Fear of Re-inury in People who have Returned to Sport Following Anterior Cruciate Ligament Reconstruction Surgery

Ardern CL, Taylor NF, Feller JA, Webster KE. J Sci Med Sport. 2012 June [Epub ahead of print] https://www.ncbi.nlm.nih.gov/pubmed/22695136

The goal of anterior cruciate ligament reconstruction (ACLR) is to restore knee function to allow patients to return to sports participation, yet 2 years after surgery only 45% of these individuals have returned to their previous level of activity [Ardern, 2011]. Fear of re-injury has been reported in athletic populations [Kvist, 2005] and time from injury to surgery as well as gender has been suggested as potential factors that influence return to sports participation in ACLR patients [Karlsson, 1999; Ardern, 2011]. The purpose of this study was to evaluate fear of re-injury among athletes with a history of ACLR and have returned to any level of sports participation.
Out of a potential 533 participants, 209 participants met the inclusion criteria for this cross-sectional study: (1) regular participation in sports prior to injury, (2) at least 2 years after surgery, (3) clearance to return to full sports participation, and (4) participation in any level of sports activity at the time of the study. The primary outcome measure, fear of re-injury, was evaluated by a series of 8 novel questions that were developed by the authors. The questions were scored on a 10-point scale, with a higher score indicating less fear of re-injury. The authors determined that there was no
sampling bias as there were no differences between individuals that completed the survey and those that did not. Furthermore, there were no differences between those that participated in the study less than 4 years after surgery and those that were greater than 4 years after surgery. As a whole, the entire cohort responded that they had minimal fear, with an average score of 60 out of 80 (75%). However when evaluated by activity level, those that had NOT returned to their previous level of activity reported a higher fear of re-injury on all questions, except one question regarding the environmental conditions of participation (e.g., concern about a wet playing field). Conversely, this same environmental question was the only question that females reported a higher fear of re-injury compared to males. There were no other differences between males and females. Participants that had undergone ACLR > 3 months after injury reported higher fear of re-injury scores than those with less time between injury and surgery; particularly regarding risk of injury while playing their sport, effort to participate at 100%, wary of injury-provoking situations, hesitant to participate in sports, and satisfaction with performance. There was no difference between any groups for the question about whether they wear a brace or strap. Finally, females who waited more than 3 months after injury to have surgery and had not returned to their previous level of activity had a higher fear of re-injury compared to other participants. 

Overall, this study found that individuals who have not returned to their previous level of activity or delayed their time from injury to surgery had a greater fear of re-injury. It is possible that fear of re-injury is a barrier to returning to previous level of sports participation; however these factors only contribute to a greater fear of re-injury after ACLR. Because of the study design we cannot determine a cause and effect relationship. Prospectively following patients from injury to 2 years after surgery using psychological measures may help provide us a better understanding of the relationship between these factors and an increased fear of re-injury. This study enabled us to identify athletes that may have a higher fear of re-injury after ACLR. Additional rehabilitation or counseling for these individuals throughout the post-operative rehabilitation phase may be warranted to allow these athletes to successfully and safely return to full sports participation. Do you provide counseling services for athletes that have undergone ACLR or traumatic athletic injuries? Do you feel that this would be beneficial to our athletes?

Written by: Kathleen White
Reviewed by: Jeffrey Driban

Related Posts:
Predictors of Failure After ACL Reconstructions
Predictors of Self-Reported Knee Function in Nonoperatively Treated Individuals with ACL Injury
Factors Used to Determine Return to Unrestricted Sports Activities After Anterior Cruciate Ligament Reconstruction

Ardern CL, Taylor NF, Feller JA, & Webster KE (2012). Fear of re-injury in people who have returned to sport following anterior cruciate ligament reconstruction surgery. Journal of Science and Medicine in Sport PMID: 22695136