Fear of Re-Injury and Return to Sport Following ACL Reconstruction

Fear of Re-injury and Low Confidence 1 Year after ACL Reconstruction: High Prevalence and Altered Self-ratings: CSM2011 Sports Section Platform Presentation
Trevor Lentz, PT, CSCS

This study won the Excellence in Research Award from the Sports Section of the APTA. Trevor’s primary clinical and research interests include rehabilitation of shoulder pathology, especially of the overhead athlete, and ACL rehabilitation including advanced rehabilitation timeframes. He is part of the research group at University of Florida that includes Dr. Steven George PT, PhD. Dr. George has been involved in a large magnitude of research related to psychosocial variables in musculoskeletal conditions. His primary research interests involve the common theme of utilizing biopsychosocial models to prevent and treat chronic musculoskeletal pain and dysfunction. So, I am not the least bit surprised he is involved in this line of questioning.


34-47% of individuals do not return to prior sports participation following unilateral, isolated anterior cruciate ligament reconstruction. This number maybe up to 70% for contact sports.

Clinical Factors Associated with Disability Following ACL Recon:

  • Knee Pain Intensity
  • Knee Flexion ROM Deficit
  • Quadriceps Weakness
  • Fear of Movement and Re-Injury

**Multiple studies have supported those findings**

Differences Between Individuals Who Return to Sport and Those Who do Not:

Fear of movement and re-injury consistently associated with self-reported function. But, not routinely measured or addressed in post-operative care.

Essentially, the group wanted to study whether fear of re-injury and or fear of movement was present, and a factor, in return to sport following anterior cruciate ligament reconstruction. They included individuals in their study who had isolated, unilateral anterior cruciate ligament reconstruction. Return to sport status was measured 1 year post-operatively. Roughly 100 participants were enrolled. They gave participants a questionnaire asking if they had returned to sport. If the answer was no, they gave a list of reasons including pain, weakness, lack of ROM, lack of clearance by MD, fear of re-injury/movement, and some other variables…


  • 49% of their cohort had not returned to sport 1 year post operatively
  • 50% of those that had not returned to sport cited fear as primary reason
  • Fear was the most commonly cited primary or secondary reason for not returning to sport

A subset of the population may not only benefit from, but require, fear of re-injury interventions. Addressing psychosocial impairment may aid in function and return to sport status. But:

  • What interventions can/should be utilized?
  • At what point during rehabilitation?
  • How do confidence, self-efficacy, and pain castrophizing affect return to sport?

The speaker did a nice job of pointing out that we need to do a better job of operationally defining and measuring “return to sport.” For example, return to any sport? return to their sport? I would go one step further and say return to previous level of function (40 yard dash time, vertical leap, strength)? Previous level of performance (minutes played, game statistics, self-perceived ability)?

In my opinion, future investigations MUST specifically tease out return to sport and return to previous level of sport performance. It is useful whether measured subjectively through self-perception and self-report OR objectively through playing time, statistics, etc. Any athlete, especially high performing athletes, will tell you that there is a difference between playing/participating in their sport AND performing at their pre-injury level.

As far as intervention, it may range from graded exposure of feared activities/sport specific tasks or graded activity progression. [Many of these cognitive behavior approaches are being utilized and studied in patients with chronic and persistent pain] Some may require even further intervention (psychological or otherwise) for their biopyschosocial impairments and barriers for return to sport.

So, fear of re-injury has been identified as present following ACL surgery and a very real, patient perceived barrier for return to sport. Now, we need to figure who develops it and why? What are the risk factors? When do we intervene and how? And, what are the long term consequences of this impairment? Looks like we have some work to do!

10 Replies to “Fear of Re-Injury and Return to Sport Following ACL Reconstruction”

  1. Thanks for the links to my blog! You’ve raised some excellent points here – and similar ones apply to knee joint replacement and hip joint replacement. Given the high prevalence of postsurgical neuropathic pain, I wonder how many other people similarly fail to return to previously enjoyed activities?

    1. Bronnie, excellent points. I think as rehabilitation professionals we need to do a better job of recognizing (and researching) the barriers to return to function and previously enjoyed activities. Classically, our profession has focused on the physical barriers affecting return to function such as strength, ROM, balance, etc, etc. We are now beginning to better understand that there are psychosocial variables and barriers as well (such as fear of re-injury, fear/expectation of pain, etc). I would propose that at times return to function in following TKA and THA is mostly a physically mediated problem (lack of strength and endurance). This has been well documented in individuals following TKA. Other times, like in the some of the individuals mentioned in this presentation, it seems to be mostly a psychosocially mediated problem (fear). For many, including joint replacements, it is probably a combination. And, I would propose that the two are intertwined. Now, we haven’t even touched upon the effect of chronic pain or severe post surgical pain, which is total joint arthroplasties is definitely a huge issue…

  2. I saw an article recently where 56 female athletes who had undergone ACL reconstruction were followed for one year (not one year from injury, just during the one year period of the study). I believe these were Div 1 athletes, but don’t quote me on it. Anyways, during this 1 year time period 13 (almost 1/4!) reinjured their affected ACL. While this was not the focus of the study, I was a little astounded by this high re-injury rate over such a short period of time. I say strengthen, strengthen, STRENGTHEN!


    1. Good case series analyzing 503 competitive athletes in Australia who played football, soccer, netball, or basketball. Did not address or measure psycho-social factors, but good information on the hop test predicting return to sport.

      Return to Preinjury Level of Competitive Sport
      American Journal of Sports Medicine.

      “Patients with good hop test results (≥85% limb symmetry index) were more likely to return than patients with poor results (<85%)"

  3. My daughter had her 1st ACL surgery on her left knee June 2009 did everything she was told to do, she returned to playing basketball January 1, 2010 by January 20, 2010 she injured her right knee but was told that she just hyper-extended it this rocked on til April 2010 when we noticed she could not field to the right playing softball so we had an MRI done guess what torn ACL in addition to the medial and lateral torn so June 2010 her second cadaver ACL was installed. Trying to get her going again has been tough to say the least she is in constant fear of re injury and trying to make her understand that she has to strength train has been almost impossible I just wonder if it’s all worth it she was good prospect for a scholarship in softball but I don’t know what the future holds for her now in sports.

  4. y daughter always excelled in sports. in 8th grade she tore her left acl with sutures in meniscus. you relentlessly rehabbed only to miss part of her sport. then she tore the other acl playing select basketball during summer 9th grade year. it was unbelievable. again, went through all the hoops, cried, depressed, pushed forward to rehab. finally junior year was injury free.. had an awesome year. then 1/20/2011 during district basketball scrimmage against boys got her right knee blown out. hard to explain the disbelief and sheer injustice. had knee surgery cant walk for 4 weeks… major depression…startingto rehab some but not quite at the intesity as before. seems to have given in at this point and understandably so. was considering college volleyball, buttttt……..

  5. Another article investigating return to competitive sport following ACL reconstruction from the British Journal of Sports Medicine: http://bjsm.bmj.com/content/45/7/596.short

    From the Abstract:
    “Conclusion The relatively low rate of return to competitive sport despite the high rates of successful outcome in terms of knee impairment-based function suggests that other factors such as psychological factors may be contributing to return-to-sport outcomes.”

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