The Psychological Impact of Re-injury during Post-

Surgical Rehabilitation of the Anterior Cruciate

Ligament

Lauren Blakey ATS, Michaela Nolte ATS, Melissa Davis ATC, Beth Funkhouser ATC, CSCS,
Chaypin Buchanan ATC, Dr. Todd Hannula, MD

4/24/2017
 Table of Contents
CLINICAL SCENARIO 2
FOCUSED CLINICAL QUESTION: 2
KEYWORDS: 2
SUMMARY OF SEARCH METHODOLOGY 2
SEARCH STRATEGY: 2
SOURCES OF EVIDENCE SEARCHED: 2
BEST EVIDENCE REVIEWED: 3
CLINICAL BOTTOM LINE 3
IMPLICATIONS FOR CLINICAL PRACTICE 3
RECOMMENDATIONS FOR FUTURE RESEARCH 4
REFERENCES: 4

1
CLINICAL SCENARIO
During the academic school year of 2016-2017 at Emory & Henry College, ten
student athletes tore their ACL during competition or recreation activities. Two percent of
the student athlete population suffered from an ACL tear in one academic year. Therefore,
as athletic training students, we have had a significant opportunity to aid in the process of
creation of their postoperative rehabilitation programs. As each athlete progressed, the
majority of them suffered from a moment of fear in regards to taking the next progression
in their return to play protocol. Fear of re-injury, also known as, kinesiophobia, is defined
as an irrational and deliberating fear of physical movement resulting from a feeling of
vulnerability to painful injury or reinjury.1 Re-injury anxiety is subjective concern for re-
injuring the reconstructed knee once resuming normal physical activities, including
performing a sport.2 A competitive athlete is defined as a person who has eligibility to
compete in an organized sport in the upcoming season. 3 Whereas, a recreational athlete
does not meet this previously mentioned criteria. 3 Based on previous research articles
reviewed, these topics mentioned previously explain that there is a need for psychological
intervention in ACL injury cases. This study has the purpose of highlighting an area that is
often forgotten in the rehabilitation and evaluation stages.4 Kinesiophobia is a serious
concern for injured athletes and can actually result in a lack of desire to return to play.
Therefore, this is clinically significant not only at Emory & Henry College, but in other cases
of athletes suffering from ACL reconstruction.

Focused Clinical Question:

Does anxiety and fear in competitive athletes and recreational athletes older than 16
years old with previous ACL tears affect their overall psychological level leading to return
to play?

Keywords:
ACL Injury and/or tear and fear or anxiety and re-injury and return to play

SUMMARY OF SEARCH METHODOLOGY

The literature was searched for studies of level 4 evidence or higher that
investigated the effect of fear of re-injury on competitive or recreational
athletes ability/ choice to return to play.
1 high quality RCT and 4 level 4 case-control studies were included.

Search Strategy:
Patient/Client Group: Recreational OR Competitive Athletes older than 16 with
ACL tear
Intervention (or Assessment): mood OR emotional response
Comparison: no intervention AND control
Outcome(s): confidence in return to play

2
Sources of Evidence Searched:
Google Scholar, MedLine Complete, Pubmed, EBSCO and SportDiscus

Best Evidence Reviewed:

The following studies were identified as the best evidence and selected for
inclusion in the research. Reasons for selecting these studies were because they were
graded with a level of 1 or 4 evidence, studied anxiety of re-injury and the link to return to
play, and described the best methods of intervention on the outcome of interest
(confidence in return to play)2.

