JORT

Psychological and Biomechanical Correlates

Kinesiophobia and Pain Catastrophizing: For frequently co-occurs with pain catastrophizing an exaggerated negative cognitive response to pain. In shoulder arthroscopy patients, those with pain catastrophizing reported higher kinesiophobia and poorer postoperative functional outcomes [12]. These cognitiveemotional factors promote hypervigilance and avoidance, reinforcing maladaptive behaviors.

Biomechanical Alterations: For manifests in observable movement changes. After ACL reconstruction, individuals with high fear scores demonstrate gait asymmetries in vertical ground reaction forces and muscle activation patterns, potentially increasing reinjury susceptibility [13]. Similarly, athletes with Achilles tendon ruptures who report for exhibit altered joint power distribution during drop jumps two years post-injury, shifting load from ankle to knee and hip [14]. These findings indicate for expresses itself through protective movement strategies.

Impact on return-to-sport Decisions: Beyond biomechanics, for influences confidence and risk appraisal. In a prospective soccer study, higher reinjury anxiety and lower self-confidence predicted increased lower extremity reinjury incidence, with each anxiety increment raising injury odds substantially [15]. This supports viewing psychological state as a measurable risk factor for subsequent injury.

Assessment of Fear of Reinjury

Early structured assessment identifies athletes at psychological risk during rehabilitation. Several validated patient-reported outcome measures are commonly used:

Tampa Scale of Kinesiophobia (TSK/TSK-11): Assesses fear of movement/(re)injury; scores >37 often indicate clinically significant kinesiophobia [16].

Athlete Fear Avoidance Questionnaire (AFAQ): Captures sportrelated fear and avoidance behaviors [17].

Injury-Psychological Readiness to Return to Sport (I-PRRS) scale: Brief 6-item measure of confidence and readiness for RTS [6].

Pain Catastrophizing Scale (PCS): Evaluates negative pain-related cognitions associated with higher FoR. [12].

Shoulder Instability-Return to Sport after Injury (SI-RSI) scale: Measures psychological readiness specific to shoulder instability [7] (Table 2).

Table 2: Common assessment tools for fear of reinjury and related constructs.

Intervention and Management Strategies

Addressing FoR requires proactive, coordinated strategies within rehabilitation.

Psychological Interventions

Cognitive-behavioral therapy (CBT): Challenges catastrophic thoughts about pain, vulnerability, and movement.

Graded exposure: Stepwise reintroduction of feared movements and sport-specific tasks to build confidence.

Motivational interviewing (MI): Collaborative conversation to strengthen rehabilitation motivation.

Imagery and mental skills training: Visualization of successful performance to enhance self-efficacy.

Integrated Biopsychosocial Rehabilitation

Education and reconceptualization: Clear explanation of tissue healing and safe loading reduces perceived threat.

Multidisciplinary communication: Regular dialogue among surgeons, physiotherapists, athletic trainers, and psychologists ensures consistent messaging.

Goal setting and mastery experiences: Realistic, time-bound goals support self-efficacy and reduce FoR.

Biomechanical and Physical Strategies

Biofeedback and wearable technology: Real-time feedback on symmetry and load demonstrates movement safety.

Sport-specific drills and RTS Testing: Structured progression guided by objective criteria bridges clinic-competition gaps.

Discussion

This review emphasizes that fear of reinjury should be regarded as a core rehabilitation target rather than a secondary consideration. Several themes carry important clinical and research implications.

Integration of findings: Across ACL reconstruction, Achilles tendon rupture, and shoulder instability, for consistently emerges as the dominant psychological barrier to RTS. Its associations with poorer patient-reported outcomes, biomechanical alterations, and higher reinjury risk demonstrate concrete clinical consequences beyond subjective concern. These observations align with fearavoidance models where pain-related fear drives avoidance and disability [5].

Clinical implications: The high for prevalence argues for routine psychological screening during rehabilitation. Relying solely on physical criteria may miss psychologically unprepared athletes. Incorporating tools like the TSK and I-PRRS at multiple time points can identify at-risk individuals, particularly females, amateurs, and those with pain catastrophizing. An integrated biopsychosocial model combining education, cognitive-behavioral strategies, and graded exposure with physical rehabilitation provides a practical framework.

Research Gaps and Future Directions: Several areas require further exploration. Injury- and sport-specific assessment protocols need refinement, as scales like the TSK may not operate identically across all populations [16]. High-quality intervention trials comparing different psychological approaches are needed. Longitudinal research tracking FoR throughout rehabilitation is limited, though existing work shows psychological factors evolve over time [20]. Social and environmental influences including coaching behavior and team culture likely shape for but remain understudied.

Multidisciplinary Collaboration: Optimal for management requires coordinated input from sports medicine physicians, orthopedic surgeons, physiotherapists, athletic trainers, and psychologists. Incorporating basic psychological assessment skills into rehabilitation professionals’ training would help ensure consistent FoR recognition and management.

Limitations: As a narrative review, this work is subject to selection bias despite structured searching. Included studies vary in design, sample size, and outcome measures, restricting direct comparison. Most research focuses on lower extremity injuries, leaving upper limb and trunk injuries underrepresented. Cultural factors influencing for expression are insufficiently addressed.

