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Detrimental effects of fear avoidance behavior on return to sport outcomes following ACLR


Introduction: Injury to the Anterior Cruciate Ligament is a common injury among athletes. Surgery is generally required followed by a lengthy rehabilitation process and gradual reintroduction to sport. Due to the severity of the injury, many athletes are unable to return to sport following surgery and rehabilitation or are unable to return to preinjury levels for various reasons. Purpose: The purpose of this study was to identify current assessment and treatment models dealing with fear avoidance behavior and its relationship in return to sport outcomes following Anterior Cruciate Ligament Repair (ACLR). Hypothesis: It is hypothesized that there is no standards for evaluation or intervention for fear avoidance behaviors following ACLR. Methods: A literature review was performed utilizing the Boise State University online database and the PubMed database utilizing the key terms of fear, sport and rehabilitation. Peer-reviewed articles focusing on fear avoidance and ACLR were chosen. Results: Fear avoidance behavior is a substantial contributor in failure to return to sport. No consistent assessment or treatment methods were identified. Current measurements in use tend to be modified questionnaires which initially addressed fear avoidance behavior relating to chronic back pain or back surgery. Steps have been recently taken to create knee and sport specific questionnaires however they are not in consistent use. Although no common intervention strategies were found, early patient education seems to be the most commonly utilized action. Self-efficacy beliefs also prove to be a helpful indicator for both success or failure. Conclusion: There are no current standards for evaluating and treating fear avoidance behavior following ACLR. Assessment and prediction for fear avoidance behavior should be conducted at the beginning of medical treatment. Early education intervention is shown to be helpful in reducing the likelihood of developing fear avoidance behavior and increasing the possibility for positive outcomes. Improved methods of identification and measurement as well as intervention are currently needed.



The study of physical rehabilitation following surgery is a common occurrence. In the realm of athletics, injuries requiring Anterior Cruciate Ligament Repair (ACLR) surgery can reduce or end careers and as such have garnered strong attention from the medical community. The current model of rehabilitation focuses primarily on bio-physical markers as it relates to successful rehabilitation outcomes, such as muscle strength and joint stability, with minimal attention or standardized evaluation for psychological recovery (Thing, 2005). Even with an abundance of engagement and research placed into physical rehabilitation, approximately 50% of athletes fail to return to sports following ACLR (C. L. Ardern, Webster, Taylor, & Feller, 2011; McVeigh & Pack, 2015; Thing, 2005) and for older athletes or those engaging in contact sports this number drops even further (Lentz et al., 2014).

The studies that have been done in regards to fear avoidance behavior show that of the 50% that do not return to sport, 25% of individuals state that fear of pain or re-injury is the primary concern (C. Ardern, Webster, Taylor, & Feller, 2010; McVeigh & Pack, 2015; Ross, 2010). Kvist found that only 36% of non-returners state physical impairment as the primary reason for not returning (Kvist, Ek, Sporrstedt, & Good, 2005) suggesting various other markers not being accounted for. Many times fear avoidance occurs in the absence of any physical deficits and in some situations physical rehabilitation and reductions in pain has been more successful with these non-returners than those who do return to sport (Ross, 2010).

The purpose of this study is to identify current assessment methods for assessing fear avoidance behaviors as well commonly used intervention strategies for improving outcomes following ACLR. Additionally, the information gained will contribute to the formation of ideas for improvement on intervention strategies as well as identify areas where information is greatly lacking and requires further research. The author expects to find a lack of appropriate methods for assessing fear avoidance and no agreed upon strategies for intervention and rehabilitation.


Initial research began utilizing Boise State University’s Albertson’s Library and PubMed databases. Key words used for the initial search included fear, sport, and rehabilitation. Articles were chosen based upon the primary content dealing with fear-avoidance behavior and return to sport outcomes following ACLR surgery as well as studies aimed at reviewing or developing methods for properly identifying and quantifying fear avoidance behaviors. Subsequent articles were then identified through the references of the initial articles deemed appropriate for the study.


Fear Avoidance Identification

No specific methods were found for measuring fear avoidance behavior as it relates to the athlete recovering from ACLR. Currently adaptations of questionnaires meant for various other situations and conditions are being utilized to best gauge fear-avoidance behavior (Dover & Amar, 2015).

One popular tool utilized is a modified version of the Tampa Kinesiophobia Scale(TSK). Although initially intended to measure fear in relation to back pain, a modified version of the TSK was adopted  and found to have high validity in measuring issues related to athletes recovering from ACLR (George, Lentz, Zeppieri, Lee, & Chmielewski, 2012; Tripp, Stanish, Ebel-Lam, Brewer, & Birchard, 2007; Woby, Roach, Urmston, & Watson, 2005).

The Fear Avoidance Belief Questionnaire (FABQ) is another utilized tool (Dover & Amar, 2015; Ross, 2010) and quantifies the level of fear about engaging in physical activity. This too was initially developed in regards to fear of activity due to back pain, however was adapted to use with patients recovering from ACLR as adjusted by Piva (Piva et al., 2009) and found to have high reliability.

