The Fear of Re-injury: Psychosocial Impact on Return to Sport “Do They Think They Are Ready”

Dr. Jonathan Hartman PT, DPT, OCS, CSCS, FAAOMPT

Dr. Marshall LeMoine PT, DPT, OCS, SCS, CSCS, FAAOMPT  

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It has been known for quite some time that athletic performance is intimately connected to psychosocial views, beliefs, and readiness to perform. It is still rarely held in high regards when compared to physical impairment testing amongst musculoskeletal and performance experts.

GOAL: 

  • Provide tests & measures regarding psychosocial return to sport testing 

  • Ways to to implement these test & measures seamlessly into your practice

IMAGINE:

  • Athletes that you believe were held back from their previous performance levels due to psychological factors…

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The question is, “was it ever addressed?”

CURRENT:

  • Psychosocial return to sport research is highly focused on outcomes with ACL reconstruction (ALC-R) surgery

  • Purpose of this surgery: 

    • Fix the mechanical failure in the body

    • Retrain the athlete back to full function and sport

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Why does standardized psychosocial testing become more of a specialized subpopulation?

Many athletes are not returning to or surpassing prior level of function due to possible psychosocial barriers. 

  • These barriers can greatly harm: 

    • Overall surgical outcomes

    • Life enjoyment

    • Postoperative complications & comorbidities  

  • Statistics:

    • 21% of postoperative athletes do not return to sport at all

    • 45% do not return to the same pre-injury level of elite sport participation

    • 40-50% of patients do not even return to recreational sports participation

  • Overall:

    • Post-operative patients get less physical exercise 

    • High rate of post-surgical ACL-R weight gain (3.8x more likely to be overweight in 3-10 years after ACL-R surgery)

    • Lack of return to sports activities with increased weight gain

    • >50% of ACL-R patients will develop increased knee OA at a much faster rate than normal

Evidence: 

In this first study (Lentz et al., 2015), physical impairments [quadriceps index (QI), quadriceps strength/body weight (QSBW), hamstring: quadriceps strength ratio (HQ ratio)], pain intensity, self-report of function (International Knee Documentation Committee (IKDC), and psychosocial (Tampa Scale for Kinesiophobia–shortened form (TSK-11) measurements were collected at 6 months and 1 year after surgery using 73 athletes with ACL Reconstruction. At 1 year the subjects were divided into ‘‘return-to-sport’’ or ‘‘not return-to-sport’’ subgroups based on their self-reported return to preinjury sport status. Patients in the “not return-to-sport” subgroup were subcategorized as NRTS-Fear/Confidence if fear of reinjury/lack of confidence was the primary reason for not returning to sports, and all others were categorized as NRTS-Other. 

This study showed that there is a strong association between a high TSK-11, a low QSBW, and a low IKDC at 1 year in the NRTS-Fear/Confidence subgroup vs the “return-to-sport” group or the NRTS-Other group. This suggests there is a strong psychologically mediated functional limitation with full post-surgical return to sport. Overall, this study supports a growing body of evidence highlighting the importance of measuring and addressing pain-related fear of reinjury, in addition to physical impairments, in standardized return-to-sport criteria (10). 

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Another study (Arden et al., 2013) looked at 187 recreational and competitive athletes, who were given the psychological readiness to return to sport, fear of re-injury, and sport locus of control subjective questionnaires. They were also asked to estimate of the number of months it would take to return to sport both preoperatively and at 4 months postoperatively. At 12 months post ACL-R only 56 athletes (31%) had returned to their preinjury level of sports participation. The results support that psychological responses before surgery and in the early recovery (4 months) were significantly associated with returning to preinjury level of sport at 12 months. This suggests that attention to psychological recovery should start to be implemented in return to function criteria, and start early, even possibly before surgery. This study concludes that screening for maladaptive psychological thought process’ in athletes prior to and soon after surgery may help clinicians identify those athletes at risk of not returning to their preinjury level of sport by 12 months (5).

