.10 and 1.31, respectively).
Lower pain catastrophizing and higher knee activity self-efficacy levels 4 weeks after ACL reconstruction were associated with better knee impairment resolution at 12 weeks post-surgery, whereas lower kinesiophobia at 4 weeks post-surgery increased the odds of meeting advanced rehabilitation criteria at 12 weeks post-surgery. The clinical implication of these findings is that measuring pain catastrophizing, knee activity self-efficacy and kinesiophobia at 4 weeks post-surgery may improve prediction of patients at risk for delayed rehabilitation progression 12 weeks post-surgery.
Level of evidence
This is a preview of subscription content, log in to check access.
Buy single article
Instant access to the full article PDF.
Price includes VAT for USA
Subscribe to journal
Immediate online access to all issues from 2019. Subscription will auto renew annually.
This is the net price. Taxes to be calculated in checkout.
Adams D, Logerstedt DS, Hunter-Giordano A, Axe MJ, Snyder-Mackler L (2012) Current concepts for anterior cruciate ligament reconstruction: a criterion-based rehabilitation progression. J Orthop Sports Phys Ther 42:601–614
Ardern CL (2015) Anterior cruciate ligament reconstruction-not exactly a one-way ticket back to the preinjury level: a review of contextual factors affecting return to sport after surgery. Sports Health 7:224–230
Ardern CL, Taylor NF, Feller JA, Webster KE (2013) A systematic review of the psychological factors associated with returning to sport following injury. Br J Sports Med 47:1120–1126
Bandura A (1977) Self-efficacy: towards a unifying theory of behavioral change. Psychol Rev 84:191–215
Baranoff J, Hanrahan SJ, Connor JP (2015) The roles of acceptance and catastrophizing in rehabilitation following anterior cruciate ligament reconstruction. J Sci Med Sport 18:250–254
Beynnon BD, Johnson RJ, Abate JA, Fleming BC, Nichols CE (2005) Treatment of anterior cruciate ligament injuries, part I. Am J Sports Med 33:1579–1602
Brand E, Nyland J (2009) Patient outcomes following anterior cruciate ligament reconstruction: the influence of psychological factors. Orthopedics 32:335
Brosky JA Jr, Nitz AJ, Malone TR, Caborn DN, Rayens MK (1999) Intrarater reliability of selected clinical outcome measures following anterior cruciate ligament reconstruction. J Orthop Sports Phys Ther 29:39–48
Brosseau L, Balmer S, Tousignant M, O’Sullivan JP, Goudreault C, Goudreault M et al (2001) Intra- and intertester reliability and criterion validity of the parallelogram and universal goniometers for measuring maximum active knee flexion and extension of patients with knee restrictions. Arch Phys Med Rehabil 82:396–402
Brown ML, Plate JF, Von Thaer S, Fino NF, Smith BP, Seyler TM et al (2016) Decreased range of motion after total knee arthroplasty is predicted by the Tampa Scale of Kinesiophobia. J Arthroplasty 31:793–797
Chmielewski TL, Jones D, Day T, Tillman SM, Lentz TA, George SZ (2008) The association of pain and fear of movement/reinjury with function during anterior cruciate ligament reconstruction rehabilitation. J Orthop Sports Phys Ther 38:746–753
Chmielewski TL, Zeppieri G Jr, Lentz TA, Tillman SM, Moser MW, Indelicato PA et al (2011) Longitudinal changes in psychosocial factors and their association with knee pain and function after anterior cruciate ligament reconstruction. Phys Ther 91:1355–1366
Clement D, Arvinen-Barrow M, Fetty T (2015) Psychosocial responses during different phases of sport-injury rehabilitation: a qualitative study. J Athl Train 50:95–104
Czuppon S, Racette BA, Klein SE, Harris-Hayes M (2014) Variables associated with return to sport following anterior cruciate ligament reconstruction: a systematic review. Br J Sports Med 48:356–364
Doury-Panchout F, Metivier JC, Fouquet B (2015) Kinesiophobia negatively influences recovery of joint function following total knee arthroplasty. Eur J Phys Rehabil Med 51:155–161
Everhart JS, Best TM, Flanigan DC (2015) Psychological predictors of anterior cruciate ligament reconstruction outcomes: a systematic review. Knee Surg Sports Traumatol Arthrosc 23:752–762
George SZ, Lentz TA, Zeppieri G, Lee D, Chmielewski TL (2012) Analysis of shortened versions of the Tampa Scale for Kinesiophobia and pain catastrophizing scale for patients after anterior cruciate ligament reconstruction. Clin J Pain 28:73–80
Hair JE, Anderson RE, Tatham RL, Black WC (1998) Multivariate data analysis, 5th edn. Prentice Hall, Upper Saddle River
Hartigan EH, Lynch AD, Logerstedt DS, Chmielewski TL, Snyder-Mackler L (2013) Kinesiophobia after anterior cruciate ligament rupture and reconstruction: noncopers versus potential copers. J Orthop Sports Phys Ther 43:821–832
Hemsley K, Sitler M, Moyer R, Oatis C (2010) Neuromuscular and psychological influences on range of motion recovery in anterior cruciate ligament reconstruction patients. J Electromyogr Kinesiol 20:684–692