CLINICAL BOTTOM LINE

There was five studies that supported that fear of re-injury was consistent with low
levels of confidence in their ability to return to play. However, the overall anxiety decreases
as rehabilitation program progressed. In addition, their fear was emboldened due to their
belief that their physical performance was limited compared to pre-injury.3 One
randomized controlled trial concluded that relaxation and imagery-based psychological
intervention had a positive impact in benefiting recovery after anterior cruciate ligament
reconstruction.2

Implications for Clinical Practice

The five studies that were reviewed within this research demonstrated a reduction
in perceived fear or anxiety as time progressed since the initial injury. These findings
indicate that general rehabilitation programs are significantly effective in reducing re-
injury anxiety in ACL injuries. Athletic trainers should consider not only the physical aspect
while providing treatment sessions, but also incorporate psychological training. Cupal et al
(2001) performed a randomized controlled trial of thirty patients separated into three
groups (treatment, placebo, and control).2 All groups demonstrated a reduction of anxiety
at 24 weeks post surgery, but the treatment groups had the most significant change.2
Utilizing the treatment group, the research concluded that psychological training, including
relaxation and imagery techniques, is most effective in reducing injury anxiety.2 There
were some important differences in the results of the individual studies that may have
resulted in the discovered findings. Lee et al (2008) discovered that out of forty-five
patients interviewed seventeen (37.8%) did not return to their previous level of sport.5
Based on these statistics, the researchers concluded that nine patients (20%) did not
return due to fear of injury while another 8 (17.8%) did not due to persistent knee
instability and pain.5 Kvist et al (2005) utilized sixty-two patients in their study and
concluded that 24% of the athletes did not return to play due to anxiety of re injury.4 Tripp
et al (2007) used a sample of forty-nine recreational athletes where they concluded that
higher fear of re-injury scores were associated with a lower likelihood of returning to his or
her previous level of activity.1 Also, greater fear lead to less confidence in their ability to
take part in sporting activities.1
Athletic trainers should focus on mental preparation in return to play protocol.

3
Within the research studies reviewed, there are questionnaires that may prove useful for
athletic trainers to give to their injured athletes in order to help understand their current
psychological state. An example of this is the Tampa Scale for Kinesiophobia, which is
composed of 17 items pertaining to thoughts concerned with fear of re-injury. This
assessment is based on a four-point Likert scale where the results with higher scores
indicate more fear. In regards to clinician outcomes, the athletic trainer must be aware of
kinesiophobia and incorporate aspects of relaxation and guided imagery in order to boost
the athletes confidence.

Recommendations for Future Research

Future research should include additional research studies, preferable of a high
level of evidence, that show how fear and anxiety impact a patient after post-surgical ACL
reconstruction. Further randomized control trials need to be conducted to determine the
correct timing of implementing psychological interventions during the rehabilitation
stages. In addition, studies should discover if there is a maximum or minimum period of
time that the program should be implemented to reduce fear of re-injury when returning to
play by the greatest margin. Furthermore, longitudinal studies are needed to determine if
individual patients experience reduced fear of movement/re injury levels and if the amount
of decrease is linked to changes in pain, function, and return to activity.6 Overall, this topic
needs further literature to enhance the validity of the results.

REFERENCES:
1. Trip DA, Stanish W, Ebel-Lam A, Brewer BW, et al. Fear of Reinjury, Negative Affect,
and Catastrophizing Predicting Return to Sport in Recreational Athletes With
Anterior Cruciate Ligament Injuries at 1 Year Postsurgery. Rehabilitation
Psychology. 2007; 52: 74-81.
2. Cupal DD, Brewer BW. Effects of Relaxation and Guided Imagery on Knee Strength,
Reinjury Anxiety, and Pain Following Anterior Cruciate Ligament Reconstruction.
Rehabilitation Psychology. 2001; 46: 28-43.
3. Morrey M, Stuart M, Smith A, et al. A Longitudinal Examination of Athletes
Emotional and Cognitive Responses to Anterior Cruciate Ligament Injury. Clin J
Sport Med. 1999; 9:63-69.
4. Kvist J, Ek A, Sporrstedt K, et al. Fear of re-injury: a hindrance for returning to sports
after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol
Arthrosc. 2005; 13:393-397.
5. Lee D, Karim SA, Chang HC. Return to Sports After Anterior Cruciate Ligament
Reconstruction. Ann Acad Med. 2008; 37:273-278.
6. Chmielewski T, Jones D, Day T, et al. The Association of Pain and Fear of
Movement/Reinjury With Function During Anterior Cruciate Ligament
Reconstruction Rehabilitation. J Orthop Sports Phys Ther. 2008; 38(12): 746-753.