This next study (Arden et al., 2014) shows how important psychosocial testing can be even with a population that is participating at a recreational level. In this cross-sectional study 164 subjects completed multiple questionnaires at 1–7 years after ACL-R surgery. The questionnaires included a knee self-efficacy (K-SES), health locus of control (MHLOC-C), psychological readiness of return to sport (ACL-RSI), and a fear of re-injury (TSK). At follow-up only 40% (66/164) had returned to their preinjury activity level. Those who did return had a more positive psychological response, reported better knee function in sport and recreational activities, perceived a higher knee-related quality of life, and were more satisfied with their current knee function. In those that did not return, the main reasons identified were not trusting the surgical knee (28%), fear of a new knee injury (24%), and poor knee function (22%). Psychological readiness to return to sport, measured with the ACL-Return to Sport after Injury scale ACLR-SI was most strongly associated with returning to the preinjury activity. Meaning if the athlete has a lower K-SES and ACL-RSI score and a higher TSK-11 score, then this may lead to a lower return to preinjury activity 1-7 years post surgically. This study suggests that including interventions aimed at improving these aspects in postoperative rehabilitation programs could be warranted to improve the rate of return to sport and recreational activities (3). 

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Next, there is a very pertinent systematic reviews (Te Wierike et al., 2013) which support psychosocial testing as an integral piece regarding return to sport and recreation. This systematic review shows that high scores on the “internal health locus of control” and “self-efficacy” tests were useful cognitive factors to facilitate recovery. Also, this study showed that postoperatively ACL-R athletes with a low level of fear of reinjury had the best knee outcomes when returning to sport. In addition, athletes who returned to sport exhibited less fear of reinjury and were more experienced athletes when compared to athletes who did not return to sport (11).

Finally, a meta-analysis of 25 studies, evaluating over 942 injured competitive athletes, uncovered three core themes across the studies chosen. The first is that emotion is associated with, and connected to, rehabilitation outcomes. The second is that there is importance in cognitions associated with rehabilitation outcomes. Third is that those cognitions correlate to behaviors associated with rehabilitation outcomes. These studies support that injury and performance-related fears, anxiety, and confidence were the most common psychosocial factors associated with rehabilitation outcomes. Therefore, practitioners need to recognize that an injured athlete’s thought, feelings, and actions may very well influence the outcomes of rehabilitation, as well as readiness to return to play. 

It can be seen that progressing our profession forward will involve a deep understanding of athletes biopsychosocial connection, and our ability to tease out which is the most limiting factor associated to suboptimal return to function/sport. Our current interpretation of successful rehab may be overly simplified, and practitioners must ensure that injured athletes are physically and psychologically ready to return to sport, with an increased emphasis in non-physical impairments. Practitioners should not assume that physical and psychosocial recovery from injury occurs within the same timeframe or that they are both improving with increased function. They need to be separately and specifically tested (9). As we head into an era focused on true biopsychosocial treatment and individualized sport specific progressive care, it is evident that a holistic approach to patient’s recovery should be addressed to attain the best possible outcomes.

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Research Quick Reference:

Practitioners need to ensure injured athletes are physically, psychologically, socially, tactically, and technically ready to return to sport (Forsdyke 2016)

Use for Pre-op to 4 months to predict who will return to sports at 12 months (Ardern 2013): 

  • TSK-11, 

  • ISP

  • ERAIQ

  • SRLC 

Use for 6 months & 12 months to predict who will be psychologically ready to return to sport (Lentz 2014):

  • QSBW

  • TSK-11

  • IKDC 

Not returning to sport reasons (Ardern 2014): 

  • Not trusting the knee (28%)

  • Fear of a new injury (24%)

  • Poor knee function (22%)

Use for not returning to sport (Ardern 2014):

  • ACL-RSI

  • K-SES

  • TASK-11 

An athlete with a lower K-SES score, lower ACL-RSI score, and a higher TSK-11 score will have a lower return rate to preinjury physical activity (Arden 2014)

Psychosocial Subjective: 

  • ACL -RSI  score >42 for practice,  score >56 for play (Ardern 13’, Webster 18’)

  • TSK-11 score <17  for practice , score <15 play (Lentz 2015, Woby 2005)

Knee function Subjective: 

  • IKDC Question #10, score >9 (M.O.O.N. Group Guidelines)

Citations

  1. Ardern, C. L., Taylor, N. F., Feller, J. A., & Webster, K. E. (2014). Fifty-five per cent return to competitive sport following anterior cruciate ligament reconstruction surgery: an updated systematic review and meta-analysis including aspects of physical functioning and contextual factors. British Journal of Sports Medicine. Nov2014, 48(21), 1543. doi:10.1136/ bjsports-2013-093398