The Knee Injury and Osteoarthiritis Outcome Score (KOOS) is a knee specific evaluation, however is intended for those also suffering from osteoarthritis as well as ACLR.  It has been utilized as a tool in measuring ACLR outcomes (Andriolo et al., 2015) however is mainly utilized at examining chronic issues arising years later after surgery (Kvist et al., 2005; Thomeé et al., 2006) and therefore not particularly helpful in addressing early rehabilitation and return to sport.

Recently Dover and Amar (2015) have created a sport injury specific questionnaire titled the Athlete Fear Avoidance Questionnaire (AFAQ) as they recognized fear avoidance behavior, devoid of actual pain sensation (Urban Johnson, Ekengren, & Andersen, 2005), can lead to chronic pain and suffering throughout life (Dover & Amar, 2015). This is the first questionnaire developed specifically to measure athletes and fear opposed to the general public (Dover & Amar, 2015) however is not knee or ACLR specific. Development of this new method for evaluation does speak to the growing concern and interest in this topic and is a step towards proper evaluation and treatment.

Although new methods are being developed and refined, a lack of consistency is present in regards to how and when to implement assessment and intervention strategies (Ross, 2010). Most studies have been conducted around the 1 year follow up (C. Ardern et al., 2010; Lentz et al., 2014; Ross, 2010) with less attention being paid to the athlete’s psychological state in the acute phase pre-surgery and immediately following injury and post-surgery (Chase, Elkins, Readinger, & Shepard, 1993; U Johnson, 1997; Urban Johnson et al., 2005). The authors of these studies postulate that earlier identification of fear avoidance behavior markers would allow rehabilitation therapists to increase successful recovery rates through earlier intervention.

Personality Types and Psychological Sabotage: Self Determination Theory, Self –Efficacy and Catastrophizing

                Personality types and self-efficacy have shown to be strong indicators as signs for the potential development of maladaptive actions such as fear-avoidance behaviors (Bandura & Locke, 2003; Heijne, Axelsson, Werner, & Biguet, 2008; Thomeé et al., 2006). One commonly identified maladaptive behavior commonly linked with low or diminishing self-efficacy is that of catastrophizing (Martorella, Cote, & Choiniere, 2008). Catastrophizing is described as the phenomenon based on fear, worry or inability to not divert attention away from the pain (Martorella et al., 2008; Tripp et al., 2007).

Many athletes, upon completion of surgery, find their lives severely and abruptly disrupted leading to an increased likelihood of catastrophizing (Martorella et al., 2008). Unexpected and sudden injury dramatically impacts athlete self-identity leading to feelings of frustration, anger, and depression (Bandura & Locke, 2003; Heijne et al., 2008; Marshall, Donovan-Hall, & Ryall, 2012; Thomeé et al., 2006; Tripp et al., 2007; Wiese-bjornstal, Smith, Shaffer, & Morrey, 1998). Because ACL ruptures create such an incredible change to lifestyle so abruptly this can be a difficult reality to handle psycho-emotionally (Heijne et al., 2008). Athletes can question their identity, feel isolated from their community and lose their sense of autonomy (Podlog & Eklund, 2006) all of which can interfere with rehabilitation and increase the likelihood of developing fear avoidance behaviors.

Self-determination theory (Ryan & Deci, 2000) has shown that all individuals desire a sense of competency, autonomy, and relatedness all of which become compromised in the injured athlete. Self-efficacy is also essential to feelings of autonomy (Bandura & Locke, 2003), and is negatively affected both in the time of injury and rehabilitation as well as initial return to sport (George et al., 2012; Lentz et al., 2014; Podlog & Eklund, 2006; Wiese-bjornstal et al., 1998).


There is no consensus on the best way to identify or intervene when working with an athlete dealing with fear avoidance behavior. Several studies involving the subjective perspectives of rehabilitation therapists do state that the most successful interventions are based around strong client education and the setting of reasonable and obtainable goals early in the rehabilitation process (Chase et al., 1993).

Chase states that early client education both prior to and immediately following surgery can set the stage for successful recovery (Chase et al., 1993). The average time frame for ACLR recovery and return to sport is 6 months and can sometimes be much longer (C. L. Ardern et al., 2011; Ross, 2010). Even when provided this information, rehabilitation therapists regularly state that most athlete patients are confident in their ability to recover and return to sport at a much quicker rate (Chase et al., 1993; McVeigh & Pack, 2015). Most times this is not the case and leads to deflated emotional states and the potential to begin developing maladaptive behaviors such as depression, catastrophizing, and reduced rehabilitation compliance (Chase et al., 1993; Martorella et al., 2008; McVeigh & Pack, 2015).

Some researchers postulate that proper education in the early development of athletes can be helpful in creating a psychological environment that is more prepared for the devastation that comes with severe injury. Informing young athletes on the realties and likelihood of injury as well as providing coping methods may decrease the chance for the development of fear avoidance behaviors when injury does occur (Heijne et al., 2008; Tripp et al., 2007). The support provided should evolve with the rehabilitation process as well. Recovering athletes have discussed the importance of social-emotional support in the beginning of the rehabilitation process with a shift to more informational support in later stages (Halley & Carroll, 1998).

