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Fear Of Reinjury Following Primary Anterior Cruciate Ligament Reconstruction (ACLR): A Systematic Review

Fear Of Reinjury Following Primary Anterior Cruciate Ligament Reconstruction (ACLR): A Systematic Review

Basit Mir, MB, BcH, BAO, LRCP and Si, CANADA Prushoth Vivekanantha, BMSc, CANADA Saihaj Dhillon, BHSc, CANADA Odette Cotnareanu, BSc, CANADA Dan Cohen, MD, CANADA Kanto Nagai, MD, PhD, JAPAN Darren L. de SA, MBA(c), MD FRCSC, CANADA

McMaster University, Hamilton, Ontario, CANADA

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Summary: Fear of reinjury or kinesiophobia is an important barrier behind recovery from ACL tear and reconstruction, and identifying the factors behind increased kinesiophobia are important for addressing this issue.


Despite vast technical and technological innovation in the performance of anterior cruciate ligament (ACL) reconstruction, and a much more nuanced understanding of the faces of physical rehabilitation to optimize during the recovery process, there remains a not insignificant amount of patients that do not return to their preinjury level of sport. In fact, despite a stable knee, full range of motion and uneventful surgical and postoperative course, a subset of patients either do not return to sport entirely, change their sport, or participate in their preinjury sport at lesser levels of competition and demand. It is becoming increasingly recognized that a gap exists in addressing the mental and emotional component of rehabilitation post-ACL surgery, and a real fear of reinjury or kinesiophobia in a subset of patients that often goes unaddressed. As such, this review aims to elucidate the most appropriate methods to quantify kinesiophobia and to identify key variables that influence the degree of kinesiophobia following primary ACL reconstruction as a first attempt to better manage the totality of the postoperative patient experience.


A systematic search across three databases (Pubmed, Ovid (MEDLINE), and EMBASE) was conducted from database inception to September 10th, 2021. Another systematic search was conducted from September 10th, 2021 to August 7th, 2022. The authors adhered to the PRISMA guidelines and the Cochrane Handbook for Systematic Reviews of Interventions. Quality assessment of the included studies was conducted according to the Methodological Index for Non-Randomized Studies (MINORS) criteria.


Twenty-six studies satisfied the inclusion criteria and resulted in 2213 total patients with a mean age of 27.6 years. Eighty-eight percent of included studies used variations of the Tampa Scale of Kinesiophobia (TSK) to quantify kinesiophobia and 27.0% used ACL-Return to Sport (ACL-RSI). The results of this study shows a common association between higher levels of kinesiophobia and poor patient-reported functional outcomes measured using International Knee Documentation Committee (IKDC) Scores, Activity of Daily Living, Quality of Life, and Sports/Recreation subscales of Knee Osteoarthritis and Outcome Score (KOOS) and Tegner/Lysholm Knee Scoring scale (TLKS)/ Lysholm activity scores. Postoperative symptoms and pain catastrophizing measured using the KOOS pain and symptom subscales and Pain Catastrophizing Score (PSC) also influenced the degree of kinesiophobia following ACLR. Patients with an increased injury to surgery time and in early postoperative periods demonstrated higher levels of kinesiophobia. Less common variables included being the female gender, low pre and postoperative activity status, low clinical functional assessments, not being enrolled in a return-to-sport training program and low self-efficacy.


Fear of reinjury or kinesiophobia following primary ACLR remains an understudied but modifiable and critical element affecting post-surgical outcomes and it needs more emphasis, much as the orthopedic community prioritizes technical and biological components to outcome optimization.

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