  2. Ardern, C. L., Taylor, N. F., Feller, J. A., Whitehead, T. S., & Webster, K. E. (2015). Sports Participation 2 Years After Anterior Cruciate Ligament Reconstruction in Athletes Who Had Not Returned to Sport at 1 Year: A Prospective Follow-up of Physical Function and Psychological Factors in 122 Athletes. American Journal of Sports Medicine (AM J SPORTS MED), Apr2015. doi:http://0-dx.doi.org.catalog.llu.edu/10.1177/0363546514563282 

  3. Ardern, C. L., Osterberg, A., Tagesson, S., Gauffin, H., Webster, K. E., Kvist, J., & Österberg, A. (2014). The impact of psychological readiness to return to sport and recreational activities after anterior cruciate ligament reconstruction. British Journal of Sports Medicine (BR J SPORTS MED), Dec2014. doi:http://0-dx.doi.org.catalog.llu.edu/10.1136/ bjsports-2014-093842 

  4. Ardern CL, Webster KE, Taylor NF, Feller JA. Return to sport following anterior cruciate ligament reconstruction surgery: A systematic review and meta-analysis of the state of play. Br J Sports Med 2011;45(7):596-606.

  5. Arden CL, Taylor NF, Feller JA, Whitehead TS, Webster KE. Psychological Responses Matter in Returning to Preinjury Level of Sport After Anterior Cruciate Ligament Reconstruction Surgery. The American Journal of Sports Medicine. 2013; 41 (7): 1549-1558. Doi:10.1177/0363546513489284.

  6. Chmielewski TL, Zeppieri G Jr, Lentz TA, et al. Longitudinal changes in psychosocial factors and their association with knee pain and function after anterior cruciate ligament reconstruction. Phys Ther 2011; 91: 1355–1366.

  7. Everhart, J. S., Best, T. M., & Flanigan, D. C. (2015). Psychological predictors of anterior cruciate ligament reconstruction outcomes: a systematic review. Knee Surgery, Sports Traumatology, Arthroscopy (KNEE SURG SPORTS TRAUMATOL ARTHROSC), Mar2015. doi:http://0-dx.doi.org.catalog.llu.edu/10.1007/s00167-013-2699-1

  8. Flanigan, D. C., Everhart, J. S., Pedroza, A., Smith, T., & Kaeding, C. C. (2013). Fear of reinjury (kinesiophobia) and persistent knee symptoms are common factors for lack of return to sport after anterior cruciate ligament reconstruction. Arthroscopy: The Journal of Arthroscopy & Related Surgery (ARTHROSCOPY), Aug2013. doi:http://0- dx.doi.org.catalog.llu.edu/10.1016/j.arthro.2013.05.015

  9. Forsdyke D, Smith A, Jones M, et al. Psychosocial factors associated with outcomes of sports injury rehabilitation in competitive athletes: a mixed studies systematic review. Br J Sports Med 2016;50:537-544.

  10. Lentz, T. A., Zeppieri, G., George, S. Z., Tillman, S. M., Moser, M. W., Farmer, K. W., & Chmielewski, T. L. (2015). Comparison of Physical Impairment, Functional, and Psychosocial Measures Based on Fear of Reinjury/Lack of Confidence and Return-to-Sport Status After ACL Reconstruction. American Journal of Sports Medicine (AM J SPORTS MED), Feb2015. doi:http://0-dx.doi.org.catalog.llu.edu/10.1177/0363546514559707

  11. Te Wierike, et al. Psychosocial factors influencing the recovery of athletes with anterior cruciate ligament injury: A systematic review. Scandinavian Journal of Medicine & Science in Sports 2013.

  12. Thomee P, Wahrborg P, Borjesson M, et al. Self-efficacy of knee function as a pre- operative predictor of outcome 1 year after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2008; 16: 118–127. 

  13. Tjong VK, Murnaghan ML, Nyhof-Young JM, et al. A qualitative investigation of the decision to return to sport after anterior cruciate ligament reconstruction: to play or not to play. Am J Sports Med 2014; 42: 336–342.

  14. Tripp DA, Stanish W, Ebel-Lam A, et al. Fear of reinjury, negative affect, and catastrophizing predicting return to sport in recreational athletes with anterior cruciate liga- ment injuries at 1 year postsurgery. Rehabil Psychol 2007; 52: 74–81.

  15. Wright RW, Haas AK, Anderson J, et al. Anterior cruciate ligament reconstruction rehabilitation: MOON guidelines. Sports Health 2015; 7: 239–243