Successful rehabilitation and minimizing the chance of fear-avoidance behaviors has been shown to be more prominent in athletes with strong self-efficacy and intrinsic motivation (Kvist et al., 2005; Lentz et al., 2014). These athletes are able to handle the challenge presented with injury and engage their rehabilitation process with greater success. They see themselves from the outset as being able to return to sport where as those with weaker self-efficacy have doubts from the beginning (Heijne et al., 2008).

Improving Management of Fear-Avoidance Behavior

                As with all medical treatment, early identification and intervention is essential to long term success. McVeigh and Pack (2015) believe that early education and identification of psychological markers will allow rehabilitation therapists to structure a more appropriate rehabilitation protocol taking into consideration both physical and psychological health. This step of intervention requires greater educational resources and training to youth coaches and support staff. With this information they may better be able to identify potential maladaptive behaviors early on and work to instill and foster a greater sense of self-efficacy and intrinsic motivation(McVeigh & Pack, 2015).

From a preventative perspective, personality evaluation methods could be utilized to identify youth who possess an athlete schema. This is important as removal of sport from their life will likely have a greater negative influence compared to those who engage in sport casually (McVeigh & Pack, 2015). Seeing as personality traits have been shown to be a strong indicator for the potential development of fear avoidance behavior (C. L. Ardern, Taylor, Feller, Whitehead, & Webster, 2013; Bandura & Locke, 2003; Thing, 2005; Thomeé et al., 2006) early intervention could prove to be a most powerful tool.

When the athlete has elected to have surgery performed a psychological screening should be conducted to identify their current psychological state. Many factors such as age, severity of injury, or time from injury to surgery could have an effect on the recovery process (Ross, 2010) and as such should be taken into account when creating realistic rehabilitation goals(Chase et al., 1993). Proper educational intervention should be created in response to the athlete’s current mental state and severity of injury, helping to alleviate issues related to unrealistic expectations and promote a greater sense of competency (McVeigh & Pack, 2015).

Appropriate goal setting allows the recovering athlete to monitor progress and recovery. If unrealistic goals are set the athlete begins to lose confidence in their ability to eventually return to sport(Chase et al., 1993; Podlog & Eklund, 2006). Strong interaction and education from the rehabilitation therapist can help clear misconceptions and, together as a team, create realistic obtainable goals (Chase et al., 1993; Podlog & Eklund, 2006). As incremental progress is made and measured the athlete will be motivated by progress and a sense of competency (Carson & Polman, 2012; Ryan & Deci, 2000; Wiese-bjornstal et al., 1998).

Interaction with positive social groups has been shown to increase successful rehabilitation compliance and eventual outcomes (Halley & Carroll, 1998; Podlog & Eklund, 2006). Pairing the recovering athlete with peers who have both succeeded in rehabilitation as well as those currently going through the process could create a community providing a sense of relatedness and increase the likelihood of compliance (Podlog & Eklund, 2006). Rehabilitation programs should create structure that allows the athlete to return to the arena of play as quickly as possible. Modified activities that allow engagement in their sport, interaction with their team and coaches, as well as provide rehabilitation function can reinforce their desire to return and slowly increase feelings of confidence and self-efficacy(Bandura & Locke, 2003; Ryan & Deci, 2000).

Lacking information and further research

                Although the studies identified throughout this paper provide insight into the impact of fear avoidance behavior as well as approaches for identification and intervention, further research is needed. All studies reviewed for this paper possessed a tremendous amount of variation and thus are not repeatable or indicative of the overall population.

Notable inconsistencies between studies, as well as within studies, included variations in the severity of injury, variations between the time of injury and the surgical procedure, variations in the types of procedures performed, variations in the subsequent rehabilitation protocol, inabilities to properly monitor athletes through the entire rehabilitation phase to ensure proper compliance, and the variation of the skill level and age of the participating athletes. Appropriate studies that better account for these variables are required to create replicable results.


Fear avoidance behavior has been shown to be a consistent variable in an athlete’s decision, or inability, to not return to sport following ACLR. Minimal diagnostic resources are currently available for the identification of fear avoidance behavior as a factor in rehabilitation, as well as no agreed upon approach for successful intervention(Dover & Amar, 2015).

Individuals who don’t return to play as a result of fear avoidance have displayed consistent psychological and personality markers in regards to poor self-efficacy and loss of autonomy, competency and relatedness (Halley & Carroll, 1998; U Johnson, 1997; McVeigh & Pack, 2015). These markers should be utilized for early screening and preventative education utilized to best prepare a vulnerable athlete for the realities of potential injury and rehabilitation.

Early education as well as providing a thorough understanding at the time of surgery can help to mitigate the chance of unrealistic expectations that leads to frustration and failure to properly comply and complete the rehabilitation program (McVeigh & Pack, 2015; Podlog & Eklund, 2006). Additionally, the setting of realistic goals can help the athlete monitor progress and feel confident in their ability to return to sport (Chase et al., 1993; Podlog & Eklund, 2006).

Further research is needed to create appropriate diagnostic tools for identifying fear avoidance likelihood in regards to ACLR as well as best practices for intervention to ensure a complete and successful rehabilitation.



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