Conclusions

Fear of reinjury is a common, modifiable, and often decisive factor determining athletes’ return to sport and post-injury performance. It measurably influences symptoms, function, movement patterns, and reinjury risk. Routine use of brief, validated measures like the TSK and I-PRRS at baseline and follow-up visits should become standard in RTS decision-making. Effective management requires team-based biopsychosocial approaches integrating physical rehabilitation with education, graded exposure, and cognitive restructuring. Future work should refine sport-specific protocols, broaden psychological training for rehabilitation professionals, and test targeted interventions in robust clinical trials. By addressing FoR alongside physical recovery, clinicians can facilitate not only return to play but also help athletes return with greater confidence and resilience.

References

1. Ardern CL, Taylor NF, Feller JA, Webster KE (2014) Fifty-five percent return to competitive sport following anterior cruciate ligament reconstruction surgery: an updated systematic review and metaanalysis including aspects of physical functioning and contextual factors. Br J Sports Med 48: 1543-1552.
2. Podlog L, Dimmock J, Miller J (2011) A review of return to sport concerns following injury rehabilitation: practitioner strategies for enhancing recovery outcomes. Phys Ther Sport 12: 36-42.
3. Hsu CJ, Meierbachtol A, George SZ, Chmielewski TL (2017) Fear of reinjury in athletes. Sports Health. 9: 162-167.
4. Everhart JS, Best TM, Flanigan DC (2015) Psychological predictors of anterior cruciate ligament reconstruction outcomes: a systematic review. Knee Surg Sports Traumatol Arthrosc 23: 752-762.
5. Vlaeyen JW, Linton SJ (200) Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain 85: 317-332.
6. Glazer DD (2009) Development and preliminary validation of the Injury-Psychological Readiness to Return to Sport (I-PRRS) scale. J Athl Train 44: 185-189.
7. Lamb CJ, Fathi A, Lin EH, Yang M, Feingold CL, et al. (2025) Athletes who return to sport after treatment for shoulder instability exhibit higher psychological readiness: a systematic review. JSES Int 9: 1443-1448.
8. Larsson E, LeGreves A, Brorsson A, et al. (2024) Fear of reinjury after acute Achilles tendon rupture is related to poorer recovery and lower physical activity postinjury. J Exp Orthop 11: e70077.
9. Kvist J, Ek A, Sporstsedt K, Good L (2005) Fear of re-injury: a hindrance for returning to sports after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 13: 393-397.
10. Sheean AJ, Lubowitz JH, Brand JC, Rossi MJ (2023) Psychological readiness to return to sport: fear of reinjury is the leading reason for failure to return to competitive sport and is modifiable. Arthroscopy 39: 1775-1778.
11. Horng JC, Czarnecki M, Cruz C, Hasegawa M, Min KS, et al. (2025) Pectoralis major tendon rupture repairs using intramedullary suture anchors shows high patient-reported outcomes in military service members. J Shoulder Elbow Surg 34: 895-900.
12. Tokgoz MA, Ergisi Yilmaz O, Mustafa Ataoglu B, Kanatli U (2021) The effect of pain catastrophizing and kinesiophobia on the result of shoulder arthroscopy. Agri 33: 232-236.
13. Tajdini H, Letafatkar A, Brewer BW, Hosseinzadeh M (2021) Association between kinesiophobia and gait asymmetry after ACL reconstruction: implications for prevention of reinjury. Int J Environ Res Public Health 18(6): 3264.
14. Jonsdottir US, Briem K, Tranberg R, Brorsson A (2021) The effect of fear of reinjury on joint power distribution during a drop countermovement jump two years after an Achilles tendon rupture. Transl Sports Med 4: 667-674.
15. Naderi A, Rahimi M, Zarghami SY, Tranaeus U, Calmeiro L (2024) Psychosocial factors associated with lower extremity reinjury risk in soccer players: contribution of self-confidence and reinjury anxiety. J Athl Train 59(10): 1035-1041.
16. Miller RP, Kori SH, Todd DD (1991) The Tampa Scale: a measure of kinesiophobia. Clin J Pain 7: 51-52.
17. Dover G, Amar V (2015) Development and validation of the Athlete Fear Avoidance Questionnaire. J Athl Train 50: 634-642.
18. Bingol E, Tiryaki K, Tumturk I, Ozden F (2025) Investigation of exercise-related leg pain, fear of pain, kinesiophobia, and injury anxiety in athletes. BMC Sports Sci Med Rehabil 17(1): 40.
19. George SZ, Zeppieri G Jr (2009) Physical therapy utilization of graded exposure for patients with low back pain. J Orthop Sports Phys Ther 39(7): 496-505.
20. Slagers AJ, Dams OC, van Zalinge SD, Greeten JH, Zwerver, et al. (2021) Psychological factors change during the rehabilitation of an Achilles tendon rupture: a multicenter prospective cohort study. Phys Ther 101(12): pzab188.
21. Tripp DA, Stanish W, Ebel-Lam A, Brewer BW, Birchard J (2007) Fear of reinjury, negative affect, and catastrophizing predicting return to sport in recreational athletes with anterior cruciate ligament injuries at 1 year postsurgery. Rehabil Psychol 52: 74-81.