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!