Fear of reinjury (kinesiophobia) and persistent knee
symptoms are common factors for lack of return to sport after anterior cruciate
ligament reconstruction.
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.
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.
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.
(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.
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?
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
Related Posts:
Return to Sport Following ACL Reconstruction Surgery – How Many Athletes Return to Preinjury Levels?
Fear of Re-injury in People who have Returned to Sport Following ACL Reconstruction
Flanigan DC, Everhart JS, Pedroza A, Smith T, & Kaeding CC (2013). Fear of reinjury (kinesiophobia) and persistent knee symptoms are common factors for lack of return to sport after anterior cruciate ligament reconstruction. Arthroscopy, 29 (8), 1322-9 PMID: 23906272
This study was very interesting to me and brought my attention because as an athletic trainer, there are multiple times I have seen an athlete nervous about returning to full participation after and ACL injury. In the study, did they look at what type of graft the patient had, and maybe there is a difference in the feeling of stability where the patient feels more comfortable then other grafts? Maybe that is something they could think about in another study in the future. Also with the patients who are afraid but still return to play, due to their timid and fear do they alter their gait at all and that could potentially cause more knee problems and worse come they re-tear their ACL or tear the other one?
Overall though I thought the article was well written and easy to read.
Callie Jedrzejek ATC, LAT
This article is of interest to me because I am currently working with an ACL-R patient who is hesitant to trust the new graft while we are working on pushing him to begin normal movements.
After reading this, some thoughts come to mind. When I think about an ACL injury and the surgery that comes afterwards (most of the time because of the population I work with) the first thing that comes to mind is the consequence of arthrogenic muscle inhinition (AMI). The knee joint, alone, has been reconstructed and is arguably the most stable it will ever be immediately after surgery. But, in the eyes of the patient, they have no muscle tone in their thigh, they cannot contract their quads, and they are in pain.
The reality of the situation is that something could be happening neurologically to cause the quads to shut down and/or undergo some kind of change. This is the most challenging aspect of rehab to overcome and return to normal functional activity and full participation in athletics.
To me, it is because of this AMI and potential change in the quadriceps quality that the patient may suffer from kinesiophobia. It is common for athletes to return to sport at around 85% of full strength compared to the uninjured limb. It has been theorized that there could be a change in muscle fiber type with a relative decrease in the fast-twitch fibers and a relative increase in slow-twitch fibers. This seems like it could be a reason that patients may regain some quad strength, but function in a constant fatigued state. I am interested to follow how the idea of kinesiophobia in ACL-R population changes with the development of research and techniques to regain normal quad activation and function following ACL-R.
Callie,
Great questions, thank you for posting! The answer to both of your inquiries is unfortunately no. The graft type was not discussed but I believe your thought is well rooted. Many studies looking at different graft types and surgical procedures exist but this was not a focus of the current study. I do agree with you though that this could be a factor that needs to be assessed further. I believe that this may eventually lead clinicians to an optimal surgical and rehabilitation protocol to optimize return to play. The study also did not address an alterations to the patient's gait patterns. This too could be a significant factor but I agree that the impact of kinesiophobia on this must be explored more in high quality studies first. Interesting points, is this change in gait pattern something you have seen in your practice?
Jake,
Great post. You have had a very interesting experience with you patient that helps insight the conversation. I too agree the future of kinesiophobia research will greatly inform clinicians everywhere. I do think though that a difficulty with this line of research will be the ever changing target of the optimal ACL reconstruction technique. What do you think. Will the fact that ACL reconstruction techniques are every changing (although minorly) will impact the applicability of kinesiophobia research?
Kyle,
This is an interesting question. However, it seems that regardless of the graft type, AMI is always present after reconstructions, which makes me think that it is the root of all of the difficulties surrounding ACL-R rehabilitation. For some reason my gut tells me that graft type will not have as large of an impact on kinesiophobia as AMI does. This is largely anecdotal, but there is some literature that supports the notion that there is little difference in patient-reported outcomes comparing graft type.
Jake,
Great feedback. I think arthrogenic muscle inhibition would definitively play a factor in kinesiophobia. I think your thought process will also be supported by an upcoming post of mine on September 25th which looks at a study by Mattias Ahlden. In the study they look at both subjective and object clinical outcome of single and double bundle ACL grafts so stay tuned for that. If this is true, then perhaps AMI is much more of a factor in returning an athlete to play. How do you address this issue with you patients?