Hsu CJ, George SZ, Chmielewski TL (2016) Association of quadriceps strength and psychosocial factors with single-leg hop performance in patients with meniscectomy. Orthop J Sports Med 4:1–8
Irrgang JJ, Anderson AF, Boland AL, Harner CD, Kurosaka M, Neyret P et al (2001) Development and validation of the international knee documentation committee subjective knee form. Am J Sports Med 29:600–613
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 Surg Sports Traumatol Arthrosc 13:393–397
Lee DY, Karim SA, Chang HC (2008) Return to sports after anterior cruciate ligament reconstruction—a review of patients with minimum 5-year follow-up. Ann Acad Med Singapore 37:273–278
Leeuw M, Goossens ME, Linton SJ, Crombez G, Boersma K, Vlaeyen JW (2007) The fear-avoidance model of musculoskeletal pain: current state of scientific evidence. J Behav Med 30:77–94
Lentz TA, Tillman SM, Indelicato PA, Moser MW, George SZ, Chmielewski TL (2009) Factors associated with function after anterior cruciate ligament reconstruction. Sports Health 1:47–53
Lentz TA, Zeppieri G Jr, George SZ, Tillman SM, Moser MW, Farmer KW et al (2015) Comparison of physical impairment, functional, and psychosocial measures based on fear of reinjury/lack of confidence and return-to-sport status after ACL reconstruction. Am J Sports Med 43:345–353
Lentz TA, Zeppieri G Jr, Tillman SM, Indelicato PA, Moser MW, George SZ et al (2012) Return to preinjury sports participation following anterior cruciate ligament reconstruction: contributions of demographic, knee impairment, and self-report measures. J Orthop Sports Phys Ther 42:893–901
Mintken PE, Glynn P, Cleland JA (2009) Psychometric properties of the shortened disabilities of the Arm, Shoulder, and Hand Questionnaire (QuickDASH) and Numeric Pain Rating Scale in patients with shoulder pain. J Shoulder Elbow Surg 18:920–926
Morrey MA, Stuart MJ, Smith AM, Wiese-Bjornstal DM (1999) A longitudinal examination of athletes’ emotional and cognitive responses to anterior cruciate ligament injury. Clin J Sport Med 9:63–69
Osborne JW (2006) Bringing balance and technical accuracy to reporting odds ratios and the results of logistic regression analyses. Pract Assess Res Eval 11:1–6
Risberg MA, Holm I, Tjomsland O, Ljunggren E, Ekeland A (1999) Prospective study of changes in impairments and disabilities after anterior cruciate ligament reconstruction. J Orthop Sports Phys Ther 29:400–412
Schober P, Boer C, Schwarte LA (2018) Correlation coefficients: appropriate use and interpretation. Anesth Analg. https://doi.org/10.1213/ane.0000000000002864
Sullivan MJ, Bishop SR, Pivik J (1995) The Pain Catastrophizing Scale: development and validation. Psychol Assess 7:524–532
Tegner Y, Lysholm J (1985) Rating systems in the evaluation of knee ligament injuries. Clin Orthop Relat Res 198:43–49
Thomee P, Wahrborg P, Borjesson M, Thomee R, Eriksson BI, Karlsson J (2006) A new instrument for measuring self-efficacy in patients with an anterior cruciate ligament injury. Scand J Med Sci Sports 16:181–187
Tichonova A, Rimdeikiene I, Petruseviciene D, Lendraitiene E (2016) The relationship between pain catastrophizing, kinesiophobia and subjective knee function during rehabilitation following anterior cruciate ligament reconstruction and meniscectomy: a pilot study. Medicina (Kaunas) 52:229–237
Tracey J (2003) The emotional response to the injury and rehabilitation process. J Appl Sport Psychol 15:279–293
Waldrop D, Lightsey OR, Ethington CA, Woemmel CA, Coke AL (2001) Self-efficacy, optimism, health competence, and recovery from orthopedic surgery. J Couns Psychol 48:233–238
Wilk KE, Arrigo CA (2017) Rehabilitation principles of the anterior cruciate ligament reconstructed knee: twelve steps for successful progression and return to play. Clin Sports Med 36:189–232
Woby SR, Roach NK, Urmston M, Watson PJ (2005) Psychometric properties of the TSK-11: a shortened version of the Tampa Scale for Kinesiophobia. Pain 117:137–144
The authors acknowledge Trevor Lentz and Giorgio Zeppieri Jr for their assistance with data collection and Ariel Botwin for his assistance with data preparation.
Conflict of interest
The authors certify that they have no commercial association that might pose a conflict of interest in connection with this article.
The study protocol was approved by the University of Florida Institutional Review Board (IRB Project #548-2006).
This work was conducted when Terese L. Chmielewski and Steven Z. George were at the University of Florida.
About this article
Cite this article
Chmielewski, T.L., George, S.Z. Fear avoidance and self-efficacy at 4 weeks after ACL reconstruction are associated with early impairment resolution and readiness for advanced rehabilitation. Knee Surg Sports Traumatol Arthrosc 27, 397–404 (2019). https://doi.org/10.1007/s00167-018-5048-6
- Anterior cruciate ligament
- Pain catastrophizing
- Fear of re-injury