Injury-Related Fear in Individuals With and Without Chronic Ankle Instability: A Systematic Review

Ashley M.B. Suttmiller and Ryan S. McCann. Journal of Sport Rehabilitation, 2021, 30, 1203-1212.

Take-Home Message

Individuals with chronic ankle instability report more injury-related fear than controls or ankle sprain copers. Clinicians can rely on the Fear Avoidance Beliefs Questionnaire (FABQ) and Tampa Scale of Kinesiophobia (TSK-11) as patient-reported outcome measures to assess injury-related fear among patients with ankle injuries.


Injury-related fear can arise after an ankle sprain, which may influence rehabilitation and recovery. However, it remains unclear if differences exist in injury-related fear among people with chronic ankle instability, controls, and ankle sprain copers and which instrument(s) may be ideal for identifying injury-related fear among patients with an ankle injury.  

Study Goal

Suttmiller and McCann completed a systematic review to identify the differences in injury-related fear among individuals with chronic ankle instability, controls, and ankle sprain copers. 


The researchers searched three electronic databases for full-text articles published before November 2020. The researchers identified studies that used the Tampa Scale of Kinesiophobia (TSK), Athlete Fear Avoidance Questionnaire (AFAQ), or Fear Avoidance Beliefs Questionnaire (FABQ). They then compared these instruments among chronic ankle instability, control, and ankle sprain coper groups. The researchers assessed methodological quality of the included articles and calculated the difference in fear scores between groups (effect sizes).


The initial search yielded 69 articles, with 11 studies included in the final analysis. The 11 studies demonstrated moderate-high methodological quality. Of the 11 studies, 8 studies provided comparisons between the chronic ankle instability and control groups, 7 for chronic ankle instability and coper groups, and 4 for coper and control groups. On average, individuals with chronic ankle instability reported greater injury-related fear than the copers or control groups. In particular injury-related fear measured with the TSK and FABQ demonstrated moderate to large differences between groups. However, the researchers observed no differences between the copers and control group.


Someone with chronic ankle instability is more likely to experience greater injury-related fear than their peers, which may need to be addressed during rehabilitation to improve outcomes in this patient population. Although the FABQ and TSK appear to be appropriate for evaluating injury-related fear based on their survey designs, they may measure different aspects of fear in patients with chronic ankle instability. In addition, while common treatments such as balance and strength interventions (see below) may improve injury-related fear, targeted “fear” interventions such as neurocognitive-enhanced training (e.g., virtual reality, dual-tasking) may provide greater benefits.

Clinical Implications

If a person has chronic ankle instability, then clinicians should consider their injury-related fear prior to their return to physical activity. Clinicians can easily integrate the FABQ and TSK-11 into their clinical practice to assess injury-related fear.

Questions for Discussion

What activities or situations do you find patients fear or avoid after recovering from an ankle injury? What techniques do you use to reduce kinesiophobia during rehabilitation in patients with an ankle injury?

Written by: Ji Yeon Choi and Adam Rosen
Reviewed by: Jeffrey B. Driban

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