Fear of reinjury (kinesiophobia) and persistent knee symptoms are common factors for lack of return to sport after anterior cruciate ligament reconstruction.
Flanigan DC, Everhart JS, Pedroza A, Smith T and Kaeding CC. Arthroscopy. 2013; 29(8) 1322-1329.
Take Home Message: Following an ACL reconstruction, persistent knee pain and/or fear of reinjury may contribute to whether or not a patient will return to their preinjury level of activity.
The purpose of an anterior cruciate ligament (ACL) reconstruction is to restore knee kinematics and anatomy, improve knee stability, and allow an athlete to return to their preinjury level of activity. However, in reality less than half of patients undergoing an ACL reconstruction will return to their preinjury level of activity. A better understanding of why these athletes do not return to their preinjury level of activity would allow clinicians to design more appropriate rehabilitation and counseling programs to mitigate factors that prevent the athlete from returning to their desired level of activity. Therefore, Flanigan and colleagues completed a retrospective cohort study to determine the patient-reported reasons for lack of return to sport after an ACL reconstruction. The authors identified 171 patients who received an ACL reconstruction from two surgeons between 2007 and 2008. A total of 135 patients completed a telephone interview (67 men, mean age ~ 29 years, 123 primary reconstructions, 12 revisions, time since surgery: 12 to 25 months). Patients answered questions about their previous and current activity level, as well as factors that contributed to their activity level. Overall, 62 (46%) returned to their preinjury level of activity (returners) and 73 (54%) did not (non-returners). A returner was more likely younger than non-returners. Most of the non-returners were recreational or high school athletes (only 8 athletes completed at collegiate or professional levels). The first and second most commonly cited reasons for not returning to preinjury level of activity was “persistent knee symptoms (pain, swelling, stiffness, instability, or weakness)” (50/73 non-returners, 68%) and fear of reinjury (38/73, 52%) respectively. Of the 50 patients who responded to having persistent knee symptoms, 25 (50%) patients also cited a fear of reinjury as a reason for not returning to their preinjury level of activity.
Overall, the data presented above should be extremely useful to clinicians. If an athlete expresses a wish to return to their preinjury level of activity, clinicians can focus on controlling knee symptoms (pain, swelling, stiffness, instability, and/or weakness) as well as discuss their fear about reinjury throughout the rehabilitation process. Although not an outcome measure in this study, it would be interesting for future research to see how much one factor influences the other. Perhaps if the “persistent knee symptoms” were resolved the patient may have an increase in confidence thus reducing their fear of reinjury. While this data is interesting, the study was limited by its inclusion of different activity levels and patients who underwent an ACL revision surgery. Patients who underwent an ACL revision surgery would have at least 1 other surgery during which the joint was subject to extra trauma. This would definitively increase the likelihood of the patient developing “persistent knee symptoms.” Further, these patients would also have failed their primary reconstruction which may lead to an increase in fear of reinjury. The inclusion of varying levels of participation is also of concern. Patients who compete for recreation may be more willing to change their activity level to meet their particular symptoms but elite athletes often do not have this option. This study and several others we’ve had on Sports Med Res (SMR) before (see below) highlight that a fear or reinjury is an important issue that we may need to address if we are to achieve our goal of returning our patients to their pre-injury level of physical activity.
Questions for Discussion: Do you believe the patient’s fear of reinjury was born from their current symptoms? How do you approach this throughout the rehabilitation and return to sport process?
Written by: Kyle Harris
Reviewed by: Jeffrey Driban
Return to Sport Following ACL Reconstruction Surgery - How Many Athletes Return to Preinjury Levels?
Factors Used to Determine Return to Unrestricted Sports Activities After Anterior Cruciate Ligament ReconstructionFear of Re-injury in People who have Returned to Sport Following ACL Reconstruction