Fear of re-injury following ACL reconstruction: an overview

The anterior cruciate ligament (ACL) tear (Figure 1) is a common sports injury in both males and females, particularly in sports that require cutting, jumping, or pivoting, with more than 200.000 incidents every year in the United States. Likewise, ACL reconstruction is a common operation (Figure 2), both in the USA and in Europe, with more than 100.000 syndesmoplasties being performed every year in the United States and 3.500 per year in Sweden. A patient with an ACL tear who is treated conservatively, with early activity modification and a neuromuscular rehabilitation programme, may be able in a few days or a couple of weeks to have a painless knee with no oedema. Later, he may also be able to return to sports (RTS), in some extend, by executing simple sports activities that do not include cutting, jumping, or pivoting movements. This way the patients may avoid the stress of the operation, however, as studies have shown, 2/3 of those patients do not return to their pre-injury activity level. When the patient decides to undergo surgical reconstruction of the ACL tear, he complies with the stress of the operation and the long post-operative rehabilitation programme, ranging from 6 to 12 months. Patients undergo surgery not only to avoid subsequent meniscal or chondral injuries and early osteoarthritis, but especially to return to their pre-injury level of activity. According to the current literature, only 40 to 70% of the cases achieve return to the pre-injury activity level following ACL reconstruction. A recent meta-analysis, which included 48 studies with a mean follow-up of 41 months, revealed that although 90% of the patients achieved normal or nearly-normal knee function, only 63% returned to their pre-injury level of participation. Thus, 1 out of 4 patients achieves complete restoration of the knee joint function, but does not return to the pre-injury level of activity. This disparity between physical function and the ability to RTS is attributed to psychosocial factors. The psychosocial factors that may affect RTS include fear of re-injury (19%), fear of job-loss due to re-injury (11%) and a change in lifestyle or family commitments (18%), when only 13% of Abstract Patients undergo ACL reconstruction not only to avoid subsequent meniscal or chondral injuries and early osteoarthritis, but especially to return to the pre-injury level of activity. Yet, this level of activity is achieved in only 40 to 70% of the cases. This inability to return to the pre-injury level of activity, even when functional tests allow medical clearance to continue sports, is mainly attributed to fear of re-injury or kinesiophobia. This fear affects the athlete’s physical abilities, function and return to sports. Thus, it should be considered as a real risk factor undermining the patients’ knee movement and should be one of the core targets for the rehabilitation programme. Healthcare professionals have to assess the athletes that present with fear of re-injury and implement into their rehabilitation programme the appropriate adjunctive interventions, such as the “graded exposure”.